Key lessons learnt from COVID-19 intra-action reviews in the Republic of Moldova, Montenegro, Kosovo and North Macedonia 2020-2021: a qualitative study.

OBJECTIVES: Our study described how the WHO intra-action review (IAR) methodology was operationalised and customised in three Western Balkan countries and territories and the Republic of Moldova and analysed the common key findings to inform analyses of the lessons learnt from the pandemic response. DESIGN: We extracted data from the respective IAR reports and performed a qualitative thematic content analysis to identify common (between countries and territories) and cross-cutting (across the response pillars) themes on best practices, challenges and priority actions. The analysis involved three stages, namely: extraction of data, initial identification of emerging themes and review and definition of the themes. SETTING: IARs were conducted in the Republic of Moldova, Montenegro, Kosovo and the Republic of North Macedonia between December 2020 and November 2021. The IARs were conducted at different time points relative to the respective pandemic trajectories (14-day incidence rate ranging from 23 to 495 per 100 000). RESULTS: Case management was reviewed in all the IARs, while the infection prevention and control, surveillance and country-level coordination pillars were reviewed in three countries. The thematic content analysis identified four common and cross-cutting best practices, seven challenges and six priority recommendations. Recommendations included investing in sustainable human resources and technical capacities developed during the pandemic, providing continuous capacity-building and training (with regular simulation exercises), updating legislation, improving communication between healthcare providers at all levels of healthcare and enhancing digitalisation of health information systems. CONCLUSIONS: The IARs provided an opportunity for continuous collective reflection and learning with multisectoral engagement. They also offered an opportunity to review public health emergency preparedness and response functions in general, thereby contributing to generic health systems strengthening and resilience beyond COVID-19. However, success in strengthening the response and preparedness requires leadership and resource allocation, prioritisation and commitment by the countries and territories themselves.

Assessment of COVID-19 pandemic responses in African countries: thematic synthesis of WHO intra-action review reports.

OBJECTIVES: We conducted a review of intra-action review (IAR) reports of the national response to the COVID-19 pandemic in Africa. We highlight best practices and challenges and offer perspectives for the future. DESIGN: A thematic analysis across 10 preparedness and response domains, namely, governance, leadership, and coordination; planning and monitoring; risk communication and community engagement; surveillance, rapid response, and case investigation; infection prevention and control; case management; screening and monitoring at points of entry; national laboratory system; logistics and supply chain management; and maintaining essential health services during the COVID-19 pandemic. SETTING: All countries in the WHO African Region were eligible for inclusion in the study. National IAR reports submitted by March 2021 were analysed. RESULTS: We retrieved IAR reports from 18 African countries. The COVID-19 pandemic response in African countries has relied on many existing response systems such as laboratory systems, surveillance systems for previous outbreaks of highly infectious diseases and a logistics management information system. These best practices were backed by strong political will. The key challenges included low public confidence in governments, inadequate adherence to infection prevention and control measures, shortages of personal protective equipment, inadequate laboratory capacity, inadequate contact tracing, poor supply chain and logistics management systems, and lack of training of key personnel at national and subnational levels. CONCLUSION: These findings suggest that African countries' response to the COVID-19 pandemic was prompt and may have contributed to the lower cases and deaths in the region compared with countries in other regions. The IARs demonstrate that many technical areas still require immediate improvement to guide decisions in subsequent waves or future outbreaks.

Lessons Learned From a Large Cross-Border Field Simulation Exercise to Strengthen Emergency Preparedness in East Africa, 2019.

Field simulation exercises (FSXs) require substantial time, resources, and organizational experience to plan and implement and are less commonly undertaken than drills or tabletop exercises. Despite this, FSXs provide an opportunity to test the full scope of operational capacities, including coordination across sectors. From June 11 to 14, 2019, the East African Community Secretariat conducted a cross-border FSX at the Namanga One Stop Border Post between the Republic of Kenya and the United Republic of Tanzania. The World Health Organization Department of Health Security Preparedness was the technical lead responsible for developing and coordinating the exercise. The purpose of the FSX was to assess and further enhance multisectoral outbreak preparedness and response in the East Africa Region, using a One Health approach. Participants included staff from the transport, police and customs, public health, animal health, and food inspection sectors. This was the first FSX of this scale, magnitude, and complexity to be conducted in East Africa for the purpose of strengthening emergency preparedness capacities. The FSX provided an opportunity for individual learning and national capacity strengthening in emergency management and response coordination. In this article, we describe lessons learned and propose recommendations relevant to FSX design, management, and organization to inform future field exercises.

Simulation exercises and after action reviews - analysis of outputs during 2016-2019 to strengthen global health emergency preparedness and response.

