The Case study of Rift Valley Fever in Calcia Learning objectives On completion of the exercise, participants will be able to: 1- Identify the responsibilities and capacities needed of the competent authority at PoE. 2- Identify the need for a contingency plan at PoE of an event that may constitute a public health emergency of international concern as described in IHR annex 1b. 3- Identify the specific requirements for procedures, communication and collaboration needed by the NFP (institute) for routine surveillance and response to events. 4- Identify the core capacity for implementing IHR (2005).

Scenario Part 1 A shipment of 5000 sheep and goats were transported by sea from the country “Alia” to the country “Calcia”. The ship’s journey took 3 days. When the shipment reached the main port (Gala) in Calcia the flocks were quarantined for one day for customs clearance. In the quarantine, the veterinary department doctors in Gala were carrying their normal examination procedure of the imported sheep & goats. The doctors were shocked to find out that almost 250 sheep were not in good health and around more than 12 goats had abortion. Note: Calcia is a country that already started implementing IHR (2005). Under the current IHR (2005): What should the Veterinarians do immediately? What other measures could be put in place at Gala port?

Answer / Feedback What should the Veterinarians do immediately? Effective implementation of the IHR depends largely on the development, strengthening and maintenance of the core capacity requirements set out in Annex 1 of the IHR (2005). The veterinarians should immediately: Report this to the port authorities, Ministry of Agriculture and Animal resources, as well as Ministry of Health if he suspected zoonotic disease, Inform NFP for IHR. Restrict the movement of the imported flocks (keep them in the quarantine) separate the diseased ones. Start collecting appropriate lab samples (blood samples) and arrange with the national lab. Intensify animal disease surveillance in the country Inform the emergency committee in the Ministry of Agriculture Alert workers/staff in the quarantine dealing with animals on precautionary measures. Veterinary Control Measures may have been put in place for the education of livestock herders and other at risk workers regarding the importance of quarantine and isolation of infected and animals. What other measures could be put in place at Gala port? Port authorities: Collaborate with Veterinary Department in restricting movement of animals. Enforce and maintain sanitary measures at the port and vessels. Coordinate with Ministries of Agriculture, Health, Commerce, Foreign Affairs (the issue of importation of sheep from Country Alia?) Alert employee and workers to take precautionary measures and necessary sanitary actions.

Scenario 2 In Alia country, there was some unofficial Information on people dying from an unknown disease. Ten years ago, there was an extensive RVF outbreak which resulted in the death of 413 people. During the last 3 weeks, Calcia was having floods in different regions resulting in increased mosquito population. The second day in the Calcia quarantine, the veterinarians reported that about 56 sheep and goats were dead and another 8 goats aborted. The National Veterinary Department reported that the clinical picture of the disease in animals is suggestive of Rift Valley Fever. Calcia has never experienced RFV outbreak before. Once the news reported to Ministry of Health, officials started to investigate and assess the health situation in Gala and surrounding regions. Important information was reported to by the port authorities that there was a previous shipment of sheep and goats reached the country 10 days ago. There were rumors that small animals were dying in the nearby regions. Health teams were sent immediately to investigate the situations there. What mechanisms should be in place in the country? What measures should be taken by health authorities?

Answer/ Feedback What mechanisms should be in place in the country? Coordination Committee of the national public health emergency response, including availability of multi-sectoral/multidisciplinary teams to respond to outbreak. What measures should be taken by health authorities? Immediate implementation of local and national control measures to prevent domestic and international spread of the disease Case detection and investigation should be carried out locally. Rapid identification and assessment of the public health risk of the event at the local and national level. Early WHO notification upon identification of the outbreak given the potential risk of spread to neighboring countries Public awareness.

Scenario 3 The lab investigations that was requested by the veterinarians confirmed the presence of RVF in collected specimens. Meanwhile the medical teams in their active surveillance in the nearby regions reported a significantly increased number of cases with influenza-like illness including fever, muscle pain, joint pain and headache. The total number reported these symptoms reached around 382 and around 42 unexplained human deaths associated with fever and haemorrhagic manifestations. The health facilities reported that there is a daily increase in the number of cases reporting with the above mentioned symptoms. Blood specimens were collected from all patients and they were sent to laboratory for testing. Would you consider this a PHEIC? If Yes WHY? What kind of recommendation should Ministry of Health have in place?

