Dr. Madhur Verma

PG JR II

DEPTT OF COMMUNITY MEDICINE

LEARNING OBJECTIVES

1. Introduction

2. Public health emergency & PHEIC

3. Criteria for decision-making in verification and

notification of public health events.

4. Public health emergency preparedness(PHEP)

5. Situation at the time of emergency

6. Epidemiologic methods at the time of PHE

7. Role of hospitals during a PHE

8. Conclusion

INTRODUCTION

Since beginning of the last decade, near the time

anthrax attacked the world, a substantial amount of money

has been spent by majority of the countries to increase their

ability to prepare for, and respond to, public health

emergencies.

Yet, despite reports suggesting that progress has been

made, it is unclear whether these investments have left

the nation better prepared to respond to a bioterrorist

attack, pandemic influenza, or any other large-scale

public health emergency.

This situation is not because of a shortage of measures

of preparedness. Hence, there arises a need to be

prepared to any kind of such situations dangerous to the

mankind known as public health emergencies.

PUBLIC HEALTH EMERGENCY

PHE is defined as “an emergency need for health care

[medical] services to respond to a disaster, significant

outbreak of an infectious disease, bioterrorist attack or

other significant or catastrophic event.”

The definition is also aligned with the all-hazards approach to

preparedness instead of focusing on a “disaster du jour” and

thus allows for the optimal development of capabilities across

scenarios and better prepares communities for the broad

spectrum of potential risks.

PHIEC – Public Health Emergency

of International Concern

An extraordinary event which is determined, as provided in these Regulations:

i. to constitute a public health risk to other Member States through international spread of disease and

ii. to potentially require a coordinated international response.

The Director General -WHO declares PHEIC

The expansive definitions of "disease", "event", "public

health risk" the IHR (2005) cover a wide range of public

health risks of potential international concern:

• whether biological, chemical or radio nuclear in origin or

source, and

• whether potentially transmitted by:

persons (e.g. SARS, influenza, polio, Ebola),

goods, food, animals (including zoonotic disease risks),

vectors (e.g. plague, yellow fever, West Nile fever), or the

environment (e.g. radio nuclear releases, chemical spills

or

other contamination).

Alert and Response Operations

Detection

Verification

Risk assessment

Response

Events that may constitute a

Public Health Emergency of International Concern need:

Event notification and determination

under IHR (2005)

WHO DG

Various disease &

event surveillance

systems within a country

National IHR

Focal Points

WHO IHR

Contact Points

Emergency

Committee

Other competent

Organizations

Detect and report any

urgent or unexpected

events

Consult events or

notify WHO of any

events that may

constitute a PHEIC

Receive, assess and

respond to events

notified

Ministries/

Sectors

Concerned

Determine whether an

event constitutes a

PHEIC and recommend

measures

Externaladvice

Coordinate

Communicate

Report

NOTIFICATION

Does not imply that an event is a PHEIC

Just “telling WHO about an event”

No immediate consequences for country

Know about the event from other sources

Start assessing the event without country’s official

notification

8/31/2014 10

Event notification

Any event that may constitute a Public Health Emergency of International Concern (PHEIC)

Within 24 hours of assessment

By the most efficient means of communication

Continue to provide WHO with detailed information

Does NOT mean a real “PHEIC”

Notification is a start of a dialogue

(i.e. ”not a big deal”)

Potential PHEIC

notified by country

PHEIC declared

by WHO

Dia

log

ue

High sensitivity,

Low positive predictive

value

It is the event itself - not

the official notification of it

- that is the basis of WHO’s

determination of PHEIC

Benefits of early Notification

1. Confidential dialogue

2. IHR protection against unjustified measures

3. Assistance by WHO and other countries

WHO will know sooner or later anyway

8/31/2014 13

Verification of events

Value unofficial sources of information for early alert

WHO requests for verification of potential public health events of international importance

Member States provide initial reply within 24 hours and provision of information

On-site assessment, when necessary

The IHR surveillance system

8/31/2014 15

National

IHR Focal

Point

WHOLocal

level

Mass media,

GPHIN, MediSYS,

Google, NGOs,

ProMED etc + other

countries

If anyone think ,

Government is delaying

notification,

Write in ProMED

(promed@promedmail.org)

Disease List

Four diseases (a single case is notifiable):

Smallpox, Poliomyelitis, human influenza (caused by a

new subtype), SARS

Utilization of the decision instrument:

Cholera, plague, viral haemorrhagic fevers, yellow

fever, …

Diseases of regional concern: dengue fever,

meningococcal diseases…

CONTENTS

INTRODUCTION

Decision Instrument

1. Is the public health impact of the event serious?

2. Is the event unusual or unexpected?

3. Is there a significant risk of international spread?

4. Is there a significant risk of international travel or trade

restrictions?

