GUIDELINE

Federal Democratic Republic of Ethiopia

Public Health Emergency

Management (PHEM)

Second Edition

Addis Ababa, Ethiopia | July, 2021

Federal Democratic Republic of Ethiopia
Ministry of Health

Public Health Emergency Management

Guideline for Ethiopia

Ethiopian Public Health Institute

Public Health Emergency Management Center
TABLE OF CONTENT
Abbreviations
Acknowledgment
Forward

01/ INTRODUCTION
Context of Ethiopia
PHEM in Ethiopia
Pillars of PHEM
Guiding Principles of PHEM
Purpose of the guidelines
Scope and Applicability of the guideline

02/ PHEM COORDINATION AND COLLABORATIONS

Definitions
Activities
General Principles
Existing Frameworks

03/ PREPAREDNESS
Definitions
Purpose
Elements
Activities and Tasks
Tools
Planning Preparedness
Logistics and Supply Chain Management
Workforce Capacity Development
Surge Capacity Management
Volunteers Management
Monitoring and Simulation

04/ EARLY WARNING AND DETECTION

Early Warning System
Surveillance System
 Event-Based Surveillance (EBS)
Community-Based Surveillance (CBS)
Integrated Disease Surveillance and Response (IDSR)
Sentinel Surveillance System (SSS)
Syndromic Surveillance
Non-Communicable Disease Surveillance (NCDS)
Laboratory Based Surveillance (LBS)
Surveillance Data Analysis and Interpretation

05/ RESPONSE
Introduction
Outbreak Management
Routine Emergency Response Activities
PHE Operation Center
Inter-Action Review (IAR)
After Action Review (AAR)
Response to other PHE
Cross-Border PHE Response

06/ RECOVERY
Introduction
Principles of Recovery and Reconstruction
Transition from Response to Recovery
Stages of Recovery
Recovery Processes
Recovery Core Capabilities

07/ HEALTH SYSTEM RESILIENCE

Introduction
PHE Preparedness at PoE
Public Health Surveillance at PoEs
Cross-Border PHE Response
Public Health Measures
08/ HEALTH SYSTEM RESILIENCE
Definitions and Basic Concepts
Attributes and Capacities
Pre-Emergency Health System Resilience
Universal Health Coverage
Health Service Continuity Planning
Testing Health System Capacity
Health System Resilience during Emergency
Post-Emergency Health System Resilience
Health System Resilience Framework

09/ MONITORING AND EVALUATION

Preparedness
Early Warning and Detection
Response
Resilience

ANNEX
Annex-1: Key Stakeholders in Public Health Emergency Management Coordination Framework
Annex-2: Key Components of Workforce Capacity Building
Annex-3: Summary of EBS-CBS Tasks and Information
Annex-4: EBS Information flow and response
Annex-5: Community Case Definition
Annex-6: How key signs and symptoms of case definitions may be described at the community level
Annex-7:
Annex-8: List of detail activities to be conducted during outbreaks/events
Annex-9: Detail roles and responsibilities
Annex-10: Analytical Matrix for the Health Sector PEA
Annex-11: Recovery plan preparation steps
Annex-12: Steps of After/Inter Action Review process
Annex-13: Health System resilience Matrix of Health System Building Blocks and Public Health Emergency
Management System
Annex-14: Identified Indicators
ABBREVIATIONS
AFP Acute flaccid paralysis
AR Attack rate
BOD Burden of disease
BPR Business process reengineering
CFR Case fatality ratio/rate
CHW Community health worker
EHNRI Ethiopian Health and Nutrition Research Institute
ELISA Enzyme Linked Immunosorbent Assay
EPRP Epidemic preparedness and response plan
EWARS Early warning and response system
GIS Geographic information system
HeRAMS Health resource availability mapping system
HEW Health extension worker
HMIS Health management information system
ICT Information communication technology
IDS Integrated disease surveillance
IHR International health regulation
MOH Ministry of Health
MOU Memorandum of understanding
NAPHS National Action Plan for Health Security
NGO Non-governmental organizations
NNT Neonatal tetanus
OR Odds ratio
PEA Post emergency / event assessment
PF Post recovery framework
PHE Public health emergency
PHEIC Public health emergency of international concern
PHEM Public health emergency management
PHEMTTF Public health emergency management technical task force
PHI Public health intelligence
PPE Personal protection equipment
RR Relative risk
RRT Rapid response team
SARS Severe acute respiratory syndrome
TOR Terms of reference
TWG Technical working group
UNICEF United Nations Childrens’Fund
VARM Vulnerability and risk assessment and mapping
VHF Viral hemorrhagic fever
WHO World Health Organization
WIR Weekly incidence rate
MDG Millennium development goal
SGD Sustainable Development Goal
NDRMC National Disaster Risk Management Center
ACKNOWLEGMENT
Ethiopian Public Health Institute (EPHI) would like to express its gratitude to all sectors and experts
involved in the revision of this guideline. We would like to thank all governmental sectors and
partners for their technical and financial contribution in the development of this national guideline.
EPHI would like to also appreciate all experts who facilitated and were actively engaged in the
revision of the guideline without reservation from the beginning up to the final edition.
Special thanks goes to printing partner namefor their financial contribution and facilitation of the
printing of this the guideline.
FORWARD
Natural and manmade public health emergencies and disasters have become major challenges around the
globe. Climate change, increasing human population, industrialization, rapidly growing international trade and
tourism, emergence and re-emergence of infectious diseases, natural disasters, rise in acts of terrorism, and
other factors further pose a risk to the public’s health. Occurrence of emergency conditions associated with the
aforementioned developments, often has a larger and more devastating impact on developing countries due to
limited capacity for early detection, preparedness and response.

Ethiopia has been showing great progress towards transforming the health sector for the past two decades.
Despite such efforts, there are still challenges associated with forecasting disasters, preparing prior to the
incident and in delivering prompt management of public health emergencies at all administrative levels. The
Ethiopian Public Health Institute’s Public Health Emergency Management (PHEM) center has been engaged in
the prevention, early warning, preparedness, and response of Public Health Emergencies (PHEs) in Ethiopia
since its inception in 2008.

The modern principles of emergency management and the implications of the International Health Regulation
(IHR) 2005 are also clearly reflected in the system. In recent years, particular emphasis has been placed on risk
management, risk based preparedness and capacity building which is considered to be a critical approach to
move away from the fire-fighting approach of responding to emergencies as they arise.

The first guideline for Public Health Emergency Management was officially launched in 2012. Since then it has
been providing guidance to surveillance officers, health workers and all other concerned bodies engaged in any
PHEM related activities. Following changes and new developments in public health emergency management,
including the need for better coordination and collaboration, need of cross-border communicable disease control
and other public health emergency management, implementation of IHR requirements, adaptation of the one
health approach and the development of the National Action Plan for Health Security (NAPHS), the rise in non-
communicable diseases and unexpected events such as the internal displacement of large populations, and the
need for improvement of national and regional capacity for early detection, preparedness and response, it was
found necessary to revise the 2012 guideline.
This revised guideline aims to address the aforementioned needs and to provide a clear and comprehensive
guidance for effective management of public health emergencies at all levels. Public health officers,
stakeholders and development partners taking part in public health emergency management are strongly
encouraged to utilize this guideline such that PHEM activities are carried out in a standardized manner across all
levels and platforms
Ato. AschalewAbayneh /EPHI DDG
01/ INTRODUCTION
Background

Country Context-Ethiopia

Population Demography, Dynamics and Socio-Economic Status

Ethiopia, occupying an area of 1.1 million square kilometers, is the second most populous nation in
Africa and home to a diverse population mix of ethnicity and religion. Based on the population projection
for 2020, greater than 117 million peoples are expected to live in the country with growth rate of 2.9 %.
Annually a total of 335 births and 78 deaths are expected to happen per 10,000 population. Life
expectancy of the country’s population is 60 years of age (57.73 years for Male and 62.35 years for
Female). Age distribution of the nation’s population shows, majority of young people between 0 to 14
years of age covers 43.21% followed by peoples aged more than 65 years of age and 2.97%.

Literatures shows, about 26% of the populations of the country, mostly women and rural residents, are
living with their income less than one dollar a day. Significant variation is also observed among genders
regarding literacy and unemployment rate. Based on the national estimate for 2013, literacy rate of the
total population is around 49.1% with 57.2% for males and 41.1% for females. Regarding unemployment
rate estimate for 2016, 25.2% youths were unemployed with 17.1% among males and 30.9% among
females.

Climatic Condition

The predominant climate type in the country is tropical monsoon, with temperate climate on the plateau
and hot in the lowlands. There are topographic-induced climatic variations broadly categorized into
three: the “Kolla”, or hot lowlands up to approximately 1,500 meters, the “Wayna Degas” which range
1,500-2,400 meters and the “Dega” or cool temperate highlands 2,400 meters above sea level.

Health System and Administrative Context-tier system

National administrative structure for health service has five layers of administration; Kebelle, Woreda /
district, zonal, regional and national level administrations. According to the health sector transformation
 plan (HSTP), Ethiopian health service is restructured into a three-health tier system; primary, secondary
and tertiary level of care in line with the health sector administrative structure. The primary level of care
includes primary hospital, health center and health post. The Primary Health Care Unit which is
composed of a health center (HC) and five satellite health posts (HPs). These provide services to
approximately 25,000 people altogether. It provides both preventive and curative services.

Major Public Health Risks and their Impacts in Ethiopia

The public health system of Ethiopia is continually challenged (directly and indirectly) by recurrent and
unexpected disease outbreaks from PHEs originated from within the country and imported from outside.
PHEs occurred at different parts of the world can exerts significant challenge at the national health
system and results significant lose and morbidity in community. This is due to the rapidly expanding
global economy, the convergence of people in large urban areas, the ease with which people and goods
travel around the world, emergence of new infectious agents, the wide distribution of manufactured
foods, and the changing nature of our environment are some of the factors challenging the public health
system to quickly recognize and respond to widely dispersed public health events.

Among the major outbreaks happened globally which impacts the country health system structure, the
2018 Ebola Virus Disease (EVD) outbreak in West Africa which resulted in over 11,000 deaths, the
ongoing emergencies of the Middle east Respiratory Syndrome Corona virus (MERS-COV) since 2012,
the 2009 H1N1 influenza pandemic which affected several parts of the world resulting in over 14,000
deaths, the 2004 avian influenza and the currently ongoing COVID-19 emergency were the major
ones.

The emergence and reemergence of new and old pathogens, new risk factors, the ease of spread of
diseases often raising political and economic concerns, has made detection and investigations of
diseases more complex in nature than they were in the past. Ethiopia has reported outbreaks of viral
hemorrhagic fever such as yellow fever, dengue fever chikungunya and sand fly fever Sicilian viruses.
Except yellow fever which was reported after 50 years of occurrence, the other diseases were reported
for the first time in the country. Outbreak of dengue fever has been reported from Dire Dawa, Somali
and Afar regions, while Syncytial virus was reported from Afar region and Yellow fever outbreak from
South Omo zone of Southern Nations Nationalities and Peoples Regions of Ethiopia.

In addition, Ethiopia has been also receiving hundreds of thousands of refugees from neighboring
countries particularly from Eritrea, South Sudan, and Somalia. It is estimated that the country hosts
close to 1 million refugees. Thus, the public health risks associated with international travel and cross-
border communicable disease spread prompts strong public health emergency preparedness and
response plans at Points of entries (PoE) across shared border with neighboring countries. Ethiopia
engages in body-temperature screening of all international travelers at all international airports and
designated land crossing-sites since 2014 EVD outbreaks in West Africa. In addition, the country in
recent years saw an unprecedented increase in the number of internally displaced persons (IDPs),
following a spike in intercommunal conflicts and extreme weather conditions (drought and floods)
leading to an estimated IDPs of 2.5 million in the first half of 2018, surpassing both Syria and Yemen.

The major public health emergencies in Ethiopia that contribute to increased morbidity and mortality of
the community includes; disease outbreaks of viral, bacterial and parasitic origin like measles, and other
vaccine preventable diseases, dengue fever, cholera and other food/water borne diseases including
typhoid fever and dysentery, meningococcal meningitis, malaria; alarmingly increasing impacts of non-
communicable diseases such as diabetes, hypertension, various types of cancer, mental health
disorders and substance abuse and other public health problems and events with higher public health
importance of the nation; maternal and perinatal deaths, road traffic accidents, displacement of
populations due to conflicts, flooding’s, air pollution, chemical spills, bioterrorism.

Besides all these, recent Ebola preparedness assessment missions to selected countries in Africa,
including Ethiopia, demonstrated that many countries do not have robust health systems and core
capacities as identified by the International Health Regulations (IHR) to effectively detect and respond to
a potential EVD outbreak or other similar serious health security threats. The main reason why
countries, remain inadequately prepared is lack of sufficiently developed national capacities of the public
health emergency management systems and the health systems in general.

Based on these evidences, the nation has repeatedly demonstrated that it remains inadequately
prepared to rapidly and effectively responds to serious public health events. Besides, health and health
related impacts of PHEs continues to disrupt the national level health care system and challenge the
management of health consequences of natural and human made disasters, emergencies, crisis, and
conflicts.

This makes the early detection of PHEs critical part of public health emergency management as it
 ensures outbreaks are responded to early and do not spread farther. In addition to putting early
detection system in place, it is also necessary to have an emergency management system which is able
to respond promptly and effectively to emergencies.

Public Health Emergency Management in Ethiopia

Historical evidences show that, the initiative to strengthen the disease surveillance system that
promotes the integration of surveillance activities in Ethiopia was started in 1996. Later in 1998 the
WHO/AFRO, following the resolution of the 48th assembly, started promoting Integrated Disease
Surveillance and Response (IDSR) for all member state to adopt as the main strategy to strengthen
national disease surveillance system.

Ethiopia as a member state adopted IDSR strategy, which is district centered and outcome oriented.
And based on the steps recommended by the strategy, the FMOH of Ethiopia and its development
partners did an assessment of the country’s surveillance system in October 1999 and subsequently
prepared a five-year national plan.

After the Business Program Reengineering (BPR) of the health sector in 2009, PHEM was identified as
one of the strategic objectives in the health sector and emerged as a core process to address the ever-
growing public health challenges related to emergencies and disasters. In line with this, the PHEM
center at EPHI has been tasked to conduct surveillance for the early identification and detection of
public health risks and prevent public health emergencies through adequate preparedness; alert, warn
and dispatch timely information during public health emergency; respond effectively and timely and
ensure rapid recovery of the affected population from the impact of the public health emergency.

Although tremendous achievements were attained since its inception, the national PHEM system’s
structuring at national level had critical gaps. Further, some regions and woredas do not even have a
minimum structure for an adequately functional PHEM system.

World Health Organization (WHO) recommends that, having strong Public Health Emergency
Management system to early detect and manage public health risks is very critical to improve the health
status of the community. Besides, the nature of Public Health Emergencies, emergence of novel public
health threats and required disciplines and technical experts and sectors for preparedness and provide
prompt response, the emergency management must fulfil the following characteristics :

► Comprehensive: emergency managers consider and take into account all hazards, all
phases, all stakeholders, and all impacts relevant to emergencies.

► Progressive: emergency managers anticipate future emergencies and take preventive and
preparatory measures to build disaster-resistant and disaster-resilient communities.

► Risk-driven: emergency managers use sound risk management principles (hazard

identification, risk analysis, and impact analysis) in assigning priorities and resources.

► Integrated: emergency managers ensure unity of effort among all levels of government
and all elements of a community.

► Collaborative: emergency managers create and sustain broad and sincere relationships
among individuals and organizations to encourage trust, advocate a team atmosphere, build
consensus, and facilitate communication.

► Coordinated: emergency managers synchronize the activities of all relevant stakeholders

to achieve a common purpose.

► Flexible: emergency managers use creative and innovative approaches in solving

emergencies

► Professional: emergency managers value a science and knowledge-based approach;

based on education, training, experience, ethical practice, public stewardship, and
continuous improvement.

Public Health Emergency Management System

Public Health Emergency Management is the process or a system 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 minimized. PHEM is designed to ensure rapid detection of
 any public health threats, preparedness related to logistic and fund administration, and prompt response
to and recovery from various public health emergencies. It is a fully integrated, adaptable, all-hazards
and all health approach of national early warning, preparedness, response and recovery. Every public
health emergency management have a starting and ending point.

Guiding Principles of PHEM

● Multi-Hazard Approach: The PHEM system evolved from a traditional communicable disease
orientation to a more modern multi-hazard approach. The attention dedicated by the system to
every hazard will be determined by the potential importance of the risk identified; such as
epidemics due to communicable disease, nutritional emergencies, IDPs due to conflicts, and
NCDs are some of the top priorities. However, any health hazard, irrespective of their origin or
source, including those caused by biological (both of an infectious and non-infectious nature),
chemical agents or radio-nuclear materials are considered by this approach.

● Risk Assessment to Recovery: PHEM will cover the entire cycle of an emergency or disaster;
from prevention and detection to response and recovery. The extent of the activities in the
process will vary according to the type of Public Health Emergency (PHE). The guiding principle
will be coordination or complementing each other to avoid duplication of other's work in a similar
area within the same sector or in other sectors.

● Risk Assessment and Mitigation: One of the major changes in public health emergency
management is change from the old concept of disease management to a new approach of risk
management. Therefore, systematic analysis of the vulnerability to health hazards and
assessment of the risk is an innovative area of focus. Each and every level in health system is
required to understand the health hazards and risks posed on their population and map them
using technology such as Geographic Positioning System (GIS).

Based on the prevailing hazards and risks, mitigation measures need to be taken. One of the
best shifting mechanisms is to be well prepared to effectively manage risks in a manner that
helps to reduce the peak burden on health care infrastructure and ultimately, to diminish the
overall case load and health impacts. This is contrasted to reactive approaches that are fire-
fighting for an already existing significant problems.
● International Health Regulation (IHR 2005): The PHEM system considered and encompassed
international obligations that Ethiopia signed for as a member state. Hence, most of the
components of the IHR 2005 are also included and its capacities are being monitored under
PHEM. The IHR 2005 is a legally binding document that entered into force on 15 June 2007
with the purpose to prevent, protect against, control and provide public health response to the
international spread of disease in ways that are relevant and restricted to public health risks,
and which avoid unnecessary interference with international traffic and trade. Peculiar to this
regard, Ethiopia has put in place a communicable disease control strategies that helps to
prevent/reduce spread of diseases of potential public health emergency that are related to
international travelers and cross-border communication. These efforts include the establishment
of health screening activities at international points of entries (PoE), preparation of public health
emergency contingency plans per the IHR recommendations, formation of communication
platforms through IHR national focal person and other activities can be mentioned.

The scope of the regulation embraces all the public health emergencies of international concern
(PHEIC), which includes those caused by infectious diseases, chemical agents, radioactive
materials, and contaminated food. In order to implement the IHR successfully, it is important
that building the core capacities such as coordination, surveillance, response, preparedness,
risk communication, human resource development, and laboratory capacity are emphasized.
These functions are also the main components of PHEM. Therefore, building a strong PHEM
system process and strengthening its capacity will ensure the proper implementation of IHR
2005.

The three main categories of events that require to be notified under the IHR 2005 are:

Four conditions that must be notified to WHO: smallpox, poliomyelitis due to wild- type
poliovirus, human influenza caused by a new subtype, and severe acute respiratory syndrome.

Other diseases and events with potential international public health concern that include the
following: cholera, plague, yellow fever, viral hemorrhagic fever, other diseases that are of
special national concern.

Any event of potential international public health concern including those of unknown cause or
source, and other events or diseases than those listed in the above two bullet points.
 The definitions of event and disease in the IHR (2005) are the building blocks of the expanded
surveillance and notification obligations. The term “event” is defined as a manifestation of
disease or an occurrence that creates a potential for disease. “Disease” means an illness or
medical condition, irrespective of origin or source that presents or could present significant harm
to humans.

Accordingly, notification may be required for:

● Events, irrespective of their origin or source, including those caused by biological,
(both of an infectious and non-infectious nature) chemical agents or radio-nuclear
materials;
● Events where the underlying agent, disease or mode of transmission is new,
newly- discovered or as yet unknown at the time of notification;
● Events involving transmission or potential transmission through persons, vectors,
cargo or goods(including food products) and environmental dispersion;
● Events that carry potential future impact on public health and require immediate
action to reduce the consequences;
● Events arising outside of their established patterns of occurrence.

As mentioned above, such potentially notifiable events extend beyond communicable diseases and
address such concerns as contaminated food or other products, and the environmental spread of toxic,
infectious material or other contaminants. The non-specific scope of the IHR (2005) does not require
that the event under assessment involve a particular disease or kind of agent or even a known agent,
nor does it exclude events based upon whether they may be accidental, natural, or intentional in nature.

Pillars of Public Health Emergency Management

The four areas highlighted in the figure correspond to the four pillars of PHEM:
(i) Early warning and Surveillance;
(ii) PHE Preparedness;
(iii) PHE Response and
(iv) Recovery.
As indicated in figure 1-1 below, the process starts with early warning and ends with recovery However,
it should be noted that in real situation the steps move forward and backward. For example, early
warning system is a continuous activity to be carried out throughout the whole process, and it is not
something that is done once and then overlooked when proceeding to the other processes. In a similar
manner, each step repeats itself based on health risks identified.

Risks to
Public Health Early
Need of the Warning
Public to be
protected

Identified Risks

Public Health
Emergency
PREPAREDNESS

System, supplies and

trained HR
Identified
Threats
Public Health
Emergency
Reports/ RESPONSE
Data

RECOVERY
Corrective
Actions

The Public will be

protected from health
consequences of
emergencies

Figure 1-1 Pillars of Public Health Emergency Management System

Purpose of the Guideline

The main aim of this guideline is to provide a clear guidance on the proper implementation of public
health emergency management activities throughout country. It has been produced as a general guide
to assist all health professionals, stakeholders and development partners, who take part in public health
emergency management to implement it in a standardized way throughout the country. It also helps
cross-border communicable disease control other public health emergency response implemented
according to IHR principles.

Scope and Applicability of the Guideline

The activities in the PHEM guideline are to be implemented nationwide with the involvement of all
relevant stakeholders. As the name implies, PHEM deals with the management of all public health
emergency issues, including disease outbreaks, nutritional emergencies and health consequences of
natural and human made disasters. Topics that will be covered in this guideline include PHEM
coordination, early warning, surveillance, preparedness, response, recovery, and resilience as well as
cross-border communicable disease control and regulations. Hence this guideline addresses all public
health emergencies related issues and shall be implemented at all levels throughout the country. The
information and activities in this guideline are intended for use by health managers and health staff at all
levels of the health system (federal, regional, zonal, woreda and health facilities) and to other sectors
and development partners who directly and indirectly support the PHEM system. These include:
● Public health /Health management teams
● PHEM Staffs
● Surveillance Officers/Focal Points
● Health Care Workers
● Experts / professionals who engaged in PHEM related activities
● Experts at community health system structure (including HEWs)
● Stakeholders involved in cross-border communicable disease control and other
public health emergencies

It is planned to update the guideline continuously based on changes in disease patterns and new issues that will
emerge during the implementation phase. Hence, it is a live document that will be updated regularly.
02/ PHEM COORDINATION AND
COLLABORATION
Definitions

Coordination: It is a systematic way of bringing all stakeholders at any level of the country's health
system structure including cross country boarder links to function together to achieve the intended
objectives of PHEM. Coordination will be better managed if a committee or task force comprising all the
relevant stakeholders is established. Instead of creating new committee for emergency coordination, it
would be helpful working within established structures and systems such as Public Health Emergency
Management Task Force, TWGs, RRTs, etc.

The Taskforces or TWGs should, as much as possible, be led by the corresponding administrative
authority at different levels and should include representatives from relevant institutions and sectors
such as water, agriculture, health facilities, universities, and partners to ensure comprehensive
coordination for PHEM functions. In case of cross-border communicable disease control and other
public health emergency measures, the extent of coordination and collaboration may extend beyond the
country. This includes coordination and collaboration with neighboring country where there is a shared
open border, and other distant countries that could be involved through international traveler’s
destination.

Governance: Governance in the context of this guideline refer to structures and processes that are
designed to ensure accountability, transparency, responsiveness, rule of law, stability, equity and
inclusiveness, empowerment, and broad-based participation in the process of managing public health
emergencies.

General Principles

● Leadership: The leadership function is responsible for overall management of the PHEM
response, including supervision of Team Leads. Public health leaders work across sectors
 to address the social, environmental, and economic determinants of health. Hence, strong
leadership and management skills are needed by the national and sub national public
health workforce of the future.

● Partner Coordination: Health partner coordination ensures that collective action results in
appropriate coverage and quality of essential health services for the affected population,
especially the most vulnerable. Different coordination models can be developed, depending
on the MOH’s capacity, the operational context, and the constraints on principled
humanitarian action. Examples include Health Sector Working Groups, outbreak
coordination groups, activated Health Clusters, EMT Coordination Cells and informal
bodies.

● Information, Communication and Planning: This function collects, analyses and

disseminates information on health risks, needs, service coverage and gaps, and
performance of the PHEM functions response. It uses information to develop and
continually refine the functional plans.

● Health Operation and Technical Experts: PHEM works with the Ministry of Health and
partners to ensure optimal coverage and quality of health services in response to
emergencies. It does this by promoting the implementation of the most effective, context-
specific public health interventions and clinical services by operational partners. This
function provides up-to-date evidence-based field operations, policies and guidance, and
technical expertise.

● Technical Support for Logistics Management: Health operations are informed by the
best available technical expertise and guidance, and adhere to recognized standards and
best practices. EPHI/PHEM often provides this technical expertise directly to the MOH,
Regional Health Bureau and collaboratively works with partners and ensures an end-to-end,
timely and efficient provision of consumables and equipment to support the emergency
operations.

This includes selection, forecasting, procurement, transportation, customs clearance,

storage and distribution of these material assets.
Multi-level PHEM Governance Structure

Public health emergencies are inherently political and require substantially different governance
approaches for the management of routine emergencies, extreme events, and disaster responses.
National, city and regional health authority under the federal and regional government of Ethiopia shall
be well positioned and can make an essential contribution to better and more flexible preparedness and
responses to public health emergencies.

The provisional governance framework presented below focus on arrangements as part of the governing
the public health emergency management process including preparedness, early warning, response,
recovery and resilience. Since 2008, the public health emergency management governance framework
in Ethiopia has organized in multilevel structure from national to district level (figure 2-1).

National/Federal Government

Federal Ministry of Health (FMOH) Ethiopian Public Health Institute (EPHI)

Regional/City Government

Regional/City Health Bureau Regional/City PHEM Department

Zonal/Sub-City level

Zonal / Sub-City Health Bureau Zonal /Sub-City PHEM Department

Woreda / District level

Woreda / District Health Bureau Woreda / District PHEM Department

Figure-2-1: PHEM governance structure

PHEM Governance Frameworks at Federal level:

● Ministry of Health (MOH): As stated on Proclamation No. 475/1995 of the Federal

Democratic Republic of Ethiopia defines the Powers and Duties of the Executive
Organs; The Ministry of health oversee the overall activities for the entire health system
including Public health Emergencies at federal level. As one of the multiple agencies in
 the Ministry of health, EPHI has the mandate to govern the PHEM system a federal
level.

● Ethiopian Public Health Institute (EPHI): EPHI is an independent institution working

closely with the Federal Ministry of Health. Based on the proclamation number
301/2013 of the Federal Democratic Republic of Ethiopia, EPHI mandated to lead and
coordinate PHEM system at federal level. The Public Health Emergency Management
center under EPHI has primarily mandated to coordinate the its key functions including
disease surveillance, detection and monitoring; outbreak investigation and control, and
IHR core capacity system improvement (including systems for detection, prevention,
response capacity to public health emergencies) at national level.

EPHI/PHEM has organized multiple departments with multidisciplinary workforce

composition focusing on the basic PHEM processes including preparedness, early
warning, response, recovery and resilience to achieve the specific objectives under
each pillars based on the feasibility and resource availability. The primary roles and
responsibilities of EPHI/PHEM includes:
o Develop/adopt national legislations, policies and regulations related to public
health emergencies
o Lead and coordinate the overall preparedness, early warning, response
activities at national level
o Develop strategic documents, plans, manuals, guidelines, SOPs etc for
effective implementation of PHEM system
o Lead and Facilitate IHR core capacity building activities towards a better
capacity on prevention, detection and response of PHE.
o Declare pandemics and epidemics at national level
o Provide technical and financial support to regional to district level
o Work on workforce capacity building activities at national level
o A primary contact point for Information sharing and communication focal for the
public related to PHE.
o Oversee effective implementation of the international health regulations
PHEM Governance Frameworks at Regional Government level

● Regional Health Bureau: the health bureau at the regional and city administration level
has the mandate to lead, coordinate and oversee the overall PHEM activities with the
respective administrative level. This includes, allocation of resources, identification of
priority disease conditions, adoption of rules and regulations, system improvement
capacity building activities towards effective management of public health emergencies.

● Regional /City PHEM Department: the regional/city level PHEM section organized by
the regional/city health bureau that coordinate the entire process of PHEM system at
regional and city administrative level. The regional Health bureau public health
emergency management section shall be organize multiple departments with
multidisciplinary workforce composition focusing on the basic PHEM processes
including preparedness, early warning, response, recovery and resilience to achieve the
specific objectives under each pillars based on the feasibility and resource availability.

Note: The Zonal/Sub-City level and District/Woreda level health bureau and PHEM
sections have similar mandate as specified above with in their perspective
administrative area.

PHEM at the Primary Health System (Hospitals, Health Facilities and Health
Posts):
The health system (hospitals, health facilities and health posts) has a key role the
PHEM process primarily of disease surveillance and response activities. Each health
facility might delegate a focal persons or PHEM team depending of the feasibility based
on existing context. The following activities are expected to be covered at the primary
health system:
o Compile and report immediately and weekly surveillance reports
o Validate and harmonize public health surveillance data through reviewing OPD
and inpatient wards medical registration books
o Archive and document surveillance data
o Conduct regular active case search within health facilities and community level
o Analyze surveillance data and draw an epidemic curve to see if the epidemic
 thresholds for specific diseases have been crossed in the catchment area.
o Ensure appropriate collection, storage and transportation of biological samples
to appropriate referral laboratories
o Ensure availability of surveillance supplies and tools including reporting forms,
guidelines, posters, case definitions, laboratory collection and transportation.
o Provide public health emergency information on morning section and other
routine forums to hospital’s medical staffs
o Establish and ensure the functionality of PHEM Club
o Disseminate or share early warning and alert letter from health authority to all
staffs of the hospitals,
o Advocate PHEM mandates and its legal frameworks to all staffs of the hospital
including administrative staffs
o Provide pre-service PHEM training to students
o Conduct emergency response exercises for infectious diseases and mass
causality management
o Continuously train and work closely with health facility staff to ensure standards
of surveillance practice are followed and case definitions are known and used
to monitor disease trends
o Collaborate with regional health bureau and zonal health department and
provide training to hospitals within its catchment population
o Provide technical support on EPRP, VRAM, case management, emergency
exercises to general and primary hospitals under its catchment area
o Conduct regular PHEM forum with general hospitals under its catchment area
under regional or zonal leadership
o Ensure the availability and functionality of isolation room
o Ensure the appropriate implementation of infection prevention and control
precautions
o Facilitate the development of facility based emergency response plans
o Collaborate with university staffs and conduct operational research on public
health emergency management operations
o Conduct disease outbreak verification and investigation,
o Coordinate with regional health bureau, zonal health department, woreda
health office and partners and establish emergency treatment center in the
 health facility if it is applicable,
o Timely request medical supplies for case management, infection prevention,
specimen collection from national and regional health bureaus
o Coordinate vaccination campaigns during outbreaks
o Facilitating the surge capacity for mass casualty care and outbreak response
o Mobilize psychiatrist from the hospital and support psychosocial response
activities

PHEM Multi-Sectorial Coordination and Collaboration

Considering the complex nature of public health emergency management framework, the entire process
in prevention, detection and response of emergencies requires the engagement and effort of multiple
governmental and non-governmental sectors. This National Coordination document outlines a multi-
sectoral system for management of public health emergencies. The primary governmental sectors in this
process includes; the Ministry of Health (multiple agencies like FDA, EPSA, EPHI etc), NDRMC, Ministry
of Agriculture, Ministry of Environment and Climate Change, the National Security Agency, the Federal
Police and other stakeholders. The possible coordination and collaboration platforms that shall be
applied in the PHEM process might include the following:

● National Coordination Task Force (NCTF): is comprised of relevant organizations

working in the prevention, deterrence and response to bio-threats. The NCTF is
responsible for coordinating the overall bio-threat management activities at the national
level. This taskforce is mandated to:
o Coordinate, monitor and guide the overall activities of PHEM process
throughout the nation
o Provide high-level decision making for PHEM activities when needed
o Coordinate response and recovery activities for the affected community(ies)
during emergencies

● Technical Working Group (TWG): is comprised of technical personnel from member

organizations working in the area of specific technical areas (specific emergency
conditions. The TWG is responsible for the activities listed below.
o Prepare contingency and harmonized plans for emergencies involving the use
 of chemical, biological and radiological materials
o Monitor the capacity building activities of relevant organizations working to
develop timely and effective responses to events involving chemical,
radiological or biological materials
o Conduct regular assessments of preparedness activities performed by relevant
organizations working with biological, chemical and radiological materials
o Prepare and disseminate early warnings related to bio-threat emergencies
based on findings/information from public/animal/plant health and law
information units
o Compile, analyze, produce and disseminate findings for relevant organizations
and the NCTF
o Provide technical advice for the NCTF and high level decision makers

● One Health Framework: It is a platform for partnership in implementation of IDSR/

PHEM. The Ministry of Health is closely working with other government sectors and
partners to promote multi-sectoral responses to food safety hazards, risks from
zoonosis, and other public health threats at the human-animal-ecosystem interface and
provide guidance on how to reduce these risks through One Health approach.

● Health Security Council: A Nation with Secured council might be also a coordinating
platform that oversee and give guidance for policy directions, strategic planning, follow-
up of capacity building activities towards demonstrable capacity to prevent, detect and
respond to public health emergencies.

The above coordination mechanism might be adopted in a similar manner at all levels
of the health system, i.e. at the regional, zonal, woreda and lower structures also follow
and adapt similar functional groups for the purpose of coordinating activities at their
respective level. In addition to this, the National, Regional, Zonal, and Woreda PHEM
structures should identify members of the RRT that is expected to take a timely
preparedness and response action when an emergency occurs. Establishment of core
PHEM coordination mechanism and formation of task forces during PHEIC and cross-
border public health emergency event should be given a special attention due to the
multiplicity of stake holders and actors at PoEs and beyond.
03/ PREPAREDNESS
Definition

Preparedness is activities undertake before the occurrence of the emergency considering the existing
hazard and expected risk getting the information from EWAR and surveillance finding making ready all
needed man power, logistics and finance for averting and minimizing the consequence of the expected
emergencies. It also works on system establishment and maintenance considering the current public
health emergency situation at each level of the health structure. It involves a range of players and
partners engaging in initiatives that promote health, prevent and control diseases and conditions and
protect people from the consequences of health emergencies due to manmade and natural causes.

