Epidemic Preparedness Response: how ready is the Ekurhuleni health district

(health facilities) to deal with an epidemic?

Group 16

Caitlin Johnstone 782379

Chanel van der Westhuizen 1608435
Alysha Govender 1064322
Christeen Olivier 1614080
Emmanuel Malesela Ndaba 1613224
Ernest Uys 713520
James Warren 1110676
Janisha Thakordas 732943
Kashmira Pillay 1054353
Kenny Mampa 735171
Kgaugelo Magoro 729383
Muhammad Afzal Soobadar 941295
Onthatile Thusi 1123360
Rejoice Katjitae 837595
Travis Chetty 1108487

Supervisor: Dr Leena Thomas

Contents
Abbreviations and acronyms.................................................................................................................4
Introduction...........................................................................................................................................5
Literature Review..................................................................................................................................5
Prevention.........................................................................................................................................5

Detection...........................................................................................................................................6

Response...........................................................................................................................................6

Research Rationale................................................................................................................................7
Research Problem..................................................................................................................................7
Research Question.................................................................................................................................7
Research Hypothesis.............................................................................................................................7
Definition...............................................................................................................................................7
Aims and Objectives..............................................................................................................................8
Study Objectives:...................................................................................................................................8
Research Methods.................................................................................................................................8
Study Design......................................................................................................................................8

Study Site...........................................................................................................................................8

Study Population...............................................................................................................................8

Sampling............................................................................................................................................9

Data Collection Process.....................................................................................................................9

Data Management & Analysis Plans..................................................................................................9

Pilot Study.........................................................................................................................................9

Sources of Bias...................................................................................................................................9

Ethics.....................................................................................................................................................9
Results.................................................................................................................................................11
Discussion............................................................................................................................................16
Prevention.......................................................................................................................................16
Detection.........................................................................................................................................17

Response.........................................................................................................................................19

Limitations...........................................................................................................................................21
Conclusions..........................................................................................................................................21
References...........................................................................................................................................21
Abbreviations and acronyms
AFP Acute flaccid paralysis

DRC Democratic Republic of Congo

EPI Expanded Programme on Immunization 

HCW Health care workers

HIV Human Immunodeficiency Virus

HREC Human Research Ethics Committee

NICD National Institute for Communicable Diseases

NHRD National Health Research Database

NHLS National Health Laboratory Service

NMCs Notifiable medical conditions

TB Tuberculosis

WHO World Health Organisation

Introduction

Despite the social changes since the transition from apartheid to democracy in South Africa, and
current public health interventions, the well-being of many South Africans are still affected by
epidemics (Mayosi & Benatar, 2014). Major outbreaks of infectious diseases can lead to political
instability, social displacement, large fatality rates and financial deprivation. Global and nationwide
HIV and TB pandemics as well as recent emerging communicable diseases outbreaks such as
Measles, Listeriosis and Ebola, amongst others, indicates the importance of epidemic preparedness
(WHO, 2018a). Epidemic preparedness and management is a process of preventing, detecting and
responding to epidemics to minimize health and economic impacts (Fatiregun & Isere, 2017).
Literature Review
Prevention

Prevention is key in the management plan of epidemics as it limits the risk of occurrence. There
are two dominant approaches to prevention. The first is the use of public health initiatives, such as
vaccinations, which limit and control the exposure and spread of pathogens to humans (Uchida et
al., 2018, Daugla et al., 2009). Whilst vaccine coverage is currently available for several diseases,
several factors can affect their compliance and hence effectiveness of the vaccination program
(Jaberi-Douraki & Moghadas, 2014).

The second, for cases where eradication of pathogens isn’t possible, is to reduce opportunity for
emergence by managing environmental and reservoir host existence, including vector control,
improving drinking water, sanitation and hygiene practices (Ooi, Goh & Gubler, 2006; Fewtrell et al.,
2005). Any breakdown in these environmental measures predisposes to the re-emergence of an
opportunistic infection. Implementing environmental measures, health education and basic spread
prevention techniques, at an inter-sectoral level can suppress and potentially halt the transmission
of infections. WHO integrated vector management suggests that the collaboration of multiple
stakeholders beyond the health sector is essential for rigorous application of control measures
within clinics and hospitals to ensure its success (Fitzpatrick, Haines, Bangert, Farlow & Hemingway,
2017). Control measures must be implemented early in an outbreak or during inter-epidemic phases
to prevent advances in transmission. Furthermore, antimicrobial resistant bacteria pose a serious
threat to public health, emerging to be one of the most important causes of nosocomial infections
(Safdar & Maki, 2002). This highlights the importance of evaluating the impact of correct
antimicrobial treatment use (MacDougall & Polk, 2005).
Detection

The WHO identified four aspects to the detection aspect of epidemic preparedness: the
laboratory system, real-time surveillance, reporting and workforce development (WHO, 2018b.). Our
focus in this project is on surveillance and reporting.

