Integrating Local,National,and International Stakeholders in Outbreak Preparedness in Developing Countries: Conclusions from a Conference in Mbeya,Tanzania

Abstract

A conference called “Outbreaks in Tanzania—Are We Prepared?” was held in Mbeya, Tanzania, on September 14 and 15, 2015, accompanied by a training workshop on infection prevention and control for local stakeholders from September 16 to 18, 2015. The objective of the conference was to revisit past disease epidemics and to reflect on the current status of surveillance and outbreak preparedness in Tanzania, including an overview of agents relevant to biosecurity. The conference brought together national authorities of Tanzania, regional public health representatives, people from research and academic institutions, and international stakeholders. Key findings of the event were: (1) although national frameworks for surveillance and preparedness exist, their implementation presents challenges, and local health structures need support in implementation; (2) the ability to identify and properly manage infectious diseases of public health concern is crucial in empowering the local health workforce to contribute to surveillance measures, which in turn allows for realistic risk assessments and management algorithms; and (3) in settings of limited resources, research activities acquire an additional responsibility toward national surveillance and capacity building and should be integrated into national epidemic preparedness plans. This event was the first of its kind in Tanzania, facilitating direct discussion among regional, zonal, national, and international stakeholders on surveillance and outbreak preparedness. The conference's conclusions are relevant to strengthening health systems in other low- and middle-income countries.

The Tanzanian health authorities, notably the Ministry of Health and Social Welfare (MoHSW), have identified disease surveillance and outbreak preparedness as a key pillar in securing healthy lives for their population. In 2011, the second edition of the Tanzania National Integrated Disease Surveillance and Response (IDSR) was adopted, which is based on the corresponding guidelines developed by the World Health Organization.¹ In this document, the Tanzanian authorities have identified priority diseases and conditions to be covered, such as outbreak-prone diseases and infections targeted for eradication or elimination. Some entities also entail compliance with the International Health Regulations (IHR).²

In pursuit of these goals, Tanzanian institutions can build on new and existing international partnerships. The scientific community in the country enjoys partnerships with foreign higher education institutions, as is the case between the National Institute for Medical Research-Mbeya Research Center (NIMR-MMRC) and the Division of Infectious Diseases and Tropical Medicine of the Medical Centre of the University of Munich, Germany. The 2 institutions share a history of 2 decades of infectious disease research in the Southwestern Zone of Tanzania. The identification through this collaboration of infectious agents with potential for bioterrorism have led to the involvement of the Institute of Microbiology of the German Armed Forces, which supports local research through the German Partnership Program for Excellence in Biological and Health Security by the federal foreign office, by transfering knowledge and supporting logistics and capacity building.

Local resources necessary for the investigation of infectious diseases of public health concern are limited, yet the need for knowledge on the spectrum of infectious agents that goes well beyond the syndromic approaches to the major causes of morbidity has been recognized. International research collaborations, as can be found in the Mbeya Region among the NIMR-MMRC, the University of Munich, and the German Armed Forces, have contributed substantially to building diagnostic capacity. As seen in different outbreak scenarios, the strength of health systems, particularly with regard to diagnostic capacity and surveillance, are crucial for containment of outbreaks.^3,4

With the goal of harmonizing and coordinating the activities of the Ministry of Health and Social Welfare and the above mentioned local, national, and international actors, and with the aim of improving the surveillance capacity and advancing the implementation of the national outbreak preparedness framework, an international conference called “Outbreaks in Tanzania—Are We Prepared?” was held in September 2015 in Mbeya, Tanzania. The event was funded by the German GIZ (Gesellschaft für Internationale Zusammenarbeit) through the European ESTHER Alliance (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau).

Objectives

The conference aimed to facilitate direct discussion between national and international stakeholders and representatives of the local government health system on outbreak preparedness in the Southwestern Zone of Tanzania in order to summarize and present existing activities in outbreak preparedness, identify challenges and research and training needs, and develop recommendations for the future.

