National Anthrax Prevention and Control Strategic Plan 2018 – 2030

1.1. INTRODUCTION 1

1.2. EPIDEMIOLOGY OF ANTHRAX 2

1.2.1. Etiology and Spore Persistence 2

1.2.2. Transmission 2

1.2.3. Clinical presentation 3

1.3. DIAGNOSIS 3

1.3.1. Clinical signs 4

1.3.2. Laboratory diagnosis 4

1.3.3. Differential diagnosis 6

1.4. PRINCIPLES OF ANTHRAX PREVENTION AND CONTROL 6

1.5. ANTHRAX SITUATION IN ETHIOPIA 6

1.5.1. Burden of Anthrax in Ethiopia 6

1.5.2. Availability of Anthrax Vaccine in Ethiopia 7

1.5.3. Anthrax Surveillance System in Humans in Ethiopia 8

1.5.3.1. Epidemiological surveillance 8

1.5.3.2. Laboratory surveillance 9

1.5.3.3. Outbreak investigation and response 10

1.5.4. Anthrax Surveillance System in Livestock in Ethiopia 10

1.5.4.1. Epidemiological surveillance 10

1.5.4.2. Laboratory surveillance 13

1.5.4.3. Outbreak investigation and response 14

1.5.5. Anthrax Surveillance System for Wildlife in Ethiopia 15

1.5.5.1. Epidemiological surveillance 15

1.5.5.2. Outbreak investigation and response 15

1.5.6. Current Anthrax Prevention and Control Activities in Ethiopia 16

1.5.6.1. Core Stakeholders for Anthrax Control in Ethiopia 17

1.5.6.2. Prevention and Control Activities in Humans in Ethiopia 17

1.5.6.3. Prevention and Control Activities in Livestock in Ethiopia 17

1.5.6.4. Prevention and Control Activities in Wildlife in Ethiopia 18

1.5.6.5. Policy, Legal and Institutional Framework supporting prevention and control of Anthrax 18

1.6. CHALLENGES IN ANTHRAX CONTROL IN ETHIOPIA 19

1.6.1. Inadequate Laboratory Capacity and Biosecurity 19

1.6.2. Inadequate Surveillance 19

1.6.3. Lack of Prevalence and Burden Estimates 19

1.6.4. Inadequate Inter-Sectoral Collaboration and Partnerships 19

1.6.5. Lack of Educational and Awareness Materials for Anthrax Prevention 19

1.6.6. Limited Supply and Distribution of Anthrax Vaccine and management of Anthrax vaccines 20

1.6.7. Funding Constraints and Competing Priorities 20

1.6.8. Lack of Integrated national guidelines and standard operating procedures (SOPs) on anthrax prevention and control 20

1.7. OPPORTUNITY FOR ENHANCING ANTHRAX CONTROL AND PREVENTION IN ETHIOPIA 20

1.7.1. Establishment of One Health Coordination Structures 20

1.7.2. Increased Interest in Enhancing Anthrax Control and Prevention 20

1.7.3. In-Country Anthrax Vaccine Production 20 CHAPTER TWO 21 2. THE STRATEGIC FRAMEWORK 21

2.1. GUIDING PRINCIPLES OF THE STRATEGY 21

2.2. VISION 21

2.3. MISSION 21

2.4. GOAL 21

2.5. GENERAL OBJECTIVES 21

2.6. STRATEGIC FRAMEWORK FOR THE PREVENTION AND CONTROL OF ANTHRAX 22

2.7. COMPONENTS OF THE ANTHRAX PREVENTION AND CONTROL STRATEGIC FRAMEWORK 23

2.7.1. Surveillance and Reporting Systems 23

2.7.2. Outbreak investigation and response 24

2.7.3. Prevention and Control of Anthrax 24

2.7.4. Anthrax Diagnostic Laboratory Capacity 25

2.7.5. Information, Education and Communication 26

2.7.6. Multi-Sectoral Collaboration 27 CHAPTER THREE 3. IMPLEMENTATION PLAN 28 3.1.PHASE 1: PLANNING, PREPARATION AND ASSESSMENT PHASE (2 YEARS) (2017-2019)

3.1.1. Specific activities to be completed in the stipulated timeframe 28

3.1.1.1. Surveillance and reporting 28

3.1.1.2. Outbreak investigation and response 29

3.1.1.3. Disease prevention and control 29

3.1.1.4. Anthrax Diagnostic Laboratory Capacity 29

3.1.1.5. Information, Education and Communication 30

3.1.1.6. Multi-Sectoral Collaboration 30

3.2. PHASE 2: IMPLEMENTATION PHASE IN TARGET AREAS (4 YEARS) (2020-2023) 30

3.2.1. Specific activities to be completed in the stipulated timeframe 31

3.2.1.1. Surveillance and reporting 31

3.2.1.2. Outbreak investigation and response 31

3.2.1.3. Disease prevention and control 31

3.2.1.4. Anthrax Diagnostic Laboratory Capacity 32

3.2.1.5. Information, Education and Communication 32

3.2.1.6. Multi-Sectoral Collaboration 33

3.3. PHASE 3: IMPLEMENTATION PHASE IN EXPANDED AREAS (7 YEARS) (2024-2030)

3.3.1. Specific activities to be completed in the stipulated timeframe 33

3.3.1.1. Surveillance and reporting 33

3.3.1.2. Outbreak investigation 33

3.3.1.3. Disease prevention and control 34

3.3.1.4. Anthrax Diagnostic Laboratory Capacity 34

3.3.1.5. Information, Education and Communication 34

3.3.1.6. Multi-Sectoral Collaboration 34

3.4. WORK PLAN FOR IMPLEMENTING PHASES-ONE 35

3.5. Monitoring and Evaluation 45 4. BUDGET SUMMARY 52 5. ANNEXES 54

5.1. Budget Narrative 54 FORWARD The Government of Ethiopia is showing encouraging commitment to the livestock and public health sectors. The Ministry of Health and Ministry of Livestock and Fisheries, has been dedicating emerging disease epidemics including neglected zoonoses, that is diseases that are transmitted burden on human health and livelihood. Anthrax is an immediately reportable disease in Ethiopia. Anthrax outbreaks have been reported from Ethiopia to the World Organization for Animal Health (OIE) every year from 1996 through per year in cattle, sheep, goats, camels and horses. Human cases are also reported, but not always from districts reporting animal cases. Recent work to prioritize zoonotic diseases for inter-sectoral engagement ranked anthrax as one of the top 5 zoonotic diseases of major public health concern in Ethiopia. We therefore need to work together to plan and prepare ourselves to deal with epidemics of all of One Health in prevention, combating and control of zoonotic diseases, the tripartite ministries, Ministry of Livestock and Fisheries, Ministry of Health and Ministry of Culture and Tourism (through the Ethiopian Wildlife Protection Authority), in collaboration with development partners (CDC, FAO, USAID, Ohio State University, WHO and other partners) established a national One Health Platform (OHP) with various technical working groups. This National Strategy for the Prevention and Control of Anthrax, therefore, is drafted by the Ministry of Health (through Ethiopian Public Health Institute (EPHI)), the Ministry of Livestock and Fisheries (through the Veterinary Public Health Directorate, Epidemiology Directorates, Disease Prevention and Control Directorate, National Animal Health Investigation and Diagnostic Center (NAHDIC) and National Veterinary Institute (NVI)), and Ministry of Culture and Tourism (through Ethiopian Wild Life Conservation Authority (EWCA)) and development partners. This strategic document plans to prevent and control anthrax in humans and animals in Ethiopia using a combination of the following strategic areas of focus: Strengthen Surveillance and Reporting system, improving Outbreak Investigation and response, Prevention and Control, strengthen Diagnostic laboratory capacity and Risk Communication. The strategic plans has three phases: PHASE 1: PLANNING, PREPARATION AND ASSESSMENT PHASE (2 YEARS) (2017-2019) PHASE 2: IMPLEMENTATION PHASE IN TARGET AREAS (4 YEARS) (2020-2023) IV PHASE 3: IMPLEMENTATION PHASE IN EXPANDED AREAS (7 YEARS) (2024-2030) control the public health impact of anthrax in humans and animals in Ethiopia through sustained surveillance, laboratory diagnosis, prevention and control systems and community awareness. This strategy will build upon and complement existing communicable disease prevention and control public and animal health systems and enhancing their collaboration in areas of common interest such as surveillance, early detection, diagnosis, rapid response, education and research. _____________________________ _________________________________ Dr Kebede Worku Dr Gebregziabher G/Yohannes State Minister State Minister Federal Ministry of Health (MoH) Ministry of Agriculture and Livestock Resources CONTRIBUTING AUTHORS The following experts are acknowledged for their contribution towards the production of the first edition of the national multi-sectoral anthrax prevention and control strategy in Ethiopia. Dr. Musse Tadesse (Researcher, EPHI) Dr. Mesfin zewdu (Senior Expert, MoLF) Dr. Elias Walelign (National OH focal point and MERS CoV coordinator, FAO-ECTAD) Dr. Antonio Veira (senior expert, US-CDC) Dr. Matios Lakew (Associate Researcher, NAHDIC) Dr. Biniam Tadesse (Associate Researcher, NAHDIC) Mr. Negga Asamene (Researcher, EPHI) Dr. Rediet Belayeneh (Associate Researcher, NAHDIC) Dr. Abebe Wossene (Technical Advisor, USAID) Dr. Assefa Deressa (Researcher, EPHI) Dr. Baye Ashenafi (Researcher, EPHI) Dr. Darsema Gulima (G/Manager, EVA) Dr. Etsegenet Tekeba (Surveillance Expert, MoLF) Dr. Feyessa Regassa (Researcher, EPHI) Dr. Kassahun Amsalu (Disease Prevention and Control Expert, MoLF) Dr. Lealemselam Negga (VPH Expert, MoLF) Dr. Aklilu Tesfaye (VPH Expert, MoLF) Dr. Takele Abayneh (Senior Researcher, NVI) Mr. Temesgen Yadeta (Wildlife and Habitat Expert, EWCA) Mr. Tesfahun Abeye (PHEM officer, EPHI) Dr. Wondessen Bekele (Director of VPH, MoLF) Mr. Behailu Gosheme (Expert, EWCA) Dr. Scott Newman (ECTAD Team Leader – Ethiopia, FAO ECTAD) V Dr. Melissa Kadzik (Public Health Analyst, US-CDC) Dr. Henry Walke (Chief, Bacterial Special Pathogens Branch, US-CDC) Mrs. Susan Mugwe (Monitoring and Evaluation Expert, FAO-African Region) Dr. Abiy Girmay (IHR Officer, WHO) Dr. Jack Mortenson (Technical Expert, USAID) Dr. Getnet Yiemr (Director, GOHI-East Africa) LIST OF ABBREVIATIONS ADNIS Animal Disease Notification and Investigation System CDC Center for Disease Control and Prevention DOVAR Outbreak and Vaccination Report ELISA Enzyme-linked Immuno-sorbent Assay EPHI Ethiopian Public Health Institute EWCA Ethiopian Wild Life Conservation Authority FAO Food and Agriculture Organization of the United Nation HSDP Health Sector Development Plans LIMS Laboratory Information Management MoCT Ministry of Culture and Tourism MOH Ministry of Health MoLF Ministry of Livestock and Fisheries MoU Memorandum of Understanding NAHDIC National Animal Health Diagnostic and Investigation Center NVI National Veterinary Institute OHP One Health Platform OSU Ohio State University PCR Polymerase Chain Reaction PPE Personal Protective Equipment SOP Standard Operating Procedure TAD Trans Boundary Animal Diseases VI TOR Terms of Reference LIST OF TABLES Table 1: Distribution of human anthrax cases by region, 2014 – 2016, Ethiopia 7 Table 2: DOVAR output demonstrating cases and deaths of anthrax for 2012-2016 12 Table 3: Cases and Deaths of anthrax in animals from 2007 to 2009 13 Table 4: Record of the wild animals affected by the anthrax outbreak at Mago national park 16 Table 5: National anthrax prevention and control strategic plan (two year work plan) 35 Table 6: Ethiopia - anthrax performance monitoring plan (Phase-one) 45 Table 7: Budget Summary by components of the Anthrax Prevention and Control Strategic Framework (2018-2030)) 52 VII LIST OF FIGURES Figure 1: Diagnostic tests and findings for B. anthracis 5 Figure 2: Flow of information and Timeline for immediately Reportable Diseases 9 Figure 3. Map of reporting and non-reporting woredas in 2016 (DOVAR) 11 Figure 4. Animal Disease Notification and Investigation System (ADNIS) pilot areas 11 VIII ACKNOWLEDGEMENT The national Strategy for the prevention and control of anthrax in animals and humans has been prepared by the anthrax Working Group (TWG) composed of participants from Ministry of Health (MoH/EPHI), Ministry of Livestock and Fishery (MoLF/NAHDIC/NVI), Ministry of Culture and Truism (MoCT/EWCA), Center for Disease Prevention and Control (US-CDC/Ethiopia), Food and Agriculture Organization (FAO-ECTAD), Global One Health Initiative (GOHI), USAID and World Health Organization (WHO). The preparation of the national Strategy has benefited from the assistance and support of many experts and representatives, including the following: 1. The participants in an Anthrax Stakeholders workshop “Anthrax surveillance, prevention and control in Ethiopia” in March 2-3, 2017 at the Ethiopian Public Health Institute in Addis Ababa, that was organized by US Centers for Disease Control and Prevention (CDC) in collaboration with EPHI. 2. The participants in Stakeholders Meeting aiming at establishment of anthrax Technical Working Group (ATWG) and development of TOR, in April 14, 2017 at Food and Agriculture Organization country office (FAO) in Addis Ababa, that was organized by US-CDC, FAO-ECTAD in collaboration with MoLF. 3. The participants in Anthrax strategic plan write-shop, in July 24-27, 2017 at Asham Africa Resort in Bishoftu town, Ethiopia; that was organized by FAO-ECTAD in collaboration with Ethiopian Public Health Institute (EPHI). 4. The participants in Anthrax strategic plan Monitoring and Evaluation write-shop, in September 18-21, 2017 at Asham Africa Resort in Bishoftu town, Ethiopia; that was organized by FAO-ECTAD in collaboration with Ethiopian Public Health Institute (EPHI). 5. The participants in Anthrax strategic plan coasting exercise write-shop, in January 3-5, 2018 at Asham Africa Resort in Bishoftu town, Ethiopia; that was organized by FAO-ECTAD and Global One Health Initiative (GOHI) in collaboration with Ethiopian Public Health Institute (EPHI) and Ministry of Livestock and Fishery (MoLF). 6. E-conferences organized by CDC and FAO-ECTAD for the participants of ATWG. The Ministry of Health under Ethiopian Public Health Institute (EPHI), the Ministry of Livestock and Fishery, the Ministry of Culture and Tourism wish to thank all experts and partners contributed to the successful completion of the strategic plan for the prevention IX and control of anthrax in Ethiopia. 1 CHAPTER INTRODUCTION 12

1.1. INTRODUCTION Anthrax is a zoonotic bacterial disease of Health has been dedicating considerable caused by Bacillus anthracis. It primarily resources to the response to Public Health occurs in herbivorous wildlife and livestock, Emergencies: from epidemics of diseases in which it is usually fatal. Anthrax causes to widespread malnutrition resulting from four main clinical forms of disease in humans: drought. cutaneous, gastrointestinal, inhalation and injection anthrax. Humans contract Cognizant of the importance of One Health cutaneous anthrax through direct skin in prevention, combating and control of contact with B. anthracis infected animals or zoonotic diseases, the tripartite ministries, during slaughtering animals or processing Ministry of Livestock and Fisheries, Ministry animal by-products. Gastrointestinal of Health and Ministry of Culture and Tourism anthrax results from consumption of raw (through the Ethiopian Wildlife Protection or undercooked meat contaminated with Authority), in collaboration with UN agencies B. anthracis. Humans develop inhalation (WHO and FAO) and development partners anthrax through inhalation of spores (CDC, USAID, Ohio State University and aerosolized during processing or contact other partners) established a national One with contaminated hides, bones, hair or Health Platform (OHP) with various technical wool. Of these forms, cutaneous anthrax working groups. Since the national OHP was comprises >95% of the human infections. established, various activities have been undertaken. One of the tasks was developing Anthrax affects many domestic and wild a list of priority zoonotic diseases as an entry animals and humans. The susceptibility for a multi-sectoral joint action to reduce of different animal species to anthrax and combat the impact of zoonotic diseases varies considerably. Most warm-blooded on public and animal health as well as on vertebrate species (including reptiles and the national economy. The national zoonotic amphibians that have been artificially disease prioritization was conducted using warmed) have been infected, naturally or a tool developed by CDC and resulted in 5 experimentally. The disease is enzootic in priority zoonotic diseases for inter sectoral several regions of the world and B. anthracis collaboration of which Rabies and Anthrax has always been high on the list of potential are the two top priorities. agents with respect to biological warfare and bioterrorism. Following the development of the list of priority zoonotic diseases, the three The Government of Ethiopia is showing ministries, in collaboration with partners encouraging commitment to the public planned to formulate strategies for the health, livestock and wildlife sectors. A new control and elimination of dog-mediated ministry dedicated to livestock, Ministry of Livestock and Fisheries, has been established, Rabies and for the prevention and control of Anthrax through a One Health approach. 1 as part of a reform in the sector Investments This National Strategy for the Prevention in public and animal health, production, and Control of Anthrax, therefore, is drafted infrastructure, and facility development are by the Ministry of Livestock and Fisheries, improving throughout the country. It is clear the Ministry of Health (through EPHI) and that the livestock industry will continue to Ministry of Culture and Tourism (through be a focus of the government at all levels. EWCA) and development partners. Furthermore, Ethiopia has implemented successive Health Sector Development Plans (HSDP) since 2004, in four phases. During this period the country has made huge stride in improving access to health service and improvement in health outcomes. Ministry

1.2. EPIDEMIOLOGY OF neck, arm, or hands or wherever the spores ANTHRAX came into contact with the skin • Incubation period: up to 17 days, but most