Surveillance is the collection, collation, and analysis of data and the dissemination to those who
need to know so that an action can result (Thacker, Choi & Brachman, 1983). The objective of
surveillance systems is to enable timely intervention through rapid epidemic detection. South Africa
has a passive surveillance system administered by the national, provincial and district health system
levels that include notifiable medical conditions (NMCs) for human health. Among African countries,
South Africa’s ability to detect disease outbreaks is advanced (James, 2018).

Reporting of cases is an integral part of detecting a disease outbreak. The standard guidelines for
reporting are highlighted in the National Institute for Communicable Diseases (NICD) guidelines with
relative adequacy. (Government Gazette. (Vol. 630, No. 41330), 2017). Data consistently shows
under-reporting of notifiable medical conditions (NMCs). A study, done in 2006 in Gauteng province
by Weber, Matjila & Harris in 2007, showed under-reporting of all notifiable conditions across all
fields and interventions.

The National Health Laboratory Service (NHLS) in South Africa aids in disease and outbreak
detection through laboratory testing.

Workforce development is crucial for epidemics to be detected and identified correctly. It deals
with developing and maintaining a highly qualified public health workforce with appropriate
technical training.
Response

An effective management response plan is of utmost importance to reduce mortality rates and
reduce healthcare burdens from disease outbreaks. There are control measures in place for
epidemic diseases such as cholera, HIV and influenza. Unfortunately, access to treatment is
prevented by weak healthcare systems in many developing countries (WHO, 2018). The key aspects
of response are coordination of responders, risk communication, health information and health
interventions.

Coordination committees oversee risk assessment to the hospital and community, identification
and implementation of measures that reduce any risks, and identification and allocation of resources
as the need arises (WHO, 2014; WHO, 2018a). This committee should comprise of representatives
from various departments within a district, hospital and its community.

How the public interpret and respond to information of the risks they face is important (Smith,
2006) as this influences trust and perceptions which in turn influences actions to mitigate risk and
consequently prevent spread of disease (WHO, 2018b). This is especially relevant because of the
effect of social media on the spread of information (Roberts, et al., 2017).

Health information is necessary to monitor and measure the impact of interventions and to guide
decision-making throughout the epidemic surveillance of the disease and information on the
interventions adopted.

Health interventions for infectious diseases should be disease specific as it results in better
health outcomes. Technology can be used to gain rapid information in an outbreak (Nic Lochlainn et
al., 2018). Vaccines are important to try and curb the spread of infection (Ohimain, 2016). During the
outbreak response, it is always important to protect the responders and uninfected people while
isolating those that were already infected. Isolation of infected people is one of the most important
interventions and it needs to be done as fast as possible according to Frieden et al. (2014). Clinicians
need to be alert, take an appropriate history including travel, isolate and rest ill clients (Frieden et
al., 2014) so that the spread of an infection does not expand.
Research Rationale
Epidemics have been topical globally as well as locally with South Africa having faced the
world’s largest Listeriosis epidemic (WHO, 2018c) at the start of 2018. Thus, it is important to assess
the health system’s preparedness for an epidemic so that the weaknesses may be addressed.

Research Problem
It is important for the health services to prepare or have protective measure against any disease
outbreak that might result in high mortality over a short period, like Ebola virus. Some countries
around the world have protective strategies on how they will deal with an outbreak in the future. In
South Africa, the Ekurhuleni health district within the Gauteng province must be able to respond
appropriately to epidemics and/or outbreaks.

Research Question
To determine how prepared the health facilities in Ekurhuleni Health District are to identify,
prevent and respond to an outbreak or epidemic.
Research Hypothesis
Epidemic preparedness is limited at a district primary health facility level.

