Capacity Development of National Reference Centers (NRC) to Face the Challenges of Emerging Infections in Côte d’Ivoire

Background: Some national and international strategies for the detection and prevention of emerging infectious diseases have been established across sectors. The capacity to carry out these tasks varies from country to country, and that remains largely undervalued. The Pasteur Institute of Côte d’Ivoire has created and implemented the capacity of national reference centers to fight against emerging and other infectious diseases. Objective: Show on the one hand the strategies used to develop the National Reference Centers and the IPCI and on the other hand the results obtained by performing these strategies. Method: Datas collection by documentary analysis (published scientific articles and grey literature) was done on Google Scholar, PUBMED and institutional reference documents. The documentary research was carried out to have a better understanding of strategies used to create and develop the NRCs in microbiology of communicable diseases. Results: Seven integrated strategies were launched: 1-training and workforce development; 2-investigation of epidemics or public health events; 3-strengthening laboratory epidemiological research; 4-strengthening surveillance systems; 5-improving communication with partners and stakeholders; 6-building national and international collaborations; and 7-strengthening technical and technological platforms. In


Introduction
Microbiology laboratories play an important role in the management of infectious diseases in terms of national or global epidemiology [1].The main objective of these medical analysis laboratories is to optimize the analyses which make it possible to improve the diagnosis and the prognosis and to make the therapeutic management of the patient more efficient.
National and international strategies for the detection and prevention of emerging infectious diseases have been created in the civil and military sectors [2] [3] [4].However, epidemiological capacity at national, regional or state and local levels is required to successfully implement many of these strategies.[3].
Health officials conduct increasingly complex outbreak investigations, implement and analyze new surveillance systems, and conduct sophisticated applied epidemiological research [3].Unfortunately, the ability to carry out these tasks varies from country to country and remains largely undervalued.In 2006, Cote d'Ivoire set up National Reference Centers (NRC) and began to strengthen its epidemiological capacity to respond to emerging infectious diseases [5].
This article aims to report on the one hand the strategies used for the development of the national reference centers of the IPCI and on the other hand the results obtained.

Context
Côte d'Ivoire is a developing west African country with seaside resorts, tropical forests and a French colonial heritage with 27.48 million inhabitants [6].Primary responsibility for public health rests with the state health ministry and approximately 33 regional health directorates and 101 local health departments.
The Pasteur Institute of Côte d'Ivoire (IPCI) is a health research institute un-der the supervision of the ministry of scientific research and higher education.
Although the IPCI has built a strong tradition of infectious disease epidemiology in Côte d'Ivoire since its creation in 1972, this tradition was largely unrecognized in the 1970s to 2000s.Significant obstacles have hampered the further development of applied infectious disease epidemiology in Côte d'Ivoire.Almost all outbreak investigations have been conducted at the local level; however, local health officials had little or no training in applied infectious disease epidemiology.Little infrastructure existed to investigate outbreaks, and No microbiology laboratory was recognized as a reference in terms of diagnosis and microbiological monitoring.
In 2005, with the help of the PEPFAR project, IPCI and representatives from the Ministry of Health developed the concept of a network of collaborating laboratories, with the aim of intensifying epidemiological research and improving infectious disease surveillance.Within this context, in June 2006, inter-ministerial decree No. 393 of June 21, 2006, signed by the minister of higher education and scientific research and the minister of health and hygiene, designated the national centers for institute reference (Table 1).This text concretizes the recognition of the work carried out by the staffs of the establishment for many years.It's also a heavy responsibility that will require better organization and coordination of these centers starting in 2007.
This has made it possible to develop and define the missions and activities of national reference laboratories, train infectious disease epidemiology teams, and create laboratory and stakeholder networks able to collate existing public health data, identify deficiencies and collect additional data where necessary.

