Border Health Strategy 1—Developing POE-Specific PHERPs and SOPs

The IHR 2005 require designated POE to demonstrate capacity for “appropriate public health emergency response by establishing and maintaining a public health emergency contingency plan” (8). At many POEs, individual agencies often know appropriate procedures to take during a public health event, yet the procedures are not documented or shared. In the absence of an agreed-upon plan, stakeholders risk gaps or redundancies in communication, surveillance, and response efforts, consequently increasing the risk of an uncoordinated and delayed response. Public health response plans and SOPs are beneficial at IHR-designated POE, as well as at smaller, less-resourced POEs.

A POE PHERP with accompanying SOPs is a multiagency coordination plan that describes procedures to prevent the introduction and transmission of suspected communicable diseases through that POE during routine and response operations. Having the SOPs in writing—available, trained on, and exercised—ensures a timely and coordinated response with all involved sectors. In the airport context, public health, civil aviation, airport authorities, safety and security agencies, airlines, medical and ambulance services, police, and other agencies that have a role in implementing the PHERP are all critical participants in developing, finalizing, exercising, and operationalizing the plan.

The International Civil Aviation Organization (ICAO), the UN specialized agency that ensures that member states’ civil aviation operations and regulations conform to global norms, has developed aviation sector guidelines in accordance with IHR 2005, including those for the development of public health emergency contingency plans at airports (15). When developing an airport plan, partners must reconcile ICAO guidance with multiple other global guidance documents as well as other key airport and country planning documents, such as the Aerodrome Emergency Plan, the National Civil Aviation Plan, and the National Public Health Plan. To facilitate the PHERP development process, IBT created a template document, consolidating the WHO Guide for Public Health Emergency Contingency Planning at Designated Points of Entry (16) and the ICAO Template for a National Aviation Public Health Emergency Preparedness Plan (17). IBT also documented the methodology to create a PHERP through a core planning team, and incorporated lessons learned from DGMQ’s experience in developing communicable disease response plans in the United States. Partner countries have also applied the PHERP development process to seaports and ground crossings.

Border Health Strategy 2—Establishing Priorities for Capacity Building at Identified POE and Border Regions

Nations often have insufficient financial and personnel resources to build robust border health capacity at all POEs and along entire international borders. To address these challenges, nations can strengthen border health by allocating resources to select POEs and border areas, prioritized by public health risk of importation or exportation of communicable disease, among other considerations. IBT has developed a low-resource field method to gather information from national, subnational, and local stakeholders and community members to characterize population mobility patterns and strength of proximal and distant intercommunity connectivity. This method consists of key informant and focus group discussion guides that a facilitator uses in conjunction with maps of the relevant geographic areas to guide participants through describing the characteristics of those who move into, through, between, and out of identified areas with population movement and connectivity patterns that may increase the impact of a public health event. Nations can use the information, summarized in reports and on maps, to inform their understanding of areas, including POEs, at disproportionately higher public health risk of importation or exportation of communicable disease based on human movement (18–20).

The WHO IHR 2005 core capacities self-assessment tool enables nations to quantitatively measure current IHR capacities at POEs (21). However, the IHR self-assessment tool was developed to evaluate capacities at designated POEs, often international airports, with established infrastructure and resources, and is not as applicable to lower-resource POEs, such as many ground crossings, especially those that are far from urban centers. Further, although the IHR self-assessment tool reserves space to record comments for each question, tool implementation and results analysis focus on the quantitative results. In 2015, IBT developed the Border Health Capacity Discussion Guide (BHCDG) and piloted it in 5 West Africa countries (22). The BHCDG complements the IHR self-assessment tool by gathering qualitative information from national, subnational, and border area stakeholders on border health capacities, where infrastructure may not be robust. Nations can use the BHCDG alone or with the IHR self-assessment tool to better understand current capacities and develop an action plan to strengthen gaps in detection, notification, and referral procedures. Specifically, the guide facilitates the collection of qualitative information on the following:

• Communication capacity: communication systems, including identified points of contact for ground crossings, to report and receive notifications of public health events and communication efforts to inform travelers and neighboring communities on public health events or interventions

• Information and data systems: border characteristics, including additional, proximal, unofficial ground crossings, traveler volume, purpose of travel; surveillance systems that incorporate health assessments and responses to public health events at ground crossings; and plans and procedures for public health data sharing with cross-border and regional counterparts about events, such as outbreaks and case investigations

• Response and referral systems: public health and medical services available at and/or near ground crossings and coordination with referral health facilities and response plans and training describing how to prepare for, and respond to, public health events at ground crossings.

Border Health Strategy 3—Timely Cross-Border and Regional Public Health Collaboration

Effective and timely national health surveillance, coupled with communication and coordination with neighboring and regional countries, supports achieving the IHR principle to protect “all people of the world from the international spread of disease” (IHR 2005 Article 3.3 [8]). Through border health strategies 1 and 2, nations build public health capacities at designated and prioritized POEs and border areas to better detect and notify public health events among most international travelers. However, persons travel across porous borders outside a POE or may pass through a POE undetected by health screening measures for several reasons, including being asymptomatic while traveling. Border health strategy 3 addresses the development of cross-border relationships that support prompt communication and coordination between neighboring and regional countries to report and respond to communicable disease events with elevated risk of cross-border transmission.

Nations should incorporate all POE, regardless of infrastructure, into their national health surveillance systems as additional peripheral reporting units expected to follow standard, site-appropriate detecting and reporting practices (23). For example, after detecting an ill traveler, a POE official could record event information on a standardized surveillance report form and submit that form to the POE’s referral facility or surveillance unit. Where POEs are not staffed, and along borders without identified POEs, nations can provide communities with additional education to empower them to report potential priority communicable diseases following standard procedures.

To support binational and multinational public health collaboration and coordination, nations can develop and disseminate clear national- and local-level plans that, among other objectives, define when and what public health event information to share across a border, and how to maintain coordination with cross-border counterparts. Some of these collaborations exist informally, but without formalized documentation they may not be clearly defined, may be challenging to supervise, and may not reflect the most current policies and priorities. In addition to documenting domestic plans at the national and local levels, nations can work with neighbors to create integrated cross-border communication and response plans. Real-time data sharing and coordination across borders benefit from maintenance of multinational plans and procedures, along with routine communication to ensure that the plans reflect current priorities.

Border Health Strategy 1

Figure

Figure. Points of entry within Nigeria, Benin, and Togo targeted for comprehensive border health capacity building through development of public health emergency response plans. Insets show location of enlarged area in West...

Port Health Services of the Federal Ministry of Health in Nigeria, with implementation support from Pro-Health International (PHI) and technical guidance from IBT, began developing, operationalizing, and training staff on PHERPs at 2 international airports: Murtala Muhammed International Airport in Lagos, the 5th busiest airport in Africa, and Nnamdi Azikiwe International Airport in Abuja, the 13th busiest (Figure) (23). To develop these plans, Port Health Services, Federal Ministry of Health, airport authority, civil aviation, airlines, immigration, customs, and security partners actively participated in a series of PHERP and SOP development workshops facilitated by IBT and PHI.

During the introductory PHERP workshops, participants established multiagency core planning teams composed of 8 to 10 persons nominated based on their experience, knowledge, and ability to represent their agencies during the planning process. PHI and Port Health Services, with technical guidance from IBT, facilitated a series of core planning team meetings for Murtala Muhammed International Airport, resulting in a complete PHERP after 10 months. The approved plan now serves as one of the first IHR 2005–compliant PHERPs in West Africa.

The Nnamdi Azikiwe International Airport core planning team, established in March 2016, also finished its PHERP after 11 months of planning. In addition, the core planning team, IBT, and PHI are initiating a new training curriculum and exercise schedule. This training and exercise series is informed by best practices from US CDC quarantine stations and designed to enable responders to execute the PHERP. These tools and workshops can be adapted for use at other types of POE, such as seaports or ground crossings.