Therefore, preparedness is a responsibility shared by all levels of government, private sector, not-for-
profit sector, institutes, and professionals’ associations. The preparedness activities need also consider
on maintaining the routine health service activities. The way forward to implement sound preparedness
measures is to accomplish first and foremost a paradigm shift from managing emergencies to managing
risks. Hence, a big educational drive is needed to install the distinctive concepts of hazards,
vulnerability, risks and the value of managing risks. High level advocacy and influential public
champions are needed to promote risk reduction in their societies.

Purpose

The aim of preparedness is to strengthen capacity in preventing, predicting, preparing, detecting,

recognizing and responding to public health emergencies through conducting regular risk identification
and analysis, establishing partnership and collaboration, enhancing community participation and
implementing community-based interventions and strategic communication during the pre-emergency
phase and ensuring their monitoring and evaluation.

The main objectives of health emergency preparedness include:

► Preventing avoidable crisis and catastrophes

► Reducing morbidity and mortality effects

 ► Ensuring availability of required resources

► Minimizing disruption to health services

► Maintaining business continuity as far as possible

► Reducing disruption to society as much as possible

► Reducing deleterious effect of the emergency on quality of life

Elements

In the public health context, the preparedness sub process is comprised of the following broad activities:

Coordination
and
Collaboration

Monitoring Capacity
and Building
Rehearsal
PHEM
Preparedness

Planning VRAM

Figure 3-1 Critical elements of PHE preparedness

Activities and Tasks

Preparedness activities and those tasks that should be done prior to the occurrence of emergency of
public health concern. 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 also includes acquiring and/or prepositioning different kinds of
resources which may include human and material resources.

The public health emergency preparedness capabilities include:

► 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
► Educating the public on related measures to be taken to prevent and control the event,
► System, infrastructure development and resilience activity based on the event condition
► Documenting finding and knowledge sharing for anticipation and responding further
emergencies

Coordination and Collaboration

A coordinated Public Health emergency management preparedness and response system is an essential
condition for effective management of public health emergencies. Coordination will be better managed if a
committee or task force of all the stakeholders and partners is established in advance. There is no need creating
need committee for emergency preparedness. Instead work within established structures and systems such as
task force, rapid response team, health committee etc.

In order to have effective preparedness and response activities, we need to have a system that will address
possible collaborators, how we will engage, alarming situation for participation, management, legal binding and
putting clear role and responsibilities.

Activities and steps required for effective coordination and collaboration are:
● Identify all sectors, collaborators and partners, their areas of intervention and capacity for
public health emergency management;
● Develop a list and keep a register of all institutions and organizations relevant to PHEM and
update the list of institution, their focal persons, and experts biannually;
● Communicate with all partners and establish a coordination/collaboration forum;
● Develop a term of reference (TOR), memorandum of understanding (MOU) to guide the
framework;
● Monitor and evaluate participation and implementation of public health emergency activities
as per the TOR or MOU;
● Report the level of status of the functions of PHEM to the next higher level and share with
all stakeholders on monthly basis or as required;
● Organize a Rapid Response Team (RRT) to initiate activities at the time of response;
● Review membership, TOR or MOU and amend/update as per the findings of the review.
Assessments

I-Baseline and Periodic Assessment

The baseline and periodic assessment is an evaluation of health status of the community through
systematic, comprehensive data collection and analysis to provide information and critical reference
point on the current levels and perspective health status of the community e.g., current burden of
disease, the patterns of health, illness, injury and the differences – if any – from community, regional
and national trends.

A baseline assessment provides information on the situation to initiate a surveillance system for that
specific disease and events. It provides a critical reference point for assessing changes and impact, as it
establishes a basis for comparing the situation before and after an intervention, and for making
inferences as to the effectiveness of the campaign. Baseline assessment should be conducted before
the actual campaign intervention.

A baseline assessment is a crucial informative campaign research, surveillance and planning, and in
any monitoring and evaluation framework. The assessment needs to be conducted when there is
occurrence of new public health problem, new diseases, diseases added to surveillance, etc. The type
of data and variables in the baseline assessment tools should be constructed to fit the disease of
interest.

The Periodic Health Assessment (PHA) is a screening tool used by PHEM Unit in collaboration with
stakeholders and partners at each level to evaluate the health and nutrition situation, based on public
health interest to evaluate the public health concerns and to know capacity and preparedness on
readiness of the surveillance system. It can be conducted alone or can be combined with other public
health readiness needs.

II-Vulnerability and Risk Assessment and Mapping (VRAM)

It is the process of determining and ranking of the risk level of a frequently existing hazards. we need to
consider many parameters that will aggravate or minimize the risk level of the hazard. Basically, during
risk assessment we need to consider the existing hazard, vulnerable condition and existing capacity on
preventing and responding the consequence of the predicted hazard. it is undertaken by organizing
multi -disciplinary and multi sectoral team having the aim of getting pertinent information on the
assessment parameters (Hazard, Vulnerable condition and existing capacity). The VRAM assessment
finding is basically used for planning purpose.

Definition of terms

Hazard: Man-made or naturally occurring event or situation with the potential to cause physical or
psychological harm (including loss of life) to members of a community, damage or loss to property,
and/or disruption to the environment or to structures (economic, social, political) upon which a
community’s way of life depends e.g., presence of outbreaks, flood, storm, chemical release.

Threat: The intent and capacity to cause loss of life or create adverse consequences to human welfare
(including damage to property and the supply of essential services and commodities), the environment
or security.

Vulnerability: The susceptibility of a community, service, or infrastructure to damage or harm by a

realized hazard or threat.

Risk: The probability of harmful consequences or expected loss (of lives, people injured, economic
activity disrupted or environmental damaged) resulting from interactions between natural or human
induced hazards conditions. For example:
● Measles epidemic (hazard) in a community - The potential impact and risk will depend
on vulnerability and Capacity based on the immunization level, nutrition status etc.
● Earthquake (hazard) - type of house (tent, poorly designed high-rise building etc.)
● Floods (hazard) - the lower in altitude and closer to a river, the more susceptible to
flooding.

Risk is a function of many factors and not only exposure to hazard. Risk is defined as a product of the
likelihood of the occurrence of a given hazard (epidemic disease, drought, flood, etc.) and the
vulnerability to the impact. Improving coping capacity reduces the risk by reducing the vulnerability to
the impact or by reducing the likelihood of the hazard.
 Vulnerability Assessment: It 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. Vulnerability
assessments also include a method of structured data collection geared towards understanding the
levels of potential threats, population likely to be affected, coping capacity, relief needs and available
resources to address them.

A vulnerability assessment provides:

● A means to inform decision-makers about the preparedness needs at different levels;
● A starting point to construct an overall plan that corresponds to the dimensions of
identified risks. This can also help to measure the levels of preparedness or
unpreparedness;
● A tool to initiate the public health emergency preparedness planning;
● The basis for monitoring trends of risks in emergency prone areas. In that sense, the
initial effort of developing a data base through vulnerability assessments should
become the basis for maintaining and updating an essential informational tool for
development planning purposes.

Planning for the Identified Risks and Hazards

Planning is the theme of the whole emergency preparedness exercise. Plans should be updated
regularly 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.
It should be exercised periodically to ensure that partners are familiar with the plan and able to execute
their assigned role. Thus, it is essential that plans reflect the preparedness cycle of plan, train, exercise,
and incorporation of after-action reviews and lessons learned.

In addition to revising of existing plans, plans for hazards which are becoming increasingly important
and may not have received due attention in the past such as chemical, biological, radiological, nuclear
(CBRN) threats, non-communicable diseases need to be prepared. The purpose of planning at this
stage is to have agreed upon, implementable and/or operable plans in place, for which commitment and
resources are relatively assured. Readiness planning includes working out agreements between people
and/or agencies as to who will provide services in an emergency to ensure an effective, coordinated
response. The written plan is a product of the planning process and needs to be operationalized.
 The activities and steps in the process of planning include:
● Identify and convene preparedness planning team(s)/experts from different sectors
including partners
● Coordinate and integrate all response and recovery agencies/organizations in the
planning process
● Identify needs required to respond to potential emergencies
● Discuss with partners to identify, endorse and agree on their roles and responsibilities
● Develop plans, to prevent, protect against, respond to, and recover from natural and
man-made disasters
● Prepare monitoring mechanisms/ tools to ensure preparedness plan is operationalized
● Ensure the integration of the plan in the sector regular plan

In line with the emergency preparedness and response planning, the service continuity plan must be
considered and prepared during planning process either by dedicated team or emergency preparedness
and response plan working team having the aim of continuous service delivery as routine during
emergency. We should to consider the infrastructural, human power, logistic and supply aspects.

Capacity Building

I- Work Force Development

Workforce capacity development is critical to developing a sustainable public health emergency

management system over time. Recruiting and maintaining highly qualified health workforce with
appropriate technical training, scientific skills and subject-matter expertise to prevent, prepare for, detect
and respond to public health emergency events is the key elements of health emergency and disaster
preparedness.

Workforce capacity building activities improve performance of the staff according to specific, defined
competencies related to planning, implementation, and monitoring of health emergency preparedness,
response and recovery activities; and this in turn helps the country to achieve required core capacities to
prevent, detect, and respond to public health emergency events and effective implementation of the
International health regulation (IHR 2005).
The workforce capacity building objectives and activities should be informed by the findings from risk
assessment and be focused on strengthening system and human resource for health needs particularly
to PHEM, such as health emergency leadership, surveillance, epidemiology, laboratory, case
management, Infection Prevention and Control (IPC), communication, and health supply and logistics
management. In the event of any health emergency response, there are a number of factors that need
to be considered to ensure appropriate management of the public health workforce, while providing
effective an response to the health emergency event and continuation of the essential health services.
The health workforce capacity development objective addresses the training or capacity building needs;
health workforce health and safety, and support program.

The following activities should be considered as part of a comprehensive workforce capacity building
strategy for health emergency preparedness and response at all levels;

● Training needs assessment to inform capacity and skill gaps

● Preparing updated list of trained staff at all levels including health facilities on the
following key areas;
o Surveillance and epidemiology, Rapid response team (RRT) and Case
management for priority risks; Laboratory testing for priority pathogens
including zoonosis in humans; and Infection prevention and control (IPC)
and WASH in health facilities; etc.
● Identifying and addressing gaps in the existing training as revision of curriculums of
health emergency workforce training programs
● Working with public health training institutions to support institutionalization of IDSR and
health emergency leadership trainings
● Planning and implementation of intermediate and/or advanced FETP and other
trainings based on need, identified gaps and health sector strategic objectives. This
includes Intermediate level FETP, Advanced FETP specialty tracks (laboratory,
veterinary) and public health emergency leadership (PHEL)
● Implementing short term in-services trainings programs to address the immediate
priorities in preparedness and response capacities at all levels such as
o Incident management system (IMS)
o Basic PHEM training for health facilities levels
 o Event-based surveillance (EBS) focused on enhancing existing community
based-surveillance system
o Emergency Medical Team (EMT) training including basic trauma and life
support, and pre-hospital care for clinicians, nurses, first aid personnel
o Infection prevention and control (IPC) trainings for PHEM officers, RRT,
clinicians, and HF managers
o Event specific trainings for PHEM officers focused on skills development
for risk assessment and investigation, surveillance, case management,
isolation and quarantine protocols. For example, SARI or Influenza like
illnesses (ILI), VHF and/or Yellow Fever, Vector borne diseases (malaria,
arboviruses), MPDSR, AEFI, etc.
o Develop an integrated in-service PHEM training which includes IHR, IDSR
and disaster management

The implementation of workforce capacity building strategies should be informed by demands and need
assessment at sub national and lower levels of the health system and the existing community structures
such as community networks, health development agents, health extension workers, and also take into
consideration the health sector priorities and strategic objectives of strengthening primary health care to
achieve universal health coverage and health security. Adequate attention and emphasis to strengthen
preparedness and response capacity at sub-national levels particularly zonal woreda and health facility
levels by implementing the following activities;

o Support zonal and Woredas to identify health workforce need by

profession, quantity, specific skill or competencies based on local context
or priority risks
o Strengthen zonal and woreda capacity to forecast and plan for human
resource needs to respond to priority public health risks at local level
o Enhance support for health facilities to improve the skill and competencies
required to diagnose and treat emerging and re-emerging infections, etc.

Strengthen collaboration between regional, zonal and woreda health leaders and local administration to
mobilize resource for health workforce capacity building.
IA-Surge Capacity: Surge capacity is the ability to provide adequate healthcare during health
emergencies that may exceed the limits of normal health system capacity (staff, supplies, space and
system) of affected country, region or community. The surge requirement may extend beyond direct
healthcare to include such tasks as, surveillance and public health intelligence, epidemiological
investigations, laboratory testing and special intervention to protect medical providers and patients to
continue routine health services. Activities that may need additional support (surge capacity) during
public health emergency response include:
► Case finding, monitoring and analysis of disease transmission and case or
contact tracing
► Case and contact management (e.g., Isolation/Quarantine)
► Infection prevention and control (e.g., use of PPE, and environmental cleaning)
► Mass drug administration or mass vaccination
► Risk assessment (e.g., assessing needs and identifying exposures)
► Risk communication (e.g., developing key message for health workers, the public)
► Data and information management (e.g., maintaining data system/record entries)
► Laboratory (e.g., specimen collection, transport and processing)
► Managing reports or enquiries within health system, the public and media (e.g.
hotlines, listening and responding to rumors)
► Supply chain and logistics (e.g., managing supplies, cold chain, stores using
SOP’s)
► Development of Standard Operating Procedures (SOPs), protocols, guidelines,
etc.)

Factors that determine surge capacity requirement: The need for surge capacity is influenced by
features of the health emergency event, available resources and support for the ministry of health or
agency responsible to coordinate the response, the need for specific expertise and needs of the affected
population. When public health demand increases or is likely to increase, workforce surge processes
should be initiated as early as possible and decisions about surge requirements should be made by
public health authorities at national or local level according to existing guideline. Surge staff is mobilized
when the magnitude of the health emergency event exceeds available capacity of existing health
workforce. Lessons from infectious diseases outbreaks in the past few years ranging from Ebola,
cholera to the ongoing Covid-19 pandemic have challenged even well-established health systems. To
effectively respond to public health emergency events, it’s important that health system has adequate
workforce capacity (number and mix of skills) to trigger timely response. This requires adequate number
of personnel trained and equipped with the necessary skills and expertise to meet rising demands of
affected health system or population. To effectively prepare for and respond to potential public health
risks, the PHEM structure at all levels should ensure the following on regular basis when planning for
health emergencies:
► A good understanding of priority public health risks and knowledge of local
population the priority public health hazards may affect
► The capacity of existing workforce in terms of skills and key expertise
(surveillance, rapid response, case management, IPC, etc.) that could be quickly
mobilized
► Availability of roster of trained staff based on local public health risks that could
be called upon when required to respond to a public health event
► A plan for continuation of essential healthcare services including protocol to
temporarily defer or relocated low priority services to alternate facilities
► Potential sources of surge workforce that may be available when additional health
staff is required including the procedure for requisition and deployment in short
time
► Training and logistics need for potential surge staff to quickly integrate into the
system

Identifying, training and deployment of surge staff: Identifying and training of surge personnel with
relevant skills is a key feature of public health emergency preparedness and will contribute to the
efficiency of a surge response. Surge staff with various backgrounds may be engaged to provide diverse
technical skills required during a surge response. Types of surge staff that contribute to health surge
response include;
► Health professionals (e.g., physicians, nurses, laboratory technologist, pharmacy
technicians, IPC specialists, health managers, epidemiologists, data managers,
health educators or promoters, etc.)
► Non-health professionals (e.g., logistic and supply chain specialists,
communications and media personnel, IT specialists, cold chain specialists, etc.)
► Administrative support personnel including human resources, business and
finance managers, plan and budget experts, etc.
IB-Volunteers Management: A volunteer is an individual, institution, agency and others who render aid and
service without pay or remuneration. Emergency volunteers may be recruited and deployed to the health
facilities by an organization (affiliated), or may present themselves spontaneously (unaffiliated). Emergency
volunteers may also be qualified healthcare professional (clinical) or without healthcare qualifications (non-
clinical). Volunteer management, also known as volunteer engagement/coordination/administration, refers to
“the systematic and logical process of working with and through volunteers to achieve an organization’s
objectives”. Having a volunteer management program in place is the most straight-forward way to ensure
effective volunteer management. Volunteer management generally follows the cycle illustrated in the figure
below.

Planning

Recognition Recruitment

Volunteer
Management Cycle

Induction and
Review Training

Supervision
and
evaluation

Figure-4.1. Volunteer management cycle

II- Logistics

IIA-Emergency Supply Chain Preparedness: When it comes to emergency supply chain

management, a little preparedness will go a long way. Investing relatively small amounts of time and
resources up-front to reach a minimum level of preparedness can significantly improve outcomes for
vulnerable populations when an epidemic occurs, minimizing the impact on people and infrastructure.
Emergency supply chain preparedness is a critical element of country’s comprehensive emergency
preparedness and response activities. The key emergency supply chain management and
preparedness activities involve: identifying disease threats and needed commodities that should be
stocked in the emergency supply chain, as well as deciding whether to stockpile some of these
commodities in advance, and planning storage, transport, and logistics in the event of an emergency.
The major areas of ESC preparedness can be viewed as: people and processes, commodity planning,
and logistics and transport. Under these categories there are key elements involved in building an in-
country emergency supply chain preparedness capability. The journey of implementing capability will
involve doing work in each of these components.

Demand Forecasting: Before procurement of Emergency products, understanding the demand MCMs
by quantity forecasting is a critical step in the Emergency Supply Chain Management (ESCM) of PHEM.
By determining how much of certain MCMs will be needed in an anticipated or actual crisis, EPHI/PHEM
lays the groundwork by preparing a preparedness plan for an effective response and it reduces supply
shortages in the event of an outbreak.

Source of data for quantification are: population at risk, attack rates, Past incidence numbers
epidemiological behavior of pathogens, previous consumption, “belg and meher” survey figures,
program data and analysis of triggers. Quantification activity is being done by different groups: Facility
Based Teams, EPSA and PHEM- National level, Response and Rehabilitation Department- NDRM,
Supply and logistics, operation in NGOs. Before proceeding to procurement there should be a quantified
product list for an emergency case.

As part of the preparedness process, needs must be estimated based on different assumptions. The
table below gives you a general approach on how to estimate the number of supplies needed according
to the number of people in area at risk. Construct a simple excel spread sheet to calculate the supplies
that are required for your level.
 Level (e.g. Population of Expected Number Number of People
ORS in Sachets Ringer's Lactate of
Woreda) the Locality of Cholera Cases with Sever etc
(E) 1000 ml bag
(A) (B) (C) Dehydration (D)

xxx 000 (B) x attack rate (C) x sever rate (D) x 6.5 (D) x 6

yyy 0000 (B) x attack rate (C) x sever rate (D) x 6.5 (D) x 6

zzz 00000 (B) x attack rate (C) x sever rate (D) x 6.5 (D) x 6

.... .... .... ... ....

TOTAL Sum above Sum above Sum above Sum above Sum above

Table XX. Sample 'excel' worksheet to estimate required supplies for management of cholera

Instantly after an emergency event strikes, the institute conducts an initial assessment (usually within 2
days after occurrence). The expected quantity of supplies required to meet the needs of the specific
emergency and the affected population is re-assessed, the stockpiles and stock of supplies available in
the country (at EPHI, EPSA and partners’ warehouses), are evaluated. Additional essential commodities
and required resources, which need to be procured from suppliers, are determined. As next step, this
assessment is translated into supply requirements, and additional resource will be solicited if there is
any gap.

IIB-Emergency Supply Chain Coordination: Effective ESC Coordination is helpful for proper
utilization of resources in emergency situations. On the contrary, Lack of coordination leads to
confusion, ineffectiveness and wastage of resources. This has huge implication in the emergency supply
chain management. This, in turn, weakens the impact of humanitarian assistance. It is important that
Governments together with all aid agencies engaged on disaster relief are clear on who does what,
when and where.

The ESC preparedness journey will take several months of significant effort and capacity by a dedicated
core team of people, with participation from a broader range of stakeholders, and then will be
maintained on an ongoing basis. Understanding the roles played by different stakeholders ahead of time
will enable the strongest response from Day 1 of an emergency, with clear, coordinated involvement
from all stakeholders. PHEM’s logistics team will be in-charge of coordinating the overall emergency
supply chain management operations of local and international players. Cognizant to this, the team will
map the local and international players in a country’s emergency supply chain to understand their roles,
responsibilities, and capacities in an emergency. The mapping involves listing the names of relevant
organizations and individuals, contact information, roles and responsibilities, and geographic location. It
should also assess each partner’s material capacity, as well as technical expertise, across the following
dimensions: personnel, stockpiled commodities, warehousing and storage space, cold chain capacity,
transport and funds. The main government stakeholders working on public health emergency should be
dedicated enough during preparedness phase as well as be responsive during the response.

● Resource Mobilization and Mapping: The integration of national disaster risk management,
health system strengthening, IHR core capacity building and achieving Universal Health
Coverage (UHC) at all levels of government is only possible through the engagement of
different sector offices and strong collaboration in resource mobilization efforts. The active
engagement of humanitarian and development partners, private sectors and communities at
large are critical in resource mobilization through existing coordination forums at all levels. The
existing preparedness, coordination and planning forums in the humanitarian and development
forums play a vital role in engaging all actors in for resource mobilization. PHEM should
coordinate resource mapping and mobilization for emergency situations.

● Local Capacity with respect to Emergency Supplies: Local production of health products is
of an essential piece of the supply chain management. As demand for products increases,
countries with limited resources are often unable to avail products needed to mount effective
responses to public health emergencies. These countries are overly reliant on international
supply chains for these products, which can lead to challenges when global demand rises, and
supply is getting limited. Encouraging local manufacturing capability across the developing
world will not only support the immediate response to specific pandemic but it also creates more
resilient health systems and supply chains going forward. In mobilizing resources, it is important
to consider the local capacities as one of the strategies to produce emergency supplies

IIIC-Emergency Procurement Management: EPHI/PHEM or through its procuring agent must

rapidly procure additional goods and services to enable an effective response. The public health and
medical resources needed during an emergency are frequently different in character and quantity than
those used daily to address routine circumstances. The institute or its procuring agent should have a
comprehensive list of potential sources for all essential commodities. First-line suppliers should be pre-
identified, vetted, and contracted ahead of time to limit lead times. Suppliers should also be diversified to
limit risks such as long production lead times or local factory shutdowns due to the spread of infection.
Monitoring and Rehearsal/Simulation

Monitoring: This activity focuses on monitoring the implementation of identified activities indicated in
the sub-processes and reporting the status to respective stakeholders based on the frequency set in the
PHEM core process design. Validation and revision of operational and epidemic preparedness and
response plan (EPRP) through exercises, training, and real-world events, and the use of after-action
reports also contribute to evidence-based assessment of functional capacities and opportunities.
Findings from these experiences guide the refinement of the successive plans that will be used at
different phases.

Conduct performance review every year (Use appropriate methods such as workshop, review meetings,
questionnaire etc.). Document findings and lessons learnt and share with all stakeholders. Monitoring
indicators found in this guideline are expected to be used as a starting point to conduct monitoring of
programs at all levels. Therefore, the indicator should be refined and qualified according to the contexts
in which preparedness activities are to be carried out.
Simulation: Simulations are conducted in order to test preparedness in the absence of an event
suitable for an after-action review, to check or validate response capacity, and monitor for improvement
in identified areas. Such exercises are structured whereby the items at all levels test efficiency and
reliability of preparedness activities in an ideal setting.

These exercises is a focused practice activities that places participants in a simulated situation and
requires them to function in the capacity that would be expected of them in a real event. It can involve all
partners that are expected to take part in each type of emergency management and contribute to the
planning process. Conducting such an exercise helps to evaluates a system’s ability to execute the plan.
It allows the system to identify and correct problems in the plan prior to a real event.

Below are major activities that should be under taken to conduct a rehearsal/simulation under ideal
settings:

► Establish ideal contexts to simulate exercise: First, set objectives and methodologies for the
risk assessment exercise. Always begin by defining the scope of the risk management activity in
the context of its roles and responsibilities. Also define the physical, social, environmental and
statutory environment within which the simulated risk might exist. Doing so will help you to
exercise your simulation in a real-world setting. The simulation should consider all the
 stakeholders relevant to the risk’s management. Identify a setting where you will evaluate your
preparedness, considering the worst-case scenario for the selected risk. e.g., take a known
flood prone area to simulate your preparedness in related to malaria epidemic response.

► Choose an appropriate mechanism: It is possible to conduct simulation in different ways,

including face to face, online, etc. You will need to choose a mechanism which is appropriate for
your purpose. There are many different types of exercises. Depending on time, funding,
resources and what you would like to evaluate you can choose the type of exercise that is most
appropriate. Exercises may be discussion-based in order to familiarize participants with or refine
current plans, policies, agreements, and procedure. They may also be operations-based to
validate plans, policies, agreements, and procedures; clarify roles and responsibilities: and
identify gaps in an operational environment.

● Orientation Seminar: An overview or introduction designed to familiarize participants with

roles, plans, procedures or equipment.

● Discussion-Based Exercises
o Tabletop exercises (TTX): A tabletop exercise is a facilitated discussion of an
emergency situation, generally in an informal, low-stress environment. It is designed to
elicit constructive discussion between participants; to identify and resolve problems;
and to refine existing operational plans.

● Operations-Based Exercises
o Drills (DR): A drill is a coordinated, supervised exercise activity, normally used to test or
train a single specific operation or function in a repeated fashion. A drill aims to practice
and perfect one small part of a response plan, and should be as realistic as possible,
employing any equipment or apparatus necessary for that part.
o Functional exercises (FX): A functional exercise is a fully simulated interactive exercise
that tests the capability of an organization to respond to a simulated event. The
exercise tests multiple functions of the organization’s operational plan. It is a
coordinated response to a situation in a time pressured, realistic situation. A functional
exercise focuses on the coordination, integration, and interaction of an organization’s
policies, procedures, roles and responsibilities.
 o Full-scale exercises (FSX): A full-scale exercise simulates a real event as closely as
possible and is designed to evaluate the operational capability of emergency
management systems in a highly stressful environment, simulating actual response
conditions. This includes the mobilization and movement of emergency personnel,
equipment and resources. Ideally, the full-scale exercise should test and evaluate most
functions of the emergency management plan or operational plan. It involves multiple
agencies and participants physically deployed in a field location.

► Identify and orient the team: Communicate with all relevant stakeholders regarding the
purpose of the simulation exercise. This is a stage where you invite partners that would be
involved in a real event to participate in the simulation exercise. It is important always to brief
participants on the purpose of the exercise so that everyone will be aware of its role as well as
their individual and collective responsibilities in action.

► Conduct exercise: Remember to notify your staff if the simulation is in house and to notify
public if the simulation is in real situation.

► Identify strengths and limitations: The overall purpose of the rehearsal exercise is to identify
strengths and weaknesses in systems and capacities prior to an event. The process must
identify strengths and weaknesses in relation to:
o Coordination and collaboration that is expected to be in place
o Vulnerability assessment and risk mapping outcomes used in the decision-making
process,
o Quality of the planning process and preparedness inclusive of response details,
o Capacity building measures taken prior to an event

► Review and update the plan: Once the simulation exercise is over, record outcomes and
findings in a written format that captures the main recommendations. Review and update plans
and implement activities according to experience with a focus on coordination and
communication between the national and sub national levels of government and sectors.
Recommendations should be specific, feasible, time-bound, measurable and adequately
translated into an action plan. ensure that the updated plan is circulated to all members who
participated in the planning and rehearsal exercise.
04/ EARLY WARNING AND
DETECTION
Early Warning System

► Definition: Early warning systems are in most instances, timely surveillance systems that
collect information on epidemic-prone diseases in order to trigger prompt public health
interventions. However, these systems rarely apply statistical methods to detect changes in
trends of health and health determinants. The current surveillance system incorporates climate
data, geographical and other relevant environmental data with the purpose of surveillance and
early warning system for health.

Early warning 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. Early warning systems are designed to alert the population and relevant authorities in
advance about possible adverse conditions that could lead to a public health emergency and to
implement effective measures to prevent, mitigate, respond and recover effectively with reduced
adverse health outcomes.

The traditional framework of early warning systems is composed of three phases: monitoring of
precursors/signals, forecasting of a probable event, and the notification of a warning or an alert
should an event of catastrophic proportions take place.

Early warning and risk communication starts by identifying cases and / or events at health
facilities, , Port of Entries (POEs) and community level and ends by sharing data and
information for all relevant stakeholders in real-time. It also uses IHR notifications on events
happening in other countries with possibility of expansion. The early warning and
communication system for public health risks in Ethiopia is undertaken by the Public Health
Emergency Management system at all levels.
► Purpose: The purpose of early warning is to enable the provision of timely and effective
information to the public and to responders, through identified institutions that allow preparing
for effective response or taking action to avoid or reduce risk.

► Major Activities
● Data collection-public health and related data
● Data cleaning and analysis
● Interpretation of analysis result
● Public health risk assessment
● Evaluate potential for epidemic transmission
● Identify Public Health emergency epidemic-prone areas and populations at risk
● Forecasting/predicting of PHE risks
● Prediction of possible health outcomes
● communication message development with suggested possible interventions
● Selection of communication medias
● Dissemination and communication of PH risks
● Evaluation of early warning system and message utilization
● amendment of communication approaches
● Sentinel surveillance focused on early warning purpose

► Indicators: Public health early warning indicators are conditions which, when they occur or
change, signal an increase in the risk of occurrence of a particular threat to public health.
These indicators are regularly monitored to identify situations for which a public health action
may be needed.

Major indicators of early warning 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
 ● Environmental changes such as air pollution, water quality changes, contamination
● Occurrence of natural disasters such as drought, fire, flood, earthquake, severe
weather (meteorological information/prediction)
● Agricultural events such as reduced harvest, occurrence of pests or diseases
● Refugees, internally displaced people, disruption of health services and
infrastructure
● Important industrial accidents; chemical spills and possible biological attack
● Risky personal behaviors / lifestyles exposing to non-communicable diseases
● Occurrence of PHEs of international concern in other countries
● Occurrence of PHEs at cross border areas

Prediction / Forecasting

It is determining what is going to happen in the future by analyzing what happened in the past and what is going
on now. Health forecasting is predicting health situations or disease episodes and forewarning future events. It
is also a form of preventive medicine or preventive care that engages public health planning and is aimed at
facilitating health care service provision in populations. Health forecasting involves a degree of uncertainty, as it
is virtually impossible to have a perfect (i.e. 100 % error free) prediction.

The main activity for predicting/forecasting possible public health risks, emergencies and events includes:
● Data collection from health and other sectoral data
● Data cleaning
● Identify predisposing factors/variables for the occurrence of PHEs
● Identification of the type of data
● Selection of the type of model to build
● Estimate the parameters
● Develop tools for model estimation
● Validate the tool
● Forecast/predict PHEs occurrence by using the newly reported data
● Develop risk mapping by using the tool
● Estimate the possible effect of forecasted/predicted PHEs
 A PHE early warning system uses a community and event-based surveillance, indicator-based
surveillance and sentinel surveillance system (as depicted in Figure 5-1) to monitor threats,
risks, signals and priority diseases and/or conditions. As a basic principle of public health
intelligence, all components are given equal attention since a signal leading to a public health
alert can originate from any one of the surveillance systems.

Early Warning System

Community and Event-Based Indicator-Based

Surveillance (CEBS) Surveillance (IBS)

IDSR
Media, rumor, community
concern, clinical concern,
sectorial information
Laboratory-Based
Surveillance (LBS)

Sentinel Surveillance
System (SSS)

Syndromic Disease Surveillance

(SDS)

Figure 4 - 1 Components of early warning system

Public Health Surveillance System

► Definition: Public Health Surveillance is an ongoing, systematic collection, organization,

analysis, interpretation and dissemination of information, in order that action may be taken. It is
the use of data to monitor health problems to facilitate their prevention and control.
Surveillance is also defined as “Information for Action”.

A functional disease and event surveillance system is essential for defining public health
problems and taking action. Proper understanding and use of the public health surveillance
system helps health workers at each structural level to set priorities, plan interventions,
 mobilize and allocate resources, detect epidemics early, initiate prompt response to
epidemics, and evaluate and monitor health interventions. It also helps to assess long term
disease and event/condition trends and patterns.

► Objectives:
● To early detect epidemics (outbreaks) so that they can be controlled in a timely
manner
● To monitor trends in endemic / priority non-communicable disease in order to
inform policy decisions for changing trends
● To evaluate an intervention so that effective and efficient policies are identified
and supported
● To monitor progress towards a control, elimination and eradication programs so
that achievements against targets are measured
● To monitor programme performance with a view to enhancing it
● To predict/forecast public health emergencies occurrence and plan health
services to prevent, mitigate, respond/control and recover effectively
● To estimate future PHEs impact and develop health services according to
predicted needs
● To predict and prevent entry/exit and spread of infectious disease from
neighboring countries and international travelers and conveyances

► Process: A signal is data and/or information considered by the Early Warning and Response
(EWAR) system as representing a potential acute risk to public health. Signals may consist
of reports of cases or deaths (individual or aggregated), potential exposure of human beings
to biological, chemical or radiological and nuclear hazards, or occurrence of natural or man-
made disasters.

Signals can be detected through any potential source (health or non-health, informal or
official) including the media. Raw data and information (i.e., untreated and unverified) are
first detected and triaged in order to retain only the one pertinent to early detection purposes
i.e. the signals. Once identified signals must be verified. When it has been verified, a signal
becomes an “event”.
A verified disease outbreak or a health threat meets one of the following criteria:

● Need to be one of the following: SARS, polio (wild-type), smallpox, or a new

subtype of influenza?
● Presents a serious threat to public health?
● Unusual or an unexpected event?
● Poses a significant risk for international spread that potentially requires
international intervention?
● Potentially causes restrictions of trade or travel?
● Has direct/indirect contribution for the occurrence of PHEs
● An indication for the future occurrence public health risks
● Poses risk of spread beyond border?

