Ebola virus disease preparedness strengthening team Burkina Faso country visit 17–24 November 2014
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© World Health Organization 2014 All rights reserved.
WHO/EVD/PCV/Burkina Faso/14
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Contents A C K N O W L E D G E M E N T S .......................................................................................... 4 SUMMARY ............................................................................................................................. 5 INTRODUCTION ................................................................................................................. 7 MISSION GOALS ................................................................................................................. 8 COMPOSITION OF THE MISSION TEAM ................................................................... 8 ACTIVITIES ........................................................................................................................... 9 ASSESSMENT ..................................................................................................................... 11 Component 1: Overall coordination ................................................................................. 11 Component 2: Rapid response team................................................................................. 13 Component 3: Public awareness and community engagement ....................................... 14 Component 4: Infection prevention and control .............................................................. 15 Component 5: Case management..................................................................................... 16 Component 6: Epidemiological surveillance ..................................................................... 17 Component 7: Contact tracing .......................................................................................... 19 Component 8: Laboratory ................................................................................................. 19 Component 9: Capacity at points of entry ........................................................................ 21 Component 10: Total budget for EVD prevention ............................................................ 22 CONCLUSIONS AND NEXT STEPS .............................................................................. 23
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ACKNOWLEDGEMENTS The mission team gives special thanks to Dr Jean Bosco Ndihokubwayo, WHO Representative to Burkina Faso, and Dr Marie Chantal Kambiré-Diarra of the WHO Country Office in Ouagadougou for their unfailing support. We would also like to thank the authorities of Burkina Faso and colleagues for their patience and for making themselves available, in particular the Director for Disease Control. We also recognize our colleagues Carolyn Mokoya, Melissa Bingham and Paolo Costa, who, from Geneva or elsewhere, gave us constant support throughout this mission.
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SUMMARY A mission comprising experts from WHO in Geneva, the WHO Regional Office for Africa and the United States Agency for International Development (USAID) visited Burkina Faso from 17 to 24 November 2014 to help the country implement its plan to prevent and respond to a possible epidemic of Ebola virus disease (EVD). The support team worked with national stakeholders and technical and financial partners in the country. This mission supplemented a previous one conducted by the WHO Regional Office for Africa. The method consisting of a review of documentation (national response plan, guidelines issued by the Department for Disease Control and technical literature), organization of a simulation exercise for relevant stakeholders and technical and financial partners, use of a standardized checklist to assess compliance with the 10 components of preparedness and response, ad hoc visits and subject-specific discussions when necessary. At the request of the national authorities, the mission trained the recently established rapid response teams. This report summarizes the strengths and weaknesses observed for each of the components and proposes recommendations in line with the strategies advocated by WHO to prevent and control EVD. The mission strongly recommends that an Ebola-specific governance structure be established, comprising an emergency operations centre, a national coordinator and technical subcommittees as defined in WHO recommendations. The subcommittees, which bring together the thematic stakeholders at national level, must prioritize the components of the response plan, organize activities and adjust the budget in consequence. The various items of the budget should be classified according to level of importance to stress priorities, existing resources and opportunities in cash or in kind resulting from coordination with the technical and financial partners. The EVD response preparedness plan of Burkina Faso will thus be stronger in terms of its operational effectiveness. The structural arrangements proposed will facilitate concerted action with financial partners. Generally speaking, it is also recommended that the guidelines familiar to the various stakeholders should be converted into standard operating procedures (SOPs) that provide readily comprehensible instructions that are easier to translate into action. These instructions should be accompanied by targeted training for the various stakeholder categories. To facilitate the establishment of rapid response teams, they should have clearer terms of reference, the composition of the teams and the logistical resources available to them should be strengthened and provision made for additional training, including field exercises and advanced modules, for example on personal protection and biosafety. Attention should be given to the national plan for communicating the risks associated with EVD, and a mechanism should be established to coordinate all social mobilization activities at national level. Community involvement in disease control activities is a weak point in the EVD preparedness activities observed to date. It is also recommended that a training programme on basic hygiene and universally applicable precautions be instituted for health workers and everyone who might come into contact with patients. The isolation units provided for in the response plan should be made operational with immediate effect. The first site currently envisaged for an Ebola treatment centre (ETC) appears to be suitable. It should be constructed according to the standards specified in this report. An EVD-specific supply system should be defined. Ambulances must be modified and their crews trained. Burial sites should be identified close to the designated ETC sites, and burial teams should be set up at district level. In order to strengthen epidemiological surveillance, the existing guidelines should include a standard protocol applicable to all public and private health care facilities and also, if possible, to traditional healers. Case definitions must be disseminated in local languages. A well-organized information reporting system should be brought up to date and established at all health facilities; greater emphasis should be placed on use of the EVD hotline number.
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The practical aspects of contact case monitoring should be reviewed. With assistance from partners, contract tracing teams should be trained in accordance with the EVD-specific protocols issued by WHO, suitably adapted to the national context. These teams should also be provided with the necessary equipment. At the time of writing, Burkina Faso lacks EVD diagnostic capacity and sends specimens to the Pasteur Institute in Lyon, France. The agreements regarding shipment of these specimens must be clarified, and the number of teams capable of taking specimens in a safe manner should be increased. It is important to check that there are sufficient stocks of personal protective equipment (PPE) and specimen-taking kits at points of entry and to ensure that staff are capable of using them in accordance with recommendations. Temporary isolation units in medical facilities should be evaluated and better prepared. Procedures for health measures and PPE should be known and tested. At ground crossings, health posts exist only at manned checkpoints, and the resources at their disposal are clearly insufficient. The WHO Country Office in Burkina Faso stands ready to assist the national authorities in implementing the response plan and coordinating with technical and financial partners.
