1. Dr. Madhur Verma
PG JR II
DEPTT OF COMMUNITY MEDICINE

2. LEARNING OBJECTIVES
1. Introduction
2. Public health emergency & PHEIC
3. Criteria for decision-making in verification and
notification of public health events.
4. Public health emergency preparedness(PHEP)
5. Situation at the time of emergency
6. Epidemiologic methods at the time of PHE
7. Role of hospitals during a PHE
8. Conclusion

3. INTRODUCTION
Since beginning of the last decade, near the time
anthrax attacked the world, a substantial amount of money
has been spent by majority of the countries to increase their
ability to prepare for, and respond to, public health
emergencies.

4.  Yet, despite reports suggesting that progress has been
made, it is unclear whether these investments have left
the nation better prepared to respond to a bioterrorist
attack, pandemic influenza, or any other large-scale
public health emergency.
 This situation is not because of a shortage of measures
of preparedness. Hence, there arises a need to be
prepared to any kind of such situations dangerous to the
mankind known as public health emergencies.

5. PUBLIC HEALTH EMERGENCY
 PHE is defined as “an emergency need for health care
[medical] services to respond to a disaster, significant
outbreak of an infectious disease, bioterrorist attack or
other significant or catastrophic event.”
 The definition is also aligned with the all-hazards approach to
preparedness instead of focusing on a “disaster du jour” and
thus allows for the optimal development of capabilities across
scenarios and better prepares communities for the broad
spectrum of potential risks.

6.  PHIEC – Public Health Emergency
of International Concern
 An extraordinary event which is
determined, as provided in these
Regulations:
i. to constitute a public health risk to other
Member States through international
spread of disease and
ii. to potentially require a coordinated
international response.
The Director General -WHO declares PHEIC

7. The expansive definitions of "disease", "event", "public
health risk" the IHR (2005) cover a wide range of public
health risks of potential international concern:
• whether biological, chemical or radio nuclear in origin or
source, and
• whether potentially transmitted by:
persons (e.g. SARS, influenza, polio, Ebola),
goods, food, animals (including zoonotic disease risks),
vectors (e.g. plague, yellow fever, West Nile fever), or the
environment (e.g. radio nuclear releases, chemical spills
or
other contamination).

8. Alert and Response Operations
Events that may constitute a
Public Health Emergency of International Concern need:
Detection
Verification
Risk assessment
Response

9. Event notification and determination
under IHR (2005)
WHO DG
WHO IHR
Contact Points
National IHR
Focal Points
Various disease &
event surveillance
systems within a country
Emergency
Committee
Other competent
Organizations
Receive, assess and
respond to events
notified
Consult events or
notify WHO of any
events that may
constitute a PHEIC
Detect and report any
urgent or unexpected
events
Ministries/
Sectors
Concerned
Determine whether an
event constitutes a
PHEIC and recommend
measures
External
advice
Coordinate
Communicate
Report

10. NOTIFICATION
 Does not imply that an event is a PHEIC
 Just “telling WHO about an event”
 No immediate consequences for country
 Know about the event from other sources
 Start assessing the event without country’s official
notification
8/31/2014 10

11. Event notification
 Any event that may constitute a Public Health
Emergency of International Concern (PHEIC)
 Within 24 hours of assessment
 By the most efficient means of communication
 Continue to provide WHO with detailed information
 Does NOT mean a real “PHEIC”

12. Notification is a start of a dialogue
(i.e. ”not a big deal”)
Potential PHEIC
notified by country
Dialogue
PHEIC declared
by WHO
High sensitivity,
Low positive predictive
value
It is the event itself - not
the official notification of it
- that is the basis of WHO’s
determination of PHEIC

13. Benefits of early Notification
1. Confidential dialogue
2. IHR protection against unjustified measures
3. Assistance by WHO and other countries
WHO will know sooner or later anyway
8/31/2014 13

14. Verification of events
 Value unofficial sources of information for early
alert
 WHO requests for verification of potential public
health events of international importance
 Member States provide initial reply within 24
hours and provision of information
 On-site assessment, when necessary

15. The IHR surveillance system
(promed@promedmail.org)
National
IHR Focal
Point
If anyone think ,
Government is delaying
notification,
Write in ProMED
WHO
Mass media,
GPHIN, MediSYS,
Google, NGOs,
ProMED etc + other
countries
Local
level
8/31/2014 15