Methods

National and international stakeholders, with representatives from the 6 regions comprising the Southwestern Zone of Tanzania, were invited to the conference. The representatives of the regions Mbeya/Songwe, Rukwa, Ruvuma, Njombe, Katavi, and Iringa were the respective regional medical officers and up to 3 additional representatives. In addition, the Zonal Referral Hospital in Mbeya was represented by the acting director general and the outbreak response team of the hospital. In addition, registration was open to interested participants from regional and international academic and faith-based partner institutions. In all, there were 57 participants.

Presentations by invited speakers were combined with panel discussions, contributions from participants, expert statements, and a small group that worked on a fictive outbreak scenario. The various formats ensured a highly participatory environment and active discussions; feedback on the activities was collected through designated rapporteurs and self-administered questionnaires.

To develop a knowledge base and present existing activities, initial lectures from national and international experts addressed the following topics:

• A priori risks of relevant pathogens based on serological studies and review of historical outbreaks in Tanzania (Dr. Gerhard Dobler, German Armed Forces; Dr. Leonard Mboera, National Institute of Medical Research)

• Basic steps in outbreak investigation (Dr. Jerry Gibson, US Centers for Disease Control and Prevention) and existing national frameworks (Dr. Rogath Kishimba, Ministry of Health and Social Welfare; Mr. Harrison Chinyuka, Prime Minister's Office, Disaster Preparedness Unit)

• The role of the international community, exemplified through the presentation of the European Mobile Lab (EM-Lab) activity (Dr. Francesco Vairo, National Institute of Infectious Diseases, INMI “Spallanzani,” Italy).

• Challenges to health systems in outbreak control, using the Ebola outbreak in Liberia as case study (Dr. Guenter Froeschl, University of Munich). This section further presented the results of a factfinding mission of 2 Mbeya Zonal Referral Hospital (MZRH) representatives who visited the International Medical Corps in Sierra Leone and their observations, and implications for outbreak preparedness in Tanzania (Dr. Anthony Nsojo, MZRH).

These presentations were followed by a general panel discussion to identify major challenges and areas of concern for the zone. On the second day, short presentations were given on preparedness plans of the regions and the referral hospital, and local research activities outlined the status of implementation of these plans in the zone, facilitating direct feedback from national and international to regional levels. Finally, participants of the different regions had the opportunity to test their respective preparedness measures through a discussion-based outbreak simulation.

Results

A Priori Risks

The Southwestern Zone of Tanzania is of high interest when studying vectorborne viral pathogens. As the origin of humans can be traced back to East Africa, the region has a long history of co-evolution of humans, viruses, and their vectors⁵—particularly dogs, rodents, bats, ticks, mosquitoes, and livestock—which might explain regional differences in pathogen prevalence, disease patterns, and antibody prevalence. As exemplified in rodent-transmitted arenaviruses, outbreaks with highly pathogenic species such as Lassa or Lujo might be limited where less pathogenic species compete for the ecological niche. Thus, a priori risks for outbreaks have to be determined based on existing regional prevalence data and remain to be established for some pathogens.

In Tanzania in general, and in the Southwestern Zone in particular, rabies, followed by influenza, is the major livestock-associated pathogen, with several outbreaks in the past.⁶ There is a much lower risk of brucellosis, Q fever, and anthrax. Where ticks are found, murine typhus, tick bite, and tickborne spotted fever are prevalent in vectors and hosts in the zone,⁷ while information on other pathogens of diseases such as plague, flea spotted fever, arboviruses, and bartonellosis is missing, despite reported cases of plague from other parts of the country. With respect to mosquitoborne diseases, West Nile fever, chikungunya, yellow fever, dengue, and Rift Valley fever viruses are likely agents, with documented national outbreaks for the latter 2.^8-11 Concerning rodents as vectors, Lassa and Lujo fever are unlikely to occur in the area, but hantavirus infections and leptospirosis should be considered, even though the existing evidence base is weak.^12,13 However, despite ongoing vaccination programs, human-to-human transmitted pathogens such as measles, rubella, and polio remain important viral agents for outbreaks in the country, while cholera, bacillary dysentery, and meningococcal meningitis are relevant bacterial pathogens. Ebola is unlikely to emerge from within the zone, however, as exemplified by phylogenetic analysis of strains from past dengue outbreaks,¹⁴ which probably were introduced in the country through individuals returning from abroad; international migration might make Tanzania vulnerable to nonendemic pathogens, again including Ebola.