1.2.1. Etiology and Spore Per- disease occurs in 1 to 7 days sistence • Exposure: butchering an animal that died Anthrax is caused by Bacillus anthracis, a gram- of anthrax or contact with contaminated positive, rod-shaped bacterium. B. anthracis animal products such as meat, hide, blood, produces a toxic complex comprising three or hair factors: oedema factor, protective antigen and lethal factor. Together, these factors • Scratches or cuts on skin may increase risk kill phagocytes, damage capillary walls and • Hand washing may decrease risk interfere with blood clotting, leading to oedema, shock and death. Protective antigen Inhalation anthrax provides the mechanism for lethal factor to • Initially- fever, chills, and fatigue may be enter cells. Once outside the host and exposed accompanied by cough; slightly later- to air, B. anthracis starts sporulation. Spores chest discomfort, headache, and nausea/ are extremely resistant to heat, cold, pH, vomiting occur; finally- shortness of breath desiccation, chemicals, irradiation and other and confusion adverse conditions, and can survive for years in soil, wool, and hair of infected animals. • Incubation period: up to 60 days, but most disease occurs in 1 to 7 days

1.2.2. Transmission • Exposure: working with spore- Bacillus anthracis can be found naturally in contaminated hides in an industrial setting soil and commonly affects domestic and wild or bioterrorism animals around the world. The animals can become infected when they ingest spores from Gastrointestinal anthrax contaminated soil, plants, or water. Spores form when bacilli in blood or bodily fluids from • Development of fever/chills, fatigue, carcasses are exposed to air, or when carcasses nausea/vomiting, and abdominal pain are opened by scavengers. The spores begin are common; diarrhea, headache, and to form soon after death, and the process confusion occur in about a quarter of of sporulation is complete within 24 to 48 patients; swelling of neck, sore throat, or hours. These spores are very hardy and they painful swallowing suggest pharyngeal contaminate the soil, where they can survive for disease many years, before being ingested by animals • Incubation period: up to 16 days, but most and re-starting the cycle. Vegetative cells within disease occurs in 1 to 7 days 2 an intact carcass will be outcompeted by other bacteria and die within 2 to 3 days. Biting flies • Exposure: eating meat from an animal that may serve as mechanical vectors after feeding died of anthrax on a carcass, contaminating vegetation. Injection anthrax

1.2.3. Clinical presentation • Similar to cutaneous anthrax, but injection Anthrax has 4 clinical presentations in humans: anthrax has the potential to spread more rapidly throughout the body Cutaneous anthrax • Incubation period: up to 20 days, but most • A clump of small blisters or lumps that may disease occurs in 1 to 7 days itch, swell, and eventually develop into an • Exposure: injecting spore-contaminated ulcer with a black center; the lesion may be illicit drugs painless and is often located on the face,

1.3. DIAGNOSIS expensive and the test is more a research tool than of practical day-to-day value in the Suspicion of anthrax arises from the field. observation of clinical symptoms, the anatomic-pathological findings and Animals epidemiological data. Rapid diagnostic methods require testing

1.3.1. Clinical signs the carcass while it is still fresh. Once the carcass is putrefied or scavenged, culture Clinical manifestations vary from species to is required to isolate B. anthracis. Samples species, presumably reflecting differences in should be collected without opening the susceptibility. Sudden death in apparently carcass, to prevent further environmental healthy animals which may be accompanied contamination. Specimens can include by bloody discharges from natural orifices, blood, tissue, exudates, other fluids, and rapid bloating of the carcass, incomplete nasal turbinates. rigor mortis and the absence of clotting of the blood are the common characteristics of anthrax in susceptible animals. In Humans more resistant species, local signs such as swellings of the oral and pharyngeal region Specimens can include blood, skin are seen. In wildlife, sudden death is the lesion exudates, pleural or ascitic fluid, invariable sign, often (but not always) with cerebrospinal fluid, or stool. Specimens bloody discharges from natural orifices, should always be collected prior to antibiotic bloating, incomplete rigor mortis and the therapy. Culture and Gram stains will likely absence of clotting of the blood. Cutaneous be negative if specimens are collected anthrax accounts for > 95% of human after antibiotic therapy has been initiated, cases worldwide. The lesions (eschars) are regardless of the form of disease. The generally found on exposed regions of the likelihood that antigen or molecular testing body almost invariably accompanied by methods will be positive decreases with marked oedema extending some distance the length of antibiotic treatment prior to from the lesion. sample collection. All samples (except sera for serology) must be collected prior to the

1.3.2. Laboratory diagnosis initiation of antibiotics. The simplest, quickest and best on-site diagnostic method is examination of a polychrome methylene blue-stained blood smear for the capsulated bacilli supported, where possible, with confirmation by culture. Genetically-based confirmation 3 by the polymerase chain reaction (PCR) is highly accepted on a stand-alone basis for many types of specimen and is increasingly available worldwide through commercial kits. Retrospective diagnosis by enzyme- linked immunosorbent assay (ELISA) in animals that have survived infection is possible, but specific antigen for this is Available tests Findings Gram stain Gram-positive rods, square-ended, in pairs or short chains Polychrome Dark blue square-ended rods surrounded by pink capsule. Rods are in pairs or methylene blue stain short chains, sometimes as single rods (M’Fadyean stain) Direct antigen Detection of antigen (usually protective antigen, but test will specify) detection Serology Seroconversion (use as a retrospective diagnosis, as need paired sera collected at least 2 weeks apart) PCR Detection of toxin and capsule DNA Culture (Gold Identification of B. anthracis by: colonial morphology, non-motile, non hemolytic, standard) 4 gamma phage and penicillin-sensitive, and capsule producing Figure 1- Diagnostic tests and findings for B. anthracis (source: Framework for enhancing anthrax prevention and control, August, 2016)

1.3.3. Differential diagnosis 1.5. ANTHRAX SITUATION IN ETHIOPIA Anthrax should be differentiated from other causes of sudden death such as: lightning 1.5.1. Burden of Anthrax in strike and accidental electrocutions, Ethiopia pasteurellosis, piroplasmosis, blackleg, malignant oedema, food intoxications, Ethiopia has a large livestock population and botulism, peracute babesiosis, chemical many rural communities depend on animals poisoning (heavy metal and other for food, income and draught power. Disease poisoning), plant poisoning, snake bite, is one of the major constraints preventing metabolic disorders (lactic acidosis), these large livestock resources from being magnesium deficiency, bloat and others. fully exploited. Anthrax is an endemic disease which occurs in May and June every

1.4. PRINCIPLES OF ANTHRAX year (‘anthrax season’) in several farming PREVENTION AND CONTROL localities of the country, causing disease both in humans and livestock. In 2000, it Control of anthrax begins with control of was reported that hundreds were affected the disease in livestock, and vaccination of in the Afar region of Ethiopia, many with livestock has long been the hub of control oral and gastroenteric infections. It is still a programs. Anthrax is also responsive significant risk in most regions in Ethiopia to antibiotic therapy provided this is and outbreaks frequently occur in humans administered early in the course of the and animals. infection. In addition to antibiotic therapy and vaccination, specific control procedures The diagnosis of reported anthrax cases are necessary to contain the disease and in humans were based on clinical signs prevent its spread. In particular: with epidemiological features and all the reported cases were not laboratory • Proper disposal of dead animals (burial confirmed due to limitations in laboratory and/or incineration); capacity in public and animal health sectors. • Not opening the carcass, since exposure Recent surveillance data (2009 to 2013) to oxygen will allow the bacteria to form shows, a total of 5,197 human and 26,737 spores; animal anthrax cases (human to animal ratio 1:5) were reported with 86 human • Quarantine of infected premises; anthrax deaths (Case Fatality Rate:1.7 %). • Cleaning and disinfection of infected The national human prevalence was found premises and fomites; to be 1.3 per 100,000 populations per five years, zero human case was reported from • Control of insects and rodents. pastoralist regions with 55-216 animal cases. The human prevalence was high in May followed by February (0.20 and 0.15 per 5 100,000 populations per year respectively). The burden of human anthrax cases was high in the Amahara and Tigray regions. From 2014 -216, a total of 2,218 human anthrax cases with a case fatality rate of 3.16 were reported from five regions. Off which the most cases were reported from the Amahara region followed by Tigray and SNNP regions (table1, below). Table 1: Distribution of human anthrax cases by region, 2014 – 2016, Ethiopia. Region 2014 2015 2016 Cases % AR Cases % AR Cases % AR Amhara 609 76.03% 3.04 428 55.80% 2.10 395 60.77% 1.90 Oromia 65 8.11% 0.20 73 9.52% 0.22 32 4.92% 0.09 SNNPR 30 3.75% 0.17 151 19.69% 0.83 0 0.00% 0.00 Somali 0 0.00% 0.00 0 0.00% 0.00 112 17.23% 2.00 Tigray 97 12.11% 1.96 115 14.99% 2.27 111 17.08% 2.15 Grand Total 801 100.00% 0.91 767 100.00% 0.85 650 100.00% 0.70 Even if the existing surveillance data in infected animals. The vaccine is administered humans indicates the magnitude of anthrax subcutaneously or intradermally at a dose by place and time, there is a limitation on the of 1ml and can effectively confer protection type of anthrax, the risk groups and personal against anthrax for a year. characteristics. The previous studies indicate that the disease is well recognized by rural The final product is available in a vial of 100 communities but little is known about its doses (100ml) in freeze dried form and must prevalence, epidemiology and public health be kept at + 2oC to + 8oC protected from light. These conditions should be maintained from significance (Teshale Seboxa et al., 1989; Esser production until utilization. Currently, NVI has et al., 2003). a capacity of producing 36 million doses per

1.5.2. Availability of Anthrax year, however, the current production capacity Vaccine in Ethiopia needs to be increased to cope up with the increasing trend in Anthrax vaccine demand Anthrax livestock vaccine is being produced at and for an effective implementation of future National Veterinary Institute (NVI) for the last anthrax control and prevention programs. 50 years. NVI is the sole supplier of the vaccine in Ethiopia and the availability of the vaccine 1.5.3. Anthrax Surveillance System in provides favorable opportunity in the control Humans in Ethiopia and prevention of Anthrax in Ethiopia.

1.5.3.1. Epidemiological surveillance The vaccine is prepared from live spores of a non-encapsulated but toxigenic variant of Implementation of anthrax surveillance Bacillus anthracis 34F2 Sterne strain. This seed activities at all levels of health system with strain is used worldwide for animal anthrax prompt laboratory confirmation of circulating vaccine production since it is stable and has pathogen is an essential strategy for early lost virulence, but is still immunogenic, due detection of anthrax outbreaks. Anthrax is a 6 to its incapability of forming a capsule, a rare, epidemic prone disease and one of the characteristic coded by the pXO2 plasmid. The twenty priority diseases under the Public Health vaccine produced is PANVAC certified for its Emergency Management system that should safety and protective efficacy. be reported immediately when encountered. The vaccine produced at NVI is composed of Routine flow of surveillance data is carried out Bacillus anthracis (Sterne strain) containing107 from reporting sites to the next level up until spores/dose, Saponine (0.1%), Stabilizer (4% the information reaches the central level. The skimmed milk). The vaccine is indicated for use community and health facilities, especially in cattle and sheep but can also be used for health posts, are the main source of information. all susceptible domestic animals which are at The information collected from these sites is risk of acquiring anthrax due to contact with compiled in standard forms, analyzed and then the contaminated soil, forages, or carcasses of forwarded, to the WHO. The first 5 suspected anthrax cases are reported using the Case- Woreda (DERF-W). The line list is completed Based Reporting Format (CRF). If more for all cases and kept at the health facility than 5 suspected cases are seen within one and woreda levels. Zones and Regions: use month, use the Line list to report daily. After the Daily Epidemic Reporting Format for 100 cases report, the summary of the line list Regions (DERF-R) to report the summarized using Daily Epidemic Reporting Format for suspected outbreak. Figure 2: Flow of information and Timeline for immediately Reportable Diseases

1.5.3.2. Laboratory surveillance through commercial kits. PCR depends on the unique specificity of the toxin The prevention and control of outbreaks and capsule and their genes. B. anthracis requires rapid identification of the pathogen cultures are easy to grow on nutrient agar and the source of infection. Anthrax is medium. Specimens or cultures can be diagnosed by growing the bacteria from grown overnight on Sheep Blood Agar (SBA) blood or other tissues. Final identification at 35-37oC. Colonies should be observed of the bacteria must be done by a public for hemolysis. Confirmation of identity health laboratory under strict biosafety and and differentiation from near relatives is biosecurity precautions. There are several generally easy with both traditional and types of specimen samples for human molecular techniques. anthrax testing. All potential B. anthracis specimens should be documented and In Ethiopia, in all health institutions except properly labeled upon arrival. To increase health posts, though the level of complexity traceability, samples should be assigned is different, laboratory services with limited a unique specimen identification number. facilities are available. Due to various This number should be clearly labeled on reasons such as lack of properly designed both the testing forms and the specimen laboratory rooms, laboratory personnel container. with awareness of public health threat from The simplest, quickest and best on-site epidemic prone diseases and response mechanisms, shortage of equipment and 7 diagnostic method is the one established supplies, absence of effective laboratory in the early 1900s – examination of a equipment maintenance and management polychrome methylene blue-stained blood system, and weak follow up and supervision, smear for the capsulated bacilli supported, many of these laboratories are not in a where possible, with confirmation by culture. position to carry out their responsibilities Modern on-site anthrax-specific antigen to the level of standard expected. Currently tests are being developed and validated but neither regional nor national Public Health are not currently available commercially. reference laboratories are performing Diagnosis by polymerase chain reaction Anthrax diagnosis either presumptive or (PCR) is becoming increasingly accepted as a confirmatory. stand-alone test for many types of specimens and is increasingly available worldwide

1.5.3.3. Outbreak investigation Passive surveillance and response Animal health Information system plays an Twenty one immediately notifiable disease important role in surveillance and provides and conditions were identified in Ethiopia information for economic assessment of under IDSR system for immediate outbreak diseases in addition to fulfilling international investigation and response. Anthrax is one reporting needs. The passive surveillance of the immediately notifiable diseases and system mainly depends on a paper based a single case of anthrax is considered as an system from woreda to the regional veterinary outbreak. A cluster of animal deaths or unusual laboratory covering the respective woredas events resembling the clinical sign of anthrax that laboratory is mandated to cover. The in humans reported to the health offices at monthly disease outbreak reports received different level followed by verification and from woreda level are entered in a web-based outbreak investigation activities. Disease Outbreak and Vaccination Activity The purpose of an investigation is to verify Reporting (DOVAR-II) system. This reporting the outbreak, recognize the magnitude system is designed to collect information of of the outbreak, diagnose the etiological any kind regarding animal health related issues agent, identify the source and the route of such as diseases occurrences or vaccination transmission as well as the people at risk, and activities performed in the woreda, including recommend measures so that the outbreak can anthrax. Currently the proportion of woredas be controlled as well as prevented in the future. reporting is around 50%, which is below the The outbreak investigation in case of anthrax international standard of 80% (Source: DOVAR- is based on the epidemiological findings (risk II database, 2016). based and clinical findings). Up on notification Figure 3. Map of reporting and non-reporting of suspected anthrax cases the health office woredas in 2016 (DOVAR) immediately investigate the cases and carry out the possible case management and outbreak investigation steps. Currently there is limited joint investigation mechanism b/n the animal health, human health and other relevant sectors. This might affects the early detection and preparedness for prompt response any upcoming epidemics of anthrax and associated health impacts in humans. 8 1.5.4. Anthrax Surveillance System in Livestock in Ethiopia Syndromic surveillance is practiced in some 1.5.4.1.Epidemiological surveillance selected areas using a mobile based daily notification system known as Animal Disease Active and passive surveillance systems are Notification and Investigation System (ADNIS). being implemented nationally by the Ministry This system is mainly intended to serve the of Livestock and Fisher for the animal health pastoral areas with a very low or poor reporting related information’s. The implementation rate. It serves for immediate notification of the surveillance system with its passive and early detection of some selected animal and active components as well as additional diseases. Currently there are around 300 sites surveys have led to a good understanding of practicing this reporting system, and there is a the disease dynamics in the country including plan to reach 3600 sites at the end of GTP-2 as status of anthrax (Source: Epidemiology a national plan. Directorate, 2017). Active surveillance Active surveillance is an essential tool for early detection of diseases and introduction of exotic diseases. Additionally, it provides information for declaring a country or a zone disease free. Currently there are 15 regional veterinary laboratories conducting active surveillance, in addition to NAHDIC. Figure 4. Animal Disease Notification and Annual sero-surveillance is being conducted Investigation System (ADNIS) pilot areas for priority diseases and trade sensitive Major gaps of passive surveillance system diseases Low return rate and poor quality of the Regarding introduction of exotic diseases, reports received, as most of the outbreak annual risk based sero-surveillance is reports are not confirmed or not supported by conducted around border areas of the laboratory diagnosis. Hence, mapping of the country and other areas with the risk of distribution of confirmed clinical outbreaks introduction of exotic diseases. is only partially practiced due to the low For other endemic diseases annual reporting rate of lab confirmed outbreaks. surveillance is conducted to know their Lack of good quality internet connection both status and gathering information for at regional veterinary labs for the purpose of national control program. accessing semi-web based system, DOVAR- In order to detect areas with active disease II server and for the immediate notification transmission, participatory disease system server from field sites. surveillance (PDS) is conducted for some Lack of post-assessment evaluation to selected diseases. quantify the clinical and the socio-economic impact of disease outbreaks. Another gap in the national surveillance system is that it is not able to capture events in wildlife. Table 2: DOVAR output demonstrating cases and deaths of anthrax for 2012-2016. Year No of cases No of Deaths Animal at risk Control Prophylaxis vaccination vaccination 2016 2015 788 1,486 222 478 541,319 742,041 541,319 407,023 941,719 351,370 9 2014 2,297 931 1,223,180 585,021 251,727 2013 4,471 1,270 1,605,727 1,605,727 1,605,727 2012 5,311 1,372 1,927,238 713,241 147,689 Total 14,353 4,273 6,039,505 3,852,331 3,298,232 Table 3: cases and deaths of anthrax from 2007 to 2009 adapted from veterinary epidemiology year book Year Outbreaks Cases Deaths PAR Vaccine production Vaccine in dose distribution 2007 927 7,781 3,002 2,081,755 8,467,600 6,467,000 2008 801 44,703 3,170 1,883,647 5,258,450 4,924,100 2009 681 4,523 1,772 1,761,990 7,083,200 3,809,500