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INTRODUCTION Burkina Faso is a vast crossroads among the countries of the sub-region. Its dense vehicular traffic transports the region’s people, who often share social and cultural norms, especially in border zones. The emergence of Ebola virus disease (EVD) in eastern Mali and then in Bamako greatly increased the chances of an EVD outbreak in Burkina Faso. The two countries share a rather porous land border hundreds of kilometres long, with point-of-entry services only at road crossings. Thus, the security of Burkina Faso is dependent on rapid detection of any imported cases and a rapid response to prevent the disease from spreading. That, in turn, depends largely on the structure of the health system and how public, private and traditional stakeholders work to interconnect it. Since 1996, the health system has been divided into three administrative levels: peripheral, intermediate and central. At the lowest level, the health districts, there are 1606 health and social welfare centres, 123 remote clinics, 14 remote maternity wards and 32 medical centres. At the level above are 45 district hospitals and medical centres with surgical units. The intermediate level comprises nine regional hospitals. At the central level are three university hospitals and a national hospital. There is an urgent to need to strengthen this system, heighten awareness of the challenges of detecting and responding to EVD and increase the number of technical and financial partners that can help meet the challenge.
In August 2014, the WHO Director-General declared EVD a public health emergency of international concern and issued recommendations for controlling the epidemic in affected countries and for preventing and responding to its appearance in unaffected countries. The International Health Regulations (IHR) Emergency Committee emphasized the importance for countries that have land borders with affected countries of: urgently establishing surveillance for clusters of unexplained fever or deaths due to febrile illness; establishing access to a qualified diagnostic laboratory for EVD; ensuring that health workers are aware of and trained in appropriate infection control and prevention procedures; establishing rapid response teams with the capacity to investigate and manage EVD cases and their contacts; and reinforcing preparedness, validating preparation plans and checking their state of preparedness through simulations and adequate training of personnel.1
In addition, the IHR Emergency Committee “emphasized the importance of continued support by WHO and other national and international partners towards the effective implementation and monitoring of these recommendations.” After a consultative meeting on EVD preparedness of WHO, at-risk countries and partners, held in Brazzaville on 8– 10 October 2014, a list of core measures was drawn up to assist countries unaffected by EVD in accelerating their readiness to face a potential epidemic. WHO implemented a strategy to help the 15 countries deemed to be at greatest risk to develop the capacity to make preparations and respond. One important aspect of this strategy is sending out teams of international experts to assess countries’ current state of readiness and to prepare specific plans for strengthening the health measures needed to manage EVD. During the first mission, in Ouagadougou on 28 October–8 November 2014, two epidemiologists sent by the WHO Regional Office for Africa worked with country teams and partners. Colleagues from WHO headquarters, the WHO 1
http://who.int/mediacentre/news/statements/2014/ebola-2nd-ihr-meeting/en/
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Inter-country Support Team for West Africa based in Burkina Faso, the Quebec National Institute for Public Health and the United States Agency for International Development (USAID) joined the mission on 17–24 November 2014 to complete the preparedness assessment and increase the ability of national experts to cope with possible introduction of EVD into Burkina Faso. This document summarizes the findings of the two missions and reports on the activities carried out by the international team on 17–24 November 2014.
MISSION GOALS The general goal of the visit was to ensure that Burkina Faso is operationally ready to deal with possible cases of EVD; that it is capable of early case detection and of investigating safely and reporting early; and that it can organize an effective response to prevent the disease from spreading. To achieve this goal, the mission reviewed the country’s plan, discussed it with stakeholders and proposed measures to strengthen preparedness, in line with WHO recommendations, to be taken within 30, 60 and 90 days.
COMPOSITION OF THE MISSION TEAM The support team comprised experts from WHO Geneva, the European Centre of Disease Control, the Quebec National Institute for Public Health, the WHO Regional Office for Africa, a private logistics consulting firm and USAID. The support team worked with national stakeholders and technical and financial partners in the country. Stephane De la Rocque (team leader), Technical Advisor, Global Alertness and Response Department, WHO, Geneva Jose Biey (epidemiologist), Inter-country Support Team West Africa, WHO Regional Office for Africa Jerome Ndaruhutse (epidemiologist), Disease Prevention and Control, WHO Country Office in Burundi Adolphe Nkongolo Mukubu (epidemiologist), WHO Country Office in the Democratic Office of the Congo Amina Benyahia Chaieb (epidemiologist), Global Alert and Response Department, WHO, Geneva Cristina Valencia (epidemiologist and contact tracing), European Programme of Interventional Epidemiology Training, European Centre for Disease Prevention and Control, Stockholm, Sweden Timon Marszalek (logistics), adviser in disaster management Anne Fortin (epidemiologist and simulations), Medical Officer and head of a scientific unit, Biological Risk and Occupational Health Department, Quebec National Institute for Public Health, Quebec, Canada Sambe Duale (public health consultant), Preparedness and Response Project, Emerging Pandemic Threats Program, USAID, USA
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ACTIVITIES The table below summarizes the mission activities.