Answer / Feedback Would you consider this a PHEIC? If Yes WHY? Yes it is a PHEIC This outbreak in Calcia highlighted several challenges with respect to IHR (2005) implementation. This outbreak is a potential PHEIC based on the following criteria: Serious public health impact: Yes – this outbreak was associated with significant morbidity and mortality. Unusual or unexpected: Yes – RVF cases were unexpected in the affected areas, population and season. International disease spread: Yes - there was a possibility of spread of the disease across the borders by the movement of the the agent, vehicle or the host. Interference with international travel or trade: Yes – Importing or exporting animals is a potentialavenue of spread of RVF through viraemic animals. These factors increased the risk human infection and subsequent spread which could potentially disrupt international trade and travel. What kind of recommendation should Ministry of Health and other line ministries have in place? Develop effective coordination mechanisms at the national, provincial and district levels. Restrict of animal movements and ban slaughtering animals. Public education to discourage practices that promote transmission to humans is the only way to reduce human infections and deaths from the disease. Food safety measures Vaccinating apparently unaffected herds of livestock Community mobilization Other interventions included heightened disease surveillance among humans and animals, integrated vector-control strategy, including indoor residual spraying and larviciding Training of Healthcare workers to care for persons suspected to be infected with RVF virus. Establish RVF wards in which appropriate infection-control measures were encouraged.

Scenario 4 Clinical and laboratory investigations confirmed that the outbreak was caused by RVF virus. WHO and other international organizations and agencies provided support and assistance to national authorities towards the preservation of international public health security. An international team was sent by international organizations to help Calcia in controlling the RVF outbreak. After 3 weeks of intensive work with the country Ministry of Health and Veterinary Department in Ministry of Agriculture the team managed to put an end to the outbreak. Although you were not informed of many details, from what you have read here what do you think of the Implementation of IHR (2005) in Calcia? What important recommendations would you give to the Ministry of Health (NFP)?

Answer / Feedback Although you were not informed of many details, from what you have read here, what do you think of the Implementation of IHR (2005) in Calcia? Implementation is still very deficient! Ministry of Agriculture and Ports were not involved or oriented about IHR There was no communication with IHR NFP Lack of awareness of IHR (2005) at the PoE No national multisectoral emergency committee No available risk assessment tool No clear collaboration between Ministry of Health and Veterinary department. Inefficient surveillance system (cases were discovered by active surveillance) No system for early warning Week animal surveillance system

Answer / Feedback What important recommendations would you give to the Ministry of Health (NFP)? In general, the main recommendation is the serious implementation of the core capacity of the IHR (2005) with emphasis in: Establish an effective communication system including a clear chain of command (intra and intersectoral) Improve Risk assessment by using the all hazards approach. Strengthen the event surveillance system. The magnitude and spread of the outbreak can be explained by the lack of early detection and surveillance systems, inadequate preparedness and weak health systems. In specific for RVF: develop RVF Control Plan which is regularly updated. Build appropriate human resource, infrastructure and other capacities that operationalize the public health response. Provide the legislative framework to carry out all necessary disease control actions need to be put in place as part of preparedness planning. Involve local NGOs to collaborate with the Ministry of Health in providing relief services to affected communities and assisting with public health education campaigns. Develop Emergency Response Plan including identification of the role of each stakeholder. Exchange of information and transparency with neighboring countries (not to forget media). Build capacity of national staff to educate communities on risk behaviors. Strengthen capacity of local laboratories. Strengthen capacity of Staff at Points of Entry. Temporary and Standing WHO Recommendations: would provide clear standardized guidance for response activities. Assistance from other agencies: Prompt notification to WHO may have facilitated more prompt and appropriate technical assistance from agencies such as the CDC and GOARN.