Public health emergencies DR. MADHUR VERMA PGIMS ROHTAK

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LEARNING OBJECTIVESIntroductionPublic health emergency & PHEICCriteria for decision-making in verification and notification of public health events.Public health emergency preparedness(PHEP)Situation at the time of emergencyEpidemiologic methods at the time of PHERole of hospitals during a PHE Conclusion

INTRODUCTIONSince 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 EMERGENCYPHE 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:

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

to potentially require a coordinated international response.

The Director General -WHO declares PHEIC

6 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).

7Alert and Response OperationsDetection


Risk assessment

ResponseEvents that may constitute aPublic Health Emergency of International Concern need:8Event notification and determination under IHR (2005)WHO DGVarious disease & event surveillance systems within a country National IHRFocal Points WHO IHR Contact PointsEmergencyCommitteeOther competent OrganizationsDetect and report any urgent or unexpected eventsConsult events or notify WHO of any events that may constitute a PHEICReceive, assess and respond to events notified Ministries/ SectorsConcernedDetermine whether an event constitutes a PHEIC and recommend measuresExternaladviceCoordinateCommunicateReport9MVSC - Established on 24 April 2008 at NICD (NCDC), DelhiTill April 2009 IDSP has reported & verified 424 health alerts through MVSC which plays a vital role in detecting and verifying unusual health events through mediaIDSPNOTIFICATION

Does not imply that an event is a PHEICJust telling WHO about an eventNo immediate consequences for countryKnow about the event from other sourcesStart assessing the event without countrys official notification8/18/20131010Event notificationAny 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 PHEIC11Notification is a start of a dialogue(i.e. not a big deal)Potential PHEIC notified by countryPHEIC declared by WHODialogueHigh sensitivity, Low positive predictive valueIt is the event itself - not the official notification of it - that is the basis of WHOs determination of PHEICBenefits of early Notification

Confidential dialogueIHR protection against unjustified measuresAssistance by WHO and other countries

WHO will know sooner or later anyway

8/18/20131313Verification of events Value unofficial sources of information for early alertWHO 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

14The past experience shows that many significant public health events have been often firstly reported by media or other unofficial sources.Under the IHR (2005), WHO is obligated to request for verification of potential public health events of international importance or concern. Member States will need to provide initial reply within 24 hours. When necessary, Member States will need to arrange joint on-site assessment. The IHR surveillance system

8/18/201315National IHR Focal Point WHO

Local level

Mass media, GPHIN, MediSYS, Google, NGOs, ProMED etc + other countriesAssess national eventsSurveillanceNotify,inform,consult in confidenceVerifySurveillanceIf anyone think , Government is delaying notification, Write in ProMED ([email protected])ProMED-mail, the Program for Monitoring Emerging Diseases, is a program of the International Society for Infectious DiseasesThe global electronic reporting system for outbreaks of emerging infectious diseases & toxins, open to all sourcesYour financial support enables ProMED to continue providing you and 48,000 others in 187 countries worldwide with reliable, independent reporting of emerging infectious diseases and outbreaks as they happen Web services for ProMED-mail are provided as a public service by the Oracle Corporation. E-mail services are provided by the Harvard School of Public HealthProMED-mail was established in 1994 with the support of the Federation of American Scientists and SatelLife. Since October 1999, ProMED-mail has operated as an official program of the International Society for Infectious Diseases, a nonprofit professional organization with 20,000 members worldwideWorld news as a topic based NewsBrief, which is updated every 10 minutes, or sent as real-time email alerts These disease incidents are automatically extracted from Medisys Articles by PULS, a "fact extraction" system at the University of Helsinki, Finland, Department of Computer Science15Disease ListFour diseases (a single case is notifiable): Smallpox, Poliomyelitis, human influenza (caused by a new subtype), SARSUtilization of the decision instrument:Cholera, plague, viral haemorrhagic fevers, yellow fever, Diseases of regional concern: dengue fever, meningococcal diseases



HIV/AIDSXDR-TBChernobylPestVHV /Ebola / Marburg

BSE/ NvCJDNipahAnthraxSARS


Animal FluChemical pollutioncholeraDecision Instrument Is the public health impact of the event serious?Is the event unusual or unexpected?Is there a significant risk of international spread?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 assessment18In brief, four criteria have been agreed to be used for the assessment of reported public health events or disease outbreaks.