Day 1 Event Meeting with the WHO Representative Place WHO Country Office Description Team introductions Briefing the WHO Representative on the mission (task, duties, responsibilities) and planned mission agenda Briefing on the findings of the preliminary mission on 17–24 November 2014 Courtesy visit to the SecretaryGeneral for Health Ministry of Health Introduction to the mission goals by the WHO Representative and the team
Division of work with the Disease Prevention and Control cluster and document revision
WHO Country Office
Report by WHO Regional Office for Africa on the consolidated checklist (working document) – available 18 November Report by WHO Regional Office for Africa on the field visits Presentation by the WHO Regional Office for Africa on the consolidated checklist
Visit to Ouagadougou International Airport
Ouagadougou International Airport
The team met with the chief physician of the airport, who showed the team the airport's health facilities and the procedures for selection, screening and isolation. There are usually four flights per day from a number of countries, including Guinea. Since the start of the outbreak, however, flights from affected countries have been cancelled. Day 2
Courtesy visit to the United Nations system coordinator Visit to EVD treatment centre Visit to two private health centres
Office of the United Nations Representative Pissy and Ouagadougou
Introduction to the agenda, mission team and goals The ETC had been the mental health clinic for the Pissy Centre and had to be repurposed to the level of the Ouagadougou ETC. Another ETC is planned for BoboDioulasso, but it was not visited on this mission. Neither is currently operational. In the event of an epidemic in areas far from these two cities, other ETCs will be set up in the affected districts. The team also visited a private health centre and a private general hospital. Review of all the simulation documents and detailed explanations of the checklist Documents and forms prepared to be handed out to participants. The team examined different scenarios and proposed a strategy for the simulation.
Preparation for the simulation
WHO Country Office
Security debriefing
WHO Country Office
The mission team attended the security debriefing to better understand the security situation in Burkina Faso.
Day 3
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Preparation for the simulation Simulation Review checklist
WHO Country Office WHO Country Office WHO Country Office
Finalization of documents, presentations, logistics (meeting rooms and group work areas) for the simulation Simulation led by two team members. About 50 people attended. Two scenarios were presented and discussed. Planning for the following day. As training had already been planned for the national coordination team, the two rapid response teams (from Ouagadougou and Bobo-Dioulasso) and the two case management teams in Ouagadougou on days 4–7 of the mission, the decision was made to include the checklist review in the training.
Day 4 National team training and assimilative exercise WHO Country Office Hotel Palm Beach, Ouagadougou The team started writing a preliminary report summarizing the strengths and weaknesses observed during the simulations and field visits. After the first mission, on 28 October–8 November, Burkina Faso asked for training for two rapid response teams and ETC case management staff. The director of the Department for Disease Control began the training at the Hotel Palm Beach. The WHO ad interim Representative to Burkina Faso was in attendance. Several presentations were given on EVD: its location, Burkina Faso's level of preparedness, ETC surveillance, laboratories and case management; and response coordination. The assimilative exercise revealed capacities that required strengthening and showed participants what practical decisions to take during an EVD situation. Day 5 National team training (continued) and checklist review Hotel Palm Beach, Ouagadougou Presentations on communication, disease prevention and control, logistics, psychological care and social assistance, contact monitoring and capacity-building at points of entry. In the afternoon, groups reviewed the checklist and made observations on strengths and weaknesses, corrective measures and action to be taken. There was a good level of participation. The team's logistics expert inspected the Ministry of Health's inventory and warehouses and met with the warehouse team to discuss the management strategy for large international freight. The team's logistics expert looked over the inventory and warehouses. met the warehouse team and discussed the management strategy for large international freight. The Essential Generic Drug Purchasing Centre is a private institution. Day 6 National team training (continued): personal protection equipment (PPE) practical exercise Hotel Palm Beach, Ouagadougou Feedback from the working groups on the checklist evaluation, then practical exercises: putting on andtaking off gloves in unsterile conditions, preparing chorine solutions, handwashing, putting on and taking off PPE. Review of tools used for monitoring and in ETCs The team finalized the report, in French. The sections were distributed among the team experts. Day 7 National team training Hotel Palm Beach, Presentations on practical aspects of case management at
Visit to the Department for Disease Control warehouse
Ouagadougou Department for Disease Control Ouagadougou Essential Generic Drug Purchasing Centre
Visit to the Essential Generic Drug Purchasing Centre warehouse
Drafting the report
WHO Country Office
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Ouagadougou
ETCs: general information about case management and new treatments, patient care and discharge, community involvement in EVD care at ETCs and ETC data management. The exercise on putting on and taking off PPE was repeated. The team wrote a preliminary report stating the strengths and weaknesses observed in the group exercises. Each item on the checklist was reviewed by all team members. A summary was written and will be shared with the Ministry of Health. The team informed the interim WHO Representative of their findings and discussed next steps.
Finalizing the report
WHO country office
Presentation of recommendations to the ad interim WHO Representative to Burkina Faso
WHO Country Office
ASSESSMENT The method used for assessing the preparedness and response capacity of Burkina Faso consisted of a review of documentation (national response plan, guidelines issued by the Department for Disease Control and technical literature), a table-top simulation exercise for relevant stakeholders and technical and financial partners, use of the consolidated checklist to assess compliance with the 10 preparedness and response components, ad hoc field visits and subject-specific discussions when necessary. This section summarizes the strengths and weaknesses observed for each of the 10 components and proposes recommendations in line with the strategies advocated by WHO to prevent and control EVD.
