Pandemic Preparedness -Risk assessment and infection control in health care settings- This lecture is developed under the Fulbright Grant for development of US-Macedonian Collaboration in Higher Education in the field of Global Public Health Security. The title of Fulbright Project is ”New educational Pathway for Global Public health Security” (http://www.cies.org/schlr_directories/vsdir08/Publ39.htm) 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 Previous experience: 1994 - 2002- Director, National Public Health Institute (Republic Institute for Health Protection), 1980 - 1994 – Industrial physician, Chief of the Department for planning and organization, Institute for Occupational Health Other present relevant position: 2009 - Present, UNDP National expert for chemicals and health 2008 – Present, Member of Editorial Board of EuroSurveillance 2007 - Visiting Professor, Erasmus Mundus-Europubhealth Master Studies, University of Sheffield, Sheffield, UK and Krakow, Poland. Courses taught: Disaster Management and International Health (Environmental disasters). 2006 – NATO Partner Country Co-director, Advanced Study Institute, Science for Peace and Security Program, Project title: Strengthening Public Health Preparedness for Chemical, Biological and Radiological Agents Threats.

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

A whole of society approach to pandemic preparedness and response INDIVIDUALS FAMILIES AND COMMUNITIES HEALTH SECTOR NON HEALTH SECTOR Provide leadership and guidance Take actions to reduce health consequences Raise awareness about risk and potential consequences. Develop guidance and implement actions needed to minimize the effects of a pandemic on non health sectors. Take actions needed to minimize the effects of a pandemic on families and individuals PLANNING AND COORDINATION COMMUNICATION

WHO Guidance, core documents Supporting Technical Documents Disease Control Measures For Pandemic Influenza Outbreak Communicat ions Global Pandemic Influenza Surveillance Laboratory Preparedness For Pandemic Influenza Surge Capacity in Health Care Facilities Non- Health Sector Preparedness Tools Self- Assessment Checklist for Preparedness Planning and Executing a Preparedness Exercise Training CD-ROMs For Trainers Rapid Containment Training Package Handbook For the Public Sample Preparedness Plans

Comparison of the 2005 and 2008 WHO pandemic phases Structure & Pandemic Disease “Risk” Structure & Pandemic Disease “Risk” Geographic Pandemic spread Predominantly animal Pandemic Phase 6 Infections; 5 - 6 Post Alert Limited Peak transmissibility Inter pandemic Post among people Sustained Post Phases 3-5 4 Pandem Pandemic Period H-2-H transmission Phases 1-2 1 - 3 Time Time

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

Risk analysis circles RISK RISK ASSESSMENT MANAGEMENT Dose assessment Decision control a z k i s r Hazard i e R t c identification a Acceptable risk r a h level definition Exposure c assessment Mitigation measures Feedback RISK COMMUNICATION

Risk assessment The risk assessment process involves the following tasks: ❍ Preparing the risk assessment matrices ❍ Determining the risk ratings ❍ Prioritizing observations

Likelihood and severity of damage, 3x3 matrix S e v e r t y Likelihoodd Low Moderate High Very Unlikelihood Low Risk (1) Moderate Risk (2) Likely High Risk (3) Very Likely Likelihood

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 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 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 setting employers 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 Gown x xd,e Surgical mask FFP3 respirator Eye protection Risk assesment

Vaccine Priority Group Recommendation 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 patients Children < 6 D Public health emergency response workers 2. A Healthy 65+ 6 months to 64 years with 1 IHRC Other public health emergency responders workers Public health safety workers (police, fire, dispatchers…) Utility workers Critical 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

Pandemic Business Continuity of Operations Planning BCOP-Essential Preparedness 2. Response 3. Recovery BCOP-E Planning Pandemic Business Continuity of Operations Planning BCOP-Essential

Business continuity plan-BCP

KEY ACTIVITIES PLANNING TRAINING AND EDUCATION