AACAHB-Basic PHEM training

1
 Training outlines
• CHAPTER ONE. Introduction to PHEM
Section 1: PHEs
Section 2: PHEM
• CHAPTER TWO: PHEM-Early warning & Data management
Section 1: Introduction to PHS
Section 2: Early warning system
Section 3: Surveillance Data analysis & Management
Section 4: PHS-Case definition
Section 5: Role of Laboratory during PHEM

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 Training outlines….
• CHAPTER THREE: PHEM- Preparedness
Section 1: Introduction
Section 2: Coordination
Section 3: VRAM
Section 4: EPRP
Section 5: Capacity building
• CHAPTER FOUR: PHEM-Response
Section 1: Introduction to PHE response
Section 2: Outbreak Investigation
Section 3: RRT during emergency
Section 4: PHEOCs
Section 5: Essential package of HS during emergency
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 Training outlines….
• CHAPTER FIVE: RECOVERY
Section 1:Post Emergency Recovery Assessment
Section 2: Mental and Psychosocial Support in Disaster
settings
Section 3: Learning from PHEs- AAR/IAR
Section 4: Humanitarian emergency
Section 5: Essential Health Service During Emergency
• CHAPTER SIX: Monitoring & Evaluation

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 Goal of the training

• To create resilient public health emergency management

system in the city administration by producing competent and

well capacitated public health response teams from the region

to health facilities

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 Training objectives
• To create well equipped PHEM officers/PHEM focal to detect
any public health events
• To create common under standing among PHEM officers/Focal
regarding reportable diseases in Ethiopia
• To strengthen surveillance system in the city administration
• To increase the capacity of PHEM officers/Focal to detect any
public health emergencies early
• To strengthen the response activity for any public health
emergencies in the city administration

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 Core competences & Expectations

• The trainer will able & able to train on how to:-

o Detect any PHE at facility level
o Report any PHE to next level on time
o Investigate any outbreaks in the community
o Complete reporting formats (CRF) for immediately
reportable disease
o Response to any PHE
o Data quality management
• Will score greater than 85% (post test)

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 Training methodologies
• Adult learning methods
• Brainstorming
• Power point presentation
• Group discussions
• Exercises (Group work and presentation)
• Daily evaluations
• Previous day recap
• Pre and post test

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 CHAPTER ONE

Public Health management (PHEM)

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 Outline

• Introduction

• Impacts of public health emergency on health system

• PHEM and its guiding principles

• Pillars of PHEM

• Structure of PHEM

• Summary

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 Enabling Objectives

• Describe definition and types of public health emergency

• Explain impacts of public health emergency on health system

• Define public health emergency management

• List guiding principles of PHEM

• Explain pillars and structure of PHEM

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 Section 1: Introduction to PHEs
Activity 1.1: Group discussion
1. What are public health emergencies
and their types?
2. How would you describe your
national and sub-national, local PHE
profiles?
Time: 20 min (10’ for discussion and
10’ for presentation)

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 Definition of Public Health
Emergency(PHE)
• PHEs are events or disasters that threaten the health of communities or
groups of people.

• PHEs usually requires substantial multi-sectoral assistance – not limited to

acute events.

• Events in PHEs may require the government to declare a state of public health
emergency

• PHEs can be categorized based on:

the onset/ duration of events or
the cause of the events
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 Classification of PHEs by onset/
duration of events
Environmental
Classification Disease events Economic events Political events
events
New/re-emerging Sudden Sudden fiscal Political events
disease event of a changes in event that forcing a sudden
climate changes available change in health
Sudden onset, and/or

sudden onset, and/or

affecting funding for health direction
expected shorter health, e.g.,
duration, e.g., COVID- floods, e.g., sudden e.g., a coup
duration

19 mudslides donor
withdrawal, oil
price shocks

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 Classification of PHEs by onset/
duration of events
Environment
Classification Disease events Economic events Political events
al events
New/re-emerging Longer term Progressive fiscal Political events
disease event of a onset of climate events changing leading to slow,
longer-term onset, change event available funding for sustained change in
Gradual onset, and /or

and/or expected long affecting health, health, e.g., health direction,

duration, e.g., NCD e.g., drought progressively e.g., inadequate
burden reduced donor leadership capacity
duration

confidence,

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 Classification of PHEs by cause

 Natural disasters/climate-related- caused by natural factors

 e.g. disease outbreaks, fire, floods, landslides, earthquake, cyclone

• Human-induced or man-made- caused due to the human activities

e.g. armed conflict/wars, structural collapse, transportation

accidents, fire accidents, industrial accidents

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 Classification of PHEs by cause …..

• Complex emergencies- are a multifaceted humanitarian crisis

in a country, region, or society where there is a total or
considerable breakdown of authority resulting from internal or
external conflict which requires a multi-sectoral international
response.
e.g. armed conflict and disease outbreak, drought and IDP

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 Impacts of PHE on Health System

Activity 1.2: Group discussion

1. Recall the health system building blocks and
share your views on how each block could be
impacted by PHEs/ shocks, if they are not
resilient?
2. Describe how to prevent and mitigate the
impacts of PHEs on health system building
blocks?
Time: 20 min (10’ for discussion and 10’ for
presentation)

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 Definition of Health System

 Health system consists of all organizations, people and actions

whose primary purpose is to promote, restore or maintain
health (WHO, 2010).

 It includes patients, families, communities, ministries of health,

health providers, and health financing bodies.
• Intrinsic aim of a health system is to protect and improve
health of the people;
• It is concerned with people's health
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 Definition of Health System…..

• A well-functioning health system is built on having;

Trained and motivated health workers
Reliable supply of medicines and technologies and well-
maintained infrastructure
Adequate and accessible funding
Timely and adequate health information
Evidence-based policies and plans – governance &
leadership
Delivering effective and affordable care
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 Health System Building Blocks (WHO)

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 Health System Building Blocks (WHO)…

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 Impacts of PHE on Health System

 Collapse of strategic health policy framework

 Leaders busy with fire fighting
 Lack of oversight function and coordination
Leadership  Inability to enforce health regulations & ensure
accountability
&
Governance

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 Impacts of PHE on Health System……
 Budget strain

 Diversion/reduction of funding

 Inadequate funds for maintenance of essential health

services
Health  Decreased affordability of healthcare service
Financing

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 Impacts of PHE on Health System……

 Collapse of system
 Inability to effectively monitor health
system performance
Health
Information
System

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 Impacts of PHE on Health System……

 Supply chain management breakdown

 Drug and supplies stock‐out
Medical  Looting, destruction, contamination of
products, medical items and infrastructure
vaccines and  Production of Poor-quality medical
technologies products

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 Impacts of PHE on Health System……
 Healthcare associated infection, illness,
disability & death
 Fatigue or burn-out
 Psychosocial stress or trauma
Health  Hardship from difficult working conditions
workforce
 Social effects(e.g. Stigmatization)
 Security risks (e.g. attack on health worker due
to community dissatisfaction)

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 Impacts of PHE on Health System……

 Impacts on mental health,

 Rise in morbidity and mortality
 Socio-economic impacts e.g. stigmatization,
Community food insecurity, financial hardship
 Environmental impacts e.g. destruction due
to disaster like earth quake

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 Impacts of PHE on Health System……

 Reduced access to health services due to

Health service
affordability, proximity
delivery
 Decreased availability and coverage
 Reduced public confidence or trust
 Reduced utilization of services
 Decreased quality of available service

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 Consequences of health services
disruption by PHEs
• Prolongation of the PHE and its direct consequences such as
increased fatality.
e.g. due to poor IPC and case management

• Excess mortality and morbidity due to other illnesses.

e.g. communicable (HIV, malaria etc.) and non-
communicable diseases (e.g. hypertension, mental health
disorders etc.)
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 Consequences of health services……

• Non-health impacts
Economic hardship from increased cost of accessing health care
due to the PHE.
E.g. Increased transportation cost to access health care that is
no-longer available nearby;
Social impacts
e.g. social disintegration of the society, social isolation, stigma,
etc.
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 Consequences of health services……

• The ability to withstand the shocks of PHEs by avoiding or

minimizing their potential impact and maintaining routine health
services is a demonstration of resilience in the health system

• Resilience is:
demonstrated during shock events,
built over time(ideally before PHEs strike) and
further developed based on experience and learning.
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 Section 2: Public Health Emergency
management(PHEM)

Activity 1.3: Self-Reflection

1. What is public health emergency
management?

Time: 5 min

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 Definition of PHEM

• PHEM is the process of

 anticipating,
 preventing,
 preparing for,
 detecting,
 responding to ,
 controlling and
 recovering from consequences of Public Health threats in order that health
and economic impacts are minimised;
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 Definition of PHEM…….

• It is having fully integrated, adaptable, all-hazards and all

health approach of national early warning, preparedness,
response and recovery with a starting and ending point

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 PHEM Vs IDSR

IDSR PHEM
• Mainly focus on Epidemic disease • Multi-hazard approach
• Surveillance data comes monthly • Surveillance data comes weekly
• Smallest reporting unit is Health • Smallest reporting unit is Health
Center post
• Week early warning system • Robust early warning system
• Delayed response
• Prompt response
• No recovery
• Recovery activities included
• No event based surveillance
• Event based surveillance
• Include only some DRM Component
• Includes all DRM components

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 Goal and objective of PHEM
Goal:
• The ultimate goal of PHEM
To reduce mortality and morbidity due to epidemics and
other PHEs and
minimize associated social and economic crisis.
Objectives
• The general objective of PHEM
To prepare for, detect early, and contain epidemics locally;
Respond timely to other public health emergencies and
Recover quickly from impacts of PHEs

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 Guiding Principles of PHEM

• Multi-Hazard-Approach:
evolved from a traditional communicable disease orientation
to a more modern multi-hazard approach

• Risk Assessment to Recovery

cover the entire cycle of an emergency or disaster; from
prevention, detection to response and recovery.

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 Guiding Principles of PHEM……

• Risk Assessment and Mitigation

Each and every level in the health system is required to
understand the health hazards and risks posed on their
population.

• International Health Regulation (IHR 2005):

The PHEM process considered and encompassed
international obligations that Ethiopia ratified.
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 Pillars of PHEM System

• There are four pillars of PHEM

Early warning and Surveillance;
 PHE Preparedness;
PHE Response and
 Recovery

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 Pillars of PHEM System…….
Institutional
framework

Vulnerability Assessment Public Health

and Risk Mapping Intelligence

Public Health
Planning Emergency Early Warning Communication
Preparedness

Capacity Monitor and Evaluate

Building

Monitor and
Rehearse
Public Health Emergency
Management

Outbreak investigation/Rapid
Assessment

Public Health Rehabilitation

Control and Prevention Emergency
measures Recovery
Response
Evaluation

Monitor and Contain

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 Pillars of PHEM System………

Risks to Public Health

- Need of the public to
Early Warning
be protected

Identified risks

Public Health Emergency

Preparedness
System, Supplies and
Trained HR
Identified
threats
Public Health Emergency
Reports/ Response
Data

Corrective Recovery
Actions

The public will be protected

from health consequences of
emergencies

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 Chapter Summary

• PHEs are events or disasters that threaten the health of

communities or groups of people.

• PHEs shocks categorized; based on the onset/ duration of

events or the cause.

• Disruption of H/S by PHEs result direct and indirect health and

non-health consequences.

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 Chapter Summary…

• Resilience is demonstrated during shock events, while it is built over

time.

• PHEM is the process of anticipating, preventing, preparing for, detecting,

responding to, controlling and recovering from consequences of public
health threats.

• The ultimate goal of PHEM will be

To markedly reduce mortality and morbidity
Minimize associated social and economic crisis
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 CHAPTER TWO

PHEM-Early warning and data management

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 Outlines

 Introduction to Public Health Surveillance

 Early warning system

 Priority diseases/conditions in Ethiopian public health surveillance system

 Surveillance Data Management

 Role of Laboratory in PHEs

 Chapter summary

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 Enabling Objectives

• By the end of this chapter, participants will be able to:

 Define public health surveillance

 Describe early warning and indicators of early warning

 Describe goal and uses of public health surveillance

 Explain cycle and types of public health surveillance

 Explain criteria for including a disease/an event under surveillance

 Describe priority diseases/conditions included in Ethiopian public health

surveillance system

 Describe importance and steps of surveillance data analysis and interpretation

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 Section 1: Introduction to Public Health
Surveillance
Activity 2.1. Self-Reflection
 How do you define public health
surveillance?
 Do you think disease surveillance is useful?
If yes, what are benefits of it?
 What types of surveillance do you know?
 Time allowed: 10 Minutes

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 Definition of surveillance

• Surveillance is derived from the French ‘Sur’ (over) ‘veiller’ (to

watch) - hence ‘to watch over’.

• Public health surveillance is an on-going and systematic health

data collection, compilation, analysis and interpretation for

public health action

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 Definition of surveillance…….

• Public health action can be;

Responding
Planning
Evaluation
Policy making

• “Information for Action”

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 Definition of surveillance…….

• Surveillance can be conducted globally, regionally (like East Africa),

nationally, or institutionally (single health facility-focused).

• Basic Principle- to serve as an “early warning system” – providing

timely information needed for action

• rapid reporting, confirmation, decision making and response

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 Critical Information in Surveillance

 Generally, a surveillance system should determine the:

 Who,
 What,
 When,
 Where, and
 How questions.

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 Critical Information in Surveillance…
• The critical information should include:
• Person: Age, sex
• Time: onset of disease, reporting period
• Place: woreda, region
• Risk factors
• Number of cases (magnitude)
• Treatment outcome: deaths, recovery (seriousness)
• Mode of treatment: inpatient/outpatient

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 Section 2: Early Warning System

Activity 2.2. Self-Reflection

 Do you know Early Warning? If Yes,

 What are the indicators of Early Warning?
 Time allowed: 10 Minutes

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 Early Warning System…….

• EW is the identification of a public health threat by closely and

frequently monitoring identified indicators and predicting the
risk it poses on the health of the public and the health system.

• It enable the provision of timely and effective information to

the public and to responders  allow preparing for effective
response or taking action to avoid or reduce risk

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 Early Warning System…….

• Major Indicators of EW include:

An increase in the number of cases beyond expected /occurrence
of outbreaks
Unexplained morbidity and mortality in human and animal
An increase occurrence of malnutrition cases (SAM, MAM, GAM)
Evidence of increase in zoonotic disease in animal and human
Evidence of increase in vector abundance of specific diseases etc.

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 Early Warning System…….

• To monitor threats, risks, signals and priority diseases and/or

conditions a PHE early warning system uses:
Community and event-based surveillance,
Indicator-based surveillance and
Sentinel surveillance system.

• As a basic principle of public health intelligence, all

components are given equal attention.
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 Early Warning System…….
Early Warning System

Community and Event-Based

Surveillance (CEBS) Indicator-Based Surveillance (IBS)

Media, rumor, community IDSR

concern, clinical concern,
sectorial information
Laboratory-Based
Surveillance (LBS)

Sentinel Surveillance System

(SSS)

Syndromic Disease
Surveillance (SDS)

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 Event-based surveillance (EBS)

 EBS is an ongoing active process  mainly for unstructured ad hoc

information (PHEs and events) at each structural level of the health
system.
 It is designed for early warning and rapid response
 A systematic monitoring of events, event assessment and verification,
and data dissemination
 The collection and collation of information that is processed in real time
 A reporting system without designated timeline or predefined structure

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 Event-based surveillance (EBS)…….

• It is an ongoing active community participation in the process of:

detecting
collecting
interpreting
notifying/reporting
responding
monitoring PHE, events and PH related risks in the community.
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 Event-based surveillance (EBS)…….

