WHO/EMC/ DIS/97.5

Report. Review of the Project for Improving Preparednessand Response to Cholera and other Epidemic DiarrhoealDiseases in Southern Africa

World Health OrganizationEmerging and other Communicable Diseases,Surveillance and Control

This document has been downloaded from the WHO/EMC Web site. Theoriginal cover pages and lists of participants are not included. Seehttp://www.who.int/emc for more information.

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Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Background/Project Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Purpose and Methods of the Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Overall Achievements of the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Laboratory Strengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Analysis of the Status of Project Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Critical Activities to be Continued and Recommended Duration of Support . . . . . . . . . . . . . . . . . . . 20

Replicability Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Provided on request:

Annex 1 Original Project Proposal

Annex 2 Overview of Project Implementation (1993-1997)

Annex 3 Proposed Action Plan for Activities to be Continued

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Executive Summary

In 1993 following the concern of Southern African countries over the yearly epidemics ofcholera that have been occurring since the late 1980's and the spread of epidemic dysentery inthe region, a sub-regional programme was initiated by WHO to help countries affected toimprove their capacity to be prepared and respond to epidemic diarrhoeal diseases. Theprogramme was funded by voluntary contributions from Switzerland, Australia, Italy and theUnited States. The sub-regional team worked with Ministries of Health and other involvednational government sectors, international agencies, as well as with non-governmentalorganizations. After three years project implementation, a joint evaluation team composed ofWHO Headquarters and Regional Office for Africa, plus donors, met in Harare to review theoutcome of the project. The evaluation group concluded that the project was very successfuland should be replicated in other regions.

Background/Project Description

Since the start of the 1990's, coincident with the most severe drought of the century, countriesin east and southern Africa have had to cope with recurrent epidemics of severe diarrhoea dueto both cholera and bacillary dysentery. These diseases have taken a heavy toll, costing thelives of thousands of people during the epidemic period and, in the longer term, through theirimpact on national economies.

In many African countries, case-fatality rates due to epidemic diarrhoea have ranged as highas 40% in the acute phases of cholera epidemics, and CFR from cholera and, occasionallyfrom dysentery, have averaged close to 10%. With rapid and effective responses to epidemicdiarrhoea disease outbreaks, experience has shown that CFR can be kept as low as 1%.Although many countries have preliminary emergency preparedness plans these are oftenincomplete and difficult to implement as demonstrated by the high case-fatality rates.

The programme was initiated by WHO following the concern of the countries of SouthernAfrica over the yearly epidemics of cholera that have been occurring since the late 1980's, andthe 1993 spread of epidemic dysentery in the region. This initiative has sought to develop andimplement a more aggressive, more coordinated, and more action-oriented approach toepidemic preparedness and control. Its goal was to reduce both morbidity and mortality,along with the other associated deleterious effects of epidemic diarrhoea, through a series ofplanned activities to be conducted during the epidemic period itself and, perhaps moreimportantly, during inter-epidemic periods.

The programme provided an opportunity to implement the recommendations endorsed byintercountry meetings of Ministers of Health and Minister of Interior in 1992 to develop anaggressive approach to the control of cholera and dysentery. The areas addressed were:

i improvement of case management in order to reduce case-fatality rates from epidemicdiarrhoeal disease, specifically cholera and bacillary dysentery;

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ii implementation of prevention programmes dealing with improved water supply andsanitation and better food safety practices;

iii enabling front-line health staff to respond rapidly to epidemics of diarrhoeal diseases;

iv minimizing the impact of epidemic diarrhoeal diseases of national economies;

v identifying and quantifying the long-term developmental needs to reducing theoccurrence of epidemic diarrhoea.

This initiative involved the development of comprehensive national plans for preparednessand response to epidemic diarrhoeal diseases. To help develop and implement activities in allthe areas mentioned above, the World Health Organization have proposed the establishmentof a Sub-Regional team to work with Ministries of Health and other involved nationalgovernment sectors, international agencies (such as the United Nations High Commission forRefugees and the Department for Humanitarian Assistance), bilateral assistance programmes,and non-governmental organizations. The team was to include a Medical Coordinator, anepidemiologist, a microbiologist or laboratory technician, a specialist in administration,procurement, and supply and a secretary.

This team worked closely with existing WHO Country/Intercountry teams ensuring effectivelinkages within WHO African Regional office and WHO/HQ, therefore benefiting fromtechnical back-up and other assistance.

The project initially has developed in four of the affected countries (Malawi, Zambia,Zimbabwe and Swaziland), included other countries of the subregion particularlyMozambique, Tanzania and Angola as the project progresses. However the surveillanceactivities have covered all the 14 countries of the subregion.

The programme is funded by voluntary contributions from development aid of Switzerlandand Australia (for 3 years), Italy (for 1 year), and the United States (USAID for 2 years). It isexpected that further funds be generated by the participating countries on a bilateral basis.The project started in September 1993.