Figure 4 - 2 Process of IDSR and EBS

Event-Based Surveillance (EBS)

It is an ongoing active process in detecting, collecting (mainly unstructured ad hoc information),

interpreting, notifying, responding to and monitoring public health emergencies and events at each
structural level of the health system. This system will complement the Indicator Based Surveillance (IBS)
system, relatively well functional at health facility level, by capturing signals and unusual occurrence of
PH risks. Information is initially captured as an alert, considered by the early warning and response
system as representing a potential acute risk (such as an outbreak) to human health. The event-based
surveillance system is very sensitive, and information received through it should be synchronized with
IBS and rapidly assessed for the risk the event poses to public health and responded to appropriately

EBS 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

Sources of data for the Event Based Surveillance includes existing channels of established formal and
routine reporting systems, and informal open channels, media scanning such as ProMed, blogs, social
media, radio, and television, health workers and community notification, private sectors and non-
governmental organizations. Sources of information that can be used for the early warning function go
far beyond traditional disease-based surveillance (including laboratory confirmation) and syndromic
surveillance. They encompass environmental/ecological surveillance and health-related behavioral
information. It also enables to capture and correct public health related misinformation circulated on
social media.

Community-Based Surveillance (CBS) has several advantages over case-based surveillance, because
case-based surveillance has at least the following limitations:
● Produces credible information but reporting is often delayed
● Is designed for known diseases and diseases are often not reported until the
etiology is known; Is not well-established in all countries
 ● Is limited to the health sector, whereas media and other types of open-source
reports often originate from highly-motivated entities, such as journalists, which
can promptly provide information to open sources

EBS Implementation Mechanisms

National Level:
● EBS implementation through hotlines and media scanning particularly at
PHEOC. This is the major function of PHEOC during the watch and alert phase of
PHEOC activation to monitor public health risks. The data collected through the
PHEOC (hotline and media scanning) need to be communicated to the right
department to be used for early warning purposes and for archival.
● Oversees implementation of EBS at lower levels (community to regional level)

Regional Level:
● EBS implementation through hotlines and media scanning particularly at PHEOC
● Supervises implementation of EBS lower levels (zonal to community level)

Zonal Level:
● District/Woreda health office ensures EBS implementation using
hotlines/landlines and media scanning
● Supervises implementation of EBS at health facility and community levels

Woreda Level:
● District/Woreda health office ensures EBS implementation using
hotlines/landlines and media scanning
● Supervises implementation of EBS at health facility and community levels

Health Facility Level:

● Health facility managers ensures EBS implementation at health facilities and
community level with the active engagement of the community dwellers
● Supervises EBS implementation at community level
Community Level:
● CBS Focal persons implement EBS at community level
● Detects and notify public health related alerts and events to the nearest health
facilities including health post
 Port Of Entry (POE):
● Passengers provide evidence of any health and related events/rumors they have
seen during their voyage to PoEs
● Travel for unexplained and unknown medical condition is traced by interview or
legal document review
● Any finding suspected to be risk for public health are captured by inspection on
the passengers baggage, cargo, containers, conveyances, goods, postal parcels,
mortum and Aircraft General Declaration

Community-Based Surveillance (CBS)

CBS is an ongoing active community participation in the process of detecting, collecting, interpreting,
notifying/reporting, responding to and monitoring public health emergencies, events and public health
related risks in the community. The scope of CBS starts from systematic and on-going detection of
public health risks/ early warning signals, collection, notification, verification, response and recovery as
necessary.

CBS systems collect various types of information from different sources such as community members,
public and private institutions, traditional healers, local associations and organizations depending on the
local context across the country. The different formal and informal sources of information can provide
timely information on health events/conditions such as cluster of cases, disease outbreak, unexpected
or unusual illnesses and deaths, rumors, new occurrences and any changes of risk factors for human
health.

CBS (CBS) widens the surveillance network to reach communities and enable to capture public health
related events that are not captured by the routine IBS system. So as to strengthen the indicator-based
public health surveillance system, engagement and empowerment of community members in public
health surveillance and response activities is crucial. Simplified/syndrome are used to facilitate rapid
detection of priority diseases, events/conditions and other public health hazards in the community.

Community and Event Based Surveillance system (CEBS) could function during pre-emergency,
emergency, and post-emergency periods. During the pre-emergency period, it provides transfer of early
warning messages and alerts about the incoming/forecasted threat by considering signal data on hand.
CEBS during an emergency period can actively detect and notify cases and deaths and engage in
response activities. CEBS at the post-emergency period can monitor the progress towards emergency
control.

CEBS provides a reliable and immediate communication structure to alert bordering areas by giving
voice to the existing local knowledge to identify and notify public health emergencies and other risks as
early as possible. Active community participation/engagement in a reliable response network is key
features of an effective CEBS system.

Generally, Community-Based Surveillance (CBS) is expected to timely capture PH early warning signals
happening in the community such as unusual and unknown occurrence of diseases or/and conditions,
cluster of cases and/or death of humans and animals that may indicate public health hazards and
rumors of unexplained death of humans and animals. It also enables capturing misperceptions and
misinformation related to public health threats circulated within the community.

EBS Implementation Mechanisms

National Level:
● MoH, EPHI and National level health partners are responsible for the coordination
and implementation of CBS system. The National Public Health Emergency
Management is the principal owner of CEBS and responsible for designing the
general CBS strategic partners at each level that support CBS planning,
implementation, monitoring and evaluation at their respective working level.
Regional Level:
● Regional Health Bureau PHEM/regional Public Health Institutes and regional level
health partners are responsible for planning, implementing, monitoring and
evaluating CBS status in the Region. RHBs can make necessary adaptations of
CBS to suit the existing contexts in their respective regions.
Zonal Level:
● Zonal Health Department, zonal steering committee and zonal health partners are
responsible to support, monitor and evaluate the status of CBS implementation.
Woreda Level:
● The Woreda PHEM, Woreda Health office head, Woreda RRT and Woreda
 women affairs office are the primary focal points for the planning, implementation,
monitoring and coordinating CBS related activities. Moreover, the administration
and working structures should be involved in the process of implementing and
monitoring CBS system implementation.
Health Center Level:
● The health center surveillance focal, RRT, health extension supervisor, local and
international NGOs and other health partners should implement/provide support
for CBS system implementation. The health center is responsible for overall
planning, implementation, monitoring and evaluation of CBS in the catchment
area.
Health Post/Kebele Level:
● HEWs, Kebele administrators, local and international NGOs and other health
partners working at community level are the actors of Community Based
Surveillance (CBS) at kebele level in detecting and notifying public health risks
and participating in other CBS activities. The HEWs are the technical coordinator
of CBS system implementation. The HEW should document and report
community notifications to the catchment health center on an immediate and/or
weekly basis.
Community Level:
● Women Development Army/Health Development Army networks are the bases
for CEBS implementation and civil societies (Edir, Equb etc.) can also play an
important role in detecting public health risks and notify to Community Based
Surveillance focal or nearby health departments.
Port of Entry (PoE):
● The community living at the national borders have to detect and notify any public
health risks happening at the bordering areas of both neighboring countries to the
nearest PoE site, CBS focal or health departments.

Critical Information Requirements (CIRs) for EBS and EBS Data

● Personal information (age and gender)

● Date of onset of the event
● location of event occurrence
 ● Major and common symptoms identified
● Any known/suspected predisposing factors
● Source of information etc

Integrated Disease Surveillance and Response (IDSR)

Indicator-based surveillance refers to structured data collected through routine integrated disease
surveillance, nutritional and laboratory surveillance. In integrated disease surveillance, the various
surveillance activities become integrated into one system within the broader national health system. It
also emphasizes all functions of surveillance activities to be carried out using similar structures,
processes and personnel.

Priority Diseases and Conditions for Surveillance

It is clear that surveillance could not be carried out for all diseases and conditions. Therefore, priority
should be given to those diseases that are of interest at national and international levels. In Ethiopia 32
diseases (17 immediately, 10 weekly, 4 monthly and 1 quarterly reportable events) are selected to be
included into the routine surveillance system.

These diseases and conditions are selected based on one or more of the following criteria:

► Diseases/conditions which have high epidemic potential (anthrax, avian human

influenza, cholera, measles, meningococcal meningitis, pandemic influenza,
smallpox, severe acute respiratory syndrome (SARS), viral hemorrhagic fever (VHF),
and yellow fever), chikungunya , COVID-19, Severe pneumonia in children under 5
years age, tuberculosis

► Diseases/conditions required internationally under IHR2005 (smallpox, poliomyelitis

due to wild-type poliovirus, human influenza caused by a new subtype, SARS)

► Diseases targeted for eradication or elimination (poliomyelitis due to wild-type

poliovirus, dracunculiasis, neonatal tetanus (NNT)

► Diseases/conditions which have a significant public health importance (rabies,

 dysentery, malaria, relapsing fever, and severe acute malnutrition, moderate acute
malnutrition, maternal death, perinatal deaths, adverse events following immunization,
Diarrhea with dehydration in children less than 5 years of age, Acute jaundice
syndrome within 14 days of illness, scabies, new HIV cases, new diabetes cases,
new hypertension cases, tuberculosis, severe pneumonia in children under 5 years
age

► Diseases/conditions that have available effective control and prevention measures for
addressing the public health problem they pose.

If the health system face newly emerged public health problem which is considered to be included in the
routine surveillance system, the following steps should be followed before decision for inclusion;

1. Collect detail information about the existed health problem (conduct research as
necessary)
2. Analyze the collected data in relation to the disease prioritization criteria listed
above
3. Develop case definition with thresholds
4. Technical experts will sent request of considering for routine surveillance to the
institute/EPHI leaderships
5. The leadership will review the request and attached evidence to be discussed at
ministry level
6. the Ministry of Health will present the request to the council/House of people
representative
7. The council will conduct detail review and discussion on the issue and request
additional clarification/evidence as needed
8. The council will approve or reject the request

Regions will also follow the same steps to consider new public health problems for surveillance at their
level. Furthermore, it is required to report the following emergency illnesses or health conditions that are
of concern to the public which need early intervention/response.
● Clusters of respiratory illness (including upper or lower respiratory tract infections,
difficulty breathing and Adult Respiratory Distress Syndrome),
● Clusters of gastrointestinal illness (including vomiting, diarrhea, abdominal pain,
 or any other gastrointestinal distress),
● Cluster influenza-like constitutional symptoms and signs,
● Clusters neurologic symptoms or signs indicating the possibility of meningitis,
encephalitis, or unexplained acute encephalopathy or delirium,
● Cluster of rash illness,
● Hemorrhagic illness,
● Botulism-like syndrome,
● Cluster of sepsis or unexplained shock, or an unexpected increase
● Cluster of febrile illness (with fever, chills or rigors), or an unexpected increase
● Non-traumatic coma or unexplained sudden death,
● Any unexplained and/or unknown occurrence of public health situation

Note: Region specific disease or events that have public health importance which warrant surveillance
can be added to their surveillance system.

Priority reportable diseases under surveillance are classified as immediately and weekly reportable
diseases as shown in table below

Immediately Weekly Monthly Quarterly

26. New HIV 32. Moderate Acute

1. Anthrax 16. Malaria
cases Malnutrition (MAM)

17. Diarrhea with dehydration in 27. Hypertension

2. Measles
children less than 5 years of age new cases

3. Human influenza caused by 18. Acute jaundice syndrome within 28. Diabetes new
new subtype 14 days of illness cases

4. Adverse events following 19. Severe pneumonia in children

29.Tuberculosis
immunization (AEFI) under 5 years age

5. Neonatal s/ non neonatal 30. Maternal

20. Viral Hemorrhagic Fever (VHF)
tetanus death

31. Perinatal
6. Rabies 21. Dysentery
death

All causes
7. Smallpox 22. Relapsing Fever
mortality indicator

8. Severe Acute Respiratory

23. Meningitis
Syndrome (SARS)
 24. Severe Acute Malnutrition
9. Yellow fever
(SAM)

10. Poliomyelitis (acute flaccid

25. Scabies
paralysis)

11. Chikungunya

12. Cholera

13. Dracunculiasis (guinea

worm)

14. Dengue fever

15. COVID-19

Table 4- 1: List of proposed reportable diseases, conditions and events in Ethiopia

Sentinel Surveillance System (SSS)

Sentinel surveillance system is a facility – based surveillance mechanism for selected

disease/conditions. It provides quality and specific data from the selected sentinel sites including case
based epidemiological information and also specimens for laboratory testing. An alternative to
population-based surveillance, sentinel surveillance involves collecting data from a sample of reporting
sites (sometimes called sentinel sites). Sentinel surveillance is not intended to serve as the sole method
for providing early warning of an unusual event. A sentinel surveillance system should, therefore, be
complemented by a more sensitive community and event-based surveillance system covering all
hazard/risk aspects of public health. The detection, reporting and investigation of such unusual events
are described in the IDSR guidelines which incorporate IHR.

Currently Ethiopia is being implementing the sentinel surveillance system for selected disease
conditions, including:
● Severe Acute Respiratory Syndrome (SARI) and Influenza Like Illness (ILI)
sentinel surveillance
● Climate sensitive diseases surveillance
● AFI (Acute Febrile Illness) and others
Based on the importance and impact of the disease condition as well as the necessity of sentinel
surveillance, other events/disease conditions might be included in the sentinel surveillance system as
required.
Syndromic Surveillance (SS)

Relatively new surveillance method that uses clinical information about disease signs and symptoms,
before diagnosis is made, often uses reports, electronic, or other forms of data from health
facilities/hospital emergency rooms.

Disease conditions manifesting common clinical signs can be detected under this surveillance system
and the data collection is based on prodrome resembling signs for common disease conditions. It also
helps to early detect disease conditions at community and health facility level such as influenza like
illness, Acute Febrile illness, Acute Flaccid Paralysis, rash, chemical emergencies, poisoning and
others. Currently, Ethiopia is implementing syndromic surveillance for Acute Flaccid Paralysis, Rashes
with fever, acute febrile illness and the like.

The syndromic surveillance collects data of the identified syndromes from the health facilities,
emergency department or any designated sites and oversees the manifestation of syndromes received
from other sites. The health facilities will send data to the PHEM office or health department for
aberration/abnormality detection and analyses. Signals requiring further diagnosis, analysis and
interpretation will be identified for epidemiological investigation.

Non-Communicable Disease Surveillance (NCDS)

Non-communicable diseases are major contributors to the burden of disease worldwide. While mortality
from these diseases is generally on the decline, population ageing means that the number of people
they affect is increasing and further strategies are needed for their prevention and control. In Ethiopia
the burden of non-communicable diseases like heart disease, kidney failure, chronic obstructive
pulmonary disease (COPD), cancer and mental illness is increasing and the data on the actual impact of
these disease conditions is limited. The implementation of non-communicable disease surveillance is
aiming to identify the magnitude by addressing it in the surveillance system that will help in policy
making, to identify appropriate prevention and control measures and strategies.

Possible sources of data:

● Incidence is collected through population-based disease registries
 ● Health facility-based registries where feasible
● Routinely collected health and administrative data systems (HMIS)
● Periodic Survey methodology representative of the national or sub-national level
might be used for estimation of the prevalence

Laboratory-Based Surveillance (LBS)

Laboratory-based surveillance is the key part of the overall surveillance as the detection and control of
outbreaks requires rapid identification of the pathogens and their source of infection. Starting from the
national level to the health post level, suspected outbreaks should be confirmed by laboratory
investigation. Objectives of laboratory-based surveillance include:
● To strengthen the existing laboratory-based surveillance
● To determine the baseline and monitor the circulating pathogenic agents in the
country
● To detect emerging pathogen strains
● To detect impending outbreaks and outbreaks of infectious disease

Case Detection/Identification and Notification

Case detection can be done at health service delivery units by health professionals or from community
level by Health Extension Workers or any community members. For detection of cases at health facility
and community level, case definitions will be used to detect priority PH events at both systems.

Case Definitions: It is a set of criteria used to decide if a person has a particular disease, or if the case
can be considered for reporting and investigation.

► Standard Case Definition: It is a case definition that is agreed upon to be used

by everyone within the country. It can be classified as confirmed, probable, and
possible or suspected. A standard case definition of suspected and confirmed
cases of the reportable diseases and conditions listed above is indicated in Table
3-2. These definitions must be used at all levels including the community, health
professionals working at health posts, health centers, hospitals, health offices at
different levels, private health facilities, other government health facilities and
 NGO clinics.

► Community Case Definition: It is a case definition of disease and conditions

adapted to suit health extension workers (HEWs) working at a health post level.
The community case definitions were modified for simplicity and ease of
understanding by HEWs. A list of 14-22 diseases and conditions are identified to
have community case definitions. A more simplified, symptomatic and loose case
definition is used by the community members to detect any public health
risks/conditions happening within the community (see Table 3.3).

Surveillance Data Reporting and Periodicity

Ethiopia is at the stage of piloting a new electronic reporting system for Integrated Disease Surveillance
(IDS) and Health Management Information System (HMIS). This system uses software that will be
installed on computers at different levels, the lowest being at health center level. Following the BPR
process, it is envisaged that woredas will be utilizing information technology opportunities to send and
share their reports electronically. The health sector will maximally use the existing and ongoing woredas
connectivity that is going on nationwide for this purpose. However, until these mechanisms are in place,
woredas are expected to send their reports with the available paper-based reporting system. The
identified 32 diseases and conditions are classified into four reporting periods (immediately, weekly,
months and quarterly) depending on their epidemic potential, acute severity, diseases targeted for
elimination and eradication. (Table 1 )

Immediate Reporting: For the immediately reportable diseases, a single suspected case is considered
as a suspected outbreak. Therefore, suspected outbreak of these diseases should be notified from level
to level within 30 minutes of identification as follows:
● From community or health post or health center to woredas health office within 30
minutes,
● From woreda health office to zone/region within another 30 minutes,
● From zone to regional office within another 30 minutes,
● From region health bureau to federal level within another 30 minutes,
● MOH to WHO within 24 hours of detection.
Report Case-Based Information to the Next level

If an immediately reportable disease, condition or other public health event is suspected:

● Make the initial report by the fastest means possible (telephone, text message,
facsimile, e-mail, radiophone). The health facility should contact the district health
authority immediately and provide information about the patient.
● Follow up the initial verbal report with a written report of the case-based report
form. A sample case-based reporting form for recording case-based information
is in Annex 2A at the end of this section. If a computer or other electronic device
is available for surveillance or case management, complete and submit the form
electronically to the next level.
● If a laboratory specimen is requested at this time, make sure that the patient’s
identifying information matches the information on the case-based reporting form.
A sample laboratory form is included in Annex 2B.65
● Disease-specific case-based reporting forms for particular diseases of concern
(cholera, VHF, maternal death, and MDR/XDR TB) are in the annex at the end of
Section 9. These forms may be used to begin gathering initial information for the
case investigation.

Note: Some epidemic-prone diseases may have specific reporting requirements depending on national
or regional policies. Please refer to disease-specific requirements in Section 9 of this guide.

● If a potential Public Health Event of International Concern (PHEIC) is suspected

(as defined in Annex 2 of the IHR 2005 guidelines), notify the National IHR Focal
Point using the fastest means of communication. A copy of the IHR decision
instrument is in Annex 2C at the end of this section.
● For events and diseases with epidemic potential detected at Points of Entry,
report immediately to the next higher level. Provide a copy of the report to the
national (or central level) for the National IHR Focal Point to assess using the
decision algorithm. Include yellow fever vaccination for those cases originating
from endemic or risk areas.
● After immediately notifying the next level about instances of immediately
reportable diseases, conditions or events, collect and report weekly summary
 information for the priority diseases, conditions and events.
● If no cases of an immediately reportable disease have been diagnosed during the
week, record a zero (0) on the reporting form for that disease. If the space is left
blank, the staff that receives the report will not be able to develop information
from a blank space. Submitting a zero for each immediately reportable disease
when no cases were detected during the week tells the staff that a complete
report has been filled.

Weekly Reporting: Reporting of the total number of cases and deaths seen within a week (Monday to
Sunday) and should be reported to the next level as follows:
● HFs report data from Monday to Sunday to woreda every Monday till midday;
● Woredas report to zone/region every Tuesday till midday;
● Zone (if applicable) report to region every Wednesday till midday;
● Region report to EHNRI /PHEM every Thursday;
● EPHI /PHEM report to stakeholders every Friday.

Monthly Reporting: Those diseases for which complete data is available on monthly basis and
provision of immediate intervention is impossible such as maternal and perinatal deaths and
chronic/non-communicable diseases/conditions. These data are mainly required for long-term
programming and policy briefing.

Quarterly Reporting: Data for some of the prioritized conditions like Moderate Acute Malnutrition
(MAM) is only available on a quarterly basis following the routine quarterly malnutrition screening
campaign. Therefore, reporting is done on a quarterly basis for such public health conditions.

Reporting can be done verbally or by telephone, printed report/paper based, radiophone or using
electronic methods such as email, fax, mobile short message service(SMS) based on the real situation
on the ground.

Reporting Tools and Period of Reporting

Reporting of prioritized diseases and conditions should be done by using their own appropriate reporting
formats. the reporting procedures might vary from reporting in the normal situations. This includes
 utilization of different disease/event specific reporting formats, change in reporting frequencies and
maintaining daily zero report, which is not routinely practiced. Different reporting tools/formats are
developed to facilitate and guide the reporting of prioritized diseases and conditions to be utilized at
different levels of the health system.

The table below shows the list of different reporting formats with their application level and periodicity of
reporting.

Level Formats to be used Periodicity

Weekly reporting format for HEW Weekly
AFP case investigation format Immediately
case-based reporting format Immediately
Health Post
Line list Daily
Rumor log book for suspected epidemics weekly
Modified IDS Case-based Reporting Format–NNT Immediately
Case-Based Reporting format Immediately
case investigation format Immediately
Modified IDS Case-based Reporting Format–NNT Immediately

Health Center / Guinea worm case-based reporting format Immediately

Hospital Influenza case-based reporting format Immediately
Rumor log book for suspected epidemics Immediately
Weekly reporting form Weekly
Line list Daily
Daily epidemic reporting format for Woreda Daily
Woreda Health
Weekly reporting format Weekly
Office
Rumor log book for suspected epidemics Immediately
Daily epidemic reporting format for region Weekly
Zone/Region Line list for guinea worm Immediately
Health
Bureau line list daily
Rumor log book for suspected epidemics Immediately

Table 4-2: List of formats to be used and the periodicity of reporting in different levels
 Figure 4-3: Formal and informal flow of surveillance data and information and feedback throughout the health system

Surveillance Data Analysis and Interpretation

Surveillance data analysis and interpretation is a crucial part that guides responses to public health
emergencies. Data analysis and interpretation should be done daily and weekly at each level where
data are collected (starting from health facility level to national level). The analysis provides key
information for taking prompt public health actions.

Data analysis provides the following important outcomes:

● Frequency count by reporting units help in identifying outbreaks or potential
outbreaks.
● Analysis of routine data provides information for predicting changes of disease
rates over time and enables appropriate action.
● Disease rates change over time. Some of these changes occur regularly and can
be predicted such as an increase of malaria cases following the rainy season.
 Analysis and use of the trends in summary data over time provides information for
improving prevention activities.
● Identifies problems in the health system; so that gaps can be effectively
implemented. For example, an outbreak of malaria should alert the public health
manager about the possibility of poor vector control, migration of infected people,
etc. in that area.
● During an outbreak, analysis of the data identifies the most appropriate and timely
control measures. Analysis in terms of person, time, and place will be help focus
the intervention.
● During an acute epidemic of a disease or condition the information that is
generated from data analysis leads to the identification of the most appropriate
and timely control actions. The actions are taken immediately to limit the epidemic
and prevent further cases from occurring.

The major steps in data analysis are: creating database or filed paper data, data cleaning and data
analyzing and interpretation (information generation).

● Create an electronic database or file paper data: The reports that are being
received daily and weekly have to be entered on daily basis into an electronic
database or kept on file using a paper format at each level of the health system. In
order to avoid loss of electronically saved data always make a backup and save it on
different computer or save it on a server.

● Data Cleaning: before starting analysis check if the data is complete. If reports are
missing or part of the data is incomplete, try to get the data before starting analysis.

● Data Analysis: Simple data analysis is done to find information related to person,
place, and time. The minimum data analysis practice that has to be 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), and Attack rate (AR). All the analysis can be
disaggregated by age, sex, place, at-risk groups, etc. File or store the information
generated through data analysis in an “analysis book”. Additionally, some of the
 graphs, tables and maps can be posted on the wall. Update the graphs tables and
maps every week.

Analyze data by time

Time includes variables such as day, week, month, and year. The purpose of “time”
analysis is to detect changes in the number of cases and deaths over time. It also
helps to compare the current disease trend with previous trends. It enables you to see
if thresholds are reached or not. Data about time is usually shown on a graph. Graphs
are made with bars (a bar graph) or lines (a line graph) to measure the number of
cases over time. The number or rate of cases or deaths is placed on the vertical or y-
axis. The time period being evaluated is placed along the horizontal or x-axis.

Example: The line graph below shows the trend of meningococcal meningitis cases in
a village of population of 27,000. Here the time period is a week. The trend of the
disease over weeks is increasing. Also it indicates that the alert threshold is crossed
at week 5.

12

10
10
Alert Threshold Line 9
8 8
8
7
6 6
6
5
4 4 4
4
Number of Cases

0
1 2 3 4 5 6 7 8 9 10 11 12

Number of Weeks

Figure 4-4 Trend of meningococcal meningitis analyzed by week

Analyze data by Place

Analyzing data according to place gives information about where a disease is

occurring such as woreda, kebele, town, etc. Establishing and regularly updating a
spot map of cases for selected diseases can give ideas as to where, how, and why
the disease is spreading. An analysis of place provides information on:
● Clusters of cases occurring in a particular area,
● Spot locations of cases and identify populations at highest risk for transmission of
the disease,
● Travel patterns that relate to the method of transmission for this disease,
● Common sources of infection for the cases,
● The population distribution and population density of the area,
● The variety of populations in an area (farming area, high-density urban area,
refugee settlement, and so on),
● Environmental factors such as rivers, lakes, pumps, and so on,
● Show distances between health units and villages (by travel time or distance in
kilometers).

Use manual methods or geographic information system (GIS) software to create a

map to use as part of routine analysis of surveillance of disease. On a map of the
area where cases occurred, mark the following:

● Roads, water sources, location of specific communities and other factors related
to the transmission risk for the disease or condition under investigation. For
example, a map for neonatal tetanus includes locations of traditional birth
attendants and health facilities where mothers deliver infants.

● Location of the patients’ residences or most relevant geographical characteristic

for this disease or condition (For example, by village, neighborhood, work camp,
or refugee settlement. When mapping young patients during a meningitis
outbreak remember to locate the school that the patients attend.)Other locations
appropriate to the disease or condition being investigated.
Analyze data by Person

Analysis by person includes the variables such as age, sex, ethnicity and other
occupational risk factors such health workers, food handlers, miners, etc. A simple
count of cases does not provide all of the information needed to understand the
impact of a disease on the community, health facility, or woreda, but simple
percentages and rates are useful for comparing information reported. Make a
distribution of the cases by each of the person variables in the reporting formats.

For example, compare the total number and proportion of suspected and confirmed
cases of measles by: Age group, Sex, Occupation, Urban versus rural residence,
Vaccination status, Risk factors, Outcomes and Final classification.

For each priority disease or condition under surveillance, use a table to analyze
characteristics of the patients who are becoming ill. For surveillance and monitoring,
use a table to show the number of cases and deaths from a given disease that
occurred in a given place and time. To make a table:
● Decide what information you want to show on the table. For example, consider
analysis of measles cases and deaths by age group,
● Decide how many columns and rows you will need. Add an extra row at the
bottom and an extra column at the right to show totals if needed.
● Label all the rows and columns.
● Record the total number of cases or deaths or both as needed.

Table 4-3 Measles cases and deaths in kebele X in 2009, aggregated by age

Number of reported
Age group Number of deaths % of reported cases
cases

0 - 4 years 40 4 40/50*100 = 80%

5-14 years 9 1 9/50*100 = 18%

15-30 years 0 0 0/50*100 = 0%

31 years and older 1 0 1/50*100 = 2%

Total 50 5 50/50*100 = 100%

To calculate the percentage of cases occurring within a given age group from the
example given above;
● Identify the number of cases reported within each age group from the data for
which time or person characteristics are known. (For example, there are 40 cases
in children 0 - 4 years age group)
● Divide the number of cases within each age group by the total number of reported
cases.(For example, for children age 0 - 4 years age group, divide 40 by 50 which
is equal to 0.8.)
● Multiply the answer with 100 to calculate the percentage.(0.8 x 100 = 80 %)
● Therefore, we can see that 80% of the measles cases occurred in children in the
0 – 4 years age group.

Case Fatality Rate (CFR): The case fatality rate helps to

● Indicate whether an outbreak is identified timely,
● Indicate whether the case-management is performed properly,
● Identify the level of response to treatment (virulent, new or drug-resistant
pathogen),
● Indicate poor quality of care or no medical care,
● Compare the quality of case management between different catchment areas,
cities, and woredas.

Public health programs can reduce the case fatality rate by ensuring that cases are
timely detected and good quality case management takes place. Some disease
control recommendations for specific diseases include reducing the case fatality rate
as a target for measuring whether the epidemic response has been effective.

To calculate CFR, use the following formula:

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑓𝑟𝑜𝑚 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑑𝑖𝑠𝑒𝑎𝑠𝑒

𝐶𝐹𝑅 = × 100
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠 𝑓𝑟𝑜𝑚 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑑𝑖𝑠𝑒𝑎𝑠𝑒

From Table 6 – 1, the overall CFR can be calculated by dividing the total number of
deaths by the total number of reported cases. Thus, the total number of reported
cases is 50 and the number of total deaths is 5. So 5 divided by 50 and multiplied by
100 bring the CFR to 10%. Therefore, 10% of the total cases died due to measles
from the outbreak data shown in Table6 – 1. It should be noted that the total number
of reported cases also includes those cases which have died as well. In a similar
manner, age-group specific CFR can also be calculated as shown in Table 6 – 2.

Table 4-4 Case fatality rate of measles outbreak in Kebele X in 2009

Age group # of reported cases # of deaths CFR

0-4 years 40 4 4/40*100 = 10%

5-14 years 9 1 1/9*100 = 11%

15-30 years 0 0 0/0*100 = -

31 years and older 1 0 4/40*100 = 0%

Total 50 5 5/50*100 = 10%

Attack Rate (AR): Calculate AR on weekly basis during an epidemic. Calculating 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

AR is a variant of an incidence rate, applied to a narrowly defined population

observed for a limited period of time, such as during an epidemic.

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑎 𝑠𝑝𝑒𝑐𝑓𝑖𝑐 𝑝𝑒𝑟𝑖𝑜𝑑

𝐴𝑡𝑡𝑎𝑐ℎ 𝑅𝑎𝑡𝑒 = × 100
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑠𝑐𝑒𝑝𝑡𝑖𝑏𝑙𝑒 𝑝𝑒𝑟𝑠𝑜𝑛𝑠

For example, from the Table 6 - 1 the number of new measles cases reported during
the year 2009 is 50. If we consider the total at risk population of kebele X is 4500,
then the AR is 50 divided by 4500, multiplied by 100 which is 1.1%. Therefore, out of
the total measles-susceptible population,1.1% acquired the infection.

Compare the current situation with previous week/months/quarter, seasons and

 years:
● Observe the trends on the line graphs and look to see whether the number of
cases and deaths for the given disease is stable, decreasing or increasing.
● If case fatality rates have been calculated, is the rate the same, higher, or lower
than it was in the previous months.
● Determine if thresholds for action have been reached or crossed.

Action and Alert Thresholds

Thresholds are markers that indicate when something should happen or change. They help surveillance
and program managers answer the question, “When will you take action, and what will that action be?”
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, and where do the diseases usually occur (example – a specific kebele
level malaria epidemic threshold should be determined based on the 5 years’
average data);
● International recommendations from technical and disease control program
experts.

Two types of thresholds, alert threshold and action threshold, are recommended for diseases under
surveillance (See Table 6 -3 below).

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,
● 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.

Action threshold: triggers a definite response. It marks that the findings from either the routine
surveillance or special investigation signal the need for action beyond confirming or clarifying the
problem. Possible actions include, communicating laboratory confirmation results to concerned health
centers, implementing an emergency response such as immunization, community awareness campaign,
or improved infection control practices in the health care setting etc.

Table 4-5 Alert and action thresholds for diseases under surveillance
Name of the diseases Alert Threshold Action threshold level

The activities associated with alert thresholds and action thresholds differ. Basic activities, as suggested
by the IDSR Technical Manual of 2009 are provided in Annex X.

Action Thresholds during Humanitarian Disasters

Most epidemic thresholds have been developed for stable populations, because these thresholds
require longitudinal data over a period of years. There are few data on the use of these epidemic
thresholds in emergency situations with recently displaced populations. Nevertheless, the establishment
of a surveillance system early in an emergency situation will ensure that baseline data on diseases with
epidemic potential are available.

This will allow an assessment of whether an increase in numbers of cases or deaths requires action or
not. At the onset of health activities, the health coordination team should set a threshold for each
disease of epidemic potential above which an emergency response must be initiated. Table 6 – 4 gives
action thresholds for selected diseases and events in a humanitarian setting.
Table 4-6 Epidemic thresholds for selected diseases in humanitarian settings (EWARS Threshold in
Humanitarian settings
Condition Alert threshold

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;
this is because generally only severe cases are hospitalized. Deaths are most
likely to be detected for cases that are hospitalized.
● Increases and decreases may be due to factors other than a true increase or
decrease in the number of cases and deaths being observed. For example, large
population movements or changes in health services can affect disease pattern.
● If no decrease is occurring while undertaking appropriate health intervention, the
number of cases is remaining the same or increasing, consider whether any of
the following factors are affecting reporting:
o Has there been a change in the number of HFs reporting
information?
o Has there been any change in the case definition that is being used
to report the disease or condition?
o Is the increase or decrease a seasonal variation?
o Are there community outreach or health education activities that
would result in more people seeking care?
o Has there been a recent immigration or emigration to the area or
increase in refugee populations?
o Has there been any change in the quality of services being offered at
the facility? For example, lines/waiting times are shorter, health staffs
are more helpful, drugs are available, and clinic fees are changed.
 Table 4-7 Summary of types of analysis, objectives, tools, and methods
Type of
Objective Tools Method
analysis

• Detect abrupt or long- • Record summary • Compare the number of

term changes in totals in a table or case reports received for
disease or unusual on a line graph or the current period with
Time event occurrence, how histogram. the number received in a
many occurred, and previous period (weeks,
the period of time from months, seasons or
exposure to onset of years)
symptoms.

• Determine where • Plot cases on a • Plot cases on a map and

cases are occurring spot map of the look for clusters or
Place (for example, to identify Woreda or area relationships between the
high risk area or affected during an location of the cases and
locations of populations outbreak. the health event being
at risk for the disease) investigated.