• Example of PHE, events and PH related risks in the community

Unusual and unknown occurrence of diseases or/and
conditions
cluster of cases and/or death of humans and animals that
may indicate PH hazards
rumors of unexplained death of humans and animals.

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 Indicator-based Surveillance(IBS)

• IBS is:
structured data collection through routine integrated
disease surveillance, nutritional and laboratory surveillance.
systematic (regular). E.gs.
Facility-based surveillance,
Sentinel surveillance system
Case-based surveillance and Syndromic surveillance
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 Indicator-based Surveillance(IBS)……

• Is a form of Indicator-Based Surveillance system

• Various surveillance activities become integrated into one system.

• Surveillance activities carried out using similar structures,

processes and personnel.

• It is a strategy for coordinating and integrating surveillance

activities by focusing on preparedness and response functions of
the disease surveillance system at all levels .
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 Integrated Disease Surveillance and
Response (IDSR)
• IDSR is a form of Indicator-Based Surveillance system in which the
various surveillance activities become integrated into one system
within the broader national health system.

• It emphasizes all functions of surveillance activities to be carried out

using similar structures, processes and personnel.

• It is also a strategy for coordinating and integrating surveillance

activities by focusing on preparedness and response functions of the
disease surveillance system at all levels.
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 Goal, use and cycle of public health
surveillance
Activity 2.3. Think/Pair/share
 What are Goals and uses of public health
surveillance?
 Time: 10Min (5min for the participant and
5min for discussion)

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 Goal of public health Surveillance

• Provide information that can be used for health action by

Public health personnel

Government leaders

The public guide public health policy and programs.

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 Uses of public health surveillance

• Estimate magnitude and scope of health problems

• Detect epidemics, health problems, changes in health behaviors

• Identify patients and their contacts for treatment and

intervention

• Measure trends and characterize disease

• Monitor changes in infectious and environmental agents

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 Uses of public health surveillance…..

• To identify changes in agents, host factors and health practices

• Assess effectiveness of programs and control measures

• Develop hypotheses and stimulate research

• Projections of future trends

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 Cycle of public health surveillance
Diagnosis / Detection

Reporting /
Evaluation Data Collection

Action!
Interpretation

Communicating Information
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 Cycle of public health surveillance

Healthcare providers:
Public health agencies: • Data collection
• Organize and analyze (reporting illnesses)
data Health care • Receive feedback
• Report results providers (sharing information)
(sharing information)

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 Types of public health surveillance

Activity 2.4. Self-Reflection

 What are the categories of public health
surveillance?
 What types of public health surveillance
do you know?
 Time allowed: 5 Minutes

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 Types of public health surveillance
• Categorized in to main types and modified forms of
surveillance.
• Main types include:
Passive Surveillance: A surveillance where reports are
awaited and no attempts are made to seek reports
Active Surveillance: public health officers seek reports from
participants in the surveillance system
Sentinel Surveillance: uses a pre-arranged sample of
reporting sources to report all cases of one or more
conditions, can be active or passive

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 Types of public health surveillance…

• Modified forms of surveillance during special events include:

Intensified Surveillance: The upgrading from a passive to an active
surveillance system for a specified reason and for a limited period
(could be because of an outbreak)
Enhanced Surveillance: The collection of additional data about
cases reported under routine surveillance
Syndromic surveillance: Focuses on one or more symptoms rather
than a physician-diagnosed or laboratory-confirmed disease
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 Priority Diseases and Conditions for
Surveillance system in Ethiopia

Activity 2.5: Group discussion

 Which disease do you think need to be under
surveillance?
 List diseases under Ethiopian surveillance
system?
 Time: 20min (10min fort the participants and
10min for discussion)

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 Criteria to include diseases/events
under surveillance
• Diseases/conditions which have:
high epidemic potential
required internationally under IHR2005
targeted for eradication or elimination
available effective control and prevention measures
significant public health importance

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 Criteria……….

prioritized as national priority through one health approach

availability of resources (human, financial and material)
Availability of required data

• Note: Region specific disease or events that have PH

importance which warrant surveillance can be added to their
surveillance system.

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 Priority diseases/conditions under
surveillance in Ethiopia
Immediately reportable diseases/conditions
1. Anthrax 12. Viral Hemorrhagic Fever (VHF)
2. Measles 13. Cholera
3. Human influenza caused by new subtype 14. Dracunculiasis (guinea worm)
4. Adverse events following immunization (AEFI) 15. Dengue fever
5. Neonatal s/ non neonatal tetanus 16. COVID-19
6. Rabies 17. Maternal death
7. Smallpox 18. Perinatal death
8. Severe acute respiratory syndrome (SARS) 19. Brucellosis
9. Yellow fever 20. Obstetric fistula
10. Poliomyelitis (acute flaccid paralysis) 21. Rift valley fiver
11. Chikungunya 22. Monkekpox
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 Priority diseases/conditions under
surveillance in Ethiopia
Weekly reportable diseases/conditions
23. Malaria 32. New HIV cases
24. Diarrhea with dehydration in children less than 5
33. Hypertension new cases
years of age

25. Acute jaundice syndrome within 14 days of illness 34. Diabetes new cases

26. Severe pneumonia in children under 5 years age 35.Tuberculosis

27. Dysentery 36. Moderate Acute Malnutrition
28. Relapsing Fever
29. Meningitis
30. Severe Acute Malnutrition (SAM)
31. Scabies

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 Section 3: Surveillance data analysis &
management

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 Surveillance data reporting periodicity

• Immediate Reporting: suspected cases of these diseases

should be notified from level to level within 30 minutes of
identification

• Weekly: Reporting of the total number of cases and deaths seen

within a week (Monday to Sunday) to the next level
 HF - Woreda – Zone – Region – EPHI (M-T-W-T until mid-day
respectively)
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 Surveillance data analysis and
interpretation
Activity 2.6. Think/Pair/share
 In your previous experience at health facility, have
you analyzed and interpreted surveillance data and
utilized or shared it for higher level officials?
 What is the importance of surveillance data
analysis and interpretation?
 Time: 10Min (5min for the participant and 5min
for discussion)

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 Surveillance data analysis and
interpretation…
• Is a crucial part that guides responses to PH emergencies.

• Analysis:
provides key information for taking prompt PH actions.
identifying outbreaks or potential outbreaks,
provides information for predicting changes of disease rates
over time and enables appropriate action.

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 Surveillance data analysis and
interpretation…….
• Analysis…
Provides information for improving prevention activities
identifies problems in the health system.
During an outbreak identifies the most appropriate and timely
control measures.
During an acute epidemic of a disease or condition 
identification of the most appropriate and timely control actions.

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 Surveillance data analysis and
interpretation……..
• Analysis…
provides information for improving prevention activities
identifies problems in the health system.
During an outbreak  identifies the most appropriate and timely
control measures.
During an acute epidemic of a disease or condition
identification of the most appropriate and timely control actions.

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 Surveillance data analysis and
interpretation…
• Data analysis and interpretation should be done daily and
weekly at each level (facility to national level)
• The type of data that is collected is defined by selected
indicators
• To be meaningful, a good indicator will be SMART

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 Counts, Ratios, Proportion, and Rates

• Count: is an enumeration of events of interest, such as the

number of affected individuals.
Used to quantify the burden of a condition
For allocating PH resources in a specific community setting.
commonly used in stable populations to describe trends
over time (e.g., in an outbreak situation using an epidemic
curve)
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 Counts, Ratios, Proportion, and Rates

• Ratios: A ratio results from a fraction whereby the numerator

is not included in the denominator.
are real numbers that can take values from 0 to infinity.
E.g. sex ratio or incidence rate ratios are commonly used in
epidemiology.

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 Counts, Ratios, Proportion, and Rates

• Rate: numerator/denominator x multiplication factor.

Numerator - is the number of health events that occurred
over a time period
Denominator - is the average number of subjects under
observation at risk during the same time period.
Rates are real numbers that can take values from 0 to
infinity.
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 Counts, Ratios, Proportion, and Rates

Epidemiological indictor Measure

Number of cases Count
Male- to -female ratio Ratio
Standardized mortality ratio (SMR) Ratio
Odds ratio Ratio
Case –fatality Proportion
Vaccine coverage Proportion
Incidence/prevalence rate Rate
Notification
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 Steps of Surveillance Data Analysis and
Interpretations
1. Preparation of data collection tools -
creating database or filed paper for data cleaning and data analyzing
and interpretation.
Is the major steps in data analysis

2. Collecting and organizing the data

Entering data on daily basis (electronic database or paper format) at
each level of the health system.
Make a backup - to avoid loss of electronically saved data
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 Steps of Surveillance Data Analysis…….

3. Data cleaning:
before starting analysis check if the data is complete.
If missing or part of the data is incomplete, try to get the
data before starting analysis

• Completeness = 𝑁𝑢𝑚𝑏 e 𝑟 of health facilities reported in that week x100

𝑇o 𝑡𝑎𝑙 𝑛𝑢𝑚𝑏 e 𝑟 of health facilities expected to report

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 Steps of Surveillance Data Analysis &
Interpretations…

4. Perform Data Analysis: By person, place, and time.

• The minimum data generated includes:

Trends over time (line graph, bar graph or histogram),
Geographic distribution of the disease or the outbreak (dot map),
Frequency of cases, deaths (table),
Case fatality rate (CFR),
Attack rate (AR)
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 Steps of Surveillance Data Analysis…..

• Note: File or store the information generated through data analysis in

an “analysis book”.
Analyze data by time: Time in day, week, month, and year.
To detect changes in the number of cases and deaths over time.
Helps to compare the current disease trend with previous
trends.
Enables you to see if thresholds are reached or not.

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 Steps of Surveillance Data Analysis &
Interpretations…
• Analyze data by place: gives information about where a
disease is occurring such as woreda, kebele, town, etc.
• Provides information on:
Clusters of cases occurring in a particular area
Spot locations of cases and identify populations at highest
risk
Travel patterns that relate to the method of transmission
Common sources of infection for the cases
The population distribution and population density of the
area, etc.

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 Steps of Surveillance Data Analysis &
Interpretations…
• Analyze data by person: Make a distribution of the cases by each of
the person variables in the reporting formats. E.g.,
Age group, sex,
occupation,
urban versus rural residence,
vaccination status,
risk factors,
outcomes and final classification
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 Steps of Surveillance Data Analysis &
Interpretations…
• Case Fatality Rate (CFR):
Indicate whether an outbreak is identified timely
Indicate whether the case-management is performed
properly
Identify the level of response to treatment
Indicate poor quality of care or no medical care
Compare the quality of case management b/n different areas
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 Steps of Surveillance Data Analysis &
Interpretations…
𝐶𝐹𝑅 = 𝑁𝑢𝑚𝑏 e 𝑟 of 𝑑 e 𝑎𝑡ℎ𝑠 f 𝑟 o 𝑚 𝑎 𝑠𝑝 e 𝑐 ifi 𝑐 di 𝑠 e 𝑎𝑠 ex100
𝑇o 𝑡𝑎𝑙 𝑛𝑢𝑚𝑏 e 𝑟 of 𝑐𝑎𝑠 e 𝑠 f 𝑟 o 𝑚 𝑡ℎ𝑎𝑡 specific disease

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 Steps of Surveillance Data Analysis &
Interpretations…
• Attack Rate (AR): Calculate on weekly basis during an epidemic.

• AR helps to:

calculate the resources needed to respond to the epidemics

evaluate if the threshold is reached

to know the speed of dissemination of the disease

• 𝐴𝑡𝑡𝑎𝑐𝑘 𝑟𝑎𝑡e = 𝑁𝑢𝑚𝑏 e 𝑟 of 𝑛 ew 𝑐𝑎𝑠 e 𝑠 𝑑𝑢𝑟 i 𝑛𝑔 𝑠𝑝 e 𝑐 ifie 𝑑 𝑝 e 𝑟 io 𝑑 𝑥 100

𝑁𝑢𝑚𝑏e 𝑟 of 𝑠𝑢𝑠𝑐 e 𝑝𝑡 i 𝑏𝑙 e 𝑝 e 𝑟𝑠 o 𝑛𝑠

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 Steps of Surveillance Data Analysis &
Interpretations…

5. Interpret the analyzed Data:

• Compare current situation with previous week/months/quarter,

seasons and years:
Observe the trends on the line graphs.
Is the AR the same, higher, or lower than it was in the previous
months?
Determine if thresholds for action have been reached or crossed.
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 Steps of Surveillance Data Analysis &
Interpretations…
• Thresholds: are markers that indicate when something should
happen or change.
Help surveillance and program managers answer the
question,
“When will you take action? and what will that action be?”

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 Steps of Surveillance Data Analysis &
Interpretations……
• Thresholds are based on information from two different
sources:
• A local situation analysis for the specific disease or condition
describing:
who is at risk for the disease?
what are the risks?
when is action needed to prevent a wider epidemic?
where do the diseases usually occur?
• International recommendations from technical and disease
control program experts

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 Steps of Surveillance Data Analysis &
Interpretations…
• Two types: alert threshold and an action threshold
An alert threshold: suggests to health staff that further investigation
is needed and preparedness activities should be initiated.

• Health staffs respond to an alert threshold by:

Reporting the suspected problem to the next level
Reviewing data from the past
Requesting laboratory confirmation

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 Steps of Surveillance Data Analysis &
Interpretations…
• Being more alert to new data and the resulting trends in the
disease or condition

• Investigating the case or condition,

• Prepositioning of drugs and supplies,

• Mobilization of the needed resources,

• Alerting the appropriate disease-specific program manager and

woreda epidemic response team to a potential problem
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 Steps of Surveillance Data Analysis &
Interpretations…
• An action threshold: triggers a definite response.

• The finding signal the need for action beyond confirming or clarifying
the problem. Possible actions include:
communicating lab confirmation results to concerned health
facility,
implementing an emergency response such as immunization,
community awareness campaign, or improved infection control
practices in the health care setting etc
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 Steps of Surveillance Data Analysis &
Interpretations…
Home take assignment

• Read the threshold levels for declaring an epidemic for diseases

under surveillance.
(Alert threshold, Action thresholds and Acceptable case
fatality rate)

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 Steps of Surveillance Data Analysis &
Interpretations…
6. Summarize the analysis results

• Consider the analysis results with the following factors in mind:

Trends for inpatient cases describe the most severe cases of
a particular disease;
generally only severe cases are hospitalized.
Deaths are most likely to be detected for cases that are
hospitalized
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 Steps of Surveillance Data Analysis &
Interpretations…
Summarize the analysis results…

• Increases and decreases may be due to factors other than a true

increase or decrease in the number of cases and deaths being
observed. E.g.,
Large population movements
changes in health services can affect disease pattern.

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 Steps of Surveillance Data Analysis &
Interpretations…
Summarize the analysis results…

• If no decrease is occurring while undertaking appropriate

health intervention, consider whether any of the following
factors are affecting reporting:
Change in the number of health facilities reporting
Change in the case definition

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 Steps of Surveillance Data Analysis &
Interpretations…
Summarize the analysis results…

• Seasonal variation

• Community outreach or health education activities

• Recent immigration or emigration to the area or increase in

refugee populations

• Change in the quality of services being offered at the facility.

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 Steps of Surveillance Data Analysis &
Interpretations…
Activity 2.7: Group Exercises
Objective: Able to perform surveillance data analysis and interpretation

Instruction:

 Be in group of 3-4 people, read the scenario below and answer the questions
on the next slide.
Scenario: In X woreda there are two kebeles with the equal number of
populations. The first kebele (Kebele - Y) population consists of 1,000 people;
300 of these people have the Ebola virus disease, 100 of whom die from the
disease. The second kebele (Kebele - Z) catchment population also has 1,000
people; 50 people have the Ebola virus disease and 40 die from it. See the table
on the next slide:

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 Steps of Surveillance Data Analysis &
Interpretations…

Activity 2.7: Group Exercises…

Indicators Kebele - Y Kebele – Z

Male Female Total Male Female Total

Total population 600 400 1000 550 450 1000

# Of EVD cases 190 110 300 33 17 50

# Of people died due to EVD 48 52 100 25 15 40

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 Steps of Surveillance Data Analysis &
Interpretations…

• Group exercise questions:

 What is the mortality rate of Ebla virus diseases in each kebele?