Purpose and Methods of the Review

Terms of Reference of the Evaluation Group are to :

i assess the status of implementation of the project in relation to the objectives andtargets;

ii appreciate the level of laboratory strengthening of laboratory services to support thecontrol of epidemic diarrhoeal diseases and the measures taken for itssustainability;

iii assess the replicability of the project;

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iv document lessons learned;

v make recommendations on the aspects of the project that still require furthersupport and for how long;

vi discuss issues related to donor and consultant inputs and co-ordination, withspecific reference to SDR, CDC/USAID.

Review Team:

External participants

Dr Sambe Duale, SARA Project (USAID)

Dr Loco Lazare, WHO/AFRO - Team Leader

Dr Maria Neira, WHO/HQ

Dr Jean-Pierre Stamm, SDR

Dr Robert Tauxe, CDC/Atlanta

Project staff

Dr Elizabeth Mason, Epidemiologist, Co-ordinator

Dr Alan Ries, Epidemiologist, CDC/Atlanta

The review was conducted in Harare, Zimbabwe, 2-6 April, 1997.

Overall Achievements of the Project

Technical Support Team

The project started in mid- September 1993 with the recruitment by WHO of a MedicalOfficer as the Coordinator of the project .

In May 1995 the Medical Epidemiologist from CDC joined the programme supported byUSAID with funds to support project activities including services of consultants fromCDC/Atlanta, USA.

A Sanitary Engineer was recruited for a period of 5 months, February - June 1996.

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The Secretary was recruited at the beginning of May 1996 and has greatly improved theefficiency of the team.

Country support and staff

Malawi : APO (Associate Professional Officer) CDD/ARI who is Medical Officer,funded by Swiss Disaster Relief (SDR), was posted to Malawi mid-December 1994 for aperiod of 2 years. He was actively supporting the CDD programme manager in theimplementation of CDD activities. His contract ended in December 1996.

Mozambique: APO (Associate Professional Officer) CDD/ARI. A Medical Officer,funded by Austria, was posted to Mozambique since February 1995 for a period of 2 years.Since then many activities are taking place. These include training in case management anddisease control and translation of training and IEC materials into Portuguese (and locallanguages for IEC materials). Completes term of duty end January 1997; contract will beextended for 6 months by the project and 6 other months by EPI/AFRO.

Zimbabwe : A Disease Control Officer for development and implementation of theepidemic preparedness and control was recruited in May 1994 on Australian funds for aperiod of 2 years. Eight environmental Health Technicians (EHT's) for the districts tostrengthen disease control activities were recruited also in May 1994. The post has beenabsorbed into the WHO country office.

Zambia : APO (Associate Professional Officer) CDD/ARI. A Medical Officer, fundedby the Dutch Government, was posted to Zambia since June 1995 for a period of 2 years.Completes term of duty; April contract will be extended for 18 months (9 by DutchGovernment and 9 by WHO)

Development of Materials and Training

The project has invested considerable resources in the development of a number of materialsrelated to preparedness and response to diarrhoea disease epidemics, and in the organizationof training activities. The development of training materials has taken a considerably longerperiod of time than the project has anticipated. This necessitated the postponement orcancellation of a number of training activities.

The programme has assisted in the development of the following materials:

i District level training materials in Participatory Methods for Environmental andPersonal Hygiene Education related to the control of Diarrhoeal Diseases.

ii District Health Workers training for Preparedness and Control of EpidemicDiarrhoeal Diseases.

iii Technical cards for use by basic level health workers with the community. A seriesof 26 cards have been developed.

iv Environmental Fact Sheets for cholera control.

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v Training materials for health workers in food safety as related to diarrhoealdiseases are being developed.

A series of laboratory materials have also been developed (cfr section on Laboratorystrengthening). The following training activities are illustrative of training efforts under the project :

i Epidemic preparedness training in Malawi (field test), Zambia and Swaziland.

ii Development of guidelines, including dysentery case management and laboratorydiagnosis in Malawi, Swaziland, Zambia and Zimbabwe.

iii Training in participatory methods for environmental hygiene in Malawi and

Zambia. Zambia has since replicated the course a number of times for district levelhealth workers

Subregional Emergency Stores for Epidemic Response

The WHO emergency stores were transferred from Nairobi, Kenya to Harare, Zimbabweduring the last quarter of 1994, with the first supplies being received in October. The logisticsof storage and movement of stocks are organized through an agreement with the Governmentof Zimbabwe Medical Stores to ensure smooth running of the stores. By the end of 1994supplies for diarrhoea epidemic response such as ORS sachets, IV fluids - Ringers Lactate,WHO emergency Health Kits, Chloramphenicol injectable, Nalidixic Acid had been received.The Nalidixic Acid was almost immediately transported to Rwanda where it was urgentlyneeded for the dysentery epidemic.

In 1995 and 1996, The WHO emergency store continued to be based in Harare with thesupplies being stored at Government of Zimbabwe Medical Stores. Several countries weresent emergency supplies of drugs on request. See annex 2 for updated list of drugs andsupplies in emergency store and responses to country requests.

