Pandemic Preparedness Initiatives of ECOWAS Regional Centres for Surveillance and Disease Control (RCSDC) of WAHO
The pandemic preparedness initiatives of the ECOWAS Regional Centres for Surveillance and Disease Control (RCSDC) came in two broad categories namely: regional planning and coordination; and regional capacity strengthening and logistics support.
Regional Planning and Coordination – ECOWAS Intergovernmental Meeting
On the 14 February 2020, an emergency meeting of ECOWAS health ministers was held in Abuja. The overall objective of this high-level meeting was to harmonize regional strategies for preparedness for the prevention, early detection and control of the a potential COVID-19 outbreak within the ECOWAS region. The ministers discussed both regional and country level preparedness in all response pillars with particular emphasis on: enhanced surveillance, case investigation, laboratory testing, contact tracing, risk communication and community engagement, case management, and infection prevention and control. Following engaging deliberations, the health ministers agreed that all response pillars needed both country level and regional support and unanimously resolved specifically to:
- Strengthen coordination, communication, and collaboration among member states in preparedness for COVID-19, particularly in the area of cross-border collaboration;
- Enhance surveillance and enforce safety protocols for COVID-19, particularly at points of entry (air, land and sea);
- Step up risk communication and community engagement to ensure that the public receives accurate, appropriate, and timely information regarding the pandemic;
- Urgently strengthen critical national capacities for diagnosing and managing cases;
- Develop a strategic costed regional preparedness plan based on member states’ priorities, to be funded by governments, with support from partners and the private sector;
- Promote multi-sectoral national efforts using the one-health approach to maximize effectiveness of response;
- Implement robust measures to ensure availability of critical medical supplies, including laboratory supplies, and personal protective equipment in the region; and
- Work closely with the relevant authorities of National Governments and the Chinese Government to protect and monitor the health situation of ECOWAS citizens resident in China.
Regional Capacity Strengthening and Logistics Support
A regional laboratory training workshop was organized on February 27- 28, 2020. It provided hands-on training for biomedical scientists of member states on how to perform RT-PCR detection of SARS-CoV-2. They were also trained on the operationalization of test algorithms, biosafety and biosecurity (BSL-3) practice, and sample referral systems within, and among member states. The ECOWAS RCSDC supported member states in capacity building and logistics for screening and laboratory testing of all persons passing through all points of entries including land borders.
From March 05 to 06, the ECOWAS RCSDC in collaboration with the Africa CDC, organized a simulation exercise on COVID-19 for a total of 50 members of the ECOWAS Regional Rapid Response Team (ERRRT) with representations from all 15 member states. The team reviewed the principles of pandemic response with focus on the epidemiology of COVID-19. Based on the known epidemiology of COVUD-19, the team discussed specific response strategies and revised preparedness and response cycle of the ERRRT’s standard operating procedures (SOPs) for COVID-19 response. Using role play, the team practiced community engagement and the design and dissemination of risk communication messages to the general public, healthcare workers, and vulnerable populations such as women and children. The logistics support from the ECOWAS RCSDC to member states included: pieces of IPC supplies, screening equipment at PoEs, and test kits for SARS-CoV-2.
Overview of National Response Activities
From early January, 2020, ECOWAS member states started acting on recommendations from WAHO and WHO on COVID-19 readiness activities towards preventing and early containment in the event of spread to the region. To ensure early case detection and laboratory confirmation, ECOWAS states stepped up surveillance activities at all points of entries, conducted laboratory readiness assessment, and trained personnel on safe sample collection, management, and testing for SARS-CoV-2. Also, the countries held incident command and coordination meetings, and started risk communication and community engagement. They were also taking steps to address human resource capacity and logistics gaps in all pillars of the COVID-19 response.
Command and Coordination
There were established multisectoral response mechanisms for epidemics coordinated by national public health institutes/divisions/agencies as the case may be in each member state. With the exception of Niger, the remaining 14 (93.3%) of member states had national preparedness and response plans for public health emergencies that could manage respiratory diseases, and these plans were being adapted to include COVID-19. Additionally, four countries namely: Burkina Faso, Ghana, Liberia, and Mali had linked these plans for managing infectious disease to include securing the legal basis for quarantine and restriction of movement. Legislative processes were underway in Ghana to give the president additional powers to institute interventions as may be warranted for the control of the pandemic.
With the exception of Cabo Verde, each of the remaining 14 (93.3%) member states had a Public Health Emergency Operation Centre (EOC) managed by their respective Incident Management Systems (IMS). However, the EOC of The Gambia was not functional due to unavailability of the information, communication technology personnel to operate the installed gadgets.