 What is the case fatality rate of Ebola virus disease in each kebele?
 In which kebele the incidence or attack rate of Ebola virus disease is higher?
Explain
 Calculate sex specific mortality rate and attach rate for both kebeles’
 How do you interpret the sex specific attack rate and mortality rate?
 In which kebele the severity of Ebola virus disease is higher? Explain
• Time: 25min (10min for the discussion and 15min for presentation for all groups)

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 Section 4: PHS-Case definition

Activity 2.8: Group discussion

 What is Case definition?
 What is standard case definition?
 What is Community case definition?
 Which one is very sensitive? (standard Vs
Community Case definition)
 Time: 10min

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 PHS-Case definition……
• Case definition is:
A uniformly applied set of criteria for deciding whether to
classify a person as having a particular disease, injury, or
other health related condition
• Standard case definition:
Is a case definition that is agreed upon to be used by
everyone with the country
Suspected
Probable
Confirmed

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 PHS-Case definition….

• Most IDSR case definitions are “tiered” based on certainty of

diagnosis (suspect vs. confirmed; possible-probable-confirmed)

• Individual countries can modify the case definitions or adapt

them to their guidelines (as Ethiopia has done with PHEM)

• You can review these case definitions on your own in the PHEM
Guidelines handbook

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 PHS-Case definition…..

Classification of case definitions

• Confirmed case:
Events that are confirmed by laboratory assessment

• Probable case:
Events that are compatible upon clinical assessment

• Suspected case:
Events that can possibly be cases if they are investigated
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 PHS-Case definition…..

Confirmed

Mo
re
inc
in
ta

lus
Probable
er

ive
c
re
Mo

Suspect or Possible

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 Some priority disease case definition

Anthrax Case definition

• Suspect cases:
Cutaneous form: Any person with skin lesion evolving over 1 to 6
days from a popular through a vesicular stage, to a depressed black
eschar invariably accompanied by edema that may be mild to
extensive
Gastro-intestinal: Any person with abdominal distress
characterized by nausea, vomiting, anorexia and followed by fever
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 Case definition …….

• Anthrax Suspected cases

 Pulmonary (inhalation): any person with brief prodromal resembling acute

viral respiratory illness, followed by rapid onset of hypoxia, dyspnea and high
temperature, with X-ray evidence of mediastina widening

 Meningeal: Any person with acute onset of high fever possibly with
convulsions, loss of consciousness, meningeal signs and symptoms; commonly
noted in all systemic infections, but may present without any other clinical
symptoms of anthrax AND has an epidemiological link to confirmed or
suspected animal cases or contaminated animal products
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 Case definition …….

Anthrax confirmed

• A confirmed case of anthrax in a human can be defined as a

clinically compatible case of cutaneous, inhalational or
gastrointestinal illness that is laboratory-confirmed by:
1. Isolation of B. anthracis from an affected tissue or site; or
2. Other laboratory evidence of B. anthracis infection based on
at least two supportive laboratory tests
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 Case definition …….

Measles suspect

• Any person with fever and maculopapular (nonvesicular)

generalized rash and cough, coryza or conjunctivitis (red eyes)

Confirmed:-

• any person in whom a suspected case with laboratory

confirmation (positive IgM antibody) or epidemiological link to
confirmed cases in an outbreak
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 Case definition …….

Chikungunya

• Suspect: Any person with acute onset of fever >38.5°C and

severe arthralgia/arthritis not explained by other medical
conditions

• Confirmed:- A suspected case with laboratory confirmation

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 Case definition …….

Adverse Events Following Immunization (AEFI)

• Suspect:-Any untoward medical occurrence which follows

immunization and which does not necessarily have a causal
relationship with the usage of the vaccine.

• The adverse event may be any unfavorable or unintended sign,

abnormal laboratory finding, symptom or disease

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 Case definition …….
Neonatal Tetanus/Non Neonatal Tetanus (NNT)
• Suspect:
Neonatal Tetanus: Any newborn with a normal ability to
suck and cry during the first two days of life, and who,
between the 3rd and 28th day of age, cannot suck normally,
and becomes stiff or has convulsions or both.
Non-Neonatal Tetanus: Any person > 28 days of age with
acute onset of one of the following: lockjaw, sustained spasm
of the facial muscles, or generalized muscle spasms.
• Confirmed:-No laboratory confirmation recommended.

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 Case definition …….

Maternal Deaths

• Suspect:- Death of a woman of reproductive age (between 15-49 years of age)

plus at least one of the following screen Died while pregnant OR Died within
42 days of termination of pregnancy OR Missed her menses before she died

• Confirmed:-The death of a woman while pregnant or within 42 days of the

end of pregnancy (irrespective of duration and site of pregnancy), from any
cause related to or aggravated by the pregnancy or its management but not
from accidental or incidental causes

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 Case definition …….

Perinatal death

• Suspected perinatal death

 “Probable perinatal death” plus the following” Birth after 7 months of

pregnancy and New-born dead at the time of birth OR Death within 28
days of delivery Seven months of pregnancy is to be determined by:
Maternal report or Anyone who knows her duration of pregnancy or GA
of 28 weeks or 196 days starting from the first date of the last normal
menstrual period (LNMP)
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 Case definition …….

Perinatal death

• Probable:-The birth of a dead fetus or death of a new-born

• Confirmed :-A perinatal death is defined as the death of a baby

of at least 28 weeks of gestation and/or 1,000 g in weight and
early neonatal death (the first seven days after birth)

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 Case definition …….

Cholera

• Suspected :-In areas where a cholera outbreak has not been declared:
Any patient aged two years and older presenting acute watery diarrhea
and severe dehydration or dying from acute watery diarrhea.

• In areas where a cholera outbreak is declared: any person presenting or

dying from acute watery diarrhea.

• Confirmed:- A suspected case with Vibrio cholerae O1 or O139

confirmed by culture
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 Case definition …….

Dracunculiasis (Guinea Worm)

• Suspect:-A person presenting a skin lesion with itching or

blister living in an endemic area or risk areas for Guinea worm,
with the emergence of a worm.

• Confirmed:- the worm is confirmed in laboratory

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 Case definition …….

Rabies

• Suspect:- A person with one or more of the following:

headache, neck pain, nausea, fever, fear of water (hydrophobia),
pharyngeal spasms, aerophobia, anxiety, agitation, abnormal
tingling sensations or pain at the wound site, when contact with
a rabid animal is suspected.

• Conformed:- A suspected case confirmed by lab

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 Case definition …….

Smallpox

• Suspect:-An illness with acute onset of fever >38 0 C followed

by a rash characterized by vesicles or firm pustules in the same
stage of development without other apparent cause.

• Confirmed:-A suspected case with laboratory confirmed

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 Case definition …….

SARS

• Suspect:-An individual with: A history of fever, or documented fever ≥ 38 °C

AND One or more symptoms of lower respiratory tract illness (cough, difficulty
breathing, shortness of breath) AND Radiographic evidence of lung infiltrates
consistent with pneumonia or ARDS or autopsy findings consistent with the
pathology of pneumonia or ARDS without an identifiable cause AND No
alternative diagnosis can fully explain the illness.

• Confirmed:-An individual who tests positive for SARS-CoV infection by the WHO
recommended testing procedures
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 Case definition …….

Yellow fever

• Suspected:-
A person with acute onset of fever followed by jaundice within two
weeks of onset of first symptoms. Hemorrhagic manifestations and renal
failure may occur.

• Confirmed:-
A suspected case with laboratory confirmation (positive IgM antibody
or viral isolation) or epidemiologic link to confirmed cases or epidemics

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 Case definition …….

Poliomyelitis (Acute flaccid paralysis)

• Suspect:-
Any child under 15 years of age with acute flaccid paralysis or
any person with paralytic illness at any age in whom the
clinician suspects poliomyelitis.

• Confirmed:- A suspected case with virus isolation in stool.

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 Case definition …….

Dengue Fever

• Suspect: - Any person with acute febrile illness of 2-7 days duration
with 2 or more of the following: headache, retro-orbital pain,
myalgia, arthralgia, rash, hemorrhagic manifestations, leucopenia.

• Confirmed Case: A suspected case with laboratory confirmation

serum specimens, positive PCR or Isolation of the dengue virus
using cell culture

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 Case definition …….

Severe Pneumonia

• Suspected: A child presenting with cough or difficult of

breathing and any general danger sign, or chest in-drawing or
stridor in a calm child.

• Confirmed: Radiographic or laboratory confirmation of

pneumonia may not be feasible in most districts

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 Case definition …….
Diarrhea with Dehydration in Children
• Suspect:- Passage of three or more loose or watery stools in
the past 24 hours with or without dehydration and:
 Some Dehydration: two or more of the following signs:
restlessness, irritability; sunken eyes; thirsty; skin pinch
goes back slowly, or
Severe Dehydration: two or more of the following signs:
lethargy or unconsciousness; sunken eyes; not able to drink
or drinking poorly; skin pinch goes back very slowly.
• Confirmed:- Suspected case confirmed with stool culture for a
known enteric pathogen
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 Case definition …….

Tuberculosis

• Suspected:-Any person with a cough of 3 weeks or more.

• Confirmed:-Smear-Positive Pulmonary TB a suspected patient

with at least 2 sputum specimens positive for acid-fast bacilli
(AFB), or one sputum specimen positive for AFB by microscopy
and radiographic abnormalities consistent with active PTB

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 Case definition …….
Diabetes New cases
• Suspected:- Any person presenting the following symptoms:
(a) Increased thirst (b) Increased hunger (c) Frequent urination
• Confirmed:- Any person with a fasting 6.1 mmol/L (110 mg/dl)
Or venous plasma glucose measurement of ≥ 7 mmol/L (126
mg/dl) or capillary glucose ≥ 6.1 mmol/L (110 mg/dl) OR Any
person with a non -fasting glucose ≥ 11.1 mmol/L (200mg/dl)
Or venous plasma glucose measurement of ≥ 11.1mmol/L (200
mg/dl

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 Case definition …….
Hypertension New cases
• Suspected new case at first visit:- Any individual presenting
with a resting blood pressure measurement (based on the
average of 3 readings) at or above 140 mm Hg for systolic
pressure, or greater than or equal to 90 mm Hg for diastolic
pressure.
• Confirmed:-Any individual presenting on at least two occasions
with a resting blood pressure measurement (based on the
average of 3 readings) at or above 140 mm Hg for systolic
pressure, or greater than or equal to 90 mm Hg for diastolic
pressure

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 Case definition …….

Obstetric Fistula

• Obstetric Fistula Suspected:- Community case definition plus at least

one of the following: Duration of labor for more than 24 hours
Delivered at home Index delivery is still borne Primi-para

• Confirmed:-Suspected case definition plus at least one of the

following: The fistula felt with digital vaginal examination The fistula
is visualized with speculum examination of the vagina Dye test is
positive
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 Case definition …….
Brucellosis
• Brucellosis suspect:- An acute or insidious onset of fever and
one or more of the following: night sweats, arthralgia,
headache, fatigue, anorexia, myalgia, weight loss,
arthritis/spondylitis, meningitis, or focal organ involvement
(endocarditis, orchitis/epididymitis, hepatomegaly,
splenomegaly).
• Probable:- Suspected case with one of the following
Epidemiologically linked to a confirmed human
• Confirmed:-Suspected case with definitive laboratory evidence
of Brucella infection
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 Case definition …….
Chemical poisoning
• Suspected case: A case in which a potentially exposed person
is being evaluated by health-care workers or public health
officials for poisoning by a particular chemical agent or
radiological hazard, but no specific credible threat exists.
OR
• A person who has contact or exposure with a particular
chemical agent or radiological hazard (by working, visiting,
utilizing) and showing any sign and symptoms, but no specific
credible threat exists.

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 Case definition …….

Chemical poisoning

• Probable case: One in which a person has an illness that is clinically

compatible with poisoning from a particular chemical agent or
radiological hazards and in which a credible threat exists

OR

• One in which epidemiologic data link the person to a confirmed case

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 Case definition…….

Chemical poisoning

• Confirmed case: Case in which a suspected or probable case of exposure has

been substantiated with laboratory testing of environmental or biological
specimens.

OR

• The case can be confirmed if laboratory testing was not performed because
either a predominant amount of clinical and nonspecific laboratory evidence of
a particular agent was present or a 100% certainty of the etiology of the agent
is known
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 Case definition …….
Rift Valley Fever
• Suspect:- A person presenting with fever and either myalgia,
arthralgia, or headache OR a person presenting with unexplained
encephalitis, hemorrhage, hepatitis, ocular pathology (retinitis), or
renal failure with or without fever and has been in the last 6 days in
an area where RVF is known to occur or has been reported.
• Probable:- A suspected case with a history of close contact with an
RVF affected ruminants (Cow, goat and sheep) during the previous 6
days.
• Confirmed:- A suspected or probable case with laboratory
confirmation either by ELISA showing the presence of anti-RVFV
IgM or by RT-PCR.
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 Section 5: Role of laboratory during
PHEM
Activity : Self-Reflection
 What are the roles of laboratories in
public health surveillance?

Time: 5 Min

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 Role of laboratory during PHEM

• Laboratories play a critical role in all disease control and

prevention programs

• Laboratory-based surveillance is the key part of overall surveillance

• The detection and control of outbreaks requires rapid identification

of the pathogens and their source of infection.

• Well-functioning and sustainable laboratory services are essential

for strong health systems and crucial for improving public health.

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 Role of laboratory during PHEM…..

• Public health laboratories perform core public health and

environmental activities including

• public health reference tests,

• disease prevention, control and surveillance

• population-based interventions

• communication with healthcare providers on patient care

• Emergency response efforts.

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 Role of laboratory during PHEM……

• The objectives of laboratory-based surveillance

• To strengthen the existing laboratory-based surveillance

• To determine the baseline & monitor the circulating pathogenic

agent

• To detect emerging pathogen strains

• To detect impeding outbreaks and outbreaks of infectious

diseases
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 Laboratory structural levels

Activity . Think/Pair/share
 What are the reasons for unavailability
sustainable and consistent laboratory service at
all level?
 Discus and explain the category of laboratory by
level in Ethiopia?
Time: 10Min

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 Laboratory structural levels….

• Reasons for the absence of sustainable laboratory service

Some tests need laboratories equipped with
Sophisticated equipment
Qualified professionals and
properly managed working environment
The absence/weak maintenance service.
Lack of equipment and supplies
Financial constraints
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 Laboratory structural levels……

Laboratories in Ethiopia are categorized into four structural levels

ranging from the community to national.

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 Specimen collection and referral

Activity : Group discussion

 Explain the type of samples collected for
diseases under surveillance in Ethiopia?
Time allowed: - 10 minutes

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 Specimen collection and referral…

• The laboratory confirmation for most of diseases under

surveillance can be performed at regional levels.