Operations Research

A number of operations research studies were gradually incorporated into the projectimplementation, these include:

i Social and environmental factors influencing the transmission of shigella dysenteryin rural and urban areas of Zimbabwe, this study has been completed and theresults are being analyzed.

ii Treatment of dysentery in Health Centres in Mozambique. This study has beencompleted and the results are being analyzed.

iii Dysentery incidence in Kwazulu-Natal Province, South Africa and modes oftransmission of dysentery in Kwazulu-Natal, South Africa. The study wasconducted with the assistance of CDC and has been completed and report

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presented.

iv Transmission of cholera, Zambia. The protocol for this study was prepared with theassistance of CDC, the study is still to be conducted.

v Clinical trial of ciprofloxacin for the treatment of dysentery due to Sd1 in children.This is a multicentre study taking place in Durban, South Africa and Harare,Zimbabwe. The recruitment has started in both centres. The study is sponsored byWHO and Bayer and is co-ordinated by the Harare team. As part of the preparationfor the study six of the members of the study teams from Durban and Harare visitedthe International Centre for Diarrhoeal Diseases in Bangladesh where a number ofstudies on dysentery have taken place.

Mechanisms for Regional Sharing of Information

Intercountry Meetings on Epidemics of Dysentery in Southern Africa. An Intercountrymeeting on epidemics of dysentery in the African Region was held 9-12 October 1995. Over50 participants from francophone and anglophone countries met to share information andexperiences on the control of epidemics and the correct management of cases of dysenterydue to Shigella dysenteriae type 1. A number of recommendations and plan of action for theirimplementation were made.

Following on from the intercountry meeting on epidemics of dysentery in the African Regionthat was held in 1995, an intercountry meeting of laboratory specialists was held inNovember. The meeting drew together 17 laboratory specialists from Malawi, Mozambique,Tanzania, Swaziland, Zambia and Zimbabwe, with facilitators from WHO, CDC andLiverpool School of Tropical Medicine. The meeting focused on the sharing of experiencesand techniques related to the confirmation of cholera and dysentery and both central andperipheral laboratories. A number of recommendations were made to be followed up by bothWHO and participants when they returned to their countries, these included regular sharing ofinformation between laboratories and the establishment of a regional reference laboratory forcholera/dysentery.

Bulletin of epidemic diarrhoeal diseases in Southern Africa - The first bulletin ofepidemic diarrhoeal diseases in Southern Africa was produced at the end of 1995. It wasplanned that the bulletin will be produced quarterly in 1996. The bulletin has been publishedthree times as of April 1997.

The circulation of the bulletin has targeted mainly individuals who have participated in theintercountry meetings on epidemic preparedness and control. A number of copies are sent toWHO country offices for distribution. The project team has received some occasionalfeedback from readers of the bulletin.

Partnerships and Coordination (+Budget)

The funds for the project implementation are donated by the Swiss and AustralianGovernments as well as from other sources. Since mid 1995 there has been a Medical

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Epidemiologist placed with the team who is funded by USAID (supported by CDC) andworking under WHO Management.

Regular reports were given to donor agencies, both written and verbal communication. Theinter-country staff participated in donor meetings for reporting back and resourcemobilization.

In February 1994, one week orientation course for SDR potential consultants held in Geneva.

Needs Assessment and Development of Action Plans

During the first four months of the project in 1993, a number of visits were made toSwaziland, Malawi, Zambia, Mozambique, and Zimbabwe to assess needs, identify priorities,and initiate the development of action plans for preparedness and response to epidemicdiarrhoeal diseases. In all countries visited, the programme was seen as a high prioritybecause cholera and dysentery have caused high case fatality rates and a disruption of routinehealth services. The specific priorities varied from country to country. However, all countriesindicated the need for support to laboratory services, surveillance, case management at healthcentres and health education. Surveillance systems were well developed in Zimbabwe andMozambique. The CDD programmes were functioning at acceptable level in Swaziland,Zambia, and Zimbabwe.

Special efforts were made by the project team during the 1994-1995 period to assist countriesin the development of policy and action plans for preparedness and response to diarrhoeadisease epidemics:

* The project provided assistance for the development of CDD and epidemic diarrhoealdiseases 5 year plans and policy formulation for Malawi.

* The epidemic diarrhoeal disease preparedness plan for Swaziland was reviewed andrevised.

* Planning has been decentralized to district level in Zambia. The CDD unit developedguidelines for planning CDD activities including preparedness for epidemics of choleraand dysentery. The CDD staff, supported by WHO visited cholera/dysentery pronedistricts to guide and assist in this planning process.

* Development of Zimbabwe’s 5 year plans for CDD programme including epidemicdiarrhoeal diseases control.

* A planning mission undertaken to Mozambique.

* Technical support visits were made to support planning of control activities and set up asurveillance system in South Africa following a request for assistance with the dysenteryepidemic in the Kwazulu-Natal Region.

