PANDEMIC PREPAREDNESS

                                              -LESSON LEARNED FROM COVID19

                                  Dr. P.C.Ranka,(M.D.Medicine)

 

The purpose of this article is to enlighten decision makers about this “new reality of pandemic.” This detailed discussion of preparedness will be followed with potential resources for healthcare leaders to ensure appropriate preparation and response. This article’s objectives are to facilitate the reader’s (1) understanding of pandemic, (2) appreciation

for how it got spread globally, (3) recognition and acknowledgement of    India’s vulnerabilities, and (4) ability to transition our organisation into being prepared to react to, and care for, patients exposed to covid 19.

 

 Steps to pandemic Preparedness Learned late still useful for future:

 

The following are four basic preparation steps that may be implemented by

healthcare managers and facilities to prepare for pandemic

These four steps are:

1. Prepare for public health issues. This step is directed toward public health authorities and their preparedness actions

2. Prepare for healthcare delivery issues. step

is inherent to healthcare managers and clinicians

3. Prepare for support issues. step of support issues handled by both the public health and private healthcare sectors

4. Prepare for security and hazard issues. This step is directed toward security and policing and general administration department.

 

They should be specifically ordered in this manner that they would become relevant to healthcare facility managers.

Step one:

The specific tasks for medical surveillance i.e.

Identify departments responsible for medical surveillance and reporting.

Develop a surveillance plan for detecting unusual medical events.

Establish medical baselines diagnosis. The public health sector, if efficient, must provide an  effective medical diagnosis of infection and define

possible pandemic strain at the earliest possible.  

 

The the second challenge to public health officials, is to

Identify the department responsible for contacting and coordinating sample submission and confirm clinical diagnosis by laboratory results,

policies and procedures in consultation with the central government, ICMR, virology labs together with major stakeholders.

Identify the process by which the public health department will provide support to the pandemic investigation team at state and central level.

Early detection of the related  organism/strain is vital to an efficient and effective healthcare preparation and response plan.

Physicians suspecting the disease should notify public health authorities and ask for aid in defining the suspected problem.  reporting must take place in a public health infrastructure, which is virtually non-existent in many districts, and very weak at the state level. To investigate, we need much more PCR laboratories to identify what the virus strain is, but such facilities exist in very few laboratories although we have such PCR facilities at in Agriculture and botany departments of academic universities. They were not utilised in the present pandemic.

Another challenge to public health preparedness, is

Identify departmental responsibility for epidemiological investigation.

Determine the method of reporting.

Identify processes and procedures for reporting suspicious disease patterns or health problem to law enforcement officials.

The epidemiological investigation should take the medical surveillance and medical diagnosis measures one step further in terms of reporting and aiding investigation.

           The epidemiological investigation should be used to determine when and where the disease  was initiated and with whom the patient has come in contact prior to their arrival at the healthcare facility. It was largely missing in present pandemic

one important challenge in public health preparation is to prepare a plan for the mass prophylaxis of a community and its surrounding areas

 The process of mass prophylaxis includes agent identification, delivery and training of protective equipment, dissemination plans for prophylaxis of the community, and, again, establishing lines of communication that will facilitate these actions.

 We need to Devise a plan to access medicines and health care delivery institutions and to Equipment.

° Acquire needed equipment to implement pandemic disaster plan (i.e., masks, gowns, filters, biohazard waste disposal systems ventilators, high flow oxygen facilities, day care facilities).

° Train personnel on equipment use.

Determine departmental responsibility and plan for supply and dissemination of prophylaxis measures  extensive IEC plan should be implemented earliest possible.

 Develop policies and procedures for sharing information among the local administration team, the public health department, and those responsible for mass prophylaxis.

 Identify points of contact for each area of support and establish lines of communication.

The last challenge for the public health system is for community leaders to address the structure of coordinating preparation efforts in their community in terms of both the infrastructure and communication networks and to avoid delicacy of efforts as several different agencies are responsible for various coordination challenge is the development of intra-agency communication methods to unite:

Local public health agencies

Local institutional health care providers

Local health professional providers

Agencies like ICMR Diagnostic services providers, State, District and local administration.

The critical ability for networking to occur among these agencies can increase or decrease the level of response taken by a healthcare organization. Thus, preparedness and communication among the local, state, and central public health representatives is essential in pandemic event.

Step Two: Preparing for Healthcare Delivery Issues

Step two consists of two key preparation challenges separate from those of the public health

systems:

1. Care of presented casualties and the worried well

2. Emergency management operations

Care of presented casualties and the worried well is defined as the actual steps and procedures necessary for healthcare facilities to prepare emergency medical systems that are fully integrated with aspects of pandemic and patient symptom assessment questionnaires specifically addressing the virus in question.

The “worried well” aspect of this step implies that when a publicized pandemic event occurs many patients, anxious about symptoms of the publicized agent, will flock to and overwhelm acute care facilities even when they have not been credibly exposed. How a healthcare facility handles, separates, and treats the presented casualties and “worried well” patients can strengthen or prohibit the spread of hysteria and true symptomatic identification.