1.5.4.2. Laboratory surveillance The national laboratory also needs to conduct specific risk assessment and prepare SoPs To deliver effective animal health diagnostic regarding the specific biosafety and biosecurity service through outbreak investigation, requirements for anthrax sample handling and export testing and to conduct national disease analysis. surveillances, the country has established laboratory system with 15 regional veterinary 1.5.4.3. Outbreak investigation labs working in collaboration with the national and response referral veterinary laboratory, the National Animal Health Diagnostic and Investigation The rapid detection of the introduction or center (NAHDIC). NAHDIC is also a supporting sudden increase in any disease of livestock laboratory for trans-boundary animal which has the potential of developing to diseases for east Africa. NAHDIC has 11 BSL II epidemic proportions and/or causing serious laboratories; including general bacteriology, socio-economic consequences or public health bacterial serology and molecular diagnostic concerns are the points to be considered in laboratories, as well asa BSL-3 laboratory livestock outbreak investigation in the country. facility for the diagnosis of zoonotic & highly The investigation embraces all initiatives and is contagious diseases like Bovine tuberculosis, mainly based on disease surveillance, reporting HPAI and planned for the future to diagnose and epidemiological analysis. These lead to anthrax. The laboratory has implemented improved awareness and knowledge of the quality management system (QMS) and it is distribution and behavior of disease outbreaks ISO/IEC 17025:2005 accredited laboratory by and infection, allows forecasting of the source SANAS. and evolution of the disease outbreaks, and monitoring of the effectiveness of disease To date in the animal health sector, outbreak control campaigns. reports of anthrax are based on history and clinical signs and there is no laboratory Whenever livestock disease outbreak occur confirmed cases at either the regional or anywhere in the country, the forefront national level. NAHDIC’s experience for the veterinarians investigate the reports to come diagnosis of anthrax is limited to polychrome up with a diagnosis whose result is largely Methylene blue staining techniques dependent on tentative judgment made by the (M’Fadyean stain), that is through staining clinician himself. blood smears from peripheral blood vessels The veterinarian will put his/her utmost effort and observing the square ended, blue rods to find out the real culprits behind the problem in short chains surrounded by pink capsule to diagnose and ultimately control the disease. through direct microscopy. Apart from this, Whenever the case is beyond the capacity of confirmatory diagnostic capacity either with the district veterinarian, more help is called molecular techniques (PCR) or through culture up from the next veterinary command chain, 10 using gamma phage is not yet established. the regional veterinary laboratory. Regional In addition to limitations in confirming anthrax, veterinary laboratories are responsible for biosafety and biosecurity issues are also of immediate outbreak investigation in their major concern for culture and identification respective operational areas. of Bacillus anthracis at the regional veterinary If the case is above the capacity of regional laboratories. There is no harmonized SoP for laboratories it is referred to NAHDIC. NAHDIC collection, transportation and handling of has experience of establishing an immediate samples from anthrax suspected cases and outbreak investigation team incorporating confirmatory test protocol for Bacillus anthracis experts from the national and regional diagnosis at laboratory level. In addition, laboratories as well as national, regional and laboratory staff’s at regional and national district veterinarians. Regarding anthrax level are not well experienced and trained on outbreak investigation most of the diagnostic confirmatory diagnostic techniques of anthrax. attempts were based on seasonal occurrence, epidemiological survey, clinical signs and not specific to anthrax. On top of this for any history. Appropriate tissue and dry swab death occurrence to wild animals, the scout samples from anthrax suspected cases automatically reports the death to the park can be collected for further identification office, and then the park office further reports at NAHDIC. All the potential B. anthracis to the Ethiopian Wildlife Conservation suspected samples should be documented Authority (EWCA). The EWCA veterinarians and properly labeled upon arrival. It was will assess the situation and if necessary only in few outbreak cases where the appropriate samples from diseased animals organism was detected from blood smears can be collected and submitted to the using M’Fadyean staining technique. Ethiopian Public Health Institute (EPHI) or National Animal Health Diagnostic In order to improve the current anthrax and Investigation Centre (NAHDIC) for outbreak investigation capacity, there is a identifying the cause of disease outbreaks need to address skill and knowledge gaps among the wild animals. Apart from this and improve laboratory capacity like through effort there is no well-organized national organizing specific training for regional and surveillance system assisting the immediate national staff on handling anthrax suspected notification, investigation and response of cases both at field and laboratory (on sample disease outbreaks among wildlife. collection, transportation, storage and anthrax diagnostic and confirmatory tests). 1.5.5.2. Outbreak investigation and response

1.5.5. Anthrax Surveillance System for Wildlife in Ethiopia Anthrax outbreak has been observed in southern parts of Mago national parks Ethiopia has around 320 species of mammals and spread to the northern part within (36 are endemic), 862 species of birds (18 two months beginning from September are endemic), 201 species of reptiles (9 are 1999. Moreover, another anthrax outbreak endemic), 63 species of amphibians (24 are from September to October 2000 has also endemic), more than 180 species of fishes been observed in this park. In the former (40 are endemic) and over 6,500 species of outbreak more than 1,600 wild animals plants (more than 700 are endemic). Their were dead from 21 different species (Table distribution and occurrence normally vary 4, below). Of all the species Lesser kudu was with elevation which starts at -110 meter severely affected, which accounts for 95% at Dalol depression up to 4,543 meter at of mortality and as a result more than 65% Ras Dashen Mountain peak, encompassing of Lesser Kudu’s population within the park major ecosystems such as afro-alpine, died. Similarly during the second outbreak savanna, desert and wetlands. To conserve even though the extent of the death was biological diversity in the different ecosystem not as previous, Lesser kudu was again the 49 different protected area categories have been established within the country. Of most susceptible species. During the second 11 outbreak further spreading of the anthrax these protected areas 20, 4, 7, 3, and 18 are was controlled by early detection and proper national parks, sanctuaries, wildlife reserves, carcass disposal. community based conservation area and controlled hunting areas respectively.

1.5.5.1. Epidemiological surveillance Survey of the presence or absence of wild animals’ disease is conducted in the protected areas once a year but this survey is Table 4: Record of the wild animals affected by the anthrax outbreak at Mago national park Common name Scientific name In 1999 G.C In 2000 G.C In 1996G.C (% male) (% male) population estimate (CV)* Ungulates Lesser kudu Tragelaphus imberbis 1531 (44.9) 526 (41.4) 2268 (20) Gerenuk Litocranius walleri 19 (68.4) 6 (67) Warthog Phacochoerus africanus 16 (62.5) 1 (0) 161 (37) Common bushbuck Tragelaphus scriptus 7 (71.4) 20 (55) 198 (29) Lelwel hartebeest Alcelaphus buselophus lelwel 7 (42.8) 0 451 (46) Dik-dik Madoqua guentheri 6 (66.7) 5 (50) Bush duiker Sylvicapra grimmia 4 (50) 2 (100) Tiang Damaliscus lunatus 4 (25) 3473 (47) Oribi Ourebia ourebi 3 (67) Waterbuck Kobus ellipsiprymnus 2 223 (31) African buffalo Syncerus caffer 2 (50) Grant’s gazelle Gazella grand 2 (50) 1228 (28) Aardvark Orycyteropus afer 1 Elephant Loxodonta africana 1 Primates Eastem black-and-white Colobus guereza 1 colobus Olive baboon Papio anubis 3 Carnivores Caracal Felis caracal 1 Mongoose Species not recorded 3 Rodents Porcupine Hystrix cristata 1 Birds Marabou stork Leptopilos crumeniferus 2 Hooded vulture Necrosyrtes monachus 1

1.5.6. Current Anthrax Prevention sectoral coordination framework to harmonize and Control Activities in Ethio- the existing efforts to bring the required result pia in preventing and controlling anthrax and Even though anthrax is a reportable disease its impact on animal and human health. The in Ethiopia, poor diagnostic capacity and technical, administrative and financial system unreliable reporting make it difficult to estimate as well as multi-sectoral and multi-disciplinary 12 the true incidence in the country. However, coordination, collaboration and harmonization, therefore, requires a strategic approach that anthrax is enzootic in most of the regional states in the country and has been reported should be agreed by all stakeholders. from nearly every corner of the country with

1.5.6.1. Core Stakeholders for Anthrax highest frequency from the highland mixed Control in Ethiopia farming areas but precise incidence among animals is unknown. Improving the coordination and collaboration of various actors - federal, regional, state and The fragmented efforts by many actors, woreda level sectoral (animal and human including the livestock and public health health) institutions will improve the prevention sector at the different administrative levels and control of anthrax through a One Health (federal, regional) Approach. The necessary partners include: employed so far were lacking of a central multi- • MoH (EPHI/PHEM, Regional and Woreda Level Bureaus of Health) is limitations in the coordination system. • Ministry of Livestock and Fisheries • The National Veterinary Institute is the (Federal, Regional and Woreda livestock one producing and supplying anthrax bureaus and Veterinary Structures, vaccine. National Animal Health Diagnostic and • Regional States have their own annual Investigation Center, National plans for preventive vaccination that Veterinary Institute, regional veterinary they submit to the NVI for production laboratories) planning. • Ministry of Culture and Tourism • Vaccination is usually done during the (Ethiopian Wildlife Conservation Anthrax outbreak season (May and June) Authority) once a year and involves all animals at risk. However its implementation is • International Development Partners not uniformly practiced due to limited (USAID funded EPT-2 program, FAO, coordination, challenges in the cold USAID P&R, chain management, trained man power, PREDICT, OHWF/OCHEA, CDC, WHO, OIE, and limitations in vaccine supply chain OHIO University) system • Local and national organizations (private • When an outbreak of Anthrax occurs sector actors, sectorial and professional (suspected or confirmed) in a certain associations eg. Veterinary Professional area, regional states or woredas buy Associations, Public Health Associations, the vaccine from the NVI and conduct local universities) ring-vaccination supported by routine sanitary measures to contain the

1.5.6.2 Prevention and Control Activities in Humans in outbreak. Ethiopia • Movement control is an option • Anthrax is one of 21 immediately implemented to control an anthrax notifiable disease in the country outbreak but there is limitations in the implementation. • In 2003 alone, some 1,096 suspected human cases were reported with a case • Community awareness creation is fatality rate of 1.5% from four regions a common practice at village levels (Tigray, Oromiya, Amhara and SNNPR) but there is limitations in formal communication and information • There is no guideline for the prevention dissemination system. and control of anthrax disease in Ethiopia

1.5.6.4. Prevention and Control • PHEM unit of EPHI has established a system that enables identification of Activities in Wildlife in Ethiopia 13 suspected human anthrax cases. Although there are cases encountered in wildlife, the Ethiopian Wildlife Conservation

1.5.6.3. Prevention and Control Authority doesn’t have any prevention or Activities in Livestock in Ethiopia control plan for the country. This is also • There is animal disease reporting partly due to lack of skilled manpower and mechanisms (ADNIS, DOVAR) and facilities within the EWCA to identify or accordingly acts to control the disease diagnose the disease. Recently there was in collaboration with concerned regional system for coordination and collaboration and district level animal health offices. between the MoLF and EWCA. Vaccination only involves domestic animals. The only • Vaccination is widely practiced measure of control practiced for wildlife is preventive measure all over the country the disposal of carcasses of suspected cases. where the disease is endemic but there

1.5.6.5. Policy, Legal and Institutional 1.6. CHALLENGES IN ANTHRAX Framework supporting prevention and CONTROL IN ETHIOPIA control of Anthrax • Currently, the prevention and control 1.6.1. Inadequate Laboratory Capacity and Biosecurity of anthrax is managed separately by institutions under three Ministries (MoLF, • Lack of regional and national laboratory MoH and MoCT) mostly at the level of capacity on anthrax confirmatory diagnosis regional bureau of Livestock/Agriculture (human and livestock) and/or Health. The national disease • Limited supply of diagnostic materials prevention and control is guided by the (human and livestock) “Animal Diseases Prevention and Control Proclamation no. 267/2002”. • Limited biosecurity and biosafety in • Health Sector Transformation Plan (HSTP) laboratories (human and livestock) provides strategic guidance for programing 1.6.2. Inadequate Surveillance and service provision, and recognized the current and persisting gaps in community • Potential under-reporting of anthrax cases health and has put significant emphasis in and outbreaks (human and livestock) promoting health service delivery through • Limited laboratory-based surveillance improving access, coverage, continuity and (human and livestock) coordination. • No SOPs/guidelines for anthrax outbreak • Livestock Master Plan (2016-2020) informs response targets set out in GTP2 for the livestock sector. The LMP document aspires for 1.6.3. Lack of Prevalence and Bur- the reduction of the impact of zoonotic den Estimates diseases on human health (consumers) by controlling zoonotic diseases and ensuring • No clear picture of prevalence since human the safety of animal products. disease high in areas where animal disease is not reported and vice-versa • Ethiopian National Health Care Quality Improvement Strategy 2016-2020 Reflects • Lack of anthrax burden and health-cost the common concern in healthcare and it related studies gives recognition to non-governmental

1.6.4. Inadequate Inter-Sectoral organizations’ role on the issue Collaboration and Partnerships • EPHI Strategic Plan (2015/16-20/21) promots a study on priority zoonotic • Poor joint anthrax investigation and diseases at human animal ecosystem response interface. It emphasized on OH approach • No data sharing and surveillance linkage 14 as a mechanism to implement the strategy. The SP also indicated the development, between sectors institutionalization and implementation • Lack of One Health/multi-sectoral approach of OH approach for strengthening cross- to address anthrax sectoral collaboration and partnership on 1.6.5. Lack of Educational and public health research. Awareness Materials for Anthrax Prevention • Poor public information on importance of livestock vaccination • Poor public education and awareness on anthrax prevention and control • Lack of training materials for health care • Development of multi-sectoral providers and animal health workers zoonotic diseases Memorandum of Understanding • Poor notification guidance for public health and animal health workers • Government commitment to anthrax prevention and control

1.6.6. Limited Supply and Distri- bution of Anthrax Vaccine and 1.7.2. Increased Interest in En- management of Anthrax vaccines hancing Anthrax Control and Prevention • The amount of vaccines that can be produced in the country is limited • Anthrax has been identified as one of the top five priority zoonotic diseases for • Potential disruption in the cold chain inter-sectoral collaboration. • Lack of national plan/strategy/calendar for anthrax vaccine distribution • Increased commitment to joint surveillance and response activities with • Lack of strong national regulatory body regards to prevention and control of the for vaccine quality assessment disease

1.6.7. Funding Constraints and • An inter-sectoral technical collaboration Competing Priorities has been initiated by the government, • Existence of competing priorities – resulting in establishment of an Anthrax other livestock/zoonotic diseases in the Technical Working Group. country

1.7.3. In-Country Anthrax Vaccine • Lack of long term funding for activities Production for enhancing anthrax control and • Anthrax livestock vaccine is prevention manufactured in Ethiopia by the National

1.6.8. Lack of Integrated national Veterinary Institute (NVI). guidelines and standard operat- ing procedures (SOPs) on anthrax • The 2016 production is about 25 million prevention and control doses of the vaccine, based on demand. NVI has the capacity to produce up to 36 • No SOPs on laboratorial procedure for million doses of the vaccine. anthrax diagnosis • Vaccine is distributed to regional • No SOPs on anthrax outbreak veterinary bureaus and sold investigation and response internationally. • No national guidelines on anthrax prevention and control • The production target is determined by the requests from the regional veterinary 15

1.7. OPPORTUNITY FOR EN- offices on a yearly basis. The vaccine is HANCING ANTHRAX CON- bought by the regional governments TROL AND PREVENTION IN not the federal government. ETHIOPIA • Vaccination is recommended once a year

1.7.1. Establishment of One for livestock and for ring vaccination Health Coordination Structures during an outbreak. • Establishment of National One Health Steering Committee • Establishment of Anthrax Technical Working Group (ATWG) 2 CHAPTER THE STRATEGIC FRAMEWORK 2.THE STRATEGIC • Generate scientific evidence to inform decision and policy changes on anthrax FRAMEWORK prevention and control

2.6. STRATEGIC FRAMEWORK

2.1. GUIDING PRINCIPLES FOR THE PREVENTION AND OF THE STRATEGY CONTROL OF ANTHRAX • Prevention and control of anthrax in Anthrax is a World Organization for Animal animals effectively reduces its impact on Health (OIE)-listed animal disease that has public health and the national economy the potential to affect many animals within a • A multi sectoral collaborative approach herd. It is important in the trade of livestock and capacity building are essential for and livestock products and is a significant successful prevention and control of public health issue. Anthrax is a notifiable anthrax disease in both the livestock and public health sectors in Ethiopia. A major outbreak

2.2. VISION of anthrax would cause severe production losses to affected producers, with potential To ensure anthrax is no longer a significant dislocation and financial losses to the public and animal health problem in Ethiopia livestock producers from effects on exports by 2030. and a significant potential fatality in humans.

2.3. MISSION The foundation of anthrax control is To significantly reduce and ultimately vaccination of livestock accompanied control the public health impact of anthrax by rapid outbreak response to limit in humans and animals in Ethiopia through environmental contamination and human sustained surveillance, laboratory diagnosis, exposures. Animal outbreak response relies prevention and control systems and heavily on effective surveillance and the community awareness. availability of rapid and reliable laboratory diagnostics. The proposed strategic

2.4. GOAL framework includes specific objectives and activities to be performed under each one of To prevent and control anthrax in human the eight main components of the anthrax and animals in Ethiopia Prevention and Control Strategic Framework.

2.5. GENERAL OBJEC- Chapter Three has the implementation Plan, TIVES subdivided into three phase, listing specific activities to be completed in the stipulated • Strengthen sectoral and multi-sectoral timeframe. anthrax surveillance systems for effective preparedness and response; This strategic document plans to prevent 17 and control anthrax in humans and animals • Improve laboratory capacity for anthrax in Ethiopia using a combination of the diagnosis at national and regional level following strategic areas of focus: • Sustain inter-sectoral collaboration • Enhancing surveillance and reporting among all stakeholders systems • Undertake anthrax prevention and • Implementing outbreak investigation control activities and response • Enhance prevention capacity in terms • Improving community awareness on of trained personnel and community the risks, transmission and prevention of awareness anthrax • Enhancing anthrax vaccine production, Activity 1.3. Review and develop animal and safety, quality, efficacy and distribution in human anthrax case definition (community animals and international standards) and update surveillance forms to ensure proper information • Planning and implementing vaccination is collected campaigns Activity 1.4. Develop anthrax surveillance • Improving sanitary measures (carcass guideline/ SoP disposal, disinfection, avoid contact with livestock) Activity 1.5. Provide trainings to address surveillance capacity gaps and awareness • Improving anthrax diagnostic laboratory for animal and public health surveillance capacity officers and the community (case definitions • Developing information, education and (community, suspected, probable and communication materials confirmed) reporting, notification, data management, data analysis and mapping and • Strengthening multi-sectoral collaboration reporting etc).