Epidemiologic Capacity: Surveillance Systems and Investigation of Outbreaks

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1993:* Surveillance systems in Zimbabwe and Mozambique were fairly good. The routine

information system in most of the countries assessed did not cater for the reportingof cholera and/or dysentery.

* The project provided computer equipment for the Department of Epidemiology ofthe MOH of Zimbabwe to utilize for surveillance and geographical informationsystem (GIS). Two vehicles (4WD) were provided also to Zimbabwe for thesupport of activities in the two worst cholera/dysentery affected provinces.

1994:* Development of the dysentery and cholera rapid and computerized surveillance

system in Malawi. This was agreed upon at the November 1993 meeting oncholera/dysentery following the needs assessment. There was a rapid response to acholera outbreak in the far northern districts of Karonga and Chitipa whichoccurred in May-June.

* In Swaziland, the surveillance of diarrhoeal diseases was identified as a very weakarea. Lack of computer equipment and training for information collection,compilation and analysis were among the problems. The project has supportedtraining of central and regional Outbreak Control Teams and ordered a computerfor the CDD Unit of the MOH.

* The project facilitated the inclusion of dysentery surveillance into the WeeklyEpidemiological Report in Zimbabwe. Zimbabwe developed guidelines/check listfor epidemic cholera and dysentery preparedness at central, provincial, district andhealth centre levels.

1995:* The compilation and dissemination of information on cholera and dysentery were

improved in Malawi with the provision of computer equipment.

* Surveillance system for diarrhoeal diseases in Swaziland was still very weak.

* An EIS officer from CDC conducted analysis diarrhoea surveillance reports inZambia for the past five years. The study led to the formulation of a plan toimprove cholera and dysentery surveillance in Zambia.

* Regular surveillance of diarrhoea diseases continued in Zimbabwe through therapid weekly reporting system and the regular monthly health information system.Three portable laptop computers were ordered to facilitate outbreak investigationsin the most affected provinces.

1996:* An epidemic preparedness training for district rapid response teams was conducted

in September 1996 in Zambia. There was initial training of 21 facilitators by theproject team from Harare, and subsequent training of health workers from 19districts in 5 separate provincial level courses. Evaluation of the effectiveness of

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the training will take place in 1997.

* The project provided technical support to review control measures undertakenduring two cholera outbreaks in Zambia in 1996. The number of cases and deathswas far below previous epidemics because appropriate control activities wereundertaken rapidly.

Case Management of Dysentery and Cholera

1993:* A DTU (diarrhoea training unit) course was offered to increase the capacity of

trained personnel in Zambia in case management of diarrhoea diseases. The coursewas for trainers of trainers (TOT) and included participants from Burundi, Malawi,Zimbabwe, Zambia, and SDR (Swiss Disaster Relief) consultants.

1994:* Training in diarrhoeal diseases in Malawi - A DTU (diarrhoea training unit) was

established at the Queen Elizabeth Hospital in Blantyre, with equipment providedthrough the programme

* In Swaziland, training of health centre staff in cholera and dysentery casemanagement took place in September and October prior to the rainy season.

1995:* Training continued at the DTU of the Queen Elizabeth Hospital of Blantyre.

Preparations for the establishment of a second DTU at the Kamuzu CentralHospital in Lilongwe were made.

* A WHO APO commenced duties in February 1995. Since then many activitieshave taken place, including a training in case management and diarrhoea diseasecontrol and a translation of IEC materials in Portuguese.

* DTU courses were offered in Zambia and Zimbabwe.

1996:* In addition to training at the DTU of Queen Elizabeth Hospital in Blantyre,

training in CDD was carried out at district level in 12 districts followed byincreased supervisory visits.

* A number of training courses in case management were held in Mozambique atcentral and provincial levels.

* Planned training for districts in Zimbabwe on dysentery/cholera prevention andcontrol and field supervision was not carried out. District epidemiology trainingwas undertaken instead.

* There were no request for diarrhoea disease case management training fromSwaziland, Zambia.

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Prevention and Control of Diarrhoea Diseases: Health Education and EnvironmentalSanitation:

1993:Needs assessment conducted in Swaziland, Malawi, Zambia, and Mozambique havefound that IEC activities for diarrhoea disease prevention and control are weak. Theproject team has identified this area as one that should be strengthened.

1994:* SDR consultancy to review the health education component of the water and

sanitation project implemented by Zambia Red Cross/SDR. It was agreed that thehealth education component needed strengthening.

* Development and dissemination of health education messages on cholera/dysentery in print and on the radio in Zimbabwe.

* A training course for environmental health technicians (EHTs) on the use of the'paqualab' water testing kits was organized in Zimbabwe.

1995:* The WHO APO in Mozambique initiated the translation of IEC materials for CDD

into Portuguese and other local languages.

* A food safety study was conducted in Zambia during March 1995. The studyfindings and recommendations are being used for the development of guidelinesand training materials for health workers and mother on food safety

1996:* Training of provincial environmental officers in Zambia and Malawi in community

participatory methods for environmental and personal hygiene for prevention andcontrol of diarrhoeal diseases.

