Implementing GHSA Biosafety Goals in Mali in Partnership with Civil Society
GHSA planning activities under Action Package 3 recommend that countries develop a strategic plan, informed by a policy framework, to guide the development and implementation of a national whole-of-government oversight program for pathogen biosafety and biosecurity. In October 2016, the Mali Association for Biosafety & Biosecurity (MABB) received funding from Global Affairs Canada to strengthen the Malian national system for biosafety and biosecurity. Collaborators on the project include the International Federation of Biosafety Associations (IFBA), the Public Health Agency of Canada (PHAC) and Pen Management & Development Consultants (PMDC).
In the midst of the 2014 Ebola outbreak in West Africa, Senegal’s infectious disease service ensured that the country’s first case was also its last.
That case was a 21-year-old man from Guinea who had traveled to Senegal, bringing the virus with him. When he presented at the Infectious Disease Service at Fann University Hospital, the presence of the virus was confirmed through diagnostic testing. Following their training, hospital staff followed biosafety protocol to prevent further spread of the illness. They also tracked individuals who had been in contact with the patient and enacted quarantine and monitoring measures. As a result of this swift and controlled action, Ebola did not spread further into Senegal, and the patient—who survived—was the country’s only confirmed case during the outbreak.
Health workers in Tanzania are staying up late for the sake of their country’s health. They are so committed to their country’s efforts to prevent an epidemic that they often wait until the wee hours, when network connectivity is most reliable, to upload local data about emerging threats into the national disease reporting system.
“Sometimes I have to wake up at midnight so that I can send the weekly report—otherwise it will not be possible due to connectivity problems,” explained a clinical officer at a dispensary in the country’s Kilimanjaro region.
Difficulty with network connectivity is among the challenges that PATH and its partner, RTI, identified while assessing obstacles to electronic integrated disease surveillance and response (eIDSR) in Tanzania.
A cholera outbreak in 2015 highlighted the importance of consistent, rapid disease reporting and response to contain the spread of an outbreak. Engaging and connecting all stakeholders in the fight against diseases like cholera is essential so that the public officials and health workers alike can be informed and educated on the best strategies for prevention.
International Federation of Biosafety Associations Advancing the Global Health Security Agenda
The IFBA is a vital GHSA partner, facilitating partnerships between our worldwide network of biosafety associations and national governments in the implementation of Action Prevent Prevent – 3: Biosafety & Biosecurity goals and objectives.
Progress to Date
To assist countries in achieving GHSA APP-3 targets, the IFBA has:
Joined the JEE Alliance, a platform for facilitating multi-sectoral collaboration on health
security capacity building and International Health Regulations implementation;
Partnered with the Global Health Security Agenda Consortium, a global network of non- governmental stakeholders committed to helping make the world safe and secure from threats posed by infectious diseases;
Worked collaboratively with its 39 regional and national member biosafety associations to advance biorisk management practices & procedures;
Expanded partnerships between civil society and national governments in developing a whole-of-government national biosafety & biosecurity framework including oversight and enforcement mechanisms to ensure compliance;
Certified the competency of biosafety professionals in the safe and secure handling of infectious disease agents.
To date, 379 professional certifications have been awarded by the IFBA to individuals from 44 countries. Another 247 professional certifications are in progress.
ONE HEALTH APPROACH IN CÔTE D'IVOIRE HELPS BUILD EPIDEMIC PREPAREDNESS
In 2014, an Ebola outbreak that started in Guinea and quickly spread to Liberia and Sierra Leone threatened health systems across West Africa. During the crisis, the Côte d’Ivoire National Institute of Public Health (INSP) mobilized a One Health cross-sectoral collaboration in the country’s western regions bordering the Ebola-affected countries and established committees to address the epidemic. The USAID Leadership, Management and Governance (LMG) project, led by MSH, quickly stepped in to focus on supporting the committees to form and run more efficiently.
Beyond the committee level, the LMG project trained committee members from across different sectors in a One Health approach—including regional and district health offices, hospitals, health centers, and the water, sanitation, agriculture, animal, and fishery sectors—to change the way they related and communicated on an individual and interpersonal level. Using the LMG project-led Leadership Development Program Plus (LDP+), an experiential learning and performance improvement process that empowers people at all levels of an organization to learn leadership, management, and governing practices, these diverse groups were able to work together, even developing detailed epidemic prevention and response plans.