Border Health Strategy 2

In 2016, Togo and Benin, with implementation support from the Abidjan Lagos Corridor Organization (ALCO) and technical guidance from IBT, used IBT field methods to better understand population movement patterns and connectivity related to economic opportunities, healthcare seeking, and cultural festivals, among other factors, with a geographic focus along the international coastal highway—critical because of the high international traveler volume. These countries are working collaboratively, along with IBT and ALCO, to interpret and map the information about crucial points of interest and linguistic, tribal, and other factors associated with the populations that congregate or travel to or through these points. In addition, the countries are using the information to improve national and cross-border surveillance plans including, for example, strengthening preparedness for movement associated with annual celebrations attracting regional visitors. Further, Togo, Benin, and Nigeria are analyzing population mobility and retrospective cholera surveillance data to inform coordinated preparedness and response plans. The countries used this approach to strengthen cross-border coordination during a multinational Lassa fever outbreak in early 2017.

The Benin and Togo ministries of health used the BHCDG following its adoption, in consultation with WHO, ALCO, and IBT, at nationally prioritized ground crossings along the corridor (Kodjoviakopé and Sanvee Condji in Togo and Hillacondji and Kraké in Benin) and a binationally prioritized ground crossing on their shared border (Tohoun and Aplahoue) (Figure). The BHCDG findings gathered from local officials at the POE revealed details about a consistent lack of plans and procedures for responding to public health events, few or no formal mechanisms for collaboration or communication with the neighboring country during a health crisis, and lack of transport and referral mechanisms in place for ill travelers identified at the border. The ministries of health, with technical support from IBT, are implementing an action plan to address the identified areas for improvement using the BHCDG results.

In Nigeria, PHI facilitated BHCDG discussions with personnel at the Semé and Idiroko ground crossings with Benin, the busiest ground crossing in Nigeria. PHI, in collaboration with WHO and the Federal Ministry of Health, adapted the BHCDG to focus on border health human resources, the surveillance system, and binational and regional data sharing—areas not covered in depth by the IHR 2005 self-assessment tool. These discussions occurred 2 weeks after a baseline IHR self-assessment conducted by WHO and national authorities. PHI presented results from the BHCDG discussions to the IHR competent authority and the WHO, who are developing a POE-specific action plan to address gaps identified through the IHR self-assessment and BHCDG activity.

Border Health Strategy 3

Nigeria’s surveillance system has identified border communities as key components and provides them with tailored training on how to detect and report public health event information. This training, implemented by PHI and the Nigeria Centre for Disease Control, led to improved relationships and communication between border area personnel, health facilities, Local Government Area (Nigeria’s district-level administrative unit) surveillance and Port Health officials, and the national level.

The International Border Team and ALCO, with cosponsoring from the US Agency for International Development (USAID) Benin, facilitated 2 multinational meetings among Nigeria, Benin, Togo, Ghana, and Cote d’Ivoire (which participated in the second meeting only), to formalize cross-border and regional public health data sharing and coordination strategies. Participants included IHR 2005 national focal points, ministry of health legal representatives, national and local public health surveillance leads, national immigration representatives, local port health and quarantine representatives, national and local agricultural and animal health representatives, and the Field Epidemiology Training Program Benin resident advisor. Products from these successful meetings include a draft memorandum of understanding and 7 supporting SOPs and annexes covering the following topics: priority diseases for real-time cross-border reporting; minimum reporting requirements for a cross-border report of a communicable disease; national activities to support cross-border coordination across public health response activation phases; determination of whether a public health event meets criteria for a cross-border report of a communicable disease; determination of whether a public health event meets criteria for responding to a cross-border report of a communicable disease; communication structure for reporting a cross-border event; and communication structure for responding to a cross-border report of a public health event.

In addition to signing the final documents, follow-up steps include consolidating and disseminating cross-border contact information for public health officials working in border districts. Participants noted that they will use the final compendium of jointly produced documents as a training manual for officials working along the borders.