2.7. COMPONENTS OF THE Activity 1.6. Provide resources (mobiles, ANTHRAX PREVENTION laptops…) to improve timely and quality AND CONTROL STRATEGIC reporting FRAMEWORK Activity 1.7. Strengthen national and regional

2.7.1. Surveillance and Report- Epi-lab networking (4 way linking) ing Systems Activity 1.8. Establish a wildlife anthrax Surveillance is a critical element in the control surveillance system and link with the national and prevention of anthrax. Effective anthrax system surveillance in humans and animals enhances Objective 2: Establish a mechanism for early detection and reporting of cases, vital reporting, feedback and information sharing of for initiating timely responses and enabling anthrax surveillance data among stakeholders informed decisions about when and where and relevant sectors to intensify anthrax control efforts. Once interventions are implemented, surveillance is Activity 2.1. Develop SOP and a mechanism for essential in generating data to monitor progress inter sectoral information sharing (surveillance or impact of the control efforts, which is data, risk mapping, hotspot identification) essential for their sustainable implementation. Activity 2.2. Review and strengthen standard Specific objectives and activities of surveillance anthrax reporting format and channels 18 and reporting Activity 2.3. Conduct a regular ATWG meetings Objective 1: Assess and enhance the existing surveillance system including data collection, Activity 2.4. Prepare and share regular joint reporting and analysis (Case definition in anthrax national surveillance reports and humans and animals, develop a reporting provide feedback to the regions and woredas formats in human and animals and notification Activity 2.5. Perform retrospective analysis and investigation/verification system) and publication of surveillance data at regional Activity 1.1. Evaluate the existing surveillance and national level system and databases to identify gaps, strength Activity 2.6. Develop a plan (SOP) for public and barriers of epidemiological and laboratory announcement/Public disclosure for anthrax surveillance in animals and humans outbreak Activity 1.2. Address challenges based on the identified gap 2.7.2. Outbreak investigation and re- sponse chain management system and SOP for monitoring of vaccine, production (GMP), Objective 3: Joint planning of preparedness, distribution, handling, storage (cold chain) investigation and response plan (Develop and administration guidelines and SOPs for response of anthrax) Activity 4.6. Establish a PPP system for Activity 3.1. Develop a national guideline implementation of vaccination campaigns and SOPs for outbreak investigation and response (case management, infection Activity 4.7. Plan and implement vaccination prevention, environmental sanitation, campaigns field investigation forms, roles and Activity 4.8. Establish a proper unused responsibilities) vaccines disposal system (expired, damaged, Activity 3.2. Establish a joint national and and inappropriately stored) regional rapid investigation and response Activity 4.9. Conduct Post vaccination team for anthrax outbreaks evaluation (using effective method) Activity 3.3. Prepare outbreak preparedness Activity 4.10. Training to animal health plan and ensure availability of supplies professionals and technicians on (vaccines, drugs, human resource, laboratory vaccine handling, transport, storage and consumables, and equipment) for anthrax administration, cold chain maintenance and outbreak investigation and response calibration Activity 3.4. Conduct simulation exercises Objective 5: Improve sanitary measures and/or training for outbreak investigation (carcass disposal, disinfection, avoid contact including sample collection, handling and with livestock) transportation, after action review and revision of the plan/SoP Activity 5.1. Develop SOP for proper infected carcass and fomite disposal, environmental Activity 3.5. Conduct/implement joint sanitation, animal movement control outbreak investigation and response system/isolation

2.7.3. Prevention and Control of Activity 5.2. Ensure availability of the Anthrax necessary supplies and equipment (PPE) for Objective 4: Enhance anthrax vaccine disinfection/environmental sanitation production, safety, quality, efficacy, Activity 5.3. Conduct training for animal distribution and rational use of the vaccine health, environmental health and public in animals health workers on best environmental sanitary practices (on proper disinfection, Activity 4.1. Asses/estimate the national demand production, distribution and case management, and carcass disposal and 19 storage capacity of anthrax vaccine quarantine techniques) Activity 4.2. Improve NVI vaccine production 2.7.4. Anthrax Diagnostic Laboratory capacity to meet the estimated national Capacity demand Objective 6: Improve national and regional Activity 4.3. Conduct cost effectiveness and animal and public health laboratory capacity feasibility of animal vaccination foranthrax diagnostic testing Activity 4.4. Conduct test vaccine efficacy, Activity 6.1. Assess national and regional safety, quality and a post market assessment/ public and animal health laboratory evaluation of the vaccine capacity for anthrax diagnostic testing (sample collection and shipment, biosafety, Activity 4.5. Develop vaccine supply biosecurity, skill and knowledge, testing, availability of necessary equipment and 2.7.5.Information, Education and supplies) Communication Activity 6.2. Prepare a laboratory Objective 8: Improve awareness and behavioral development plan based on identified gaps change in the community regarding the risks, (sample collection, transport, submission, transmission and prevention of anthrax processing and confirmatory testing, training, Activity 8.1. Assessment of existing consumables, and equipment) communication activities and materials for Activity 6.3. Review laboratory sample communities (situational analysis) referral SOPs (biosafety, biosecurity, handling, Activity 8.2. Conduct community survey transport, processing and testing) to assess KABP (Knowledge, attitude and Activity 6.4. Organize trainings for public and behavioral practice) in targeted audiences animal health laboratory professionals and Activity 8.3. Develop an evidence based field staff (sample collection, preservation national and regional communication strategy and transport, submission, reporting and (identify different audience groups, appropriate confirmatory diagnosis) channels, materials and key messages) Activity 6.5. Procurement of necessary Activity 8.4. Develop appropriate anthrax laboratory supplies and equipment related messages and concept testing based on Activity 6.6. Introduce anthrax rapid diagnostic survey findings for different audience groups field tests; research on new testing methods Activity 8.5. Train professionals on Activity 6.7. Strengthen a laboratory quality communication strategy management system; equipment maintenance Activity 8.6. Produce, pre-test and disseminate and calibration system Information Education Communication (IEC)/ Activity 6.8. Build capacity of the National Social Behavior Change Communication (SBCC) Veterinary Institute to manufacture diagnostic materials materials Objective 9: Improve the knowledge and skill Activity 6.9. Establish a national germ bank to of health/veterinary professionals preserve circulating isolates of B. anthracis Activity 9.1. Review of the existing educational Objective 7: Establish and enhance inter materials for health/veterinary professionals sectoral inter laboratory networking (public Activity 9.2. Assess the knowledge and skills and animal health) (KAP) of the health/veterinary professionals Activity 7.1. Map and linking existing public Activity 9.3. Perform field level testing of the 20 and animal health laboratories based on the assessment developed educational materials Activity 9.4. Develop training manuals Activity 7.2. Review compatibility of existing and provide training to public, animal and laboratory information management (LIMS environmental health professionals and LIS) systems Activity 9.5. Distribute information and Activity 7.3. Establish an inter-laboratory educational materials to relevant sectors at all resource sharing networking mechanism; levels (woreda, regional, national) MoU, ToR Activity 7.4. Organize regular inter-laboratory 2 fora (networking, information sharing, joint plan) .7.6. Multi-Sectoral Collabora- tion Objective 10: Strengthen existing national platforms (OHSC, Anthrax TWG) and support the establishment of coordination platforms at regional and woreda level Activity 10.1. Review the existing TOR and conduct regular meeting of ATWG Activity 10.1. Support establishment of regional and woreda level anthrax prevention and control coordination platforms (Develop TOR and work plan for all regional TWG) Activity 10.3. Organize regular technical discussions and meetings on data sharing, analysis, risk mapping, recommendation to inform prevention and control Activity 10.4. Ensure regular communication and reporting to the OH steering committee Objective 11: Obtain buy in and secure resources for implementation of the plan Activity 11.1. Develop an advocacy plan to obtain buy-in from governmental stakeholders and engaging private sectors, international partners in a national anthrax control plan Activity 11.2. Develop a budget for implementation of plan and secure potential source of funding for implementation of the plan Activity 11.3. Obtain official endorsement of anthrax plan from all relevant ministries to ensure a sustainable public funding mechanism 21 3 CHAPTER IMPLEMENTATION PLAN 3. IMPLEMENTATION • Provide resources (mobiles, laptops…) to improve timely and quality reporting PLAN • Review and develop animal and human

3.1. PHASE 1: PLANNING, PREPA- anthrax case definition (community and RATION AND ASSESSMENT international standards) PHASE (2 YEARS) (2017-2019) • Develop anthrax surveillance guideline During the first phase of the anthrax • Establish a wildlife anthrax surveillance prevention and control strategy, the Ethiopian system and link with the national system anthrax technical working group will focus on • Develop SOP and a mechanism for inter working together in a One Health approach sectoral information sharing (surveillance to work on activities related to assessment data, risk mapping, hotspot identification of current situation of anthrax surveillance, outbreak, laboratory and vaccination • Conduct a regular review meeting, systems in the country and defining overall workshops with stakeholders responsibility for implementing anthrax • Prepare and share regular joint anthrax control strategies, resource mobilization, national surveillance reports and provide training and capacity building. At the end feedback to the regions and woreda of Phase 1, the country will have a well- established Anthrax TWG, have fully assessed • Develop a plan (SOP) for public surveillance systems, developed guidelines announcement/Public disclosure for and SOPs to enhance anthrax surveillance and anthrax outbreak control, and improved technical capacity and 3.1.1.2. Outbreak investigation and laboratorial capacity to provide confirmatory response diagnostic for anthrax. At this point, Ethiopia • Develop a national guideline and will be ready to start implementation SOPs for outbreak investigation and activities in selected target areas. response (case management, infection

3.1.1. Specific activities to be com- prevention, environmental sanitation, pleted in the stipulated time- field investigation forms) frame • Prepare outbreak preparedness plan and ensure availability of supplies (vaccines,

3.1.1.1. Surveillance and reporting drugs, human resource, laboratory • Evaluate the existing surveillance system consumables, and equipment) for anthrax and databases to identify gaps, strengths outbreak investigation and response and barriers to epidemiological and • Conduct simulation exercises; training laboratory surveillance in animals and (outbreak investigation, on sample • humans Address challenges based on the collection, handling and transportation, after action review, revise the plan 23 identified gap • Conduct/implement joint outbreak investigation and response • Provide trainings to address surveillance capacity gaps and awareness for animal • Establish a joint national and regional and public health surveillance officers rapid investigation and response teams and the community (case definitions for anthrax outbreaks (community, suspected, probable and • Prepare outbreak preparedness plan and confirmed), reporting, notification, data ensure availability of supplies (vaccines, management, data analysis and mapping drugs, human resource, laboratory and reporting etc). consumables, and equipment) for anthrax outbreak investigation and response • Conduct simulation exercises; training • Prepare a laboratory development plan (outbreak investigation, on sample based on identified gaps (sample collection, collection, handling and transportation, transport, submission, processing and after action review, revise the plan confirmatory testing, training, consumables, • Conduct/implement joint outbreak and equipment investigation and response • Organize trainings for public and animal

3.1.1.3. Disease prevention and control health laboratory professionals and field staff (sample collection, preservation • Asses/estimate the national demand and transport, submission, reporting and production, distribution and storage confirmatory diagnosis capacity of anthrax vaccine • Procurement of necessary laboratory • Conduct cost effectiveness and feasibility of supplies and equipment animal vaccination • Review laboratory sample referral SOPs • Conduct test vaccine efficacy, safety, quality (biosafety, biosecurity, handling, transport, and a post market assessment/evaluation of processing and testing) the vaccine • Organize regular inter-laboratory fora • Develop vaccine supply chain management (networking, information sharing, joint plan) system and SOP for monitoring of vaccine, production (GMP), distribution, handling, 3.1.1.5. Information, Education and Com- storage (cold chain) and administration munication • Establish a PPP system for implementation • Assessment of existing communication of vaccination campaigns activities and materials (situational analysis) • Training to animal health professionals and • Review of the existing educational materials technicians on vaccine handling, transport, for professionals storage and administration, cold chain maintenance and calibration • Assess the knowledge and skills (KAP) of the profession • Develop SOP for proper infected carcass and fomite disposal, environmental sanitation, • Develop appropriate anthrax related animal movement control system/isolation messages and concept testing based on survey findings for different audience groups • Ensure availability of the necessary supplies and equipment (PPE) for disinfection/ 3.1.1.6. Multi-Sectoral Collaboration environmental sanitation • Review the existing TOR and conduct regular 24 • Conduct training for animal health, environmental health and public health meeting of ATWG • Organize regular technical discussions workers on best environmental sanitary and meetings on data sharing, analysis, practices (on proper disinfection, case risk mapping, recommendation to inform management, and carcass disposal and prevention and control quarantine techniques) • Ensure regular communication and 3.1.1.4. nthrax Diagnostic Laboratory reporting for the OH steering committee Capacity • Develop an advocacy plan to obtain buy- • Assess national and regional of public and in from governmental stakeholders and animal health laboratory capacity for anthrax engaging of private sectors, international diagnostic testing (sample collection and partners in a national anthrax control plan shipment, biosafety, biosecurity, skill and knowledge, testing • Develop a budget for implementation of plan and secure potential source of • Provide resources (mobiles, laptops…) to funding for implementation of the plan improve timely and quality reporting • Obtain official endorsement of anthrax • Establish a wildlife anthrax surveillance plan from all relevant ministries and system and link with the national system ensuring sustainable public funding • Conduct a regular review meeting, mechanism workshops with stakeholders

3.2. PHASE 2: IMPLEMENTA- • Prepare and share regular joint anthrax TION PHASE IN TARGET national surveillance reports and provide AREAS (4 YEARS) (2020- feedback to the regions and woreda 2023)

3.2.1.2. Outbreak investigation and During Phase 2, Ethiopia will start response implementation of the priority activities • Prepare outbreak preparedness plan and identified in this Strategic Plan. The ensure availability of supplies (vaccines, implementation will be phased and will drugs, human resource, laboratory start in selected target (high burden) consumables, and equipment) for anthrax areas, depending on the proposed activity. outbreak investigation and response Activities to be implemented during Phase 2 include pilot Projects, operational research, • Conduct simulation exercises; training systems enhancements and development (outbreak investigation, on sample of mechanisms for enhanced anthrax collection, handling and transportation, prevention and control. At the end of after action review, revise the plan Phase 2, in addition to the outcomes from • Conduct/implement joint outbreak Phase 1, target regions will have enhanced investigation and response surveillance systems, joint outbreak response, improved anthrax control • Establish a joint national and regional measures, improved laboratorial capacity, rapid investigation and response teams improved inter-sectoral collaboration and for anthrax outbreaks communication. At this point, Ethiopia will • Prepare outbreak preparedness plan and be ready to re-evaluate the strategic plan ensure availability of supplies (vaccines, and extend the implementation area to drugs, human resource, laboratory additional areas, with a goal of extending consumables, and equipment) for anthrax activities to a national level. outbreak investigation and response • Conduct simulation exercises; training

3.2.1. Specific activities to be com- pleted in the stipulated time- (outbreak investigation, on sample frame collection, handling and transportation,

3.2.1.1. Surveillance and reporting action review, revise the plan 25 • Conduct/implement joint outbreak • Strengthen national and regional Epi-lab investigation and response networking (4 way linking)

3.2.1.3. Disease prevention and con- • Provide trainings to address surveillance trol capacity gaps and awareness for animal and public health surveillance officers • Improve NVI vaccine production capacity and the community (case definitions to meet the estimated national demand (community, suspected, probable and • Conduct test vaccine efficacy, safety, confirmed), reporting, notification, data quality and a post market assessment/ management, data analysis and mapping evaluation of the vaccine and reporting etc). • Plan and implement vaccination campaigns • Establish an inter-laboratory resource sharing networking mechanism; MoU, ToR • Establish a proper unused vaccines disposal system (expired, damaged, and 3.2.1.5. Information, Education and Com- inappropriately stored) munication • Conduct Post vaccination evaluation (using • Conduct community survey to assess appropriate method) KABP (Knowledge, attitude and behavioral practice) in targeted audiences • Training to animal health professionals and technicians on vaccine handling, transport, • Develop an evidence based national and storage and administration, cold chain regional communication strategy (identify maintenance and calibration different audience groups, appropriate channels, materials and key messages) • Ensure availability of the necessary supplies and equipment (PPE) for disinfection/ • Develop appropriate anthrax related environmental sanitation messages and concept testing based on survey findings for different audience • Conduct training for animal health, groups environmental health and public health workers on best environmental sanitary • Train professionals on communication practices (on proper disinfection, case strategy management, and carcass disposal and • Develop training manuals and provide quarantine techniques) training to public, animal and environmental

3.2.1.4. Anthrax Diagnostic Laboratory health professionals Capacity • Produce, pre-test and disseminate • Organize trainings for public and animal Information Education Communication health laboratory professionals and field • Perform field level testing of the developed staff (sample collection, preservation educational materials and transport, submission, reporting and confirmatory diagnosis) • Distribute information and educational materials to relevant sector • Procurement of necessary laboratory supplies and equipment 3.2.1.6. Multi-Sectoral Collaboration • Build capacity of the National Veterinary • Review the existing TOR and conduct regular Institute to manufacture diagnostic meeting of ATWG materials • Organize regular technical discussions • Organize regular inter-laboratory fora and meetings on data sharing, analysis, (networking, information sharing, joint plan) risk mapping, recommendation to inform 26 • Introduce anthrax rapid diagnostic field prevention and control tests; research on new testing methods • Ensure regular communication and • Strengthen a laboratory quality management reporting for the OH steering committee system; equipment maintenance and calibration system • Support establishment of regional and woreda level anthrax prevention and control • Establish a national germ bank to preserve coordination platforms (Develop TOR and circulating isolates of B. anthracis work plan for all regional TWG) • Map and linking existing public and animal health laboratories based on the assessment • Review compatibility of existing laboratory information management (LIMS and LIS) systems

3.3. PHASE 3: IMPLEMENTA- (outbreak investigation, on sample TION PHASE IN EXPANDED collection, handling and transportation, AREAS (7 YEARS) (2024- after action review, revise the plan 2030) • Conduct/implement joint outbreak During Phase 3, Ethiopia will extend the investigation and response implementation area to outside the target • Establish a joint national and regional areas, aiming at extending activities to rapid investigation and response teams a national level. Activities implemented for anthrax outbreaks at Phase 3 include selected activities • Prepare outbreak preparedness plan and successfully implemented during Phase ensure availability of supplies (vaccines, 2, applied to areas where the activity is drugs, human resource, laboratory relevant. At the end of Phase 3, Ethiopia will consumables, and equipment) for anthrax achieve its goal of substantial reduction of outbreak investigation and response the public health and economic burden of anthrax in the country. • Conduct simulation exercises; training (outbreak investigation, on sample