Component 1: Overall coordination Strengths • The Ministry has been proactive since the start of the epidemic and highly aware of the risks. It began drafting its response plan in August 2014 and revised it in November 2014 to incorporate the lessons learnt in the USAID-sponsored regional workshop in Abidjan, Côte d’Ivoire, on preparing and responding to epidemics of unknown origin (including EVD). The Ministry also adjusted its plan to account for the changing situation and the WHO’s recommendations in the manual Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation.2 The plan was budgeted and distributed to technical and financial partners. • At the same time, the Department for Disease Control developed national guidelines along the same lines as the response plan. They specify the action to be taken in each epidemiological phase (pre-epidemic, alert, epidemic, post-epidemic). These guidelines were sent to all the regional health departments, the 70 health districts and 1606 health and social welfare centres, and to sensitive places such as district hospitals and points of entry. Private facilities were made aware of the guidelines through the Association of Promoters of Private Clinics. • If the virus were introduced, several management tools could be used: that of the National Council for Emergency Assistance and Rehabilitation, headed by the Minister for Social Welfare and National Solidarity and represented at regional, provincial and departmental levels; the Disaster Plan, coordinated by a crisis 2
www.who.int/csr/resources/publications/ebola/manual_EVD/en/. Page 11
committee consisting of representatives of several ministries and headed by the Prime Minister, the provincial governor, the high commissioner or the mayor, depending on the scale of the crisis, with crisis centres and operational groups; and the Comprehensive National Disaster Preparedness and Response Plan, which involves all sectors and associations and nongovernmental organizations. • Requirements at each level of the health system and for each action in the response plan were clearly identified and quantified. • The many technical partners are concerned and eager to become involved. • Good cooperation with the WHO Country Office, which helped to develop the guidelines Weaknesses • There is no EVD-specific committee or task force, no emergency operations centre at central level or lower and no one specifically named as the EVD coordinator. EVD is managed by the Epidemic Management Committee, which consists of representatives of the relevant technical departments under the ministries of Health, the Interior and Finance. The Committee meets weekly and is led by the Department for Disease Control. It was recently expanded to include technical and financial partners. According to its members, the Committee is essentially a forum for sharing information but should play a greater coordinating role. • There are currently no plans to adopt the WHO-recommended coordination structure (national coordination committee and technical subcommittees). There are no technical subcommittees involving multiple partners. In the event the disease appears, the health authorities must rely on the Disaster Plan for crisis management. In such emergency conditions, it will be impossible to form working groups calmly. • The proposed budget in the response plan is tied to the chronological order of the epidemiological phases described by WHO. The resources to be mobilized should be prioritized. Failing this, the budget will not be sorted by category, and some budget items will be large and difficult for donors to handle. • The guidelines indicate what should be done, but the method should be described in greater detail in the form of SOPs that can be easily understood by all stakeholders in the field. • The guidelines are ambitious in terms of the human resources to be marshalled. Confirmation should be sought that these numbers are indeed available or easily assembled without severely neglecting other priority areas of public health. Recommendations • Establish an EVD-specific governance structure, comprising a national coordinator, a coordination committee and technical subcommittees as recommended by WHO (within 30 days). • Set up an emergency operations centre and centralize EVD-specific administration and information: identify and assemble the personnel (managers, administrators and technicians) and equipment, including decentralized methods of communication (GSM or satellite phones, HF/VHF radios, Internet), electric generators, computers, printers, maps of medical facilities that are required to coordinate operations in real time at central level in the event of an EVD outbreak (within 30 days). • Decide on subcommittee membership and operation (coordination, roles and responsibilities), and plan their work (within 30 days). • Identify EVD focal points and their deputies in all the participating agencies and organizations (within 30 days). • Ask subcommittees to prioritize their response activities, and adjust the budget accordingly (within 30 days). Page 12
• Assess the value of creating these bodies at regional level, if justified by the presence of specific stakeholders (nongovernmental organizations in particular) (within 30 days). • Review the human resources needed and the options for re-assigning personnel, and propose a mobilization plan, keeping in mind the effect on other areas of health (within 30 days). • Make the guidelines into SOPs to provide easy-to-follow instructions for the pre-epidemic phase (within 30 days), epidemic phase (within 30 days if possible, otherwise 60 days). This work falls to the subcommittees, which should specify the role, division of labour and good practices for each of the participants. Training of technical staff in the SOPs will be needed (within 30 days). • Set up an SOP calendar to train all technical staff (within 60 days).
Component 2: Rapid response team Strengths • The national guidelines clearly define what is expected and the focal points, provide the necessary documentation (investigation and reporting forms) and are adapted to the local context. • The alert and reporting systems in place are effective. Eight potential cases were reported and handled. The laboratory results were negative for all of them. • Two rapid response teams have been formed, one in Ouagadougou and one in Bobo-Dioulasso, made up of physicians, nurses, psychiatrists, hygienists and epidemiologists. They have received their letters of assignment. The response plan also provides for regional and district rapid response teams. • There is an ambulance dedicated to EVD response in each region. • Health care facilities and the core isolation units (322 of the 1606 health and social welfare centres) have been listed and mapped. Weaknesses • No terms of reference for the rapid response team. Not all stakeholders fully understand the roles and tasks of the rapid response teams. • No written procedures (SOPs) for the rapid response teams • The material and financial resources for the rapid response teams are insufficient. • A disaster control and operations centre has not yet been set up to manage the rapid response teams. • The rapid response teams have insufficient training in EVD preparedness and response. This mission included 3.5 days of training for the rapid response teams.3 Additional specialized training adapted to Burkina Faso's response plan should, however, be considered on topics such as biosafety, so that the rapid response teams can work safely. Field simulations are also recommended.
