The World Health Organisation (Who)’s Country Representative, Dr Charles Sagoe-Moses shares insight on the Hepatitis E Virus rapid assessment in this Question and Answer session.
Q: We understand the Who conducted a rapid assessment on HEP E response late last year. What prompted this assessment?
CSM: “Following the declaration of the Hepatitis E Virus (HEV) outbreak in December 2017, the outbreak has since spread to other parts of the country, including Erongo, Omusati, Ohangwena, Oshana, Oshikoto, and Kavango regions and now recently the Omaheke Region. It’s no longer confined to the informal settlements of Havana and Goreagab, it is now almost a national outbreak.
Despite interventions instituted by the government in collaboration with its partners since the declaration of the outbreak, we continue to record new cases weekly in all affected areas. Hence, the need to conduct a rapid assessment of the outbreak response operations to better understand the challenges behind this protracted outbreak, and provide appropriate advice on remedial solutions.
The assessment was carried out as a joint partnership between the Ministry of Health and Social Services and the World Health Organization from 11-31 October 2018. The main objective of the assessment was to establish strengths, weaknesses, and opportunities in the overall response to enable the national and regional health emergency coordination committees to implement appropriate interventions and end the outbreak.”
Q: What are the main findings of the assessment?
CSM: It’s important that in any health emergency, the response is coordinated by a multi-sectoral committee under the leadership of the Ministry of Health and Social Services. This committee for Namibia is the National Health Emergency Coordination Committee which was activated immediately after the government’s declaration of the outbreak. A number of essential sub-committees were formed to address coordination, surveillance and laboratory support, cases management, water, sanitation, and hygiene as well as communication and social mobilization. All these are critical to ensuring a comprehensive response to the outbreak.
The assessment, therefore, reviewed in each region, the overall coordination and whether the sub-committees are established and functioning. Each affected region is expected to activate a similar response coordination mechanism with an action plan and involvement of different stakeholders at regional and district level.
The findings were in accordance with the thematic groups and include:
Under coordination: There is a need to strengthen the coordination committee in each region to represent all stakeholders and to meet frequently. It was found that the committees need support to understand their role in the monitoring and management of the outbreak. In some regions, we witnessed commitment from both the regional and municipal councillors including the governors offices and in other instances, this was lacking. The good news is that almost all regions have a response plan in place, although in some instances this needed to be reviewed for better results. In addition, and partly due to limited capacity at regional and district levels, the sub-committees were not established and responses would rest mainly with the field epidemiologists.
One positive outcome of the assessment was the quality of care for patients with HEP E. It is commendable how the health facilities responded and prioritized these patients. More still need to be done on educating the public on the treatment of HEP E, but overall, this is an area that the ministry has given priority to.
There is a great need for community engagement. In response, Who has provided training to Red Cross Volunteers in Khomas and Omusati regions as well community volunteers in the Erongo Region under the Swakopmund Municipality, to strengthen community engagement and health education and also to complement the work of the health extension workers who have been in the field since the declaration of the outbreak. The support may not be sufficient as there is a need for continuous and sustained health education at the community level and we would like to invite other partners to come on board.
Another issue that required attention was the slow turnaround of laboratory results. Again, in response, a number of partners including Who have provided Rapid Diagnostic Test kits to the National Institute of Pathology to allow for testing at the point of service. This reduces the turnaround of results and the cost of sending the specimen to SA for testing. Who will continue to strengthen this area in collaboration with other partners.
Issues related to access to safe drinking water, sanitation and hygiene remain a challenge across all affected communities. For the most part, communities are getting water from a safe source, however, water gets contaminated at household level through transport from the water point, storage, and usage. There are instances where the source of water is contaminated but this is not in all affected communities and municipalities in at least Windhoek made provision for additional water points, although these were vandalized. Secondly, open defecation remains a challenge, and we are appealing to the municipalities to explore the community total- led sanitation approach where communities build their own sanitation facilities from local resources. It will make a huge difference in reducing active transmission. We also found that the way community wash hands are a great source of infection. These practices include washing hands in one bowl both at households and at shebeens. Communication materials on correct handwashing have been distributed widely in local languages, there have been numerous radio talks in local language stations and the health extension workers and community volunteers include this in their door-to-door campaign. But it is obvious we need to redesign our messages to influence this practice.
Q: You referred to the support by Who and other partners, is there any other support that Who is providing to the government in halting the outbreak?
CSM: Since the outbreak in late 2017, Who has been supporting the government through the Ministry of Health and Social Services; one; set up the coordination mechanism for the response, draft the response plan and provide support to all the thematic areas.
Recently, we brought in two experts for coordination and surveillance and the other for risk communication to strengthen the government’s effort.
Who also committed US$195,000 (approximately over N$2,7 million) to address gaps identified in coordination, risk management, surveillance, and case management interventions. Among the key intervention that Who carried out recently include:
The rapid assessment in seven of the HEV affected regions from 11-31 October 2018. Key gaps have been identified and recommendations proposed. Both the minister of health and the executive director (formerly known as PS) have started implementing these recommendations from February 2019.
Sensitised regional directors and surveillance officers from the border regions along Namibia Angolan border (Omusati, Kunene, Ohangwena, Kavango regions of Namibia; and Cunene Province and Namibe provinces of Angola), in Ondjiva Angola, 24 October 2018.
Supported the Ministry of Health and Social Services to train and deploy community volunteers from Red Cross Society and Swakopmund Municipality for community surveillance, disease prevention, and health promotion activities in Erongo (Swakopmund District), Khomas and Omusati regions.
Strengthened local diagnostic capacity for the national laboratory by providing reagents and supplies for HEV testing - HEV testing is now done locally in Namibia and no longer in South Africa. Rapid diagnostic testing kits have been provided to the ministry of health and are in use and ongoing in some facilities for surveillance purposes.
Supported the training and deployment for surveillance for HEV – detection, investigation, and reporting – including line listing and submission of complete /timely HEV situation reports. Trainees are expected to continue strengthening HEV surveillance in all HEV affected regions from 1 March 2019, after completion of the surveillance training in February 2019.
Who together with the United Nations Population Fund (UNFPA) and the United Nations’ Children Fund (Unicef) supported the Ministry of Health and Social Services in developing social mobilisation activities, airing of health education messages in electronic and print media.
Q: Any final words?
CSM: We would like to reassure the government of our continued support and commitment to halting this outbreak. And would like to commend the new minister of health Dr Kalumbi Shangula on recommitting the government in addressing the outbreak. The appointment of the Special Adviser on Health under the Office of the Vice President is a welcome development and we assure him of our support.