Operational but Fragile: A Mixed-Methods Assessment of Outbreak Preparedness in Addis Ababa's Tertiary Hospitals

BackgroundEmerging viral infections (EVIs) present a critical challenge to global health security, with tertiary hospitals serving as essential hubs for outbreak response. In low-resource settings like Ethiopia, these institutions face systemic vulnerabilities, yet a comprehensive assessment of their preparedness, encompassing both measurable capacities and underlying operational cultures, is lacking. This study aimed to evaluate the outbreak preparedness for EVIs for Addis Ababas tertiary hospitals. MethodsA hospital-based, mixed-methods study was conducted between January and April 2025 public and private tertiary hospitals. Descriptive analysis was done for quantitative component gathered using structured observational checklist adapted from WHO and CDC tools, assessing ten core domains of preparedness, from coordination to logistics. Thematic analysis was performed on the qualitative data obtained through 21 in-depth interviews with purposively selected key informants, including hospital leadership, infection prevention personnel, and frontline clinicians. ResultsThe median total preparedness score was 63.61/100, classified as Operational Preparedness. Laboratory capacity was the weakest domain (36.4/100), only 3.5% of staff were trained in outbreak response, and no hospital had negative-pressure isolation rooms. Only 30.4% of clinical staff had access to N95/N99 respirators. Qualitative interviews revealed that coordination was often improvised; as one emergency doctor stated, "Committees are formed immediately when such events occur, but there is no permanent structure." Furthermore, the absence of proactive, disease-specific protocols led to reliance on generalized measures, delaying effective response. Conclusion/ImplicationsWhile scoring at an operational level, the preparedness of these hospitals is fundamentally fragile and reactive. The infrastructural and training gaps are severely compounded by a non-proactive institutional culture and a lack of systematized protocols. Moving from reactivity to resilience requires substantial investment in laboratory infrastructure, permanent isolation facilities, and mandatory simulation training, coupled with institutionalizing leadership structures, developing disease-specific plans, and integrating psychosocial support for healthcare workers.