General Approach
The overriding objective of the health authorities was to establish a sustainable national epidemiological capability in the fight against communicable diseases.
The initial priorities of the NRCs were to develop the capacity to identify and respond to epidemiological emergencies, to conduct applied epidemiological research and to assist the Ministry of Health in carrying out its activities and developing their own epidemiological programs.Six (6) missions [5] have been assigned to the NRCs and constitute their core business: expertise in the biology of infectious agents; contribution to epidemiological surveillance; alert by immediately informing the authorities of any finding that could have repercussions on the state of health of the population; microbiological monitoring of infectious agents; conservation and contingency of infectious agents; advice to public authorities and health professionals in this area.
The IPCI's NRC activities can be broken down as follows: *Surveillance: Most NRCs are involved in epidemiological surveillance, resistance monitoring or epidemic investigations.The study used two data collection methods: a documentary analysis and in-depth qualitative interviews, respectively, to achieve the study objective.
The data collection method of a literature review and an in-depth qualitative interview, respectively were done.The literature search was carried out to better understand the design and development strategies of NRCs in communicable disease microbiology.This enabled a global understanding of issues relating to the West African region and particularly the Ivory Coast concerning current NRCs.The literature review included published articles, national reports, organization reports and data and information sheets.These articles were consulted using search engines such as Google Scholar and Pubmed, using a snowball effect and including any reference documents and grey literature that would provide a better understanding of the situation.IPCI annual activity reports from 2006 to 2021 were consulted.
To further explore the points raised by the literature review, a follow-up semi-structured interview was conducted with IPCI management and heads of laboratories involved in the implementation process.This enabled the challenges and enabling factors highlighted in the literature review and survey questionnaire to be explored in greater depth.
All data collection was carried out in French, the official language commonly used in Côte d'Ivoire.The two-stage process of survey and interview enabled better triangulation of data and guaranteed its quality.Data collection was carried out using Microsoft Excel.
The implementation of these missions was achieved through integrated strategies [3] by the IPCI: developing training programs for NRC staff, investigating epidemics or public health events and epidemiological research; strengthening surveillance systems; improving communications between the IPCI and its partners and stakeholders; and establishing international collaborations (Figure 1).

Training and Workforce Development
The lack of trained staff at the applied epidemiology of infectious diseases has made the training of heads of NRCs in the short and long term a key priority.The long-term program was to develop a group of biologists and epidemiologists (capable of carrying out outbreak investigations, epidemiological research and surveillance) who would later serve as trainers themselves [3].
The short-term training program was designed to equip NRC health staff with the practical skills and understanding needed to conduct and report laboratory activities during an epidemic, and to carry out more complex epidemiological research and surveillance activities in collaboration with national or international epidemiologists.The short-term training program aimed to equip health NRC staff with the practical skills and understanding needed to conduct and report laboratory activities during an outbreak and to conduct more epidemiological research and surveillance activities in collaboration with national or international epidemiologists.An annual short-term training plan consisted of a 12-to 24-week laboratory applied epidemiology course for public health laboratory managers, designed to impart practical skills (Table 2).This 6 to 12 month training program, known under the name of "cours Pasteur" at the Pasteur Institute in Paris, started in 2005 for the first generation of the IPCI with an intern.Then the heads of NRC each began their training between the years 2000 and 2015.The profile of all these heads of laboratories showed that they are medical biologists and two were biologists.All of these physicians also held a specialized study certificate in medical biology, microbiology option (virology, bacteriology, parasitology) and PhD and PhD biologists.All had to complete at least one outbreak investigation, one surveillance project and one research project, as well as present their work at a scientific conference, participate as trainers in epidemiology courses and write at least one article each in a peer-reviewed scientific journal and in national and international communicable disease journals.To date, 20 heads of laboratories and departments have been trained between 2006 and 2021.Most of the staff in the units that house NRCs work full time as public officials for these activities, in particular case confirmation activities.
The diversification of skills materialized during 2006.The IPCI welcomed health practitioners (doctor, pharmacist, dental surgeon) general practitioner or specialist in public health and epidemiology, technicians specialized in quality control, in Sanitation.This made it possible to implement the epidemiology and clinical research department and to strengthen the capacities of the units, to create cross-functional units: molecular biology platform (PFBM), laboratory input production unit (UPIL), biological resource center (CeReB), training department.The activities of these departments and units have gradually been put in place.It is beginning to assist the Biology teams in developing projects and managing data.
During the second IPCI Scientific Council held from 22 to 23 September 2006, the members of the Scientific Council noted "significant progress with regard to the 2005 recommendations and a better awareness reflected in an internal dynamic within a more motivated and therefore much more committed team".
The efforts undertaken by the researchers and their collaborators have begun to bear fruit, but it is the year 2007 which will truly be a year of progress thanks to the facilities which were put in place in 2006 and at the begining of the year 2007, namely offices, a conference room, an internet connection and internship grants in high-performance laboratories: Canada, France.
Today, several heads of laboratories are experts and consultants of the World Health Organization and other international organizations.The number of researchers has increased from 10 in 2004 to ninety (90) in 2021 with 12 senior researchers and 32 junior researchers 46 junior researchers.Table 3 gave an overview of some of the national and sub-regional training courses that reference laboratory managers have been able to provide on the basis of their expertise.