Definitions
Health Facility in this context refers to primary health care clinics in this health district.

Epidemic and outbreak are interchangeable terms referring to an increase, usually sudden, above
the normal or expected number of cases of certain diseases within a certain population or
geographical area (CDC, 2012).

A notifiable medical condition is a disease, usually communicable, which has been identified by the
government as high risk for an epidemic and thus must be reported to the health department.

Aims and Objectives

Our primary aim was to determine how prepared the primary healthcare clinics of the
Ekurhuleni District are to manage an epidemic by assessing the ability of the district to control the
emergence of an infectious disease outbreak. In conjunction with this, our secondary aim was to
identify gaps in epidemic preparedness with the intention of improving the general capacity of
epidemic preparedness within district health facilities.

Study Objectives:
• To assess staff awareness of disease outbreaks and determine staff knowledge regarding
vaccinations as a preventative measure in the Primary Healthcare Clinics of the Ekurhuleni
District.

• To determine staff knowledge regarding detection of notifiable diseases and reporting

procedures of notifiable diseases at district health facility, the understanding of current
surveillance systems for early detection of outbreaks in the Primary Healthcare Clinics of the
Ekurhuleni District.

• To determine staff awareness of the protocol to respond to a disease outbreak, assess the
availability of resources that are required to respond to an outbreak and determine staff
knowledge of the dissemination of health information to the surrounding community.

Research Methods
Study Design

A cross-sectional descriptive survey was carried out from October 2018 to June 2019.
Study Site

Ekurhuleni Metropolitan Municipality was chosen as it was previously identified as an area that
warrants improvement and investigation in epidemic preparedness. The study area was limited to
44 of the 93 health facilities located within Ekurhuleni, South Africa. The 44 clinics were selected
based on poor performance assessed on national core standards regarding public health. Of these
44, 26 clinics were randomly sampled.
Study Population
Health care professionals, specifically nurses and doctors working at the various health facilities
were the focus of the research.

Sampling

Simple Random sampling was used in selecting the clinics within the district. Based on 6 groups
of researchers, 26 of the 44 clinics were surveyed generating an equal work load and sufficient
sample size. Purposive sampling was used to select staff members allowing us to select the
personnel who plays the most important role in epidemic control. Personnel included facility
managers, EPI nurses, infection control nurses and doctors.
Data Collection Process

Participants were presented with a background information sheet and consent to participate in
the study was ascertained before beginning the interview. Data was collected by means of interview
guided questionnaires determining the prevention, detection and response preparedness
individually; that took approximately 20 minutes to complete. An average of 3 interviews were
conducted per clinic, depending on staff availability. 59 questionnaires were done within 26 clinics.
One clinic was not able to be included as the facility manager declined participation on multiple
attempts despite returning with the documentation she said was required and the other was too
busy to spare nurses for interviewing.

Data Management & Analysis Plans

We entered quantitative data into Microsoft Office Excel sheets and coded the responses to
ensure anonymity. The presented statistics are descriptive in frequencies and percentages. We
manually aggregated qualitative data and performed non-thematic analysis.
Pilot Study

The questionnaires were piloted at 7 different clinics. The questionnaires were found to be
sufficient, and hence was not re-evaluated. The results of the 7 clinics were therefore also included
within the final results from total clinics.

Sources of Bias

There is potential for bias in this study since the assessment requires the discretion of the
interviewer (interview bias). There may also be inconsistency in the results amongst the 15
interviewers. To address this, we had a thorough group briefing on the questionnaires and
techniques for interviewing and recording the answers on the questionnaires. There may also be
recall bias in which the staff are unable to recall information pertinent to the questionnaire.

Ethics
Informed consent was obtained from all participants through voluntary participation.
Confidentiality of participants was maintained by coding all personal information. There was no
direct benefits or harms to participants who participated in the study.

Research approval from the district, Wits HREC and the NHRD was given.
Results
The data obtained is stratified into data pertaining to clinics and data pertaining to healthcare
workers at these clinics.