3
In the final evaluation, 85% of participants considered that the goals of the workshop had been met, 96% considered that the facilitators were clear, 70% that the time was well managed, 93% that the facilitators gave relevant answers to questions, 76% that the discussion time was sufficient, 82% that the materials were good, 96% that they learnt something and 94% said they would apply what they had learnt in their daily work. The Ministry of Health, which requested the workshop, was entirely satisfied.
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• Members of the rapid response teams are not equipped to take blood samples. As described in component 8, specimens are taken and managed at the Murraz centre in Bobo-Dioulasso in south-western Burkina Faso. Staff travel when necessary. They would be quickly overwhelmed in the event of simultaneous alerts. Recommendations • Draw up terms of reference, practical instructions and SOPs for the rapid response teams (within 30 days) • Expand EVD preparedness and response training, in particular on biosafety (in progress), by helping Burkina Faso develop clear training modules in all areas, based on the experience of countries that have successfully contained EVD and lessons learnt in the three most affected countries (within 30 days). • Increase the numbers and tasks of the rapid response teams (all expertise and for all tasks) (within 30 days). • Provide more material and logistical support to the rapid response teams (within 30 days). • Conduct a case management simulation (within 90 days).
Component 3: Public awareness and community engagement Strengths • In the response plan, there is a full communication plan and budget for engaging with the media and the public. There are regular TV and radio spots on EVD. • The response plan addresses public awareness and community engagement. • Some public messages have been translated into local languages. • The essential communication networks (TV, radio, social media) have been identified and action plans drawn up in the appropriate languages. • EVD awareness-raising posters are visible in some health centres, in the airports and in some government buildings and public places. These posters give a number for the information and prevention hotline (see component 4). Weaknesses • Placement of an ETC in an area in which the local residents are vehemently opposed (e.g. Yagma ETC) indicates lack of community involvement in some sensitive decisions. • Functioning coordination and communication mechanisms that involve all government sectors and other partners (including civil society and nongovernmental organizations, traditional healers and communities) are not yet in place. • No coordination in drawing up, reviewing, approving and sharing messages with partners, which increases the chances of mixed, incomplete or even contradictory messages being communicated. • Influential key actors and mobilizers such as religious leaders, politicians, traditional healers and the media in urban and rural zones are not yet sufficiently involved. • Little local communication and under-use of rural radio
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Recommendations • Communicate more with civil society and local communities. • Set up a coordination mechanism or committee for public awareness and communication activities (within 30 days). • With partner institutions and civil society, develop and implement a national communication plan on the risks associated with EVD; clarify the messages, and involve experienced partners (e.g. UNICEF, nongovernmental organizations), particularly in rural areas (within 30 days).
Component 4: Infection prevention and control Strengths • Technical posters on EVD, prevention measures and hand hygiene were distributed and were posted in the health centres visited. • Guidelines have been drawn up and distributed by the Ministry of Health on: identifying isolation and case management areas for potential EVD cases, strengthening infection prevention measures among health workers, improving hygiene in facilities and biomedical waste management. • The annexes to the guidelines provide the relevant SOPs and protocols, such as how to put on and take off PPE, wash and disinfect hands, trace contacts, prepare chlorine solutions, etc. • Disinfection materials (sprays) are available in the regional hospitals. They must be distributed. PPE was available in the WHO-recommended quantities in the health centres visited but, according to several sources, not in many other centres. • In all, 322 health facilities throughout the country at local, regional and national levels have designated for isolation units for suspected cases. These units are in health centres or in institutions near health centres (schools, for example). There is a map of the core isolation units. • Compensation or incentives are planned for health workers assigned to the ETC. Weaknesses • Basic hand hygiene and precautions are not applied uniformly. • There are insufficient quantities of materials for basic hand hygiene and universal precautions: soap, hand sanitizer, chlorine, gloves and masks. PPE is not available in sufficient quantities in all health centres (currently, two per centre). • Patients in private-sector health centres must pay for materials for basic hand hygiene and precautions. • Not all health centres have operational incinerators. • Other than posters, there are no general awareness-raising activities about hygiene and how to effectively implement infection prevention and control. • Core isolation units are not adequately equipped. • Health workers, including hygienists and cleaning staff, in hospitals, health centres and health posts are not trained. Page 15
• The families of health workers receive no compensation if they are infected or die. Recommendations • Start a training programme for health workers on basic hygiene and universal precautions, test that the knowledge has been assimilated, and implement the measures in field visits (within 30 days). • Ensure that materials and equipment for basic hand hygiene and precautions are available throughout the country: soap, water, hand sanitizer, chlorine, bleach, gloves, masks (within 30–60 days). • Assess the number and state of repair of incinerators and waste management in health centres. As appropriate, make available or repair incinerators in health centres (within 30 days). • Review and deplace the core isolation units so that they are in health facilities. If there is insufficient indoor space, a tent could be used, for example (within 30 days). • Make operational the designated core isolation units in health centres (within 60 days) • Equip and train health workers, giving priority to external providers and emergency services for hospitals (they are the first contacts), and staff of core isolation units in EVD control health centres (within 30–60 days). • Provide compensation (occupational or family) in the event that a health worker contracts or dies of EVD (within 60 days).