• Samples of a few diseases should come to the national

laboratory to be examined or sent to advanced laboratories

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 Specimen collection and referral…

AFP
Neonatal tetanus
• Causative agent - Polio virus
• Specimens – • Causative agent – C.tetani
A. Stool
B. Rectal swab • Specimens – Whole blood
C. Serum
• Laboratory test –
• Laboratory test –
1.Cell culture(A and B) 1.ELISA
• Referral to – EPHI(1)
• Referral to – EPHI(1)
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 Specimen collection and referral…

Anthrax

• Causative agent - B. anthracis

• Specimens – (Blood, Stool, CSF, Nasal swab, Sputum , Ascetic

fluid, Peritoneal fluid, Swab from cutaneous vesicular lesion)

• Laboratory test – (1.Cell culture, 2. Polychrome methylene blue,

3.ELISA, 4.Culture, 5.PCR)

• Referral to – EPHI(1,4) Regional laboratory (1) Hospital (1)

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 Specimen collection and referral…….
Avian human influenza(AHI)
• Causative agent - AHI virus type A
• Specimens –
A. Oropharyngeal swab/lavage
B. Throat swab
• Laboratory test – (1.Tissue Cell culture, 2.IFA, 3.PCR,
4.Serological test (Hemagglutination inhibition & micro
neutralization)
• Referral to – EPHI(1)

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 Specimen collection and referral…….
Cholera
• Causative agent - Vibrio cholera O1 & O39
• Specimens –
A. Stool
B. Rectal swab
C. Water
• Laboratory test –
1.Stool culture(A and B), 2.Rapid test(A) , 3.PCR(from micro-
isolates)
• Referral to – EPHI(1,2 and 3), Regional Labs (1, 2) Hospitals (2)
Health Centers (2)
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 Specimen collection and referral…….

Measles

• Causative agent – Measles virus

• Specimens - Whole blood Serum, Urine ,

Throat/nasopharyngeal swab and Saliva

• Laboratory test – 1.Serological (ELISA)

• Referral to – EPHI(1)

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 Specimen collection and referral…….

Pandemic influenza (H1N1)

• Causative agent – H1N1 Influenza virus

• Specimens - Throat swab

• Laboratory test – 1.Real time PCR, 2.Rapid influenza antigen,

3.IFA, 4.Cell culture

• Referral to – EPHI(1)

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 Specimen collection and referral…….

Rabies
• Causative agent – Rabies virus
• Specimens – Saliva, Neck biopsy Serum, CSF, Brain biopsy
• Laboratory test – 1.Real time PCR, 2.IFA, 3. Viral neutralization
• Referral to – EPHI(2)

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 Specimen collection and referral…….

SARS
• Causative agent – Coronavirus (SARS-Cov)
• Specimens – Throat swab
• Laboratory test – 1.Serological test (antibody test), 2.Cell culture,
3.Real time PCR
• Referral to – EPHI(3)

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 Specimen collection and referral…

Yellow fever

• Causative agent – Yellow fever Virus (Flavivirus)

• Specimens – Serum Blood Liver tissue

• Laboratory test – 1.Antibody neutralization, 2.IgM

capture ,3.PCR

• Referral to – EPHI(1)

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 Specimen collection and referral…..

Viral hemorrhagic fever (VHF)

• Causative agent – Arbovirus, Arenavirus, Marburgvirus, Ebola virus,
Hantavirus , Dengue fever
• Specimens – Blood Serum

• Laboratory test – 1.Reverse passive hemaglutination (RPHA), 2.Tissue

culture, 3.Cell culture, 4.ELISA for Ag/Ab , 5.Immunochemistry,
6.Histochemistry,7.Real Time PCR
• Referral to – EPHI(3)
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 Specimen collection and referral…..

Dysentery

• Causative agent – A.E. histolytica, B.Bacillary dysentrae

• Specimens – Stool

• Laboratory test – 1.Microscopy(A), 2.Bacterial Culture(B)

• Referral to – EPHI(1,2) Regional Labs(1, 2) Hospitals (1,

partially 2) , Health center (1)

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 Specimen collection and referral…..

Malaria

• Causative agent – Plasmodium species

• Specimens – Blood ,Serum ,plasma

• Laboratory test – 1. Microscopy, 2. RDT

• Referral to –All health facilities except health post (1 and 2)

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 Specimen collection and referral…..
Meningitis
• Causative agent – N. meningitides , S. Pneumonia, H. Influenza
and E. coli
• Specimens – A. CSF, B. Blood
• Laboratory test – 1.Gram stain (A), 2.Bacterial Culture (A,B),
3.Latex agglutination(A)
• Referral to –EPHI (1,2, 3), Regional Labs (1,2, 3), Hospitals (1,
partially 2,
• 3) and Health centers (1)

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 Specimen collection and referral…..

Relapsing fever

• Causative agent – Borrelia recurrentis

• Specimens – Blood

• Laboratory test –1. Microscopy

• Referral to –All health facilities except health posts (1)

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 Laboratory Safety Considerations

• What type of samples to collect

• What method(s) to use to collect the samples

• How to store the samples

• Which laboratory can receive and test the samples

• How to pack, label, and ship the samples

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 Chapter Summary

• A PHE early warning system uses a community and event-based

surveillance, indicator-based surveillance and sentinel
surveillance system to monitor threats, risks, signals and priority
diseases and/or conditions

• Public health surveillance can be defined as “information for

action”.

• The main function of public health surveillance is to serve as an

“early warning system”
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 Chapter Summary…..

• There are different types of public health surveillance

• In Ethiopia there are diseases which are reported immediately

and some diseases which are reported weekly.

• Surveillance data analysis and interpretation is a crucial part that

guides responses to public health emergencies.

• Laboratories play a critical role in all disease control and

prevention programes
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 CHAPTER THREE

PHEM-Preparedness and Capacity Building

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 Outline

• Introduction to public health emergency preparedness

• Coordination and collaboration

• Vulnerability risk assessment and mapping (VRAM)

• Emergency preparedness response plan (EPRP)

• Capacity building

• Summary

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 Enabling Objectives

• By the end of this chapter, participants will be able to:

Describe what is the public health emergency Preparedness
Elaborate Vulnerability risk assessment and mapping (VRAM)
Elaborate Emergency Preparedness Response Plan (EPRP)
Demonstrate capacity building
Describe monitoring and evaluation
 Describe public health coordination and collaboration
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 Section 1: Introduction to preparedness

Activity 3.1. Self reflection

 What is public health emergency
preparedness?
 What are the objectives of public health
emergency preparedness?
 What are the activities during public health
emergency preparedness?
 Time: 20min (10min fort the participants and
10min for discussion)
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 Introduction to preparedness

• Preparedness consist of
Coordination and collaboration
 VRAM
 EPRP
 Capacity building
 Monitoring and evaluation

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 Introduction…….

• Preparedness is defined as “the range of deliberate, critical tasks

and activities necessary to build, sustain, and improve the
operational capability to prevent, protect against, respond to,
and recover from incidents”.

• Preparedness activities and tasks are those things that should

be done prior to the occurrence of emergency.

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 Introduction…….
• Development of plans, procedures, protocols, and systems;
establishment of mutual aid agreements; provision of training;
and the conduct of exercises are among other preparedness
tasks.
• Preparedness is a responsibility shared by all level of
government, private sector, institutes and professional
association
• All activity during preparedness should be monitored and
evaluated according to plan

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 Introduction…….
• The main aim of health emergency preparedness:
• Preventing avoidable crisis and catastrophes
• Reducing morbidity and mortality effects
• Minimizing disruption to health services
• Availing resources
• Prepare HSCP
• Maintaining business continuity as far as possible
• Reducing disruption to society as much as possible

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 Introduction…….

• The PHE preparedness capabilities:

Putting in place the necessary logistics and funding
Building the essential systems specific to protection,
prevention and response
Equipping public health personnel and respondents with the
necessary knowledge and tools.

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 Introduction…….

• The PHE preparedness capabilities:

Educating public on prevention and control measures.
Infrastructure development and resilience activity
Documenting findings and knowledge sharing for
anticipation and responding further emergencies

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 Introduction…….

• Preparedness consist of
Coordination and collaboration
 VRAM
 EPRP
 Capacity building
 Monitoring and evaluation

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 Section 2: Coordination & Collaboration

Activity 3.2: Group discussion

 What is Coordination?
 Why we need Coordination & Collaboration
during emergency?
 Time: 10min

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 Coordination & Collaboration

Strong Coordination, why?

Natural and man made incidents present special
circumstances, unusual events,
It is a cross cutting issues
Hazards are not limited to specific sectors

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 Coordination & Collaboration…..

• A single sector/partner can’t manage a given hazards

• Coordination and Collaboration in disaster reduction are

essential and critical

• We need to pull together and network our strengths and

capacities, share available resources

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 Coordination & Collaboration…..
• Activities during Coordination & Collaboration:
Mapping all relevant stakeholders
 Develop ToR/MoU and sign up
 Assign Chair, deputy chair and Secretary
Regular meeting
 Keep the list of expert and update yearly
 Establish a coordination/collaboration mechanism like TWG
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 Coordination & Collaboration…..

• Activities during Coordination & Collaboration:

Conduct orientation/capacity building for stakeholder’s
experts
 Follow the activity based on ToR.
Monitor and evaluate participation and implementation as
per the TOR and or MOU.

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 Coordination & Collaboration…..

• Activities during Coordination & Collaboration:

Report the level of preparedness to the next higher level
and share with all stakeholders regularly
Organize a Rapid Response Team (RRT), Incident
Management Team (EMT) to initiate activities at the time of
incident
Review membership, TOR or MOU as per the findings
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 Coordination and Collaboration …

Stakeholders to be engaged in PHE (depend on the event)

Industry • Minster of Health/EPHI
 Sub city health office • Hospitals
 Agriculture/Abattoirs
• Justice/Police
 Social and Labour affairs
 Environment and Climate change
• Water and sewerage
 Laboratory Institution • Bureau other departments
 Health Regulatory • Universities
 Health bureau • Investment
 Transport sector • Partners,etc
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 Section 3: Vulnerability Risk
Assessment and Mapping (VRAM)

Activity 3.3: Group discussion

• Activity 2.1. self reflection
• What is Hazard
• What is Risk
• What is Vulnerability
• What is coping capacity
• What is the importance of VRAM?
• Share your experience on VRAM?
• Time: 10 Min

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 VRAM

• Risk can be measured

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 VRAM…….

Hazard:
• Any dangerous situation or phenomenon which has a potential to
cause damage, loss or injury to human, property or environment

Classified as: • Depending on speed of onset

• Depending on origin Rapid
 Geological
Slow
 Hydro-meteorological • Depending on Cause
 Biological Natural
 Socio-economic
 Technological Human induced
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 VRAM…….

Vulnerability Definition

• Is the characteristics and circumstances of a community,

system, or asset that make it susceptible to the damaging effects
of a hazard

• Describes two aspects of the subject:-

Susceptibility
Resilience
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 VRAM…….

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 VRAM…….

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 VRAM…….

Vulnerabilities

• Pre-existing conditions

• Much more determined by human behavior than Hazards

• Varies across geographic space and among and within social

groups

• Scale dependent (individual, household, region, country, etc.)

• Dynamic (change over time)

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 VRAM…….

Vulnerability Assessment and Risk Mapping:

• One of the pre emergency activities of preparedness

• Vulnerability assessment is a continuing, dynamic process of

assessing hazards and risks that threaten the population and the
health system and determining what can be done about it

• Done periodically to predict and be prepared to mitigate the

problems which come as a result of them
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 VRAM…….

Vulnerability Assessment and Risk Mapping:

• It is the process of determining and ranking of the risk level of frequently

existing hazards

• Risk & Vulnerability assessment is part of risk management; it is a

systematic process for;
Gathering, assessing and documenting
Assigning a level of risk,
taking action to manage and reduce the negative consequences of public
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 VRAM…….

A vulnerability assessment provides:

• A means to inform decision-makers about the needs of preparedness at

different levels;

• A starting point to construct an overall plan that corresponds to the

dimensions of identified risks.

• A tool to initiate the public health emergency preparedness planning;

• can also help to measure the levels of preparedness or unpreparedness;

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 VRAM………

Risk

• Risk is defined as a product of the likelihood of the occurrence

of a given hazard (epidemic disease, drought, flood, etc.)

• Disaster Risk: potential disaster losses in lives, health status,

livelihoods, assets and services, which could occur to a
particular community or a society over some specified future
time period
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 VRAM………

• Disaster: A serious disruption of the functioning of a

community or a society involving widespread human, material,
economic or environmental losses and impacts, which exceeds
the ability of the affected community or society to cope using
its own resources

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 VRAM……….

Disaster Risk Assessment

• A methodology to determine
The nature and extent of risk by analyzing potential hazards
and evaluating existing conditions of vulnerability that
together could potentially harm exposed people, property,
services, livelihoods and the environment on which they
depend
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 VRAM……….

• Risk Analysis: is the process of computing the level of risk by bringing

together the various attributes that contribute to the reduction or
amplification of risk from a given hazard to individuals and
communities

• Risk mapping of exposure and vulnerability including the physical,

social, health, economic and environmental dimensions; and the
evaluation of the effectiveness prevailing and alternative coping
capacities in respect to likely risk scenarios
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 VRAM……….

Risk analysis:

• It is a combined effort of identifying, analysing, quantifying and

prioritizing the potential events that may negatively impact
individuals, institution and/or the environment to implement
reduction measures

• The purpose of conducting risk analysis is to plan for the

identified risks and to take mitigation measures
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 VRAM……….

• Public health risk mapping is a graphical representation of specific

adverse health effects the population of a community or geographical
zone might experience as a result of exposure to a hazard.

• It helps inform and communicate to policy makers and other

stakeholders a better understanding of the geographical distribution
of hazards and the country’s public health risk profile; and facilitates
prioritization in planning for response interventions.

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 VRAM……….

• Risk mapping involves:

hazard analysis
identification hazards
risk analysis
understand the likelihood and consequences of these hazards
occurring
Identify ability to cope in the various geographic zones of the
country.
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 VRAM……….

• Vulnerability Assessment:
It is continuous, dynamic process of assessing hazard and
risks that threatens the population and the health system
and determining what we can do

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 VRAM……….

• A Vulnerability Assessment provides:

A means to inform decision on preparedness
A starting point to construct an overall plan that
corresponds to the dimensions of identified risks.
A tool to initiate PHE preparedness planning
The basis for monitoring trends of risks

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 Types Hazard

Natural Hazards
Category Hazard type Example of health risk
Emerging diseases Covid-19, Dengue fever
Epidemic prone disease Malaria, meningitis, Cholera
Biological Zoonosis Rabies, Anthrax, Brucellosis
Food and water borne diseases Cholera, Shigellosis, typhoid fever
Insect infestations Vector born disease,
Earthquake Mass casualties, trauma
Geological Volcanic activity Mass casualties, malnutrition
Tsunami Mass casualties, Respiratory problems
Landslides Trauma, Malnutrition
Vector borne disease, cholera,
Flooding
Hydro metrological malnutrition
Storm Electrical shock, poisoning, malnutrition
Drought Malnutrition, famine
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 Types Hazard…….

Man made hazard types

Category Hazard type Example of health risk
Armed conflict Trauma, epidemic prone diseases
Societal
Civil unrest Trauma, mass casualty
Terrorism Trauma, mental health/public fear
Industrial disasters Chemical intoxications, chronic diseases
Technological
Structural failures (bridges,
Trauma, crush, respiratory distress
buildings)
Explosions or fires Burns, trauma, respiratory distress
Respiratory diseases, acute
Air pollution
cardiovascular disease
Food or drug contamination Chemical intoxications, E. coli, Salmonella

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 Hazard Analysis

• Hazard analysis done for identification of the most likely hazards

encountered by the health system.
Seasonality and Periodicity: Likelihood of identified hazards is
classified as scale by considering seasonality, periodicity and health
consequence.
Severity: Morbidity rate, Mortality rate, transmissibility rate ,availability
of treatment and preventive measures and the status of the community
either for exposure or preventive measures were taken in to account in
determining of the severity of the hazard.
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 Hazard Analysis……..