Disease Surveillance in Tanzania

Based on the WHO African Region Resolution AFR/RC48/R2 (1998), Tanzania adopted the WHO African Region Integrated Disease Surveillance Framework in 1998 and began implementation in 1999, conducting the recommended country assessment in 1998. According to the national framework, communities and health facilities are responsible for identifying and reporting alert cases and participating in any response campaigns, with the hub of decision making and resource mobilization located at the district level. The regional level supports this response through provision of enhanced laboratory capacity, training, and outbreak investigation, guided by health policy developed on the national level, which is responsible for leading public health interventions, training key cadres of health workers, and providing clinical services to back up areas that are not adequately covered.

The priority diseases identified by the Tanzanian IDSR are not limited to likely agents of epidemics, but also include diseases targeted for elimination and diseases of public health importance, including those in children under 5 years of age, notably malaria, tuberculosis, HIV, sexually transmitted infections, diabetes mellitus, and other noncommunicable diseases. Next to demographic and health surveys, and aside from immediate, weekly, and monthly reports from facility level through the district level, Tanzania maintains 9 influenza sentinel surveillance sites. Of these sites, 6 are run by the Ministry of Health and Social Welfare and 3 by the Tanzanian Armed Forces, who also cover 1 site in the Mbeya region.

Using the history of cholera outbreaks in the country, it could be shown that the existing structures have sufficient capacity to be able to monitor the impact of public health interventions—for example, showing a reduction of mortality following the introduction of rapid diagnostic tests in satellite laboratories, a revision of management guidelines, and the implementation of the National Sanitation Campaign.

Challenges in Surveillance

The Ministry of Health and Social Welfare identified major challenges, as the country so far scores only 57% on the IHR core capacities. Case detection is hampered by a lack of real-time information and by the inability to detect and diagnose, for example, viral haemorrhagic diseases and tuberculosis drug resistance. In order to improve reporting time and data quality, the country currently is transitioning to a computer-based reporting system (eIDSR) and plans sentinel sites for emerging syndromic diseases, particularly acute flaccid paralysis and respiratory illness. In addition, it will strengthen a joint animal and human surveillance system in its One Health concept. To improve diagnostic capacities, computer-based laboratory IDSR and information systems have been introduced, new guiding documents have been implemented, aiming for increased laboratory networking, and potential additional point-of-care diagnostics (eg, for dengue) are being explored.

However, during discussions and presentations of preparedness frameworks of the regions, it also became clear that dissemination of national guidelines and national efforts to strengthen reporting capacity have not fully reached the Southwestern Zone, which—as the network of influenza sentinel sites does not extend here—relies only on surveillance data reported from the facility level. Here, laboratory capacity is limited and does not allow differential diagnoses of symptomatic entities, and rapid tests, such as the cholera rapid tests, are not available. Only 1 region mentioned the use of standard syndromic case definitions to identify suspected cases of reportable diseases on the health facilities or community level. What adds to the dilemma is that the regional epidemic preparedness frameworks that could guide regional surveillance activities are mainly focused on Ebola and Marburg outbreaks, which are unlikely to develop in Tanzania and are not fully generalizable to other, more likely disease entities.

In discussions of possible ways to improve surveillance, the use of smart phone–based disease reporting and integrating research activities, such as the Homa study, were addressed. This study aims to investigate the etiology of febrile illnesses and the epidemiology of arthropodborne diseases in southwestern Tanzania and is currently implemented in Kyela and Mbeya Urban districts through NIMR-MMRC in collaboration with the University of Munich and the German Armed Forces.

Outbreak Response and Management

Various legislative frameworks provide the basis for disaster response in the country. Outbreak responses fall under this category.