3.3.1. Specific activities to be com- collection, handling and transportation, pleted in the stipulated time- after action review, revise the plan frame • Conduct/implement joint outbreak

3.3.1.1. Surveillance and reporting investigation and response • Provide trainings to address surveillance 3.3.1.3. Disease prevention and capacity gaps and awareness for animal control and public health surveillance officers • Conduct test vaccine efficacy, safety, and the community (case definitions quality and a post market assessment/ (community, suspected, probable and evaluation of the vaccine confirmed), reporting, notification, data management, data analysis and mapping • Plan and implement vaccination and reporting etc). campaigns • Provide resources (mobiles, laptops…) to • Establish a proper unused vaccines improve timely and quality reporti disposal system (expired, damaged, and inappropriately stored) • Establish a wildlife anthrax surveillance system and link with the national system • Conduct Post vaccination evaluation (Sero monitoring) • Conduct a regular review meeting, workshops with stakeholders • Training to animal health professionals • Prepare and share regular joint anthrax and technicians on vaccine handling, transport, storage and administration, 27 national surveillance reports and provide cold chain maintenance and calibration feedback to the regions and woreda • Ensure availability of the necessary

3.3.1.2. Outbreak investigation supplies and equipment (PPE) for disinfection/environmental sanitation • Prepare outbreak preparedness plan and ensure availability of supplies (vaccines, • Conduct training for animal health, drugs, human resource, laboratory environmental health and public health consumables, and equipment) for anthrax workers on best environmental sanitary outbreak investigation and response practices (on proper disinfection, case management, and carcass disposal and • Conduct simulation exercises; training quarantine techniques)

3.3.1.4. Anthrax Diagnostic Laboratory • Specific activities and how they will be Capacity prioritized within the stipulated timeframe of the specific phase • Organize trainings for public and animal health laboratory professionals and field • Stakeholders that will take responsibility for staff (sample collection, preservation specific activities and transport, submission, reporting and confirmatory diagnosis) • Key indicators that will result in an activity being considered as “accomplished” • Procurement of necessary laboratory supplies and equipment • Build capacity of the National Veterinary Institute to manufacture diagnostic materials • Organize regular inter-laboratory fora (networking, information sharing, joint plan)

3.3.1.5. Information, Education and Communication • Produce, pre-test and disseminate Information Education Communication • Perform field level testing of the developed educational materials • Distribute information and educational materials to relevant sectors

3.3.1.6. Multi-Sectoral Collaboration • Review the existing TOR and conduct regular meeting of ATWG • Organize regular technical discussions and meetings on data sharing, analysis, risk mapping, recommendation to inform prevention and control 28 • Ensure regular communication and reporting for the OH steering committee

3.4. WORK PLAN FOR IMPLEMENTING PHASES-ONE The implementation of each Phase’s activities will be based on a phase-specific action plan that will be developed by the Ethiopian anthrax multi-sectoral technical working group. The phase-specific action plans will be composed of documents that will supplement the national strategy by providing detail on the following items: Table 5: NATIONAL ANTHRAX PREVENTION AND CONTROL STRATEGIC PLAN (TWO YEAR WORK PLAN) Vision: To see Anthrax is no more a significant public and animal health problem in Ethiopia by 2030 Mission: To significantly reduce and ultimately control the public health impact of anthrax in humans and animals in Ethiopia through sustained surveillance, laboratory diagnosis, prevention and control system and community awareness. Goal: To prevent and control Anthrax in human and animals in Ethiopia Note: The detailed work plan for implementation of Phase-one activities are listed on the table below (Table 5), Strategic Plan Owner- EPHI/MoLF Phase 1: Planning, Preparation and Assessment Phase (2018-2019) Monitoring- For Completed Quarterly Progress: Select one of the On Progress Option in the Drop Down Menu Not Started Outcomes Outcome1.1. The strength, Weakness/gap, Opportunity Strategy and Threat in the existing Specific Activities Detail activities surveillance system will be identified and Addressed challenges/gaps 2018 2019 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Responsibility St 1: Enhancing Evaluate the existing Review of the existing surveillance system and data base EPHI/MOLF Surveillance and surveillance system Reporting Systems and databases Prepare checklist to evaluate existing surveillance systems EPHI/MOLF Evaluate the process of case reports (sensitivity, completeness EPHI/MOLF and timeliness of data flow; and association with animal and human case)/surveillance evaluation on selected sites Forward recommendations based on assessment result(Writing a report) EPHI/MOLF 29 Develop anthrax Review existing local and international anthrax surveillance EPHI/MOLF surveillance guideline guidelines Prepare a concept note EPHI/MOLF Review of literature and other relevant documents EPHI/MOLF Preparation of draft guideline (write shop) EPHI/MOLF Finalize the guideline EPHI/MOLF Organize a validation workshop EPHI/MOLF printing and dissemination EPHI/MOLF Formulate a team of surveillance in EWCA EWCA/ MOLF Establish a wildlife Prepare a plan/guidance to establish surveillance system EWCA/MOLF anthrax surveillance system and link with the national system Fulfill the necessary supplies/requirements EWCA/MOLF Initiate surveillance activities EWCA/MOLF Identify the necessary supplies/material EPHI/MOLF Provide resources Procurement of the materials EPHI/MOLF (mobiles, laptops…) to improve timely and EPHI/MOLF quality reporting Distribution of the materials Prepare training materials (presentations, participants guide and EPHI/MOLF instructors guide) Outcome 1.2: Information Provide trainings to Preparation for the training (prepare the Agenda, Venue, Hotel EPHI/MOLF sharing mechanism among address surveillance accommodation, invitation of participants etc…) sectors will be established capacity gaps Deliver the training EPHI/MOLF Write training report/evaluation report EPHI/MOLF Review and modify Review existing anthrax reporting formats/channels and identify EPHI/MOLF standard anthrax the limitations reporting format/ Prepare a draft SOP and reporting formats EPHI/MOLF channels and SOP for inter sectoral EPHI/MOLF Share the draft work to TWD members to be reviewed and information sharing commented Compile the suggestions/comments and finalize the document EPHI/MOLF Printing and dissemination EPHI/MOLF Review and Monitoring of surveillance data (regularly) EPHI/MOLF Give feedback for reporting sites EPHI/MOLF Prepare and share regular joint anthrax Sharing of the finding/surveillance data (MoLF and EPHI on a EPHI/MOLF national surveillance regular basis/Monthly) reports Plan and implement the possible actions EPHI/MOLF Summarizing and writing report (regularly) EPHI/MOLF 30 Plan to conduct a Meeting/Panel/workshop (Identifying the agendas, venue, involved stakeholders etc...) EPHI/MOLF Conduct a regular review meeting, Official communication with the stakeholders (invitation letter) EPHI/MOLF workshops with Preparation on presentations for each stakeholders (CDC, EPHI, EPHI/MOLF stakeholders MoLF, NVI, NAHDIC) Meeting,/Panel/Work shop EPHI/MOLF Perform retrospective Collection and analysis of retrospective anthrax surveillance data EPHI/MOLF analysis and writing a manuscript EPHI/MOLF publication of surveillance data Publish the materials EPHI/MOLF Outcome 2.1: Strengthened Develop a national Prepare a concept note EPHI/MOLF St 2: Strengthening the outbreak investigation guideline and Outbreak and response system SOPs for outbreak investigation and through development of investigation and response System joint preparedness plans response and activities Review of literature and other relevant documents EPHI/MOLF Preparation of draft guideline, SOP (write shop) EPHI/MOLF share the document for TWG members and Conduct a meeting/ EPHI/MOLF workshop to discuss on the draft document Finalize the guideline and dissemination EPHI/MOLF Prepare a concept note EPHI/MOLF Prepare outbreak Review of literature and other relevant documents EPHI/MOLF preparedness Preparation of preparedness plan (write shop) EPHI/MOLF plan and ensure availability of share the document for TWG members and Conduct a meeting/ EPHI/MOLF necessary supplies workshop to discuss on the draft document Finalize the EPRP and dissemination EPHI/MOLF Prepare for stakeholders meeting EPHI/MOLF Establish a joint national and regional Stakeholders meeting (identify the expertise from each sector EPHI/MOLF rapid investigation and prepare a roster) and response teams Formulate a team of RRT EPHI/MOLF for anthrax outbreaks Develop SOP for RRT activities EPHI/MOLF EPHI/MOLF Prepare training materials (presentations, participants guide and instructors guide) Conduct simulation EPHI/MOLF Preparation for the training (prepare the Agenda, Venue, Hotel exercises; training accommodation, invitation of participants etc…) Deliver the training EPHI/MOLF Write training report/evaluation report EPHI/MOLF 31 Prepare for field work (meeting, identify all the necessary EPHI/MOLF Conduct/implement supplies) joint outbreak investigation and Deploy RRT to the affected area EPHI/MOLF response Implementation of joint investigation and response EPHI/MOLF Outcome 3.1: Improved NVI/MOLF vaccine production, St. 3: Enhancing distribution, storage/ Prevention and handling and administration Control of Anthrax system that meets the Asses/estimate the demand at national and national demand regional level production, Develop a concept note distribution and storage capacity of Review of the existing situation NVI/MOLF anthrax vaccine Writing a proposal for estimation of vaccine demand NVI/MOLF Conduct a baseline survey (Onsite/field) NVI/MOLF Writing a baseline survey report and share with TWG NVI/MOLF prepare a concept note and proposal NVI/MOLF Share the concept note and proposal to TWG and finalize the NVI/MOLF proposal (work plan) Conduct cost Identify the most sustainable vaccination programs and degree NVI/MOLF effectiveness and of public-private shared responsibilities feasibility of animal vaccination Modeling of the coast effectiveness with government NVI/MOLF perspective and producers perspective Writing a report NVI/MOLF Share the report for the relevant sectors NVI/MOLF Support VDFACA to NVI/MOLF/ undertake vaccine Writing a concept note VDFACA efficacy, safety, NVI/MOLF/ quality and a post Meeting with VDFACA officials and identify SWOT VDFACA market assessment/ evaluation NVI/MOLF/ Address the identified gaps VDFACA Review existing anthrax Vaccine management system (local and NVI/MOLF/ international practices) VDFACA Prepare a draft SOP NVI/MOLF/ Develop vaccine VDFACA supply chain management Share the draft work to TWD members to be reviewed and NVI/MOLF/ system and SOP for commented VDFACA monitoring of vaccine NVI/MOLF/ chain, Compile the suggestions/comments and finalize the document VDFACA 32 Printing and dissemination NVI/MOLF/ VDFACA Review existing PPP and vaccination activities/plan (local and NVI/MOLF/ international practices) VDFACA Prepare a draft Vaccination plan (Workshop) NVI/MOLF/ VDFACA Establish a PPP and implementation Share the draft plan to TWD members to be reviewed and NVI/MOLF/ of vaccination commented VDFACA campaigns NVI/MOLF/ Compile the suggestions/comments and finalize the document VDFACA NVI/MOLF/ Conduct Vaccination on the selected areas VDFACA Prepare training materials (presentations, participants guide and NVI/MOLF/ instructors guide) VDFACA provide Training Preparation for the training (prepare the Agenda, Venue, Hotel NVI/MOLF/ to animal health accommodation, invitation of participants etc…) VDFACA professionals and technicians on NVI/MOLF/ vaccine management Deliver the training VDFACA NVI/MOLF/ Write training report/evaluation report VDFACA Review existing environmental sanitation practice (local and NVI/MOLF/ international practices) VDFACA Develop SOP for Prepare a draft SOP NVI/MOLF/ Outcome 3.2: Improved the proper infected VDFACA environmental sanitation carcass and practice nationwide fomite disposal, Share the draft work to TWD members to be reviewed and NVI/MOLF/ environmental commented VDFACA sanitation, animal NVI/MOLF/ movement control Compile the suggestions/comments and finalize the document VDFACA system/isolation NVI/MOLF/ Printing and dissemination VDFACA Ensure availability Identify the necessary supplies/material ( access and demand) EPHI/MOLF of the necessary Procurement of the materials EPHI/MOLF supplies and equipments (PPE) Distribution of the materials EPHI/MOLF Prepare training materials (presentations, participants guide and EPHI/MOLF instructors guide) Conduct training on Preparation for the training (prepare the Agenda, Venue, Hotel EPHI/MOLF best environmental sanitary practices accommodation, invitation of participants etc…) Deliver the training EPHI/MOLF 33 Write training report/evaluation report EPHI/MOLF Review existing laboratory diagnostic capacity assessment tools/ EPHI/NAHDIC checklists EPHI/NAHDIC Assess national and Adapt/prepare the checklists and include anthrax diagnostic regional of public capacity assessment questions and animal health Organize review and validation workshops EPHI/NAHDIC laboratory capacity for anthrax diagnostic Conduct assessment of national and regional public and animal EPHI/NAHDIC testing health laboratories anthrax diagnostic capacity and identify limitations (on site visit) Writing a report EPHI/NAHDIC Compile sector specific assessment reports EPHI/NAHDIC Prepare a laboratory Support preparation of the lab development plan based on EPHI/NAHDIC Outcome 4.1: Improved Diagnostic capacity identified gaps anthrax testing capacity of plan for anthrax the national and selected (based on identified Organize a consultation meeting to review the development EPHI/NAHDIC regional laboratories gaps) and SOP plan Finalize the plan and disseminate to the relevant sectors EPHI/NAHDIC St. 4: Improving Anthrax Diagnostic Procurement of Identify the necessary supplies/material ( access and demand) EPHI/NAHDIC Laboratory Capacity necessary laboratory EPHI/NAHDIC Procurement of the materials supplies and equipment Distribution of the materials EPHI/NAHDIC Prepare training materials (presentations, participants guide and EPHI/NAHDIC instructors guide) Organize trainings on Preparation for the training (prepare the Agenda, Venue, Hotel EPHI/NAHDIC anthrax laboratory accommodation, invitation of participants etc…) testing procedures Deliver the training EPHI/NAHDIC Write training report/evaluation report EPHI/NAHDIC Review compatibility of existing laboratory information EPHI/NAHDIC management (LIMS and LIS) systems Map and linking EPHI/NAHDIC Outcome 4.2: Enhanced existing public Establish an inter-laboratory resource sharing networking inter sectoral inter and animal health mechanism; MoU, ToR laboratory networking laboratories based on EPHI/NAHDIC the assessment Organize regular inter-laboratory fora (networking, information sharing, joint plan) Reporting (regular meeting) EPHI/MOLF 34 Assessment Collect available communication and information materials EPHI/MOLF of existing (bulletins, posters, pamphlets, …) on anthrax prevention and communication control activities and EPHI/MOLF materials (situational Identify type and contents of communication materials which analysis) can further be produced St. 5: Enhancing Prepare a concept note EPHI/MOLF Information, Outcome 5.1: Improved Prepare a proposal (questioners, identify sites) EPHI/MOLF Education and Conduct community awareness of the survey to assess KABP Communication community on the risks and Conduct KABP survey (on identified sites) EPHI/MOLF system prevention of anthrax Writing and disseminate a report EPHI/MOLF Review of standard communication strategy EPHI/MOLF Develop an evidence EPHI/MOLF Review of the KABP assessment based national and regional Develop appropriate anthrax related messages EPHI/MOLF communication Pre-test of draft IEC/BEC materials EPHI/MOLF strategy Produce and disseminate IEC/BEC materials EPHI/MOLF Review of the existing educational materials for professionals EPHI/MOLF Assess the knowledge Prepare a proposal (questioners, identify sites) EPHI/MOLF and skills (KAP) of the professionals Conduct KABP survey (on identified sites) EPHI/MOLF Writing and disseminate a report EPHI/MOLF Outcome 5.2: Skilled health Review of standard training manuals EPHI/MOLF professionals on IEC system Develop training Review of the KAP assessment EPHI/MOLF manuals and perform Develop draft training manuals (workshop) EPHI/MOLF field level test of the materials Finalize the training manual EPHI/MOLF Printing and disseminate training manuals EPHI/MOLF Prepare training materials (presentations, participants guide and EPHI/MOLF instructors guide) Provide training to public, animal and Preparation for the training (prepare the Agenda, Venue, Hotel EPHI/MOLF environmental health accommodation, invitation of participants etc…) professionals Deliver the training EPHI/MOLF Write training report/evaluation report EPHI/MOLF 35 Review the implemented activities (reports, TOR..) EPHI/MOLF Review the existing TOR and conduct regular meeting of TWG Plan to conduct a Meeting/Panel/workshop on Anthrax EPHI/MOLF surveillance system (Identifying the agendas, venue, involved Regular stakeholders etc...) Outcome 6.1: Strengthened communication and existing national one health reporting for the Official communication with the stakeholders (invitation letter) EPHI/MOLF platforms Anthrax TWG and OH Preparation on presentations for each stakeholders (CDC, EPHI, EPHI/MOLF steering committee MoLF, NVI, NAHDIC, FAO...) Meeting,/Panel/Work shop (Identifying SWOT) EPHI/MOLF Prepare joint and sectorial activity/summary reports EPHI/MOLF Avail the reports during OHSC meetings EPHI/MOLF St. 6: Strengthening Develop an preparation of an advocacy plan EPHI/MOLF Multi-Sectoral advocacy plan to Organize/use high level events/workshops to advocate and get EPHI/MOLF Collaboration obtain buy-in from endorsement on anthrax prevention and control governmental and non-governmental Share the developed strategic plans, guidelines, SOPs and EPHI/MOLF stakeholders materials for leadership approval Organize a stakeholders validation workshop of the national EPHI/MOLF Outcome 6.2: Endorsed/ anthrax prevention and control strategy valid national anthrax Obtain official prevention and control endorsement of Finalize the document based on inputs from the validation EPHI/MOLF strategic plan anthrax plan from all workshop relevant ministries and Printing and dissemination for the relevant sectors and funding EPHI/MOLF agencies Secure potential Identify the possible source of funding EPHI/MOLF source of funding for Submit the strategic plan and financial plan to relevant funding EPHI/MOLF implementation of agencies the plan 36 Develop a monitoring and evaluation plan /check list EPHI/MOLF Prepare for supervision (identifying the sites, date of supervision, involved stuffs and prepare required materials) EPHI/MOLF Onsite supervision EPHI/MOLF Monitoring of each Writing compiled supervision report EPHI/MOLF activity Share the report with the concerned body (TWG) EPHI/MOLF Monitoring Preparation for a review meeting (prepare the Agenda, Venue, etc…) EPHI/MOLF Review meeting (identify SWOT and put possible recommendation to be implemented) EPHI/MOLF Writing a report and dissemination EPHI/MOLF Review of the planned activities and outcomes EPHI/MOLF Prepare an evaluation plan/checklist EPHI/MOLF Intreme evaluation of the phase 1 Conduct an evaluation on the effectiveness of the implemented Evaluation activities (onsite visit) EPHI/MOLF Writing a report EPHI/MOLF Organize an evaluation workshop EPHI/MOLF 37