Answering "yes" to any two of the criteria requires a member state to notify WHO

Criteria for assessment

A. Is the event serious?

Morbidity and mortality

Does the event have potential for high impact?

Population at risk

Cases in health staff; highly infectious

Factors affecting response e.g. war, natural

catastrophe

High population density

Immediate or potential need for external

assistance

B. Is the event unexpected?

Is the cause of the event unknown?

Are the circumstances unusual?

Cases worse than usual

Treatment failures

Event unusual for place/season

Caused by eliminated/eradicated agent

Suspected or known intentional or accidental release of chemical, biological or radiological agent

C. Is the event likely to spread internationally?

Similar cases in other countries where it was

unexpected?

Factors alerting to cross-border implications?

Caused by epidemic-prone organism

Source suspected/ known to be related to food

import/export

Index case with international travel history

In area with international tourism/ traffic, person or

goods

In border areas with limited capacity for control

D. Is event likely to result in international travel

and trade restrictions?

Similar events previously led to restriction

on travel/ trade?

Source known or suspected food product/

goods known to be imported or exported?

In area with international tourism?

Attracted media attention?

Is the event serious?

Is the event unexpected?

Could it (or has it) spread

internationally?

Risk for international

sanctions?

Not

notified

at this

stage.

No

Notify the event under the International Health Regulations

YesNo

No

No

Is the event unexpected?

Yes

Yes

Yes

Yes

No

Could it (or has it) spread

internationally?Yes

No

Combinations of answers

requiring notification

Serious and unexpected

Serious and risk for international spread

Serious and risk for international

restrictions

Unexpected and risk for international

spread

Unexpected and risk for international

restrictions

Public health threats are always present.

These threats can anytime lead to the onset of public

health incidents.

Being prepared to prevent, respond to, and rapidly

recover from public health threats is critical for protecting

and securing our nation’s public health.

But we face multiple challenges, including an ever-

evolving list of public health threats.

Strong state and local public health systems are the

cornerstone of an effective public health response.

How can we reduce the risk?

Risk reduction can be done in two ways:

A. Preparedness:

B. Mitigation.

PUBLIC HEALTH

EMERGENCY

PREPAREDNESS (PHEP)Preparedness encompasses all those measures taken

before a disaster event which are aimed at

minimizing loss of life,

disruption of critical services and damage when the

disaster occurs.

Thus, preparedness is a protective process which

enables governments, communities and individuals to

respond rapidly to disaster situation and cope with

them effectively.

Preparedness includes

development of emergency response plans

effective warning systems,

maintenance of inventories,

training of manpower etc.

involves a coordinated and continuous process of planning and implementation that relies on measuring performance and taking corrective action.

Mitigation

encompasses all measures taken to reduce both the effect of

hazards itself and the vulnerable conditions in order to reduce

the losses in a future disaster.

Examples of mitigation measures include:

making earthquake resistant buildings,

water management in drought prone areas, management of

rivers to prevent floods etc

PHEP is not a steady state; it requires

continuous improvement, including frequent

testing of plans through drills and exercises and

the formulation and execution of corrective

action plans.

PHEP also includes the practice of improving

the health and resiliency of communities.

ELEMENTS OF PUBLIC HEALTH

EMERGENCY PREPAREDNESS

1. Health risk assessment. Identify the hazards and vulnerabilities (e.g., community health assessment, populations at risk, high-hazard industries, physical structures of importance) that will form the basis of planning.

2. Legal climate. Identify and address issues concerning legal authority and liability barriers to effectively monitor, prevent, or respond to a public health emergency.

3. Roles and responsibilities. Clearly define, assign, and test responsibilities in all sectors, at all levels of government, and with all individuals and ensure each group’s integration.

4. Incident Command System. Develop, test, and improve

decision making and response capability using an

integrated Incident Command System (ICS) at all response

levels.

5. Public engagement. Educate, engage, and mobilize the

public to be full and active participants in PHEP

6. Epidemiology functions. Maintain and improve the

systems to monitor, detect, and investigate potential

hazards, particularly those that are environmental,

radiological, toxic, or infectious.

7. Laboratory functions. Maintain and improve the systems to

test for potential hazards, particularly those that are

environmental, radiological, toxic, or infectious.

8. Countermeasures and mitigation strategies.

Develop, test, and improve community mitigation

strategies (e.g., isolation and quarantine, social

distancing ) and countermeasure distribution strategies

when appropriate.