• Describe reasons for • Extract specific • Depending on the

changes in disease data about the disease, characterize
occurrence, how it population affected cases according to the
occurred, who is at and summarize in data reported for case-
Person greatest risk for the a table. based surveillance such
disease, and potential as age, sex, place of
risk factors work, immunization
status, school
attendance, and other
known risk factors for the
diseases.

Data Quality: Completeness and Timeliness

For routine weekly surveillance data calculate the completeness of the reports. All
woredas and levels above should calculate the completeness of the reports received
on weekly basis. A report is said to be complete if all the reporting units within its
catchment area have submitted the reports on time. E.g. if 9 out of 10 health facilities
have submitted, then the report is said to be incomplete (or 90% complete).

𝑡ℎ𝑒 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 ℎ𝑒𝑎𝑙𝑡ℎ 𝑓𝑎𝑐𝑖𝑙𝑖𝑡𝑖𝑒𝑠 𝑤ℎ𝑖𝑐ℎ 𝑟𝑒𝑝𝑜𝑟𝑡𝑒𝑑 𝑖𝑛 𝑡ℎ𝑎𝑡 𝑤𝑒𝑒𝑘

𝐶𝑜𝑚𝑝𝑙𝑒𝑡𝑛𝑒𝑠𝑠 = × 100
𝑡𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 ℎ𝑒𝑎𝑙𝑡ℎ 𝑓𝑎𝑐𝑖𝑙𝑖𝑡𝑖𝑒𝑠 𝑒𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑡𝑜 𝑟𝑒𝑝𝑜𝑟𝑡
Note that “the number of health facilities that are expected to report” for a particular
level (e.g. for a woreda) is the sum of all government hospitals, health centers, health
posts, other health facilities such as NGO health facilities, and other government
health facilities.

A report (from a reporting unit) is said to be on time, if it reaches the designated level
within the prescribed time period. If it reaches later, then the report is considered to
be late. The timeliness of a reporting unit can be calculated by assessing how many
of its expected reports have come on time.

Communication of Surveillance Information

The main objective of outbreak communication is to communicate with the public in

ways that build, maintain or restore trust, and encourage participation in the early
warning activities. Mechanisms of accountability, involvement, and transparency are
important to establish and maintain trust. Elements of communication include risk
communication, alert/ warning and provision of feedback.

Provide feed-back: Often, health facilities or woredas/zones health offices reliably

report surveillance data to the next level as required. If the facility does not receive
information back about how the data were used or what the data meant, health staff
may think that their reporting is not important. As a result, future reporting may not be
as reliable because health staff will not know if the information they sent to other
levels was useful or necessary. They will have a good understanding of the health
situation at their own level, but they will not know or understand the situation at a
woreda/zone/regional, or national level.

When the woreda receive data, they should respond to the health facilities that
reported it. And all the levels have to give feedback to the level that sends those
reports. The purpose of the feedback is to reinforce efforts of the health staff to
participate in the surveillance system. Another purpose is to raise awareness about
certain diseases and any achievements of disease control and prevention activities in
the area. Feedback may be written, such as a weekly or monthly newsletter, or it may
be given orally, for example, during a monthly staff meeting, reaching them
electronically or written reports.

Risk Communication and Information Sharing

The primary purpose of data sharing is to advance public health by permitting

analyses that allow for the fullest possible understanding of health challenges, to help
develop new solutions, and to ensure that decisions are based on the best available
evidence.

Data sharing benefits:

● To make better decisions about public health and resource allocation
● To eliminate errors in data, and to support the correct interpretation of data,
including by repeated independent validation
● Advance scientific understanding by allowing for analysis and hypothesis testing
by multiple groups of researchers
● Maximize transparency and accountability in tracking progress of health
programmes and in the conduct and funding of scientific investigations
● Provide for better-informed activities to establish health guidelines, norms and
standards
● Promote more complete and reliable systematic reviews and meta-analyses
● Lead to more comprehensive estimates of morbidity and mortality, more
comprehensive estimates of the effect of exposures and health interventions, and
improved systems.
● Build trust among institutions that contribute and use data

To avoid adverse consequences, the process of data sharing should:

● Should follow data sharing policy and guidelines of EPHI
● Safeguard the security of sensitive data, which may influence e.g. travel and
trade
● Safeguard the privacy and anonymity of individuals.
 Risk Communication: refers to activities for sharing information and ideas about
risks and actions to deal with real and potential dangers that could lead to an
indiscriminate demand that is impossible to meet. Effective communication and
warnings have to be short, concise, understandable, and actionable, answering the
questions of "what?", "where?", "when?", "why?", and "how to respond?”. The use of
plain language in simple, short sentences or phrases enhances the user’s
understanding of the warning.

Effective warnings should also include detailed information about the threat with
recognizable or localized geographical references. Therefore, proper communications
keep the public informed to calm fear and to encourage cooperation with the epidemic
response. Develop community education messages to provide the community with
information about recognizing the illness, how to prevent transmission and when to
seek treatment. Begin communication activities with the community as soon as an
epidemic or public health problem is identified.

● Decide what to communicate by referring to disease specific recommendations. Make

sure to include:
o The standard case definition of the disease,
o When to report and where to report,
o Signs and symptoms of the disease,
o How to treat the disease at home, if home treatment is recommended
o Prevention measures that are feasible and that have a high likelihood
of preventing disease transmission,
o When to come to the health facility for evaluation and treatment,
● Decide how to state the message. Make sure that the messages:
o Use local terminology
o Are culturally sensitive
o Are clear and concise
o Address beliefs about the disease
● Use appropriate communication methods that are present in the woreda/region
o Radio
o Television
 o Newspapers
o Meetings with health personnel, community, religious and political
leaders
o Posters
o Flyers
o Presentations at markets, health centers, schools, women’s and
other community groups, service organizations, religious centers
o Meetings with health personnel, community, religious and political
leaders
o Other (stickers, banners, brochures, etc.)
o Give health education messages to community groups and service
organizations and ask that they disseminate them during their
meetings.
On a regular basis, meet with the community spokesperson to give:
● Frequent, up-to-date information on the epidemic and response,
● Clear and simple health messages that the media should use without editing,
● Clear instructions to communicate to the media only the information and health
education messages from the PHEM guideline.
05/ RESPONSE
Definition

The involvement of the entire health system and the broadest possible intersectoral and inter-
institutional collaboration by developing policies and plans, and executing activities that reduce the
public health impact of emergencies and disasters.

Purpose

Public health emergency response to disease outbreaks, disasters, displacements, and other public
health issues which requires the integration and effective application of skills of multidisciplinary experts
and logistics. There must be a series of measures that are operating at the same time, each to a high
level of efficiency. This requires keeping clear objectives in mind and the efficient application of
resources.

A well-designed and sensitive early warning and detection system coming from both formal and informal
sources, within and outside of the health sector signals and alerts to respond rapidly to emergency
health threats. The efficient collection of pertinent information informs and guides the public health
response to all acute public health events including: unknown, unusual or unexpected diseases or
disease patterns of all origins of biological, chemical, radiological or nuclear as well as hazards that
could potentially pose a risk to human health.

It is therefore important to strengthen the public health emergency operations centers as part of a
comprehensive response program by implementing a common organizational model or Incident
Management System or frameworks to all levels of emergency management responsibility within a
jurisdiction, from national government to front-line emergency response services to routine emergency
disaster management activities, epidemic and non-epidemic public health emergencies particularly at
woreda and community levels.
Nature of Public Health Emergencies

Some public health emergencies or outbreaks occur suddenly while others occur gradually giving you
time to think. The size of the public health emergency can be small or large. Principal activities that are
required during each phase of a public health emergency response are indicated below.

Table 5-1 Response activities to be carried out at different levels according to the different phases of the emergency

Sudden Onset Crisis Slow Onset Crisis

Phase I: First 24-72 hours Phase I: First 1-2 weeks

 Activation of the EOC at Federal/Regional level  Preliminary working scenarios (anticipated health
 Notification of activation of EOC needs and risks)
 Activation of the contingency plan and /or EPRP  Inventory of “ Who-Where-When-What’ (the 4Ws)
 Preliminary enquiries and consolidation of and gap analysis
information  Preparation and dissemination of PHEMTTF
 PHEM TF meetings – Federal/Regional minutes and reports
 Conduct of regular task force meeting, planning
 Collection of baseline information
 Planning the initial rapid assessment
 Intensify the surveillance system

Phase II: First 4-10 days Phase II: First month

 Health Resource Availability and Mapping System  Regular health coordination meeting –
(HeRAMS) Federal/Regional
 Conduct the initial rapid assessment  Update working scenarios, resource inventory and
 Intensify the surveillance system gap analysis
 Establish disease surveillance at the temporary  Review/update health sector plan
site (if there is any)  Review/update the sectoral humanitarian
 Review and distribution of standards and requirement Preparation and distribution of regular
protocols bulletin /feedback

Phase III: 4-6 weeks (disaster) to up to 3 months (conflict) Phase III: 2-3 months
 Operating based on the HeRAMS information  Communicate objectives, strategies and action
 Fully operational Early Warning and Response plan with all concerned
System (EWARS) and regular exchange of  Implementation of response strategies and
surveillance data and response operations monitoring
 Continuation of regular meeting  Preparation/update of multi-sectoral response
 Finalization of the response strategy appeal
 Planning scenarios (identified health problems  Resource mobilization
and risks)  Frequent updating of resource inventory and gap
analysis
 Establishment of technical working groups as
 /when needed
 Organization and conduct of integrated training
as/when needed
 Coordination of logistic support
 Monitoring implementation of PHE response
strategies and the plan and task force activities

Phase IV: Continuing humanitarian response and Phase IV: Continuing humanitarian response and
progressive recovery progressive recovery
 Continuation of regular coordination  Periodic updating of planning
meeting (e.g. bi weekly) scenario and HeRAMS
 Periodic updating of planning  Establishment and /or suspension of
scenario and HeRAMS technical working groups
 Establishment and /or suspension of  Maintenance of enhanced
technical working groups surveillance
 Maintenance of enhanced  Real time or interim/mid-term evaluation of the
surveillance sector response status
 Real time or interim/mid-term evaluation of the  Comprehensive assessment as needed
sector response status  Updating of strategic plan with increasing focus on
 Comprehensive assessment as needed recovery Contingency planning for possible
 Updating of strategic plan with increasing focus on changes in the situation
recovery Contingency planning for possible
changes in the situation

Phase out: Phase out:

 Phase out plan for emergency programs as  Phase out plan for emergency programs as
recovery activities increase recovery activities increase
 Final evaluation and lessons learned  Final evaluation and lessons learned
exercise exercise
 Deactivation of the PHEOC  Deactivation of the PHEOC

Legal Considerations: All outbreak investigation and response activities needs to be guide by the rules
and regulations of the country. Emergency laws that place limitations on individual freedoms must:
 Respond to a pressing public or social need;
 Pursue a legitimate aim;
 Be proportionate to the legitimate aim; and
 Be no more restrictive than required to achieve the purpose sought by restricting the right.
Outbreak Management

Receiving of Alerts and Declaring an Outbreak/Event

The Early Warning System of Public Health Emergency Management Centers would be the primary
sources of information for front-line responders and/or health authorities regarding public health threats,
emergency events/incidents that may require emergency notification of all or parts of the concerned
bodies or the public.

Upon receipt of an alert, rumor, or detection of a deviation the disease or condition from the expected
trend while performing weekly surveillance data analysis, communicate the respective level immediately
for verification. For some communicable diseases, a single suspect case is the trigger for taking action,
reporting the case to a higher level, and conducting an investigation. For other diseases, the trigger is
when a case threshold is reached. Rapid response limits the number of cases and geographical spread,
shortens the duration of the public health emergency, and reduces fatalities. These benefits not only
help save resources that would be necessary to tackle public health emergencies, but also reduce the
associated morbidity and mortality.

The ministry of health and Ethiopian public health institute will have the leading role at the national level
and the Regional health bureau and Regional public health institutes will have the leading role at the
regional level; the Zonal and Woreda health offices will also have the leading role in emergency
notification, declaration and taking appropriate response measures related to any public health events or
outbreaks. The Ministry of Health/EPHI/ also has the primary responsibility to advocate on the centrality
of health in emergency disaster risk management (EDRM) across all hazards – natural, technological,
societal, and biological.

PHEM unit at each level of the health system will generally have the responsibility to convene key
partners and stakeholders within Ministry (WASH, medical service directorate, emergency and critical
care directorate etc) or outside of the Ministry such as, concerned private and government sectors
(security, agriculture, education, transportation sectors etc) to ensure their appropriate contributions to
public health emergency management, including the development of essential response capacities.
Outbreak Investigation

Definition: An outbreak investigation is a method for identifying and evaluating

people/animal/environment which have been exposed to an infectious disease or affected by an
unusual health event.

Purpose: The investigation provides relevant information for taking immediate action and
improving long-term disease prevention activities. It also helps to establish the existence of an
outbreak by collecting specimen and relevant information. In addition, it identify source of
infection or cause, transmission pattern and appropriate response activities to control the
epidemic.

Timing: Upon receipt of an outbreak/emergency alert, a systematic joint multidisciplinary

outbreak/emergency investigation will be undertaken to verify the occurrence of a public health
events/ disease outbreak and to scientifically identify the source, transmission mechanism and
contributory factors, as a basis for outbreak/emergency response.

Woredas should aim to investigate suspected epidemics within 3 hours of notification.

It is expected to conduct an investigation when: a report of a suspected epidemic of an

immediately notifiable disease is received, an unusual increase is seen in the number of deaths
during routine analysis of data, alert or action thresholds have been reached for specific priority
diseases, communities report rumors of deaths or a large number of cases that are not being
seen at a health facility, a cluster of deaths occurs for which the cause is not explained or is
unusual (for example, an adult death due to bloody diarrhea).

Steps: In investigating an outbreak both speed of the investigation and getting the right answer
are essential. To satisfy both requirements follow the following 10 steps:

I-Prepare for Field Work:

● If epidemic preparedness activities have taken place in the woreda or health facility,
staff who might be able to take part in the investigation should already be identified
and trained. This team is termed as the Rapid Response Team.
 Rapid Response Team (RRT): It should ideally involve the following experts but might be
expanded depending on the disease suspected and the control measures required. The RRT
should include: An epidemiologist; Clinician; Laboratory technician; Environmental health
specialist; Public health officer; a representative of the local health authority; and more
professionals based on the type of the PHE. Prior to deployment, all members of the RRT should
be briefed on the situation, the roles and responsibilities they are expected to play, means, time,
and frequency of communication etc. One member of the team should be assigned as the team
leader.
● Identify and assign the roles and responsibilities of other sectors and partners in the
investigation.
● Reactivate the epidemic response committee or technical working group.
● Arrange a meeting as soon as an epidemic is suspected or recognized. Then meet
as often as needed to plan, implement, monitor and report on the epidemic
response.
● Conduct Rapid Need Assessment
● Review information already known about the suspected illness, including its
transmission method and risk factors.
● Use this information to define the geographic boundaries and target population for
conducting the investigation.
● Begin the investigation in the most affected places.
● Avail relevant resources that are required during the field activity such as: case
based formats, line list, outbreak reporting formats, guideline, Supplies for
collecting lab specimens, personal protective equipment (PEE), laptop, wireless
network and mobile phone).

Table 5 - 2 Principal steps in organizing and undertaking a rapid needs assessment

Steps Activities

Initial decision Agreement among health related agencies and the government that an
assessment is needed

Planning the Half day planning meeting and follow up work by individuals and sub groups to:

Assessment • Compile available (secondary) data and agree on a working scenario,

Day 1 • Agree on objectives, scope of work and timeframe(dates) for the

assessment and its relationship to other assessment activities,
 • Agree on information requirements, data collection methods, and
criteria for deciding where to go (site selection procedures) and
with whom to talk,
• Design a rapid assessment tool, interview guides, identify any
additional questions/observation that need to be added,
• Identify personnel for field work,
• Prepare maps, supplies, equipment and background information kits
for field teams,
• Assemble and train field team,
• Arrange transport and communication for the field team,
• Inform key persons (Council, MoH and partners) in areas to be visited,
• Plan (arrange for) the processing and analysis of data during and after
the field work.

• Visits by teams to purposely-selected areas /sites.

Field Work 5-6 • Interview and collect data from officials and other key informants at
Days administrative and health facility levels.
• Interview community groups and households.

• Processing and analysis of data (primary and secondary data).

Analysis and Identification of priority problems, needs, risks and gaps.

Reporting • Analysis of possible strategies and development of

3-4 days recommendations. Preparation of the report.
• Dissemination of the report.

II-Establish the Existence of an Outbreak: In order to establish the existence of an

outbreak:

● Review trends in cases and deaths due to the disease over the last 1-5 years (if
available);
● Determine a baseline number to describe the current extent of the disease in the
catchment area;
● Know the epidemic threshold for that particular disease;
● Compare the reported case versus the baseline and the threshold per month or
week under that particular catchment area;
● Take into account factors influencing disease occurrences such as seasonal
variations in some of the diseases such as malaria and meningitis;
● Based on the finding, decide whether the outbreak exists or not.
III-Verify the Diagnosis: Diagnosis must be confirmed either on a clinical basis by senior
clinical workers or by laboratory tests, in which 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.

When verifying the existence of an outbreak early in the investigation, you must also

● Identify as accurately as possible the specific nature of the disease.

● Examine patients at the health facility and review records to confirm that the signs
and symptoms meet the standard case definitions.
● Review laboratory results for the people who are affected. If you are at all uncertain
about the laboratory findings, you should have a laboratory technician review the
techniques being used. Collect samples to isolate the organism or identify the
evidence for infection.

An assessment of current clinical and epidemiological information is the starting point for
dealing with the problem of an outbreak of unknown origin. The historical knowledge of
regional endemic and epidemic diseases, as well as their seasonality, further defines the
possible causes. Since a variety of infectious agents can cause a similar clinical picture, the
initial steps of the outbreak investigation (case definitions, questionnaires, etc.) should
generally elaborate on known syndromes.

One or more specimen types may be required to define the cause of the outbreak.
Laboratory confirmation of initial cases is necessary for most diseases when an outbreak is
suspected. Specimens obtained in the acute phase of the disease, preferably before
administration of antimicrobial drugs, are more likely to yield laboratory identification of the
cause.

During the outbreak investigation, the information contained in the case investigation and
laboratory request forms is collected along with the specimen. Assign each patient a unique
identification number. It is the link between the laboratory results on the line listing form, the
specimens, and the patient, which guides further investigation and response to the
outbreak. This unique identification number should be present and used as a common
reference together with the patient’s name on all specimens, epidemiological databases,
and forms for case investigation or laboratory request.

IV-Define and Identify Additional Cases: Once the initial cases have been confirmed and
treatment has begun, actively search for additional cases. Your next task as an investigator
is to

● Establish a case definition, or a standard set of criteria for deciding whether, in this
investigation, a person should be classified as having the disease or health
condition under investigation.
● Search for additional suspected cases and deaths in the registers in the health
facilities where cases have been reported,.
● Look for other patients who may have presented with the same or similar signs and
symptoms as the disease or condition being investigated.
● Search for suspected cases and deaths from neighboring health facilities.
● Search for suspected cases, deaths and contacts in the community by identifying
areas of likely risk where the patients have lived, worked, or travelled.
● Talk to other informants in the community such as health extension workers,
pharmacists, school teachers, veterinarians, farmers and community leaders etc.
● Collect information that will help to describe the magnitude and geographic extent
of the outbreak.
● Refer newly identified cases to an appropriate health facility for treatment.
● Record information about additional cases on a case-based reporting forms for at
least the first five patients.
● Record information on a case-based form for all those patients from which
laboratory specimens will be taken.
● Record any additional cases on a line list when more than five to ten cases have
been identified, the required number of laboratory specimens have been collected,
● Use the line list as a laboratory transmittal form if 10 or more cases need laboratory
specimens collected on the same day and specimens will be transported to the lab
in a batch.
V-Analyze Data Collected in terms of Time, Person and Place: the methods for
analyzing outbreak data are similar to the analysis of routine surveillance data. Once you
have collected some data, you can begin to characterize an outbreak by time, place, and
person. Characterizing an outbreak by these variables is called descriptive epidemiology. In
fact, you should perform this step throughout the course of an outbreak.

During an epidemic, these data will need to be updated frequently (often daily) to see if the
information being received changes the ideas regarding the causes of the outbreak.

● Analyze Data by Time: Prepare a histogram using data from the case-based
reporting forms and line lists. Plot each case on the histogram according to the date
of onset. As the histogram develops, it will illustrate an epidemic curve. Draw the
epidemic curve for each of the localities separately. For example, decide if the
curve should describe the entire woreda or the health facility catchment area where
the case occurred.

● Determining incubation period and period of exposure: In common source

outbreaks involving diseases with known incubation periods, epidemic curves can
help determine the probable period of exposure. This can be done by looking up
the average incubation period for the organism and counting back from the peak
(median) case the amount of time of the average incubation period.

The purpose for highlighting date of onset of the first (or index) case, Date the first
case was seen at the health facility, When the health facility notified the
woreda/zone, When the woreda/zone began the case investigation, A concrete
response began and When the woreda/zone notified the regional/national level
etc with arrows is to evaluate whether detection, investigation, and response to the
epidemic was timely.
 Epidemic Curve
It can provide information on the following characteristics of an outbreak:
- 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 can reveal the type (pattern) of outbreak
which are: Common source, point source and propagated.

Common Source Outbreak: It is one in which people are exposed continuously or

intermittently to a common harmful source. The period of exposure may be brief or long. A
continuous exposure will often cause cases to rise gradually (and possibly to plateau, rather
than peak). An intermittent exposure in a common source outbreak often results in an epidemic
curve with irregular peaks that reflect the timing and extent of the exposure).

Point Source Outbreak: It is a common source outbreak in which the exposure period is
relatively brief, and all cases occur within one incubation period. It has a sharp upward slope
and a gradual downward slope typically describes a point source outbreak.

Propagated Outbreak: It is one that is spread from person to person. Because of this,
propagated epidemics can last longer than common source epidemics, and may lead to
multiple waves of infection if secondary and tertiary cases occur. The classic propagated
epidemic curve has a series of progressively taller peaks, each an incubation period apart, but
in reality the epidemic curve may look somewhat different.

● Analyze Data by Person: Review the case-based forms and line lists and compare
the variables for each person suspected or confirmed with the disease or condition.
For example, depending on the factors that must be considered in planning a
specific response, compare the total number and proportion of the suspected and
confirmed cases according to Age or date of birth, sex, occupation, residence,
immunization status, inpatient and outpatient status, risk factors, outcome of the
episode such as whether the patient survived, died or the status is not known, and
Laboratory results, final classification of the cases and other variables relevant to
the disease (for example death by age group). Please see the disease specific
guidelines for recommendations about the essential variables to compare for each
disease.
 ● Analyze Data by Place: Construct a spot map by using the place of residence on
the case reporting forms or line lists. Then see what the map look like and this will
helps to describe the geographic extent of the problem, Identify and describe any
clusters or patterns of transmission or exposure, depending on the organism that
has contributed to this epidemic, specify the proximity of the cases to likely sources
of infection, calculating place/location specific attack rates in addition to examining
the number of cases in each locality allows comparison on the rate of transmission
in different population sizes

VI-Develop a Hypothesis: At this point in an investigation, after you have interviewed

some affected people, spoken with other health officials in the community, and
characterized the outbreak by time, place, and person, your hypothesis will be sharpened
and more accurately focused. The hypothesis should address the source of the agent, the
exposures that caused the disease, etc. For example, when there is measles outbreak, the
first hypothesis could be failure of vaccination or vaccine failure. While developing
hypotheses consider what you know about the suspected disease outbreak and look at the
issues such as: What is the agent’s usual reservoir? How is it usually transmitted? What
vectors are commonly implicated? What are the known risk factors?

Descriptive epidemiology often provides some hypotheses. If the epidemic curve points to a
narrow period of exposure, ask what events occurred around that time. If people living in a
particular area have the highest attack rates, or if some groups with particular age, sex, or
other personal characteristics are at greatest risk, ask why. Such questions about the data
should lead to a hypothesis that can be tested.

VII-Evaluate Hypotheses: There are two approaches you can use, depending on the
nature of your data: Comparison of the hypotheses with the established facts and analytic
epidemiology, which allows you to test your hypotheses. Use the first method when your
evidence is so strong that the hypothesis does not need to be tested. Use the second
method when the cause is less clear. With this method, you test your hypothesis by using a
comparison group to quantify relationships between various exposures and the disease.
There are two types of analytic studies: cohort studies and case- control studies. Cohort
studies compare groups of people who have been exposed to suspected risk factors with
groups who have not been exposed. Case-control studies compare people with a disease
(case-patients) with a group of people without the disease (controls). The nature of the
outbreak determines which of these studies you will use.

VIII-Refine Hypotheses and Carry out Additional Studies: When analytic

epidemiological studies in steps above do not confirm your hypotheses, you need to
reconsider your hypotheses and look for new vehicles or modes of transmission. This is the
time to meet with cases to look for common links and to visit their homes to look at the
products on their shelves. Even when your analytic study identifies an association between
an exposure and a disease, you often will need to refine your hypotheses. Sometimes you
will need to obtain more specific exposure histories or a more specific control group.

When an outbreak occurs, whether it is routine or unusual, you should consider what
questions remain unanswered about the disease and what kind of study you might use in
the particular setting to answer some of these questions. The circumstances may allow you
to learn more about the disease, its modes of transmission, the characteristics of the agent,
and host factors. While epidemiology can implicate vehicles and guide appropriate public
health action, laboratory evidence can confirm the findings. Environmental studies often
help explain why an outbreak occurred and may be very important in some settings.

IX. Implement Control and Prevention Measures: Implementation of control and

prevention measures should be started as soon as possible. Take steps to support
improved clinical practices in the district. Review the recommendations for treating cases of
different diseases during an outbreak.

The data gathered in the course of these investigations should reveal why the outbreak
occurred and the mechanisms by which it spread. This in turn, together with what is known
about the epidemiology and biology of the organism involved, will make it possible to define
the measures needed to control the outbreak and prevent further problems.
In addition, grading of the public health emergency with the scale, complexity, urgency,
capacity, and reputational risk of the public health emergency helps to determine the level
of operational response required by the local/regional/national PHEM.

o Ungraded: PHE or event that is being monitored by EPHI and/or

regional health bureau but that does not require an EPHI response
(It can be handled at local level by zonal and woreda PHEM).

o Grade-I: Limited national/EPHI response/involvement but the

regional health bureau engagement is required. Regional health
bureau has to reorganize staff and functions, but has most of the
capacity to provide the support required by the event. In this case,
EPHI may deploy a team of experts for minimal support.

o Grade-II: Moderate national level response required. Local and

regional health bureau requires external inputs to organize the
response and probably one or more external Incident Management
Team staff.

o Grade-III: Major/maximal national level response required due to

higher extent of the PHE or event with higher scale, complexity and
urgency affecting wider area involving more than one regional state
and population. When the external support required is such that it
mobilizes national PHEM/MOH organizational wide assets.

Mobilize Public Health Emergency Rapid Response Team (RRT)

A Public Health Emergency Rapid Response Team (PHERRT) is a technical,

multidisciplinary team that is readily available for quick mobilization and deployment in case
of emergencies to effectively investigate and respond to emergencies and public health
events that present significant harm to humans, animals and environment irrespective of
origin or source. PHERRT should be established at the district, regional and national levels.
The PHERRT would have already been identified during preparedness activities. Mobilize
the teams and make sure that their membership reflects the technical needs of the
response. Neighboring districts, zones or regions should be informed about the public
health events and coordinate response efforts with them for intended outcomes.

Roles and responsibilities of the national, regional and district PHERRT

o Investigate rumors and reported outbreaks, verify diagnosis and
other public health emergencies including laboratory testing;
o Collect additional samples from new patients and old ones if
necessary (human, animals, food, and water);
o Conduct follow-up by visiting and interviewing exposed individuals,
establish a case definition and work with community to find
additional cases;
o Assist in laying out mechanisms for implementing infection
prevention and control measures;
o Assist in generating a line list of cases and conduct a descriptive
analysis of data (person, place and time) to generate hypothesis,
including planning for a further analytical study;
o Propose appropriate strategies and control measures including risk
communications activities;
o Establish an appropriate and coordinated risk communication
system through a trained spokesperson;
o Coordinate rapid response actions with national and local
authorities, partners and other agencies;
o Initiate implementation of the proposed control measures including
capacity-building;
o Conduct ongoing monitoring/evaluation of the effectiveness of
control measures through continuous epidemiological analysis of
the event;
o Conduct risk assessments to determine if the outbreak is a potential
public health emergency international concern (PHEIC);
o Prepare detailed investigation reports to share with PHEMC
committee;
o Contribute to ongoing preparedness assessments and final
 evaluation of any outbreak response;
o Meet daily during outbreaks and quarterly when there is no
outbreak; and
o Participate in Simulation Exercises.

Select and Implement Appropriate Public Health Response Activities

Implementing a response means executing the operational steps so that the actions are
carried out as planned. The data gathered in the course of the investigations should reveal
why the outbreak occurred and the mechanisms by which it spread. This in turn, together
with what is known about the epidemiology and biology of the organism involved, will make
it possible to define the measures needed to control the outbreak and prevent further
problems.

Review investigation results and data analysis interpretation provided by Public Health
Emergency Rapid Response Team (PHERRT) to select appropriate response activities that
would contain the confirmed outbreak or public health event. Depending on the outbreak or
event, the success of the response depends on activation of the IMS and implementation of
intervention strategies such as:

● Overall coordination;
● Case management as well as infection, prevention and control (IPC);
● Logistics and supply chain management;
● Laboratory or diagnostic surveillance and epidemiology;
● Social mobilization and risk communication;
● Reactive vaccination;
● Water, sanitation and hygiene (WASH);
● Vector control.

The selected activities for responding to outbreaks or public health events include the
following:

● Build the capacity of response staff: Provide relevant capacity-building

 opportunities for response staff on the outbreak or event case definition, case
management procedures, reporting process and required data elements. It is
essential that members of the PHERRT are aware of and have access to any
indicated personal protection equipment and IPC practices relevant for the
disease targeted by the response. If there are immunization requirements for
responding to the particular disease or condition, ensure that members of
PHERRT are protected with the required vaccines.

● Enhance surveillance during the response: During a response to an outbreak,

health staff at all health facilities must be vigilant in surveillance of the disease,
condition or events, by liaising with the community health worker or any person
identified as a community focal person. During response, it is important also to
work closely with neighboring districts to ensure that the outbreak does not spill to
another district. It is important to share information and also plan for joint
surveillance and response activities. Initiate the establishment of the cross-border
disease surveillance and response committees to provide a platform for sharing
surveillance data, epidemiological and related information during the outbreak.

● Engage the community during the response: Effective risk communication is

an essential element of managing public health events. It is a crosscutting activity
that can impact other technical areas of the response such as WASH,
vaccination, community surveillance, etc. It is also essential to create trust
between first responders and the community. When the public is at risk of a real
or potential health threat, treatment options may be limited, direct interventions
may take time to organize, and resources may be few. Communicating advice
and guidance, therefore, may be the most important public health tool in
managing a risk.

● Inform and educate the community: Keep the public informed to calm their
fears and encourage cooperation with the response efforts. Develop community
education messages with information about recognizing the illness, how to
prevent transmission and when to seek treatment. Begin communication activities
with the community as soon as an epidemic or public health problem is identified.
 Identify community groups or local NGO or outreach teams that can help gather
information and amplify the messages. Ensure consistency in content of
messaging between all messengers (community leaders, health care personnel,
religious leaders, etc.).Collaborate with the national immunization and disease
prevention control (IVD) program managers/directors to conduct a mass
vaccination campaign, if indicated.

● Conduct a mass vaccination campaign: Develop or update a micro-plan for the

mass vaccination campaign as soon as possible. Speed is essential in an
emergency vaccination because time is needed to obtain and distribute vaccines.
Determine the target population for the activity based on the case and outbreak
investigation results (see the IVD program guidelines for specific
recommendations about delivery of the indicated vaccines).

● Ensure Appropriate and Adequate Logistics and Supplies: A dedicated

logistic team is needed during an outbreak response. Throughout the outbreak,
monitor the effectiveness of the logistics system and delivery of essential supplies
and materials. Carry out logistical planning to make sure transport is used in the
most efficient ways. Monitor the reliability of communication between teams
during the outbreak and if additional equipment is needed (e.g., additional airtime
top-up for mobile phones), take action to provide teams what they need to carry
out the response actions.

● Monitoring the management of the outbreak or event: The monitoring results

are important for they will be included in the response report submitted to the
supervisory levels and to community leaders and needed for future advocacy. For
example, make sure there is ongoing monitoring of: disease trends to assess the
effectiveness of the response measures, the scope of the epidemic and risk
factors; the effectiveness of the response: case fatality rate, incidence;
implementation of the response: program coverage, meetings of the epidemic
management committee, etc.; availability and use of adequate resources,
supplies and equipment; community acceptability of response efforts; regular
reporting on stocks of supplies provided during emergencies.
 ● Improve access to clean and safe water: Make sure the community has an
adequate supply of clean and safe water for drinking and other uses. The daily
water needs per person during non-outbreak situations are presented below.
Water needs are much higher during an outbreak situation, especially outbreaks
of diarrheal diseases. As indicated by the outbreak or event, take action to reduce
exposure to hazards or factors contributing to the outbreak or event. This may
involve chemical, physical or biological agents. Technical requirements for
reducing exposure will be determined according to national policy and through
collaboration with those who have experience in these areas.

● Ensure safe and dignified burial and handling of dead bodies: Dead body
management is crucial in combating the spread of infectious diseases both in
case detection and surveillance as well as in the management of potentially
infectious material. VHF, cholera and unexplained deaths in suspicious
circumstances are situations that require the careful handling of bodies. It is also
essential to ensure the safe and dignified disposal of bodies by trained personnel,
given the infectious nature of epidemic-prone diseases. The disinfection or
decontamination of homes and hospital wards (where people have died of an
infectious disease) should be implemented. Safe burials can be conducted in the
community at approved burial sites at the discretion of the families.

● Strengthen case management and infection prevention and control

measures: During a response to an outbreak, encourage health staff at all health
facilities to be vigilant in surveillance of the disease or condition. Make sure that
health staff: Search for additional persons who have the specific disease and
refer them to a health facility or treatment center for treatment or quarantine the
household and manage the patient, Update line lists and monitor the
effectiveness of the epidemic or response activity, Monitor the effectiveness of
the outbreak response activity and report daily the surveillance data.