Along with the problem of hysteria among the uninfected is the issue of how a healthcare facility will handle the surge of truly afflicted patients into their facility

At the present time hospitals are running very near to capacity. They

are financially strapped and short of personnel. Many of the hospitals

in major metropolitan health settings could not accommodate a

sudden surge of 50 acutely ill new patients. Thus, issues of personnel and finance must be addressed in terms of the “worried well” and the

possibility of a surge of patients, both infected and uninfected, to healthcare facilities across the nation in the event of pandemic. The challenges in providing health care for presented casualties and the worried well are:

● Creating a modular emergency medical system (MEMS) or similar plan

● Coordinating MEMS with all hospital emergency preparedness plans (EPPs)

● Preparing plans for legal issues such as liability of providers and worker’s compensation

● Formulating plans to integrate mutual aid and state and central assistance

● Developing a detailed questionnaire for rapidly collecting patient’s identification and background

information (such as where the patients were in the previous few days, etc.)

● Performing exercises of MEMS and/or EPPs

The Citizens are likely to believe they will receive the best care possible by EMS and thus, the public believes that hospitals “have an inherent obligation to the community for pandemic preparedness. The question is, will hospitals actually be getting it done? Or will hospitals provide incomplete, misleading information to the public in order to ease public

opinion?

Coupled with addressing presented casualties and worried well patients is the preparation of an actionable emergency management plan and definition of continuing operations. The most vital piece of this plan is the recognition and report of key signs to the emergency operations

center (EOC). The specific emergency management operations tasks to achieve this second challenge of healthcare delivery are:

● Review local plans that call for activation of an EOC and make sure an “unusual medical event” triggers activation.

● Identify key stakeholders

Possible key signs and symptoms should be outlined in the written plan to notify the proper personnel in healthcare facilities that an “unusual medical event” may be occurring. If these are not built into a facility’s EOC, the preparation technique of an EOC could be useless; if unusual signs and symptoms are not reported early, continuing infection may occur. As in the previous steps mentioned, proactive communication with personnel is vital to an efficient and useful EOC.

Step Three: Preparing for Support Issues

Step three consists of four support issues for which the healthcare facility and its community

must be prepared:

1. Fatality management

2. Resource and logistic support

3. Continuity of infrastructure

4. Family support services

 Fatality management, the first challenge of support issues, comprises the creation of a fatality management plan and includes tasks such as:

● Creating a fatality management plan that deals with the potential for overwhelmed city morgues and the religious concerns of relatives

 ● Establishing safe handling procedures

This plan is different from the EOC in that it must include how the facility and/or community will deal with overwhelming surges at city morgues, funeral homes, and family counselling services. Another aspect to be considered, based on the mission of the healthcare facility, is religious counselling and religious services provided for the dying and their families. While caring for the fatally sick, healthcare facilities must develop plans for positive identification of the dead, as well as handling and tracking procedures as the deceased are moved from facility to facility.

The resource and logistic support aspect of this step includes the development of plans to organize and statistically quantify the resources used and on which patients they are used. This second support issue includes these tasks:

Creating and assigning responsibility for a resource support plan

Creating and assigning responsibility for a logistic support plan

Resource and logistic plans should include recommendations for supply continuation in case a facility’s primary supply source is terminated or difficult to use during the pandemic.

Due to the current financial crisis of the health care system, hospitals that use “just-in-time” inventory, for example, will have minimum on-site storage of sterile supplies, vital equipment, and pharmaceuticals. “Re supply” and “back-up” mechanisms are often shared by all local and regional medical institutions and health department:

Thus, there is a fear among healthcare personnel and physicians that the tracking of resources may not be efficient enough to enable facilities to access needed resources and/or

that resources will be easily depleted in particular communities. Devising resource and logistic communication networks prior to a pandemic event is vital in ensuring that healthcare facilities have the ability to respond with necessary equipment effectively will aid in lessening this inevitable  confusion and enhance a healthcare facility’s

ability to respond.

Continuity of infrastructure refers to plans made to continue providing services(health care, water, sewage, electricity, foodstuffs, etc.) once a   pandemic event has occurred.

To help ensure the continuity of infrastructure, the third challenge of support issues, it is important to assign responsibility for completion of a local infrastructure plan.

“Few hospitals now have comfortable operating margins” due to the restrictions of government support, several expensive or underfunded regulatory mandates, high expectations that hospitals maintain increasing levels of charity medical care, and the national shortage of nurses and personnel, and many are without the provisions for extraordinary surge capacity. Accordingly, it is unlikely that hospitals can meet surges of capacity during a mass casualty event and expect to immediately continue their normal care after the surge capacity of patients has been treated. Although many of the primary services in this plan must be operated by the local district health authorities, it is vital that hospitals, emergency clinics, and private clinics prepare plans on how they will provide professionally trained personnel administering to the community during a time of pandemic crisis.

