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
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�� 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?
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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
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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,
individuals, spokespersons!
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individuals, spokespersons!
� Set deadlines and define baselines
� Identify resources (financial and human)
� Determine gaps and constraints
individuals, spokespersons!
� 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
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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
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� 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
� Of those who do, roughly 80% of cases are mild/moderate
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� Of those who do, roughly 80% of cases are mild/moderate
� 10 - 20% are severe
� 1% benchmark for case fatality rates is rarely met
� Of those who do, roughly 80% of cases are mild/moderate
� 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
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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
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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
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� 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)
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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
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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 alert and standby procedures
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� Determine alert and standby procedures
� Determine lead/executive responsibilities
� Emergency Operations Centre
� Incident Management Mechanism
� Determine alert and standby procedures
� 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
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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
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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:
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- 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
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Community Mobilization: Checklists
www.cotsprogram.comCommunity Mobilization: Checklists
www.cotsprogram.com
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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
� Access: which tools/mediums are easily accessible
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� Access: which tools/mediums are easily accessible
to which audiences?
� Technological constraints and illiteracy
� Contingency plans
� Access: which tools/mediums are easily accessible
to which audiences?
� Technological constraints and illiteracy
� Contingency plans
Intersectoral CoordinationIntersectoral Coordination
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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
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� 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
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� 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
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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.
a. http://www.who.int/cholera/technical/prevention/control/en/i
ndex.html
b. http://www.emro.who.int/csr/Media/PDF/cholera_whopolicy.
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