In the wake of the COVID-19 outbreak, NPHIs of all member states had held planning meetings involving the human, animal, and environmental to create a common understanding of their institutional and collective roles in preparing to respond to a possible COVID-19 outbreak. The political leadership of health ministries of member states had also held multidisciplinary coordination meetings at the national and subnational levels with representations from other ministries and international partners notably US CDC and WHO. Following recommendations from these meetings, governments from some member countries had dedicated funds to support the emergency response preparedness activities. For example, the government of Ghana had approved the Ghana cedi equivalent of 100 million US dollars as an initial financial support for preparedness and response activities. Aside direct financial commitment, governments of other member states had demonstrated a serious national approach to the oncoming crisis as related by some national response focal persons:
"The situation is being monitored at the very highest level of the State ... because government meetings were held on the preparation for COVID-19" (MoH, Burkina Faso).
“We have activated a health crisis management committee. It is within this committee that decisions are made. This committee is chaired by the minister of health. Above this committee, the government has set up an inter-ministerial committee including the ministries of health, foreign affairs, animal resources, and ministry of the living environment. This inter-ministerial committee supervises all the response operations carried out.” (MoH, Benin).
In non-outbreak times, three (3) member states viz. Cabo Verde, Liberia, and Togo had no dedicated financial support for surveillance, preparedness and response to emerging diseases. Gambia had no officially designated quarantine facility and health authorities have advised suspected case to do self-quarantine.
National Laboratory Systems
Of the 15 member states, 13 (86.7%) had the in-country laboratory capacity to test for COVID -19. The remaining two (2) which did not yet have the capacity as of March 06, 2020 were Liberia and Cabo Verde. These two countries had engaged infectious substance certified shippers at key laboratories for shipping the specimens abroad for testing in other member countries – Ghana testing for Liberia, and Senegal testing for Cabo Verde. In the meantime, Liberia and Cabo Verde were preparing their laboratory infrastructure, training laboratory personnel, and procuring essential logistics and supplies to start testing in-country. Some member states had multiple laboratories with the capacity to test. For example, Mali had four (4) of such laboratories viz. Laboratoire Union des Centres de Recherche Collective (UCRC), Laboratoire Institut National de Santé Publique (INSP), Laboratoire Virologie et maladies émergentes, and Laboratoire Centre d'Infectiologie Charles Mérieux (CICM) (laboratoire mobile). Guinée (Conakry) had three (3) viz. Institut National de Sante Publique (INSP), Institut Pasteur de Guinée (IPGui), and Centre de Recherche Médecine, Science, Santé et Société (CEREMES). Ghana had two viz. the Advance Laboratories of Noguchi Memorial Institute for Medical Research (NMIMR), and the Kumasi Centre for Collaborative Research (KCCR) both of which were already testing for cases. All the 13 member states with in-country laboratory capacity had each conducted laboratory readiness assessment for COVID-19 testing. Also, all member states had documented incident action plans in which they outlined plans for boosting surge capacity through training laboratory personnel, case investigators, contact tracers, increasing number of testing centres, and stockpiling critical supplies in anticipation of the spread of outbreak. Ghana had a drone delivery system for critical medical supplies, blood, and blood products across the country and was ready to adapt this system for the rapid transport of COVID-19 samples and other critical supplies should the need arise.
Surveillance and Risk Assessment
For a start, all member states had activated their national and subnational health systems (public and private) to inform healthcare workers (HCWs) and laboratories on prevailing case and contact definitions, and reporting protocols. COVID-19 protocols were already being enforced at airports and sea ports, but not particularly vigorous at land borders as at March 06, 2020. With the exceptions of Burkina Faso, Cabo Verde, and Liberia, the remaining 12 (80%) of member states had pre-existing respiratory disease surveillance systems for influenza-like illnesses (ILI) on which they leveraged to establish their respective COVID-19 surveillance systems. As at March 06 2020, all member states had started trainings for HCWs for various roles in COVID-19 detection, contact tracing, data management, case management, and risk communication and community engagement. With exception of Ghana and Mali, all the remaining 13 (86.7%) member states had already included the private sector HCWs in their COVID-19 trainings. In Ghana and Nigeria, the Surveillance, Outbreak Response Management and Analysis System (SORMAS) which had already been deployed by Helmholtz Centre for Infection Research (HZI) of Germany in collaboration with German Development Co-operation (GIZ) and ECOWAS/RCSDC had been updated with a COVID-19 module and being scaled up to cover at least 400 districts of over 85 million population. The Ghana Health Service and ECOWAS/RCSDC were supporting the scale up of this updated version of SORMAS to enhance real time case-base reporting and outbreak response management and assist with accurate mapping of cases and contacts for efficient deployment of field workers and needed response logistics and supplies.
Readiness of Rapid Response Teams
All 15 member states had functional Public Health Rapid Response Teams (RRTs). Except for Niger and Cabo Verde, the 13 other member states had started training their RRTs on contact tracing and conducted simulation exercises on COVID-19 outbreak response using adopted WHO protocols and tools. Following the trainings, member states developed country-specific tools for COVID-19 case investigation, contact tracing, case management, and risk communication. The RRTs of all member states were multidisciplinary and included: epidemiologists, surveillance officers, public health practitioners, physicians, nurses, paramedics, veterinary doctors, biomedical scientists and technicians, environmental health officers, risk communicators, psychologist, and health administrators.
