Adapting Existing National Plans for new health ...

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Pan AmericanHealthOrganization

Adapting Existing National Plans for new health emergencies Adapting Existing National Plans for new health emergencies

-- CholeraCholera

Dr Robert LeeDr Robert Lee

Emergency Preparedness

and Disaster Relief Area

BackgroundBackground

�� All Caribbean Countries have:All Caribbean Countries have:

oo National Emergency PlansNational Emergency Plans

oo National Influenza Pandemic PlansNational Influenza Pandemic Plans

oo IHR PlansIHR Plans

�� All Caribbean Countries have:All Caribbean Countries have:

oo National Emergency PlansNational Emergency Plans

oo National Influenza Pandemic PlansNational Influenza Pandemic Plans

oo IHR PlansIHR Plans


�� Foundations of public health control Foundations of public health control

�� Essential elements of a NCPEssential elements of a NCP

�� Foundations of public health control Foundations of public health control

�� Essential elements of a NCPEssential elements of a NCP

� Characterized by a sudden

onset of acute watery diarrhea

with(out) vomiting

� Transmitted by contaminated

water, food, dirty hands, vomit

and faeces

� Characterized by a sudden

onset of acute watery diarrhea

with(out) vomiting

� Transmitted by contaminated

water, food, dirty hands, vomit

and faeces

What is cholera?What is cholera?


and faeces

� Extremely virulent, spreads

rapidly and can quickly (within

hours) lead to death from

severe dehydration

and faeces

� Extremely virulent, spreads

rapidly and can quickly (within

hours) lead to death from

severe dehydration

Recent EpidemicsRecent Epidemics


Source: Harris, B.J. et al.

Lancet, Vol 376, Dec 11, 2010

Developing a health emergency

plan: first steps

Developing a health emergency

plan: first steps

� Establish a planning committee with reps from all relevant

sectors

� Agree (provisionally) on roles & responsibilities

� Designate who is responsible for what: lead agencies,

individuals, spokespersons!

� Establish a planning committee with reps from all relevant

sectors

� Agree (provisionally) on roles & responsibilities

� Designate who is responsible for what: lead agencies,




� Set deadlines and define baselines

� Identify resources (financial and human)

� Determine gaps and constraints


� Set deadlines and define baselines

� Identify resources (financial and human)

� Determine gaps and constraints

Elements of a national health emergency planElements of a national health emergency plan


Foundations of Prevention & ControlFoundations of Prevention & Control

� Treatment: oral rehydration salts (ORS)

� Prevention: improvement of and access to safe

water and sanitation

� Treatment: oral rehydration salts (ORS)

� Prevention: improvement of and access to safe

water and sanitation


� Preparedness: community mobilisation

� Intersectoral coordination

� Preparedness: community mobilisation

� Intersectoral coordination

Perspectives to aid planning for an

outbreak

Perspectives to aid planning for an

outbreak

In most cholera outbreaks, roughly:

� 75% of infected individuals do not develop symptoms

� Of those who do, roughly 80% of cases are mild/moderate

In most cholera outbreaks, roughly:

� 75% of infected individuals do not develop symptoms




� 10 - 20% are severe

� 1% benchmark for case fatality rates is rarely met


� 10 - 20% are severe

� 1% benchmark for case fatality rates is rarely met

Risk Assessment: ScenariosRisk Assessment: Scenarios

� Determine the cholera attack rate (AR) in previous years (check WHO annual cholera report)

� If not, assume an AR of 0.2% in endemic areas and 0.6% in endemic areas with poor sanitary conditions

� Determine the cholera attack rate (AR) in previous years (check WHO annual cholera report)

� If not, assume an AR of 0.2% in endemic areas and 0.6% in endemic areas with poor sanitary conditions


0.6% in endemic areas with poor sanitary conditions

� AR = [(estimated total no. of cases)/(pop)] x 100

0.6% in endemic areas with poor sanitary conditions

� AR = [(estimated total no. of cases)/(pop)] x 100

WHO Risk Assessment ChecklistsWHO Risk Assessment Checklists


Planning for health care facilitiesPlanning for health care facilities

� Establish estimates for the (surge) capacity of health facilities for: a) triage; b) outpatient management; c) referral to CTC for severe cases

� Functionality: medical

� Establish estimates for the (surge) capacity of health facilities for: a) triage; b) outpatient management; c) referral to CTC for severe cases