16. Disease List
 Four diseases (a single case is notifiable):
 Smallpox, Poliomyelitis, human influenza (caused by a
new subtype), SARS
 Utilization of the decision instrument:
 Cholera, plague, viral haemorrhagic fevers, yellow
fever, …
 Diseases of regional concern: dengue fever,
meningococcal diseases…

17. CONTENTS
 INTRODUCTION

18. Decision Instrument
Criteria for assessment
1. Is the public health impact of the event serious?
2. Is the event unusual or unexpected?
3. Is there a significant risk of international spread?
4. Is there a significant risk of international travel or trade
restrictions?
Answering "yes" to any two of the criteria
requires a member state to notify WHO

19. A. Is the event serious?
 Morbidity and mortality
 Does the event have potential for high impact?
 Population at risk
 Cases in health staff; highly infectious
 Factors affecting response e.g. war, natural
catastrophe
 High population density
 Immediate or potential need for external
assistance

20. B. Is the event unexpected?
 Is the cause of the event unknown?
 Are the circumstances unusual?
 Cases worse than usual
 Treatment failures
 Event unusual for place/season
 Caused by eliminated/eradicated agent
 Suspected or known intentional or accidental
release of chemical, biological or radiological
agent

21. C. Is the event likely to spread internationally?
 Similar cases in other countries where it was
unexpected?
 Factors alerting to cross-border implications?
 Caused by epidemic-prone organism
 Source suspected/ known to be related to food
import/export
 Index case with international travel history
 In area with international tourism/ traffic, person or
goods
 In border areas with limited capacity for control

22. D. Is event likely to result in international travel
and trade restrictions?
 Similar events previously led to restriction
on travel/ trade?
 Source known or suspected food product/
goods known to be imported or exported?
 In area with international tourism?
 Attracted media attention?

23. Is the event serious?
Is the event unexpected?
Is the event unexpected?
Yes
No Yes
Could it (or has it) spread
internationally?
Could it (or has it) spread
Yes internationally?
Risk for international
sanctions?
No
No
Not
notified
at this
stage.
No
No
Yes
Yes
Yes
No
Notify the event under the International Health Regulations

24. Combinations of answers
requiring notification
 Serious and unexpected
 Serious and risk for international spread
 Serious and risk for international
restrictions
 Unexpected and risk for international
spread
 Unexpected and risk for international
restrictions

25.  Public health threats are always present.
 These threats can anytime lead to the onset of public
health incidents.
 Being prepared to prevent, respond to, and rapidly
recover from public health threats is critical for protecting
and securing our nation’s public health.
 But we face multiple challenges, including an ever-evolving
list of public health threats.
 Strong state and local public health systems are the
cornerstone of an effective public health response.

26. How can we reduce the risk?
Risk reduction can be done in two ways:
A. Preparedness:
B. Mitigation.

27. PUBLIC HEALTH
EMERGENCY
PREPAREDNESS (PHEP)
Preparedness encompasses all those measures taken
before a disaster event which are aimed at
 minimizing loss of life,
 disruption of critical services and damage when the
disaster occurs.
Thus, preparedness is a protective process which
enables governments, communities and individuals to
respond rapidly to disaster situation and cope with
them effectively.

28. Preparedness includes
 development of emergency response plans
 effective warning systems,
 maintenance of inventories,
 training of manpower etc.
 involves a coordinated and continuous
process of planning and implementation that
relies on measuring performance and taking
corrective action.

29. Mitigation
encompasses all measures taken to reduce both the effect of
hazards itself and the vulnerable conditions in order to reduce
the losses in a future disaster.
Examples of mitigation measures include:
making earthquake resistant buildings,
water management in drought prone areas, management of
rivers to prevent floods etc

30.  PHEP is not a steady state; it requires
continuous improvement, including frequent
testing of plans through drills and exercises and
the formulation and execution of corrective
action plans.
 PHEP also includes the practice of improving
the health and resiliency of communities.

31. ELEMENTS OF PUBLIC HEALTH
EMERGENCY PREPAREDNESS
1. Health risk assessment. Identify the hazards and
vulnerabilities (e.g., community health assessment,
populations at risk, high-hazard industries, physical
structures of importance) that will form the basis of
planning.
2. Legal climate. Identify and address issues concerning
legal authority and liability barriers to effectively
monitor, prevent, or respond to a public health
emergency.
3. Roles and responsibilities. Clearly define, assign,
and test responsibilities in all sectors, at all levels of
government, and with all individuals and ensure each
group’s integration.