3.5 Monitoring and Evaluation Monitoring and evaluation is the routine and continuous tracking of planned activities using a set of indicators to assess whether objectives are being achieved. The process can be used to measure the effectiveness and feasibility of programs focused on proper prevention and control of anthrax in humans and animals. The time frame for monitoring of each activity will be as described in the work plan (Table 6, above). The effectiveness of each activities planned in Phase-one will be measured and monitored using a measurable indicators as indicated in the table below. Table 6: ETHIOPIA - ANTHRAX PERFORMANCE MONITORING PLAN Strategy Output 1: Enhancing Surveillance and Reporting Systems Activity Sub-activities Measurable Means of indicators of Deliverable Target verification achievement Assess the Evaluate the existing Existing surveillance Gaps, 1 Assessment existing Anthrax surveillance systems system and database Recommendations and report surveillance and databases described Propose a solutions of system the existing surveillance system and database documented Develop anthrax Existence of anthrax Endorsed Anthrax 1 Anthrax surveillance guideline surveillance guideline surveillance guideline surveillance guideline Establish a wildlife Existence of an wildlife anthrax 1 Wildlife anthrax anthrax surveillance interoperable wildlife surveillance results Surveillance system and share anthrax and national integrated in to MoLF reports information with surveillance system national surveillance MOLF system Provide resources # of reporting Reporting equipment TBD Asset/hand over (mobiles, laptops…) equipment distributed apportioned (After the registry, Timely to improve timely and evaluation) and complete quality reporting Surveillance reports Train professionals # of professionals Competencies anthrax 120 Training report (from all sectors) to trained in anthrax surveillance acquired Participants address surveillance surveillance capacity gaps Establish a Review and modify Existence of modified Modified anthrax 8 reporting Standardized mechanism standard anthrax anthrax reporting reporting format and format and Surveillance for reporting, reporting format/ format and SOP SOP in place 1 SOP reports; SOP feedback and channels and SOP information for inter sectoral sharing information sharing Prepare and share # of joint anthrax Joint anthrax national 8 Surveillance regular joint anthrax national surveillance surveillance reports reports 38 national surveillance reports reports produced shared Conduct a regular # of stakeholder Stakeholder meetings 4 Meeting minutes review meeting, meetings Conducted convened workshops with stakeholders Perform Joint Retrospective burden Retrospective burden N/A Submitted retrospective analysis of anthrax described of anthrax documented Manuscript/ and publication of and published publication surveillance data (Research paper) Strategy Output 2: Strengthening Outbreak Management system Activity Sub-activities Measurable Means of indicators of Deliverable Target verification achievement Develop a Joint Develop a national Existence of national National guideline 1 National guideline preparedness, guideline and guideline and SOPs for and SOPs for outbreak and SOP investigation and SOPs for outbreak outbreak investigation investigation and response plan investigation and and response response in place response Prepare outbreak Existence of outbreak Endorsed Outbreak 1 Preparedness plan preparedness plan preparedness plan; preparedness plan; Establish a joint # of joint national Joint national and 3 RRT roster national and regional and regional anthrax regional rapid anthrax rapid rapid investigation investigation and investigation and and response teams response teams for response teams established. anthrax outbreaks in place. Conduct outbreak # of professionals Competencies on 120 Simulation management/ trained in anthrax outbreak Participants training report response simulation anthrax outbreak management acquired (>75% pass exercises management competency test) Conduct/implement Proportion of Joint outbreak >90% of outbreak joint outbreak suspected anthrax investigations and suspected investigation and investigation and cases jointly response conducted anthrax response reports response investigated cases jointly investigated Strategy Output 3: Enhancing Prevention and Control of Anthrax Activity Sub-activities Measurable Means of indicators of Deliverable Target verification achievement Improve Asses/estimate the National demand Gaps and N/A Assessment anthrax vaccine national demand against production, recommendations of reports production, production, distribution and production, distribution safety, quality, distribution and storage of anthrax and storage of anthrax efficacy, storage capacity of vaccine described vaccine documented distribution and anthrax vaccine rational use in animals Conduct cost Alternative Alternative vaccination N/A Study report effectiveness and vaccination models/ models/strategies feasibility study of strategies described documented animal vaccination Increase Anthrax Increment of National demand TBD NVI vaccine vaccine production vaccination for anthrax vaccine production report capacity production level production fulfilled Improve vaccine supply chain management system Presence of Updated vaccine supply chain management system Vaccine supply chain management system improved N/A Assessment reports 39 Develop/Update # of SOPs developed Endorsed SOPs for TBD SOPs SOP for production, for production, production, distribution, distribution, storage distribution, storage storage and delivery and delivery and delivery Establish Sanitary Number of contractual Enhanced vaccination TBD Signed PPP mandate contract agreements (PPP) coverage and efficiency contracts (PPP) for vaccination with PPP involvement campaigns train animal health # of people trained Competencies on 80 Training report professionals and on anthrax vaccine anthrax vaccine technicians on management management acquired vaccine management Improve sanitary Develop SOP for # of SOPs developed SOPs for infected TBD SOPs measures proper disposal of for proper infected carcass and fomite (Carcass disposal, infected carcass and carcass and disposal, environmental disinfection, fomite, environmental fomite disposal, sanitation, animal Avoid contact sanitation, animal environmental movement control and with livestock) movement control sanitation, animal isolation in place. system/isolation movement control system/isolation Ensure availability Proportion of high Sustainable PPE >75% of Procurement of the necessary risk professionals supplies, in place identified records supplies and equipped with PPE sites equipment (PPE) received the supplies Conduct training on # of people trained Competencies on 80 Training report best environmental on environmental environmental sanitary sanitary practices sanitary practice practice Strategy Output 4: Improving Anthrax Diagnostic Laboratory Capacity Activity Sub-activities Measurable Means of indicators of Deliverable Target verification achievement Improve national Assess national #, list of laboratories Gaps and 1 Assessment and regional and regional public assessed for anthrax recommendations of reports animal and public and animal health diagnostic testing anthrax diagnostic health laboratory laboratory capacity capacity (16 Animal testing capacity capacity for anthrax diagnostic health and 5 public documented. for anthrax testing health labs assessed diagnostic testing (including NAHDIC, NVI and EPHI) # of laboratory Endorsed Laboratory 1 Project report development plans development plans produced (1 for public and 1 for animal health sector Prepare a laboratory # number of SOPs Endoresed SOPs 4 SOPs development plan (Sample collection, available for use and SOP (based on handling & biosafety, identified gaps) preservation & cold chain, transportation and submission, testing and reporting) developed (for each sector) Procurement and # of laboratories Laboratory supplies and 4 Asset register distribution of equipped with the equipment procured necessary laboratory necessary supplies and distributed supplies and and equipment equipment procured Train lab staff on # of professional staff Competencies in 120 Training reports anthrax laboratory trained on anthrax anthrax laboratory testing procedures laboratory testing testing procedures 40 Establish and Map and link existing procedures. #, list of public acquired. Public and animal health N/A Assessment enhance inter public and animal and animal health laboratories mapped. report sectoral inter health laboratories laboratories mapped. laboratory based on the #, list of public Interoperable/ 15 Laboratory networking assessment and animal health linked LIM and other reports (public and laboratories with communication systems animal health) interoperable(linked) LIMs laboratory information systems Strategy Output 5: Enhancing Information, Education and Communication system Activity Sub-activities Measurable Means of indicators of Deliverable Target verification achievement Improve Assessment # of institutions Gaps in the existing 7 Assessment community of existing assessed for existing communication and report awareness of the communication communication and advocacy materials risks, transmission activities and advocacy materials documented. and prevention of materials (situational anthrax analysis) Conduct community Findings from Gaps and 1 KAPB Survey survey to assess KABP the KABP survey recommendations reports recommendations described. from the KABP survey documented. Develop an evidence Existence of Endorsed evidence 1 Communication based national an evidence based national strategy communication based national communication strategy document strategy communication in place. strategy. Develop appropriate Proportion of Tested anthrax related 100% Field test report anthrax related developed anthrax messages available messages1 and related messages concept testing for tested different audience groups Disseminate # of disseminated IEC materials availed 5000 Dissemination Information materials to target areas/ report Education communities Communication (IEC)/Social Behavior Change Communication (SBCC) materials Improve the Assess the knowledge #, list of professionals Gaps and 150 Study report knowledge and and skills (KAP) of the assessed recommendations of skill of health/ professionals professional’s skills veterinary documented professionals Develop training #, list of training Endorsed Training 2 Training Manual manuals and perform manuals developed manuals developed field level test of the materials Provide training to # of professionals Competencies on IEC 80 Training reports public, animal and using the training acquired environmental health manual professionals Distribute information # of information and Educational materials 200 Educational and educational educational materials availed to targets materials materials to relevant distributed (copies) sectors 41 Strategy Output 6: Strengthening Multi-Sectoral Collaboration Activity Sub-activities Measurable Means of indicators of Deliverable Target verification achievement Strengthen Regular communication Proportion of OH Recommendations N/A Steering existing national and reporting for the OH steering committee implemented committee platforms steering committee recommendations communique (OHSC, Anthrax addressed TWG) Obtain buy Develop an advocacy plan Existence of an Advocacy plan in 1 Project report in and secure to obtain buy-in from advocacy plan place resources for governmental and non- implementation governmental stakeholders of the Anthrax Obtain official endorsement Existence of endorsed EndorsemeD N/A Project report prevention and of the Anthrax prevention national anthrax of anthrax plan control strategic and control strategic plan prevention and obtained plan from all relevant ministries control strategic plan and stakeholders Secure potential source of Sum of resources Funding secured TBD Financial funding for implementation mobilized agreement of the plan NOTE: Endorsement of all the documents listed in the table will be by the director General of each relevant sectors The target stated in the table is only for Phase 1(Two years plan) activities and it doesn’t indicate the target of all the three Phases (which will be determined based on the evaluation of Phase one implementation statuses All the assessment findings in Phase one will serve as a baseline data Laboratory testing: including sample collection, transport, submission, lab analysis, interpretation and reporting Laboratory Information Systems; may include LIMS and other communication systems Institutions assessed; Ministry of Health (EPHI), Ministry of Livestock and Fisheries, Ministry of Culture and Tourism (EWCA), Ministry of Environment, Forest and Climate Change, Professional associations (EVA, EPHA), Development partners (OSU, CDC, FAO, etc) Message tools: posters, flyers, brochures, media messages, etc. 42 4. BUDGET SUMMARY An estimated birr 384,200,272.00 (14,125,010.00 USD) is required for the implementation of activities under the three Phases (2018-2030). Of the total estimated coast 16.41% (63,052,864.00 birr/721, 2,318,120.00 USD) will be for the implementation of planned activities under Phase- one of the strategic plan, the remaining 34.38% (45,233,491.20 birr/132,084,288.00 USD) and 49.21% (189,063,120.00 birr/6,950,850.00 USD) will be for the implementation of planned activities under Phase-two and Phase-three aiming to expand at regional level. From the total budget under Phase-one, the majority (85.2%) will be utilized for mass vaccination campaign and laboratory capacity building at national level (NAHDIC and Microbiology laboratory in EPHI) and the remaining 9.3% of the estimated coast also for the capacity building of professionals through training and for development of relevant documents through workshops. The estimated travel coasts (5.54%) will be for in-country travels for survey studies and Assessment activities that involves additional stuffs for data collection in identified hot-spot areas. This assessment activities will include evaluation of the surveillance system by conducting surveys in selected areas, for a survey study on the awareness level of the community which will serve as a baseline information. The allocated budget will help the national human health and animal health sectors to strengthen the surveillance and outbreak investigation and response capacity for anthrax in animals and humans in the next two year, through laboratory capacity building at national level, improvement of workforce capacity in surveillance, Outbreak investigation and laboratory testing knowledge and skills. Table 7: Budget Summary by components of the Anthrax Prevention and Control Strategic Framework (2018-2030) Phase 1 Phase 2 Phase 3 Strategy (by Total Costs outcomes) Total Costs Total Costs Total Costs Total Costs Total Costs (local (USD) (local Currency) (USD) (local Currency) (USD) Currency) St 1: Enhancing Surveillance and Reporting Systems $1,806,624.00 $66,420.00 $4,669,696.00 $171,680.00 $6,718,944.00 $247,020.00 Outcome1.1. The strength, Weakness/gap, Opportunity and Threat in the existing surveillance system will be identified and Addressed challenges/ gaps $1,421,472.00 $52,260.00 $3,899,392.00 $143,360.00 $5,563,488.00 $204,540.00 Outcome 1.2: Information sharing mechanism among sectors will be established St 2: Strengthening $385,152.00 $14,160.00 $770,304.00 $28,320.00 $1,155,456.00 $42,480.00 43 Outbreak investigation and response System $961,248.00 $35,340.00 $1,754,944.00 $64,520.00 $1,012,928.00 $37,240.00 Outcome 2.1: Strengthened the outbreak investigation and response system through development of joint preparedness plans and activities $961,248.00 $35,340.00 $1,754,944.00 $64,520.00 $1,012,928.00 $37,240.00 St. 3: Enhancing Prevention and Control of Anthrax $2,439,840.00 $89,700.00 $11,333,696.00 $416,680.00 $6,164,064.00 $226,620.00 Outcome 3.1: Improved vaccine production, distribution, storage/ handling and administration system that meets the demand at national and regional level $1,671,168.00 $61,440.00 $5,803,936.00 $213,380.00 $3,619,776.00 $133,080.00 Outcome 3.2: Improved the environmental sanitation practice nationwide $768,672.00 $28,260.00 $5,529,760.00 $203,300.00 $2,544,288.00 $93,540.00 St. 4: Improving Anthrax Diagnostic Laboratory Capacity $53,657,712.00 $1,972,710.00 $106,336,224.00 $3,909,420.00 $159,014,736.00 $5,846,130.00 Outcome 4.1: Improved anthrax testing capacity of the national and selected regional laboratories $53,657,712.00 $1,972,710.00 $106,336,224.00 $3,909,420.00 $159,014,736.00 $5,846,130.00 Outcome 4.2: Enhanced inter sectorial inter laboratory networking St. 5: Enhancing Information, Education and Communication system $2,400,672.00 $88,260.00 $4,416,192.00 $162,360.00 $9,005,376.00 $331,080.00 Outcome 5.1: Improved awareness of the community on the risks and prevention of anthrax $979,200.00 $36,000.00 $1,958,400.00 $72,000.00 $2,937,600.00 $108,000.00 Outcome 5.2: Skilled health professionals on IEC system $1,421,472.00 $52,260.00 $2,457,792.00 $90,360.00 $6,067,776.00 $223,080.00 St. 6: Strengthening Multi- Sectorial Collaboration $285,328.00 $10,490.00 $570,656.00 $20,980.00 $570,656.00 $20,980.00 Outcome 6.1: Strengthened existing multi-sectorial collaboration $285,328.00 $10,490.00 $570,656.00 $20,980.00 $570,656.00 $20,980.00 Monitoring $1,175,040.00 $43,200.00 $2,350,080.00 $86,400.00 $4,700,160.00 $172,800.00 Evaluation $611,728.00 $22,490.00 $1,223,456.00 $44,980.00 $2,446,912.00 $89,960.00 Total Budget $63,052,864.00 $2,318,120.00 $132,084,288.00 $4,856,040.00 $189,063,120.00 $6,950,850.00 Grand Total $384,200,272.00 $14,125,010.00 Note: The budget narrative for the implementation of Phase-I activities is presented in annex 5.1, below. 5. ANNEXES

5.1 BUDGET NARRATIVE Note: the budget narratives described below is only for implementation of planned activities under Phase-I of the strategic plan. Justification: 44 A. Assessment Activities Strategy 1: Enhancing Surveillance and Reporting Systems Outcome 1.1: The strength, Weakness/gap, Opportunity and Threat in the existing surveillance system will be identified and addressed challenges/gaps

1.1.3. Evaluate the process of case reports (sensitivity, completeness and timeliness of data flow; and association with animal and human case)/surveillance evaluation on selected sites Cost Average # Average # of Total Total Costs Total Strategy Items Per Day of Days Per Participants Rounds of (local Costs USD (USD) assessment Per assessment assessment Currency) 1 Participants Per Diem $20.00 10 20 1 $4,000.00 $108,800.00 Participants Trav- 2 el/ Transportation $100.00 10 20 1 $20,000.00 (Average) $544,000.00 Sub total $24,000.00 $652,800.00 Justification Evaluating the existing surveillance activities in the selected sites will provide the strengths and weakness of the surveillance system. Underreporting and incompleteness of surveillance data might leads to delayed response as a result of late detection of anthrax cases both in animals and animals. Evaluating the sensitivity, flexibility, quality and other factors of the surveillance and reporting system with respect to anthrax helps to identify the gaps. The evaluation will be carried out on selected hotspot areas by using checklists and standard questioners. A total of 5 surveillance officers (EFLTP residents) and 15 data collectors will be involved in the evaluation. The allocated budget will be used for perdiem and other logistics like transportation and stationary. Strategy 3: Enhancing Prevention and Control of Anthrax Outcome 3.1: Improved vaccine production, distribution, storage/handling and ad- ministration system that meets the demand at national and regional level

3.1.1. Asses/estimate the national demand production, distribution and storage capacity of anthrax vaccine (baseline survey) Total Cost Average # Average # of Total Total Costs Strategy Items Per Day of Days Per Participants Costs Rounds (local (USD) assessment Per assessment USD Currency) S3 Participants Per Diem $20.00 10 5 1 $1,000.00 $27,200.00 Participants Travel/ S3 Transportation $100.00 10 5 1 $5,000.00 (Average) $136,000.00 Sub total $6,000.00 $163,200.00 Justification: National veterinary institute have been producing and distributing anthrax vaccine for animals. The exact animal population that requires anthrax vaccine provides the demand and comparing the production capacity of NVI will help to identify the gaps in the demand and production level of the vaccine. Currently such information is not properly documented and/ or further assessment will be necessary. Furthermore, the vaccine distribution and storage capacity in various regions/areas were not adequately assessed. The allocated 163,200.00 birr will help to identify the strengths and gaps in vaccine production and distribution (the overall vaccination system); used for perdiem and other logistics like transportation and stationary.