Risk Communication
The ministries of health of member states were the lead state institutions for risk communication and community engagement on COVID-19. They coordinate communications across ministries and partners, and also across the different levels of subnational health administrations. All member states had trained professionals in risk communication who may be called upon to design and implement risk communication strategies and messages during crisis such as epidemics. Similarly, they all had a coordination mechanism that involved relevant actors in risk communication. The list of partners, their contact details, roles and responsibilities were well spelt out in their respective national incident action plans. These communication response systems were able to quickly detect and respond to rumours, misinformation, myths, and frequently asked questions through monitoring of the various traditional and social media networks, hotlines, and reports of community workers. The most significant gap was the lack of a risk communication and community engagement (RCCE) plan. Only five (33.3%) of the 15 states viz. Benin, Ghana, Liberia, Mali and Togo had RCCE plans. The representatives from other member states expressed the desire to adopt the RCCE plans from these sister states.
Points of Entries (PoEs)
Except Burkina Faso, Niger, and Cabo Verde, the remaining 12 (80%) of the member states had country-specific PoE public health emergency contingency plan, which can be used for potential COVID-19 events. Nonetheless, all member states had oriented and trained staff working at PoEs on the appropriate methods for managing ill passenger(s) detected before boarding, on board conveyances such as planes, boats, and ships and on arrival at PoEs. There were ongoing stockpiling of personal protective equipment (PPEs) at PoEs for screening all travellers. One common anticipated challenge of member states was that there may not be adequate rigor of screening at the diplomatic sections of the airports due to longstanding difficulties in getting politicians and other diplomats to strictly comply with safety protocols.
Except Burkina Faso and Cabo Verde, each of the remaining 13 (86.7%) of the member states had identified appropriate places at their PoEs for rapid health assessment and holding places for suspected COVID-19 cases. All member states had started screenings at airports as at March 01, 2020; and also at seaports of the 12 (80%) member states with these points of entries. With the exception of Carbo Verde, the remaining 14 (93.7%) of the member states had put in place mechanisms for transporting potential COVID-19 infected travellers safely to designated hospitals, including the identification of adequate ambulance services. All member states had some form of ground services for environmental cleaning and disinfection at PoE using a cleaning and disinfection protocol for potential COVID-19 events; but admitted that their systems needed more supervision to ensure satisfactory compliance.
Case Management
Six (40.0%) of the member states viz. Benin, Burkina Faso, Ghana, Ivory Coast, Mali, and Nigeria had medical teams trained on case management of severe acute respiratory infections (SARIs). These states had conducted some refresher orientation and reassessment of the availability and functionality of case management facilities and equipment. In the case of The Gambia, a one day orientation training on case management of severe respiratory infections was planned for 40 general clinicians with support from WHO in the third week of March 2020. The remaining countries had similar plans of training but these were still at early stages of consideration. However, for all member states, there were ongoing country level efforts to make provisions for additional mechanical ventilation, N95 masks, surgical masks, gloves, and coveralls in addition to the pre-existing levels to cater for possible increase in the number of patients that would require intensive care. Eleven (73.3%) of member states have designated health facilities responsible for managing COVID-19 cases; the four exceptions were Burkina Faso, Cabo Verde, Niger, and Togo. None of the 15 member states had life and disability insurance for their frontline health workers at risk of acquiring COVID-19 and its related disability or death; even though Ghana is said to be considering this initiative as a part of a number of motivational packages for frontline workers would be responding to the pandemic. All the 15 member states are at various levels of developing country-specific plan for patient placement and transportation based on patients’ COVID-19 clinical status.
As at March 10, 2020, Sierra Leone had quarantined 94 suspected cases with epidemiological link to China - 67 of whom had completed 14 days monitoring.
Infection Prevention and Control
To minimize cross-infections, all member states had identified isolation facilities in some designated hospitals for the management of COVID-19 patients. Health personnel who will be managing these cases were receiving refresher trainings in the appropriate use of personal protective equipment (PPEs), general best practices of standard precautions, and transmission-based infection prevention and control. Though all member states had protocols for environmental cleaning and disinfection, none of them was confident they had adequate numbers of trained personnel to correctly apply these protocols in events of environmental contamination with SARS-CoV-2. Also, none of the member states had a documented plan for the management of COVID-19 medical waste. Only three countries viz. Guinea, Liberia, and Sierra Leone were confident about the availability of trained safe burial teams with satisfactory community support to perform safe and dignified burials should this become necessary.
Logistics, procurement, supply management
Each of the 15 member states had a logistics & supply management focal person assigned to the COVID-19 response. These focal persons were part of the multidisciplinary national rapid response teams and were able to link with all pillars for supply forecasting. Each member state had a stock management system to ensure continual availability of appropriate logistics and their seamless distribution for COVID-19 response. All member states described their stock levels of COVID-19 supplies as scanty, and their transport and distribution systems as weak and incapable of supporting the demands of a potential pandemic of the scales being witnessed in already affected countries in Asia and Europe.