This new cross-sectoral partnership was put into action when there was a suspected case of Ebola detected in the border region of Côte d’Ivoire. The Regional Health Director reached out to the Prefet, local authorities, and leaders from both health and non-health sectors who had learned to work together as a team through the LDP+, quickly networked and were able to identify the suspected case, run a test, determine a negative result, and quell the rumors and panic that were building in the local community.
The LMG project experience in Côte d’Ivoire showcased the importance of inter-sectoral coordination when facing an epidemic like Ebola. Stakeholders learned that addressing a disease outbreak cannot be the purview of the health sector alone. Adequately preparing for, combatting, and eradicating epidemics involves the cooperation of other sectors, such as agriculture, the environment, security, and education.
ONE HEALTH APPROACH IN CÔTE D'IVOIRE HELPS BUILD EPIDEMIC PREPAREDNESS
Since 2015, the U.S. Department of State’s Biosecurity Engagement Program (DOS-BEP) has funded CRDF Global in supporting the establishment of a One Health program in Somalia. In consultation with Global Implementation Solutions (GIS) and Somali representation from the human and animal health sectors, the Somalia One Health Technical Working Group (SOH-TWG)
was successfully established. This Working Group is dedicated towards the following objectives:
- Improving the cross-sectoral communication capabilities among laboratory, human and veterinary health care workers
- Establishing district-level coordinating mechanisms from both animal and human health sectors to detect and respond to zoonotic diseases across Somalia in a coordinated manner
- Improving effective disease detection and animal caretaking practices to minimize zoonotic disease transmission and improve outbreak response
- Characterizing and mitigating biosecurity gaps, and securing pathogens of high consequence.
- Improving Somalia’s ability to coordinate with neighboring countries to address zoonotic diseases
With program oversight and support from CRDF Global, under the guidance of subject matter experts from GIS and via knowledge-sharing workshops that included members of the Kenya Zoonotic Disease Unit (Kenya-ZDU), the SOH-TWG finalized a One Health Strategic Plan in April 2017. Importantly, the SOH-TWG has been officially recognized by the national leadership in Somalia as a committee under the direct oversight of the Directorate of Medical Services and Directorate of Animal Health in Somalia.
The SOH-TWG remains dedicated to meeting the goals and objectives outlined in the country’s Strategic One Health Plan via a comprehensive five-year implementation plan. This activity begins to address country needs as identified in the Joint External Evaluation (JEE) of the International Health Regulations (2005)(IHR) Core Capacities in the Republic of Somalia that was carried out in October 2016*.
*Joint External Evaluation of IHR Core Capacities of the Republic of Somalia. Mission report: 17-21 October 2016.
Creating Long-Term Solutions for Real-Time Surveillance and Reporting
In support of Guinea’s health information and surveillance systems strengthening activities, RTI partnered with the Ministry of Health (MOH), Centers for Disease Control (CDC), World Health Organization (WHO) and other partners to adapt an electronic information system for surveillance of high-priority epidemic-prone diseases. It was adapted as a subsystem within DHIS2, which supports the national routine health information system. As an opensource platform, DHIS2 is a low-cost, flexible, well-supported tool that has been adopted by countries around the world. It can easily integrate data from other sources, such as laboratory systems, and includes a wide variety of tools for data visualization, management, and analysis. Case reports can be entered in real-time and immediately accessed by authorized users. As part of the long-term strategy to strengthen health information systems in Guinea, RTI first helped launch and support implementation of DHIS2 for routine surveillance. RTI collaborated with the MOH and other partners to raise awareness of DHIS2 and minimize the use of parallel systems. RTI has been one of the leading organizations collaborating
with MOH and its partners, to plan for and implement the DHIS2 platform. RTI assisted with piloting DHIS2 for routine health information (monthly health reports) in Conakry and the Kindia district.
The routine health information system lays the foundation for using DHIS2 for surveillance and enables Guinea to make maximum use of its resources. Using an integrated approach to combine surveillance data with the national Health Management Information Systems (HMIS) platform, RTI is maximizing resources, reducing burden on personnel, and promoting the harmonization of data and analysis across systems. Users will be able to compare reported disease totals from routine and surveillance information systems in the
DHIS2, and through this process strengthen data quality and eventually reduce parallel, redundant reporting. RTI is helping to build a team of people within the MOH with expertise to maintain the system over time, using a system that is widely supported and open-source.