The Tanzanian government has adopted several international documents, including the Integrated Disease Surveillance and Response framework and the International Health Regulations. In addition, a disaster management framework exists, which is outlined by several legislative acts and policies, including the National Disaster Management Policy of 2004, the Tanzania Emergency Preparedness and Response Plan, and the National Platform for Disaster Risk Reduction of 2005.

The coordinating structure is headed by the Disaster Management Department in the Prime Minister's office, which carries out the task of coordinating all disaster response efforts in the country. In case of epidemic outbreaks, it collaborates with the Ministry of Health and Social Welfare, the World Health Organization (WHO), key ministries, and international partners. The coordinating body as set forth by these regulations is hierarchical, with Disaster Management committees at the regional and district levels headed by the respective regional and district commissioners. Experiences with the administrative functionality of this framework were exemplified by implementation of preparedness and response plans in the light of pandemic avian influenza and Rift Valley fever. Following the Ebola outbreak in West Africa, the Ministry of Health and Social Welfare has engaged in various activities for national outbreak preparedness. Included in these activities was the development of a national response plan that envisions permanent isolation wards separate from hospitals on the regional level of the country. Subsequently, regions were required to develop aligning regional preparedness contingency plans. Although all regions could present a concept of Ebola outbreak response that mainly focused on training, community engagement, logistics, outbreak/case management, implementation, and communication and organizational structures of staff in response teams and task force, only the Mbeya Region had submitted a complete contingency plan to the Ministry of Health and Social Welfare at the time of the conference.

The EU-Mobile Lab Project (www.emlab.eu) was presented as an example of the role of international partners. The project deployed 3 portable labs to West Africa to assist in the recent outbreak, also under the WHO umbrella. Following their current mission in West Africa and according to the original project plan, Tanzania will be one of the future permanent host countries of a mobile lab unit and will provide technical staff for operations that are planned to serve the East African Region.

Challenges in Outbreak Management

In the discussion with the representatives of the various regions in the Southwestern Zone, it became clear that, although the theoretical framework of response coordination had been communicated down to the lower administrative levels, there is still a strong need to support the district-level coordinating bodies in implementing and executing response capacity preparation. It seems that local health authorities, and particularly the primary healthcare workforce as primary points of contact with potentially outbreak-prone agents, would be overwhelmed should an acute situation materialize. In a final statement session held by Dr. Gerhard Dobler of the Institute of Microbiology of the German Armed Forces, the key capacities for empowerment of the primary healthcare workforce in outbreak detection and response were highlighted; these can be summarized as the ability to identify the unusual case or case series from the usual patients, without necessarily being able to properly diagnose or categorize the condition itself. Also, the primary healthcare worker should dispose of means of taking up contact to experts at higher levels in order to communicate suspicions of a given condition and initiate a case investigation.

Several regional representatives stated the need for a scale-up of diagnostic and treatment capacities, although the expected benefit of requested high-tech laboratory capacities and high-maintenance isolation wards has apparently not been thoroughly reflected upon. In this respect, international experts recommended that, in the light of limited resources, diagnostic capacities need to be located at central levels. Isolation of patients as a primary response measure can be executed in most cases and settings by efficient use of the existing health facilities, and by implementation of basic hygiene practices for healthcare workers facing infectious diseases in general. Isolation wards as complex, preexisting structures can hardly be expected to play an important role in any initial outbreak scenario. They may be considered as structures accompanying existing referral-level health facilities, preferably sidelining referral laboratory structures, allowing for clinical investigation and research on highly contagious diseases once they are identified and transferred. To avoid parallel structures and maximize synergies, the decision makers at the Ministry of Health and Social Welfare should evaluate the potential of existing research laboratories, which have already established a surveillance infrastructure, such as the NIMR-MMRC laboratory, to serve as referral laboratories in national preparedness and response plans.

It was further noted that, despite the laboratory of the Mbeya Zonal Referral Hospital being identified as the only Ebola reference laboratory in the country, the role of the consultant hospital remains to be clearly defined in the national preparedness and response plan, to adequately use and develop its capacities with respect to patient management and training.