Component 5: Case management Strengths • The site for the ETC in Ouagadougou is on the premises of the Pissy medical centre, which has a surgical unit. It is a good location, and there is sufficient space. • The design of the ETC is being drawn up. • The site can now be prepared for construction (refurbishing the building and isolation, cleaning and bringing the premises up to standard). • Purchasing and stocking of essential materials has begun (e.g. PPE, sprays, disinfectants, triple-packaging). • The Department for Disease Control has received a special import licence for certain products; adding a product to a delivery takes less than 24 h. Weaknesses • Plans for the ETC are not yet complete, and construction has not yet begun; patients use the planned site in fields as toilets, and hygiene is problematic (the hospital has pay toilets). • Plans have not been made for ETCs elsewhere in the country or at transit hubs (no common survey information about population density and informal points of entry); vulnerable populations should be identified. A recommended architecture for ETCs and practices to take into account are available. • It was not possible to verify whether the health centres meet international standards for isolation of a suspected case in terms of infection risks and waste management because a national measles vaccination campaign made a visit impossible. An insufficient number of PPE was reported in private health centres and clinics, and procedures were lacking for visits by companion and families to isolation units. Page 16
• The terms of references of staff are not included in the job profiles; staff and training requirements are not described in sufficient detail. Training for all personnel involved (nurses, physicians, psychosocial support staff, hygienists, burial teams, attendants, drivers, warehousemen and others) is urgently required. • 13 ambulances throughout the country (one per region) have been dedicated to EVD preparedness and response, but most are not yet operational; i.e. they are not prepared for use as EVD ambulances: no divider between driver and patient, arrangement of seats and storage not suitable, lack of essential materials and equipment, staff require training. • The warehouses of the Department for Disease Control are in several buildings in Ouagadougou, which complicates inventory management; it is unclear whether all the necessary materials are in stock or available at short notice (no product definition or coding system, no centralized inventory, no standard stock list). • Several “PPE kits” have been delivered (by WHO in April 2014, the USAID avian influenza kit, by WHO in August– November). The definition and contents of a “PPE kit” are ambiguous because the items are not the same (different sizes, different levels of protection from “light” to “full”, some items are one-time use, some are reusable). Some kits might be incomplete or unusable. • Potential burial sites have not yet been identified, and communities have not yet been made aware of the issue. • Burial teams have not been designated or trained in at least half the regions, and they are not equipped. There is no system for transporting contaminated bodies (availability and location of specialized vehicles and teams). • SOPs for ETCs, isolation units and burials are incomplete.
Recommendations • Build an ETC to international standards (WHO, Médecins sans Frontières) in terms of infrastructure. In view of the space available, it would be wise to plann for a future expansion; equip the ETC with the materials necessary for it to become operational. • Select a site in Bobo-Dioulasso in which a second ETC could be built if necessary. • Select, train and equip ETC personnel. • Select, train and equip ambulance personnel. • Draw up terms of references for all jobs. • Implement an EVD-specific supply, transport and storage system, with standardized product definitions and coding, a centralized warehouse and inventory, goods transport, warehouses throughout the country, stock levels known and reviewed. • Select the vehicles for EVD response (transport of teams, goods, bodies). • Repurpose the ambulances for use as EVD ambulances. • Formally select the burial site(s) for EVD victims, with approval from the community. • Select, equip and train burial teams in each of the remaining regions.
Component 6: Epidemiological surveillance Page 17
Strengths • The hotline for reporting diseases at community, regional and national levels has been set up. The number for the hotline is 80 00 11 20. Calls are actively monitored. • The hotline number was posted in the health care facilities visited. • There is a team of epidemiologists in the Department for Disease Control. • Guidelines on EVD surveillance are available. • Surveillance has revealed suspected cases. All tests were negative. • The case definition and investigation forms were distributed nationally (central, intermediate and peripheral levels). • The staff at Ouagadougou hospital and in the two regions bordering Mali and Côte d'Ivoire were trained in detecting and managing EVD cases. • There is a Government fund for general disease response. Weaknesses
• There is only one central line for receiving calls on the hotline; the line covers the whole country but can receive only one call at a time. • The hotline is not EVD-specific. Hotline staff are not trained in call management or basic EVD knowledge. There is confusion about the specific purpose of the hotline. Active monitoring of calls is irregular. • The investigation and case definition forms have not been updated to the latest WHO definitions. • The simplified EVD case definition is not available in all languages for community surveillance. • Burkina Faso has not identified all the gaps in its EVD-specific surveillance. The EVD surveillance protocols have not been formalized, and the reporting chain among health bodies has not been standardized. • Some health centre personnel have not been trained in EVD investigation or initial case management. • Local nongovernmental organizations, religious leaders and other key actors are not systematically included in EVD community surveillance. • There is no database for information on EVD cases (place, name, date, etc.). Recommendations • Add additional lines to the hotline. • Select and train hotline operators in sorting information and in basic EVD knowledge. • Set a standard protocol for the hotline. Standardize information gathering and reporting by hotline operators. • Train all health workers in detecting, reporting and managing EVD cases in accordance with the terms of reference for each personnel category. • Update the case definitions and investigation form. • Prepare simplified case definitions in the local languages and disseminate them in the community.
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• Update the EVD surveillance guidelines; standardize the reporting protocols in all health facilities; establish a protocol for the reporting phases, and distribute it to all health centres. • Provide all health facilities with telephones, credit and access to the hotline. • Involve nongovernmental and civil society organizations more closely in surveillance, particularly communitybased surveillance.