Laboratory Strengthening

Terms of reference point 2: Appreciate the level of laboratory strengthening of laboratoryservices to support the control of epidemic diarrhoeal diseases and the measures taken for itssustainability

Laboratory Team

Several consultants have provided input to the evaluation and training activities of the project.In addition to the short term consultants, since 1995 a full time staff member has assisted inplanning, initiating, and coordinating the laboratory based activities in the countries under the

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initiative. The team in Harare, in collaboration with AFRO and WHO/HQ developed a planto mobilize technical assistance from several relevant organizations mentioned below.

Short term consultants

Swiss Disaster Relief (SDR) (1993-97)Marco JerminiGabriele ZürcherChristina Ferrari

Liverpool School of Tropical Medicine (1993-96)Catherine Mundy

Centers for Disease Control, Atlanta (CDC) (1995-97)Joy WellsCheryl Bopp

Italian Cooperation (1995-96)F. Capucinelli

Permanent Staff

WHO (1995-97)Allen Ries

Materials Developed 1. Laboratory support for the investigation and control of cholera and dysentery in

Swaziland; December 1993; Jermini and Mundy.

2. Laboratory support for the investigation and control of cholera and dysentery in Malawi;April 1994; Mundy and Ferrari.

3. Laboratory support for the investigation and control of cholera and dysentery in Zambia;October 1994; Mundy and Zurcher.

4. Continuation of laboratory support for the investigation and control of cholera anddysentery in Swaziland; April 1994; Mundy and Ferrari.

5. WHO intercountry laboratory meeting on improving preparedness and response toepidemic diarrhoeal diseases in Southern Africa; November 1996.

6. Dysentery and cholera control training workshop for laboratory technicians andtechnologists, Masvingo Public Health Laboratory; June 1994; Epidemiology andDisease Control Unit, Ministry of Health, Zimbabwe.

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7. Bacteriologic examination of water supplies. “Simplified procedures suitable for use bydistrict hospital laboratories, mobile teams and field workers”; Mundy.

8. Laboratory support for the investigation and control of cholera and dysentery in Malawi--Follow up visit; October 1994; Mundy and Zurcher.

9. Laboratory diagnosis of cholera and epidemic dysentery, “Simplified procedures for useby district hospital laboratories and mobile teams; 1994; Mundy.

10. Laboratory methods for the diagnosis of epidemic dysentery and cholera; Draft, 1996;Wells, Bopp, and Ries.

11. Summary of laboratory evaluation, training, and planning in Southern Africa, February1995 to November 1996; February 1997; Wells.

12. In addition, trip reports and other documents exist for visits, evaluations, and training.

Reinforcement of National Laboratory Capacity

Below are described the trips to the countries in which laboratory work was the main or alarge portion of the team terms of reference. However, most of the country visits contained atleast some component of laboratory evaluation or support. APOs permanently present in thecountry also provided ongoing support.

Malawi

April 1994; Laboratory support and training course for laboratory technicians

October 1994; Follow-up of April training course

July 1995; Evaluation of laboratories in Southern and Central Regions

September 1995; Evaluation of laboratory diagnostic methods, Central and Northern Regions

July 1996; Laboratory follow up

March 1997; Laboratory follow up

Swaziland

November 1993; Laboratory support and training course for laboratory technicians

April 1994; Follow up of training course

May 1995; Follow up

Zambia

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October 1994; Laboratory needs assessment

August 1995; Assessment of laboratory capacity in cholera affected areas

September 1995; Laboratory evaluation and planning for course

October 1995; Workshop on laboratory methods for diagnosis of epidemic dysentery andcholera. Laboratory reagents supplied to 8 of 9 provinces and to the 2 central laboratories

February 1996; Follow up of laboratories with special reference to cholera

September 1996; Follow up

February 1997; Follow up of laboratories with special reference to cholera

Zimbabwe

June 1994; Training course for laboratory technicians on the diagnosis and sensitivity test forcholera and dysentery.

August 1994; Development of a laboratory surveillance system.

June 1995; Technical assistance to develop laboratory capacity, 2 months

July 1996; Technical assistance to develop laboratory capacity, 3 months

1996-1997; Laboratory capacity building as part of study ciprofloxacin in treating paediatricdysentery.

Mozambique

1996; Provided laboratory equipment and reagents to support the upgrading of provinciallaboratories

March 1996; Brief laboratory review and provision of materials

July 1996; Training course for laboratory technicians

South Africa

February 1996; Field training and evaluation; Provided laboratory supplies

1996-1997; Microbiologist sent to CDC for training and to develop Shigella dysenteriae type1 rapid diagnostic test (1 year).

1997; Technician from South African Institute of Medical Research (SAIMR) sent to CDCfor 3 month training

1996-1997; Laboratory capacity building as part of study ciprofloxacin in treating paediatric

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dysentery.

