Pandemic Preparedness -Risk assessment and

infection control in health care settings-

Elisaveta Stikova, Ronald LaPorte, Faina Linkov, Margaret Potter, David Piposzar,

Sam Stebbins

Learning objectives To introduce student with five components of

pandemic preparedness and response and whole society approach

To enlighten the differences between WHO’s 2005 and 2008 pandemic phases

To add more information about risk assessment, use of risk assessment matrix and risk classification of the

workers To bring forward to the development of the one

peak-week scenarios for needs assessment To set up hierarchy of control measures for

workers’ protection during the pandemic

SEE Public Health Preparedness Supercourse Network

Elisaveta Stikova Present position

1991-Present, Professor, University “Ss. Cyril and Methodius”, Medical faculty, Skopje, Macedonia (courses taught: Occupational Health, Public Health, Medical Ecology, Hygiene

1994 – Present, Director and Advisor, National Public Health Institute, Skopje, Macedonia

2009 – Fulbright Visiting Scholar, Pittsburg University, Graduate School of Public Health – New Educational Pathway for Global Public Heath Security

SEE Public Health Preparedness Supercourse Network

Co-Authors and collaborators: Ronald E. LaPorte, PhD, UPGSPH, Director,

Disease Monitoring and Telecommunication, WHO Collaborating Center

Faina Linkov, PhD, Assistant Professor, Cancer Institute

Margaret Potter, JD, MS, Associate Dean and Director, UPGSPH, Center for Public Health Practice

David Piposzar, MPH, UPGSPH, PPLI Co-director Sam Stebbins, MD, MPH, UPCPHP Principal

Investigator/Director, Center for Public Health Preparedness

What is pandemic ?

Public health emergency that rapidly takes on significant political, social an economic dimension

Influenza Pandemic would be: extended event multiple waves (2-3) each waves will last 6-8 weeks

Five components of pandemic preparedness and response

Planning and coordination Communication Situation monitoring and risk

assessment (likelihood and severity) Reducing the spread – infection

control Striving to ensure continuity of

health care provision and businesses

WHOLE OF SOCIETY

HEALTH SECTOR

Provide leadership and guidance

• Take actions to reduce health consequences

•Raise awareness about risk and potential consequences.

NON HEALTH SECTOR

• Develop guidance and implement actions needed to minimize the effects of a pandemic on non health sectors.

INDIVIDUALS FAMILIES AND COMMUNITIES

• Take actions needed to minimize the effects of a pandemic on families and individuals

PLANNING AND COORDINATION

COMMUNICATION

A whole of society approach to pandemic preparedness and

response

WHO Guidance, core documents

DiseaseControl

MeasuresFor

PandemicInfluenza

OutbreakCommunicat

ions

GlobalPandemicInfluenza

Surveillance

LaboratoryPreparedness

ForPandemicInfluenza

SurgeCapacity in

HealthCare

Facilities

Non-HealthSector

Preparedness

Self-AssessmentChecklist for

Preparedness

Planning andExecuting a

PreparednessExercise

TrainingCD-ROMs

For Trainers

RapidContainment

TrainingPackage

HandbookFor thePublic

SamplePreparedness

Plans

Tools

Supporting Technical Documents

Comparison of the 2005 and 2008 WHO pandemic phases

2005 PhasesStructure & Pandemic Disease “Risk”

2008 PhasesStructure & Pandemic Disease “Risk”

Time Time

Inter pandemic

Period

PandemicAlert

Pandemic

PostPandem

PostPeak

PostPandemic

Geographicspread

Predominantly animalInfections;

Limitedtransmissibilityamong people Sustained

H-2-Htransmission

Phases 1-2

Phases 3-5

Phase 6

1 - 3

4

5 - 6

Risk assessment

The risk assessment analyzes:• Threat (probability of occurrence)• Consequences of the occurrence • Vulnerability

RISK ASSESSMENTRISK

MANAGEMENTDose

assessment

Hazardidentification

Exposureassessment

Ri s

k

ch

ara

cte

riz

ati

on

Decision control

Acceptable risklevel definition

Mitigationmeasures

RISK

COMMUNICATION

Feedback

Risk analysis circles

Risk assessment

The risk assessment process involves thefollowing tasks:

❍ Preparing the risk assessment matrices❍ Determining the risk ratings❍ Prioritizing observations

Likelihood and severity of damage, 3x3 matrix

Likelihoodd Low Moderate High

Very Unlikelihood

Low Risk (1)

Low Risk (1)

Moderate Risk (2)

Likely Low Risk (1)

Moderate Risk (2)

High Risk (3)

Very Likely Moderate Risk (2)

High Risk (3)

High Risk (3)

Likelihood

S e v e r t y

Classifying workers exposure to pandemic influenza at work

Occupational Risk Pyramid

Critical infrastructure and key resources workers

First line responders

Health care workers with direct patient contacts Workers engaged in health care supporting

services Public health emergency respond workers Public safety workers (police, firefighters,

dispatchers…) Utility service workers Transportation workers Mortuary services’ workers

Very high exposure risk occupations

Healthcare workers performing aerosol-generating procedures on known or suspected pandemic patients

Healthcare or laboratory personnel collecting or handling specimens from known or suspected pandemic patients

High exposure risk

Health care delivery and support staff exposed to known or suspected pandemic patients

Medical transport of known or suspected pandemic patients in enclosed vehicles

Performing autopsies on known or suspected pandemic patients

Medium exposure risk

Workers with high-frequency contact with the general population

Lower exposure risk (caution)

Workers who have minimal occupational contacts with general public and other co-workers

What an influenza pandemic might look like

One waves – peak week scenario severity and extend

25% Attack rate 35% Attack rate 50% Attack rate

Per 100 000

Total MKD

Per 100 000

Total MKD

Per100 000

Total MKD

Affected –symptomatic patients

25000 500 000 35 000 700 000 50 000 1 000 000

Out patient contacts (22%)

5500 110 000 7700 154 000 11 000 220 000

Complication (25% of symptomatic)

1370 27 500 1 700 34 000 2 400 48 500

Hospitalization(rate 4%)

200 4000 310 6500 440 8800

Critical care (25% of hospitalization)

50 1000 80 1550 110 2200

Deaths (rate 2,5%)

140 2800 200 4000 280 5600

How pandemic influenza could affect our business?