Component 7: Contact tracing Strengths • The national guidelines include forms for contact tracing. • Staff in Ouagadougou and the two regions bordering Mali and Côte d’Ivoire have been trained in the basic principles of contact tracing. • For the suspected cases, contact tracing was begun by health workers. • Contact tracing is carried out in partnership with the Red Cross, which has a network of volunteers. Weaknesses • No contract tracing until a suspected case is confirmed • Training of personnel in contact tracing and monitoring is limited and not nationwide. • No protocols or SOPs for contact tracing and monitoring • No definition of a contact • The basic material required for contact tracing and monitoring not sufficiently identified • No teams on standby for tracing contacts in each region Recommendations • Select and form teams for contact tracing in collaboration with the Red Cross in every region of the country. • Develop EVD-specific protocols and management tools (database, reporting process) for contact monitoring. • List the requirements for contact tracing. • Disseminate the WHO standard definition of a “contact” to all health centres. • Determine the basic material requirements for contact tracing and monitoring.
Component 8: Laboratory Strengths • There is a clearly identified national laboratory (Murraz Centre in Bobo-Dioulasso, National Reference Centre for haemorrhagic fevers, P2-equivalent virology laboratory) that safely takes specimens and prepares samples to be sent to the reference laboratory in triple packaging. The Murraz Centre currently has two response teams, comprising an epidemiologist, a biologist and a biomedical technician, and sufficient materials and capacity Page 19
(two agents certified in shipping category A biological samples internationally, and one agent from the Pharmaceutical, Drug and Laboratory Division). • The guidelines concerning taking specimens and sending samples to the Pharmaceutical, Drug and Laboratory Division to be shipped abroad are clear. • The Ministry of Health has concluded an agreement with the reference laboratory in France via the Réseau Afrique de l'Ouest de Laboratoires (RESAOLAB) network of the Mérieux Foundation. Through this agreement, prepaid shipments may be sent to the Jean Mérieux P4 laboratory in Lyon. This mechanism was used efficiently for recent suspected cases. • To bolster rapid response teams, the Murraz Centre could train additional biomedical technicians in taking specimens safely, if called upon to do so. • RESAOLAB conducts technical training in biosafety, information, input management and quality control. • There is a supply of about 40 triple-packaging kits. Approximately half are at the Murraz Centre. Weaknesses • Burkina Faso currently has no in-country diagnostic capability, even serological. The delay for receiving results from Lyon varies from 48 hours to 5 days and depends on commercial flights. • The biosafety level at the Murraz Centre is insufficient for EVD serological testing. • Only the Murraz Centre is currently capable of taking specimens, and staff must travel from Bobo-Dioulasso when needed. Its two teams would be quickly overwhelmed if the situation progressed. • More detailed instructions for taking specimens from human remains are needed. • The Murraz Centre does not have a fixed budget allocated for its activities. Thus far, it has used its own financial, human and logistical resources. Recommendations • • Ensure continuation of the agreement with RESAOLAB if the number of samples to be tested increases (within 30 days). Meet potential transporters and negotiate shipment conditions for samples of suspected EVD. Check that there is a World Courier representative (WHO has a global contract with World Courier for handling samples) (within 30 days). Consider setting up diagnostic capability in-country. Definitely back the idea of a P3-level mobile laboratory, if one can be obtained. Do not neglect the training needs of associated technical personnel. Identify a technical and financial partner that could provide support for strengthening biosafety and the diagnostic capability at the Murraz Centre with EVD PCR technology or by making a mobile laboratory available (within 90 days). Begin training additional staff (including rapid response teams) to take specimens and prepare samples safely, including from human remains (within 60 days). Prepare SOPs for taking specimens from human remains (within 30 days). Plan to acquire the additional consumables for taking specimens (kits with bins for sharps) and P620 triplepackaging (UN2814) (within 30 days). Page 20
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Assess whether the certifications of personnel who are already trained to ship category A biological samples internationally require renewal.
Component 9: Capacity at points of entry Strengths • There is a plan for detecting suspected cases at all points of entry. • An infrared camera is available at Ouagadougou Airport. • Teams have been selected and made aware of EVD, with 24 h/24 h 7 d/7 d coverage. • There is an isolation area in Ouagadougou Airport. • A suitably outfitted ambulance is available at Ouagadougou Airport. Weaknesses • No adequate EVD PPE at the airport. • There is a plan, but the medical aspect must be improved; an EVD-specific plan should be added to the airport’s disaster plan. • The ambulance in Bobo-Dioulasso should be fitted with compartments. • Maintenance and re-supply of chorine solutions and disinfectant gels at the airport are not formalized or documented. • There are not always isolation areas, and those that exist are not all up to standard or reserved for the intended use. • There are not enough human resources at most land crossings. Recommendations • Procure PPE and specimen-taking kits, and distribute them appropriately to points of entry. • Incorporate the health plan into the civil aviation disaster plan. • Add compartments to ambulances at large-capacity points of entry deemed to be at risk. • Accelerate preparations for isolation areas at important points of entry. • Build capacity in terms of equipment, personnel and training in hygiene measures and surveillance at all points of entry. • Improve the work areas for health personnel at points of entry. • Draw up SOPs for health measures and PPE at points of entry. • Follow WHO and IHR Emergency Committee recommendations on travel and international trade.