• When conducting the severity assessment for biological hazards, the

following information is required:
Transmission potential (mode of transmission or basic reproduction
number [R0])
Level of negative consequences on population (morbidity, forced
displacement of a population and mortality, population movement
restrictions)
Disruption to essential health and other services
Effect on health workforce (risk to health workers)
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 Assessment of vulnerability

• Vulnerability refers to the characteristics and circumstances of

an individual, community, system or asset that make it
susceptible to the damaging effects of a hazard.

• When assessing vulnerability as it relates to a particular

hazard, the following factors should be considered in relation to
the population:

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 Assessment of vulnerability…..

Assessment of hazard-specific coping capacity

• Coping capacity measures how people, organizations, and

systems use available skills and resources to manage adverse
conditions, risks or disasters as related to the identified hazard.

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 Assessment of vulnerability…..

• Information generated from risk and vulnerability assessments can be

used for
Pre-determining possibility of PHEs
Identifying cause and potential impact of PHEs
Risk mitigation interventions
Planning infrastructure e.g. health facilities planning
Decision making e.g. resource allocation
Policy formulations e.g. public health policies
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 Assessment of vulnerability…..

• Training e.g. trainings on IPC, pre-hospital care

• Informed planning e.g. service continuity planning, EPRP,

developing health sector operational plans

• Setting up resilience structures / functions for leadership

Risk =hazard *vulnerability /capacity

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 Assessment of vulnerability…..

• Summary of steps required to follow in conducting a VARM are.

Step 1: Contextualization
Step 2: Hazard identification
Step 3: Risk analysis
Step 4: Risk Evaluation
Step 5: Risk Reduction
Step 6: Monitoring, reviewing and publishing
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 Risk Characterization
• Impacts/consequences analysis
Grade/ Rating Criteria
Insignificant • Minor Injury, No or basic first aid required
Minor • Medical or paramedical treatment without fatalities
• Up to four days lost time from work
• Need more than 4 days treatment/admission at hospital with some fatalities
Moderate • Short term disruption of the main activities of the organization (in days)
• Normal community functioning with some inconvenience
Major • Permanent impairment/disability (unable to return to work)
• Uncontrolled hazardous chemical spill/release
• Significant financial loss- some financial assistance required
• Significant Fatality/s
Catastrophic • General and Widespread displacement for extended duration
• Long term cessation of core activities
• Community unable to function without significant support

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 Risk Characterization…..

• Likelihood/probability analysis
Grade/ Rating Criteria
Very unlikely May only occur in exceptional circumstances(>100yrs)
Unlikely The risk event could occur at some time(during a specified
period), but it is unlikely (21-100yrs)
Possible Might happen at some time; occurrence would not be unusual
May occur once every 11-20 years

Likely Will probably occur in most circumstances

May occur once every 5-10 years

Very Likely Is expected to occur in most circumstances
May occur once every 1 to 4 year

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 Risk Characterization…..
• Combine likelihood and impacts using the risk matrix to
determine the risk rating

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 Group Exercise

• Hazards

• Risks

• Vulnerability

• Capacity

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 Group Exercise…

• Bacteria H
• Choking agents H
• Diseases R
• Limited trained personnel V
• Cooperative community C
• Mixed residential and
industrial zones V

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 Group Exercise…

• Syringes with needles H

• Herbicides H
• Distance of the health institution
from the community V/C
• Fire R
• Strong political commitment C
• Fertilizer
H

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 Group Exercise…

• Existence of partners C

• Death R
• Skin Cancer R
• Low awareness level of the community
V

• Still birth R
• Strong inter-sectoral collaboration C
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 Risk Management

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 Management response
• Elimination: Eliminate DDT because it is already banned
chemicals
• Substitution: The DDT chemical can be substituted with less
hazardous chemicals with similar functions. eg Permethrin
• Engineering Controls: This may not be applicable on this
scenario
• Administrative controls: Spraying should be conducted by
healthy, adult, male individuals; conduct during non-windy
time, consider wind directions, etc
• PPE: Wear full cover, google, and masks, hair cover, etc

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 Risk Communication

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 Risk Communication

Activity 3.4: Group discussion

How do you communicate risks in your areas?
What is the importance of risk communication?

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 Risk Communication

• Risk Communication refers the real-time exchange of information,

advice and opinions between experts or officials and people who are
at risk of CBRN hazards.

• It is a continuous process that needs to be conducted before, during

and after an incidents

• Its ultimate purpose is to enable everyone at risk to make quick,

informed decisions about their health, property, community, and for
their wellbeing when an incident occurs
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 Risk Communication…….

• Communities expect to hear from their leaders in times of

emergencies

• Communicating in an timely, transparent, and credible manner

during a crisis situation is a key leadership skill

• Communicating during crises/emergencies is different from

communicating during normal conditions

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 Risk Communication…….

• Area of risk communication

• Levels of health or environmental risks

• The significance or meaning of health or environmental risks

• Decisions, actions or policies aimed at managing or controlling

identified risks

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 Risk Communication…

• Why Risk Communication

• To achieve a common understanding of risk

• To develop credible interventions

• To inform interested parties about an issue which is submitted to a

decision making

• To allow to the decision makers to take better decisions

• To promote the participation and involvement of all interested parties

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 Risk Communication…

Risk assessment and risk

management should be well
communicated.

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 ERC Strategies and principles
• Emergency Risk Communication Strategies (ERCS) and
principles support the public health practitioners, officials &
other stakeholders
• Communicate health risks according to a plan that is sensitive
to the needs of the community
• Integrate/engage the community into the process of managing
risk
• Help establish confidence and reduce fear, anger, or rage
• Disseminate clear, concise, and audiences’ need based
information

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 ERC Strategies …

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 ERC Strategies……….

• ERC strategies are communication approaches which can guide our

communication planning & intervention process

• There are four risk communication strategies:

• Precautionary advocacy

• outrage management

• Crisis communication

• Health education/stakeholders relationship

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 ERC Strategies……….
• There are six Principles of crisis and ERC:
 Be first:
public health emergency is time-sensitive.
Fist impressions count; people will remember the first message
they hear and compare all other messages to that message.
The first source of information often becomes the preferred
source.
 Be right: Accuracy establishes credibility. But it does not mean
you have to have all the facts. Share what is known, what is not
known and what is being done to fill in the gaps. Share updates if
any.
 Be credible: Honesty and truthfulness should not be compromised

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 ERC Strategies……….

• Express empathy: Crisis creates harm. The suffering should be

acknowledged in words. Addressing what people are feeling, and
the challenges they face, build trust and rapport

• Promote action: Giving people meaningful things to do calms

anxiety; it can help restore a sense of control

• Show respect: Always treat people the way you want to be treated.
Respectful communication is important when people feel vulnerable

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 ERC Strategies……….

• Sharing of information in a timely & accurate manner can help

the public to take informed decision, dispel rumours and
misunderstandings

• It is necessary for rapid and effective assistance for emergency

or to prevent an emergency proactively

• It is the basis for coordination and decision making

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 Risk communication material
development
• The message developed for risk communication needs to qualify & full fill The
‘7 C’s
Command attention
Clarify message
Communicate the benefit
Consistency Counts
Cater to the heart & the Mind
Create Trust
Call for action
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 Audience Analysis
• Understanding Audience: understand the needs of your
audience
• Audience Needs: to look at their psychological proximity to an
incident (e.g. One who looses his family due to flood knows the
pain of a flood and fears when seeing and/or hearing about
flood more than others)
• Demographic Differences: age, education, income level,
religious beliefs, geographic location, languages spoken & read,
cultural norms and values, current subject knowledge &
experience

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 Audience Analysis…

• Cultural Differences:
 language & perception of risk,
 beliefs about institutions, credible sources of information,
 rituals for grief and death

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 Message Mapping

• Message mapping is a framework used to create compelling,

relevant messages for various audience segments

• It serves as an organizational alignment tool to ensure message

consistency

• Initial messages should be short, relevant, repeated and

communicated using positive action steps

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 Message mapping …

• There are 5 common Communication Mistakes to be avoided

Mixed messages from multiple experts:
Information released late:
Paternalistic attitudes: behaving as if you and your
organization know what is best for others
Public power struggles and confusion: Make communities
part of the response process and decision-making.
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 Other Risks

• Other Risks Can be categorized in to two (Health facility and non Health
facility)

• All Public health professionals should be Level all health facility in his/her
Catchment area (V. High, High, Medium, Low) based on risk level yearly at
the beginning of the year by considering
Load
Specialty
Previous performance
Interest
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 Other Risks…….

• Other risks Focus on risk Traditional healers

Environment Hotels etc
Holly water
TBA • NB:- Identify with specific
Wogesha site/GPS and report to the
Schools next level
HF • follow and establish
Mosque communication
Market • Update every six month or
Transportation annually
protection site
abattoirs
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 Section 4: Emergency preparedness and
response plan (EPRP)

• Activity 3.5 . Self Reflection

What is emergency preparedness

response plan?
What is the importance of EPRP?
Share your experience on EPRP?

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 EPRP…….

• EPRP is a plan that describes how an agency, organization or a country

will manage its responses to emergencies of various types by providing
a description of the objectives, policy and concept of operations for the
response to an emergency.

• It clearly delineate the roles, structure, authorities and responsibilities

for a systematic, coordinated and effective emergency response.

• A HF (EPRP) describes how the health sector structures and organizes

itself for the management of an emergency response
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 EPRP…….

• Planning is the theme of the whole emergency preparedness

exercise.

• Plans should be updated regularly and exercised periodically

especially following major incidents and mock exercises to
include lessons learned.

• The plans should form the basis of estimation of required

resources for predictable emergencies including training.
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 EPRP…….

• The EPRP steps:

Identify and convene preparedness planning
team(s)/experts from different sectors and partners,
Coordinate and integrate all response and recovery
agencies/organizations in the planning process,
Identify needs required to respond to emergencies

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 EPRP…….

Discuss with partners on roles and responsibilities

Develop plan prevent, respond and recover disasters,
Prepare monitoring tools to ensure preparedness plan is
operationalized

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 Health facility Disaster response
planning
• During times of disaster, HF play an integral role within the
health-care system by providing essential medical care to their
communities.
• The responsible hospital administrator or medical director
should facilitate preparation of detailed plans for hospital
services in the event of a disaster.
• These plans should ideally be available in all HF (from primary
to tertiary hospitals).
• The plan should also have detailed structural and functional
relationships

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 Objectives and goals HF Disaster Plan

• The main objective of a hospital emergency/disaster plan is to

optimally prepare the staff and institutional resources of the hospital
for effective performance in different disaster situations.

• The hospital disaster plans should address not only the mass
casualties which may result from MCI that has occurred away from
the hospital, but should also address the situation where the hospital
itself has been affected by a disaster – fire, explosion, flooding or
earthquake.
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 Principles of HF Disaster Plan
• Predictable and simple
• Flexible: Plan should have wiggle room
• The plan should be executable for various disasters
• Concise: Short and clear definition of authority
• Clear functional structure
• Comprehensive and Adaptable
• Anticipatory: plans should consider worst scenarios
• Integration: The plans have to be integrated with the regional
(Woreda/Zone) plan for proper implementation

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 Approach for making Disaster Plan for
Health Facility
• Hospital disaster planning is divided into 3 phases:
a. Pre disaster phase
Planning: Most of the assessment and planning is done in
the pre disaster phase, hospital plans are formulated and
then discussed in forum for approval.
The disaster manual: The hospital disaster plan should be
written down in document form and copies of same should
be available in all areas of hospital.
Staff education and training
Regular staff training by suitable drills

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 Approach …

b. Disaster Phase
Phase of activation: Alter and notify emergency
Activation of the chain of command in hospital
Operational phase: actual tackling of mass casualties Phase of deactivation

c. Post Disaster Phase

This is an important phase of disaster planning where the activities of the
disaster/ emergency phase are discussed and the inadequacies are noted
for future improvements.

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 Simulation exercise (SIMEX)

• Simulation exercises can help develop, assess, and test the functional
capabilities of emergency systems, procedures and mechanisms to
respond to outbreaks and public health emergencies.

• It is a fully simulated, interactive exercise that tests the capability of

an organization or other entity to respond to a simulated emergency,
disaster or crisis situation.

• It is normally run as field exercises.

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 Simulation exercise (SIMEX)……..

• The scenario takes place in real-time, and requires a variety of

resources to operate – both human and material

• SimEx’s are exercises for practical operations in which the

participants’ actions are evaluated

• The actions that are taken and the way decisions are made in
response to the particular situation will determine the
development of the exercise
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 Types of simulation exercises

• There are four types of simulation exercise.

Tabletop Exercise
Drill
Functional Exercise
Full-Scale Exercise

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 Types of simulation …….

1. Table top Exercise

• Facilitated analysis of an emergency situation in an informal stress-free

environment .

• It is designed to elicit constructive discussion as participants examine

and resolve problems based on existing operational plans and identify
where plans need to be refined.

• Minimal attempt at simulation in which equipment is not used,

resources are not deployed, and no time pressures are introduced.
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 Types of simulation …..
2. Drills
• A coordinated, supervised exercise activity normally used to
test a single specific operation or function of one small
response plan.
• There is no attempt to coordinate organizations.
• The effectiveness is its focus on a single, relatively limited
portion of an overall system.

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 Types of simulation …..

3.Functional Exercises

• It is shows fully simulated interactive exercises to test the capability of

an organization to respond to event

• It tests multiple functions of the organization’s operational plan

• It is the coordinated response to a situation in a time pressured, realistic

simulation and focuses on the coordination, integration, and interaction
of an organization’s policies, procedures, roles and responsibilities
before, during, or after the simulated event.
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 Types of simulation …..

4. Full-Scale Exercise

• It simulates a real event as closely as possible and designed to evaluate

the operational capability of emergency response

• It conducted in a stressful environment that simulates actual response

conditions

• It requires the mobilization and actual movement of emergency

personnel, equipment, and resources that tests and evaluates most
functions of the emergency plans.
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 Surge capacity

• It is ability of health service to expand beyond normal capacity to

meet increased demand for clinical care

• It is an important factor of hospital disaster response and should be

addressed early in planning process

• Surge capacity is the increased capacity available during mass casualty

situations and disasters

• Surge capacity must be developed and maintained to include

continued medical care of all other patients
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 Surge capacity…..

• Surge capacity is not defined by time

• When capacity is breached, patients must be transferred safely to other

treatment facilities

• The four S’s of Surge

• Space:- physical structures, temporary facilities

• Staff -- capability, sufficiency, training

• Supplies:- medicine and equipment

• System:- SOPs, protocols

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 Surge capacity…..

• Recommended action surge capacity

Calculate capacity required for patient admission and care, human
and essential resources…etc
Estimate the increase in demand for hospital services
Identify method of expanding facility inpatient capacity
Designate care areas for patient overflow (e.g.lobby)
Increase hospital capacity by outsourcing the care of non-critical
patients
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 Surge capacity…..

• Verify the availability of vehicles and resources required for

patient transportation

• Establish a contingency plan for interfacility transfer

• Identify and address potential gaps in the provision of medical

care

• Identify additional sites that may be converted to patient care

units (e.g. homes, hotels, schools, gyms)
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 Surge capacity…..

• Prioritize/cancel nonessential services

• Adapt hospital admission and discharge criteria and prioritize

clinical interventions

• Designate an area for use as a temporary morgue.

• Formulate a contingency plan for post mortem care with the

appropriate partners (e.g. morticians, medical examiners and
pathologists)
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 Supply Chain Management System

Activity. Self-Reflection
• Question:
What is supply chain management?
What are the activities/processes of
supply chain management?