Prevention

Preventi oN: VACCINATON PROTOCOL

Yes No
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
EPI vaccination Catch up Monthly Local Availability of
plan vaccination vaccine epidemics and routine
plan coverage antibiotic vaccines
record resistance
records

Figure 1: Graph showing vaccination strategies

 Preventi on: STAFF AWARENESS OF
OUTBREAKS
Yes No
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Aquainted with Aquainted with
local epidemic national
outbreaks epidemic
outbreaks

Figure 2: Staff’s awareness of disease outbreak in all clinics

Objective 1 were evaluated by questions with regards to staff awareness of disease outbreaks, as
well as assessing if an appropriate functioning vaccination plan as a preventative measure exist.

All 26 clinics reported having an EPI vaccination program, a catch-up program and a record system
for the vaccinations. 18 (69%) clinics reported having records of local epidemics and cases of
antibiotic resistance. 17 (65%) clinics reported having access to routine vaccines. 36 (61%) of
healthcare workers were aware of recent local epidemics while 47 (79%) of healthcare workers were
aware of national epidemic outbreaks.

Detection
 DETECTION: PROTOCOL REPORTS
Yes No
100%
80%
60%
40%
20%
0%

Figure 3: Graph showing the protocol documentation on medical conditions

Detecti o n : KNOWLEDGE MANAGEMENT

Yes No
100%
80%
60%
40%
20%
0%

Figure 4: Graph showing staff knowledge of medical conditions

 Objective 2 included questions directed at staff knowledge regarding detection and reporting
procedures of notifiable diseases at district health facility, in addition to current surveillance systems
for early detection of outbreaks

All (100%) clinics investigated had a protocol regarding notifiable medical condition. In addition to
this, all (100%) of clinics investigated had access to notification forms. Of the 26 clinics investigated,
25 (96.1%) clinics kept record of notifiable medical conditions and 23 (88.5%) clinics kept record of
priority conditions. The study also found that 22 (84.6%) of 26 clinics had regular clinical meetings
and case discussions. Regarding the outcomes of assessment of healthcare workers, 57 (96.6%) of 59
healthcare workers assessed were acquainted with notifiable medical conditions and 57 (96.6%)
were acquainted with the signs and symptoms of notifiable medical conditions.
Response

Response: OUTBREAK RESPONSE

PROTOCOL
Yes No Some
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Exsistand Resources
available available to
outbreak deal with an
response outbreak
protocol

Figure 5: Graph showing responses to outbreak and resources needed thereof

 Response: KNOWLEDGE INFORMATION
MANAGEMENT
100%
Yes No
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Aquainted Aqu
w...

Figure 6: Graph showing outbreak management and dissemination of information

Objective 3 consisted of questions to determine the existence of an outbreak response protocol, in

addition to the availability of resources to deal with adverse events. Furthermore, questions
addressed staff knowledge with the procedure to follow in an event of an outbreak, as well as
knowledge of the dissemination of health information to the surrounding community.

All 26 of the clinics reported they have an existent outbreak response protocol. 4 out of 26 clinics
reported they have the available resources necessary to deal with an outbreak. 12 clinics reported
they have some of the resources available, and 10 clinics reported that they did not have the
resources available. 83% of staff reported they are acquainted with the procedure to follow in the
event of an outbreak, whereas 17% of staff reported they are not acquainted with the procedure.
92% of staff reported they are acquainted with key role players to aid in communicating health
information to community, whereas 8% of staff are not.
Discussion

Prevention

EPI vaccination plans existed in all the clinics (26 out of 26), as well as catch-up plans and a record
thereof. This is a very good indicator as EPI is important for the paediatric population who are
vulnerable to disease, especially in crèches which are areas of relatively high density and likely to
spread disease quickly in the event that an outbreak occurs.

Despite EPI vaccination plans that’s in place, 9 of the 26 clinics reported shortages of vaccines.
Rabies and tetanus vaccines were reported as being out of stock. These are important vaccines to
have in stock as they are used in emergency cases and need to be administered straight after an
incident. The lack of these vaccines in clinics is therefore worrying. While neither of these diseases
are transferable between people and therefore not likely to cause an outbreak, they can still lead to
the rapid loss of life.

Furthermore, the quality of the vaccines was not assessed as this was beyond the means of this
project. So, the vaccines being used could be suboptimal and this is an important factor to consider
with regards to the effectiveness of vaccine dependent prevention as mentioned by Jaberi-Douraki &
Moghadas (2014).

Staff awareness of the importance of vaccines is excellent and all staff displayed a good
knowledge of the vaccination plans that exist at the clinics. The shortages of vaccines that many
clinics experience is beyond the control of the staff at each clinic.