3.1.2. Conduct cost effectiveness and feasibility study of animal vaccination 45 Cost Total Average # Average # of Total Per Total Costs Strategy Items of Days Per Participants Costs Day Rounds (local assessment Per assessment USD (USD) Currency) S3 Participants Per Diem $20.00 10 5 1 $1,000.00 $27,200.00 Participants Travel/ S3 $100.00 10 5 1 $5,000.00 Transportation (Average) $136,000.00 Sub total $6,000.00 $163,200.00 Justification: Understanding of the Coast effectiveness and feasibility of the existing animal vaccination activities is better to strengthen and/or using better vaccination mechanisms adapted from international experiences. The allocated 6,000 USD will help to assess cost effectiveness and feasibility of currently used animal vaccination system. Strategy 4: Improving Anthrax Diagnostic Laboratory Capacity Outcome 4.1: Improved anthrax testing capacity of the national and selected regional laboratories

4.1.1. Conduct assessment of national and regional public and animal health laboratories anthrax diag- nostic capacity and identify limitations (on site visit) Average # Average # of Total Costs Cost Per Total Total Strategy Items of Days Per Participants (local Day (USD) Rounds Costs USD assessment Per assessment Currency) Participants Per S4 $20.00 10 20 1 $4,000.00 Diem $108,800.00 Participants Travel/ S4 Transportation $100.00 10 20 1 $20,000.00 (Average) $544,000.00 Sub $24,000.00 $652,800.00 total Justification The overall confirmation mechanism for anthrax in animals and humans case is based on the clinical findings and simple staining practices. Such diagnostics practices will provide incomplete evidence on the identification of anthrax and which might leads to false datas. Furthermore absence of laboratory diagnostic capacity for anthrax in veterinary and human health sector will affect the early response, prevention and control efforts towards anthrax. The allocated 652,800.00 birr will help to Conduct assessment of national and regional public and animal health laboratories anthrax diagnostic capacity and identify limitations (on site visit). The assessment will be conducted by four team (5 members in one team) in five selected regions. The assessment of national and regional microbiology laboratories will be carried out using standard checklists that helps to assess their capacity in terms of facilities, supplies, reagents and skilled laboratory professionals. The identified gaps based on the assessment will be addressed and improved for better confirmatory capability at least at national and some selected regional levels. The allocated budget will be used to cover the logistics and perdiem cost of the participants in the assessments. Strategy 5: Enhancing Information, Education and Communication system Outcome 5.1: Improved awareness of the community on the risks and prevention of anthrax 5.1.2.Conduct KABP survey (on identified sites) Cost Average # Average # of Total Costs Total Total Costs Strategy Items Per Day of Days Per Participants Per (local Rounds USD 46 Participants Per (USD) assessment assessment Currency) S5 $20.00 10 30 1 $6,000.00 Diem $163,200.00 Participants Travel/ S5 Transportation $100.00 10 30 1 $30,000.00 (Average) $816,000.00 Sub total $36,000.00 $979,200.00

5.2.1. Conduct KABP survey (on identified sites for professionals) Average # of Cost Average # Participants Total Total Costs Total Costs (local Strategy Items Per Day of Days Per Per Rounds USD Currency) (USD) assessment assessment S5 Participants Per Diem $20.00 10 20 1 $4,000.00 $108,800.00 Participants Travel / S5 $100.00 10 20 1 $20,000.00 Transportation (Average) $544,000.00 Sub total $24,000.00 $652,800.00 Justification: The allocated budget will be used for the assessment of the knowledge, skill and behavioral attitudes in the community and also health professionals towards the risks of encountering anthrax and the prevention measures. Standard questioners will be prepared and the data collection will be done by trained data collectors. For this activity five teams will be formulated having four data collector, one supervisor and one coordinator. Each team will be assigned in selected one region and a total of five regions will be covered in the survey. The finding will be published and documented. This will give a clear picture in the awareness of the community and leads to develop appropriate IEC materials and systems for improving the awareness of the community. Monitoring and evaluation 7. 1 Monitoring of each activity (Onsite supervision) Average # of Cost Average # Total Costs Participants Total Rounds of Total Costs Strategy Items Per Day of Days Per (local Per supervision USD (USD) assessment Currency) assessment Participants Per S7 $20.00 10 6 6 $7,200.00 Diem $195,840.00 Participants Travel / S7 $100.00 10 6 6 $36,000.00 Transportation (Average) $979,200.00 Sub total $43,200.00 $1,175,040.00

8.1. Intreme evaluation of the phase 1/Conduct an evaluation on the effectiveness of the implement- ed activities (onsite visit) Average # of Cost Average # Total Costs Participants Total Rounds Total Costs Strategy Items Per Day of Days Per (local Per of evaluation USD (USD) assessment Currency) assessment Participants Per S8 $20.00 10 10 1 $2,000.00 Diem $54,400.00 Participants Travel/ S8 $100.00 10 10 1 $10,000.00 Transportation (Average) $272,000.00 Sub total $12,000.00 $326,400.00 Justification: Monitoring of the implementation of the planned activities will help to assess the 47 effectiveness of the program towards achieving its objectives. Regular supervision of the selected active sites will address the progress of the planned activities and planned to carry out this activity every four months period. The allocated budget will be for transportation and perdiem coast of the supervisors. Training and others (workshop and meetings) Strategy 1: Enhancing Surveillance and Reporting Systems Outcome 1.1: The strength, Weakness/gap, Opportunity and Threat in the existing surveillance system will be identified and addressed challenges/gaps

1.2.4. Preparation of draft anthrax surveillance guideline (write shop) Average Total Average # of Total Cost Per Day # of Days Total Rounds of Costs Strategy Items Participants Per Costs (USD) Per write workshop (local write shop USD shop Currency) S1 Venue $100.00 2 1 2 $400.00 $10,880.00 Venue Package/ S1 $8.00 2 15 2 $480.00 Tea Break $13,056.00 S1 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S1 $130.00 1 10 2 $2,600.00 Transportation (Average) $70,720.00 Participants and S1 $20.00 4 15 2 $2,400.00 Trainers Per Diem $65,280.00 Training Materials S1 $10.00 1 10 2 $200.00 (Average) $5,440.00 S1 Stationery $10.00 1 10 2 $200.00 $5,440.00 Sub total $7,080.00 $192,576.00

1.2.5. Organize a validation workshop (Surveillance guideline) Average Total Average # of Cost Per Day # of Days Rounds Total Total Costs (local Strategy Items Participants (USD) Per write of Costs USD Currency) Per write shop shop Training S1 Venue $100.00 2 1 1 $200.00 $5,440.00 Venue Package/ S1 $8.00 2 15 1 $240.00 Tea Break $6,528.00 S1 Facilitators Fee $20.00 4 5 1 $400.00 $10,880.00 Participants Travel/ S1 $130.00 1 10 1 $1,300.00 Transportation (Average) $35,360.00 Participants S1 and Trainers Per $20.00 4 15 1 $1,200.00 Diem $32,640.00 Training S1 Materials $10.00 1 10 1 $100.00 (Average) $2,720.00 S1 Stationery $10.00 1 10 1 $100.00 $2,720.00 Sub total $3,540.00 $96,288.00 48 1.2.6. printing and dissemination of surveillance guideline Amount Total Costs (local Strategy Item Requested No. Needed Unit Cost Requested Currency) Printing of S1 surviellance 1,000 $4.00 $4,000.00 guideline $108,800.00 Sub Total $4,000.00 $108,800.00 Justification: Guidance for anthrax surveillance activities is important to ensure rapid detection, reporting and effective response to emerging outbreaks of anthrax. This budget will be used to develop a guideline for surveillance of anthrax both in humans and animals. The guideline will incorporate detailed instructions, and protocols on reporting activities, active case searches etc to deal with overall surveillance activities in the involvement of different sectors including ministry livestock and fisheries and ministry of health. Two separate surveillance guidelines will be prepared for veterinary sector and health sector. The guideline will be prepared by the stuffs of each ministries and the allocated budget will cover the coasts for the workshop (write shop and validation workshop). The remaining 108,000 birr will be for printing and dissemination of the guideline.

1.3. Provide trainings to address surveillance capacity gaps Average Total Cost Average # of Total Total Costs # of Days Rounds Strategy Items Per Day Participants Costs (local Per write of (USD) Per Training USD Currency) shop Training S1 Venue $100.00 2 1 2 $400.00 $10,880.00 Venue Package/ S1 $8.00 2 40 2 $1,280.00 Tea Break $34,816.00 S1 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S1 Transportation $130.00 1 40 2 $10,400.00 (Average) $282,880.00 Participants and S1 $20.00 4 45 2 $7,200.00 Trainers Per Diem $195,840.00 Training Materials S1 $10.00 1 10 2 $200.00 (Average) $5,440.00 S1 Stationery $10.00 1 45 2 $900.00 $24,480.00 Sub total $21,180.00 $576,096.00 Justification: Anthrax diseases is known to be shared problem among sectors, the collaboration remains 49 very weak. In this regard, the understanding and practice of joint surveillance fir anthrax and other zoonotic diseases in Ethiopia has been lagging behind. Thus, sensitization and awareness creation is very critical. Training for decision makers in public health and animal health from across all regions, and also, animal and human health professionals in the ground will strengthen collaborative efforts against emerging health threats. An estimated 45-45 health and veterinary professionals selected from each region will be trained on joint anthrax surveillance system. This help will be used to cover the coast for the planned training.

1.4. Conduct a regular review meeting, workshops with stakeholders Cost Average # Average # of Total Total Costs Total Strategy Items Per Day of Days Per Participants Costs (local Rounds (USD) write shop Per write shop USD Currency) S1 Venue $100.00 2 1 4 $800.00 $21,760.00 Venue Package/Tea S1 $8.00 2 15 4 $960.00 Break $26,112.00 S1 Facilitators Fee $20.00 4 5 4 $1,600.00 $43,520.00 Participants Travel/ S1 Transportation $130.00 1 10 4 $5,200.00 (Average) $141,440.00 Participants and S1 $20.00 4 15 4 $4,800.00 Trainers Per Diem $130,560.00 Training Materials S1 $10.00 1 10 4 $400.00 (Average) $10,880.00 S1 Stationery $10.00 1 10 4 $400.00 $10,880.00 Sub total $14,160.00 $385,152.00 Justification: This budget will be used to cover the coasts for conducting a regular review meeting, workshops with stakeholders. The meeting will be held on a regular basis (every quarter) which will further strength inter-sectoral communication and information sharing regarding surveillance findings and other related activities. Strategy 2: Strengthening Outbreak investigation and response System Outcome 2.1: Strengthened the outbreak investigation and response system through development of joint preparedness plans and activities

2.1.1. Develop a national guideline and SOPs for outbreak investigation and response (write shop) Average Average # of Total Cost # of Total Total Costs Participants Rounds Strategy Items Per Day Days Per Costs (local Per write of (USD) write USD Currency) shop Training shop S2 Venue $100.00 2 1 2 $400.00 $10,880.00 S2 Venue Package/Tea Break $8.00 2 15 2 $480.00 $13,056.00 S2 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S2 $130.00 1 10 2 $2,600.00 Transportation (Average) $70,720.00 Participants and Trainers 50 S2 Per Diem Training Materials $20.00 4 15 2 $2,400.00 $65,280.00 S2 $10.00 1 10 2 $200.00 (Average) $5,440.00 S2 Stationery $10.00 1 10 2 $200.00 $5,440.00 Sub total $7,080.00 $192,576.00

2.1.2. Prepare outbreak preparedness plan and ensure availability of necessary supplies Average Average # of Cost # of Total Total Costs Participants Total Strategy Items Per Day Days Per Costs (local Per write Rounds (USD) write USD Currency) shop shop S2 Venue $100.00 2 1 2 $400.00 $10,880.00 S2 Venue Package/Tea Break $8.00 2 15 2 $480.00 $13,056.00 S2 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S2 $130.00 1 10 2 $2,600.00 Transportation (Average) $70,720.00 Participants and Trainers S2 $20.00 4 15 2 $2,400.00 Per Diem $65,280.00 Training Materials S2 $10.00 1 10 2 $200.00 (Average) $5,440.00 S2 Stationery $10.00 1 10 2 $200.00 $5,440.00 Sub total $7,080.00 $192,576.00 Justification: Absence of a standard guideline, preparedness plan and SOP for effective outbreak investigation and response faces a great challenge for Ethiopia in outbreak management activities. This budget will help ministries (MOH and MoLF) to develop a separate Outbreak investigation guideline, outbreak preparedness plan and SOP for anthrax. The guideline will be prepared by stuffs of the ministries or the TWG in a write shop. The guideline will provide appropriate guidance on the steps and procedures of anthrax outbreak investigation and response for the RRT members and other professionals that might facilitate early control of the spread of the disease and further reduce associated public health impacts.

2.1.3. Conduct simulation exercises; training Cost Average Average Total Total Total Costs Per # of # of Rounds Strategy Items Costs (local Day Days Per Participants of USD Currency) (USD) training Per training Training S2 Venue $100.00 2 1 2 $400.00 $10,880.00 Venue Package/Tea S2 $8.00 2 40 2 $1,280.00 Break $34,816.00 S2 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S2 Transportation $130.00 1 40 2 $10,400.00 (Average) $282,880.00 S2 Participants and Trainers Per Diem $20.00 4 45 2 $7,200.00 $195,840.00 51 Training Materials S2 $10.00 1 10 2 $200.00 (Average) $5,440.00 S2 Stationery $10.00 1 45 2 $900.00 $24,480.00 Sub total $21,180.00 $576,096.00 Justification: Limited knowledge and skill on outbreak investigation and response activities (joint outbreak investigation and response) with regard to anthrax in humans and animals has be the challenge for proper implementation of outbreak management activities. This budget will help to provide a simulation exercise and training of veterinary and human health rapid response teams selected from each region. The training is aiming to improve the knowledge and skill of the stuffs/team members on proper management of anthrax outbreak in animals and humans. Strategy 3: Enhancing Prevention and Control of Anthrax Outcome 3.1: Improved vaccine production, distribution, storage/handling and administration system that meets the demand at national and regional level 3.1.5a. Prepare a draft Vaccination plan (Write shop) Cost Average # Average # of Total Total Costs Per Total Strategy Items of Days Per Participants Costs (local Day Rounds write shop Per write shop USD Currency) (USD) S3 Venue $100.00 2 1 2 $400.00 $10,880.00 S3 Venue Package/Tea Break $8.00 2 15 2 $480.00 $13,056.00 S3 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S3 $130.00 1 10 2 $2,600.00 Transportation (Average) $70,720.00 Participants and Trainers S3 $20.00 4 15 2 $2,400.00 Per Diem $65,280.00 Training Materials S3 $10.00 1 10 2 $200.00 (Average) $5,440.00 S3 Stationery $10.00 1 10 2 $200.00 $5,440.00 Sub total $7,080.00 $192,576.00 Justification: Absence of standardize anthrax vaccination plan addressing the seasonality, demand and all geographic area with respect to the appropriate time had an impact on the effectiveness of animal vaccination. This challenge might be addressed through development of a standardize vaccination plan based on the assessment findings. This budget will be used to develop a national animal’s vaccination plan for anthrax. The vaccination plan will incorporate detailed instructions to deal with overall animal vaccination activities in the involvement of different sectors including ministry livestock and fisheries and partners.

3.1.6. Provide Training to animal health professionals and technicians on vaccine management Average Total Cost Average # of Total Total Costs # of Rounds Strategy Items Per Day Participants Costs (local Days Per of (USD) Per training USD Currency) training Training S3 Venue $100.00 2 1 4 $800.00 $21,760.00 S3 Venue Package/Tea Break $8.00 2 40 4 $2,560.00 $69,632.00 S3 Facilitators Fee $20.00 4 5 4 $1,600.00 $43,520.00 Participants Travel/ S3 $130.00 1 40 4 $20,800.00 Transportation (Average) $565,760.00 52 S3 Participants and Trainers Per Diem $20.00 4 45 4 $14,400.00 $391,680.00 Training Materials S3 $10.00 1 10 4 $400.00 (Average) $10,880.00 S3 Stationery $10.00 1 45 4 $1,800.00 $48,960.00 Sub total $42,360.00 $1,152,192.00 Justification: Limited knowledge and skill on vaccine management has been the challenge for proper implementation anthrax vaccination activities including planning, distributing, handling and administration of the anthrax vaccine. This budget will help to provide training for veterinary professionals selected from each region. The training is aiming to improve the knowledge and skill of the stuffs on proper and effective management of vaccination campaign. Outcome 3.2: Improved the environmental sanitation practice nationwide

3.2.3. Conduct training on best environmental sanitary practices Cost Average # Average # of Total Total Total Costs Strategy Items Per Day of Days Per Participants Rounds of Costs (local (USD) training Per training Training USD Currency) S3 Venue $100.00 2 1 2 $400.00 $10,880.00 S3 Venue Package/Tea Break $8.00 2 40 2 $1,280.00 $34,816.00 S3 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S3 $130.00 1 40 2 $10,400.00 Transportation (Average) $282,880.00 Participants and Trainers S3 $20.00 4 45 2 $7,200.00 Per Diem $195,840.00 S3 Training Materials (Average) $10.00 1 10 2 $200.00 $5,440.00 S3 Stationery $10.00 1 45 2 $900.00 $24,480.00 Sub total $21,180.00 $576,096.00 Justification: The best prevention and control measures of anthrax includes proper disposal of dead animal body/carcass and environmental sanitation practices. Limited knowledge and environmental sanitation practice has been one of the challenge that hinders the prevention measures. The allocated budget will help to provide the best environmental sanitation practices to the environmental health professionals selected from all regions. The training will be held in two rounds and an estimated 80 individuals will be participated. This will improve the knowledge of the health professionals on environmental sanitation methods and practices. Strategy 4: Improving Anthrax Diagnostic Laboratory Capacity Outcome 4.1: Improved anthrax testing capacity of the national and selected regional laboratories 4.1.3: Organize trainings on anthrax laboratory testing procedures Cost Average Total Average # of Total Total Costs Per # of Rounds Strategy Items Participants Costs (local Day Days Per of Per training USD Currency) (USD) training Training S4 Venue $100.00 2 1 2 $400.00 $10,880.00 Venue Package/ S4 $8.00 2 40 2 $1,280.00 Tea Break $34,816.00 S4 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 S4 Participants Travel/ Transportation $130.00 1 40 2 $10,400.00 53 (Average) $282,880.00 Participants S4 and Trainers Per $20.00 4 45 2 $7,200.00 Diem $195,840.00 Training S4 Materials $10.00 1 10 2 $200.00 (Average) $5,440.00 S4 Stationery $10.00 1 45 2 $900.00 $24,480.00 Sub total $21,180.00 $576,096.00 Justification: Laboratory based surveillance and outbreak investigation has a vital role in early detection and response for anthrax suspected cases in animals and humans. Currently no laboratory confirmation is done for any anthrax suspected cases due to limited laboratory capacity and trained laboratory professionals on anthrax diagnostic tests. This budget will help to provide trainings on anthrax laboratory testing procedures for laboratory professionals selected from all regions which will improve their technical capacity and further strength the surveillance and outbreak investigation activities. Strategy 5: Enhancing Information, Education and Communication system Outcome 5.2: Improved health professionals knowledge and skill on IEC system

5.2.2. Develop draft training manuals (workshop) Total Total Cost Average # Average # of Total Rounds Costs Strategy Items Per Day of Days Per Participants Costs of write (local (USD) write shop Per write shop USD shop Currency) S5 Venue $100.00 2 1 2 $400.00 $10,880.00 S5 Venue Package/Tea Break $8.00 2 15 2 $480.00 $13,056.00 S5 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S5 $130.00 1 10 2 $2,600.00 Transportation (Average) $70,720.00 Participants and Trainers S5 $20.00 4 15 2 $2,400.00 Per Diem $65,280.00 Training Materials S5 $10.00 1 10 2 $200.00 (Average) $5,440.00 S5 Stationery $10.00 1 10 2 $200.00 $5,440.00 Sub total $7,080.00 $192,576.00 Justification: This budget will help to organize a write shop aiming to develop Information, Education and Communication materials/documents. The training manuals will help to improve the health professionals to properly deliver awareness regarding the risks and preventive measures of anthrax to the community and other professionals. The gaps identified on the KABP assessment will be addressed in the manuals and will serve as a national guidance comprising of all the necessary contents and messages regarding anthrax in humans and animals.