Capacity Building

Various training activities to strengthen outbreak preparedness were presented during the conference: On a national level, the Ministry of Health and Social Welfare in collaboration with the US Centers for Disease Control and Prevention is implementing the Field Epidemiology and Laboratory Training Program (FELTP) on basic, intermediate, and advanced levels, and an online IDSR course and the Community Health Care courses are used to promote community-based surveillance.

On a zonal level, the MZRH has developed a training curriculum particularly for building response capacities to an Ebola outbreak using publicly available WHO training material, which will be revised to integrate experience gained during a fact-finding mission of a MZRH delegation to the Ebola outbreak response in Sierra Leone. Additionally, projects implemented in collaboration with international partners, such as the EM-Lab and the Homa study, conduct project-specific capacity building as part of their project missions.

However, discussions showed that training needs remain, both with respect to practical training for local healthcare workers and strategy training for regional decision makers.

Discussion

To our knowledge, this conference is the first activity in Tanzania that aims to directly connect international, national, and regional stakeholders to support outbreak preparedness in the zone. Using the zone as a case study, it provides novel insights into the reality of outbreak preparedness in developing countries on a subnational level, allowing for identification of practical obstacles and needs on the ground that should be addressed to improve efficient outbreak preparedness.

With respect to a priori risks, our conference highlighted the need to determine a zonal profile of likely pathogens, which is based on regional surveillance and research data but also takes into account animal and human migration that might introduce new pathogens. This profile should guide the targeted use of limited resources as much as guidelines and syndromic case definitions. In this respect, frequent concerns were raised that, compared to the northern and coastal zones of Tanzania, the Southwestern Zone is underserved, and active support from the central level to implement effective surveillance is lacking. It was made clear that laboratory capacities in the zone make differential diagnosis difficult, hampering adequate reporting through a diagnosis-based reporting system. With respect to surveillance, it hence was recommended that, next to improvement of established structures and a strengthening of syndromic base reporting, novel approaches to simplify reporting of reliable and qualitative surveillance data should be explored, taking into account the increasing availability of mobile internet technology but also the possibility of using and integrating data collected outside established health system structures, such as data generated in research projects.

With respect to outbreak management, it became clear that the recent Ebola epidemic has wielded a double-edged sword for outbreak preparedness in Tanzania. On one hand, it has triggered critical assessment of outbreak response capacities, initiated activities to address response plans and capacity building, redirected budget lines, and increased laboratory capacity. On the other hand, the strong focus on a single disease entity that is highly unlikely to occur in Tanzania has taken Ebola response out of its context of a general surveillance and outbreak response framework, diverting attention from more imminent surveillance needs such as drug-resistant tuberculosis and cholera. The current focus on infrastructure requirements for outbreak management, which featured prominently in frequent variations of the topic of funding personal protective equipment, specialized laboratory tests, or isolation wards on a regional level, reveal missed opportunities in the prevention of outbreaks with more likely occurring pathogens. Possibilities to use the momentum generated by Ebola to strengthen a more general framework should be explored. This framework could build on one side on an adequate management of index patients at a primary health facility level through fully implemented general infection prevention measures, and on the other side on an efficient and rapidly deployable central-level outbreak investigation team supported by specialized reference laboratories that are integrated into already existing government- or donor-funded infrastructure. The development of the latter is already in progress through the Ministry of Health and Social Welfare/CDC–led FELT program. However, the training needs of community and health facilities as major stakeholders in surveillance and outbreak prevention still remain to be addressed. Conferences such as ours combined with targeted practical training could contribute to generating solutions for this need.

Footnotes

Acknowledgments

The authors thank our funding institutions, which made this event possible, namely the Gesellschaft für Internationale Zusammenarbeit (GIZ) and the ESTHER Initiative (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau). They also express their gratitude to all participants and presenters of the regions Mbeya/Songwe, Iringa, Rukwa, Ruvuma, Njombe, and Katavi. GD, NN, NH, BF, and CM are members of the Homa study team.

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