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Component 10: Total budget for EVD prevention Strengths • A detailed budget is associated with the response plan. The budget is organized according to the epidemiological phases in WHO’s recommendations (pre-epidemic, alert, epidemic and post-epidemic), and the requirements for each phase of the recommended actions are listed. The budget items are therefore justified. They are based on a scenario of 1000 cases over 12 months. The total budget for the plan is 41 834 764 406 CFA francs (US$ 79 434 billion4), with US$ 23 984 billion for the pre-epidemic phase, US$ 42.431 billion for the alert phase, US$ 10 962 billion for the epidemic phase and US$ 2 057 billion for the post-epidemic phase. • To date, US$ 4 814 billion appear to have been raised: US$ 2.1 billion from the Government budget and US$ 2.34 billion from the European Union. • Burkina Faso has begun using the available budget for the pre-epidemic phase to hold informational and coordination meetings with many stakeholders, partners and beneficiaries, to produce information materials and to buy materials, including ambulances. • Technical and financial partners are invited to weekly meetings of the Disease Control Management Committee to learn how the response plan is being implemented. • Burkina Faso can count on the WHO Country Office for help with advocacy and mobilizing donors. Weaknesses • Although the budget is broken down by action, it still cannot be read easily by donors. The amounts are large and should be put into perspective by creating a classification by priority and level of urgency. • The budget fails to emphasize the existing resources, especially human and logistical (e.g. vehicles). As a result, it is difficult to see the impact of each budget item on the operational plan. • The budget is in a linear list. If the budget lines were associated with committees and technical subcommittees, it would be easier to see the potential impact of thematic stakeholders, in cash or in kind, and to reduce the amounts. • Some budget items may not be justified given the current risk level (e.g. surveillance of animals). Note: The mission was limited to examining the pre-epidemic and alert phases. It is possible that analysis of subsequent phases would reveal opportunities for cross-over and economies of scale. Recommendations • Classify the budget to reveal the priority actions, better align it with the operational plan, and propose subbudgets by level of importance. • Organize the budget by topic in accordance with the WHO-recommended governance structure to facilitate adoption by thematic partners and stress contributions in cash or in kind. The very large budget could be reduced by allowing partners to handle some tasks. • Check on the availability of liquid assets, which may have been affected by recent political events. • Use the Disease Control Committee or any other future coordinating mechanism to prepare a platform for dialogue among financial partners. 4
At the official United Nations exchange rate on 22 November 2014
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CONCLUSIONS AND NEXT STEPS The mission to strengthen EVD preparedness achieved its double objective of (1) reviewing Burkina Faso's preparedness and response strategy and (2) training the recently formed rapid response teams, with the unfailing support of the Ministry of Health and the WHO Country Office in Burkina Faso. For the first objective, field visits, the simulation exercises and the workshop to review the consolidated checklist showed the main strengths and weaknesses and resulted in recommendations to the Ministry of Health and WHO. Because the mission was short and organized on short notice, it was not possible to travel to the regions or to carry out a field simulation. Some points should be confirmed (posts at land border crossings, reference laboratory in Bobo-Dioulasso) by more thorough investigations. For the second objective, the authorities expressed their satisfaction to WHO. Although some modules were essentially introductions and should be investigated again in more thorough exercises, the participants gained an appreciation of the various aspects of EVD preparedness and response. This report summarizes the strengths and weaknesses observed for each of the components of the consolidted checklist and proposes recommendations in line with the strategies advocated by WHO to prevent and control EVD. The main recommendations are listed below. Discussions with technical and financial partners should continue, and the WHO Country Office in Ouagadougou is available to provide support for these discussions and help implement the national preparedness and response plan.
The mission strongly recommends that an EVD-specific governance structure be established, comprising an emergency operations centre, a national coordinator, a coordination committee and technical subcommittees as defined in WHO recommendations. The subcommittees, bringing together thematic stakeholders at national level, must prioritize the components of the response plan, organize activities and adjust the budget accordingly. The various budget items should be classified according to level of importance to stress priorities, existing resources and opportunities in cash or in kind resulting from coordination with technical and financial partners. The structural arrangements proposed above will facilitate concerted action with the financial partners. Generally speaking, it is also recommended that the guidelines familiar to the various stakeholders be converted into SOPs that provide readily understandable instructions that are easy to translate into action. These instructions should be accompanied by training programmes for the various categories of stakeholder. To facilitate the establishment of rapid response teams, the terms of reference should be clarified, the composition of the teams and the logistical resources available to them strengthened, and provision made for additional training tailored to the response plan, including field exercises and advanced modules, for example on biosafety. Obtaining the support of the population is crucial, especially for components of the plan that are sensitive and potentially difficult for communities to accept. The national plan for communicating the risks associated with EVD should be finalized and a mechanism established to coordinate social mobilization activities. It is also recommended that a training programme on basic hygiene and universally applicable precautions be instituted for health workers and everyone who might come into contact with EVD patients. The isolation units provided for in the response plan should be made operational with immediate effect. The first site currently envisaged for an ETC appears suitable, and the centre should be built according to the standards specified in this report. A second site should be selected in Bobo-Dioulasso. An EVD-specific supply system
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must be created. Ambulances must be modified and their crews trained. Burial sites should be selected and efforts made to prepare burial teams. In order to strengthen epidemiological surveillance, the existing guidelines should be include a standard protocol applicable to all public and private health care facilities and also, if possible, to traditional healers. Case definitions must be disseminated in local languages. An information reporting system should be established and greater emphasis placed on use of the hotline. It is recommended that the practical aspects of contact case monitoring be reviewed. With assistance from partners, contract0tracing teams should be trained in accordance with EVD-specific protocols to be developed. These teams should be given the necessary equipment. At the time of writing, Burkina Faso lacks EVD diagnostic capacity and sends specimens to France. The agreements regarding shipment of these specimens should be confirmed, and the number of teams capable of taking specimens in a safe manner should be increased. It is important to check that sufficient stocks of PPE and specimen-taking kits are available at points of entry and that staff know how to use them. Isolation units must be better prepared. Procedures for health measures and PPE should be known and tested. At land crossings, health posts exist only at manned checkpoints, and the resources at their disposal are clearly insufficient.
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