Prevention of Exposure: the source of infection is reduced to prevent the disease

spreading to other members of the community. Depending on the disease, this may involve
prompt diagnosis and treatment of cases using standard protocols (e.g. cholera), isolation
and barrier nursing of cases (e.g. viral hemorrhagic fevers), health education, and
improvements in environmental and personal hygiene (e.g. cholera, typhoid fever and
shigellosis), control of the animal vector or reservoir (e.g. malaria, and yellow fever) and
proper disposal of sharp instruments (e.g., hepatitis B).

Prevention of Infection: susceptible groups are protected by vaccination (e.g. meningitis,

yellow fever and measles), safe water, adequate shelter and good sanitation.

Prevention of Disease: high-risk groups are offered chemoprophylaxis (e.g. malaria

prophylaxis may be suggested for pregnant women in outbreaks) and better nutrition).

Prevention of Death: through prompt diagnosis and management of cases, effective health
care services (e.g. acute respiratory infections, malaria, bacterial dysentery, cholera,
measles, and meningitis).

Patient Isolation: The degree of isolation required depends on the infectiousness of the
disease. Strict barrier isolation is rarely recommended in health facilities, except for
outbreaks of highly infectious diseases such as viral hemorrhagic fevers. The isolation room
must be in a building separate from other patient areas and access must be strictly limited.

Good ventilation with screened doors is ideal, but fans should be avoided as they raise dust
and droplets and can spread aerosols. Biohazard warning notices must be placed at the
entrances to patients’ rooms. Patients must remain isolated until they have fully recovered.

During outbreaks, isolation of patients or of those suspected of having the disease can
reinforce stigmatization and hostile behavior of the public toward ill persons. The
establishment of isolation rules in a community or in a health facility is not a decision to be
taken lightly, and should always be accompanied by careful information and education of all
members of the involved community. Every isolated patient should be allowed to be
attended by at least one family member.
 Table 5-3 General precautions to be taken for isolation of cases in outbreaks(Annex)

Isolation Contagiousness of Type of protective

Route of transmission Diseases
measure cases measure

Direct or indirect contact

Hand-washing, safe Most infectious diseases
Standard with feces, urine, blood,
Moderate disposal of contaminated except those mentioned
precautions body fluids and
articles below
contaminated articles

Cholera, shigellosis,
Direct contact with typhoid fever,
Enteric
High patients and with feces Contact precautions Gastroenteritis, caused
isolation
and oral secretions by rotavirus, E. coli,
hepatitis A

Direct contact with Meningococcal

Respiratory Separate room, masks,
High patients or oral meningitis, diphtheria,
isolation contact precautions
secretions and droplets measles

Airborne, Direct contact

Strict with infected bloods, Separate room,
Very High Viral hemorrhagic fevers
isolation secretions, organs or Biohazard notification
semen

Regular Response Situation Update

Situation update is produced and distributed on a regular basis, daily to weekly, depending on
the public health emergency events. An email distribution list, decided by the IM, will be formed
containing all response members. The update should be disseminated to response members,
relevant private and government sectors, and partners. This communication usually takes two
forms: an oral briefing for local health authorities and a written report. Select appropriate
communication methods that are present in your area such as: Radio, Television, Newspapers,
Meetings with health personnel, community, religious and political leaders, Posters, brochures,
leaflets, stickers, banners, and presentations at markets, health centers, schools, women’s &
other community groups, service organizations and religious centers.

Select and use a community liaison officer or health staff to serve as spokesperson to the
media. As soon as the epidemic has been recognized release information to the media only
through the spokesperson to make sure that the community receives clear and consistent
information.
 Document the response
During and at the end of an outbreak, the district health management team should:
● Collect all the documents including minutes of any meeting, activity or process;
epidemic reports; evaluation reports; and other relevant documents;
● Prepare a coversheet listing of all the above documents;
● Document lessons learnt and recommended improvements and accordingly
update the country EPR plan, event/disease-specific plan and other relevant
SOPs and tools, where appropriate (After-Action Review). This will become an
essential source of data for evaluating the response.

Response Coordination for Public Health Emergencies

Emergency response activities could be initiated with or without the activation of the EOC incident
management system. Depending on the emergency response mechanisms this could be:

Emergency Response without EOC Activation

This section provides guidance and information on response activities that should be initiated regularly
without the activation of public health emergency incident management systems. When a public health
event or condition is detected, an investigation should be conducted to determine its cause. The results
of the investigation are expected to guide the emergency response actions. Regardless of the specific
recommended response, the federal, or regional or district’s role in selecting and implementing a
recommended response is essential for safeguarding the health and well-being of communities at the
respective levels.

Once an epidemic threshold is reached at woreda level, the head of the woreda PHEM unit should notify
the zonal PHEM team/ regional PHEM and subsequently the national level PHEM. Depending on the
event, at the national level PHEM, and the IHR national focal point(NFP) will assess whether the event
is a potential public health event of international concern (PHEIC) using the International Health
Regulations (IHR) decision instrument. The NFP will liaise with the director general within the Ministry of
Health, to notify the WHO IHR AFRO Office.
Emergency response with EOC Activation
● Concepts of EOC: Public Health Operations Center (PHEOC) is a physical or
virtual space that public health emergency management personnel assemble,
coordinate operational information and resources, strategically manage public
health events and emergencies. The primary objectives of the PHEOC at
national, regional and district levels are improving continuity, collection,
organization, analysis, presentation and utilization of data and information,
communication and coordination with internal and external response partners,
preparation of public communications to support community awareness, outreach
and social mobilization, identification, prioritization, acquisition, deployment and
tracking of resources such as human, material and financial to support all PHEOC
functions, mobilization of resources, monitoring financial commitments and
providing administrative services. A PHEOC will bring together multi-disciplinary
and multi-sectoral experts to coordinate responses to PHEs in a structured
manner using the IMS, which is a standard and proven response management
system.

● Activation Levels of EOC: Activation of the EOC enhances EPHI/MOH ability to

provide immediate response in the event of a public health emergency. An
activated EOC supports rapid response through various activities, including not
limited: mobilization of staff and resources, organizations of response actions and
centralized location of technical expertise and subject matter experts for decision
making and the drafting of plans. The EOC may be activated for an event
anywhere within the district, region or the nation. Whenever any of the public
health emergency response activation criteria are met, the PHEOC Manager
informs all key stakeholders and partners within 1 hour through a phone call
followed by email or other available communication tools. EOC activation levels
are designated based upon a level of effort, and not strictly by the total number of
personnel involved in the response. There are three activation modes.

o Watch Mode: The watch mode corresponds to the normal day to day
activities. The watch staff constantly monitors and triage information on
 public events by facilitating the collection, organization, analysis,
dissemination and archiving of information. The PHEOC is constantly in
watch mode throughout the different modes of operation. The
responsibilities of watch staff include, but not limited to: Rumor
collection, communication and/or verification; Media (social media, TV
news, newspaper, radio and etc.) and web scanning; Screening routine
public health surveillance data for unusual occurrence; Preparing and
sharing of weekly summary report; Preparing and sharing of SPOTRep
and SITREP; Compilation and documentation of events and the
intervention activities; Ensure that the PHEOC has supplies and are
functional; Familiarity with the responding agency’s culture or system;
Authority to administer finance and mobilize resources.

o Alert Mode: This is the early standby phase of activation when an

emergency has occurred or is imminent. The PHEOC conducts intensive
monitoring of an incident or event in preparation for a potential PHEOC
activation. Besides the watch mode activities, the alert mode activities
include, but not limited to: Intensified monitoring or enhanced
surveillance; Intensified communication with the relevant stakeholders;
Ensure a preliminary assessment conducted for PHEOC activation;
Initiation of preparation for deployment of resources; Identification of
experts to staff the IMS positions and More staff could be mobilized from
the other units. Official letters signed by the DG or delegate shall be sent
to all stakeholders and external partners to notify them about the
possible PHEOC activation. Pre-activation notification will be sent for the
identified IM, section chiefs and general staffs from the available roster
through phone calls / SMS and email to fill the IMS functions (Pre-
activation notification template).

o Response Mode: The response mode is the phase after the PHEOC
activation notification sent. In the initial phase of PHEOC activation, the
PHEOC manager or the PHEM lead will temporarily assume the IM
position. In the meantime, the public health institute top leadership shall
 assign the IM from a relevant government office within 48 hours of
activation in consultation with respective agencies or sectors. S/he will
have all the staff available during the alert mode phase and additional
surge staff shall be mobilized to assist existing from other directorates of
EPHI, FMoH, organizations, external partners and others staff
depending on the level of the activation, type and scale of the incident.

Incident Command System

It is normally structured to facilitate activities in five major functional areas: command, operations,
planning, logistics, and finance and administration. The Incident Management System (IMS) is expected
to be a scalable, flexible system for organizing emergency response functions and resources
characterized by principles. An effective IMS hinges on the integration and coordination of staff, systems
and infrastructure, which is typically managed from an EOC.

NDRM FMOH

PHEM TF EPHI PHEOC Manager

Incident
Manager

Public Information
Officer Liaison/Partnership

Security/Safety Operations Section

Officer
Planning Section

Logistics Section

Admin/Finance Section

Regional Health Bureau-PHEM

Figure 5-1: Organogram for Incident Management System (IMS), Ethiopian Public Health Institute
Deactivation of EOC: EOC deactivation is a process that begins while the EOC is activated and
requires the attention of EOC staff during the response phase of a public health emergency. The
objective of an EOC is reaching deactivation, because it indicates that the public health threat has been
stabilized. When the response is declared over or incident is stabilized, the PHEOC will be deactivated
and return to normal or routine operation. (refer for the National Public Health EOC guideline)

Table 5 - 4 PHEOC steady state and activation guide

Level Conditions PHEOC Duties Activation Staffing

Steady-
1. Maintenance 1.PHEOC Manager
state 1.None 1. None
2. Routine surveillance 2.. Watch Staff
(Green)

1. If a reportable disease 1.Steady-state

Alert mode threshold is reached as 1.Heightened surveillance staffing
1. None
(Blue) defined by the PHEM 2.Alert Regional Health Bureaus 2.Early warning and
manuals response staff

1. One or more activation 1. National leadership for incident

1.Incident Manager
criteria has been met, but (IM)
Level 3 1.Lowest 2.Minimal IMS Staff
the overall threat is 2.Centralized information
(Yellow) level 3.Subject matter
limited in scale or management
expert as needed
geographic scope 3.Unified response strategy

1. The capacity of the

local response has been 1.Ministry and Partner
overwhelmed coordination 1. Level 3 Staff
1.Requires
Level 2 2.The incident affects 2.Single point of communication 2. Additional IMS staff
significant
(Orange) multiple regions and coordination for messaging 3.Ministry and
staff
3.The incident has the 3. Single entry and exit point for Partner involvement
potential to rapidly activities
deteriorate

1. The conditions of a
PHEIC have been met
2. The incident is 1. Large
Level 1 1. Full staffing of
expected to expand in 1. All PHEOC response duties scale
(Red) EOC[AB(1]
scale, scope, or cost response
3.Level 1 is deemed
necessary by leadership
Response to other Public Health Emergencies

Public health emergencies arising from mass causalities, flooding, landslides, in the immediate
aftermath of drought, population displacement due to conflicts, biological, chemical, radiological etc…
are considered in this document as other public health emergencies. In general this
emergencies/disasters have a secondary health impact to the community and environment. The health
sector also has a critical role in preventing and minimizing the health consequences of emergencies due
to natural, manmade, technological, and societal hazardous.It can only fulfil these responsibilities in
close collaboration with at risk communities and other sectors including Water, Peace, Education, etc.
Foster strong partnership for effective coordination and at all levels of response with NGOs, local
administration and community leaders, and private sector. They interfere with health service delivery
through damage and destruction of health facilities, interruption of health programs, loss of health staff,
and overburdening of clinical services.

Sectors institutions at federal, regional and woreda levels are playing a leading role with respect to
hazards and related disasters relevant to their respective sectors in providing and coordinating response
operations. So, the Ministry of Health shall act as a lead institution with respect to food shortage induced
malnutrition affecting children and mothers and other human epidemics associated with disasters.
Maintaining essential health services, prevention and control of disease outbreaks, investigation of
outbreaks, risk communication and community engagement, essential drugs and supplies availability
and monitoring and evaluation mechanisms are crucial components of public health disasters’
responses. This types of emergencies could be managed by activating emergency operation centers in
ad hoc bases at the emergency sites.

Essential Intervention in Humanitarian Settings

● Essential Health Services: is a key component of response to humanitarian

affected communities. Based on the context, essential health services need to be
availed, maintained or scale up. In IDP sites where no health facility is available,
essential health services should be provided using outreach services, mobile
services, and setting up temporary clinics based on the context.
● Prevention and Control of Disease Outbreaks: In humanitarian settings is also
the other key area of response. Displacement increased vulnerability to various
disease transmissions as result of overcrowding, low hygiene and sanitation
conditions, access to health services can be constrained, etc. As result,
communities affected by PHEs are prone to different disease outbreaks such as
cholera, other diarrheal diseases, measles, and malaria outbreaks. Hence, the
response included provision of measles vaccination campaign to children,
distribution of Long-lasting insecticide treated nets (LLINs) in malaria risk areas,
scale up hygiene and sanitation activities to prevent cholera and diarrheal
diseases. Disease surveillance and effective reporting are required for early
detection and contained disease outbreaks in PHEs settings.

● Risk communication and community engagement (RCCE): Aimed to reach

risk and affected communities on messages on the prevention and control of
disease outbreaks and use of essential health services in PHE affected
communities. RCCE activities used various platforms to reach to large affected
communities using effective strategies including community platforms, schools,
religious, media, etc.

● Drugs and supplies: need to be provided and continuously replenished during

the response period. The drugs and supplies list is long and the following kits are
key parts of the list: emergency drug kits (EDKs), trauma kits, reproductive health
kits, long lasting insecticide treated nets (LLINs), Cholera treatment Center (CTC)
kits, nutrition supplies, vaccines, cold chain supplies and equipment, personal
protective equipment (PPE).

● Monitoring of the PHE response: It is an integral part of the response at various

levels using key indicators listed in the response plan. The performance of each
pillar of PHE response need to be closely monitored and adjustment is made
accordingly. Under other health emergencies, response to population
displacement due to various reasons will be dealt. The main causes of
population displacement in Ethiopia are due to conflict, floods, drought and land
 slide. As any health emergencies, coordination of the response including
activation of Emergency operation centers (EOCs) at various levels are crucial.

Inter-Action Review (IAR)

An interaction review allows relevant national and sub-national (regional, zonal, woreda) stakeholders to
evaluate an ongoing emergency response. An IAR goal is to reflect on ongoing response activities to
identify gaps, best practices, and lessons learned and recommend corrective actions to improve and
strengthen the continued response. It also helps is to quickly identify readily implementable actions to
immediate and pressing issues that will improve the current response. The followings are steps to
conduct IAR:
● Planning and Structuring: The first step in planning an IAR is to identify the
scope; the scope should be determined by the government agency or leadership
requesting the IAR.

● Identify Participants: To maximize IAR's value, The WHO recommends

including no more than 10-20 participants. However, the number of participants
can vary depending on the scope.

● Timeframe: An IAR can be conducted at any time at the national and sub-
national level when the country or institution identifies the need to evaluate the
ongoing response

● Format: The IAR may last a few hours to a few days depending on the review's
scope. Providing a safe space where participants can be open and express
themselves freely without judgment is essential. An IAR involves conduct a desk
review of the existing documents.

● Documenting: The note-takers sole responsibility is to summarize, and document

discussions and critical action points identified during the IAR conversations.

● Following Up: A small team should be created at the end of the IAR to track
implementation and monitor the completion of activities proposed.
After-Action Review (AAR)

An after action review (AAR) is a qualitative review of actions taken in response to an event of public
health concern. An AAR is a means of identifying and documenting best practices and challenges
demonstrated by the response to the event. The AAR is one component of the International Health
Regulations (IHR) (2005) Monitoring and Evaluation Framework. After action review (AAR) of the
emergency response should be conducted within two weeks after the deactivation of the PHEOC. A
hot wash debrief may be a useful adjunct to a more formal evaluation. This can be built into the end
of mission debrief of the response to EPHI and FMoH.

Cross-Border Public Health Emergency Response

Ethiopia has a common porous border with frequent trans-border migration of population with six
countries namely Kenya, Somalia, Sudan, S/Sudan, Djibouti and Eritrea. Population movement has
increased dramatically in recent years because of trade and commerce, employment opportunities,
political conflict situations, livestock grazing, pilgrimage, migration of labor forces for development
projects and agriculture. Health services in the border districts are poor and inadequate especially in
peripheral areas. The paradigm of cross-border control of priority communicable diseases needs an
integrated and coordinated approach.

Cross-Border Specific Response Activities

► Laboratory Setup and Services: Every PoE must be linked to a laboratory with
a minimum capacity to conduct tests of major outbreak-prone diseases. Such
laboratories can be designated from existing government or private laboratories,
or newly established for this purpose. Requirements of the laboratory may vary
for different disease conditions under surveillance at the PoE and this shall be
decided by EPHI. Standards of the laboratory should be subject to national legal
or policy requirements, as well as any national laboratory quality-assurance
system.

► Cross-border Infection Prevention and Control: Infection prevention and

control (IPC) measures in public health and health-care settings are of central
importance to the safety of patients, health-care workers and the environment,
 and to the management of communicable disease threats to the local and global
community.

► Case Management at the border crossing: A targeted health response at

borders as an immediate ad-hoc emergency measure and eventually as part of a
well-planned integrated health and border management system is essential to
eliminating cross-border transmission. A full consideration of the mobility patterns,
therefore, offers opportunity for more comprehensive and effective communicable
diseases case management and border health interventions. There shall be a
designated treatment facility for disease conditions identified at the PoE.

► Screening, Quarantine and Isolation of Cases at PoEs: every PoE shall have
a designated screening sites and quarantine center for suspected travelers and
goods. Such facilities can be on-site for a short-time quarantine. However, a long-
term quarantine requires fulfilling complex needs including security,
accommodation, food, and hygiene, and needs specifically designated places and
hence be located away from PoEs. A PoE may provide short-term isolation while
the ill traveler is awaiting transport to the designated medical facility.

► Joint Outbreak investigations: conducting a public health cross-border joint

outbreak investigation is no simple endeavor. Add the complexities of legal and
cultural differences, and arguably one of the biggest challenges facing regional
corporations today. An outbreak investigation involves several overlapping
epidemiologic, case, and contact investigation. In fact, it requires a combination of
diplomacy, logical thinking, problem-solving ability, quantitative skill,
epidemiologic know-how, and judgment. Recommended steps of outbreak
investigations should be considered for a better results.

► Dead Body Document Requirement: The documentary requirements must be

confirmed with both the country of departure and of destination prior to
arrangement of transport with aircraft operator or ground-crossings and be
submitted to the freight forwarder / aircraft or ground crossing operator for
 arrangement of transport. Transportation of dead bodies via air and ground
crossings should be governed by national and international guidelines.

Transition from Response to Recovery

Recovery actions should be initiated as quickly as possible, generally after life safety issues have
been addressed, as the sooner a community focuses efforts on the increased likelihood of enabling
recovery. Therefore, recovery actions shall be conducted concurrent to response activities. Due to
the overlap of response and recovery actions, the transition from response to recovery is not
definitive, but can be measured by the following transition conditions: Integrated leadership,
collaboration, and coordination established and situational and impact assessments conducted; Risk
to life-safety is reduced and life-saving activities, such as search and rescue, are nearing completion;
Emergency Support Services are established (physical, mental, and spiritual health, shelter, food and
water); Initial assessment of damage complete for cultural land use and critical infrastructure
including roads, railways, airports, ports, buildings and systems; Services restored to essential critical
infrastructure; Establishment of national and sub-national staging areas, if required, with movement of
relief supplies, response personnel and other critical resources and goods into the impacted area,
including those of spiritual, cultural, and environmental importance/significance; Surge capacity of
additional human and other culturally appropriate resources deployed/employed to assist the local,
regional and national levels of response
06/ RECOVERY
Definition

Recovery can be defined as the process of rebuilding, restoring, and rehabilitating the community
following an emergency, but it is more than simply the replacement of what has been destroyed and the
rehabilitation of those affected. It is a complex social and developmental process rather than just a
remedial process. The way recovery processes are undertaken is critical to their success. Recovery is
best achieved when the affected community can be able to exercise a high degree of self-determination.

Purpose

The goal of recovery is to ensure the economic sustainability of a community and the long term physical
and mental well-being of its citizens, to rebuild and repair the physical infrastructure, and to implement
mitigation activities to reduce the impact of future disasters. The regional and local health departments
have a key role to play in all these response and recovery activities.

Disasters can have a profound impact on the livelihoods and health of affected populations. Restoring
lifesaving services and assisting communities to cope with former and new health threats is a necessity
to mitigate the impacts. It can be difficult to distinguish between response and recovery activities. While
they can be similar, the intent of the two is different. Public health emergency/disaster response is
focused on the immediate need to protect human life and the physical infrastructure from the immediate
effects of the disaster. Recovery on the other hand, is broader in scope.

Recovery in the health sector represents opportunities to catalyze action on health policy strengthen the
capacity of countries and communities to manage risks of future events. As recovery is community-led,
policy implementation at the local level will be the responsibility of the community. Recovery should be a
deliberate, planned process that allows the community to define its own goals for recovery and assist on
that.In fact, the challenge is to find the right balance in restoring the system to its previous level and how
much better it needs to be rebuilt. This will depend on the status of development of a country and what a
country can afford to sustain. First, it is better that the reconstruction addresses key issues currently
 faced by the health sector and provide better health service like accessibility to the poor and other
vulnerable population sub-groups. Second, the future health system should be designed to be prepared
for and responsive to all major hazards in the future. Third, the existing health system in the affected
areas may need to be streamlined to meet the changed needs because of different population profiles
and epidemiology.

Principles of Recovery and Reconstruction

Recovery is most effective where recovery management arrangements provide a comprehensive and
integrated framework for managing all potential emergencies and where assistance measures are
provided in a timely, fair, and equitable manner and are sufficiently flexible to respond to a diversity of
community needs. Recovery is most effective when it leverages partnerships; therefore, national,
regional and districts are encouraged to work together whenever possible.

This is especially effective where smaller communities lack overall staffing capacity, or the impacts are
spread across a wider area and it would be more effective for one community recovery manager to build
a plan for the collective recovery effort.

The following lists are the key recovery principles

► Equity: Expansion of service to underserved areas, the poor and vulnerable population;

► Effectiveness: Increasing the access to and the quality of key services;

► Appropriateness: Adoption of new service delivery models to respond to new health needs
if the previous system was outdated;
► Efficiency: Greater overall efficiency with savings used to finance some of these measures.

For the purpose of PHEM, the goal of recovery is to implement short- and mid-term recovery processes
after a major public health incident. This will include identifying the extent of damage caused by an
incident, conducting thorough post-event assessments and determining and providing the support
needed for recovery and restoration activities to minimize future loss from a similar event.
Stages of Recovery

Recovery consists of short-, medium-, and long-term stages and the promotion of disaster risk reduction
to minimize future damage to the community and environment. It includes measures such as the return
of evacuees, provision of psychosocial support, resumption of impacted businesses and services,
provision of financial assistance, and the generation of economic impact assessments and recovery
strategies, infrastructure repairs and environmental rehabilitation. When moving through the three
stages mentioned above, the affected community should be assisted to set appropriate priorities for its
recovery, articulate the roles and responsibilities of all involved, set realistic milestones to gauge
progress; and ensure the effective transfer of knowledge, expertise, services, and support. The extent of
the recovery process, and the type and level of national and regional activation, is based on the
complexity and scope of the event. Smaller recovery events that are localized in nature can be managed
by the community and are monitored at the regional level.

When an event escalates and it is determined that national coordination is required, national resource
mobilization may be applied through the activation of one or more recovery sectors. When resources are
exceeded at the regional level or the emergency event is such that it spans multiple regions and
requires significant coordination and it is determined that additional support is needed, the nation will
establish appropriate levels of support through existing mechanisms, including the Emergency
Management.

Table 6-1 Stages of Recovery

Stage of Recovery Features

• Begins simultaneously with the onset of response activities.

• Ensures basic human needs are met and key support services are provided.

Short-term (e.g., • Informed by a Post Disaster Needs Assessment, work begins on planning objectives.
days to weeks after
• Restoring basic functions of society depends on how quickly recovery activities and plans are
the emergency
initiated.
/disaster)
• Some people and groups will focus on response activities while others transition to restoration
and recovery activities. (The duration and timing of the overlap depends on the type and severity
of the damage incurred.)
 • Involves completing emergency response activities and transitioning to activities geared
specifically to recovery. There is greater involvement of NGOs, insurers, financial institutions,
and volunteer groups.
Medium-term (e.g.,
• Is informed by iterative post-disaster needs assessments.
weeks to months)
• Focuses on movement of goods and services, infrastructure repairs, resuming business and
economic functions, cultural and spiritual reconnection to the environment, social health and
wellness, and environmental rehabilitation.

• Involves sustained efforts to adapt to the changed conditions, which may include replacement,
rebuilding, or improvement. Financial, environmental issues, and elements of cultural
significance are addressed, and efforts made to rehabilitate or improve the livelihood of disaster-
affected communities.

Long-term (e.g., • Focuses on risk reduction through changes in building codes and land-use designations
months to years) (transitioning to mitigation), permanent housing and facilities, business resumption, and long-
term mental health and social support services to individuals.

•The objective is to use the recovery, rehabilitation and reconstruction phases to increase
community resilience through the integration of practical disaster risk reduction measures in the
restoration of physical and societal systems.

Recovery Processes

After an emergency or a disaster, the impact of damage that occurred on the health of the population
and the system that serves them needs to be objectively assessed to clearly identify the gaps and to
design the appropriate strategy for the specific context. Hence, a major activity during the recovery
process is an effective Post Emergency/Event Assessment (PEA) to guide the implementation of
recovery activities. Hence, the next pages are dedicated to see how best to conduct this assessment
and benefit from this process.

► Recovery Need Assessment (Post Emergency Assessment):After an emergency or a disaster, the

impact of damage that occurred on the health of the population and the system that serves them needs
to be objectively assessed to clearly identify the gaps and to design the appropriate strategy for the
specific context. Hence, one of a major activity during the recovery process is an effective Post
Emergency/Event Assessment (PEA) to guide the implementation of recovery activities.
The elements within each building block to be taken into account during the assessment include the
following examples:

● Service delivery: availability and accessibility of essential services, damage to

infrastructure (pre-hospital units, mobile clinics etc.); package of services; organization
and management; safety and quality.
● Leadership and governance: health sector policies; harmonization and alignment;
oversight and regulation; governance capacity; and coordination mechanisms.
● Health workforce: national workforce policies and plans; human resource norms,
standards and data; (remaining) numbers and types of health workers, distribution and
competencies of health workers; supervision mechanisms; effects on and capacities of
training institutions.
● Information: facility and population based information and surveillance systems;
analyses capacity for decision making.
● Medical products, vaccines and technologies: access to essential medical products,
vaccines and technologies with assured quality, safety, and efficacy, norms, standards,
and policies; procurement and supply chains; quality; drug donations; health transport
and logistics, warehouses, cold chain.

The assessment required to estimate damage and losses is integrated in this matrix, as the assessment
of infrastructure needs to be analyzed together with their functionality to provide services, the health
system functions required to support such services, and the impact the disaster had on the health of
communities.

● Pre-crisis baseline: health status and pre-existing health risks, pre-existing policies,
performance and challenges in the health system (including preparedness strategies
and plans, disaster risk management program in the health system)
● Impact of the disaster: Impact on the BOD, health infrastructure and on health system
functions. Impact averted by preventive and mitigation efforts, capacity of the health
system to respond.
● Response: includes humanitarian interventions to address changes in the BOD, (re)-
establish lifesaving services, and restore the functioning of the health system (where
the costs for these interventions are borne by the Ministry of Health, they are included
in the estimation of losses).
The health sector PEA is led and coordinated by the health sector itself, from Ministry of
Health/Ethiopian Public Health Institute to the woreda health offices depending on the degree of the
emergency, in collaboration with its partners and other sectors. It also needs to be linked with
humanitarian coordination mechanisms as well as with pre-existing sector wide coordination and (multi-
sectoral) development partners.

The health sector PEA identifies the relevant issues that need to be assessed in the context of the six
health system building blocks by giving emphasis on: changes in the epidemiology of the burden of
disease (BOD), damage and loss, and the performance of the main health programs. To gather
situational understanding and determine what resources and support a community requires to advance
recovery, post-disaster needs assessments (PDNA) must be conducted by the responsible organ (MOH,
EPHI).

Conducting PDNA enables us to inform and determine priorities, funding mechanisms, and recovery
coordination for all relevant sectors at national, regional, and local levels. PDNAs may be conducted by
the functional incident management unit in the Emergency Operations Centre or a separately
established recovery team, if applicable. The communities may elect to deploy local focal
representatives or a local team to assist with the PDNA conducting expertise team, to help connect
communities with resources available, and to provide additional guidance to ensure there is no delay in
initiating recovery actions. The national or regional recovery teams will then work with the local focal
representatives or a local team and provide coordinated high-level support throughout the process of
recovery.

Managing the PEA process and its outputs:

The health sector PEA is led by the Ministry of Health structure in collaboration with other relevant
sectors, and the overarching national governmental body managing disasters such as the Ministry of
Agriculture. This ensures alignment of the recovery framework to the national health development plan.
Clear roles and responsibilities should be developed and assigned to different departments, and various
levels. It is important to include the health development partners in the PEA process, such as WHO,
UNICEF, donors, NGOs, community-based organizations, civil society, professional associations, and
the private sector.
 ● Staffing requirements and logistics for PEA health team: The PEA health team will
be led by the focal points as appointed by the government. Sectoral experts will be
asked to assist. In general, the team needs to have at least one health system expert,
and one health economist, an additional epidemiologist is required. Transport for the
assessment team is required to meet stakeholders and to conduct site visits for direct
observation and consultation with affected communities, representative of the health
authorities in the affected area and managers of affected health facilities.

● Data collection process, assessment tools, methods and indicators: The data
collection strategy and information requirements for the health sector recovery should
be seen as a process and placed in the cycle of PHEM. This means that assessments
and information required for (early) recovery build on data that is collected before the
disaster happened, from routine IDS, HMIS and other reports, including from disaster
preparedness, as pre-disaster baseline, and rapid assessments in the early
humanitarian phase. It should then become a monitoring system of the health system
performance.

● Capacity assessment: Assessing capacities in the health sector is essential for

two reasons: The first is to understand the ability of the national health system to
manage the recovery process. This includes assessing the financial management and
procurement aspects of health system as these are necessary for effective
management of the response. Assessing the adequacy of the financial management
system is required to make choices on managing the resources being made available,
and to judge the absorption capacity for recovery funding. The second reason is to
identify technical support needs for planning effective capacity strengthening
interventions, as required for medium- and long-term recovery.

Links to other sectors and cross cutting issues

Inter-sectoral discussions should take place prior to the design phase of any assessment or more
generally any data collection or analysis exercise to agree on standards which will provide a solid basis
for data comparability and therefore cross-sectoral analysis. Several other sectors are considered as
determinants of health such as environmental health (including hygiene, water and sanitation), nutrition
and food security, shelter and education.

Recovery Plan

The PDNA will inform the development of a recovery plan. A recovery plan is developed in consultation
and active involvement of local authorities and the target community, and must integrate into the overall
recovery and rehabilitation plan, outlines recovery needs, and describes the actions envisaged in the
plan to take in delivering recovery services to the affected communities, infrastructures and the health
system, including funding required and timeframes for implementation. The regional and local authorities
can assist with identifying programs available for communities to implement the post emergency recovery plan;
however, the community needs to be involved to define how the implementation of the recovery plan looks like
and should ultimately share responsibilities for the implementation.

● Prioritization of Recovery Actions: The post Disaster Need Assessment (PDNA) and
recovery plan will assist the responsible authorities and partners to allocate recovery
resources, including human and financial, by identifying priority recovery needs and
recovery objectives. Prioritization across the four sectors: People and Communities,
Economy, Environment, and Infrastructure – ensures equitable and need-based
recovery across affected communities, systems, functions, services and promotes
gender-sensitive and pro-vulnerable recovery agendas.

Primary consideration for recovery priorities emphasize protection and promotion of the
health and well-being of affected citizens, including but not limited to restoration of
health services; provision of mental health and wellness supports; and temporary
lodging. These should be activities that lessen humanitarian impacts as soon as
possible. The next phase of prioritization is identifying medium to long-term recovery
needs and the generation of sustainable and resilient livelihoods. Prioritization is based
on the scope and scale of recovery needs and availability of resources by sector.

● Measuring Recovery Progress: Measuring progress of disaster recovery is critical

from all partners involved, including all levels of government, communities, non-
 government organizations, private sector and other partners. Recovery strategies and
key indicators of how progress will be measured need to be identified through
qualitative and quantitative metrics. These metrics for measuring progress need to be
directly linked to the Post-Disaster Needs Assessment (PDNA).The following are
factors that should be considered for measuring progress:

(i) Leverage available pre-disaster data to ensure a reliable baseline level for
progress to be measured against. This data should include indicators related directly
to each of the four sectors: People and Communities, Economy, Environment, and
Infrastructure;

(ii) Ongoing monitoring of both implementation and activities to ensure there is a

holistic approach to recovery. Activity-monitoring should support results-monitoring to
create a complete overview of progress made. Results-monitoring refers to measuring
the progress against direct objectives and priorities, whereas activities-monitoring
should be done by individual recovery partners measuring their respective sectors
and programs. The results of activity monitoring will be consolidated by the lead
coordinating entity;

(iii) Ensure that milestones and expectations are achievable and realistic for
communities to achieve with the resources available;

(iv) Metrics for measuring progress of recovery activities must be developed through
consultation with community members (representatives) and recovery partners.
These metrics need to also take into consideration the vulnerabilities within the
community and apply an intersectional lens;

(v) Ensure the metrics developed to measure the progress of recovery are utilized to
make early adjustments to activities.

Recovery Core Capabilities

● Natural and Cultural Resources: The Natural and Cultural Resources (NCR) core
capability integrates the expertise and resources of all individuals; local,
regional/metropolitan, state, tribal, territorial, insular area, and Federal governments;
 other natural and cultural resource stakeholders such as nongovernmental, nonprofit,
and voluntary organizations; and private sector entities to preserve, protect, and restore
the affected community’s natural and cultural resources and historic properties in a way
that is inclusive, sustainable, and resilient.