Absenteeism Change in patterns of commerce Interruption of supply/delivery

Key responsibilities of every organization

Estimate the level of staff absence Estimate potential impact on its

own activities Estimate potential impact of its

resources to the community

Impact on the workforce

Up to 50% of the workforce may require time off at some stage over the entire period of the pandemic

15% and 20% of staff may be absent during the peak lasting

Up to 30–35% absenteeism for small organisations/units/teams (5 to 15 staff)

5–6% of staff could be absent as a result of school closures or other restriction

Protection in an occupational settingemployers duty:

Provide safe place of work Require to maintain safe working systems Implement protective measures based on

local risk assessments Implement appropriate infection control

measures Provide physical barriers o stop

transmission Working procedure adjust to needed social

distances Enhance cleaning regime Provide appropriate PPE

Business continuity plan-BCP

Plan for the impact of a pandemic on business

Plan for the impact of a pandemic on employees and customers

Establishment of appropriate working policies during a pandemic

Allocation of resources to protect employees and customers during a pandemic

Communication to and educate employees Coordination with external organizations

How to reduce the risk of workplace exposure during

pandemic influenza

“Hierarchy of controls” – workplace risk assessment matrix

Work Practice and Engineering Control

Administrative Controls Personal Protective Equipment (PPE) Vaccination

Infection control precautions - Key points

Standard infection control Hand hygiene among staff and patients

Droplet precautions Respiratory hygiene - managing coughing

and sneezing Use of PPE proportionately to the risk Placement of patients within the facility

Single room “Cochorted” patients (epidemiological and

clinical data) Duration of isolation precautions

Vaccination

Infection control - Supplementary guidance

Primary health care clinics General practice premises Primary care teams making home visits Allied health professionals (AHP) Transfer and transport of patients Centres for mental health Elderly people care Dental practices

Infection control - Supplementary guidance

Guidance for non-healthcare settings and personnel, including:

Prisons Fire and rescue service Police service Universities and schools Funeral workers

General practices – Infection control

Key points non-essential clinics should be cancelled staff should be allocated to either influenza or non-

influenza patients a separate waiting area should be set aside for

influenza patients hand hygiene facilities and paper tissues should be

made available the environment should be cleaned frequently with

neutral detergent Organisation of work flow and

appointments Telephone triage Segregation

Checklist for pandemic infection control in GP

practices(1)

Layout and configuration of the practice separate waiting areas for influenza and non-

influenza patients. designate particular clinical rooms or doctors’ offices

for * influenza patients * non-influenza patients

remove extraneous items (toys, soft furnishings, magazines) from waiting areas.

mortuary issues

Organisation of work flow and appointments

telephone triage entry points procedure

Checklist for pandemic infection control in GP

practices(2)

Staffing assign GPs for influenza or non-influenza patients

Infection control

Availability of hand hygiene facilities for staff and patients(sinks, soap, alcohol hand rub, paper towels)

Personal protective equipment supplies of PPE appropriate for needs perform risk assessment for aerosol-generating

procedure

Checklist for pandemic infection control in GP

practices(3)

Education and training Provide training in pandemic influenza infection

control procedures Tested FFP3 and training for proper use

Record keeping Track and document staff sickness and absence Track and document staff assignments

Patient information Display posters provide information sheets, pamphlets…

Personal protective equipment

ENTRY TO CONORTED AREA

BUT NO CONTACT WITH

PATIENTS

CLOSE PATIENT CONTACT

(WITHIN ONE METRE)

Hand hygiene

Gloves xb c

Plastic apron xb

Gown x xd,e

Surgical mask FFP3 respirator x x

Eye protection x Risk assesment

Vaccine Priority Group Recommendation

1. A

HCW with direct patient contact and PHW and vaccinators

B Persons > 65 years with 1 or more IHRC (Influenca high-risk conditions) Persons 6 months to 64 years with 2 or more IHRC

C Pregnant women Household contacts

Immunocompromised patientsChildren < 6

D Public health emergency response workers

2. A

Healthy 65+ 6 months to 64 years with 1 IHRC

B Other public health emergency responders workers Public health safety workers (police, fire, dispatchers…)

Utility workersCritical infrastructure

3. Healthy persons 2 – 64 years

Checklist for pandemic infection control in GP practices

Environmental infection control:

Clinical and non-clinical waste Linen and laundry Staff uniforms Environmental cleaning and disinfection

Patient care equipment Furnishings

PlanningPlanning

BCOP-EBCOP-E

1.1. Preparedness 2. Response 3. RecoveryPreparedness 2. Response 3. Recovery

Pandemic Business Continuity of Operations Planning

BCOP-Essential

Business continuity plan-BCP

KEY ACTIVITIES

PLANNINGPLANNING

TRAINING AND TRAINING AND EDUCATIONEDUCATION