18 clinics reported having records of local epidemics and cases of antibiotic resistance. This is
69% of the clinics investigated and is a worryingly small number especially with regard to the
importance of this information as antimicrobial resistant bacteria is a very real public health risk
(Safdar and Maki, 2002). It would be better if the clinics kept better records of the incidence of
antibiotic resistance in the area.

23 of 59 staff workers knew of no recent (within 5 years) outbreaks in the area. Most healthcare
workers were aware of measles outbreaks in the area. Measles is an important notifiable medical
condition (NMC) and thus it is a good sign that it is well-known, especially since outbreaks are often
recurrent and cyclical; it is good to be able to easily recognise it. Also, because it affects children it is
considered of higher importance, this is possibly why it is so well-known. Other conditions
mentioned were Whooping cough, TB, and Ebola, these conditions were mentioned far more rarely
however.

47 of 59 healthcare workers were aware of global and national outbreaks. Outbreaks mentioned
were Listeria, Malaria, typhoid, cholera, swine flu and Ebola both here and in the DRC. It is important
to note even the massive outbreaks that made headlines (listeria, Ebola, and swine flu) were only
mentioned by a few health care workers.

To address objective 1 of the study we see that this all points to a lack of understanding of the
importance of notifiable medical conditions, since knowledge of recent outbreaks in the area should
put staff nearby on high alert for symptoms and signs of these diseases, and thus improve the
prevention of such outbreaks.

It may also show that healthcare facilities need to have a better system in place which informs
the healthcare workers of current outbreaks in the area and nationally. Informed healthcare workers
are important as they need to be ready and aware of outbreaks to detect them efficiently. Diseases
such swine flu and Ebola spread rapidly and are lethal. Appropriate control is necessary to prevent
dangerous outbreaks.

TB and Malaria are common conditions in South Africa but are also notifiable conditions. They
were mentioned rarely by health care workers. The high burden of disease may have de-sensitized
people to the severity of the diseases and their notifiable status.

Possible solutions could be to have refresher courses on the NMC’s including some indication of
the importance of these conditions. This should be done in a novel way such that it remains
interesting; it should also be kept as simple as possible as this also aids retention of knowledge.
Further, more meetings are clearly required to keep staff up to date about happenings in the area as
well as nationally. It may also be feasible to have posters or lists of NMCs and signs to keep the
knowledge accessible to the staff daily.
Detection

All 26 of the clinics investigated had a protocol in place with regards to notifiable medical
conditions. Having a protocol is important to ensure that notifiable communicable diseases are
detected in communities so that effective response measures may be implemented (National
Institute of Communicable Diseases, 2018).
 Most of the clinics knew to report to the EPI co-ordinator, however there were many variations
with regards to who the first point of contact would be, which could have resulted from a
misinterpretation of the question.

Following that, it was noted that many of the clinics knew to further investigate the patients and
screen close contacts, as well as to conduct outreach programs in the community regarding
prevention of the disease in question. Something that was not reported on as adequately, however,
was the further management of the patient, with only a few saying that they would refer the patient
to a hospital, and even fewer reporting that they would begin immediate treatment.

The uncertainty in further patient management could be due to the broadness of the questions
asked in the study, as most protocols are disease specific. However, it could also be due to
inadequate knowledge of the further management of the conditions with most relying on tertiary
institutions to initiate treatment.

With regards to the notification of the diseases, the systems do appear functional in creating a
response in the community in question, however the initial management of the contact source is not
as clearly described. This could be addressed by ensuring that the individual protocols for each
condition are known and displayed, as the management would vary depending on the condition.

All 26 of the clinics investigated reported having access to notification forms. This is important as
it is how active communicable diseases are captured and reported to higher structures who then
implement measures to address the outbreak (National Institute of Communicable Diseases, 2018).

Most of the clinics further reported keeping records of notifiable conditions. However, 1 out of
the 26 clinics reported not keeping records. This is important, as this is study only included 26 clinics;
if extrapolated it could mean that there are many clinics in the country that do not keep records of
notifiable medical conditions. Keeping records of notifiable conditions is important as it enables
commonly encountered conditions to be detected, and anticipation and response measures to be
created (National Institute of Communicable Diseases, 2018).