Investigation of Epidemics or Public Health Events
The benefits of developing National Reference Laboratory (NRL) capacity on outbreaks were filling a public health gap in the ability to respond to epidemiological emergencies; develop relationships between the IPCI and its partners, such as clinical health and research laboratories and health departments responsible for surveillance; formulate hypotheses and bases for future research; provide training opportunities; and recognition of public health, epidemiology [3].
In 2006, the first avian influenza viruses in Abidjan were diagnosed at the Pasteur Institute in Côte d'Ivoire from samples sent by the veterinary services.This also testifies to the collaborations that exist with our colleagues in the veterinary services.There is no doubt that this enabled Côte d'Ivoire to take measures very quickly in order to avoid human cases.
Twenty-two ( 22) investigations of disease outbreaks or public health events requiring field trips were completed, increasing from five (5) in 2006 to three (3) in 2009; 2010 and 2012 then at 1 the other years (Table 4).Each survey was carried out at the request and with the approval of the departments responsible for monitoring the National Institute of Public Hygiene (INHP) of the Ministry of Health.
Eleven (11) of these outbreaks were of vector origin: seven (7) were traditional outbreaks due to mosquitoes (Table 4, event number 8; 21; 31; 35; 36; 37; 38) and three (3) came from waterborne products (event no.3; 23; 27).The other outbreaks were due to a diverse group of agents and modes of transmission and covered areas as large as Africa (Table 4).
Among the conclusions of these investigations were the recognition of N meningitidis as a potentially common pathogen of human origin (epidemic 2; 10; 15; 28; 32; 40) and the emergence of N meningitidis W135, the recognition of multi-resistant bacteria (MRB) infections as an emerging pathogen in Côte d'Ivoire (partly due to the urbanization in the immediate vicinity of farms or grazing areas, the unsanitary conditions of hospitals, the overload of work and use of hospital services, insufficient hospital infrastructure; events 26; 30) and the human rabies virus in localities in Côte d'Ivoire (events 18, 32).Cote d'Ivoire's new epidemiological capacity enabled it to participate in two multinational outbreaks among returnees from overseas travel COVID-19 and Ebola (event 35, 39) as well as communicable disease surveillance organized by the world health organization and the ministry of health (event 7, 9, 11, 13, 16 -18, 22).

Epidemiological Research in the Laboratory
Research activities have been better organized since 2006, there is no doubt that the start of the department of epidemiology has contributed to the drafting of innovative and collaborative projects.
The objective is to create a self-sustaining laboratory applied epidemiological research program focusing on foodborne and diarrheal diseases; AIDS and other sexually transmitted diseases, including hepatitis; vaccine-preventable diseases; The final stage, a fully realized research program with field epidemiologists specializing in each of the research areas and with integrated surveillance, laboratory and prevention components, is a long-term goal.The program would have a steady stream of research funding for short-and long-term projects, with priority determined by IPCI and its collaborating partners based on immediate and long-term public health needs.

Strengthening Surveillance Systems
The current International Health Regulations (IHR) use case definitions, and many pathogens are newly identified.There are provisions for laboratory reports.Since 2006, the NRCs for surveillance of communicable diseases have been set up by interministerial decree and the data obtained by the system are published in an annual report to the Ministry of Health.
A 2017 order from the Ministry of Health on infectious diseases classifies pathogens into 4 categories came into force in January 2017 and the 2020 orders from the prime minister's office organizing the response to public health events: Order of 20 March 2020 from the prime minister setting the organizational framework for the fight against the Coronavirus pandemic (COVID-19), decree of April 30, 2020 of the prime minister on the creation, organization and functioning of the operational monitoring committee for the response plan against the Coronavirus pandemic.In addition to authorizing single case notifications using case definitions and specifying both laboratory and healthcare providerbased notification, these new orders also give a clear mandate for laboratories and the IPCI to be the central authority for the organization and conduct of surveillance and applied laboratory research on infectious diseases.
The time it took to draft and pass these infectious disease orders allowed the IPCI and new surveillance programs to develop.Thus, NRL staff members have already undergone training, which will facilitate the implementation of the new monitoring system in the field.In addition, IPCI management has initiated studies to assess existing surveillance systems or initiate sentinel surveillance.