● Health and Social Services: Timely restoration of health systems (i.e., hospitals, and
social services is critical to a community’s recovery and requires a unified effort from all
partners and stakeholders in the affected region. These partners and stakeholders
include government agencies; aging, disability, nonprofit, voluntary, faith-based, and
community organizations; for-profit businesses; service providers; and individuals and
families accessing services. By working together in an inclusive planning process,
recovery stakeholders can identify pre-disaster deficits, assess incident-related impacts,
target appropriate resources for pre-and post-disaster activities, and develop strategies
to promote the health and wellbeing of affected individuals and communities to foster
community resilience. The Health and Social Services core capability includes
anticipated incident impacts to health care services, social services, behavioral health
services, and environmental and public health, as well as food and medical supply
safety, children in disasters, and long-term health issues specific to responders. Identify
affected populations, groups and key partners in recovery, complete an assessment of
community health and social service needs.

● Economic Recovery: The Economic Recovery core capability integrates the expertise
and resources of agencies and organizations, both governmental and private sector, to
facilitate the pre- and post-disaster efforts of individuals; local, regional/metropolitan,
state, tribal, territorial, insular area and Federal governments; and the private sector to
sustain and/or rebuild businesses and employment and to develop economic
opportunities that result in inclusive, economically viable communities.

● Infrastructure System: The Infrastructure Systems core capability integrates the efforts
of the owners and operators of public and private infrastructure. It is the extension of
steady state operations and maintenance that, in some situations, defines new
construction and system upgrade projects. The goal of the recovery process is to match
the post-disaster infrastructure to the community’s projected demand on its built and
 virtual environment. Infrastructure Systems core capability partners promote planning
through their networks. Communities that engage in highly inclusive, public private
planning efforts are generally able to function better before, during, and after an
incident. Additionally, mitigation efforts help to minimize disaster consequences and put
structures in position to recover more effectively.

Funding

The funding for recovery will be informed by the Post-Disaster Needs Assessment (PDNA) and
the community recovery plan. The recovery manager will work with other responsible
stakeholders and ministry representatives as required, to inform and validate short, medium,
and long- term community needs as identified through the PDNAs and community recovery
plan. Needs articulated must be reasonable in terms of proposed expenditure and level of
support. If additional funding is required, the ministry recovery sector leads can identify options
and provide recommendations to the recovery team. For medium to long-term recovery actions,
the community recovery plan will include a reporting requirement. Within the community
recovery plan the community will describe the planned recovery actions and will propose how
they will be funded. Regular reporting to the higher authority on the status of implementation of
the actions, funds allocated, will be required.

Escalation and Decision Making

Escalation of recovery coordination from the district level to the regional level or to national level
are determined based on scope and scale of the event. The following considerations support
and guide the decision to escalate the level of support: capacity at the local level is exceeded or
is expected to be exceeded; when the geographical area of an event spreads beyond one local
authority or region; where the scale of an event is deemed catastrophic and the event has
caused significant impacts to a community. Following the escalation of recovery activities from
the community level to the regional or national level considerations must be made, when
possible, to ensure that coordination is maintained at the local level. Regional and national level
activities will support recovery activities at the local level, rather than replace them. In respect to
specific recovery activities, escalation to the regional or national level may occur without overall
recovery coordinating being escalated to the higher level. In doing so, local authorities and
communities can maintain autonomy of their recovery activities.
07/CROSS-BORDER PHE
PREPAREDNESS & RESPONSE
Introduction

Globalization and resultant human mobility has increased in recent years. Human mobility is a complex
and dynamic phenomenon that has been attributed to amplify the spread of communicable diseases
and the impact of public health events. The 2014-2016 Ebola Virus Disease (EVD) outbreak in West
Africa, the 2016-2017 Zika Virus and the current COVID-19 pandemics have demonstrated the
contribution of human mobility in increased public health risk and in turn intensified the need for
enhancing the global health security.

The International Health Regulations 2005 (IHR-2005) aimed to prevent, protect against, control and
provide a public health response to the international spread of disease in a way that are commensurate
with and restricted to public health risks, and avoid unnecessary interference with international trade
and traffic, provides a framework for countries to build capacities to prevent, detect, and respond to
public health emergencies.

The IHR-2005 defines a point of entry (PoE) as "a passage for international entry or exit of travelers,
baggage, cargo, containers, conveyances, goods, postal parcels, and human remains/ash as well as
agencies and areas providing services to them on entry or exit." There are three types of PoEs: an
international airport, ports, and ground crossings, which are further classified as designated and non-
designated. Ethiopia shares a large border size with Eritrea, South Sudan, Kenya, Sudan, Djibouti,
Somalia and Somali land.

Besides, Bole international airport, the hub for more than 127 destinations, is the passage for millions of
passengers and cargo a year. In the presence of such intense and complex traffic of passengers and
cargo across PoEs, the task of safeguarding the public health safety become undoubtedly demanding,
requiring coordinated efforts of various sectors present at the PoEs.
 During all annual state parties’ self-assessment and report (SPAR) and joint external evaluation (JEE)
conducted before 2021, Ethiopia has been scoring sub optimal on the IHR recommended capacity for
public health emergency response at PoEs. Recently Ethiopia has recognized the demand for
strengthened Public health emergency response capacities and has made clear its strong political will
both to promote global health security and meet obligations under IHR. For instance, the ministry of
health (MoH) has launched a multi-sectoral five-year costed national action plan for health security
(NAPHS, 2019-2023) and enacted proclamation No.1112/2019 to undertake the regulatory activities
related to communicable disease at PoEs

PHE Preparedness at Port of Entry (PoE)

Member countries must comply with the legal requirements set out for designated POE by IHR 2005
which states that each country should ensure the core capacity requirements (at all times & for
responding to events that may constitute the public health emergency of international concern (PHEIC))
for designated POE are in place by June 2012, in principle.

Public Health Emergency Response Contingency Plan (PHERCP): IHR 2005 compliance requires a
public health emergency response contingency plan be developed and maintained in designated POE
to respond for events that may constitute a PHEIC. PHERCP is a multi-agency coordination plan to
prevent the introduction, transmission, or spread of communicable disease. Effective use of a PHERCP
facilitate a coordinated and timely response to a PHE at a PoE, mitigating the threat of global disease
spread by international travelers. The plan should be developed in accordance with proclamation
number 1112/2019, 72(2), IHR 2005 and other involved stakeholders legal background. It is intended
not to look at only communicable or epidemic prone diseases but to address all unusual health events
or public health emergencies.

All the relevant stakeholders such as Ethiopian Civil Aviation Authority (ECAA), Federal Police at PoE,
Air Traffic Control (ATC), National Intelligence and Security Service (NISS), Aviation Security,
Immigration Nationality and Vital Events Agency (INVEA), Ethiopian Custom Commissions, Ethiopian
Pharmaceuticals Supply Agency (EPSA), Ethiopian Food and Drug Administration (EFDA), Ministry of
Foreign Affairs (MoFA), Ethiopian Airline Groups etc. should be part and parcel of the PHERCP
development as both PoE health team and stakeholders play their critical roles and responsibilities in
implementing the PHERCP when a PHE occurs.
● Laboratory Facility: the laboratory's requirements may vary for different disease
conditions at the PoE. Each PoE must be linked to a laboratory (government or private) with
a minimum capacity to conduct lab tests for outbreak-prone diseases. The laboratory
standards should be subject to national legal, policy, and lab quality-assurance
requirements.

● Isolation Facility: there should be a separate center to isolate suspected cases onsite at
the PoE or nearby health facilities usually for short period of time till the case transferred to
a designated treatment facility/center. Isolation shall take place on board, in a cabin,
ashore, in a healthcare facility or other institution including at home as appropriate.

● Quarantine Facility: there should be a designated quarantine center at the PoE (usually for
short period of time) or nearby (a long-term quarantine requires fulfilling complex needs,
including security, accommodation, food, hygiene etc.) where passenger suspected of
exposure to the public health threat separated from the public for the period of time required
to ensure that there is no risk of transmission.

● Mapping and Establishing Referral Linkage: establishing a referral system ensures

suspected cases/passengers to get access for laboratory test, health care services as well
as follow-up visits. Referral linkage can be done within the country or to the neighboring
countries as per the agreement among the neighboring countries.

● Finance/Fund: the plan for responding to the public health threat at PoE should be included
in the broader national emergency preparedness and response plan. Apart from this regular
domestic and contingent fund must be allocated to properly respond to public health threat if
happened at PoEs.

● Logistic and Supplies: ensuring availability of medical supplies and logistics must not be
the task performed merely during public health emergency, it must be accustomed that the
needed logistic and supplies are identified and gaps are filled timely. Emergency
Preparedness includes stockpiling of necessary medical and non-medical supplies.

● Human Resource and Working Documents for PoE: as part of preparedness measures
to any public health threat, identifying the need for surge capacity and designing strategy for
 later mobilization during response is of paramount importance. One of the strategies to put
in place ready for deployable surge capacity is rostering the needed qualification in
sufficient number, providing necessary training/ pre-deployment orientation, developing and
distributing necessary documents for the responders etc.

● Simulation Exercise (SIMEX): the SIMEX enable PoE health team and stakeholders to
practice their roles and functions and can help to develop, assess and test functional
capabilities of emergency systems, procedures and mechanisms to respond public health
emergencies, identify gaps and enhance preparedness capacity for response before an
actual emergency occurs. Based on the available resources and objectives to be achieved,
table top, drill, functional, and field /full scale exercise can be done.

Public Health Surveillance at PoES

Implementing public health surveillance at PoE is different from community setting and requires different
approach

● Collecting public health surveillance data is not a major concern or viewed as a priority by
key stakeholders at PoE (e.g. customs, immigration officials, conveyance operators service
providers, veterinary and quarantine authorities).
● The lack of medical personnel in the majority of the conveyances or at PoE is a challenge
for efficient public health surveillance and should be compensated by effective mechanisms
for intersectoral communication, coordination and information-sharing.
● The IHR require surveillance with an “all-hazard approach” including biological, chemical,
and radiological hazards. In PoE and conveyances, this relates to the passage of travelers
including passengers and crews, animals, plants, and goods of diverse origin.
● Events can be detected before, during or after travel or when travelers left the conveyance.
Therefore, investigation and public health measure activities takes place retrospectively.
● The approach to surveillance is often focused on detecting and reacting rapidly to individual
events, and usually does not include on-going systematic data collection for analyzing and
calculating epidemiological indicators

IHR Principle of Surveillance at PoE: the principle of the establishing surveillance at PoEs is to
prevent, protect against, control and provide a public health response to the international spread of
disease in ways that are commensurate with and restricted to public health risks, and which avoid
unnecessary interference with international traffic and trade.

Objectives of Surveillance at PoEs: main objectives include

● To detect, investigate and control public health risks and events of all origins rapidly
● To assist PoE Health team and other sectors in adopting preventive measures,
investigation, management and follow up of events;
● To prevent and/or manage the importation and exportation of travel related health hazards
(including diseases and their agents) in a country;
● To prevent international spread of vector borne diseases by controlling vectors

Hence, PoE health team should promptly receive all pertinent information generated elsewhere that may
contribute to their public health surveillance objectives.

Source of Information for Surveillance at PoEs:

● Passengers travel itinerary, destination, health documents, non-invasive medical
examination, travelers’ health declaration form (THDF)
● Inspection of baggage, cargo, containers, conveyances, goods, postal parcels etc
● Health Part of the Aircraft General Declaration form
● Any information relating to health conditions on board during an international voyage

Application of Surveillance for Event Detection: early detection of events allows for timely
implementation of public health measures, response, containment, and prevention of further potential
exposure.

Risk Assessment: once public health event was detected, verification of the event by collecting
accurate information (usually from other travelers, conveyance operators, other medical service centers
at port etc.) is important and part of the standard preliminary response of the PoE health team and other
stakeholders. Preliminary risk assessment information (type of event, level of severity, trend, hazard
level etc.) should be reported to the national PHEM/EOC and other stakeholders as necessary by the
PoE health team before full assessment of the event takes place.
 Figure 1: Information flow from the PoE to the EPHI and vice versa

Data utilization: the relevant traveler’s information should be registered on standardized disease
specific format, THDF at PoE or while on travel. These information usually be entered, in to the
electronics database, analyzed at PoE by the health team and will be sent to national PHEM/ EOC.

Cross-Border PHE Response

Collaboration and Coordination: the major regional economic blocs of the Intergovernmental
Authority on Development (IGAD), the Common Market for Eastern and Southern Africa (COMESA), the
East African Community (EAC) with legally binding protocols that include free trade and the movement
of people across international borders, are expanding rapidly. Casual and unofficial cross-border
movement of communities including pastoralists living along national borders in search of services and
other social events are common.

Cognizant of such situations, cross-border collaboration, development of bilateral and multilateral joint
plans of action and the establishment of an effective mechanism to enable respective national health
authorities and PHEMs to communicate directly, during health emergencies are crucial first steps for the
implementation of cross-border prevention and control/response activities. MoU among the parties
should take place to make the joint execution and evaluation of response activities (joint planning,
surveillance, joint outbreak investigations, communication, SIMEX, update relevant regulations, update
about referral linkages etc.) effective. The diverse nature of border health management also needs
collaboration and coordination with stakeholders in the country such as Regional Health Bureaus and
bordering districts, (INVEA), Custom Commission, (NIC), Federal Police, All Airlines Operators,
Ethiopian Airports, Ethiopian Civil Aviation Authority and Ethiopian Railway Corporation, National
Defense etc. The national IHR focal point also plays crucial role in realizing collaboration to the
neighboring countries.

Specific Public Health Emergency Response Activities at PoE

● Laboratory Setup and Services: Ensure designated PoEs are linked to laboratories
(government/private) with a minimum capacity to conduct tests of major outbreak-prone
diseases that can spread through cross border movements. Preferably the testing sites will
be at PoE level so that issue related to transport, safe package etc. will be minimized. Tests
that require sophisticated laboratory and special conditions for specimen handling should be
done at laboratories with proven capacity.

● Case Management at PoE: health response at borders as an immediate ad hoc emergency

measure and eventually as part of a well-planned integrated health and border management
system is essential to mitigate cross-border transmission as well as treat cases who need
immediate health care. There should be a designated temporary treatment/isolation facility
(TIF) to treat suspected cases detected at PoE for short period of time before they
transferred to a designated treatment center for further management and laboratory test.
Strict IPC (standard or transmission based), proper waste disposal (considering all types of
wastes) should be applied during treating and transferring of the suspect.

● Screening, Quarantine and Isolation of Cases at PoEs: every designated PoE shall have
a screening sites and quarantine center for suspected travelers and goods. Such facilities
can be on-site for a short-time quarantine but exposed individuals/objects that needs longer
time for quarantine should be transferred to designate quarantine facility away from PoE.

● Provision of Vaccine: countries are required to provide vaccine to major outbreak prone
diseases at designated PoEs.
● Human remain and Ash Management: An incoming and outgoing human remains should
be regulated to ensure that it is free of infectious diseases that may pose public health risk
 during transport, at PoEs and at its destination. Although most organisms in the human
remains are unlikely to infect healthy persons, some infectious agents may be transmitted
when persons come into contact with blood, body fluids, or tissues of the human remains of
persons with infectious diseases requiring implementation of ‘standard precautions’ handling
it. When handling human remain,
o Privacy and confidentiality regarding information of human remain should be ensured
o IPC measures should be followed based on the risk human remain pose to the public
o Make sure the human remain covered well as per recommendation
o Ensure required mandatory (death certificate, embalming certificate, certificate
showing non-infectious/non-contagious human remain) and supporting
(passport/lese-pasee, transport bill) documents are available.

Public Health Measures

● Conveyances and Cargo: According to the Proclamation No. 1112/2019 article 72,
conveyances considered to have a public health risk/ had travel history to the affected areas
shall be inspected on arrival or departure by PoE health team. During inspection of
baggages, containers, conveyances, facilities and goods or postal parcels etc., have risk of
public health threat to the public, health measures (disinfection, decontamination,
disinfection, deratings, isolation/quarantine, destruction/removal etc.) should be
implemented based on the available SOPs.

● Animals: More than 75% of emerging diseases like SARS CoV-1, MERS CoV, Ebola, Avian
Influenza etc. originate from animals (particularly wildlife).Because of wild meat
consumption and transporting live animals (dogs, cats, reptiles, rodents, non-human
primates, horses, poultry, captive birds, bovines, porcine, ovine, caprine etc.) by
conveyance, infected animals can travel across different country and continent with in few
hours or days posing public and global health security threats. In such case of cross border
zoonotic diseases, the public health measures with respect to animal will be implemented
per the advice (collaboration) provided by the group of experts to be assembled from the
MoA and human health under the umbrella of one health steering committee (OHSC).
08/ RESILIENCE
Definition

Resilience: The unified definition of resilience by the UN is “the ability of individuals, households,
communities, cities, institutions, systems and societies to prevent, resist, absorb, adapt, respond and
recover positively, efficiently and effectively when faced with a wide range of risks, while maintaining an
acceptable level of functioning and without compromising long-term prospects for sustainable
development, peace and security, human rights and well-being for all” (United Nations Chief Executive
Board, 2017).

Health System Resilience (HSR): Health system resilience is defined “as the capacity of health actors,
institutions, and populations to prepare for and effectively respond to crises; maintain core functions
when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it”.
Health systems are resilient if they protect human life and produce good health outcomes for all during a
crisis and in its aftermath.

The ongoing and recurrently occurring epidemics and public health emergencies in Ethiopia has
demonstrated the critical importance of resilient health systems in safeguarding the national health
security.

It’s well-recognized that during the public health emergencies like COVID-19 pandemics and other
disasters, health system remains severely overwhelmed by the combination of a large surge of patients
seeking care and for other routine healthcare needs and reported lack of sufficient space, supplies and
staff to treat patients.

Therefore, improving resilience within health systems can build on pre-existing strengths to enhance the
readiness of health system actors to respond to crises, while also maintaining core functions. Resilient
health systems are important for supporting response efforts during an infectious disease outbreak or
natural hazard, and help ensure the continued delivery of routine services needed by the community in
nonemergency periods.
 Building Health System/ Service Resilience aims to:
● Enable health workers, heath facilities and health organizations to better withstand and
recover from a disruptive acute PHE more quickly and effectively;
● Reduce the impact of chronic stresses on the health system, such as PHEs, economic
stressors, and improving the ability to maintain essential functions during these shocks;
● Improve the public’s trust in the health system and therefore better utilization of health
services which improve population health outcomes
● Avert the high socio-economic cost of responding to PHEs and other shocks with poor
preparedness and lack of resilience capacities
● Encourage investments in the health system by producing positive and sustainable results
from previous investments thereby increasing the likelihood of continuity during
disturbances

Linkages-HSR, Universal Health Coverage and Health Security

Universal health coverage means that all people are able to receive needed health services of sufficient
quality to be effective, without fear that the use of those services would expose the user to financial
hardship. Universal health coverage comprises a set of objectives i.e. equity in service use, quality, and
financial protection towards which all countries strive to achieve.

Building resilient health systems, that can withstand shocks and sustain provision of regular health
services, is significantly escalate the efforts towards achieving universal health coverage. In turn,
achieving universal health coverage is a requirement to ensure health security of the community, as
health security and universal health coverage are considered as a two side of one coin.
 Ensure Health Security of the Nation

Equitable Health
Outcomes and Well- Productivity and
being Development

Universal Health Coverage

All people and communities receive the quality

health services they need without financial hardship

Health System Resilience

Figure 7-1:Inter-linkage between health system resilience, universal health coverage and health security

HSR Attributes and Capacities

Resilient health systems have been characterized in one framework as having five key features:
knowledge of available resources and emerging challenges, versatility to act against a broad range of
challenges, ability to contain health crises and avoid damaging reverberations in other parts of the
health system, capacity to form a multi-sectoral response that integrates a range of actors and
institutions and flexible processes that allow for adaptation during crises. These health system resilience
attributes and capacities can be built in pre-emergency phase (before crisis hits) during emergency
phase (during response to the crisis) and post emergency phase (after the crisis ended).
Health system resilience attributes

● Awareness: knowing the health system capacity as well as health risks (assets and
weakness of the system). Detects health threats before they strike.

● Diverse: this attribute is described by effectively respond to a range of health needs.

Delivers range of services with universal health coverage.

● Self-regulation: the health system should be able to predict the potential health threats,
maintain essential functions or services and leverage the outside capacity. Prevents health
disruptions from turning into disasters.

● Integration: the health sectors should work in coordination with non-health actors as well
as by engaging the community. Within the health sector also, there should be a coordination
mechanism. Rapidly deploys resources from beyond the health system.

● Adaptive: this attribute described by shifting resources depending on the need, promote
rapid local decision making and rebounds from shocks stronger than before.

Health system resilience capacities

An alternative framework for resilience focuses on three aspects: absorptive, adaptive and
transformative capacities. These relate to the protection of service delivery during crises, the ability of
the system to manage health crises using fewer resources and its ability to introduce realistic reforms in
response to the changing environment.

● Adapt and coping capacity: the capacity of the health system actors to deliver the same
level of healthcare services with fewer and/or different resources, which requires making
organizational adaptations.
● Absorptive capacity: the capacity of a health system to continue to deliver the same level
(quantity, quality and equity) of basic healthcare services and protection to populations
despite the shock using the same level of resources and capacities.
● Transformative capacity: the ability of health system actors to transform the functions and
structure of the health system to respond to a changing environment.
 Figure 7-2 Health system resilience attributes and capacity across emergency phases

Pre-Emergency Health System Resilience

Health system resilience in pre-emergency phase focuses on building capacities of the system to
forecast the potential risks, knowing health system capacities, mitigating the potential impact and
preparing to the potential health system shocks.

Capacity to forecast and mitigate public health risks

Forecasting the potential public health risks is one of the key resilience health system capacity in pre-
emergency phase. Once the public health risks are identified, the next step, in parallel with
preparedness planning, should be mitigating the potential impacts of public health emergencies. Public
health emergency mitigation includes avoid or reduce avoidable risks by reducing/avoiding hazards or
vulnerability (risk aversion/prevention/primary mitigation) and reduce the severity of the human and
property damage caused by the disaster (secondary mitigation).
The public health emergency mitigation process includes the following activities:

● Identify and estimate the magnitude of vulnerability

● Identify and engage all stakeholders relevant to the public health emergency mitigation
process
● Developing and designing mitigation strategies specific to the identified risk/risks by
considering all hazard approach principle
● Include disaster mitigation measures in health sector policy and in the planning and
development of new facilities.
● Ensure that disaster mitigation measures are taken into account in a facility’s
maintenance plans, structural modifications, and functional aspects
● Inform, sensitize, and train those personnel who are involved in planning, administration
and operation of disaster mitigation

Emergency preparedness and health service continuity planning

The emergency preparedness plan is a scenario-based planning to response to potential emergencies

while health service continuity planning is a process of planning with the main purpose of maintaining
continuity of essential health services and protecting lives and health of the affected population. It is
important for public and private health services providers to ensure continued health service delivery
during public health emergencies or shocks to the health system. The operationalizability of both
preparedness and health service continuity plans need to be tested with simulation exercises, this could
be discussion based or operation-based exercise. Continuity of essential health services during PHEs is
vital to global, regional, national and local health security as well as to ensure Universal Health
Coverage (UHC). Health service continuity planning should be framed in all hazard approach. This plan
could be part of emergency preparedness and response plan or a separate plan.

The following steps are recommended for health service continuity planning using the all-hazard
planning approach.

● Form a collaborative planning team;

● Conduct risk assessment and prioritize risks;
● Determine overall objectives and operational priorities;
 ● Conduct capacity assessment;
● Develop service continuity plan;
● Test (exercise) and update the plan;
● Implement the plan and monitor the implementation;
● Post event or post-exercise review and improvement of the plan

Health System Resilience during Emergency

Building health system resilience is an ongoing process, however the resilience capacity of the health
system is tested during health crises. During public health emergencies, in parallel with responding to
the ongoing health event, essential health services and essential public health function have been given
due attention. The Ethiopian Public Health Institute and Ministry of Health at national level and their
counter parts at sub national level, in collaboration with relevant stakeholders, are responsible to ensure
the continuity of essential health service and essential public health functions during emergency
response.

Maintaining Essential Service during Emergency Response

Public health emergency responses require additional resources which can compromise the routine
health service delivery. But there are health services by any means should be available, these are
essential health services. Hence, maintaining he pre-determined minimum standard health services
during emergency response is one of the key features of health system resilience. The major
components of the essential health services of Ethiopia are organized into the following nine
components:
1) Reproductive, maternal, neonatal, child and adolescent health services
2) Major communicable diseases
3) NCDs
4) Surgical care
5) Emergency and critical care
6) NTDs
7) Hygiene and environmental health services
8) Health education and behavior change communication services
9) Multi-sectoral interventions
Health Service Quality during Emergency Response

Public health emergencies have direct and indirect negative effects on quality of health care at all levels
of service delivery. All domains of quality must be factored into all interventions and actions to
management the emergency i.e. people-centeredness, safety, efficiency, integrated care, effectiveness,
timeliness and equity.

● People Centered: Providing care that considers the preferences and aspirations of
individual service users and the culture of their community.
● Safety: Delivering health care that minimizes risks and harm to service users, avoiding
preventable injuries and reducing medical errors.
● Efficiency: Delivering health care in a manner that maximizes resource use and avoids
waste.
● Integrated Care: Providing care that is coordinated across levels and providers and
makes available the full range of health services throughout the life course.
● Effectiveness: Providing services based on scientific knowledge and evidence-based
guidelines.
● Timeliness: Reducing delays in providing and receiving health care.
● Equity: Delivering health care that does not differ in quality according to personal
characteristics such as gender, race, ethnicity, geographical location or socioeconomic
status.

Maintaining Essential Public Health Function

Essential public health functions are indispensable set of actions, under the primary responsibility of the
state, that are fundamental for achieving the goal of public health which is to improve, promote, protect,
and restore the health of the population through collective action. The essential public health functions
should be maintained during health emergency responses.

These are;
1) Surveillance of population health and well-being
2) Preparedness and public health response to disease outbreaks, natural disasters and
other Emergencies
3) Health protection, including management of environmental, food, toxicological and
occupational safety
 4) Health promotion and disease prevention through population-based interventions,
including action to address social determinants and health inequity
5) Effective health governance, public health legislation, financing and institutional support
6) Sufficient and competent workforce for effective public health delivery
7) Communication and social mobilization for health
8) Public health research to inform and influence policy and practice

Post Emergency Health System Resilience

Emergencies often have a direct impact on the health systems and public health systems of an affected
region or country, particularly in resource-constrained areas. The effects of an emergency on the
performance and capacity of these systems depend upon a variety of interrelated factors, which include
the pre-disaster status of the systems, the type of emergency, the effectiveness of the response, and
the initiation of recovery activities.

Humanitarian Development Nexus

Humanitarian development nexus is an approach of addressing needs and reducing risks and
vulnerabilities through the combined effort of both humanitarian and development communities and
other actors as appropriate. Within the mandate and humanitarian imperative to save lives, humanitarian
responses can and need to consider the longer-term consequences of their actions, and how
interventions interface with and can contribute to building resilience during the crisis and longer-term
recovery and development whenever the environment stabilizes. During post emergency recovery,
optimizing the quality and coverage of health services provided to affected populations collectively by all
health actors using all available resources, while laying the foundation for health system resilience is a
key consideration. Therefore, the humanitarian and the development actors should involve in the
following process jointly;

● Preparedness: It is important to development actors to invest on risk reduction,

preparedness and contingency plans, and scaling up treatment capacity for response.

● Joint Assessment: A main first step in this process is to jointly conduct a structured
health system assessment with the objective of identifying common challenges to
humanitarian and development activities and bottlenecks, and proposing
 recommendations to address those jointly. The assessment could be conducted by a
small team of humanitarian development nexus experts, with combined knowledge of
humanitarian and development processes and structures.

● Joint Planning: Based on the findings and recommendations, government,

humanitarian and development partners will jointly develop and commit to a
humanitarian development nexus roadmap consisting of prioritized and costed actions
with predictable funding. This roadmap will inform the development of the multiyear
humanitarian response plan, the national health strategic plan, the health sector
humanitarian operational plan and the national and subnational annual health
operational plans. These plans will define the roles and responsibilities of each actor.

● Coordinated Implementation: Government and humanitarian and development

partners will implement the activities defined under responsibilities in a coordinated
way. They will use different partner coordination mechanisms, such as the health
security council and the health cluster. A special humanitarian development nexus
coordination structure or processes will also be established.

● Joint Monitoring and Evaluation: In accordance with the monitoring and evaluation
frameworks, government, humanitarian and development partners will jointly monitor
and evaluate progress and performance of their humanitarian and development
activities, as well as indicators specific to the humanitarian development nexus. In doing
so, the existing public health emergency management coordination and collaboration
platforms as well global humanitarian response and development program coordination
platforms would be utilized.

Learning from Emergency Experiences to Build Health System Resilience

To learn from the experience of the past public health emergency, the after and/or inter action reviews
should be conducted. The after and/or inter action review can be conducted at national, regional, zonal
or woreda levels and even at health facility level depending on the extent and type of the event. The
after and/or inter action review of the usual public health emergencies involving small geographic area
can be conducted at local level. However, the after and/or inter action review for new public health
emergencies or for public health emergencies involving a wider geographic area can be conducted at
regional or national level. An after/inter action review is a qualitative review of actions taken in response
 to an event of public health concern. It is a means of identifying and documenting best practices and
challenges demonstrated by the response to the event. After action review (AAR) conducted after the
response efforts are completed and the emergency is declared over, ideally within three months after
the emergency is declared over.

An AAR/IAR seeks to identify:

● Actions that need to be implemented immediately, to ensure better preparation for the
next event;
● A medium- and long-term actions needed to strengthen and institutionalize the
necessary capabilities of the public health system.

The AAR/IAR process involves three phases i.e. pre-AAR, during AAR and post AAR.

Pre-AAR During AAR Post-AAR

1-DESIGN 2-PREPARE 3-CONDUCT 4-RESULTS 5-FOLLOW-UP

1. Designing an AAR
1. Collect and 1. Conduct the analytical 1. Conduct AAR 1. Documenting
2. Select an
review relevant part of an AAR debriefing progress: post-
appropriate AAR
background AAR follow-up
format
information a. Identification of a. AAR team 2. Lessons
3. Build an AAR team
2. Refine the trigger capacities debriefing learned
4. Develop a budget
questions b. Timeline of key b. Senior database
5. Develop a checklist
3. Identify and brief milestones management
and agenda
facilitators/intervi c. Identification of debriefing
6. Summarize in a
ewers strengthens, c. AARs as an
concept note
4. Setting up an challenges and opportunity
7. Inform key
AAR new capacities for advocacy,
stakeholders and
developed resource
facilitators
d. Evaluation of IHR mobilization
8. Select a venue
(2005) core and strategic
capacities partnership
performance
2. AAR final report
2. Build consensus
among participants
3. Close an AAR and
conduct participant
AAR evaluation

1-3 days: AAR Setup

Immediately and
1-3 days: Conduct Continuous and
3-4 Weeks before AAR over the next 2
AAR ( The Interview as needed
weeks
format may vary)

Figure 7-1 Steps of after/inter action review process

Depending on the location and number of participants, cultural context, the complexity of the health
event, and the resources available to conduct the review, the format/method on the review should be
determined. The following are formats/methods of an AAR

● Debrief: This format is the simplest type. It is a facilitator-led discussion held over less
than half a day, involving a small group and a plenary review of a limited number of
functions.

● Working Group: This is an interactive, structured methodology based on group

exercises, plenary discussions and interactive facilitation techniques. It blends group
work (in groups of 6–12 people) and plenary sessions. Each working group
corresponds to a particular pillar of the response (for example, surveillance, case
management).

● Key Informant Interview (KII): It consists of a longer, more in-depth review of an

event. It includes research into background materials, such as peer-reviewed literature,
media reports and grey literature. The research is followed by semi structured
interviews and short focus group discussions in which key informants are encouraged
to provide honest feedback on their experiences. Feedback can also be gathered
through surveys sent to those involved in the response.

● Mixed: This approach blends the formats of the debrief, working group and key
informant interview AARs. This approach can be used to review the response to
emergencies for which it might not be possible to bring responders together for a
working group format.

Post-emergency Health System Transformation

The impact of public health emergencies is quantified with human lives and suffering, the psychosocial
impact, and the economic slowdown constitute strong reasons to translate experiences into actionable
lessons, not simply to prevent similar future crises, but rather to improve the whole spectrum of
population health and the health system. In addition to restoring the health system functions to its pre-
emergency/disaster level, emphasis should be given to transform the health system in a better way. So
that, the health system can absorb or adapt to similar or other public health emergencies in the future.
 The focus areas in transforming the health system are;
● The health system infrastructure
● The health information management system
● Health service delivery modalities
● Health workforce management and capacity building
● Community level mitigation strategies
● Restructuring or reforming the coordination platforms or the health system as a whole
● Revision or development of health emergency related policies, guidelines and
strategies

Health System Resilience Framework

The interconnected health system building blocks are important starting points for building the overall
resilience of the health system to public health emergencies and strengthen existing health system
capacities. Therefore, to build a resilient health system, it requires continuous improvement and
sustainable capacity of the health system capacity to adopt and absorb health system shocks and to
transform after crisis.

● Continuous System Improvement: continuous improvement is a systematic,

sustainable approach to enhancing the health system capacity. Building a continuous
improvement culture is not a turnaround project or a quick fix but a journey that never
really ends, requiring commitment, investment and persistence. The improvement could
be based on the lesson learned from previous health emergencies or crises.

● Sustainable System Capacity: health system is continuously challenging by natural

and manmade disasters, disease outbreaks and population dynamics. Therefore,
sustaining the health system capacities during and after health emergencies or crises is
the core of a health system resilience.
 Adaptive and Coping capacities Absorptive capacities Transformative capacities

People/ Community

Figure 7-4 Health system resilience building blocks and their connection with the public health emergency management system to build a resilient health system through continuous improvement and
sustainable development
09/ MONITORING AND
EVALUATION
Definition

Monitoring: It is a continuous internal process for making sure that the activities under the
programme /project as Public Health Emergency Management are on track. Monitoring of
project activities, use of resources, results achieved and institutional systems (staffing, policies,
etc.) should be done on a regular basis.

Evaluation: It is a systematic way of collecting, analyzing and using information to answer

basic questions about a project/programme. It assesses whether the objectives set are
achieved or not. It can be internal, external or involving many key stakeholders. It can be done
by–Process evaluation: assess whether an intervention/model was implemented as planned,
whether the target population was reached, and what were the major challenges and
successful strategies used or by-Outcome evaluation: determine whether and to what extent
the expected changes occurred and whether these changes can be attributed to the
programme activities.

Thus, Monitoring and evaluation is usually carried out using a selected and agreed up on
indicators; it can also measure progress toward implementing an overall program target.
Measuring the level of preparedness of the PHEM system at different levels is critical to know
the capacity of the program to handle outbreaks/events and any other emergencies in an
effective manner.