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 Supply Chain Management System

• SCM is the management of flow of the supply from all stages of production and
utilization cycles.

• Putting in place the necessary logistics and funding is one of the PHE
preparedness capabilities.

• The logistic part focuses on stockpiling drugs, vaccines ,PPE, emergency health
kits, required for prevention and control of epidemics, and nutritional
supplements.

• This has to be augmented with securing funds for related operational

activities
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 Supply Chain Management System …..

• Four major processes of SCM :

Supplies forecasting: selecting and quantifying necessary medical
supplies that will be required in the event of public health
emergencies or for the purpose of stock-piling
Procurement and framework agreements: procuring the fore-
casted quantities and entering
Logistics and stockpile
Simulation exercises
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 Supply Chain…..
• Process of supply chain management in the health system

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 Supply Chain…..

Waste Management

• During emergency response, there is high potential for medical supplies

to unexpectedly become hazardous and contaminate their surrounding

• These should be monitored and disposed properly.

• Waste management may involve different procedures including burning,

recycling, or chemical treatment

• EPSS is mandated for this role.

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 Section 5: Capacity Building

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 Capacity building ….

• Focuses on stockpiling drugs, vaccines, personal protection

equipment (PPE), Test kits, laboratory chemicals and
equipment’s, emergency health kits and medical supplies
required for prevention and control of the incident.

• This has to be augmented with securing funds for related

operational activities

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 Capacity building……

• Incident investigation form • Chemical antidotes

• Checklists • Anti-viral drugs
• Emergency response guide • Decontaminants
• PPE • Laboratory reagents
• Antibiotics • Radiation detectors
• Vaccine • Test kits
• Software Devices

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 Capacity building……

• Capacity building Training deals primarily with obtaining the

knowledge, attitudes and skills needed to carry out a specific
procedure or activity.

• Effective training emphasizes application of knowledge and

attitudes in the performance of skills

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 Capacity building……

• The Goal of Capacity buildings Training is:

• To assist health professionals in learning to provide safe, high quality

health care services to clients through improved performance.

• To bring change in: -

Cognitive (Knowledge)
Psychomotor (Skill)
Affective (Attitude)

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 Capacity building……

• Learning is most Productive and Effective when:

Participants are ready to learn
It builds on what the participants already know or have
experienced
Delivered in variety of training methods and techniques

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 Capacity Buildings.…

Laboratory P.
(Human &
Environmental
sample analysis)

PHEM/ Capacity
Surveillance Building Case
officers Management P.
Training

Industries
/Organization/
Institution

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 Capacity Buildings.……

• Capacity building activities shall be carried out in order

to effectively mitigate, prepare for identified risks, and
respond to any occurrence of PHE events / Incident

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 CHAPTER FOUR

PHEM-Response

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 Outlines

• Public health emergency response

• Outbreak investigation and response

• Emergency coordination system

• Essential health services continuity

• Summary

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 Objectives

• Define public health emergency management response

• Describe outbreak investigation and response

• Elaborate emergency coordination system

• Describe essential Health Services Continuity during

emergency

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 Section 1: Introduction to Public health
emergency response (PHER)
• Activity 4.1.Group Activity
 Select one/two of the public health emergencies
you experienced and describe the response
activities you conducted?
 What were the strengths and challenges during
your response?
 Time:20 minutes

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 Introduction……

• PHER is provision of emergency services and public assistance

during or after a public health emergency to:

• save lives

• reduce health impacts

• ensure public safety to meet the basic subsistence needs of the

people affected

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 Introduction……

• PHE response such as;

• disease outbreaks

• disasters

• displacements

• other public health issues requires the integration and effective

application of skills of multidisciplinary experts and logistics

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 Activity 4.2. Group Activity

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 Section 2: Outbreak investigation

• Epidemic is refers to an increase, often sudden, in the number

of cases of a disease above what is normally expected in that
population in that area

• Outbreak is the same definition of epidemic, but is often used

for a more limited geographic area

• Cluster :aggregation of cases in a given area without number of

cases is more than expected
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 Outbreak investigation…..

• Reasons to investigate:

• Control/prevention

• Research opportunities

• Training

• Public, political, or legal concerns

• Program considerations

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 Outbreak investigation…..

• Conduct an investigation when:

Alert or action thresholds have been reached
A report of a suspected epidemic of an immediately
notifiable disease
Communities report rumors of deaths
A cluster of deaths occurs for which the cause is not
explained or is unusual
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 Steps of an Outbreak Investigation
1-Prepare for field work
2-Establish the existence of an outbreak
3-Verify the diagnosis
4-Define and identify additional cases
5-Analyze data collected in terms of time, person and place
6-Develop a hypothesis
7-Evaluate hypotheses.
8-Refine hypotheses and carry out additional studies.
9. Implement control and prevention measures.
10. Communication (regular response situation update)
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 Steps of an Outbreak Investigation…….

1. Preparation

• Scientific knowledge: review literature, consult experts, sample

questionnaires

• Supplies :consult with laboratory

• Equipment :hand book, laptop, camera etc.

• Administration-assure personnel resources, funding

• Travel arrangements (orders)

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 Steps of an Outbreak Investigation….

2. Establish existence of an outbreak

• Is an outbreak truly occurring?

• Review number of cases and deaths in the last fifteen years

• Determine baseline number of describe cases currently in the catchment

area

• Determine presence treshold for particular disease

• Compere reported cases baseline verses with the threshold per month or
week in the catchment area
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 Steps of an Outbreak Investigation….

3. Verify the Diagnosis

• Diagnosis must be confirmed by laboratory tests

• case specimens must be sent to a laboratory for testing.

• The goals in verifying the diagnosis are:

• Ensure that the problem has been properly diagnosed and

• Rule out laboratory error as the basis for the increase in diagnosed
cases
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 Steps of an Outbreak Investigation…..

4 Define and identify additional cases

• Once the initial cases have been confirmed and treatment has begun:

• Establish a case definition

• Actively search for additional cases based on a case definition

• Search for suspected cases, deaths and contacts in the community by

identifying the patients have lived, worked, or travelled

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 Steps of an Outbreak Investigation……

5 Perform Descriptive Epidemiology

• After collection of data characterize the outbreak by:

Time

Place

Person
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 Steps of an Outbreak Investigation…..

Analyze data by Time

• An epidemic curve can provide information :

Pattern of the spread of the disease
Magnitude
The trend of the disease over time
Exposure period and/or the disease incubation period

• The overall shape of the epidemic curve: common source, Point

source ,Propagated
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 Steps of an Outbreak Investigation…..

Analyze Data by Person

• Age or date of birth, sex, occupation

• Residences area

• Immunization status

• Inpatient and outpatient status

• Risk factors

• Outcome; whether the patient survived, died or the status is not known.

• Laboratory results
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 Steps of an Outbreak Investigation…..

Analyze Data by Place

• Geographic extent of problem

• Clusters or patterns providing important etiologic clues

• Spot maps
Where cases live, work or may have been exposed

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 Steps of an Outbreak Investigation….

6. Develop Hypotheses

• Generating the hypothesis address

Source of the agent
Mode of transmission
Exposure that caused disease, reservoir, transmission, common
vehicle
Additional; Talk to several case-patients and descriptive
epidemiology e.g. epi curve
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 Steps of an Outbreak Investigation….
7. Test Hypotheses
• Evaluate the credibility of your hypotheses
Compare with established facts When clinical, lab,
environmental and/or epi data undoubtedly support
hypothesis
Use analytic epidemiology to quantify relationships and
explore the role of chance
Cohort studies
Case control studies

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 Steps of an Outbreak Investigation….

8. Refine hypotheses and do additional studies

• Epidemiologic
Laboratory when analytical epi unrevealing need to reconsider your
hypotheses
Go back and gather more information
Conduct different studies
Additional tests

• Environmental studies
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 Steps of an Outbreak Investigation….

9. Implement Control /Prevention Measures

• Control strategies fall into four major categories of activity:

Control and prevention measures for specific disease
Prevent exposure (e.g. isolation of cases in cholera outbreak).
Prevent infection (e.g. vaccination in measles outbreak)
Treat cases with recommended treatment as in national or
WHO guidelines
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 Steps of an Outbreak Investigation….

10.Communicate the Findings

• Orally within facility/community

• Written reports for planning, record of performance, legal

issues, reference, adding to knowledge base

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 Section 3: Rapid response team (RRT)
during emergency

Activity 4.3. Self reflation

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 RRT during emergency

• The RRT is a multi-disciplinary team, trained to provide support

to regional/district and local health authorities in the event of
any public health emergency

• Public health emergencies are best managed with :

• Collaborative approach or

• Making multidisciplinary public health RRTs essential to a

country public health emergency response system
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 RRT during emergency….
• RRT members
Team Leader
Epidemiologist
Environmental Health Officer
Clinician (Medical Officer/Clinical Officer/Nurse)
Medical Laboratory Scientist/ Technician
Health Promotion Officer
Nutritionist
Logisticians / Administrators
• Expanded team depending on the disease suspected and the
control measures
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 RRT during emergency….

• Common Duties of RRT during emergency

Investigation of rumors/outbreaks and other public health
problems
 Proposing appropriate strategies and measures for the rapid
containment of the epidemics
Preparing detailed investigation report and providing feedback to
all concern bodies
Contributing to the deaths evaluation of the outbreak response
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 RRT during emergency….
• Common Duties of RRT during emergency
Ensure that the case, outbreak or event is confirmed by the
laboratory.
Identify cases using standard case definitions
Describe the outbreak in terms of time, place and person
Reports: suspected cases to the next level.
Respond: quantify and mobilize resources and implement
the appropriate public health response
Provide feedback

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 RRT during emergency….

• During Non-Emergency Phase includes:

Training
Readiness
Roistering
Staffing
SOP Development and Improvement Planning

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 RRT during emergency….

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 Section 4. Public Health Emergency
Operation center (PHEOC)

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 Public Health Emergency Operation
center (PHEOC)
• PHEOC is central location where responsible personnel gather to
coordinate operational information and resources for strategic
and tactical management of public health events and emergencies

• Personnel are responsible for:

 planning, coordinating, organizing, acquiring and allocating
resources and providing direction and control can focus these
activities on responding to the emergency

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 PHEOC…..

• PHEOC can be developed at all levels Federal, Regional, Zonal

and Woredas

• The three essential elements for establishing and operating a

PHEOC includes
Staffing
Systems
Infrastructure
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 Objective of PHEOC

• The PHEOC will be used as a center for coordinating the Public

Health Emergency:
preparedness,
response and
recovery activities bringing together multi-disciplinary and
multi-sectoral experts

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 Factor to be considering during PHEOC
establishment
• Location

• Accessibility

• Safety

• Size

• Systems capability

• Survivability

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 Incident management system (IMS)

• IMS structure and protocols that provide an approach to

guiding government, the private sector, nongovernmental
organizations and other actors to work in a coordinated
manner, primarily to respond to and mitigate the effects of all
types of emergencies

• There are four major sections under the IMS: Administration,

Planning, Logistics, and Operations
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 Incident management system (IMS)

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 The four components of PHEOC

• It includes
Plan and procedures
PHEOC Infrastructure
PHEOC information system and data Standards
Staffing/HR and required competencies

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 Plan and procedures

• A PHEOC operates based on the following plans:

All hazard response plan
Hazard-specific response and management plan
Prevention and mitigation plans
PHEOC Internal communication plan
Public communication plan and Incident action plan (IAP)

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 PHEOC facilities

• There are three types of PHEOC facilities

Dedicated Facilities: Using dedicated space for a PHEOC is
the most ideal arrangement.
Multi-Purpose: The most common PHEOC facility is multi-
purpose.
 Modular: It is mobile type PHEOC facility that can be
shipped to any location and set up
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 PHEOC Information System and Data
Standards
• Protecting a PHEOC includes both physical security and
defending it from data breaches

• A PHEOC processes large amounts of sensitive information on

open displays,

• It is important that only validated personnel are allowed into

the PHEOC location

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 Modes of PHEOC

• There are three modes of PHEOC Operation:

Watch(coded as Green) :monitoring public health events or
incidents
Alert - (coded as Blue):monitor the public health situation
more rigorously
Response modes :PHEOC will be activated and staffed to
meet the demands of the situation
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 Modes of PHEOC…..

Watch mode

• Corresponds to the normal day to day activities

• The watch staff constantly monitors and triages information on public

health events by facilitating the:
 collection
organization,
 analysis,
 dissemination and archiving of information
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 Modes of PHEOC…..

• Alert mode
Early standby phase of activation when event has occurred
The PHEOC conducts:
 intensive monitoring of an incident or
 event in preparation for a potential PHEOC activation

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 Modes of PHEOC…..

Response mode
PHEOC is partially or fully activated
Use the IMS for coordination
Surge staff will be called to undertake appropriate activities
The PHEOC mobilizes additional resources
 Work extended business hours up to 24/7

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 Mode of Operation

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 Activation of PHEOC
Criteria that could be considered for activation:
• Any confirmed outbreak of epidemic potential
• Significant number of people at risk ( large-scale disease
outbreak)
• Any reportable incident under IHR 2005
• Response coordination required because of:
Geographical dispersion
Multiple emergency sites
Several responding agencies

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 Activation notification

• Notifies EPHI staffs, MOH, relevant government sectors and

agencies, RHB and key partners about PHEOC activation

• within 1 hour through letter or email and might be followed by

a phone call / SMS

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 Deactivation of PHEOC

• Response objectives are met

• When the demand for resources slows down

• The trends and data from the field begin to suggest decline

• The issue is no longer a public health threat or the affected area

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 Deactivation notification

• Notifies EPHI staffs, MOH, relevant government sectors and

agencies, regional health bureaus and key partners about
PHEOC deactivation.

• Within 48 hours once decided through letter or email.

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 Section 5: Essential Package of Health
Services during emergency (EPHS)

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 Essential Package of Health Services
during emergency (EPHS)
• EPHS is a package of services that the government is providing
citizens in an equitable manner.

• This can be due to:

 reduced access
 increased need for emergency care
 changes in the health workforce and supply chains

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 Major components of the EHSP of
Ethiopia
• Reproductive, maternal, neonatal, child and adolescent health
• Major communicable diseases
• Non-communicable diseases
• Surgical and injury care
• Emergency and critical care
• Neglected tropical diseases
• Hygiene and environmental health services
• Health education and behavior change communication services
• Multi-sectoral nutrition interventions
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 Importance of the EHSP

• To reduce high burden of diseases

• To protect the population against catastrophic health

expenditures

• To increase equitable access to health services and interventions.

• To increase the efficiency of the health system

• To increase public participation and transparency

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 Interventions to maintain delivery of
EHS
A) Coordination;

• To ensure established committees at the national, regional,

zonal, woredas levels and HF

B) preparing and using of guidance;

• The ministry of health or EPHI should develop guidelines to

ensure the continuity of essential health services. Health facility
should use accordingly
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 Interventions to maintain delivery of
EHS……..
C) Provision of financial resources:

• The interventions to EHS requires financial support /mobilization

of funds from government and international agencies to strengthen
health facilities for emergency response

D) Infrastructure and Commodities:

• The uninterrupted supply of commodities at HF and making

provision will be achieved through reviewing supply emergencies
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 Interventions to maintain delivery of
EHS…….
F) Risk communication and health promotion

• The MoH/EPHI also develop information education and

communication (IEC) materials and health facilities should use
those materials

• Health Facilities Conduct media campaigns encouraging people

to continue to access health services during emergency

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 Interventions to maintain delivery of
EHS…….
G) Health Service Delivery

• The essential Reproductive, maternal, newborn, child and nutrition

( RMNCH-N) services that should continue at each health facilities
during public health emergency

• Non-communicable diseases :HF provision of the required health

care must be provided to these patients without interruptions along
with adequate supply of medicines and medical counselling services

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 Interventions to maintain delivery of
EHS…….
• Immunization services : will continue to be regularly maintained at
vaccination service delivery points

• Communicable diseases

• Make sure that severe malaria, TB cases, and other epidemics are still
getting service at the health facility

• In IDP sites where no health facility is available, essential health

services should be provided using outreach services, mobile services,
and temporary clinics set up based on the context
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 Summary
• The propose emergency public heath response is disease
outbreaks, disasters, displacements, and other public health
issues requires the integration.
• Ten steps are recommended for investigating an outbreak in
order to simplify the investigation and get the right answer.
• Things to be considered during establishment of PHEOC are:
accessibility, location, safety, size, systems capability,
survivability.
• During an emergency, nine EHS Packages must be provided
without interruption.