Uganda

March 1997; Brief evaluation and visit to central public health laboratory and one regionallaboratory

Intercountry Meeting

November, 1996; Intercountry laboratory meeting in Harare on improving preparedness andresponse to epidemic diarrhoeal diseases. Laboratory reagents supplied to participatingcountries.

Operations Research

With the support of the intercountry team, countries under the initiative developed and carriedout laboratory based research protocols.

South Africa

February 1996; Intensified laboratory based surveillance for organisms causing dysentery.

Malawi

1997 Laboratory based study of etiologic agents causing dysentery planned.

Quality Assurance

Countries under the initiative have sent isolates of Shigella spp. and Vibrio cholerae O1 tointernational reference laboratories for confirmation of identification and antimicrobialsusceptibility patterns.

Several countries under the initiative are now participating in external quality control(unknown isolates sent quarterly to the laboratories for identification) through SAIMR.

Other Technical Assistance

During team visits to the participating countries, information was shared and results evaluatedon an informal basis.

Periodic communication takes place between the countries and the team office in Harare asneeded.

The quarterly epidemiologic Bulletin published out of the team office in Harare provides aforum for sharing laboratory results among countries.

Laboratory supplies were provided to all the participating countries.

A list of national central laboratories and their primary personnel is available; the capacity of

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each central laboratory is known.

Discussions on developing a sub regional reference laboratory are in progress.

Analysis of the Status of Project Implementation

The indicators for assessing project implementation and its impact were not well defined atthe beginning of the project. This was in part due to the urgency of the response needed, andbecause the project grew quickly from a small project in one country to a large intercountryproject. Nonetheless, the group was able to identify an number of indicators in retrospect.The following points were identified for analyzing the benefits of the project:

1. Case fatality rate

The evaluation group decided that tracking the case fatality rate (CFR) was a reliableindicator for assessing the impact of the project. The group found that the trends in casefatality rate (CFR) decreased both for cholera and dysentery over the 3 to 4 years for whichdata are available. The CFR for dysentery may not reflect the real picture because theavailable data cover mostly outpatients. The decrease in case fatality rate indicates a trend forbetter case management for cholera and dysentery. The group interpreted this as an impact onthe efforts of the intercountry team through training, visits, providing information, etc.However the group admits that other factors may also have affected the CFR. Trends inincidence rates of number of cases for cholera and dysentery were not considered as part ofthis evaluation since many factors can influence the incidence rate.

2. Preparedness and national capacity to respond to diarrhoeal disease outbreaks

The evaluation group compared the status of preparedness in the countries under the initiativein 1994 and the present situation, 1996 and 1997 and found an improvement in responsecapabilities over time. The response to the 1996 outbreaks in Malawi and Zambia illustratethis point. For the cholera outbreak in Zambia, the number of cases and deaths was far lowerin this outbreak compared with the previous one because adequate treatment and controlactivities were appropriately undertaken.

Concerning preparedness and response for outbreaks of Shigella dysenteriae type 1 (Sd1), abig effort has been made, since materials and understanding of epidemic dysentery were verylittle at the outset of the project. Now guidelines for control of epidemics caused by Sd1 arein place in all affected countries; standard procedures for collection and transport ofspecimens and laboratory methods for diagnosis of the organism have been developed,distributed, and are in place in all countries. A number of countries have made localadaptation of the guidelines, and have distributed to health centers. Mozambique hastranslated the guidelines into Portuguese.

3. Subregional emergency stocks

The regional team provided emergency treatment supplies to countries within the initiative as

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well as to other countries in the African region. The subregional emergency stores have beenappropriately maintained and replenished with supplies to respond to diarrhoea diseaseoutbreaks and other emergencies (e.g. flood in Madagascar). The team has dispatchedemergency supplies in a timely manner with WHO/AFRO clearance. The project hasfacilitated the expansion of the role of the emergency stocks to cover all health emergencies.

4. National plans of action for the control of epidemic diarrhoeal diseases in place

All of the countries involved in the initiative have developed plans of action for the control ofepidemic diarrhoeal diseases, or have updated the plans that already existed. The evaluationgroup is not in a position to confirm at which level the action plans have been implemented ineach country. But, the recent cholera outbreak in Zambia provides a good example ofappropriate action by a country based on a plan of action. The way that all of the countriesunder the initiative are responding to dysentery outbreaks leads the group to believe that theaction plans are in place and implemented.

5. Materials developed and disseminated

A wealth of documents have been developed under the initiative, including informationdocuments, training materials, reports, and guidelines. A special emphasis was placed ondeveloping materials that did not previously exist that are relevant for epidemic dysentery.These are described in detail elsewhere. These materials are useful not only for the countriesunder the initiative, but are useful to other countries as well and have been used by countriesin other regions. The materials cover many different areas, including laboratory issues, casemanagement, preparedness, environmental sanitation, and health education.

A number of the materials developed have been used during training activities organized bythe project team and participating countries. The materials have been distributed through theWHO channels. However, there is still a need for some efforts in finalizing and improvingthe dissemination, and ensuring a better use of the materials.