Of the 26 clinics, 23 reported keeping records of priority notifiable medical conditions that must
be reported within 24 hours such as measles, meningitis and acute flaccid paralysis. Most clinics that
kept a record of the conditions did it manually using hardcopies and only a few used electronic filing
systems. Most of the clinics that recorded information manually did not record priority conditions
separately. It would have been better to do so since they require more urgent investigations. It is
quite concerning that 3 other clinics did not keep track of the priority conditions. This could possibly
mean that there are more clinics that default in record keeping, hence contributing to under
reporting.

Of the clinics that kept records of the notifiable and priority conditions, most made use of both
hard copies and electronic records. Keeping hard copies is advantageous as a back-up measure in the
event of electronic system failures, however it has the disadvantages of being difficult to store and
retrieve information in large volumes. Electronic records are advantageous in their ability to store
large quantities of information as well as their ease of use in the location of information and transfer
of information between facilities, however they are disadvantaged in that they are subject to proper
functioning of the electronic system. Combined, each method of record keeping covers the other’s
disadvantages and provides a functional system for the record keeping of notifiable medical
conditions.

Of the 26 clinics, 22 reported to have regular meetings to discuss the data on the clinical cases
seen. The rest indicated that they did not have these meetings but there were no follow up
questions to find out the reason why. Extrapolating this data to rest of the district would probably
show that there are even more clinics that do not meet to discuss the cases seen. It is important for
data to be analysed and discussed so that there is better decision making, which would help for
measurement, planning, management and learning purposes (Islam et al., 2018). This would also
help in identifying disease trends, hence detecting outbreaks faster. Furthermore, these meetings
can be beneficial to the healthcare workers, especially those who are still in training. They can help
to reinforce the knowledge in different aspects such as the signs and symptoms of the notifiable
conditions and the protocols to follow.

Of the 59 healthcare workers interviewed 57 were acquainted with the notifiable medical
conditions. However, when looking at the responses of the interviewees the top responses included
diseases such as measles, TB, polio/AFP and malaria. While most these conditions mentioned are
category 1 conditions other category 1 conditions were not mentioned at all such as acute rheumatic
fever, viral haemorrhagic fever or diphtheria to name a few (National Institute of Communicable
Diseases, 2019). This suggests that there may be a gap in the knowledge of what conditions are
notifiable. Despite most the HCWs interviewed knowing what some of the notifiable conditions are,
there were a few who did not know any. This is worrying since our study draws on a sample of the
clinics in one district of one province in the whole country. This could be overcome by
implementation of training of the notifiable conditions to all HCWs in a clinic either when they start
working at the clinic or ideally with refresher courses every year.
 Regarding the knowledge of HCWs that are acquainted with the actual signs and symptoms of the
notifiable medical conditions the listed, 57 of the 59 HCWs interviewed could list the signs and
symptoms. This could imply that these HCWs know the signs and symptoms of all notifiable medical
conditions. However, when analysing their responses, it was found that most HCWs quoted the signs
and symptoms for measles. The most common clinical features quoted includes Coryza, cough and
conjunctivitis. However, when looking at the questionnaire, it asked for signs and symptoms of only
one of the medical conditions they were asked to name. Despite this, two HCWs did not know the
signs and symptoms of the NMCs. This may be addressed by supplying clinics with information
regarding the various NMCs allowing quick detection of NMCs.
Response

Outbreak response protocols being available for staff enables the multidisciplinary teams in
clinics to work together effectively during times of outbreaks, as it specifies the roles for each
member of the team. All the clinics involved in the study reported that there is an outbreak response
protocol available at each clinic.

Resources that were identified as needed commonly are vaccines and medication, medical
equipment like syringes and cotton wool as well as human resources, specifically health promoters,
outreach staff, school nurses and professional nurses. Also, mentioned, but less emphasized, was
personal protective equipment, transport or mobile clinics and media support.

Storage conditions of vaccines were also mentioned, but undervalued, since ensuring cold chain
transport and handling of vaccines is essential to maintaining its quality.

Gaps that were identified regarding resources are their availability, or lack thereof. Reasons for
this weren’t identified, and require further investigation as well as solutions. Possible reasons could
include limited availability nationwide or decreased supply to specific regions. Specific resource
allocation to needy areas during an outbreak can be implemented.