Family support services must be involved with the previously mentioned plans. The key task in supporting family services is ensuring that hospital emergency preparedness plans reference local emergency response plans for family support services.

Not only should healthcare-related facilities be prepared to continue their services, but they also may wish to plan for additional family support services such as religious services, counselling, social services, financial services, and guidance to find missing loved ones

Step Four: Preparing for Security and Hazard Issues

Least likely to be handled by an individual healthcare facility, but still pertinent to the preparation for pandemic, are the challenges regarding security and hazard issues. Tasks to be accomplished by authorized personnel in the community are:

1. Control of affected area/population

2. Residual hazard assessment and mitigation

Controlling the affected area/population is a security issue that is primarily the responsibility of the local and state police departments during the event of pandemic attack. Police departments must have physical plans for the affected buildings, streets, and transportation systems, and so on. Police departments should also set up proper communication channels enabling the local public health department, police departments, and EMS respondents to communicate with one another. The key tasks in controlling the affected area and population, the first challenge of security and hazard issues, include:

The local police department should establish physical security plans that address the potential areas affected by pandemic event.

Consider establishing and promulgating a policy that only public affairs officials talk to the press.

Establish points of contact for a local public affairs office with the police.

The creation of policies indicating that only public affairs officials should talk to the press is extremely critical to maintaining the credibility of healthcare facilities. This will also limit the communication of inaccurate information, control hysteria among the population, and control

the response of the “worried well” and community individuals worried about their loved ones.

Develop protocols for such situations to facilitate response to a pandemic.

 

Conclusion Regarding Preparedness

The readers of this article are likely to be managers of healthcare organizations that will encounter pandemic in the future. For such organizations, there are three related issues: Pandemic preparedness, response, and change in response to a direct attack or based on experience from other countries or states.

. Although no one can foretell the specifics of such pandemics, the healthcare systems must have response plans in place for any number

of events because each type of pandemics has a set of

characteristics and dangers and needs specialized equipment and very specialized treatment means and procedures. Pandemics preparedness should be bioagent-specific and involve significant levels of planning.

The preparation by a healthcare facility for a pandemic is by no means simple or inexpensive.

Outlined and practiced procedures, instructional manuals, the development of communication networks, and the training of personnel on bioagents are

absolutely vital to any facility, healthcare or not, to be ready for a potential attack.

 This article serves only as an introduction to how intricate and, at times, extremely difficult preparing for an event of such magnitude can be for the administrators of a healthcare facility.

Extensive training and retraining are needed so that the plans are not sitting on healthcare leaders and professionals must participate

in realistic exercises to practice skills developed in training and to identify areas that need improvement. All too often the healthcare members who believe they are prepared come to discover gross inadequacies during simulation exercises. Until practice and drill exercises can be performed to perfect emergency reaction plans, it is probably safe to say that healthcare facilities are unprepared and there is reason to have serious concern about their preparedness.

Epilogue

According to the assessment, virtually all the states reported a “poor” performance in

the following categories:

● Health outcome monitoring

● Emergency telecommunications service

● Resources to reduce barriers to health services

● Assessed ability to increase health care five to ten fold

● Assessed pharmaceutical inventories

● Medical triage procedures

● Emergency protective equipment in hospitals

● Assessed emergency response of public health workforce

● Education of healthcare providers/lab workers

● Training on decontamination procedures

● Public health workforce cross-trained with emergency response system

● Training on emotional/mental health aspects

● Dissemination of research information by local public health system

It is clearly showed that public health, healthcare facilities, police departments, and local and state governments are not ready for pandemic. With the dissemination of information, incomplete communication structures, and inefficient emergency operation plans, the central govt. is also not prepared. demonstrates that we have a long road to travel yet.

Because an emergency preparedness plan can never plan for all possibilities of mass casualty, responding to pandemic is extremely difficult to plan for in its entirety. The current financial crisis of the Indian healthcare system directly affects preparedness and response for mass

casualty incidents in several ways. It is argued that the lack of proper funding to hospitals and response facilities causes an inadequate response to lack of equipment, personnel, and training; even if a preparation plan is devised by the facility, a plan cannot be implemented if the financial institutions do not exist to implement the plan. The lack of financial infrastructure in current healthcare facilities is only one hindrance to an adequate response to pandemic

Therefore, should the Indian population still worry about adequate preparedness? Most definitely, but it should not stop there. The public should help prepare local organizations, but also should work with others in the community. Everyone needs to be ready to “defend in depth”

patients, co -workers, and loved ones. The truth of the new reality of pandemic is not that it can kill, but that it has the potential to kill alarming numbers of people.

 To keep up to date knowledge of  the changing pandemic context, a variety of sources should be monitored—not only the news, WhatsApp or social media, but also specific Web sites like that of WHO. ICMR, CDC etc. These sites will enable the reader to access a wide range of insights into pandemic, disease management as those realities continue to change.