6. Operational research

Many studies were conducted, are in progress, or are in preparation. The group consideredthat the findings of the operation research are important, especially for case management.

7. Laboratory capacity

A detailed description of laboratory capacity development has been written and is included inthis report. The analysis of the project implementation shows that the special efforts indeveloping the laboratory capacity was one of the main components of the initiative and hasled to some improvement in the laboratory capacity. At least one laboratory in each countryis able to accurately and reliably identify Vibrio cholerae and Shigella species. As a follow-upof the recommendation of the intercountry laboratory meeting, countries are now participatingin external quality control. The external quality control is very important to ensure thereliability of laboratory data, especially for monitoring drug resistance, for the region and to

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provide continuing education to laboratory staff. Since no full time laboratory staff wereassigned to the project, the intercountry team had to rely on short term consultants for someof the laboratory input. Many laboratories in the region are now initiating research projectson their own.

8. Health education

Health education was identified as a priority area in the needs assessment for the project.Health education materials have been developed and studies on identifying risk factors fordysentery were conducted. One important and relevant document produced is the CommunityParticipation for the Prevention of Diarrhoeal Diseases using participatory methodologywhich has been used in training courses in Malawi and Zambia. The project focused onraising awareness of national authorities to assist in developing health education messages.However, no systematic technical support has been provided through the project.

9. Epidemiologic surveillance system

Before the project began, countries were not able to identify dysentery outbreaks through theirsurveillance system because bloody diarrhoea and watery diarrhoea were reported together.Now all of the countries under the initiative report bloody diarrhoea separately from waterydiarrhoea. The evaluation group considers this change as a direct result from input of theintercountry team. The early warning system for epidemic diarrhoeal disease appears to befunctional in most countries, as outlined by numerous examples. Through the project, mostcountries received computers to assist with epidemiologic surveillance. APOs are helpingcountries in building their capacity in the use of computers.

A Bulletin of epidemic diarrhoeal diseases in Southern Africa produced by the project team isused to share epidemiological information among countries.

10. Ineffective control measures

The intercountry team made efforts to change misconceptions about control measures forcholera (e.g., quarantine and excessive isolation, massive use of chemoprophylaxis). InZambia, the control measures improved over two years of observation and a decrease inineffective control measures led to a more appropriate response for cholera control and bestuse of available resources.

11. Water and Sanitation

Fact sheets and technical cards on environmental sanitation were produced. The intercountryteam provided this information to the national levels of the participating countries. Anenvironmental sanitarian assisted in these efforts for 5 months. In Zimbabwe, more supportand training was provided at the request of the country.

12. Co-ordination with other health programmes

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The project has benefited from a strong technical collaboration with other WHO-sponsoredprogrammes such as the Health Systems Research Project. The project implementationapproaches have also facilitated strong linkages and better use of resources of intercountryprogammes housed at WHO in Harare.

Lessons Learned

1. Targets and Indicators should be defined at the beginning of the project in order to clarifygoals and to facilitate monitoring and evaluation of the project.

2. A mid-term review of the project, incorporating relevant partners, should be planned fromthe beginning in order to review progress and replan as necessary.

3. A prior knowledge of the region by the Project Co-ordinator, facilitates the needsassessment and development of the project within countries and is essential for the smoothrunning of the project.

4. The initial needs assessment carried out in the countries enabled planning of appropriateinputs according to the countries needs and capacities.

5. The core group of staff including administrative support, identified in the projectdocument, should be in place at the beginning of the project to fulfil the needs and goals ofthe project.

6. Short-term consultants are useful for specific technical input (eg training). The MedicalCo-ordinator should be responsible for the identification of needs for specific technical inputto support the project, co-ordinate and ensure optimal use of the consultants.

7. The role of each agency and the personnel involved in the project needs to be clarified atthe beginning of the project or as soon as they become involved in the project, in order toavoid duplication of effort and in order to maximize efficiency.

8. The designation of a WHO focal point in each country (Medical Officer, APO or nationalofficer) is essential to ensure continuity and follow-up of the intercountry team support. Theadministrative support of the WHO country office is paramount to the success of the project.

9. The project activities should be integrated as much as possible with other relevant activitiesin the countries in order to maximize efficiency and effectiveness of the programme (eg addon to disease surveillance already in place, rather than create a parallel system).

10. Strong national commitment of the participating countries to the project, arising fromidentified needs facilitated the implementation. Other similar projects should target problemswith similar national commitment.

11. Development of new training materials or guidelines is resource intensive (involvementof manpower, finances, adequate time etc). This needs to be considered whereimplementation of activities relies on the production of new materials. Materials developed

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should be applicable to other countries/regions wherever possible.

12. Conduction of Research activities should be used as an opportunity for national capacitybuilding in addition to the use of the outcome of the studies.

13. The Medical Co-ordinator role in fund raising activities can have a positive impact on theproject.

14. The availability of specific intercountry project funds enabled planing of country activitieswith MOH and national focal points.