The procedure followed in the event of an outbreak is guided by disease specific protocols. The
guidelines are determined by the National Department of Health and they aim to diagnose, treat and
prevent the spread of notifiable medical conditions. 83% of staff reported that they were aware of
the procedure to follow in the event of an outbreak while 17% reported that they were not
acquainted with the procedure. This however is not a reflection on the accuracy of the knowledge of
the procedure but rather an awareness of key aspects involved. Individual staff knowledge of the
procedure could be further investigated.
 An outline of the procedure as expressed in the regulations relating to the Surveillance and the
Control of Notifiable Medical Conditions emphasises the need for medical examination which
includes the collection of specimens for investigation, administration of prophylaxis or treatment,
implementing isolation procedures and follow up of close contacts (Department of Health, 2017). All
the aspects were mentioned by staff members as a collective; however individual staff members
failed to express each of the key components. Furthermore, there was great variability between
individual staff member’s responses.

To improve the percentage of staff members acquainted with the procedure to follow in the
event of an outbreak, simulated drills may be implemented which model the events of an infectious
disease outbreak and improve staff competence and preparedness (Hsu et al., 2006).

Communication is vital during a disease outbreak. A lack thereof may lead to the public reacting
disproportionately with apprehension, causing an even further disruption (Hsu et al., 2017).

Sampled Ekurhuleni district clinics staff have identified various key role players to communicate
the health information to communities. Appointed individuals include: Health promoters, being the
most common method of communication, Ward Based Outreach Teams, community counsellors and
organizations, professional nurses, ward counsellors, school nurses, schoolteachers, clinic committee
and traditional healers. Targeted areas include: Churches and other community gatherings and local
radio stations.

Not all the sampled clinic staff are aware of the communication channels during the disease
outbreak. 8% of the clinic staffs did not know the communication procedure and the individual
responsible for communication of the information.

Limitations

A study done on the epidemic preparedness is the first of its kind in the Ekurhuleni district.
Consequently, there are numerous limitations which are inherent to this study. The first point is the
ambiguity of the questionnaire used as an assessment tool. Certain questions pertaining to
notifiable diseases were broad, which resulted in individualized responses from interviewees. If the
study had looked at specific clusters of important NMCs this would create a more reliable evaluation
of HCWs understanding of these diseases. This limits the inferences which can be drawn from the
responses to these open-ended questions. Furthermore, when looking at the questionnaire, it
asked for signs and symptoms of only one of the medical conditions they were asked to name. This
limits the actual significance of their response as they would naturally answer what was easiest and
most relevant at the time of questioning.

Similarly, the HCWs understanding of the protocols for specific NMCs was not thoroughly
evaluated in this study. Responses were limited to awareness of these protocols but this cannot infer
understanding. Thus, providing poorly assessed indicators of detection and response.

According to the WHO major aspects of evaluating detection in epidemic preparedness are
laboratory systems, real- time surveillance, reporting and workforce development. In our study, we
only evaluated the two latter points due to time constraints. Holistically, it is important to
understand the time frame in which an outbreak occurs, responses from the ministry of health in
such events and the efficacy of allocated laboratories. Therefore, further research can be conducted
on these aspects.

Furthermore, the WHO endorses a one-health approach which assesses the level of human,
animal and wildlife surveillance (WHO, 2017). This provides a clearer picture of the readiness within
districts since epidemics might stem from more than one source, including zoonosis amongst others.
This study however, was limited to human surveillance.

The financial implications of this study were not evaluated prior to its onset. An in-depth cost
analysis might have suggested the necessity of additional financing. This funding would allow a
higher number of clinics to be studied, increasing the sample size and the reliability of the results.

Conclusions

This cross-sectional descriptive survey has highlighted the strengths and pitfalls of epidemic
preparedness amongst clinics in the Ekurhuleni district. Although structures for epidemic
preparedness exist in the district, as laid out by the National Department of Health, the measures in
place are not uniform across the district and there are likely to be pockets of areas showing
elements of ill-preparedness. Such elements could probably emanate from inefficient workforce
development that may impair detection, while poor provision of resources may deter prompt
response in the event of an epidemic. Comprehensive supplementation and further research aimed
at strengthening all three levels of epidemic preparedness may need to be developed.
Recommendations

References
I’ll sort these out once the rest is finalised.