Improved Communication
Because the impact of emerging and re-emerging infectious diseases on public health has been vastly underestimated, a deliberate communication strategy was needed to raise public awareness [3].It was also important to involve health service personnel in implementing new surveillance initiatives and conducting outbreak investigations using analytical epidemiology.Finally, the collaboration of other scientific authorities, such as university research departments and professional associations, was necessary.IPCI participates in meetings of the public health emergency operations center (COUSP) located at the national institute of public hygiene (INHP) Five communication strategies were used and the main target groups were identified (Figure 2).Outbreak investigations were initially a high priority, in part to get the public to recognize infectious disease threats and the role of public health authorities in responding to those threats.Subsequent public health guidelines also highlighted the roles of IPCI and health services in promoting science-based public health.Guidelines on the diagnosis and management of sexually transmitted infections (STIs) (Table 6) a biosafety manual, a guide to the fight against Ebola and several other manuals have been developed (Table 6).
The Epidemiology Bulletin (le Vigile) reaches a wide audience, including the media, public health services and other researchers.It provides a weekly source of epidemiological findings and surveillance data, giving IPCI, INHP and participating health services a regular and visible central role in infectious disease epidemiology.Additionally, the bulletin publishes public health guidelines for one communicable infectious disease per month.
The journal Bioafrica (scientific journal with reading committee) receives scientific publications on communicable diseases at national and international level.
To give credibility and to support the NRCs fighting against communicable diseases, scientific conferences, congresses and symposiums are regularly organized at the IPCI.
Although the emphasis is on publication in national journals, publication in international medical journals is essential as it is more widely read by public health practitioners.
Several general public communication actions are undertaken.In 2009, participation in a television program on the second national channel enabled the head of the NRC to contribute to raising public awareness of rabies.In 2012, the positive consequences of the awareness of the previous cholera epidemic of 2010 to 2011 were still vivid in the population.
In 2012, the NRC Ivorian Network for the Investigation and Surveillance of Nosocomial Infections (RIISIN) organized assistance to professionals for clinical services through the microbiological control of the effectiveness of disinfection of sensitive sites at the university hospital of cocody (resuscitation neonatology pediatric surgery).And for the general public, a TV program on the second channel of national television (TV2) on the occasion of Global Hand washing Day.
In 2014 the NRC haemorrhagic fever participated in the development of public awareness spots in the written and audio-visual press, conferences and train-ing on how to behave were carried out by the department and the management of IPCI on behalf of Ebola virus fever

Building National and International Collaborations
Although the primary focus of the infectious disease NRCs is national, the integration ofCote d'Ivoire into WHO, ECOWAS, and european and american networks required that the NRCs have an international presence.Some measles and polio NRCs are Africa-wide regional surveillance laboratories, through networks, requiring many member states to play an active role in managing one or more multinational surveillance systems.To help build this capacity, heads or staff of the NRCs of the IPCI took part in sub-regional missions to support the establishment of national reference laboratories in certain southern countries.

Establishment of Technical and Technological Platforms
The management of biological risks linked to certain events requires that a policy concerning the management of biological risks in the laboratory (biosafety and biosafety) be put in place in accordance with international regulations resulting in the issuance of a Ministerial Order on pathogens at risk [8].The level of lab security varies from lab to lab.Respectively laboratories are of level P1, P2 and P3.Most laboratories have only certified level 2 biosafety cabinets (PSM type II).
With regard to samples, samplings and packagings of samples from all NRCs are processed according to international standards.
In view of the high costs of laboratory equipment, technical and technological platforms have been set up.To meet the requirements of containment and conservation of biological resources [9] of the NRCs, a biological resource center was set up in 2010 with a variety of conservation methods: by freeze-drying, encapsulation of nucleic acids by IMAGENE ® , conservation in liquid nitrogen in straws and in microtubes [10].A high-level security laboratory has been under construction since 2019.
A molecular biology platform was set up with a view to pooling molecular biology diagnostic equipment in 2010 for the molecular characterization of infectious pathogens [11] [12] [13].
The IPCI has set up a genomic sequencing pole, a microbial genomics and metagenomics laboratory.One of these activities was to determine the variants of the corona virus that circulated in Abidjan during the pandemic.This genomics and meta genomics platform has been in service since 2021 to support the genetic characterization of infectious pathogens

Funding of NRCs
The financing of the various NRCs as part of their activities is mainly carried out by the IPCI.In particular, there is no funding from other national institutions.
The development partners, in particular the united nations system, through the WHO, provide considerable financial support, in particular to the NRC Poliovirus and to the NRC Measles and NRC yellow fever, NRC Influenza.