Through a series of meetings and workshops, RTI has engaged surveillance stakeholders in discussions of what data should be included, how it flows, who is responsible, and which indicators and data elements to feature in reports and dashboards. Participants increased their understanding of the system and became invested in its success. With successful implementation, Guinea will be one of few countries that have successfully integrated case-based surveillance directly into its DHIS2 system, and will be able to share lessons learned
with other countries. The importance of the system was highlighted in a national news report.
RTI supports the MOH to lead the process of implementation by working hand in hand with MOH personnel to plan for and conduct trainings, supervision, and maintenance. To increase sustainability, the Guinea MOH selected people from across the organization to serve as the DHIS2 technical team and undergo the mentoring and training necessary to provide expertise for the long term. RTI will continue to support Agence National de Sécurité Sanitaire (ANSS) in the development, updating and distribution of surveillance
standard operating procedures and guidelines as well as IDSR training activities. By working collaboratively with the MOH to implement the DHIS2, RTI is building the capacity of MOH personnel to use and maintain the system and creating a large pool of human resources to help sustain the system into the future.
Actively Engaging Communities In Disease Detection
RTI teamed with the Ministry of Health (MOH), Centers for Disease Control (CDC), World Health Organization (WHO), and other key partners to develop and implement a sustainable CEBS strategy for Ebola and five other high priority diseases (cholera, meningitis, polio, measles, and yellow fever). At the national level, RTI is helping to adapt IDSR guidelines, reporting tools, and training modules to the Guinean context. Based on feedback from the MOH and district-level health workers, RTI updated and simplified case
definitions and data collection forms to promote better disease detection and reporting at the community level. RTI has also developed guidelines and tools to help provide consistent and structured monitoring across Guinea’s 38 health districts. Additionally, RTI supports implementation of CEBS activities in two high-priority health districts identified by the MOH. To promote local engagement and ownership, RTI works closely with community leaders and local health authorities to select community health workers (CHWs) to conduct CEBS. Selecting community members who are well-integrated and respected helps ensure the success of the program. The CHWs are trained to address misinformation that jeopardizes trust in the system and keeps people from seeking care. This is helping to restore community confidence in the formal health care system. One health zone reported that monthly health center consultations rose from 200 to 700 after the initiation of CEBS.
A cadre of 252 CHWs have been trained and equipped with materials to support surveillance activities, such as bicyclesand mobile phones with credits. In addition, RTI trained 37 supervisors, composed of health workers from nearby facilities. The supervisors received additional training and tools to support case investigation, data management, and oversight of CEBS activities. In the urban health zone, Matam, RTI adapted its implementation strategy to include upervisors from both public and private health facilities. This ensures that the surveillance activities reflect the population’s health-seeking behaviors and provides better coverage of supervisory activities.
Promoting Sustainable Case Detection and Infection Control Through Enhanced Screening Practices
The enhanced screening and triage activities, implemented by RTI with funding from Centers for Disease Control (CDC), supported the Government of Guinea’s efforts to prevent outbreaks of highly infectious diseases. RTI facilitated the launch of triage units in 44 health facilities in 13 districts and the capital, Conakry. RTI successfully trained and deployed Public Health Specialists to assigned field-level districts, where they have provided valuable technical assistance and other support to health facilities. More than 500 health personnel
have been trained in IPC and enhanced screening and triage, and more than 600 Community Health Workers (CHWs) have been informed about the triage efforts.
In addition to triage procedures, health workers learned protocols for proper hand hygiene, cleaning of blood and other body fluid spills, and disinfection of areas potentially contaminated with infectious material. These staff are now poised and ready to contribute to the MOH’s efforts to detect disease outbreaks early, isolate potential cases and control further infection, and notify appropriate health authorities. In January 2017, three RTI-supported screening centers identified, isolated, and promptly reported suspected cases of epidemic-prone diseases (meningitis, measles, and yellow fever). This allowed the MOH to react effectively, provide accurate confirmation and refer to appropriate care.
This success provides confidence that screening and triage procedures are functioning as intended. RTI simultaneously established a physical infrastructure to support enhanced screening and triage activities in the 44 facilities by providing materials to create improved “welcome” centers and isolation rooms to rapidly detect and isolate suspected cases. This included medical equipment and furniture, solar panels to provide a sustainable source of electricity, and computers to maintain electronic registries and databases. RTI worked hand-in-hand with the district health authorities as well as with other partners at the district level in designing and implementing triage activities. This has increased buy-in and commitment from local stakeholders.