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 CHAPTER FIVE

PHEM-RECOVERY

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 Outlines

 Post Emergency Recovery Assessment

 Mental and psychosocial support in disaster settings
 Post Emergency Recovery Plan
 Learning from PHEs- AAR/IAR
 Decommissioning
 Chapter summary

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 Enabling Objectives

• By the end of this chapter, participants will be able to:

• Elaborate the post emergency recovery and rehabilitation assessment

• Explain the role of mental and psychosocial support in disaster

settings

• Describe the post emergency recovery and rehabilitation plan

• Elaborate the AAR/IAR, its types and processes

• Explain decommissioning
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 Section 1: Post Emergency Recovery
Assessment
Activity 5.1. Self-Reflection

 What is recovery and mention stages of recovery?

 What is the importance of recovery assessment?

 What tools/methods you know for recovery

assessment?

Time: 5 Min

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 Post Emergency Recovery Assessment

• Recovery is the process of rebuilding, restoring, and

rehabilitating the community following an emergency

• Key recovery principles;

Equity
Effectiveness
Appropriateness
Efficiency
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 Post Emergency……
Stage of Recovery Features
 Meeting basic human needs and providing key support services: This
includes providing food, water, shelter, and medical care to those affected by the
disaster.
Short-term (e.g., days
to weeks after the  Planning objectives: A post-disaster needs assessment is conducted to inform the
emergency /disaster) development of recovery objectives, goals and targets.

 Restoring basic functions of society: Efforts are made to restore basic

services and infrastructure, such as power, transportation, and communication systems

 Transitioning from emergency response to recovery activities

Medium-term (e.g.,
 Infrastructure repairs and resuming business and economic
weeks to months)
functions

 Social health and wellness and environmental rehabilitation

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 Post Emergency……
Stage of
Features
Recovery
 Addressing long-term issues and rebuilding
 Risk reduction and mitigation
Long-term (e.g.,  Building community resilience: The objective is
months to to use the recovery, rehabilitation, and
years) reconstruction phases to increase community
resilience, hence, the community can better cope
with future disasters.

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 Post Emergency…….
• Objective assessment of the impact of damage on the health of
the population and the health system is necessary following a
disaster or emergency.
• This assessment should focus on key areas of infrastructure and
assets, service delivery, new and emerging risks, and
opportunities to improve the system during recovery.
• Different methods of assessment can be used, including
• routine HMIS data,
• Rapid Assessments during the early humanitarian response, or
• Using HeRAMS.

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 Section 2: Mental and Psychosocial
Support in Disaster settings
• Psychosocial support refers to processes of facilitating
resilience within individuals, families, and communities by
respecting their independence, dignity, and coping mechanisms.
• The psychological and social component of disaster
management has become increasingly important in recent
years.
• Psychosocial support promotes social cohesion, restores
infrastructure, and builds resilience in the face of new
challenges.
• Psychosocial support have both curative and preventive aspects

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 Mental and Psychosocial Support.…
• Preventive Psychosocial Support: Decreases the risk of
developing mental health problems by promoting psychosocial
well-being.
• Curative Psychosocial Support: Helps individuals and
communities overcome and deal with psychosocial problems
arising from the shock and effects of crises.
• Both preventive and curative aspects of psychosocial support
contribute to building resilience in the face of new crises or other
challenging life circumstances.
• Psychosocial support plays a crucial role in protecting and
promoting psychosocial well-being and helping individuals and
communities recover from the effects of disasters.
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 Mental and Psychosocial Support…
• Mental health and psychosocial problems in disaster settings
are interconnected and support for these problems are closely
related and overlapping
• Examples of mental health issues faced during disaster include
pre-existing mental disorders and disaster-induced problems
such as distress, grief, anxiety, depression, and PTSD
• Psychosocial Problems include poverty that continues after the
disaster, family separation, disruption of social networks, and
destruction of community structures or traditional support
mechanisms.

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 Mental and Psychosocial Support.…
• Ethiopia has suffered numerous traumatic events such as
natural disasters, armed conflicts, and displacements
• Numerous attempts have been made to prepare and provide
psychological and social support in different situations
• Despite increased attention, the topic of mental health during
disasters has not yet received adequate attention or scrutiny
• Psychosocial support can have positive outcomes such as
reducing the risk of developing mental health problems,
improving individual and communal self-confidence and
resources, and building resilience.

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 Post Emergency recovery planning
• Recovery planning is a process of developing strategies and
actions to assist the health system in rebuilding after a
shock/PHE
• Recovery planning should be informed by a comprehensive post-
emergency assessment that identifies the specific needs and
impacts of the emergency on the health system and community.
• An integrated approach to health system recovery planning is a
holistic and coordinated approach
• This approach takes into account immediate needs, long-term
implications and impacts of the PHE on the overall health system
and the community
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 Post Emergency recovery planning
• The goal is to build a resilient health system that can better
cope with future disasters or emergencies

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 Section 3: Learning from PHEs-
AAR/IAR

Activity 5.2. Self-Reflection

In your public health emergency response

experience, Reflect your exposure on:-
 AAR benefits
 Types/Approaches of AAR
Time: 5 minutes

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 Learning from PHEs- AAR/IAR
• After Action Reviews (AARs) are a way to evaluate the
effectiveness of response actions during a public health
emergency
• AAR is one of the voluntary International Monitoring and
evaluation framework,
• AARs aim to identify best practices and challenges in order to
make improvements for future responses
• Intra-Action Reviews (IARs) are country-led evaluations of
ongoing response efforts

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 Learning from PHEs…….

• IARs focus on identifying current best practices, gaps, and lessons learned
and proposing corrective actions

• The ideal timing for conducting an AAR is within three months of the
official end of the event

• IARs can be conducted at any time during the response when the
government or an institution identifies the need.

• IAR is desirable to conduct when outbreak response plans are updated at

the national and sub-national levels.
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 Learning from PHEs…….

• Conducting a successful AAR/IAR

 Provides opportunity to share experiences and analyze response to outbreak
 Identifies challenges and best practices
 Provides basis for updating and validating preparedness and response plans
 Documents and applies lessons learned to health system strengthening and
building resilience
 Building Health System Resilience through AAR/IAR

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• Evaluates resilience of health systems and services during real-
life events/PHEs

• Informs development of health security legislation, policies,

and strategies

• Prioritizes areas for mobilization and allocation of resources to

strengthen health system and build resilience for future events

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 Steps in AARs

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 Pre AAR /IAR
Pre AAR /IAR
Design Prepare

Designing an AAR Collect and review relevant background

information
Select an appropriate AAR format Refine the trigger questions
Build an AAR team Identify and brief
facilitators/interviewers
Develop a budget
Develop a checklist and agenda
Summarize in a concept note
Inform key stakeholders and facilitators
select a venue
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 Pre AAR /IAR
• Criteria to select PHE/Event for review
• At least one of the core capacities of International Health
Regulations 2005 was tested by the event.
• The event was declared as a public health emergency of national
or international concern
• Any public health emergency which engaged multiple
stakeholders at any level
• The event was a graded emergency under the WHO Emergency
Response Framework (level 2 or 3)
• The public health emergency operations center was activated at
the sub-national and national level
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 Pre AAR /IAR

Activity 5.3. Group exercise

 Discusses AAR formats/methods and present to the

participants.
Time- 40 minutes (25 minutes for group work and 10
minutes for discussion, 5 minutes for summarizing)

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 Pre AAR /IAR

• Based on location, number of participants, cultural context,

complexity of public health event, and available resource to
conduct resource there are 4 AAR formats:
Debrief
Working Group
Key Informant
Mixed Method
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 Pre AAR /IAR…..
1. Debrief AAR

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 Pre AAR /IAR…..
2.Working Group AAR

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 Pre AAR /IAR…..
3.Key Informant AAR

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 Pre AAR /IAR…..
4. Mixed AAR

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 During AAR/ IAR
Activity 5.4 : Group discussion
 In your previous experience as a response
team member for any public health
emergency response, discuss on major
activities that could be implemented during
AAR
Time: 25 min (15min for reading and
discussion and 10min for presentation)

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 During AAR /IAR….
During AAR /IAR
Conduct AAR
1. Conduct the analytical
a) Identification of capacities
b) Timeline of key milestones
c) Identification of strength, challenges and , new capabilities developed
d) Evaluation of IHR (2005) core capacities performance
2. Build consensus among participants

3. close an AAR and conduct participant AAR evaluation

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 Key Milestones
Outbreak/event milestones Definition
Date of outbreak start Date of the symptom onset in the primary case or
earliest epidemiologically linked case

Date of an outbreak or event detection The date that the outbreak or event is first recorded by
any source or in any system

Date of an outbreak or event The date that the outbreak or event is first reported to
notification a public health authority

Date of an outbreak or event Earliest date of outbreak or event verification through

verification a reliable verification mechanism

Date of laboratory confirmation Earliest date of laboratory confirmation in an

epidemiologically linked case

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 Key Milestones Cont…

Outbreak/event milestones Definition

Date of outbreak or event response Earliest date of any public health intervention to control the
outbreak or event

Date of emergency operation center Date that an emergency operation center officially activated

activated

Date of public communication Date of first official release of information to the public from the
responsible authority

Date of outbreak or event peak Date that the most cases recorded

reached

Date of outbreak or event end Date that the outbreak or event is declared over by responsible
authorities
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 Root Cause Analysis
• Root cause analysis in AAR/IAR is used to identify factors that
led or contributed to strength or challenge concerning
reviewed pillars of PHE
• Root cause analysis should be used when a problem is
identified that clearly requires deeper examination, or for
which the cause of a challenge is not yet fully understood
• Different methods such as Pareto Chart, 5 Whys, Fishbone
Diagram, Scatter Plot Diagram, and Failure Mode and Effects
Analysis (FMEA) can be used in root cause analysis

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 Root Cause Analysis Cont…
• The "five whys" method is the simplest and most frequently
used approach to root cause analysis.
• This technique is most appropriate in the framework of an AAR
group discussion.

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 Post AAR /IAR…….

Results Follow up
Conduct AAR debriefing Documenting progress: post AAR follow
a) AAR team up
debriefing
b) Senior
c) Post-AAR
management
debriefing
AARs as an
Opportunity for advocacy,
resource
mobilization and strategic
partnership
AAR final Report lessons learned database

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 Post AAR/ IAR……
• The AAR/IAR report is an important tool for sharing the findings
and lessons learned from the response efforts with all members of
the team, from the national to the community level, and different
stakeholders.
• The report provides the basis for knowledge management
deliverables such as technical reports, publications, and policy
briefings, as well as improvement plans.
• Its recommended that the draft report be completed within 1-2
weeks after conducting the AAR/IARC which allows for fresh
memories of the response efforts to be captured.
• For IAR, the implementation and draft report completion is
recommended to be done within a shorter time frame
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 Decommissioning
• Decommissioning/returning to normalcy is the process of
removing, reducing, reorganizing, or replacing health-care
services and facilities following a Public Health Emergency
(PHE).
• It helps health facilities to safely return to their normal
functions and services, especially where they had been
repurposed or reconfigured for emergency response purposes.

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 Chapter summary
• The goal of health system recovery is to restore essential health
services following a public health emergency through a plan for
rebuilding.
• By promoting positive recovery, strengthening coping mechanisms,
and building resilience, psychosocial support plays a vital role in
helping individuals and communities prepare for future challenges.
• Health system recovery assessment helps to estimate damage and
losses in order to prepare recovery plan
• Recovery planning refers to developing a set of strategies and
actions to assist the health system in rebuilding after a shock /PHE

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 Chapter Summary cont…

• AARs are reviews that identify and document best practices and
challenges revealed by the response to a public health
emergency, as outlined by WHO guidance.
• The benefit of AAR/IAR was to Inform areas to be prioritize for
mobilization and allocation of resources to strengthen the
health system and build resilience to future PHEs
• There are four commonly used formats of AAR/IAR this are
Debrief, Working group, Key informant, and Mixed method.
• Decommissioning/returning to normalcy refers to the planned
process of removing, reducing, reorganizing or replacing
health-care services and facilities following a PHE
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 Section 4: Humanitarian emergency

ACTIVITY:5.5 Group Discussion

1. What does Humanitarian Emergency Response mean?

2. What are the principles and strategies needed to implement

Humanitarian response plan?

3. Discuss the major activities should be done by Health Facilities

to improve health service delivery in Humanitarian setting?

Time: 15 min (10minute for discussion and 5 minutes for

presentation)
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 Humanitarian Emergency Response

• Is activities intended to save lives, alleviate suffering and

maintain Human dignity during and after man made crises and
disasters caused by natural hazards, as well as to prevent and
strengthen preparedness for when such situation occur

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 Humanitarian Emergency Response…..

• Humanitarian response should be governed by the key

humanitarian principles of:
Humanity
Impartiality
Neutrality and
Independence

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 Humanitarian Emergency Response…..

• Humanity refers to the provision of aid to all who are in need,

wherever the need exists, with the purpose to protect and
respect all human beings

• Neutrality is the responsibility of organizations not to choose

sides in conflict or to favor a particular political, religious or
ideological bent

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 Humanitarian Emergency Response…..

• Impartiality demands aid be given based on need alone and

based on any other distinctions including gender, race,
nationality, ethnicity, class, political party or religious belief.

• Independence refers to the requirement that aid

organizations are autonomous from any political or military
objectives

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 Humanitarian Response Strategies

• Strength multisector coordination and partnership platform at

all level (activate coordination units and revitalize emergency
task force, technical working group and IMS)

• Avail essential health services and emergency nutrition

response for by using nearby health facility or establishing
temporary clinics at IDPs site

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 Humanitarian Response Strategies…..

• Strengthen public health preparedness and response

• Identify need (Emergency need assessment), develop plan and

fill the gaps (human, finance, logistics.)

• Strength risk communication and community engagement

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 Humanitarian Response Strategies……

• The health sector identified different activities that will be

done to improve the health care services Delivery
Coordination and management
Strength public health surveillance
Logistics and supply chain management
Provision of essential health care services

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 Humanitarian Response Strategies…..

• Provision of essential nutrition services

• Provision of mental health and Phyco-social support

• Strength WASH activity at HF and IDPs sites

• Strength risk communication and community engagement

• Monitoring and evaluation

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 Emergency need assessment

ACTIVITY 5.6 Self reflection

1. How do you define Emergency Need Assessment?
2. Do you think emergency need assessment useful for
emergency humanitarian response? If yes, what are the
benefits of it?

3. Explain the steps, process and objectives of Emergency Need

Assessment?
Time: 10 Minute

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 Emergency Need Assessment….

• Emergency need assessment can be defined as a data collection

exercise usually conducted at a single point in time to gain an
understanding of the protection issues, availability of
resources, sources of problems and their impact on the affected
population (PIM Matrix, 2016)

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 Emergency Need Assessment….