Every year:
• Through the IPCI's annual budget allocated by the ministry of higher education and ecientific research (staff salaries, small equipment, reagents and consumables, maintenance, subscriptions, etc.).
• Through an annual allocation from the WHO for certain NRCs: Polio, Measles.By projects and/or on an ad hoc basis, particularly in the event of epidemics: • By the ministry of health and public hygiene as part of the plans (Flu Action Plan, Global AIDS and Tuberculosis Fund).
• Through occasional support from development partners (donations of equipment, reagents and consumables, etc.).
• Through research projects funded outside Côte d'Ivoire.
• Through the international network of the Pasteur Institute (support for strengthening expertise (study grants) and quality control and improving capacities such as the biosafety of premises and equipment).The financial balance sheet for the IPCI's NRC activities is proving difficult, and is directed towards development partners.Additional funds are needed to improve the microbiological surveillance network (for nosocomial infections and to develop the network for food-borne and vector-borne diseases), but also to give greater visibility to the IPCI's support for national health programs in Côte d'Ivoire and the West African region.A final key to the program's success has been a gradual and deliberate plan to develop a network of partners in the field and in the lab and to market the program to information consumers.

Weakness and Challenges
Beyond the improvement of their internal functioning, several indices nevertheless show the difficulties of the CNRs in giving visibility to their activity of scientific contribution and in articulating it with the actors of research: few collec-tions declared in connection with networks themes, accumulation of stored cryo samples, difficulty of exhaustive inventory of biological resources and low percentage of samples used, contributions to publications that are difficult to assert.
In the future, the consolidation of NRC structuring investments should focus on infrastructure, improving the interface with surveillance, research, conservation and biomedical industry teams.This interface is not reduced to establishing a "preformatted" technical service according to "quality" standards, but must take into account many elements established between partners.It involves the management of the establishment to define a real strategy and governance of activities.

Conclusions and Perspectives
Since 2000, the policy led by the IPCI, the INHP has enabled the overall and national structuring of the CNRs in support of the surveillance and research teams for communicable diseases.Structuring investments have made it possible to improve the organization and operation of these technical platforms, in particular through the diversification of diagnostic confirmation and response preparation services and through the implementation of operating information systems and management of associated data, through the implementation of a national quality approach.
There is great heterogeneity in the volumes of activity according to the NRCs, linked to the size and volume of activity of the health establishments which are in their network and to the event of national scope.On the other hand, there is an organizational distinction according to the network of the reference laboratory.The scientific contribution activity results from local investments, to improve the quality of the service and contribute to research projects.
The objective, undertaken by the IPCI for several years, of optimizing the confirmation of cases, surveillance in the NRCs and their use for research, has been pursued and reinforced.
The actions and recommendations of the IPCI aim to optimize the organization of NRCs with a view to the surveillance of communicable diseases, according to a local strategy and within the framework of multicentre networks.
The need to set up an information system whose objective is to stimulate the federation of different actors to constitute, around the transmissible diseases under surveillance, clinical epidemiological and biological databases associated with biological samples.This surveillance database is a tool for collecting and managing data relating to individuals, patients and/or subjects suspected of communicable diseases.The data combines clinical information, scientific and medical analyzes carried out on biological samples taken from samples, surveys or questionnaires, administrative and demographic information.
The database must make it possible to optimize, on a national scale and for a defined pathology, the collection of all this information, its integration and its transversal exploitation by different research disciplines (epidemiological, fundamental, translational, clinical).It must make it possible to study relations for a large number of cases.
The multicentric and multidisciplinary organization aims to standardize the collection of data and associated biological resources, their pooling and their sharing with the scientific and medical communities.This evaluation is also necessary for the supervisory bodies, in order to measure the impact of investments in indirect support for research and to justify their renewal.
Today the measurement of the scientific contribution of the NRCs is all the more difficult to achieve as the measurement of the scientific impact of a research project is already complex and sometimes shifted in time.
The IPCI to propose a model for access to state subsidies in support of NRC contributions.This would involve an evaluation of the NRCs, according to specifications and according to developments in recent years.The subject is important, and raises questions about the objectives, the eligibility criteria, the evaluation methods.An in-depth reflection will be carried out, in conjunction with the professionals, in order to define, communicate and organize this evaluation in complete transparency, on the basis of our achievements and in order to consolidate them.