RTI developed a triage-specific database for the MOH to track the number of people visiting each health facility, and record those that fit the criteria needed for early disease outbreak detection – a critical component of surveillance. The data will help measure the volume of attendance over time, which helps the MOH to make programmatic decisions such as resource allocation. RTI will work to integrate the collection of data from the screening process into the national health information system so that this information is available at all levels for surveillance and response activities. To ensure that the enhanced screening and triage units would be well-received, RTI organized information sessions with CHWs to provide information, explain the importance of enhanced screening, and invite community feedback. A total of 602 CHWs attended the sessions. In several instances, CHWs expressed concerns that the installation was a sign
that Ebola was resurging. In one session, they recommended that the triage unit be called an “improved welcome center” (Centre d’accueil amélioré) to destigmatize the purpose. The project has adopted this recommendation and used this terminology for all the units.
Leveraging Experience in the Fight Against Ebola Virus Disease—International Medical Corps’ Ebola Research Team
International Medical Corps played an important role in fighting the 2014-2016 West Africa outbreak of Ebola Virus Disease (EVD). In August 2015, we established the Ebola Research Team, with the goal to collect, aggregate, standardize, analyze and disseminate all data and results from any analyses conducted during the outbreak for the benefit of the entire humanitarian community. In addition, the team partnered with external investigators to research new drugs and devices that can aid in the future management of EVD. Finally, we are partnered with local Ministries of Health (MOH), the World Health Organization (WHO) and several other humanitarian partners to share data and knowledge in the hopes of improving the response to future epidemics. For a list of publications coming from this effort, please follow this link on the International Medical Corps website: https://internationalmedicalcorps.org/emergency-response/ebola/
Building Biosafety Leaders
Public health laboratory biosafety officers—the scientists charged with preventing disease transmission inside laboratories and to the local community—must be strong leaders who can embrace change, manage people and processes, and anticipate future needs.
In September 2017, with support from CDC, APHL launched the first in a series of leadership workshops for biosafety officers at the state public health laboratory in Hawaii. The workshop series is designed to develop the skills of biosafety officers at US public health laboratories, including state, local, territorial and US-Affiliated Pacific Island laboratories.
At the first workshop, 14 scientists from public health laboratories in Hawaii and the US Affiliated Pacific Islands, the University of Hawaii and Vietnam joined in four days of training. Sessions examined leadership qualities, project management, public policy, communications, building training programs and implementing evaluation measures.
In addition to these leadership workshops, APHL is helping public health laboratories build biosafety and biosecurity capacity in other ways: hiring biosafety staff, updating protocols, training clinical and public health laboratory staff, and engaging partners. The association:
- Serves as a Subject Matter Expert, providing guidance and support to public health laboratories and resources for outreach to strengthen biosafety practices at clinical laboratories
- Maintains a Biosafety and Biosecurity Committee where members guide the development of resources (e.g., risk assessment templates, checklists)
- Convenes Biosafety Partners Forums, bringing together representatives from federal and non-governmental organizations to discuss opportunities to strengthen biosafety and biosecurity in clinical and public health laboratories
- Maintains a Community of Practice where biosafety officers from public health laboratories can exchange information and seek assistance from colleagues
- Offers a Biosafety Peer Network which pairs biosafety officers from public health laboratories for mentorship, site visits and knowledge exchange
- Conducts Site Visits that provide recommendations to assist labs with workflow and other safety initiatives
- Offers Educational Opportunities
-In partnership with Behavioral-Based Improvement Solutions, offers a monthly webinar series, BioSafe360
-Convenes webinars to share experiences in outreach to clinical laboratories, lessons learned from exercises and proficiency testing, and technical information from risk assessments and other sources
-Offers technical workshops
- Promotes Biosafety and Biosecurity initiatives via APHL communications
- Facilitates Public Policy discussions including a Biosafety Position Statement and fact sheets for Congressional staff and other policy makers.
- Strengthens Biosafety Practices Globally
-Partnered with CRDF Global to support Global Fellowship Programs such as the Robin Copeland Memorial Fellowship
-Delivered a Biological Safety Cabinet Training in selected African countries
-Conducted reviews of biosafety practices and policies in Ghana, and provided recommendations and a template for a countrywide -Biorisk Management Framework
For more information about APHL's biosafety and biosecurity initiatives, contact APHL's Director of Public Health Preparedness and Response, Chris Mangal, MPH.