� Functionality: medical


� Functionality: medical personnel

� Accessibility: transport and remote areas

� Excess mortality: disposal of corpses

� Functionality: medical personnel

� Accessibility: transport and remote areas

� Excess mortality: disposal of corpses

� Electrolyte solution containing

fluids and vital salts

� Lancet report estimates that

>1.4 million deaths of children

� Electrolyte solution containing

fluids and vital salts

� Lancet report estimates that

>1.4 million deaths of children

Oral Rehydration Treatment (ORT)Oral Rehydration Treatment (ORT)


under 5 can be prevented with

correct use of ORT every year

under 5 can be prevented with

correct use of ORT every year

Network of cholera treatment centersNetwork of cholera treatment centers


Oral Rehydration Posts: treat

individuals who display non-life

threatening symptoms

Alert, Response,CoordinationAlert, Response,Coordination

� Criteria to determine what constitutes an emergency

� Define categories/levels of response according to the

scale of the incident

� Determine alert and standby procedures

� Criteria to determine what constitutes an emergency

� Define categories/levels of response according to the

scale of the incident




� Determine lead/executive responsibilities

� Emergency Operations Centre

� Incident Management Mechanism


� Determine lead/executive responsibilities

� Emergency Operations Centre

� Incident Management Mechanism

PED Situation Room

REMIT OF IC

•analyzes disaster scenarios &

determines operational priorities

•identifies and mobilizes staff (int. &

ext.) with requisite skills

•coordinates and leads response


REMIT OF EOC Manager

•manages the EOC - not the

incident

•facilitates and coordinates

•solves problems

•mobilizes key personnelcaptures, organizes and analyzes all

information related to incident

compiles, organizes and analyzes all

information related to the health impact

of emergencies

Sanitation & Safe WaterSanitation & Safe Water

� Expand and ensure access to clean water and sanitation

� All sanitation facilities and water sources are potential ‘vehicles

of transmission’ and should be disinfected to prevent

contamination.

� Boiling or disinfection of water with chorine solution (0.5mg/litre)

are easy ways to provide safe drinking water

� Expand and ensure access to clean water and sanitation

� All sanitation facilities and water sources are potential ‘vehicles

of transmission’ and should be disinfected to prevent

contamination.

� Boiling or disinfection of water with chorine solution (0.5mg/litre)

are easy ways to provide safe drinking water


Community MobilizationCommunity Mobilization

� Preparation of ORS should be taught in high risk populations

� If community mobilization is to be effective it

should:

� Preparation of ORS should be taught in high risk populations

� If community mobilization is to be effective it

should:


- be context specific and culturally sensitive

- be ‘process oriented’ not ‘product oriented’

- use visuals/pictures as much as possible

(illiteracy may be common)

- be context specific and culturally sensitive

- be ‘process oriented’ not ‘product oriented’

- use visuals/pictures as much as possible

(illiteracy may be common)

Community MobilizationCommunity Mobilization


Community Mobilization: Checklists

www.cotsprogram.comCommunity Mobilization: Checklists

www.cotsprogram.com


CommunicationsCommunications

� Specific messages for specific audiences

� Clear lines of communication between key

decision makers

� Clear protocols for communicating with press

� Access: which tools/mediums are easily accessible

� Specific messages for specific audiences

� Clear lines of communication between key

decision makers

� Clear protocols for communicating with press




to which audiences?

� Technological constraints and illiteracy

� Contingency plans


to which audiences?

� Technological constraints and illiteracy

� Contingency plans

Intersectoral CoordinationIntersectoral Coordination


Evaluating SuccessEvaluating Success

� Is Case Fatality Rate a good indicator of success?

� Need for composite metric to capture impact of

prevention & control strategies (morbidity) &

improvements in health/sanitation

� Is Case Fatality Rate a good indicator of success?

� Need for composite metric to capture impact of

prevention & control strategies (morbidity) &

improvements in health/sanitation


� Need to distinguish between outputs (e.g. access

to health services/coverage) and outcomes (e.g.

reductions in CFR)

� Need to distinguish between outputs (e.g. access

to health services/coverage) and outcomes (e.g.

reductions in CFR)

Gaps and ChallengesGaps and Challenges

� Acceptance and utilisation of ORS is a challenge – first weeks of epidemics are problematic

� Death rate from diarrhea is unacceptably high: WHO meta-study showed that 1/5 children received all three components i.e. effective ORT

Should “cholera fluids” be routinely employed during

� Acceptance and utilisation of ORS is a challenge – first weeks of epidemics are problematic

� Death rate from diarrhea is unacceptably high: WHO meta-study showed that 1/5 children received all three components i.e. effective ORT

Should “cholera fluids” be routinely employed during


� Should “cholera fluids” be routinely employed during cholera outbreaks?

� What about remote areas and access to rehydration therapy: are ORPs enough?

� Should “cholera fluids” be routinely employed during cholera outbreaks?

� What about remote areas and access to rehydration therapy: are ORPs enough?

ConclusionsConclusions

� Four foundations of prevention & control plan

� Effective functioning of these is based on good

planning and preparedness

� Need for development and use of standardized clinical

resources/tools

� Four foundations of prevention & control plan

� Effective functioning of these is based on good

planning and preparedness

� Need for development and use of standardized clinical

resources/tools


resources/tools

� Ability to respond, modify and adapt to local

circumstances and constraints is critical

resources/tools

� Ability to respond, modify and adapt to local

circumstances and constraints is critical

ReferencesReferences

a. http://www.who.int/cholera/technical/prevention/control/en/i

ndex.html

b. http://www.emro.who.int/csr/Media/PDF/cholera_whopolicy.

pdf

a. http://www.who.int/cholera/technical/prevention/control/en/i

ndex.html

b. http://www.emro.who.int/csr/Media/PDF/cholera_whopolicy.

pdf


pdfpdf

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