BACKGROUND: Under the International Health Regulations (2005) [IHR (2005)] Monitoring and Evaluation Framework, after action reviews (AAR) and simulation exercises (SimEx) are two critical components which measure the functionality of a country's health emergency preparedness and response under a "real-life" event or simulated situation. The objective of this study was to describe the AAR and SimEx supported by the World Health Organization (WHO) globally in 2016-2019. METHODS: In 2016-2019, WHO supported 63 AAR and 117 SimEx, of which 42 (66.7%) AAR reports and 56 (47.9%) SimEx reports were available. We extracted key information from these reports and created two central databases for AAR and SimEx, respectively. We conducted descriptive analysis and linked the findings according to the 13 IHR (2005) core capacities. RESULTS: Among the 42 AAR and 56 SimEx available reports, AAR and SimEx were most commonly conducted in the WHO African Region (AAR: n = 32, 76.2%; SimEx: n = 32, 52.5%). The most common public health events reviewed or tested in AAR and SimEx, respectively, were epidemics and pandemics (AAR: n = 38, 90.5%; SimEx: n = 46, 82.1%). For AAR, 10 (76.9%) of the 13 IHR core capacities were reviewed at least once, with no AAR conducted for food safety, chemical events, and radiation emergencies, among the reports available. For SimEx, all 13 (100.0%) IHR capacities were tested at least once. For AAR, the most commonly reviewed IHR core capacities were health services provision (n = 41, 97.6%), risk communication (n = 39, 92.9%), national health emergency framework (n = 39, 92.9%), surveillance (n = 37, 88.1%) and laboratory (n = 35, 83.3%). For SimEx, the most commonly tested IHR core capacity were national health emergency framework (n = 56, 91.1%), followed by risk communication (n = 48, 85.7%), IHR coordination and national IHR focal point functions (n = 45, 80.4%), surveillance (n = 31, 55.4%), and health service provision (n = 29, 51.8%). For AAR, the median timeframe between the end of the event and AAR was 125 days (range = 25-399 days). CONCLUSIONS: WHO has recently published guidance for the planning, execution, and follow-up of AAR and SimEx. Through the guidance and the simplified reporting format provided, we hope to see more countries conduct AAR and SimEx and standardization in their methodology, practice, reporting and follow-up.

Getting the most from after action reviews to improve global health security.

BACKGROUND: After Action Reviews (AARs) provide a means to observe how well preparedness systems perform in real world conditions and can help to identify - and address - gaps in national and global public health emergency preparedness (PHEP) systems. WHO has recently published guidance for voluntary AARs. This analysis builds on this guidance by reviewing evidence on the effectiveness of AARs as tools for system improvement and by summarizing some key lessons about ensuring that AARs result in meaningful learning from experience. RESULTS: Empirical evidence from a variety of fields suggests that AARs hold considerable promise as tools of system improvement for PHEP. Our review of the literature and practical experience demonstrates that AARs are most likely to result in meaningful learning if they focus on incidents that are selected for their learning value, involve an appropriately broad range of perspectives, are conducted with appropriate time for reflection, employ systems frameworks and rigorous tools such as facilitated lookbacks and root cause analysis, and strike a balance between attention to incident specifics vs. generalizable capacities and capabilities. CONCLUSIONS: Employing these practices requires a PHEP system that facilitates the preparation of insightful AARs, and more generally rewards learning. The barriers to AARs fall into two categories: concerns about the cultural sensitivity and context, liability, the political response, and national security; and constraints on staff time and the lack of experience and the requisite analytical skills. Ensuring that AARs fulfill their promise as tools of system improvement will require ongoing investment and a change in mindset. The first step should be to clarify that the goal of AARs is organizational learning, not placing blame or punishing poor performance. Based on experience in other fields, the buy-in of agency and political leadership is critical in this regard. National public health systems also need support in the form of toolkits, guides, and training, as well as research on AAR methods. An AAR registry could support organizational improvement through careful post-event analysis of systems' own events, facilitate identification and sharing of best practices across jurisdictions, and enable cross-case analyses.

Validating Joint External Evaluation reports with the quality of outbreak response in Ethiopia, Nigeria and Madagascar.

To date more than 100 countries have carried out a Joint External Evaluation (JEE) as part of their Global Health Security programme. The JEE is a detailed effort to assess a country's capacity to prevent, detect and respond to population health threats in 19 programmatic areas. To date no attempt has been made to determine the validity of these measures. We compare scores and commentary from the JEE in three countries to the strengths and weaknesses identified in the response to a subsequent large-scale outbreak in each of those countries. Relevant indicators were compared qualitatively, and scored as low, medium or in a high level of agreement between the JEE and the outbreak review in each of these three countries. Three reviewers independently reviewed each of the three countries. A high level of correspondence existed between score and text in the JEE and strengths and weaknesses identified in the review of an outbreak. In general, countries responded somewhat better than JEE scores indicated, but this appears to be due in part to JEE-related identification of weaknesses in that area. The improved response in large measure was due to more rapid requests for international assistance in these areas. It thus appears that even before systematic improvements are made in public health infrastructure that the JEE process may assist in improving outcomes in response to major outbreaks.

Misconceptions about Ebola seriously affect the prevention efforts: KAP related to Ebola prevention and treatment in Kouroussa Prefecture, Guinea.

INTRODUCTION: Guinea is the third hardest hit country in the region with 2,806 cases and 1,814 deaths as of January 11, 2015 after Sierra Leone and Liberia respectively. This KAP study was conducted in three sub-prefectures of Kouroussa in the Kankan region of Guinea from 15 December 2014 to 15 January 2015. It was conducted with the general objective of examining the knowledge, attitude and practice related to Ebola prevention and care among the public of Kouroussa Prefecture. METHODS: A cross-sectional study design was employed to collect quantitative data to examine knowledge, attitude and practice related to Ebola. Structured questionnaire was administered by trained data collectors who were supervised by doctors and epidemiologists from WHO and Africa Union. Data were collected from 358 individuals (93% response rate) and analyzed in STATA 13 while tables and graphs are used to display results. RESULTS: Over 96% of the respondents have ever heard about Ebola while only 76.2% believed the disease existed in Kouroussa. Avoiding physical contacts including hand shaking and contacts with body fluids, and early treatment of persons sick from Ebola were the two important prevention methods frequently mentioned (96.8% and 93.9%). Only 35.7% of respondents were found to have comprehensive knowledge about Ebola (composite of correctly accepting three methods of prevention (85%) and rejecting misconceptions (55.7%)). CONCLUSION: The high level of knowledge about modes of transmission and prevention methods has not positively affected the level of comprehensive knowledge about Ebola. In contrast, the prevailing high level of misconceptions surrounding Ebola was found to be responsible for a low comprehensive knowledge.