Lessons Learned
Our experiences during the first 10 years of the program have shown that a NRC program applied to communicable diseases organized with a high degree of technical expertise at the national level is necessary to respond effectively to emerging infections.
For example, by taking into account the 21 epidemic events studied to date, 4 were traditional epidemics of vector origin originating from the same mosquito.
Most of the others concerned multinational or sub-regional COVID 19 and Ebola epidemics, disease threats or community epidemics of rare agents or bacterial strains, difficult to detect or resistant to several drugs or new viruses: crimea congo or lassa.The traditional approach to outbreak investigation that emphasizes the collection by a single health service of case samples for microbiological analysis would not have been adequate to determine the extent of the almost-all of these events nor to identify their modes or vehicles of transmission.IPCI's activities to date have formed the basis for the continued development of a national reference laboratory program with integrated surveillance, research and prevention components for most transmissible pathogens.Further development is essential, as experiences to date suggest that biologists, epidemiologists, public health officials and laboratory scientists are likely to become involved in increasingly complex scientific endeavors as they respond to emerging infections in Côte d'Ivoire.

Figure 1 .
Figure 1.Strategic interventions used by the Pasteur Institute of Côte d'Ivoire for the development of the capacities of CNRs in the fight against infectious diseases (Source: Petersen L. R. et al. 2000 [3]).

Figure 2 .
Figure 2. Communication strategies and main target groups for capacity development of the NRCs for infectious diseases at the Pasteur Institute of Côte d'Ivoire (Source: Petersen L. R. et al. 2000 [3]).

4. 1 .
Strengths: "Success Stories" Several factors have contributed to the success of NRCs of IPCI.The first was to achieve a broad consensus on the scope and objectives of the program among future NRC participants and partners.In Cote d'Ivoire this included the ministry of health, ministry of scientific research, state health services.The second ingredient of the program's success was the initial emphasis on training, particularly for the development of a national epidemiological program.The short-term training program quickly produced a growing network of collaborators in the health services.Long-term (European) training programs have produced technically competent biologists,

Table 1 .
Infectious agents and clinical syndromes important to health for which there are national reference laboratories in Côte d'Ivoire.Expertise: IPCI NRCs are requested for their expertise in case confirmation, evaluation of new diagnostic tests, support for health programs, development of tools and guides, and microbiology training.All CNRs are equipped with conventional techniques and use molecular tools.So Expertise in molecular techniques makes the NRCs competitive at national level.
**Alert: The IPCI was actively involved in the first detection of new viruses in the country, notably the avian flu virus and the first case of SARS COV2 in 2020.*Consulting: IPCI has been asked to participate in the development of control measures for the Ministry of Health and Public Hygiene.Many practitioners turn to IPCI for advice on antibiotic therapy.

Table 2 .
Training received by CNR staff reported by the IPCI, 2006-2021.

Table 3 .
Training given by NRC staff reported by the IPCI, 2006-2021.
Training of regional health directors, district chief medical officers, district surveillance officers and EPI officers in the methods of collecting and transporting samples to the laboratory

Table 4 .
Epidemics or public health events reported by the national reference centers (NRC) of the Pasteur Institute de Côte d'Ivoire (IPCI), 2006-2021.
[14]age group most affected by cholera is between 16 and 45 years old.Children were the least affected (Report 2006[14]).D. K. Maxime et al.DOI: 10.4236/ojim.2023.133021191Open Journal of Internal Medicine Outbreak investigations provided a concrete first stage of activity between NRC and collaborative partners in the field, such as health services and laboratory scientists.In addition, outbreak investigations have revealed health issues that require further planned epidemiological investigation.These surveys have forged collaborations between the laboratories (LNR), the University laboratories (Cocody, Nangui Abrogoua), the veterinary health department (VHD), the laboratories of the regional hospital centers (RHC).A technical laboratory working group (TWG-Laboratory) was formed in the one health approach to develop a future research and surveillance program for communicable diseases.The second stage of the program was to initiate targeted studies involving unique research projects to address specific health issues.Seventeen (17) shortterm research projects were initiated.These included a study of hepatitis B and C, risk factors for the development of quinolone resistant diseases in one hospital, prevalence and risk factors of Staphylococcus aureus methicillin resistance in hospitals, three studies on the influenza vaccination coverage (Table 5).epidemiology and laboratory science.IPCI has received an average of 850,000 US$ per year for the President's Emergency Plan for AIDS Relief (better known as PEPFAR) for a decade and an average of 600,000 US$ per year for the global DOI: 10.4236/ojim.2023.133021196 Open Journal of Internal Medicine

Table 6 .
Publications reported by the NRCs of the IPCI in the activity reports from 2006-2021.