Purpose

Monitoring and Evaluation is the important component of PHEM. It is carried out at each level
starting from preparedness to recovery from incidents. Thus, it would have benefits of:

● Ensuring intense demand for data by decision makers at National and

Sub-National levels, partners and stakeholders across all levels
● Providing guidance about: minimum and optional data to collect and
 measure the performance of key components of PHEM activities and to
take corrective action when needed
● Indicating the use of information systems to collect, store, analyze and
disseminate any relevant information.

Monitoring and Evaluation Framework

The Monitoring and Evaluation logic model was adapted from the third Strategic Planning
Management (SPM-III) documents considering the four major pillars of PHEM. In this
framework, the early warning and communication, preparedness and response activities are
taken as processes and the outputs of the performances would be the results under recovery
and resilience. The outcomes would be improved health services and systems and decreased
morbidity and mortality and the impact will be improved health security in the country (Figure-).

Figure-8-1: Monitoring and Evaluation Logical Framework of PHEM

Important process, output, outcome and impact indicators were selected to measure
performances of the core activities of PHEM. The primary data sources in measuring the
indicators include: Routine monitoring through administrative systems comprise any data
generated by facilities or providers through periodic reports, logistics management information
systems; Periodic surveys as either directed at households or facilities and providers,
evaluating aspects of service delivery; and Surveillance systems (IBS and EBS).
Preparedness

Preparation for responding outbreaks has several activities that can be implemented across all
levels of the health system. Among the many preparedness activities, the M and E team
measures progresses of the below listed core activities to track their successful implementation
and achievements.

● Capacities in conducting various forms of assessments (VRAM, Periodic

Surveys)
● Presence of an epidemic preparedness and response plan (EPRP) and
demand forecasting
● Availability of emergency stocks of drugs, vaccines and supplies during
the last 12 months
● Availability of funds for outbreak response
● Presence of a well-equipped, trained woreda/zonal /regional and
national rapid response team to conduct an outbreak investigation
● Epidemic management committee
● Presence of a functional PHEM task force at all level
● Availability of trained/oriented health staffs (surge capacity, volunteers)
for the response
● Availability of redundant and uninterrupted communication facility
● Existence of strong coordination and collaboration
● Monitoring and rehearsal/simulation

Early Warning and Communication

Most activities of early warning and communication are directly linked with surveillance system
by which many forms of data are collected from different data sources for possible actions. In
one way or another, the activities of this section are linked with monitoring and evaluation.
Thus, the M and E team should measure the existence of strong surveillance and risk
communication system on the ground in order to ensure:

● Capacities in conducting assessments (VRAM, Periodic Surveys)

● Capacities in early detection, prediction and forecasting of risks
● Existence of strong surveillance system (IBS and CEBS)
● Fast Risk Communication mechanisms and feedback provision systems
 Timeliness and completeness of reports are critical dimensions towards detecting a risk and
conducting a prompt and effective response. When reports are late, or are not submitted, the
aggregated information for a specific area will not be accurate as a result outbreaks can go
undetected and other opportunities to respond to public health problems will be missed.

Response

Up-to-date information is needed on a continuous basis throughout the emergency to inform

decisions on response actions, monitor the effects of health interventions and enable
adjustments to be made when necessary, and to support resource mobilization efforts.

The following are some of the elements to be monitored:

● Disease trends in order to assess the effectiveness of the response
measures, the extension of the outbreak and risk factors
● Resources assessment of the rational utilization, adequacy and
sufficiency and determination of additional needs
● Performances of alerting and declaring of an event/outbreak
● Quality of the Outbreak Investigation processes
● Prevention and Control mechanisms of exposures, transmissions, and
deaths Activation of Emergency Operating Centers
● Practices of preparing quarantine and isolation sites and proper use of
the sites
● Effectiveness of the response: case fatality rate, incidence rate
● Implementation status of the identified intervention activities
● Continuation of Essential Health Services and response to other PHE
● Establishing PHM Committee, Mobilizization of RRT and Incident
Management System
● Inter-Action Review (IAR)/AAR
● Drugs and Supply
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.
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

● Pre-emergency: forecasting and mitigation, preparedness and Health

Service continuity
● During emergency: maintaining EHS and Public health services, Health
service quality
● Post-Emergency: Humanitarian-Development Nexus, Learning
ANNEXES
Annex-1: Key stakeholders in public health emergency management coordination framework
Annex-2: Key Components of Workforce Capacity Building

The following activities should be considered as part of a comprehensive workforce capacity building strategy for health emergency
preparedness and response at all levels;

a. Training needs assessment to inform capacity and skill gaps

b. Preparing updated list of trained staff at all levels including health facilities on the following key areas;
 Surveillance and epidemiology, Rapid response team (RRT) and Case management for priority risks; Laboratory
testing for priority pathogens including zoonosis in humans; and Infection prevention and control (IPC) and WASH
in health facilities; etc.
c. Identifying and addressing gaps in the existing training as revision of curriculums of health emergency workforce training programs
d. Working with public health training institutions to support institutionalization of IDSR and health emergency leadership trainings
e. Planning and implementation of intermediate and/or advanced FETP and other trainings based on need, identified gaps and health
sector strategic objectives. This includes Intermediate level FETP, Advanced FETP specialty tracks (laboratory, veterinary) and Public
health emergency leadership (PHEL)
f. Implementing short term in-services trainings programs to address the immediate priorities in preparedness and response capacities
at all levels such as
 Incident management system (IMS)
 Basic PHEM training for health facilities levels
 Event-based surveillance (EBS) focused on enhancing existing community based-surveillance system
 Emergency Medical Team (EMT) training including basic trauma and life support, and pre-hospital
care for clinicians, nurses, first aid personnel
• Infection prevention and control (IPC) trainings for PHEM officers, RRT, clinicians, and HF managers
 Event specific trainings for PHEM officers focused on skills development for risk assessment and
investigation, surveillance, case management, isolation and quarantine protocols. For example
o SARI or Influenza like illnesses (ILI), VHF and/or Yellow Fever, Vector borne diseases (malaria,
arboviruses), MPDSR, AEFI, etc.
 Develop an integrated in-service PHEM training which includes IHR, IDSR and disaster management
g. Focusing capacity strengthening at sub-national levels
The implementation of workforce capacity building strategies should be informed by demands and need assessment at lower
levels of the health system, and also take into consideration the health sector priorities and strategic objectives of strengthening
primary health care to achieve universal health coverage and health security. Adequate attention and emphasis to strengthen
preparedness and response capacity at sub-national levels particularly zonal woreda and health facility levels by implementing
the following activities;
 Support zonal and Woredas to identify health workforce need by profession, quantity, specific skill or
competencies based on local context or priority risks
 Strengthen zonal and woreda capacity to forecast and plan for human resource needs to respond to priority public
health risks at local level
 Enhance support for health facilities to improve the skill and competencies required to diagnose and treat
emerging and re-emerging infections, etc.
 Strengthen collaboration between regional, zonal and woreda health leaders and local administration to mobilize
resource for health workforce capacity building
Annex-3: Summary of EBS-CBS Tasks and Information

Sources of Information Tasks

The tasks for EBS and CBS are in line with IDSR core functions namely:
 Using lay simplified case definitions to identify priority diseases, events,
• Community members
conditions or other hazards in the community.
• Clan leaders
 Participating in verbal autopsies to determine causes of death.
• Traditional healers
 Sending notification, timely and regularly, to the nearest health facility of the
• Religious organizations
occurrence of unexpected or unusual cases of disease or death in humans and
• Model families
animals for immediate verification and investigation according to the
• School principals
International Health Regulations (IHR) and in line with the IDSR strategy.
• Community associations
 Involving local leaders in describing disease events and trends in the
(youth association,
community.
women associations etc.)
 Supporting health workers during case or outbreak investigation and contact
• Law enforcement
tracing.
personnel, Police and
 Participating in risk mapping of potential hazards and in training including
refugee camps
simulation exercises.
• Health extension workers
 Participating in response activities including home-based care, including
• Journalists, bloggers
sensitization of the community on the adoption of behaviour facilitating the
• Internet and media
containment of the outbreak.
sources (social medias,
 Using feedback from the CBS Coordinator to take action, including health
radio, TV, newspapers…)
education and coordination of community participation.
 Verifying if public health interventions took place as planned with the
involvement the community.
 Having a forum for feedback to the community on outbreak/event assessment.
Annex-4:EBS Information flow and response
 Annex-5: Lists of Community Case Definitions
Disease/Condi
Suspected Case Confirmed Case
tion
Any person with acute onset of fever >38.5°C and
Chikungunya severe arthralgia/arthritis not explained by other A suspected case with laboratory confirmation.
medical conditions.

Adverse Any untoward medical occurrence which follows

Events immunization and which does not necessarily
Following have a causal relationship with the usage of the
Immunization vaccine. The adverse event may be any
(AEFI) unfavorable or unintended sign, abnormal
laboratory finding, symptom or disease.
Any person presenting unexplained acute lower A person meeting the criteria for a suspected case AND
respiratory illness with fever (>38 ºC) and cough, positive laboratory results from a laboratory whose H5N1 test
shortness of breath OR difficulty breathing AND results are accepted by WHO as confirmatory.
one or more of the following exposures within the
NB: Include IHR case definition for reporting of human
7 days prior to symptom onset:
infection with a novel influenza virus

(a) Close contact (within 1 meter) with a person

(for
example, caring for, speaking with, or
touching) who is a
suspected, probable, or confirmed H5N1
case;

(b) Exposure (for example, handling, slaughtering,

de-
feathering, butchering, preparation for
consumption) to
poultry or wild birds or their remains or to
Human environments
influenza contaminated by their faeces in an area where
caused by a H5N1
new subtype infections in animals or humans have been
suspected or
confirmed in the last month;

(c) Consumption of raw or undercooked poultry

products in
an area where H5N1 infections in animals or
humans
have been suspected or confirmed in the last
month;

(d) Close contact with a confirmed H5N1 infected

animal
other than poultry or wild birds;

(e) Handling samples (animal or human)

suspected of
containing H5N1 virus in a laboratory or other
setting.
 Any person with fever and maculopapular (non-
A suspected case with laboratory confirmation (positive IgM
vesicular) generalized rash and cough, coryza or
Measles antibody) or epidemiological link to confirmed cases in an
conjunctivitis (red eyes) or any person in whom a
outbreak.
clinician suspects measles.

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
Neonatal has convulsions or both.
Tetanus/Non-
Neonatal Non-Neonatal Tetanus: Any person > 28 days of
Tetanus age with acute onset of one of the following:
lockjaw, sustained spasm of the facial muscles, or
generalized muscle spasms. Confirmed case: No
laboratory confirmation recommended Neonatal
Tetanus
The death of a woman while pregnant or within 42
days of the delivery or termination of pregnancy,
Maternal irrespective of the duration and site of the
Deaths pregnancy, from any cause related to or
aggravated by the pregnancy or its management
but not from accidental or incidental causes.

A person bitten by suspected rabid dog and

Rabies presented with fever, nausea, vomiting, agitation, A suspected case confirmed by lab.
pharyngeal spasms (hydrophobia/ aerophobia).

An illness with acute onset of fever >38 0 C A suspected case with laboratory confirmed
followed by a rash characterized by vesicles or
Smallpox
firm pustules in the same stage of development
without other apparent cause.
Any person with history of fever, or documented A suspected case whose tests positive for SARS-Cov (cell
fever >38 0 C AND One or more symptoms of culture)
lower respiratory tract illness (Cough, difficulty of
breathing, shortness of breath) And Radiographic
evidence of lung infiltrates consistent with
SARS
pneumonia or autopsy findings consistent with
pathology of pneumonia or Acute Respiratory
Distress Syndrome without an identifiable cause
And NO alternative diagnosis can fully explain the
illness.
A person with acute onset of fever followed by
A suspected case with laboratory confirmation (positive IgM
jaundice within two weeks of onset of first
antibody or viral isolation) or epidemiologic link to confirmed
Yellow fever symptoms. Hemorrhagic manifestations and renal
cases or epidemics.
failure may occur.

Any child under 15 years of age with acute flaccid

Poliomyelitis A suspected case with virus isolation in stool.
paralysis or any person with paralytic illness at
(Acute flaccid
any age in whom the clinician suspects
paralysis)
poliomyelitis.
Perinatal A perinatal death is defined as the death of a
deaths 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)

A stillbirth is defined as any death of a baby

before birth and with no signs of life at birth of at
least 1 000 g birth weight and/or at least 28 weeks
gestation and 35 cm long.

Early neonatal death is defined as any death of

a live newborn occurring before the first seven
complete days of life. Day 1 is clinically
considered the first day of life.
Any person with acute onset characterized by
A confirmed case of anthrax in a human can be defined as a
several clinical forms which are:
clinically compatible case of cutaneous, inhalational or
gastrointestinal illness that is laboratory-confirmed by:
1. Cutaneous form: Any person with skin lesion
evolving over 1 to 6 days from a popular through 1. isolation of B. anthracis from an affected tissue or site; or
a vesicular stage, to a depressed black eschar
invariably accompanied by edema that may be
mild to extensive. 2. Other laboratory evidence of B. anthracis infection based
on at least two supportive laboratory tests.
2. Gastro-intestinal: Any person with abdominal
distress characterized by nausea, vomiting, Note: It may not be possible to demonstrate B. anthracis in
anorexia and followed by fever clinical specimens if the patient has been treated with
antimicrobial agents
Anthrax 3. 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

4. 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
In areas where a cholera outbreak has not been A suspected case with Vibrio cholerae O1 or O139 confirmed
declared: Any patient aged two years and older by culture or PCR polymerase chain reaction and, in
presenting acute watery diarrhoea and severe countries where cholera is not present or has been
Cholera dehydration or dying from acute watery diarrhoea. eliminated, the Vibrio cholerae O1 or O139 strain is
In areas where a cholera outbreak is declared: demonstrated to be toxigenic
any person presenting or dying from acute watery
diarrhoea.

Rumors: Information about the occurrence of A case of guinea-worm disease is a person exhibiting a skin
Guinea worm disease (Dracunculiasis) from any lesion with emergence of a Guinea worm, and in which the
Dracunculiasis source. worm is confirmed in laboratory tests to be D. medinensis.
(Guinea That person is counted as a case only once during the
Worm) calendar year, that is, when the first worm emerges from that
A person presenting a skin lesion with itching or person. All worm specimens should be obtained from each
blister living in an endemic area or risk areas for case patient for laboratory confirmation and sent to the
 Guinea worm, with the emergence of a worm. United States Centers for Disease Control and Prevention
(CDC). All cases should be monitored at least twice per
month during the remainder of the calendar year for prompt
detection of possible emergence of additional guinea worms

Dengue Fever Confirmed Case: A suspected case with

laboratory confirmation (positive IgM antibody, fourfold or
greater increase in IgG antibody titers in paired (acute and
convalescent) serum specimens, positive PCR or Isolation of
the dengue virus using cell culture).
Dengue Haemorrhagic Fever: A probable or confirmed
case of dengue with bleeding tendencies as evidenced by
one or more of the following: positive tourniquet test;
Dengue Fever: Any person with acute febrile petechieae, ecchymoses or purpura; bleeding: mucosa,
illness of 2-7 days duration with 2 or more of the gastrointestinal tract, injection sites or other; haematemesis
following: headache, retro-orbital pain, myalgia, or melaena; and thrombocytopenia (100 000 cells or less per
Dengue Fever arthralgia, rash, haemorrhagic manifestations, mm3) and evidence of plasma leakage due to increased
leucopenia. vascular permeability, manifested by one or more of the
. following: 20% rise in average haematocrit for age and sex,
20% drop in haematocrit following volume replacement
therapy compared to baseline, signs of plasma leakage
(pleural effusion, ascites, hypo-proteinaemia)
Dengue Shock Syndrome: All the above criteria, plus
evidence of circulatory failure manifested by rapid and weak
pulse, and narrow pulse pressure (≤ 20 mm Hg) or
hypotension for age, cold, clammy skin and altered mental
status.
Clinical case definition (IMCI) for pneumonia Radiographic or laboratory confirmation of pneumonia may
not be feasible in most districts.
A child presenting cough or difficult breathing and:
(a) 50 or more breaths per minute for infant
age 2 months up to 1 year
(b) 40 or more breaths per minute for young
child 1 year up to 5 years.
Note: A young infant age 0 up to 2 months with
Severe cough and fast breathing is classified in IMCI as
Pneumonia in “serious bacterial infection” and is referred for
Children under further evaluation.
5 years of age Clinical case definition (IMCI) for severe
pneumonia:
A child presenting cough or difficult breathing and
any general danger sign, or chest in-drawing or
stridor in a calm child. General danger signs for
children 2 months to 5 years are: unable to drink
or breast feed, vomits everything, convulsions,
lethargy, or unconsciousness.
 Passage of three or more loose or watery stools Suspected case confirmed with stool culture for a known
in the past 24 hours with or without dehydration enteric pathogen.
and:
Diarrhoea with Some Dehydration: two or more of the following
Dehydration in signs: restlessness, irritability; sunken eyes;
Children less thirsty; skin pinch goes back slowly, or
than five years
Severe Dehydration: two or more of the following
of age
signs: lethargy or unconsciousness; sunken eyes;
not able to drink or drinking poorly; skin pinch
goes back very slowly.

A positive ELISA for confirming HIV and a rapid

test for confirming the positive results are
New HIV Case
sufficient for an epidemiologic case definition for
HIV Infection.
Smear-Positive Pulmonary TB:
(a) a suspected patient with at least 2 sputum specimens
positive for acid-fast bacilli (AFB), or
(b) one sputum specimen positive for AFB by
microscopy and radiographic abnormalities consistent
with active PTB as determined by the treating medical
officer, or
(c) one positive sputum smear by microscopy and one
sputum specimen positive on culture for AFB.
Smear-Negative Pulmonary TB: a patient who fulfils all the
following criteria:

(a) two sets taken at least 2 weeks apart of at least two

Tuberculosis Any person with a cough of 3 weeks or more. sputum specimens negative for AFB on microscopy,
radiographic abnormalities consistent with PTB and a
lack of clinical response despite one week of a broad
spectrum antibiotic, a decision by a physician to treat
with a full course of anti-TB chemotherapy, or

(b) a patient who fulfils all the following criteria: severely

ill, at least two sputum specimens negative for AFB by
microscopy, radiographic abnormalities consistent with
extensive pulmonary TB (interstitial and miliary), a
decision by a physician to treat with a full course of anti-
TB chemotherapy, or

(c) a patient whose initial sputum smears were negative,

who had sputum sent for culture initially, and whose
subsequent sputum culture result is positive.
Any person with a fasting 6.1 mmol/L (110 mg/dl) Or venous
Any person presenting the following symptoms: plasma glucose measurement of ≥ 7 mmol/L (126 mg/dl) or
Diabetes New (a) Increased thirst capillary glucose ≥ 6.1 mmol/L (110 mg/dl) OR Any person
cases (b) Increased hunger with a non-fasting glucose ≥ 11.1 mmol/L (200mg/dl) Or
(c) Frequent urination venous plasma glucose measurement of ≥ 11.1mmol/L (200
mg/dl
Any individual presenting a resting blood pressure Any individual presenting on at least two occasions a resting
Hypertension
measurement (based on the average of 3 blood pressure measurement (based on the average of 3
New cases
readings) at or above 140 mm Hg for systolic readings) at or above 140 mm Hg for systolic pressure, or
 pressure, or greater than or equal to 90 mm Hg greater than or equal to 90 mm Hg for diastolic pressure
for diastolic pressure.

Any person above age of one month with discrete 1. Hepatitis A: positive for antibodies to hepatitis A virus
onset of an acute illness with signs and symptoms (anti-HAV), immunoglobulin (IgM), or an epidemiological link
of: with confirmed case(s).
(a) Acute infectious illness such as fever, malaise, 2. Hepatitis B: positive for antibodies to hepatitis B virus
Acute fatigue), core antigen (antiHBcAg)-IgM.
Jaundice
Syndrome or AND 3. Hepatitis E: positive for antibodies to hepatitis E virus
Acute (anti-HEV) IgM, or an epidemiological link with a confirmed
(b) Liver damage such as anorexia, nausea,
Hepatitis case(s)
jaundice, dark colored urine, right upper quadrant
(Within 14 tenderness of the abdomen, 4. Hepatitis C: positive for hepatitis C virus antibodies (anti-
days) HCV); or HCV RNA in the absence of anti-HCV; or positive
AND/OR
for anti-HCV and negative for anti-HAV IgM, anti-HBc IgM
(c) Raised liver enzyme, alanine aminotransferase and anti-HEV IgM;
(ALT), levels more than ten times the upper limit
of normal

Any person with fever or fever with headache,

Malaria rigor, back pain, chills, sweats, myalgia, nausea, A suspected case confirmed by microscopy or RDT for
and vomiting diagnosed clinically as malaria. plasmodium parasites.

Illness with onset of fever and not showing A suspected case with laboratory confirmation (positive IgM
improvement to treatments of usual causes of antibody or viral isolation), or epidemiologic link to confirmed
Viral
fever in the area, and at least one of the following cases or epidemic.
Hemorrhagic
signs: bloody diarrhea, bleeding from gums,
Fever (VHF)
bleeding into skin (purpura), bleeding into eyes
and urine.
Suspected case with stool culture positive for Shigella
Dysentery A person with diarrhea with visible blood in stool. dysentariae 1

Any person with sudden onset of fever (>38.50 C A suspected case confirmed by isolation of N. meningitis
rectal or 380 C axillary) and one of the following from Cerebrospinal fluid or blood
Meningitis*
signs: neck stiffness, altered consciousness or
other meningeal sign.
A suspected case with demonstration of Borrelia in peripheral
Relapsing Any person presented with an abrupt onset of
blood film
fever rigors with fever, usually remittent, headache,
arthralgia and myalgia, dry cough, epistaxis.
Children age from 6 months to 5 years with
MUAC less than 11cm and/or children with
Severe Acute bilateral edema regardless of their MUAC.
Malnutrition Children with MUAC less than 11cm and/or
children with bilateral edema regardless of their
MUAC.
Low Birth Weight Neonates: Any new born with
Moderate a birth weight less than 2500 grams (or 5.5 lbs)
Malnutrition Malnutrition in children:
(a) Children under five who are underweight
 (indicator: weight for age<-2 Z Score)
(b) Children 6 to 59 months with MUAC (high risk
of mortality)
(c) Bilateral pitting Oedema

Malnutritin pregnant women:

Pregnant women giving birth to low birth weight
babies (birth weight < 2.5 Kg) (poor nutritional and
health status of the women, can predict which
population groups may benefit from improved
antenatal care of women and neonatal care
for infants).
AMR
Brucellosis
SARS-CoV-2
(COVID-19)
Scabies
Annex-6: Examples of how key signs and symptoms of case definitions may be described at the
community level
Diseases or
Case Definitions Used at Community
Conditions

Acute Flaccid Any child under 15 years old with a sudden onset of weakness and /or inability to use their
Paralysis (AFP) hand(s) and or leg(s)

Acute Watery
Any person with 3 or more loose stools within the last 24 hours
Diarrhoea

Acute haemorrhagic Any person who has an unexplained illness with fever and bleeding or who died after an
fever syndrome unexplained severe illness with fever and bleeding

Adverse event
following Any unusual event that follows immunization
immunization (AEFI)

Diarrhea in children
Any child who has three or more loose or watery stools in the past 24 hours with or without
less than 5 years of
dehydration
age

Diarrhoea with blood

Any person with diarrhoea, stomach pain and visible blood in the stool
(Dysentery)

Guinea Worm Any person presenting a skin wound living in an endemic area or risk areas of Guinea worm, with
(Dracunculiasis) a worm coming out

Hepatitis Any person with fever and yellowing in the white part of the eyes

Any person with a sense of apprehension, headache, fever, malaise and indefinitive sensory
Animal bite
changes often referred to the site of a preceding animal bite. Excitability and hydrophobia are
(potential rabies)
frequent symptoms.

Any person with fever or a history of fever in the previous 24 hours and or the presence of pallor
Malaria [If in an
(whiteness) of the palms in young children [If in a non-endemic country]: Any person who has been
endemic country]:
exposed to mosquito bite and a history of fever or fever in the previous three days

Measles Any person with fever and rash

Meningitis Any person with fever and neck stiffness

Maternal death The death of a woman while pregnant or within 42 days after delivery
 Neonatal death Any death of a live newborn occurring before the first 28 complete days of life

Pneumonia Any child less than 5 years of age with cough and fast breathing or difficulty in breathing.

Tuberculosis Any person with cough for 3 weeks or more

Viral haemorrhagic Any person who has fever and two or more other symptoms (headache, vomiting, yellow eyes,
fever running stomach, weak in the body) or who died after serious sickness with fever or bleeding

Any person who has fever and two or more other symptoms (headache, vomiting, running
Yellow fever
stomach, weak in the body, yellow eyes) or who died after serious sickness with fever or bleeding

Two or more persons presenting similar severe illnesses in the same setting (for example,
household, workplace, school, street) within one week.
Two or more persons dying in the same community within one week.
Increase in number of animal sicknesses and/or deaths, including poultry, within one week

Any human illness or death after exposure to animals and animal products, including poultry (for
Unusual health example, eating, physical handling.
events
Any person who has been bitten, scratched, or whose wound has been licked by a dog, or other
animal
Two or more persons that pass watery stools and/or vomiting after eating/drinking at a given
setting (for example, wedding, funeral, festival, canteen, food sellers, etc)
Unexpected large numbers of children absent from school due to the same illness
 Any event in the community that causes public anxiety
Annex-7: Reporting procedures and formats to be used for each disease conditions
Disease/Condition Reporting Procedures and Formats to be used

Report the first 10 suspected cases using Case-based Reporting Format (CRF). If more than 10 suspected
cases seen during an outbreak use the PHEM line list to report Daily,
Chikungunya
Woredas: After 100 cases report the summary of the line list using the Daily Epidemic Reporting Format for
Woreda (DERF-W). The line list should be filled for all cases and kept at health facility and woreda levels.

Zones and Regions: use Daily Epidemic Reporting Format for Regions (DERF-R) to report the
Adverse Events
Following
All Adverse events following immunization cases should be reported using the case based format
Immunization
(AEFI)

Report the first 10 suspected cases using the case-based format specific for the disease(Case Based
Reporting Format – Influenza) If more than 10 suspected cases seen during the outbreak use the PHEM
Line list to report daily;
Human influenza
caused by a new Woredas: After 100 cases report the summary of the line list using Daily Epidemic Reporting Format for
subtype Woreda (DERF-W). The line list should be filled for all cases and kept at health facility and woreda levels.

Zones and Regions: use the Daily Epidemic Reporting Format for Regions (DERF-R) to report the
summarized suspected outbreak.

Report the first 5 suspected cases using Case-based Reporting Format (CRF) If more than 5 suspected
cases seen within one month use the PHEM Line list to report daily;

Woredas: After 100 cases report the summary of the line list using Daily Epidemic Reporting Format for
Measles
Woreda (DERF-W). The line list should be filled for all cases and kept at health facility and woreda levels.

Zones and Regions: use the Daily Epidemic Reporting Format for Regions (DERF-R) to report the
summarized suspected outbreak.

Neonatal
All suspected cases of NNT should be reported daily using the Case-based Reporting Format (CRF).
Tetanus/Non-
Conduct a detailed investigation using Modified IDS Case-based Reporting Format–NNT
neonatal Tetanus

Maternal Deaths All Maternal deaths should be reported using the Case-based Reporting Format (CRF).
 Report the first 5 suspected cases using the Case-based Reporting Format (CRF) If more than 5 suspected
case seen within one month, use the PHEM Line list to report daily;

Woredas: After 100 cases report the summary of the line list using Daily Epidemic Reporting Format for
Rabies
Woreda (DERF-W). The line list should be filled for all cases and kept at health facility and woreda levels.

Zones and Regions: use the Daily Epidemic Reporting Format for Regions (DERF-R) to report the
summarized suspected outbreak.

Smallpox All suspected cases should be reported daily using the Case-based Reporting Format (CRF).

SARS All suspected cases should be reported daily using the Case-based Reporting Format (CRF).

Yellow fever All suspected cases should be reported daily using the Case-based Reporting Format (CRF).

Poliomyelitis
All suspected cases of AFP should be reported using the case based format specific for AFP(Case-based
(Acute Flaccid
Reporting Format - Case Investigation Form –AFP)
Paralysis)

Peri-Natal deaths All Maternal deaths should be reported using the Case-based Reporting Format (CRF).

Report the first 10 suspected cases using Case-based Reporting Format (CRF) If more than 10 suspected
case seen during the epidemics use PHEM Line list to report daily;

Woredas: after 100 cases, report a summary of the line list using the Daily Epidemic Reporting Format for
Anthrax
Woreda (DERF-W). The line list should be filled for all cases and kept at health facility and woreda levels.

Zones and Regions: use the Daily Epidemic Reporting Format for Regions (DERF-R) to report the
summarized suspected outbreak.

Report the first 10 suspected cases using Case based Reporting Format (CRF)
Cholera
If more than 10 suspected cases seen during the outbreak use the PHEM line list to report daily;

Dracunculiasis All suspected cases of Dracunculiasis or Guinea Worm should be reported using case based format specific
(Guinea Worm) for the disease (Case Based Reporting Format – EDEP Guinea worm case investigation form (CIF)

Report the first 10 suspected cases using Case-based Reporting Format (CRF). If more than 10 suspected
cases seen during an outbreak use the PHEM line list to report Daily,

Dengue Fever Woredas: After 100 cases report the summary of the line list using the Daily Epidemic
Reporting Format for Woreda (DERF-W). The line list should be filled for all cases and kept at health facility
and Woreda levels.

Zones and Regions: use Daily Epidemic Reporting Format for Regions (DERF-R) to report the

Report all confirmed or suspected cases of Pneumonia on a weekly basis. If the epidemic threshold is
Severe Pneumonia
surpassed then start reporting on daily basis using the Daily Epidemic Reporting Format for Woreda (DERF-
in Children under 5
W) and Daily Epidemic Reporting Format for Regions (DERF-R).
 Diarrhea with
Diarrhea with dehydration cases should be reported of on a weekly basis. If the epidemic threshold is
dehydration in
surpassed then start reporting on daily basis using the Daily Epidemic Reporting Format for Woreda (DERF-
children less than
W) and Daily Epidemic Reporting Format for Regions (DERF-R).
five years of age

All New HIV cases should be reported of on a weekly basis. If the epidemic threshold is surpassed then start
New HIV Case reporting on daily basis using the Daily Epidemic Reporting Format for Woreda (DERF-W) and Daily
Epidemic Reporting Format for Regions (DERF-R).

All New Tuberculosis cases should be reported of on a weekly basis. If the epidemic threshold is surpassed
Tuberculosis then start reporting on daily basis using the Daily Epidemic Reporting Format for Woreda (DERF-W) and
Daily Epidemic Reporting Format for Regions (DERF-R).

All New Diabetic Cases should be reported of on a weekly basis. If the epidemic threshold is surpassed
Diabetes New
then start reporting on daily basis using the Daily Epidemic Reporting Format for Woreda (DERF-W) and
cases
Daily Epidemic Reporting Format for Regions (DERF-R).

All newly diagnosed Hypertension cases should be reported off on a weekly basis. If the epidemic threshold
Hypertension New
is surpassed then start reporting on daily basis using the Daily Epidemic Reporting Format for Woreda
cases
(DERF-W) and Daily Epidemic Reporting Format for Regions (DERF-R).

Acute jaundice
Acute jaundice syndrome or Acute Hepatitis (within 14 days) cases should be reported of on a weekly basis.
syndrome or Acute
If the epidemic threshold is surpassed then start reporting on daily basis using the Daily Epidemic Reporting
Hepatitis (within 14
Format for Woreda (DERF-W) and Daily Epidemic Reporting Format for Regions (DERF-R).
days)

Report all confirmed or suspected cases of malaria on aweekly basis. If the epidemic threshold is surpassed
Malaria then start reporting on daily basis using the Daily Epidemic Reporting Format for Woreda (DERF-W) and
Daily Epidemic Reporting Format for Regions (DERF-R).

Viral Hemorrhagic
All suspected cases should be reported daily using the Case-based Reporting Format (CRF).
Fever (VHF)

Dysentery Report these disease or conditions on a weekly basis

Report the first 10 cases of suspected meningitis cases during the epidemic to determine the Nm sero group
Meningitis* using the Case-based Reporting Format (CRF). Report all confirmed or suspected cases of meningitis on
weekly basis. If epidemic threshold is surpassed then start reporting on daily basis using Daily Epidemic
Reporting Format for Woreda (DERF-W) and Daily Epidemic Reporting Format for Regions (DERF-R)

Report all confirmed or suspected cases of relapsing fever on weekly basis. If an epidemic is declared then
Relapsing fever start reporting on daily basis using the Daily Epidemic Reporting Format for Woreda (DERF-W) and Daily
Epidemic Reporting Format for Regions (DERF-R).

Severe Acute
Report all Severe Acute Malnutrition cases on weekly basis.
Malnutrition

Malnutrition Report all Severe Acute Malnutrition cases on weekly basis.

AMR
 Brucellosis
Scabies
SARS Cov2
(COVID 19)

Annex-8: PHEM Structures with responsibilities across all levels

Level Responsibility

 Depending on the activation criteria the national EOC will be activated.

 Prepare a request for assignment of resources from the Emergency Fund at the EPHI and initiate steps for
National rapid replenishment by the MoH.
PHEM  Mobilize and deploy Rapid Response Teams.
 Call periodic (daily or weekly according to the type of emergency) coordination meetings with partners.
 Mobilize required resources for the response operation and ensure appropriate allocation and utilization of
resources.
 Provide technical assistance to the affected population upon request of the Regional health bureau. Implement
response operations at field level if the PHE:
 Involves more than one region
 is assessed to be highly infectious/communicable in nature with severe morbidity and mortality outcomes
 Prevention and control strategies are not being implemented properly.
 If the regional health bureau requests support
 Coordinate response operations with partners and other government sectors when and where applicable.
 Monitor the progression of the epidemic and the status of control activities and communicate findings to
relevant stakeholders and partners.
 Maintain and disseminate, in cooperation with partners, a list or database of Who is doing What Where
(3W) for the specific emergency.
 Request technical assistance internationally if the response requires their involvement.
 Determine when the health emergency phase is over and declare formally the emergency phase terminated and
inform accordingly all partners.