5.2.3. Provide training to public, animal and environmental health professionals on IEC system 54 Strategy Items Cost Per Day Average # of Days Per Average # of Participants Total Rounds of Total Costs Total Costs (local (USD) Training USD Training Per Training Currency) S5 Venue $100.00 2 1 2 $400.00 $10,880.00 S5 Venue Package/Tea Break $8.00 2 40 2 $1,280.00 $34,816.00 S5 Facilitators Fee $20.00 4 5 2 $800.00 $21,760.00 Participants Travel/ S5 $130.00 1 40 2 $10,400.00 Transportation (Average) $282,880.00 Participants and Trainers S5 $20.00 4 45 2 $7,200.00 Per Diem $195,840.00 Training Materials S5 $10.00 1 10 2 $200.00 (Average) $5,440.00 S5 Stationery $10.00 1 45 2 $900.00 $24,480.00 Sub total $21,180.00 $576,096.00 Justification: Information, education and communication mechanism for delivering of appropriate messages on the risks and preventive measures of anthrax plays a crucial role in improving the awareness of the community. The content of the messages and the method of delivery to the community require special skills and the training will improve the health professionals on effective communication systems. Limited knowledge and skill of the health professionals on the methods of community awareness affects the prevention and control activities of anthrax. The allocated budget will cover the coasts for organize the training aiming to improve knowledge and skill of the health professionals on IEC methods. The training will be conducted in two rounds and an estimated 80 individuals will participate on the training Strategy 6: Strengthening Multi-Sectoral Collaboration Outcome 6.2: Endorsed/valid national anthrax prevention and control strategic plan 6.2.2.Organize a stakeholders validation workshop of the national anthrax prevention and control strategy Cost Average Average # of Total Total Total Costs Per # of Participants Rounds Strategy Items Costs (local Day Days Per Per of USD Currency) (USD) workshop workshop workshop S6 Venue $100.00 2 1 1 $200.00 $5,440.00 Venue Package/Tea S6 $8.00 2 40 1 $640.00 Break $17,408.00 S6 Facilitators Fee $20.00 4 5 1 $400.00 $10,880.00 Participants Travel/ S6 Transportation $130.00 1 40 1 $5,200.00 (Average) $141,440.00 Participants and S6 $20.00 4 45 1 $3,600.00 Facilitaters Per Diem $97,920.00 S6 Stationery $10.00 1 45 1 $450.00 $12,240.00 Sub total $10,490.00 $285,328.00 Justification: The national anthrax prevention and control strategic plan developed by the anthrax TWG contains detailed activities that will be implemented in the stipulated timeframe with the vision of significantly reducing and ultimately controlling the public health impact of anthrax in humans and animals in Ethiopia through sustained surveillance, laboratory diagnosis, prevention and control system and community awareness. The allocated budget will help to organize a validation workshop aiming to present the drafted strategic activities and to get 55 approval and buy in from the authorized officials of each ministry for the implementation of proposed activities on the strategic plan. 8. EVALUATION

8.2. Organize an evaluation workshop Cost Average # Average # of Total Total Total Costs Per Strategy Items of Days Per Participants Rounds of Costs (local Day workshop Per workshop workshop USD Currency) (USD) S8 Venue $100.00 2 1 1 $200.00 $5,440.00 S8 Venue Package/Tea Break $8.00 2 40 1 $640.00 $17,408.00 S8 Facilitators Fee $20.00 4 5 1 $400.00 $10,880.00 Participants Travel/ S8 $130.00 1 40 1 $5,200.00 Transportation (Average) $141,440.00 Participants and Facilitaters S8 $20.00 4 45 1 $3,600.00 Per Diem $97,920.00 S8 Stationery $10.00 1 45 1 $450.00 $12,240.00 Sub total $10,490.00 $285,328.00 Justification: The proposed validation work shop is to evaluate the effectiveness of implemented activities on phase-1 with respect to its objective. During the validation work shop the reports on all implemented activities under phase-1 will be presented and the associated outcomes in preventing and control of anthrax in humans and animals. Furthermore, the outcomes will be evaluated based on the identified indicates. The strengths and weakness on the implementation of phase-1 activities will be identified and further improved for phase-2 activities. An estimated 40 delegates from the relevant sectors will be expected to participate on the two days validation workshop and the allocated budget is to cover the coasts to organize a validation workshop. Equipment’s and supplies Strategy 4: Improving Anthrax Diagnostic Laboratory Capacity Outcome 4.1: Improved anthrax testing capacity of the national and selected regional laboratories 4.1.3.Procurement of necessary laboratory supplies and equipment Unit Total Costs Total cost Strategy Item Requested Unit Quantity price (local (USD) (USD) Currency) S4 Thermocycler Pcs 10 10000 $100,000.00 $2,720,000.00 S4 Gel electrophoresis apparatus Pcs 10 10000 $100,000.00 $2,720,000.00 56 S4 Microfuge Pcs 10 2500 $25,000.00 $680,000.00 S4 UV trans illuminator and Polaroid camera Pcs 10 2500 $25,000.00 $680,000.00 S4 Micropipettes with volume range of 1-10 μl Pcs 10 300 $3,000.00 $81,600.00 S4 Micropipettes with volume range of 5-20 μl Pcs 10 300 $3,000.00 $81,600.00 S4 Micropipettes with volume range of 20-100 μl Pcs 10 300 $3,000.00 $81,600.00 S4 Clean Class II hoods Pcs 10 15000 $150,000.00 $4,080,000.00 S4 vortex mixer Pcs 10 1000 $10,000.00 $272,000.00 S4 Shaker Incubator Pcs 10 4000 $40,000.00 $1,088,000.00 S4 Centrifuge Pcs 10 8000 $80,000.00 $2,176,000.00 S4 Class II cabinet Pcs 10 15000 $150,000.00 $4,080,000.00 S4 Microscope Pcs 10 5000 $50,000.00 $1,360,000.00 S4 Autoclave Pcs 10 10000 $100,000.00 $2,720,000.00 S4 Incubator Pcs 10 3000 $30,000.00 $816,000.00 S4 Waterbath Pcs 10 1000 $10,000.00 $272,000.00 S4 Bunsen burner Pcs 10 30 $300.00 $8,160.00 S4 Permanent Masks Pcs 10 25 $250.00 $6,800.00 S4 Epindorf tube pack of 100 Pack 10 20 $200.00 $5,440.00 S4 Disposable face masks pack of 100 Pack 10 10 $100.00 $2,720.00 S4 Blood agar base medium, 500gram Bottle 10 150 $1,500.00 $40,800.00 S4 Nutrient Agar , 500gram Bottle 10 100 $1,000.00 $27,200.00 S4 Nutrient broth 500gram Bottle 10 100 $1,000.00 $27,200.00 PLET agar (polymyxin, lysozyme, EDTA Bottle, S4 [ethylene diamine tetra-acetic acid], thallous 10 200 $2,000.00 500gram acetate) $54,400.00 Penicillin antimicrobial discs (One pack contains 5 cartage each having 50 Pack /5 S4 10 100 $1,000.00 antimicrobial discs and each disc has 10 units Cartage/ concentration) $27,200.00 Vial of S4 0.5% McFarland turbidity standard solution 100 10 $1,000.00 5-7ml $27,200.00 S4 Mueller Hinton agar, 500gram Bottle 20 150 $3,000.00 $81,600.00 S4 MacConkey Agar bottle 20 150 $3,000.00 $81,600.00 S4 Brain Heart infusion broth bottle 20 150 $3,000.00 $81,600.00 Ready made Polychrome methylene blue Bottle of S4 20 100 $2,000.00 stain(MacFadyean’s stain) 500ml $54,400.00 Vial of S4 Ready made Giemsa stain reagent 20 100 $2,000.00 500ml $54,400.00 S4 Sodium bicarbonate, 100gram Bottle 20 50 $1,000.00 $27,200.00 Catalase reagent /3% hydrogen peroxide S4 liter 20 30 $600.00 solution/ $16,320.00 S4 Nutrient gelatin bottle 20 100 $2,000.00 $54,400.00 S4 Egg yolk agar bottle 20 100 $2,000.00 $54,400.00 S4 Motility medium with tetrazolium salt bottle 20 100 $2,000.00 $54,400.00 S4 Sterile swab, pack of 100 pack 20 80 $1,600.00 $43,520.00 S4 Peridish pack of 10 pack 5000 15 $75,000.00 $2,040,000.00 S4 Labeling markers pack of 10 pack 150 4 $600.00 $16,320.00 S4 Syringe and needles 24-26 gauge pack of 100 pack 1000 10 $10,000.00 $272,000.00 S4 Vacutainer needles pack of 100 pack 1000 10 $10,000.00 $272,000.00 S4 Vacutainer tubes pack of 100 pack 1000 10 $10,000.00 $272,000.00 S4 Test tubes/ bottle screw caps pack of 10 pack 1000 15 $15,000.00 $408,000.00 S4 Microscope slides pack of 100 pack 1000 5 $5,000.00 $136,000.00 S4 Slide cover slips pack of 100 Pack 1000 3 $3,000.00 $81,600.00 S4 immersion oil Bottle 1000 5 $5,000.00 $136,000.00 S4 lens paper pack of 100 Pasteur pipettes, preferably plastic disposable Pack 1000 3 $3,000.00 $81,600.00 57 S4 Pack 1000 15 $15,000.00 pack of 100 $408,000.00 S4 Autoclavable discard bags pack of 100 Pack 100 15 $1,500.00 $40,800.00 S4 Disinfectant spray “gun” Bottle 100 4 $400.00 $10,880.00 S4 Inoculation loops pack of 10 Pack 160 3 $480.00 $13,056.00 Sodium hypochlorite (10,000 ppm) bottle of S4 Bottle 50 100 $5,000.00 1 litre $136,000.00 Gamma phage of Bacillus anthracis (or cherry S4 Vial 40 100 $4,000.00 phage) $108,800.00 Filter membrane of 0.45 μm pore size pack of S4 Pack 100 100 $10,000.00 100 $272,000.00 S4 Sterne vaccine strain of B. anthracis (34F2) vial 200 100 $20,000.00 $544,000.00 S4 Primers Vial 1000 100 $100,000.00 $2,720,000.00 S4 Nucleotides(dNTPs) Vial 1000 100 $100,000.00 $2,720,000.00 S4 Taq polymerase enzyme Vial 1000 100 $100,000.00 $2,720,000.00 S4 Agarose powder Bottle 1000 100 $100,000.00 $2,720,000.00 S4 PCR grade water Bottle 1000 100 $100,000.00 $2,720,000.00 S4 Positive Control DNA Vial 1000 100 $100,000.00 $2,720,000.00 S4 1kb DNA ladder 1000 100 $100,000.00 $2,720,000.00 S4 Microcentrifuge tube racks Pcs 1000 50 $50,000.00 $1,360,000.00 2.0ml microcentrifuge tubes with O-ring pack 1000 50 S4 Pack $50,000.00 of 500 $1,360,000.00 S4 1.5ml Microcentrifuge tubes Pack of 500 pack 1000 25 $25,000.00 $680,000.00 Total $1,927,530.00 $52,428,816.00 Justification: Currently in our country the national and regional laboratories do not confirm any anthrax suspected cases this is mainly due to limited laboratory capacity and trained laboratory professionals on anthrax diagnostic tests. Hence, these laboratory consumables will be used by the twob211 National referral laboratories, that is bacteriology laboratories at Ethiopian Public Health Institute (EPHI) and National Animal Health Diagnostic and Investigation Center (NAHDIC) for confirming anthrax suspected disease outbreaks both in human and animals. The consumables will be used to collect sample from anthrax suspected case from all over the country and then the collected samples will be cultured and identified at laboratory using biochemical tests and gamma phages. Field level testing of smear samples will also be made using MacFadyean’s stain from animal blood smear. Moreover, direct detection of the antigen using PCR techniques will also be carried both from human and animal samples. After establishing and strengthening the national laboratories capacity in diagnosing anthrax, then the experience will be shared for regional laboratories. List of hospital and regional public health laboratories Ser. No Region Laboratory Assessed Level of laboratory AA EPHI Bacteriology Lab National Reference Laboratory AA EPHI Virology Lab National Reference Laboratory Amhara Bahirdar Regional Lab Regional Laboratory Amhara Dessie Regional Lab Regional Laboratory Oromia Nekemt Regional Lab Regional Laboratory Oromia Adama Regional Lab Regional Laboratory Harar Harar Regional Lab Regional Laboratory Afar Afar Regional Lab Regional Laboratory Diredawa Diredawa Regional Lab Regional Laboratory AA Aa Regional Lab Regional Laboratory Tigray Mekele Regional Lab. Regional Laboratory 58 Somali SNNPR Somali Regional Lab Hawasa Regional Lab Regional Laboratory Regional Laboratory SNNPR Mizan Sub- Regional Lab Sub -Regional Laboratory SNNPR Jinka Sub- Regional Lab Sub- Regional Laboratory SNNPR Arbaminch Sub- Regional Sub- Regional Laboratory Amhara Gondar University Teaching Hospital Hospital Laboratory Benishngul-Gumuz Asossa Hospital Hospital Laboratory Gambella Gambela Referal Hospital Hospital Laboratory Oromia Jimma Specialized Hospital Hospital Laboratory SNNPR Arbaminch General Hospital Hospital Laboratory Tigray Humera Hospitsal Hospital Laboratory SNNPR Hawasa Unive Teaching Hospital Hospital Laboratory Ser. No Region Laboratory Assessed Level of laboratory SNNPR Jinka Zonal Hospital Hospital Laboratory SNNPR Wolayta Sodo University Teaching Hospital Laboratory Hospital Oromia Shasheme Referral Hospital Hospital Laboratory Addis Ababa Yekatit 12 Hospital Hospital Laboratory Somali Karamara Hospital Hospital Laboratory Oromia Ambo Hospital Hospital Laboratory Addis Ababa Alert Hospital Hospital Laboratory Addis Ababa Armed Force Hospital Hospital Laboratory Tigray Axum Zonal Hospital Hospital Laboratory Tigray Haider Referral Hospital Hospital Laboratory Amhara Tefera Hailu Hospital Hospital Laboratory SNNPR Mezanaman Hospital Hospital Laboratory Afar Dubti Hospital Hospital Laboratory Amhara Debremarkose Hospital Hospital Laboratory Oromia Metukarl Hospital Hospital Laboratory SNNPR Mezanaman Hospital Hospital Laboratory Addis Ababa Black Lion Hospital Hospital Laboratory Addis Ababa Armauer Hanssen Research Institute Research Laboratory List of animal health regional laboratories s/ Name of National and Regional Regional Location Major activities no Veterinary Lab states 1 National Animal Health Diagnostic and MOLF Sebeta Diagnosis, outbreak investigation, export Investigation Center (NAHDIC) testing, research, surveillance and capacity building 2 National Veterinary Institute (NVI) MOLF Debre Zeit Diagnosis, research and vaccine production and capacity building 3 Mekele Regional veterinary Laboratory Tigray Mekele Diagnosis, outbreak investigation and surveillance 4 Kombolcha Regional Veterinary Amhara Kombolcha Diagnosis, outbreak investigation and Laboratory surveillance 5 Bahir Dar Regional Veterinary Amhara Bair dar Diagnosis, outbreak investigation and Laboratory surveillance 6 Semera Regional Veterinary Laboratory Afar Semera Diagnosis, outbreak investigation and surveillance 7 Shola veterinary Laboratory Addis Ababa Addis Ababa Diagnosis, outbreak investigation and surveillance 8 Assosa Regional Veterinary Laboratory Benshangul Asosa Diagnosis, outbreak investigation and 9 Bedelle Regional Veterinary Laboratory gumz Oromia Bedelle surveillance Diagnosis, outbreak investigation and 59 surveillance 10 Asela Regional Veterinary Laboratory Oromia Arsi Diagnosis, outbreak investigation and surveillance 11 Hirna Regional Veterinary Laboratory Oromia Hirna Diagnosis, outbreak investigation and surveillance 12 Yabello Regional Veterinary Laboratory Oromia Yabello Diagnosis, outbreak investigation and surveillance 13 Sodo Regional Veterinary Laboratory SNNPRS Wolayita Diagnosis, outbreak investigation and Sodo surveillance 14 Mizan Regional Veterinary Laboratory SNNPRS Mizan aman Diagnosis, outbreak investigation and surveillance 15 Jinka Regional Veterinary Laboratory SNNPRS Jinka Diagnosis, outbreak investigation and surveillance 16 Jigjiga Regional Veterinary Laboratory Ethiopian Jijiga Diagnosis, outbreak investigation and Somali surveillance 17 Dire Dawa Regional Veterinary Dire Dawa Dire Dawa Diagnosis, outbreak investigation and Laboratory surveillance