9. Mass health care. Develop, test, and improve the

capability to provide mass health care services.

10. Public information and communication. Develop,

practice, and improve the capability to rapidly

provide accurate and credible information to the public in

culturally appropriate ways.

11. Robust supply chain. Identify critical resources for public

health emergency response and practice and improve the

ability to deliver these resources throughout the supply chain.

B. Expert and fully staffed workforce1.Operations-ready workers and volunteers.

Develop and maintain a public health and health

care workforce that has the skills and capabilities

to perform optimally in a public health emergency.

2. Leadership. Train, recruit, and develop public

health leaders (e.g., to mobilize resources, engage

the community, develop interagency relationships,

communicate with the public).

C. Accountability and quality improvement

1. Testing operational capabilities. Practice,

review, report on, and improve public health

emergency preparedness by regularly using

real public health events, supplemented with

drills and exercises when appropriate.

2. Performance management Implement a

performance management and accountability

system.

3. Financial tracking Develop, test, and improve

charge capture, accounting, and other financial

systems to track resources and ensure

adequate and timely reimbursement.

Epidemiologic Methods in Disasters

After a disaster (Reconstruction Phase):

Conducting post-disaster epidemiologic follow-up studies

Identifying risk factors for death & injury

Planning strategies & specific interventions to reduce impact-related morbidity &mortality.

Evaluating effectiveness of interventions

Conducting descriptive & analytical studies

Planning medical & public health response to futurEdisasters

Conducting long-term follow-up of rehabilitation /reconstruction activities

AT THE TIME

OF

EMERGENCY

MAJOR AREAS TO BE STRESSED

UPON 1. Health systems and infrastructure

2. Emergency health services

3. Reproductive health care

4. Emergency mental health and psychosocial support

5. Epidemiology and surveillance

6. Control of communicable diseases

7. Water, sanitation and hygiene in emergencies

8. Food and nutrition

9. Management(Financial management for humanitarian response)

Health systems and infrastructure

Essential tasks: prioritizing health services1. Conduct an initial assessment;

2. Identify the major causes of morbidity and mortality;

There are three major sources of disease among the

displaced:

a. Diseases Arising in camps because of unhealthy living

conditions (e.g acute respiratory infections, diarrhoea,

and measles).

The risk of acquiring these diseases is increased by

malnutrition;

b. Within a new environment against which

displaced persons might lack immunity

(e.g., malaria or meningitis);

c. Imported by displaced persons from a previous

environment (e.g. TB,

HIV/AIDS, body lice, parasites) or that is

unique to their population (e.g., sickle cell

disease). These diseases are

usually less common causes of morbidity and

mortality than others

3. Use evidence-based intervention to address major causes of

morbidity and mortality; Triangulate the information collected

in the assessment.

Triangulation is a technique for minimizing biases in the

information collected during the initial assessment

4. Develop a health information system to identify epidemics and guide changes needed in interventions.

Introduce interventions in phases. Some services must be introduced during the acute

emergency phase while others should be planned but not implemented until the postemergency phase.

Essential tasks:

ensure access to health services

ƒIdentify vulnerable groups and their specific needs;

ƒ Organise services to improve access to vulnerable groups;

ƒ Involve community members and other concerned groups

in the initial assessment and in the design and

development of interventions; and

ƒ Seek women’s views about health problems and ways to

improve health services.

ƒThere is active collaboration with other sectors in the

design and implementation of priority health

interventions, including water and sanitation, food

security, nutrition, shelter and protection.

ƒThe Crude Mortality Rate (CMR) & The Under-Five

Mortality Rate (U5MR) is maintained at, or reduced to,

less than twice the baseline rate documented for the

population prior to the disaster.

Essential tasks: post-

emergency phase

Task 1: Continue to evolve the health

information system and interventions as

indicated

Task 2: Increase capacity of the

community and local health leaders to

design/redesign and implement of health

services

Task 3: Utilise the referral system

established by the lead health authority

Task 4: Whenever possible, base health

services and interventions on

scientifically sound methods

Task 5: Utilise technologies that are

appropriate and socially and culturally

acceptable

Essential tasks: Post-

emergency phase

Task 1: Ensure equity

Task 2: Utilise an inter-sector approach

Task 3: Expand health promotion and

prevention services

Challenges for

Epidemiologists

Applying epidemiologic methods in the context of:

Physical destruction

Public fear

Social disruption

Lack of infrastructure for data collection

Time urgency

Movement of populations

Lack of local support and expertise

Selecting study designs:

Cross-sectional:Studies of frequencies of deaths, illnesses, injuries,adverse health affectsLimited by absence of population counts

Case-control:Best study to determine risk factors, eliminateconfounding, study interactions among multiplefactorsLimited by definition of specific outcomes, issues ofselection of cases & controls

Longitudinal:Studies document incidence and estimate magnitudeof risk Limited by logistics of mounting a study in apost-disaster environment and subject follow-up

Need standardized protocols for data collectionimmediately following disaster

Need standardized terminology, technologies, methodsand procedures

Need operational research to inventory medicalsupplies and determine

1) actual needs,

2) local capacity,

3) needs met by national/international communities

Need evaluation studies to determine efficiency andeffectiveness of relief efforts and emergencyinterventions

Challenges for Epidemiologists Need databases for epidemiologic research based

on existing disaster information systems

Need to identify injury prevention interventions

Need to improve timely and appropriate medical care following disaster (search & rescue, emergency medical services, importing skilled providers, evacuating the injured)

Need measures to quickly reestablish local health care system at full operating capacity soon after disaster

Challenges for Epidemiologists

Need uniform disaster-related injury definitions and classification scheme

Need investigations of disease transmission following disasters and public health measures to mitigate disease risk

Need to study problems associated with massive influx of relief supplies and relief personnel

Need cost-benefit and cost-effectiveness analyses

Role of Hospitals in Disasters/PHE

Hospitals are central to provide emergency

care when a disaster strike the society.

What constitutes a disaster/PHE for a

hospital?

Whenever a hospital or a health care facility is confronted

by a situation where it has to provide care to a large

number of patients in limited time, which is beyond its

normal capacity, constitute a disaster for the said hospital.

In others words when the resources of the hospitals are

over-whelmed beyond its normal capacity and additional

contingency measure are required to control the event, the

hospital can be said to be in a disaster situation.

Assessment of the capacity of a hospital to respond to a

given emergency situation can be assessed by the following

two ways:

Hospital Treatment Capacity (HTC), is defined as the

number of casualties that can be treated in the hospital in

an hour and is usually calculated as 3% of total number of

beds

Hospital Surgical Capacity (HSC) is Hospital Surgical

Capacity (HSC) the number of seriously injured patients

that can be operated upon within a 12-hour period i.e.

HSC= Number of operation rooms x 7x 0.25 operations/12

hrs.

A. Based on the Number of Casualties

( for 1000

bedded 30 hospital)

According To WHO: The Mass Casualty Emergencies

can be categorized in one of the following ways:

Category 1 : Up to thirty patients

belonging to a single accident or

any other emergency, coming to a

hospital casualty at one time.Category 2: Thirty to fifty patients

Category 3: More than fifty patients

Categorisation Of Patients Based on TYPE OF

CASUALTIES:

Category A: Patients in critical condition

Category B: Patients in serious but not life threatening

condition

Category C: Walking , but wounded.

Categorization of the CONTINGENCY PLAN into three classes :

Class A: The plan can be put into practice withoutany disruption to the normal and routine work of theinstitution.

Class B:The plan can be put into practice with minordisruption to the day to day functioning of the hospitaland with some readjustments. The plan may beupgraded to C if the numbers of casualties increase.

Class C:There would be definite disruption of routinework. Major readjustments would be required inhospital

functioning, inpatient treatment, duty arrangements

Organization of Health Delivery System in Disaster/ Emergency situations

Pre-Hospital Management:: To render first aid to victims at the spot of disaster and their transportation to nearby

hospital as an essential part of life saving measures.

a) First aid Parties & Posts(static and mobile)

b) Ambulance service

c) Mobile Surgical Units.

Emergency Hospital Organization

a) Emergency Hospital Services (including critical care facilities)

b) Emergency Surgical Services

c) Emergency Transfusion Services

CONCLUSION

The absence of a clear definition of PHEP makes it

difficult to determine whether the nation is better prepared

to respond to a bioterrorist attack or major disease

outbreak now than it was nearly a decade ago.

Moreover, without an agreed-upon definition,

policymakers and other stakeholders will continue to

struggle to determine what it will take to get ready for

such attacks and outbreaks , as well as how to prioritize

future investments.

The definition presented here provides a concise, broadly

applicable vision of what a prepared community looks like,

along with a short list of actionable and measurable steps

for attaining that vision.

At the most general level, the definition and action-

oriented elements can help provide a set of shared terms

for discussion among various governmental and

nongovernmental actors about what exactly is involved in

enhanced community preparedness.

THANK YOU