• Types of Emergency need assessment can be:

• Initial need assessment (time frame is 3-5 days)

• Rapid need assessment (2-4 weeks)

• In-depth need assessment (1-4 months)

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 Emergency Need Assessment….

• Assessment in an emergency is critical and ongoing step in

determining humanitarian needs and meeting obligations

• It help to identify the most appropriate response options

• It also helps to gain accurate data about the needs and operating
context

• Is a critical step in program planning therefore it must be

conducted by a team of different expertise
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 Emergency Need Assessment….

• The preparation, fieldwork, analysis, and reporting stages of

the assessment are all handled by the assessment team

• They must be able to recognize, evaluate, and convey the issue

immediately

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 Emergency Need Assessment….
• Objective: to understand needs and analysis of the situation
and to establish a response plan
• Tools: are necessary and can act as reminders and guidance
• Interagency assessment techniques is advocated during
emergency
• It is always a good idea to share evaluation information and
findings with governmental and NGOs
• A checklist can be used as a tool for ENA

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 Critical Steps in ENA
It has 4 steps: Planning

Develop Questions

Select Data
Collection Method

Analyze and
Prioritize Data

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 Standards for ENA

• Assessment in an emergency situation is a continuous procedure

• IRA should be conducted as soon as possible after identifying the

emergency (within 24–72 hrs)

• A rapid, brief and general assessment may lead to immediate

implementation of response activities

• In the early stages of an emergency, speed is more important than

attention to detail
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 Standards for ENA…….

• Should be well organized, but should not be slowed down or

hindered by the need to get everything right at first

• Should aim to take a ‘good-enough approach’ while addressing

basic standards

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 Section 5: Essential Health Service
During Emergency
ACTIVITY: 5.7. Self reflection
How do you explain Essential Health Services?
What are the roles of EHS during humanitarian
emergency?
Do you think EHS useful during humanitarian
emergency? If yes, what are the benefits of it?

Time: 10 minutes

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 EHS During Emergency Humanitarian
Crisis
Definition:

• EHS is a set of interventions or services (preventive, promotive,

curative, rehabilitative, and palliative) across different levels of care
based upon burden of disease, cost-effectiveness analyses, budget
impact, fairness, cultural acceptability and/or equity with priority to
the worst off

• It is a set of services endorsed by the government at the national level

(Global Health Cluster 2020)
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 EHS During Emergency…….

• Defining the EHS in humanitarian settings is important because it:

Helps to plan, budget and operationalize humanitarian response

Is critical in supporting the inter-agency standard committee

(IASC) commitment to Accountability to Affected Populations

(AAP) and the population’s right to know what services they are

able to receive
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 EHS During Emergency…….

• In nations impacted by natural disasters and armed conflict,

millions of people died every year from preventable causes

• Most of these deaths are the result of weak HS and crisis-

related disruptions, including poor sanitation, shortages of food
and medicine, and inadequate prevention efforts

• IRC provides risk reduction assistance for recovering from

conflict and disaster
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 Components of EHS
• Based on the revised Ethiopian EHSP guide the major components of
the EHS are organized into nine:
1. Reproductive, maternal, neonatal, child and adolescent health
services
2. Major communicable diseases
3. Non Communicable Ds (NCDs)
4. Surgical care
5. Emergency and critical care
6. Neglected tropical Ds (NTDs)
7. Hygiene and environmental health service
8. HE and behavior change communication services
9. Multi-sectoral interventions/Nutrition/
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 Components of EHS……

• The most urgent medical issues must be the main focus of

emergency humanitarian help

• Following assessment, the recommended Rx must reduce excess

mortality and morbidity as well as foresee potential health

issues resulting from the developing emergency scenario

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 Components of EHS…..

• Child Health
Rx for ailments that affect children frequently, such as pneumonia,
diarrhea, and malaria
As part of ICCM and integrated management of newborn and child
illnesses, Rx must be accessible in healthcare institutions, through
mobile clinics, and in many cases, directly in the communities by
community health workers (IMNCI)
Encourage the administration of routine vaccinations to children in
remote locations
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 Components of EHS…..

• Non-communicable Disease
By incorporating NCD programming into recovery and
development activities to guarantee clients receive
continuous Rx, provide care for crisis-affected persons living
hypertension, CVDs, DM, and COPD
CHWs can support the management of NCDs through
community follow-up in particular situations
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 Components of EHS…..

• Sexual and reproductive Health

The core SRH package ensures care before, during and after pregnancy:
Including safe and respectful maternity and delivery services for
women and newborns
Access to clients’ contraceptive of choice
Treatment of sexually transmitted diseases
Post abortion care; and
Clinical care for survivors of sexual assault

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 Components of EHS……

• Mental health and psychosocial support

Enhance community support networks while incorporating
MHPSS into primary health care programs
This includes offering pharmaceutical and/or non-
pharmacological care

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 Components of EHS…..

• Nutrition
Conduct nutrition screenings, expand patient access to
therapy for acute malnutrition, and maintain the treatment
over time
E.g., Supplementary feeding is often the primary strategy for
preventing and treating moderate acute malnutrition (MAM)

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 Components of EHS……

• Two types of supplementary feeding programs are common:

Blanket supplementary feeding programs for prevention
Targeted supplementary feeding programs for treatment of
moderate acute malnutrition and prevention of severe acute
malnutrition

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 Chapter summary
• The goal of health system recovery is to restore essential health
services following a public health emergency through a plan for
rebuilding.
• By promoting positive recovery, strengthening coping
mechanisms, and building resilience, psychosocial support plays a
vital role in helping individuals and communities prepare for
future challenges.
• Health system recovery assessment helps to estimate damage and
losses in order to prepare recovery plan
• Recovery planning refers to developing a set of strategies and
actions to assist the health system in rebuilding after a shock
/PHE
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 Chapter summary…..
• AARs are reviews that identify and document best practices and
challenges revealed by the response to a public health
emergency, as outlined by WHO guidance.
• The benefit of AAR/IAR was to Inform areas to be prioritize for
mobilization and allocation of resources to strengthen the
health system and build resilience to future PHEs
• There are four commonly used formats of AAR/IAR this are
Debrief, Working group, Key informant, and Mixed method.
• Decommissioning/returning to normalcy refers to the planned
process of removing, reducing, reorganizing or replacing
health-care services and facilities following a PHE.
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 Chapter summary…..
• Humanitarian response should be governed by the
humanitarian principles of Humanity, Impartiality, Neutrality
and Independence
• Coordination is crucial for effective Humanitarian response
activity.
• During humanitarian crisis ENA helps to identify the most
appropriate response options to an emergency
• EHS is a set of interventions or services across different levels
of care based upon burden of disease, cost-effectiveness
analyses, budget impact, fairness, cultural acceptability and/or
equity with priority
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 CHAPTER SIX

PHEM-Monitoring and Evaluation

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 Outline

• Introduction to Monitoring and Evaluation (M&E)

• M &E Framework

• M & E data collection tools and techniques

• M & E for public health surveillance

• M & E for public health emergency preparedness

• M & E for public health emergency response

• M & E for public health emergency recovery and resilience

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 Enabling Objectives

• At the end of this chapter participants will be able to analyze

surveillance data to monitor and evaluate public health
emergency management using selected indicators.

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 Monitoring and Evaluation

Activity 6.1. Self-Reflection

1. What is monitoring and evaluation?
2. What is the similarity and difference between
monitoring and evaluation?
3. What are the rationales of monitoring and
evaluation in PHEM?
Time required 15 minutes.

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 Overview to Monitoring and Evaluation

• Measuring the level of the PHEM system at different stages from

design to the end is most important to know the management of
public health emergency outbreaks and any other emergencies in an
effective manner.

• M and E is a process of continual gathering of data and generation

of information to determine whether progress is in accordance with
pre-specified goals and objectives and to highlight whether there
are any unintended effects from a PHEM and its activities.
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 M & E………
• Monitoring defined as "a continuing function that uses
systematic collection of data on specified indicators to provide
management and the main stakeholders of an ongoing
development intervention with indications of the extent of
progress and achievement of objectives and progress in the use
of allocated funds "
• Evaluation: as "a systematic and objective assessment of an on-
going or completed project, program or policy, its design,
implementation and results to answer basic questions about a
PHEM.

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 Rationale of Monitoring and evaluation

• The followings are some rationales/purposes of PHEM M and E: -

To collect real-time data
To generate information that helps for decision making
To communicate with the public at large through information sharing
To assess the level of community’s engagement in planning,
implementation and decision making
To avail real time data for effectively monitor the implementation of
PHEM at Facility level
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 Monitoring and evaluation Framework

• This M&E framework is meant to guide the monitoring and

evaluation of the performance of PHEM at Health Facilities and
their use/implementation.

• It includes the logical relationship of the result chain from

public health emergency system inputs to outputs, output to
outcomes and then ultimately to impact.

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 Logical Framework for M&E

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 Indicators

• Indicators are measures of progress/lack of progress used to

assess progress towards meeting stated objectives.
• It provides a clearly defined unit of measurement and a target
detailing the quantity, quality and timing of expected results
• It also provides quantitative or qualitative evidence that will be
used to assess progress towards an objective.
• Provide the basis for monitoring progress and evaluating the
achievement of outcomes.
• Some core indicators are identified to monitor and evaluate the
Impact, Outcome, Output, and Input indicators are selected in a
balanced way
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 Indicators
• In selecting the indicators, there were thoroughly defined
selection criteria mainly based on relevance, availability of data
source, measurability, sensitivity, national and international
priority health interventions, and requirements.
• The primary data sources in measuring the indicators include
Routine monitoring through administrative systems comprising
any data generated by facilities or providers through periodic
reports, Toll-free hotline, rumors registration logbooks;
assessment, Population, & social media Surveys, and Evaluation.

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 Data Source, Data collection tools and
techniques
Activity 5.2. Group Exercise
Instruction: Be a group of 4/5 individual and
discuss on the following question. reflect your
discussion: -
What is 1. Data, Public health data?
2. Data sources?
3. Data type ?
Time given. Total 30 minutes

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 Data Source

• Public health data is data generated from health service,

health facilities and organizations that work on health and
related care systems, academic and research institutes and it
represents demographic and other health related content

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 Data Sources……

• Data sources in measuring indicators include

• Routine monitoring through administrative systems comprise any data

generated by facilities or providers through periodic reports,

• Logistics management information systems;

• Periodic assessments as either directed at households or facilities and

providers,

• Evaluating aspects of service delivery; and Surveillance systems (IBS and

EBS).
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 Data Source

M &E Data Sources

• Routine M & E data Source: - This type of data collected

periodically for monitoring the routine activities and evaluating
the projects or programs.

• M &E non-routine data source: - population and facility-based

data sources that include population-based surveys, vital
registration, and census.
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 Data Source…..
Type of PHEM data
• Based on nature
Qualitative data: data that can be identified by name or
categories.
Nominal data
Ordinal data
Quantitative data: A quantitative data is one that can be
measured & expressed numerically, and they can be of two
types; either discrete or continuous.

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 Data Source…..

Type of data

• Based on sources
 Primary data: -
 Secondary data

• Based on the nature of Public Health data

Non-Sensitive data
Sensitive data
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 Data collection tools and techniques

Activity 6.2.Think/Pair/share
1. What are data collection tools, and techniques?
2. Mention some software and application for data
collection you know/experienced and its purpose
3. What is data quality, data quality dimensions?
Time: 10 min

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 Data collection tools and techniques….

• Data collection reporting formats

Paper based: - used to describe a system that keeps
information on paper, rather than on a computer.
Software based

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 Data collection tools and techniques….

• Data Collection Tools

Questionnaires: (It can be Open ended or close ended)
Checklist: A list of items used for validating or inspecting
the procedures/steps have been followed
Audiovisual: - Audio, photographs and videos show still or
moving images providing additional information.

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 Data collection tools and techniques….

• Data collection methods/techniques

Interview
Document review
Focus group discussion
Observation
Rapid appraisal (assessment)

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 M and E techniques at Health Facility
Level
• Routine surveillance data analysis (Trend analysis, Plan Vs
Achievement)

• Strategically-timed user meetings/workshops, and Review

meetings

• Database to manage data and facilitate access and use

• Supportive Supervision

• Mentorship and coaching

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 Data Quality

• Data quality in monitoring and evaluation is often defined as

fitness for use, and fit for their intended uses in planning,
monitoring and evaluation, decision-making, and operations.

• A quality data meets reasonable standards when checked

against criteria for quality in monitoring and evaluation.

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 Dimension of data quality

• The following are major data quality dimensions components:

Accuracy
Consistency
Completeness
Validity
Uniqueness
Timeliness
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 Data Quality

• Data cycle: Transforming data into information and action

• The cycle includes how data is gathered, analyzed, interpreted,

reported, shared, and used in decision-making.

• To address the requirements for M & E of PHEM data analysis,

summarization, visualization, and progress tracking will be
augmented through the development and use of digital tools will be
used for data collection, analyzing, and visualizing of the activities.

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 Use of public health information at
facility level
• To early detect and avert any public health rumors and risks
• To prevent any diseases outbreak or health events
• To mitigate any diseases outbreak or health events
• To prepare for the anticipated public health threats
• To provide prompt and robust response that can
• To provide a recovery and rehabilitation responses
• To have effective and efficient resource utilization system
• To monitor the continuum of care, and address equity, access,
and accountability

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 Dissemination and communication

• Monitoring and evaluation findings will be disseminated to

stakeholders using different platforms.

• weekly, Monthly, quarterly and annual reports will be produced

and submitted to the relevant stakeholders.

• Furthermore, documentation of best practices and

dissemination of results will also be promoted.

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 M and E for preparedness

• Preparation for responding outbreaks has several activities that

can be implemented across facility levels of the health system.
Capacities in conducting various forms of assessments (VRAM,
rapid need assessment)
Presence of epidemic preparedness and response plan (EPRP)
Availability of emergency stocks of drugs, vaccines and supplies
Availability of funds for outbreak response

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 M and E for preparedness……

Availability of trained/oriented health staffs (surge capacity,

volunteers) for response
Availability of redundant and uninterrupted communication
facility
Existence of strong coordination and collaboration
Monitoring and rehearsal/simulation

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 M and E for Response
In Response,
• Up-to-date information is needed on a continuous basis
throughout the emergency to inform decisions and monitor the
interventions
• The following are some of the elements to be monitored:
Trends to assess effectiveness of response measures, extent
of outbreak and risk factors
Resource assessment rational utilization, adequacy and
sufficiency and additional needs
Performances of alerting and declaring of an event/outbreak

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 M and E for response

• Quality of the Outbreak Investigation processes

• Prevention and control of exposures, transmissions, and deaths

• Practices of preparing quarantine and isolation sites

• Effectiveness of the response: case fatality rate, incidence rate

• Implementation status of the identified intervention activities

• Continuation of Essential Health Services

• Drugs and Supply

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 M and E for Recovery

• In the recovery phase, overall, of core capacities of the health

system and affected communities and areas would be measured
together with the assessing funding and other resources
availability for decision making and escalation in collaboration
with all stakeholders.

• Post disaster assessment

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 M and E for Resilience

Resilience

• Monitoring the level of responses given to recover rehabilitate

the community affected by major public health emergency will
give as the level of completeness of our overall response
activities. The following key areas would be assessed

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 Chapter Summary
• M and E is a process of continual gathering of data and
generation of information to determine whether progress is in
accordance with pre-specified goals and objectives and to
highlight whether there are any unintended effects from a
PHEM and its activities.
• A quality data meets reasonable standards when checked
against criteria for quality in monitoring and evaluation.
• Data collection techniques for PHEM M and E were Interview,
FGD, Observation
• Type of data based on nature, time and sources

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