15. Intersectorial collaboration is necessary for the implementation of certain activities eg inwater and sanitation. The difficulties encountered in this intersectorial collaboration mayinfluence the impact of these activities.

Critical Activities to be Continued andRecommended Duration of Support

The evaluation group examined what the project accomplished and so far and what areasshould be continued. With continued support of personnel and funds, it is likely that manyof the developments will become institutionalized and thus sustainable. In order for this tohappen, the project will need to continue for 2 more years and the intercountry team(including Co-ordinator, Medical Epidemiologist, and secretary) will need to remainedstationed in Harare.

The evaluation group identified five categories of critical activities to be continued under theproject.

1. Laboratory activities

At this point, laboratory activities still require some external support in supplies, technicalfollow up and quality assurance. With continued efforts, these abilities could be reinforcedand would likely be sustainable. The specific areas to be continued are as follows:

(a) Follow up of laboratory trainingProvide technical support and follow up to laboratories that have received trainingin order to insure that procedures are being carried out correctly, that results areaccurate, and to insure that laboratories will be able to continue these activities ontheir own in the future.

(b) Quality assurancei Continue external quality assurance by the sending of unknown organisms to

the participating laboratories every quarter (organized through SAIMR).ii Continue to develop a regional reference laboratory with the capabilities of

confirming identification and antimicrobial susceptibility patterns, providing

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quality assurance for antisera and media.iii Continue support in the confirmation of the identification and antimicrobial

susceptibility patters of isolates while regional reference laboratory is beingdeveloped (work is currently done at CDC/Atlanta).

(c) Laboratory suppliesi Continue to supply laboratories with the reagents needed to identify the

causes of cholera epidemic dysentery in the area.ii Assist the countries in identifying their own sources of supplies of good

quality for future use and developing the means to obtain them.

(d) Laboratory based surveillanceInstitutionalize a system for laboratory based surveillance in the following threeareas:i Identification of organisms causing Vibrio cholerae and Shigella spp.ii Identification of antimicrobial susceptibility patterns for Vibrio cholerae and

Shigella spp.iii Ability to identify emerging causes of cholera and dysentery (Vibrio cholerae

O139 and Escherichia coli O157:H7).

2. Finalizing, translating and disseminating materials

(a) Finalizing and field testing laboratory manual for diagnosis of organisms causingepidemic diarrhoea.

(b) Finalize other materials in progress.

(c) Continue to provide technical support to the running of the ciprofloxacin trial andassist in the analysis and writing of the final report.

(d) Translate selected materials into Portuguese and French for broader distribution.

(e) Disseminate the developed materials at least to the national level and encouragecountries to further disseminate them.

3. Epidemic surveillance and research

(a) Continue to produce the intercountry Bulletin for epidemic diarrhoeal diseases 3 to4 times a year. Explore ways to improve the distribution and dissemination.Encourage submission of laboratory and research results.

(b) Obtain more accurate data about the epidemiology of epidemic dysentery,including inpatient and outpatient case fatality rates, size and extent of outbreaks,modes of transmission, efficacy of interventions.

(c) Assist countries in developing their own sustainable research strategies.

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4. Training and follow up of training activities

(a). Continue to train facilitators for the training materials, epidemiological surveillanceand management of epidemics at the district level. Encourage and supportcountries in carrying out these courses in districts at risk.

(b) Follow up the district level training to evaluate the level of implementation and toassess the impact.

(c) Follow up other training activities.

5. Intercountry meeting

(a) Intercountry laboratory meeting for laboratory workers involved in theidentification of organisms causing epidemic diarrhoea.

(b) Intercountry meeting for public health officers involved in the prevention andcontrol of epidemic diarrhoeal diseases, with special focus on epidemic dysentery.

(c) Consider having one or two days of overlap between these meetings in order toencourage exchange of information and ideas between laboratory workers andpublic health personnel.

Replicability of the Project

The project is a successful model of a rapid sub-regional response to an emerging epidemicdisease. It should be considered as a way of addressing epidemic diarrhoeal diseases in otherlocations, or other emerging epidemic infections. Critical elements to this model include:-

1. The project enabled a rapid and flexible response to a specific problem at sub-regionallevel, using the awareness created by the epidemic situation to develop preparedness.

2. The core intercountry team based in Harare, ensured sustainability of the project.

3. The use of short term consultants from partners agencies to assist the countries inspecific areas.

4. The project had it's own funds which facilitated flexibility in planning implementation ofactivities in countries.

5. The project is time limited.

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6. The flexibility of the project enabled adaptation of the plan of action according to thechanging needs of the countries.

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Recommendations

In view of the review of the project the following recommendations were made:-

1. In view of the project outcomes, especially related to laboratory and training support, theproject should be continued for an additional two years. This will ensure sustainability of theachievements made in the countries. Additional funds will be needed to do this.

2. Materials developed by the project should be completed and disseminated as soon aspossible.

3. It may be useful to replicate the project in other areas affected by outbreaks of emergingand re-emerging epidemic diseases.

4. The findings from this review can be used in developing other similar projects.