A. Is the event serious?Morbidity and mortalityDoes the event have potential for high impact?Population at riskCases in health staff; highly infectiousFactors affecting response e.g. war, natural catastropheHigh population densityImmediate or potential need for external assistanceB. Is the event unexpected?Is the cause of the event unknown?Are the circumstances unusual?Cases worse than usualTreatment failuresEvent unusual for place/seasonCaused by eliminated/eradicated agentSuspected or known intentional or accidental release of chemical, biological or radiological agentC. 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 organismSource suspected/ known to be related to food import/exportIndex case with international travel historyIn area with international tourism/ traffic, person or goodsIn border areas with limited capacity for controlD. 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. NoNotify the event under the International Health Regulations

Yes NoNoNoIs the event unexpected?Yes Yes Yes Yes NoCould it (or has it) spread internationally?Yes No23Combinations of answers requiring notificationSerious and unexpectedSerious and risk for international spread Serious and risk for international restrictionsUnexpected and risk for international spreadUnexpected 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 nations 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 etcPHEP 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 PREPAREDNESSHealth 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.Legal climate. Identify and address issues concerning legal authority and liability barriers to effectively monitor, prevent, or respond to a public health emergency.Roles and responsibilities. Clearly define, assign, and test responsibilities in all sectors, at all levels of government, and with all individuals and ensure each groups 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 improvement1. 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 DisastersAfter a disaster (Reconstruction Phase):Conducting post-disaster epidemiologic follow-up studiesIdentifying risk factors for death & injuryPlanning strategies & specific interventions to reduce impact-related morbidity &mortality.Evaluating effectiveness of interventionsConducting descriptive & analytical studiesPlanning medical & public health response to futurE disastersConducting long-term follow-up of rehabilitation /reconstruction activities

36 AT THE TIME OF EMERGENCY MAJOR AREAS TO BE STRESSED UPON Health systems and infrastructureEmergency health servicesReproductive health careEmergency mental health and psychosocial supportEpidemiology and surveillanceControl of communicable diseasesWater, sanitation and hygiene in emergenciesFood and nutritionManagement(Financial management for humanitarian response)Health systems and infrastructure

Essential tasks: prioritizing health servicesConduct an initial assessment; Identify the major causes of morbidity and mortality; There are three major sources of disease among the displaced: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

Identify vulnerable groups and their specific needs; Organise services to improve access to vulnerable groups; Involve community members and other concerned groups in the initial assessment and in the design and development of interventions; and Seek womens views about health problems and ways to improve health services.There 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.

The 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 servicesTask 3: Utilise the referral system established by the lead health authority Task 4: Whenever possible, base health services and interventions on scientifically sound methodsTask 5: Utilise technologies that are appropriate and socially and culturally acceptableEssential tasks: Post-emergency phaseTask 1: Ensure equity Task 2: Utilise an inter-sector approachTask 3: Expand health promotion and prevention servicesChallenges for Epidemiologists

Applying epidemiologic methods in the context of:

Physical destructionPublic fearSocial disruptionLack of infrastructure for data collectionTime urgencyMovement of populationsLack of local support and expertise

49Selecting 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, eliminate confounding, study interactions among multiple factors Limited by definition of specific outcomes, issues of selection of cases & controls

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

50Need standardized protocols for data collection immediately following disaster

Need standardized terminology, technologies, methods and procedures

Need operational research to inventory medical supplies and determine 1) actual needs, 2) local capacity, 3) needs met by national/international communities

Need evaluation studies to determine efficiency and effectiveness of relief efforts and emergency interventions

51Challenges for EpidemiologistsNeed 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

52Challenges for EpidemiologistsNeed uniform disaster-related injury definitions and classification schemeNeed investigations of disease transmission following disasters and public health measures to mitigate disease riskNeed to study problems associated with massive influx of relief supplies and relief personnelNeed 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.54

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.

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 without any disruption to the normal and routine work of the institution.

Class B:The plan can be put into practice with minor disruption to the day to day functioning of the hospital and with some readjustments. The plan may be upgraded to C if the numbers of casualties increase.

Class C:There would be definite disruption of routine work. Major readjustments would be required in hospital functioning, inpatient treatment, duty arrangementsOrganization 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.First aid Parties & Posts(static and mobile)Ambulance serviceMobile Surgical Units.

Emergency Hospital OrganizationEmergency Hospital Services (including critical care facilities)Emergency Surgical ServicesEmergency Transfusion ServicesCONCLUSIONThe 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.