 Organize and convene coordination meetings with all partners (Government, NGOs, UN agencies, Red
Cross, etc.) either weekly or daily according to the nature of the emergency.
 Activate Regional EOC in full form.
 Deploy the Regional RRT and conduct outbreak investigation/Rapid Assessment and launch Quick
Response.
 Request Federal government assistance for the emergency response when additional resources may be
useful or the risk is extending beyond the region.
 Collaborate with Federal level response operation team when/if the ongoing PHE requires or calls for the direct
involvement of the Federal PHEM.
 Monitor and disseminate daily or weekly report with an updated number of affected, dead, missing, sick or
displaced as well as the number of health installations damaged or destroyed when applicable. Share this
Regional information with central EOC and all partners locally.
 Organize frequent visits by technical experts, managers and decision makers to the affected areas.
Coordinate the response activities of partners.
 Maintain a MoH presence in the field and especially in larger temporary settlements with displaced population
or refugees.
 Keep national EOC informed of the situation and implement directives received from the DRMFSS or other
cross-sectorial coordination authority.
 Ensure that the needs of vulnerable groups are well covered.
 Maintain and disseminate, in cooperation with partners, a list or database of Who is doing What Where
(3W) at regional level for the specific emergency .Share this information widely.
 In consultation with the key partners, determine when the health emergency phase should be terminated
and advice the Center accordingly

 Organize coordination meetings with all partners (Government, NGOs, UN, Red Cross, etc.) either weekly
or daily according to the nature of the emergency.
 Conduct Outbreak investigation/Rapid Assessment and launch Quick Response.
Zonal
 Request or accept regional government assistance for the emergency response when additional resource
is required.
 Monitor and disseminate daily or weekly report with an updated number of affected, dead, missing, sick or
displaced as well as the number of health installations damaged or destroyed when applicable.
  Organize frequent visits by experts, managers and decision makers to the affected areas.
Coordinate the response activities of partners.
 Ensure that the needs of vulnerable groups are well covered.
 Monitor prevention and control activities and take corrective actions as per the findings.

 Organize coordination meetings with all partners (Government, NGOs, UN, Red Cross, etc.) either weekly
or daily according to the nature of the emergency.
 Deploy the woreda RRT and conduct outbreak investigation/Rapid Assessment and launch Quick
Response.
 Monitor and communicate daily or weekly report to higher level as per agreed frequency and format with an
updated number of affected, dead, missing, sick or displaced as well as the number of health installations
Woreda damaged or destroyed when applicable.
 Organize frequent visits by experts, managers and decision makers to the affected areas. Monitor
control and prevention activities and take corrective actions as per the findings. Coordinate the
response activities with partners.
 Ensure that the needs of vulnerable groups are well covered.
 In consultation with the key partners, determine when the health emergency phase should be
 terminated and Inform the regional health bureau accordingly.

 Notify the public health emergency to WoHo.

 Deploy multidisciplinary team/ RRT/ and conduct outbreak investigation/Rapid Assessment and launch
Health Quick Response
facilities  Monitor and communicate daily or weekly report to woreda health office as per agreed frequency and
format with an updated number of cases and deaths or events.

 Notify the public health emergency to catchment facility

 Conduct rapid assessment, verify the situation and respond to PHE independently or as part of deployed
Health
team
posts
 Monitor and communicate daily or weekly report as per agreed frequency and format

Annex-9: List of details activities to be conducted during outbreaks /Events

Selected
Detailed Activities to be Conducted
Activities

(a)Train and equip health workers at the district level to implement these measures.
(b) Ensure that clinicians receive laboratory confirmation results where necessary.
(c) Ensure that health workers record all patients in a recognizable standardized register and a line list.
(d) Ask the officer-in-charge at each health facility to identify an area that can be used to accommodate a large
number of patients during epidemics involving a large number of cases.
(e) Provide standard operating procedures (SOPs) that include IPC guidelines.
(f) Implement IPC and risk mitigation measures such as:
Strengthen
(i) establish triage and isolation wards for highly infectious diseases (Ebola, cholera,
case
SARS, etc.). See Annex 6H for cholera treatment centre;
management
(ii) ensure that health staff have access to safety and personal protective equipment
and infection
for any infectious diseases (especially for Ebola and SARS);
prevention and
(iii) ensure that there are safe practices and protection of non-health workers
control (IPC)
(supporting staff, e.g. security, cleaners, administrative staff);
measures
(iv) assess and assure WASH standards for health facilities;
(v) provide oversight about disposal of PPE and other contaminated supplies; and
(vi) Ensure appropriate biosafety and biosecurity for animals (farms, markets, etc.).
(g) Ensure that the necessary medicines and treatment supplies are available.
(h) Ensure that the proper treatment protocols are available.
(i) Review the standard operating procedures for the referral system;
(ii) Ensure that a proper discharge protocol of cases linked to social workers is available.

(a) Give clear and concise directions to health workers and other staff participating in the response.
(b) Select topics for orientation or training. Emphasize case management and infection prevention and control for
the specific disease according to disease-specific
recommendations. Select other training topics depending on the risk of exposure to the specific public health
hazard, for example:
(i) case management protocols for cases;
(ii) enhancing standard precautions (use of clean water, hand-washing and safe disposal of sharps);
(iii) barrier nursing and use of protective clothing;
(iv) isolation precautions;
(v) treatment protocols such as delivering oral rehydration salts (ORS) and using intravenous fluids;
Build the
(vi) disinfecting surfaces, clothing and equipment;
capacity of
(vii) safe disposal of bodies and dignified burials;
response staff
(viii) safe disposal of animal carcasses;
(ix) others which may seem necessary and may include client-patient interactions and counseling
skills, orientation on how health worker would interact with CBS focal persons etc.
(c) Conduct orientation and training
(i) Orient or reorient the district PHEMC, public health rapid response team and other health and non-
health personnel on epidemic management based on the current epidemic.
(ii) In an urgent situation, there often is not time for formal training. Provide on-the job training as
needed. Make sure there is an opportunity for the training physician or nursing staff to observe the
trainees using the updated or new skill.
(iii) Monitor participant performance and review skills as needed.
 (a) search for additional persons who have the specific disease and refer them to the health facility or treatment
centres, or if necessary, quarantine the household and manage the patient, ensuring that they have access to
consistent/adequate food, water, and non-food items (i.e. soap, chlorine, firewood, medicines, sanitary pads,
etc.);
(b) ensure timely provision of laboratory information to the team;
(c) update the line list, make data analysis by time (epi curve), person (age and sex) and place (mapping of
cases);
Enhance (d) ensure timely provision of laboratory information to the team;
surveillance (e) update the line list, make data analysis by time (epi curve), person (age and sex) and place (mapping of
during the cases);
response (f) monitor the effectiveness of the outbreak response activity;
(g) report daily at the beginning of the epidemic; once the epidemic progresses, the District PHEMC can decide
on a different frequency of reporting;
(h) actively trace and follow up contacts as indicated (See Section 4 for how to do contact tracing);
(i) monitor the effectiveness of the outbreak response activity;
(j) report daily at the beginning of the epidemic; once the epidemic progresses, the district public health
emergency preparedness and response (PHEPR) committee can decide on a different frequency of reporting;
(k) actively trace and follow up contacts as indicated (how to do contact tracing).

Enhance (a) Focal person responsible for IDSR;

surveillance (b) Focal person responsible for laboratory services;
with (c) Medical officer of health;
neighboring (d) Focal person responsible for environmental health;
border districts (e) Focal person responsible for clinical services; and
and establish (f) Focal person responsible for animal (domestic and/or wildlife) health, local immigration officials and the local
committee district commissioner.

(a) Engage and inform community leaders with information on the situation and actions that can be taken to
mitigate the situation.
(b) Provide first aid and call or send for medical help.
(c) Keep people away from a ‘risk’ area (potentially contaminated water source).
(d) Respectfully isolate anyone with a potentially infectious disease paying particular
attention to cultural sensitivities.
Engage (e) Quarantine for animals, market closures, etc.
community (f) Provide community education including specific actions the community can take to protect themselves.
during (g) Engage in IPC and hygiene promotion in coordination with any efforts at strengthening the availability of
response materials/infrastructure for IPC and hygiene.
(h) Identify local effective channels for delivery of the information to the community
(i) Organize door-to-door campaigns using trusted individuals to reach every household within the catchment
area in order to curb the spread of the public health event and to encourage self-reporting, treatment and health-
seeking behavior among people who have had contact with the public health event or are suspected to be public
health event cases
(j) Engage community members as stakeholders and problem solvers, not merely beneficiaries

(a) Decide what to communicate by referring to disease-specific recommendations

(i) signs and symptoms of the disease;
(ii) how to treat the disease at home, if home treatment is recommended and how to prepare
disinfectant solutions;
Inform and
(iii) prevention behaviors that are feasible and that have a high likelihood of preventing disease
educate the
transmission;
community
(iv) when to come to the health facility for evaluation and treatment;
(v) Immunization recommendations, if any. At the same time, maintain active processes for collecting
qualitative information needed to establish and address any circulating rumors.
(b) Decide how to state the message. Make sure that the messages:
 (i) use local terminology;
(ii) are culturally sensitive and acceptable;
(iii) are clear and concise;
(iv) consider local traditions;
(v) address beliefs about the disease.

NB: Consider pre-testing the messages from similar settings before dissemination. Sample community education
messages are found in Annex 6F at the end of this section.
(c) Select the appropriate communication methods available in your district. For example:
(i) mass media, (radio, television, newspapers);
(ii) meetings (health personnel, community, religious, opinion and political leaders);
(iii) educational and communication materials (posters, fliers);
(iv) multimedia presentations (e.g., films, video or narrated slide presentations) at the markets, health
centres, schools, women’s and other community groups, service organizations, religious centres;
(v) social media (Facebook, Twitter, WhatsApp, etc.);
(vi) community drama groups/play groups;
(vii) public address system;
(viii) corporate/ institutional website;
(ix) e-mail/ SMS subscriptions.
(d) Give health education messages to community groups and service organizations and ask that they
disseminate them during their meetings.
(e) Give health education messages to trusted and respected community leaders and ask them to transmit to the
community.
(i) Designated person from the MoH should serve as spokesperson to the media. Tell
the media the name of the spokesperson, and that all information about the outbreak will be provided
by the spokesperson.
(ii) Release information to the media only through the spokesperson to make sure that the community
receives clear and consistent information.
(f) On a regular basis, district and regional medical officers will meet with local leaders to give:
(i) frequent, up-to-date information on the outbreak and response;
(ii) clear and simple health messages for the media;
(iii) clear instructions to communicate to the media the information and health education messages
from the PHEMC.

(a) piped chlorinated water;

(b) safe drinking water obtained through chlorination at point-of-use;
(c) water obtained from protected sources (such as wells closed with a cover, rainwater collected in a clean
container);
(d) boiled water from any source.

Improve access
If no local safe water sources are available during an emergency, water may need to be brought from outside.
to clean and
To ensure that families have safe and clean drinking water at home (even if the source is safe) do the following:
safe water
(a) Provide community education on how to keep home drinking water safe.
(b) Provide containers that prevent water contamination. For example, containers with narrow openings are ideal
because users would not be able to contaminate the water by putting their hands into the container.
(c) Ensure that waste disposal sites, including for faeces, are located at least 30 metres away from water
sources.
 (a) Assign teams to inspect local areas for human and animal waste disposal. Safe practices include disposing
Ensure safe of faeces in a latrine or burying them in the ground more than 10 meters from water supply.
disposal of (b) If unsafe practices are found such as open defecation, educate the community on safe disposal of such
infectious waste. Construct latrines appropriate for local conditions with the cooperation of the community.
waste (c) Conduct effective community education on sanitation practices.

(a) conduct community education on food hygiene practices for the general public and those in the food industry;
Improve food- (b) visit restaurants, food vendors, food packaging factories and other venues to inspect food handling practices,
handling focusing on safe practices such as proper hand-washing, cleanliness and adherence to national standards;
practices (c) close restaurants, vending areas or factories if inspection results show unsafe food handling practices;
(d) Strengthen national controls for food safety as necessary.

(a) promote indoor residual spraying;

(b) conduct community education on the proper use of bed nets and the avoidance of dusk-todawn mosquito
bites;
(c) promote the use of locally available ITNs and other insecticide-treated materials (bed nets, blankets, clothes,
sheets, curtains, etc.);
(d) encourage environmental cleanliness (e.g., draining stagnant water, clearing bushes etc.).
Reduce
exposure to Encourage the prevention of diseases transmitted by rodents by helping people in your district reduce their
infectious or exposure to these animals. For example, rodents can transmit the virus that causes Lassa fever or they may be
environmental infested with fleas that carry plague. Work with the vector control officer in your district to encourage the
hazards community to:
(a) avoid contact with rodents and their urine, droppings and other secretions;
(b) keep food and water in the home covered to prevent contamination by rodents;
(c) keep the home and cooking area clean and tidy to reduce the possibility of rodents nesting in the room;
(d) use chemicals (insecticides, rodenticides, larvicides etc.) and traps as appropriate
based on environmental and entomological assessment;
(e) Educate the community on personal protection to reduce exposure.
Annex-10: Recovery plan preparation steps
Step Details

Conduct a readiness A readiness assessment is used to determine whether the prerequisite resources, structures, and
1
assessment capacity are in place to develop a monitoring and evaluation system.

Outcomes are the end results the implementing body is working towards and begin to frame what
Agree on outcomes to
2 successful recovery looks like. Outcomes should be developed in consultation with the community
monitor and evaluate
representatives and ensure that there is a holistic approach taken.

Indicators are the quantitative or qualitative variables that provide a simple and reliable means to
Select key indicators to
3 measure progress and help assess the performance of recovery programs or strategies against
monitor outcomes
the stated outcome.

Identify baseline data The baseline data is the first measurement of an indicator. It sets the current condition against
4
on indicators which future change can be tracked.

Plan for improvements: Baseline indicator level (baseline data) + desired level of improvement = target performance
5
select results targets (within a specific timeframe).

There are two types of monitoring: results and implementation. Implementation monitoring
examines the activities and strategies used to achieve a given outcome. Results monitoring is the
6 Monitor results
continuous process of collecting information on the indicators selected. Program implementers
must develop systems to measure both the implementation and results.

Evaluation is the assessment of a planned, ongoing, or completed program to determine its

relevance, efficiency, effectiveness, impact, and sustainability. Quality evaluations have the
7 Conduct evaluations
following characteristics: are impartial, relevant and understandable, meet technical standards,
involve all recovery partners, communicated and disseminated, and offer value for money.

The information collected is used as a management tool, and thus the information needs to be
reported to the relevant recovery partners to ensure that relevant decisions can be made in a
8 Report findings
timely manner. It is important to understand the audience and choose a method that is effective to
report the findings collected.

Projects, programs, and policies may be enhanced or expanded based on the findings collected.
9 Use findings By using the findings reported, decision makers can make early adjustments to recovery strategies
to ensure effective and efficient implementation.

Monitoring and evaluation systems should be regarded as a long-term effort, and not short-term
Sustain the monitoring approaches. It is important to validate the system developed to ensure it is still effective and
10 and evaluation system providing value.
within the organization
 5. Health financing
4. Health information system
3. Human resource for health
2.Leadership and governance
Health programs and Health system
functions

1a. Service delivery; health programs

6. Medical products, vaccines and technology

services, including infrastructure, equipment, transport
1b. Service delivery; Organization and management of
Annex-11: Analytical matrix for the health sector PEA

Pre-crisis challenges
Baseline indicators

Impact of the crisis, key challenges for

early recovery

Humanitarian response

Response for recovery, Strategy for

reconstruction
Products and expected results for
recovery, short and medium term

Activities and resources for the short and

medium term
Key
Indicators for monitoring
Annex-12:Details Format for Assessment of Loss in the Health Sector

Loss per Months after the disaster Total

component
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Duration of
recovery period,
months

A. Loss of revenues

1. Pre-disaster
number of
patients

2. Post- disaster
number of
patients

3. Lower number
of patients, post
disaster (1 - 2)

4. Average
revenue per
patient,
$/patient

5. Loss of
revenue, $ (3 * 4)

B. Costs of increased services

6. Increased cost
of medical
treatment of
injured during
emergency stage,
$*
7.
Transportation
cost of injured to
available
facilities, $

8. Increasd cost
of medical
treatment in
higher cost,
private facilities, $

9. Increased cost
of disease
surveillance after
disaster,
$

10. Increased
cost of disease
Annex-13:Details roles and responsibilities of different sectors
Sectors Responsibility

• Remain vigilant about outbreak /possibility of any epidemics and take effective steps against them.
• Determine the need for recovery or rehabilitation (sanitation, temporary settlements, psychosocial
assistance, reconstruction etc.)and disseminate those needs to partners.
• Send reports of health related activities in affected areas to the national level for future planning
purposes.
Federal PHEM
• To account for expenditures and determine the cost of the emergency.
• Organize, when appropriate, a lessons learned workshop or meeting for improving future
preparedness and response. Consider the convenience of including selected (most active) partners
in this exercise.

• Organize initial and subsequent technical assessments of the emergency management processes
and nature of relief required.
• Request national government assistance for early recovery when additional resources may be
needed.
• Keep the Regional Emergency Management Committee and the national level informed of the
situation.
Regional
• Ensure supply of nutritional treatment, safe drinking water, medical supplies and other emergency
items to the affected population with special attention to those groups most vulnerable or with
limited access to government services.
• Asses the need and make arrangement to provide psychosocial assistance as necessary. Visit,
coordinate and document the implementation of various rehabilitation programs.
• Coordinate the activities of NGOs in recovery and rehabilitation programs

• Organize initial and subsequent technical assessments of the emergency management processes
and nature of relief required.
• Request regional government assistance for early recovery when additional resources may be
needed.
• Ensure supply of nutritional treatment, safe drinking water, medical supplies and other emergency
Zonal items to the affected population with special attention to those groups most vulnerable or with
limited access to government services.
• Asses the need and make arrangement to provide psychosocial assistance as necessary. Visit,
coordinate and document the implementation of various rehabilitation programs.
• Coordinate the activities of NGOs in recovery and rehabilitation programs.
 • Organize initial and subsequent technical assessments of the emergency management processes
and nature of relief required.
• Request regional/zonal government assistance for early recovery when additional resources may
be needed.
• Ensure supply of nutritional treatment, safe drinking water, medical supplies and other emergency
Woreda items to the affected population with special attention to those groups most vulnerable or with
limited access to government services.
• Asses the need and make arrangement to provide psychosocial assistance as necessary.
• Visit, coordinate and document the implementation of various rehabilitation programs. Coordinate
the activities of NGOs in recovery and rehabilitation programs

● Share, aggregate, and integrate economic impact data to assess economic issues and identify
potential inhibitors to fostering stabilization of the affected communities.
● Implement economic recovery strategies that integrate the capabilities of the private sector, enable
strong information sharing, and facilitate robust problem solving among economic recovery
stakeholders.
● Ensure the community recovery and mitigation plan(s) incorporate economic recovery and remove
inhibitors to post-incident economic resilience, while maintaining the rights of all individuals.
● Facilitate the restoration of and sustain essential services (public and private) to maintain
community functionality.
● Coordinate planning for infrastructure redevelopment at the regional, system-wide level.
● Develop a plan with a specified timeline for developing, redeveloping, and enhancing community
Other infrastructures to contribute to resilience, accessibility, and sustainability.
government ● Provide systems that meet the community needs while minimizing service disruption during
Sectors restoration within the specified timeline in the recovery plan.
● Implement measures to protect and stabilize records and culturally significant documents, objects,
and structures.
● Mitigate the impacts to and stabilize the natural and cultural resources and conduct a preliminary
assessment of the impacts that identifies protections that need to be in place during stabilization
through recovery.
● Complete an assessment of affected natural and cultural resources and develop a timeline that
includes consideration of available human and budgetary resources for addressing these impacts
in a sustainable and resilient manner.
● Preserve natural and cultural resources as part of an overall community recovery that is achieved
through the coordinated efforts of natural and cultural resource experts and the recovery team in
accordance with the specified timeline in the recovery plan

• Assist the PHEM Center, when pertinent, in the economic valuation of the damages to the health
sector.
International
Organizations • Implement rehabilitation works as per the organization’s capacity and area of expertise.
Mainstream risk considerations into all new development projects and activities.
and NGOs
• Prepare reports on assessment of damage and actions taken, and make them available for general
review and planning.

• Provide periodic reports on execution of rehabilitation activities in the field

Annex-14: Health system resilience matrix of health system building blocks and public health emergency management system

Health Emergency Phase

Domain
Pre-Emergency During Emergency Post-Emergency

 Develop policies, legislations and strategies for  Prepare detail emergency response plan  Establish platforms to bring humanitarian and
integrating emergency response with development developmental agencies together for recovery activities
 Ensure functional multi-sectoral coordination and collaboration
(humanitarian-development nexus)
 Prepare emergency preparedness plan
 Establish emergency response coordination platform at all
Leadership  Conduct regular monitoring of recovery activities
 Establish coordination platforms at all levels levels
and  Develop a strategic plan for better recovery
governance  Conduct Simulation Exercises o Emergency Operation Center (EOC)
o Transformation
 Design risk reduction strategies at all levels  Initiate cross-border coordination and collaboration
 Conduct routine monitoring and evaluation  Conduct supervision, monitoring, and evaluation of emergency
health responses

 Identify the source of a budget for emergency  Financing protocol during emergency response  Mobilize allocated resources/funds for health system
response recovery
 Ensure availability of adequate fund for emergency responses
Health  Ensure availability of budget as per the emergency  Establish sustainable health financing systems
 Mobilize financial resources
Financing preparedness plan
 Strengthen government financial management systems
 Establish an emergency pull fund for health
emergency at all levels

 Conduct robust surveillance (electronic-based  Develop emergency response/ad hoc surveillance protocol  Conduct post-disaster need assessment
surveillance)
 Run continuous data analysis and information generation  Identify and analyse losses due to the public health
o Integrated surveillance emergency
 Ensure functionality of regular risk and public communication
Health
o Sentinel surveillance platforms  Held regular public communication and community
Information
awareness
Management o Community-based surveillances  Conduct risk assessment and analysis
System  Conduct health resource and service availability
o Event-based surveillance  Early warning of infectious disease outbreaks and health event
risks o HeRAMS
 Predict Risks by conducting VRAM
 Identifying Index Case
  Provide training with follow-up supervision  Develop deployment protocol  Assess the impact of a disaster on HRH
 Establish a surge system at all levels and monitor  Provide refresher trainings depending on the type of emergency  Develop HRH emergency plans for scaling up capacity
activities of the teams for new and/or increased health demands
 Ensure availability of a pull of additional health workforces
o The Emergency Medical Team  Establish a task-shifting system among the staff if
Health  Run regular monitoring and updating of health workforce
needed
Workforce o Rapid Response Team database
o Surge team  Engage volunteers in the response
 Facilitate volunteers’ participation

 Ensure availability and accessibility of functional  Arrange emergency supply dispatching mechanism during the  Strengthen supply chain management system
health infrastructure emergencies
 Institutionalize of quality assurance mechanisms for
 Ensure availability and efficient use of medicines,  Track utilization of resources medical products, vaccines, and equipment
supplies and equipment and logistics
Medical  Manage emergency revolving stock  Standardization of medical equipment according to
product,  Preposition of medicines, supplies and logistics and levels of care and strengthening maintenance functions
 Equip National and Sub-national EOCs
vaccine and equipment for identified hazards and skills
technology  Provide safety materials for health workers
 Establish of a quality assurance system for essential  Recover/maintain the cold chain system
medicines
 Establish supply chain systems

 Triage out-patients and in-patients routinely  Maintain essential health service during emergency response  Ensure services such as mental health and
psychosocial support and SGBV at health facilities
 Ensure quality health services  Establish outbreak response centers
 Ensure functionality of health facilities/services at all
 Ensure the functionality of referral pathways and  Establish temporary isolation unit at each health facility
Service health facilities
processes including private facilities
delivery
 Identify non-functional services and take corrective
 Build a point of care and reference laboratory  Build point of care laboratory diagnostic capacity
actions
capacity for detection
 Ensure functionality of case and laboratory specimen referral
 Develop health emergency contingency plan systems

 Engage community in surveillance, preparedness  Engage the community in emergency response efforts as well  Engage community in every step of the recovery
People/comm planning and risk prediction activities as emergency planning process
unity o Starting from recovery planning to the evaluation
phase
Annex-15: Identified PHEM Indicators categorized by its pillars

Type of
Indicators Level Means of Verification Frequency
Indicator
GOAL: Build a Resilient Public Health Emergency Management system and capacity for Strong National Health Security
Sub-theme Component: EARLY WARNING AND COMMUNICATION
Every 2
1 Availability of risk communication systems (yes/no) Outcome All levels Evaluation/Assessment
years
2 Proportion of laboratories regulated on handling and use of hazardous pathogen and toxin Output RHBs/National Progress Report (SS) Bi-annually
Availability of AMR surveillance system for testing the human animal environment interface
3 Output National Progress Report Annually
(ecosystem)-(Yes/No)
Every 2
4 Capacity of law enforcement sectors in early detection towards bio threats at national level (Yes/No) Outcome National Evaluation/Assessment
years
IBS, EBS (Rumors, hotlines), Outbreak Immediately
5 Number of epidemics detected at the national level that were missed by the districts Output National
Investigation , /Weekly
Proportion of disease patterns/events verified within 24 hours of notification (Denominator: total notified
6 Output All levels Log book, Quarterly
diseases)
Proportion of disease patterns/events verified within 24 hours of all verified diseases (Denominator: total
7 Output All levels Log book, Quarterly
verified diseases)
Proportion of suspected outbreaks of epidemic prone disease notified to next level within 30 minutes of
8 Output All levels Log book Monthly
surpassing the alert / epidemic threshold
9 Proportion of weekly surveillance reports submitted by health facilities to the next level (completeness) Process All levels Weekly reports Weekly
10 Proportion of weekly surveillance reports submitted fto next level on time (timeliness) Process All levels Weekly reports Weekly
Proportion of suspected outbreaks of epidemic prone disease notified to the National level within 2
11 Output National Log book Quarterly
hours of surpassing the alert threshold
Proportion of (woredas/zones) that maintain line graphs for selected priority diseases (malaria,
12 Output Woredas/Zones SS reports Quarterly
meningitis, Measles) for the past 3 months.
Weekly,
13 Death rate for each disease /event Impact National IBS, Evaluation/Assessment
Annually
Proportion of (woredas/zones/regions) preparing weekly epidemiologic bulletin/summarized surveillance
14 Process All levels Weekly bulletin, SS report Quarterly
report
Laboratory reports, Outbreak
15 Proportion of laboratory investigated outbreaks/events that required laboratory tests Output RHB/National Bi-annually
investigation reports
Log of suspected outbreaks and
Proportion of confirmed outbreaks for which a nationally recommended public health response was WoHO/ZHB/RHB/
16 Outcome rumors, Outbreak investigation reports
given National
Supervisory Reports
17 Proportion of regions that report laboratory data for diseases under surveillance Output RHB/National Laboratory reports Quarterly
Proportion of health facilities laboratories that received at least one supervisory visit with written
18 Output RHBs/National SS Report Quarterly
feedback
Sub-theme Component: PREPAREDNESS
Available linkage between public health and security authorities including law enforcement, border
1 Outcome National Evaluation/Assessment Annually
control, customs during a suspect or confirmed biological event (Yes/No)
SS, Evaluation/Assessment, Meeting
2 Functionality of multisectoral coordinating mechanisms at each level (Yes/No) Outcome All levels Annually
Minutes
Functional system for sending and receiving Medical Counter Measures during a public health IAR/AAR Reports, Procurement and
3 Outcome National Annually
emergency (Yes/No) Distribution reports
4 Availability of coordination and collaboration system among sectors and stakeholders at all levels Output All levels SS reports, Evaluation/Assessment Annually
Existing of a system for sending and receiving trained health personnel during a public health
5 Output National Evaluation/Assessment Annually
emergency (Yes/No)
Quarterly,
6 Proportion of functional Public Health Emergency Operation Centers (PHEOCs) at Sub-National levels Output National SS Report, Evaluation/Assessment
Annually
7 Number of regions with designated preparedness or logistics officer Output RHBs SS Report Quarterly
WoHOs/ZHBs/RH
8 Proportion of (Regions/Zones/Woredas) that have conducted VRAM Output SS Report, VRAM Report Annually
Bs
Proportion of (Regions/Zones and Woredas) with public health Emergency Preparedness and
9 Output All Levels SS Report, EPRP Annually
Response Plan (EPRP).
Proportion of prepared with incorporation of continuity of routine health services in the event of public WoHOs/ZHBs/RH
10 Output SS Report, EPRP Annually
health emergencies Bs
Proportion of (Woredas/Zones/Regions/National) with allocated budget for emergency preparedness WoHO/ZHD/RHB/
11 Input Financial Report Annually
and response National
Proportion of public health emergency medical and supplies stores established at national and regional
12 Output RHBs/National SS Report Quarterly
levels.
Proportion of health facilities with basic equipment and supplies during emergencies as per specified
13 Output HFs Evaluation/Assessment Annually
National guideline
14 Amount of public health emergency relevant stocks (Drugs and Supplies) procured based on the EPRP Input National Procurement Reports Annually
Minimum amount (target: 3 months stocks) of prepositioned public health emergency-relevant stock Annually,
15 Input All levels Distribution Reports, SS Report
(medicines and supplies) identified for all levels of care Quarterly
Availability of functional and up to date roster of a readily available multidisciplinary RRT for emergency
16 Output All Levels SS Report, Rosters Bi-Annually
response and surge capacity (Yes/No)
17 Proportion of woredas with trained front-line Field Epidemiology Training Program (FETP) Output WoHO Training Reports, SS Reports Quarterly
18 Proportion of health facilities with trained Basic Level PHEM Training Output HFs Training Reports, SS Reports Quarterly
19 Proportion of (Health Facilities/ Woredas/Zones/Regions) that participated in any Simulation Exercise Output All levels SimEx Report Annually
 (SimEx)
Proportion of targeted health professionals who took need-based trainings excluding FETP, BLT, VRAM
20 Output All Levela Training Reports Quarterly
and EPRP (Denominator: Plan)
21 Proportion of staffs trained in VRAM and EPRP at all levels Output All Levels Training reports Quarterly
Quarterly,
22 Proportion of identified potential emergencies with adequate trained manpower Output All Levels SS Report, After-Action Review (AAR)
Annually
23 Proportion of children who received MCV-1, MCV-2, OPV-3, IPV, and other antigens Outcome National DHIS-2 Monthly
24 Proportion of regions with prepared/customized comprehensive PHEM Strategic Plan Input RHB SS Report, PHEM Plan Annually
Proportion of (Regions/Zones/Woredas/HFs)with the required minimum PHEM structure aligned with HFs/WoHOs/ZHD
25 Input SS Report Quarterly
the National PHEM structure s/RHBs
Sub-theme Component: RESPONSE AND RECOVERY
Proportion of (HFs/Woredas/Zones/Regions) which deployed Rapid Response Team (RRT) according
1 Output All Levels Progress report Bi-Annually
to the standard
Number of (Intra-Action/After-Action) Reviews that were conducted for improvement of each response /
2 Output National IAR, AAR Reports Annually
activation
3 Proportion of epidemics controlled within the accepted range of mortality rate Outcome RHB/National AAR Reports, Investigation Reports Annually
Proportion of PHE with prevention and control measures initiated within 48 hours of identification of AAR Report, Outbreak Investigation
4 Output All Levels Bi-Annually
risks and characterization of threats and Response Report
5 Proportion of rehabilitated health facilities Output All Levels SS Report, AAR Report Bi-Annually
Outbreak Investigation Reports,
6 Proportion of suspected or verified Public Health Emergencies investigated Output All Levels B-Annually
Bulletins, SitReps
Proportion of out breaks/events contained with an acceptable containment time (as per specific AAR Reports, Outbreak Investigation
7 Outcome All Levels Annually
guidelines recommendation) Reports, Bulletins, SitReps
8 Proportion of Post-Emergency Assessments/Recovery Need Assessment conducted Output All Levels Assessment Report Annually
Outbreak Response, Need Assessment
9 Proportion of affected populations who received mental health and psychosocial support Output All Levels Annually
Reports, SitRep
Sub-theme Component: RESILIENCE
Proportion of health facilities in emergency affected areas which provided Routine Health Services
1 Output HFs Progress report Quarterly
/Essential Health Services/ without interruption
2 Proportion of health facilities where customer satisfaction assessment conducted Output HFs Evaluation/Assessment Annually
3 Proportion of health facilities which conducted community to health facility forums Output HFs Evaluation/Assessment Annually
Proportion of health facilities with community suggestion box or other suggestion collection mechanism
4 Output HFs Evaluation/Assessment Annually
in main service points
Proportion of health facilities with adequate surges for routine service provision according to the facility
5 Output HFs Evaluation/Assessment Annually
standard
6 Proportion of health facilities that maintained prioritized health services appropriate for the level of care Output HFs Evaluation/Assessment Annually
 during emergencies
7 Proportion of public health emergency with its own clinical protocol for case management Output National Evaluation/Assessment Annually
Proportion of health facilities that have Networks (updated roster list, Joint planning i.e. Multi-sectorial
8 Input HFs Evaluation/Assessment Annually
and Multi-partners or MoU)
9 Proportion of health facilities which met WASH Score Outcome HFs Evaluation/Assessment Annually
Proportion of health facilities with improved Infection Prevention Control (IPC) score compare to
10 Outcome HFs Evaluation/Assessment Annually
previous assessment score
11 Proportion of health facilities with improved Food and Drug Authority (FDA) standard Outcome HFs Evaluation/Assessment Annually
Proportion of health facilities with user fees waiver mechanisms for PHE-related health cares
12 Output HFs Evaluation/Assessment Annually
(consultations, treatment, investigations and provision of medicines)
Proportion of secured budget for supporting the continuity of essential services in the event of
13 Output National Progress report Quarterly
emergency
14 Number of health facilities with accessible contingency / service continuity funding Output HFs Progress report Quarterly
15 Number of PHEM related experience sharing and lesson learning forums organized at all levels Output All Levels Progress report Quarterly
Proportion of health facilities with access to or being covered by dedicated occupational safety and
16 Output HFs Assessment report Annually
health management systems and services
17 SPAR health service provision capacity (C9) score Outcome National SPAR report Annually
Availability of a designated health system focal person or team responsible for providing input in the
18 Output National SPAR report Annually
SPAR C9 assessment process
Every 2-3
19 Increase Health Security Index from 0.63 to 0.78 Outcome National Evaluation/Assessment
years
20 Proportion of health posts providing comprehensive health services Input HFs HMIS Annual
Proportion of health facilities (health centers and hospitals) with basic amenities (water, electricity,
21 Input HFs HMIS Annual
latrine, waste management services)
22 Number of new/improved technology (Diagnostics, Therapeutics, Tools, or Vaccines) transferred nput AHRI/EPHI AHRI/EPHI report Annual