32. 4. Incident Command System. Develop, test, and improve
decision making and response capability using an
integrated Incident Command System (ICS) at all response
levels.
5. Public engagement. Educate, engage, and mobilize the
public to be full and active participants in PHEP
6. Epidemiology functions. Maintain and improve the
systems to monitor, detect, and investigate potential
hazards, particularly those that are environmental,
radiological, toxic, or infectious.
7. Laboratory functions. Maintain and improve the systems to
test for potential hazards, particularly those that are
environmental, radiological, toxic, or infectious.

33. 8. Countermeasures and mitigation strategies.
Develop, test, and improve community mitigation
strategies (e.g., isolation and quarantine, social
distancing ) and countermeasure distribution strategies
when appropriate.
9. Mass health care. Develop, test, and improve the
capability to provide mass health care services.
10. Public information and communication. Develop,
practice, and improve the capability to rapidly
provide accurate and credible information to the public in
culturally appropriate ways.
11. Robust supply chain. Identify critical resources for public
health emergency response and practice and improve the
ability to deliver these resources throughout the supply chain.

34. B. Expert and fully staffed workforce
1.Operations-ready workers and volunteers.
Develop and maintain a public health and health
care workforce that has the skills and capabilities
to perform optimally in a public health emergency.
2. Leadership. Train, recruit, and develop public
health leaders (e.g., to mobilize resources, engage
the community, develop interagency relationships,
communicate with the public).

35. C. Accountability and quality improvement
1. Testing operational capabilities. Practice,
review, report on, and improve public health
emergency preparedness by regularly using
real public health events, supplemented with
drills and exercises when appropriate.
2. Performance management Implement a
performance management and accountability
system.
3. Financial tracking Develop, test, and improve
charge capture, accounting, and other financial
systems to track resources and ensure
adequate and timely reimbursement.

36. Epidemiologic Methods in Disasters
After a disaster (Reconstruction Phase):
 Conducting post-disaster epidemiologic follow-up studies
 Identifying risk factors for death & injury
 Planning strategies & specific interventions to reduce
impact-related morbidity &mortality.
 Evaluating effectiveness of interventions
 Conducting descriptive & analytical studies
 Planning medical & public health response to futurE
disasters
 Conducting long-term follow-up of rehabilitation
/reconstruction activities

37. AT THE TIME
OF
EMERGENCY

38. MAJOR AREAS TO BE STRESSED
UPON
1. Health systems and infrastructure
2. Emergency health services
3. Reproductive health care
4. Emergency mental health and psychosocial
support
5. Epidemiology and surveillance
6. Control of communicable diseases
7. Water, sanitation and hygiene in emergencies
8. Food and nutrition
9. Management(Financial management for
humanitarian response)

39. Health systems and infrastructure
Essential tasks: prioritizing health services
1. Conduct an initial assessment;
2. Identify the major causes of morbidity and mortality;
There are three major sources of disease among the
displaced:
c. Imported by displaced persons from a previous
environment (e.g. TB,
a. Diseases Arising in camps because of unhealthy living
b. Within a new environment against which
HIV/AIDS, body lice, parasites) or that is
unique to their population (e.g., sickle cell
conditions (e.g acute respiratory infections, diarrhoea,
displaced persons might lack immunity
and measles).
disease). These diseases are
(e.g., malaria or meningitis);
The risk of acquiring these diseases is increased by
malnutrition;
usually less common causes of morbidity and
mortality than others

40. 3. Use evidence-based intervention to address major causes
of
morbidity and mortality; Triangulate the information
collected
in the assessment.
Triangulation is a technique for minimizing biases in the
information collected during the initial assessment
4. Develop a health information system to identify epidemics
and guide changes needed in interventions.
 Introduce interventions in phases. Some services must be
introduced during the acute
 emergency phase while others should be planned but not
implemented until the postemergency phase.

43. Essential tasks:
ensure access to health services
 ƒIdentify vulnerable groups and their specific needs;
 ƒ Organise services to improve access to vulnerable groups;
 ƒ Involve community members and other concerned groups
in the initial assessment and in the design and
development of interventions; and
 ƒ Seek women’s views about health problems and ways to
improve health services.

44.  ƒThere is active collaboration with other sectors in the
design and implementation of priority health
interventions, including water and sanitation, food
security, nutrition, shelter and protection.
 ƒThe Crude Mortality Rate (CMR) & The Under-Five
Mortality Rate (U5MR) is maintained at, or reduced to,
less than twice the baseline rate documented for the
population prior to the disaster.

45. Essential tasks: post-emergency
phase
 Task 1: Continue to evolve the health
information system and interventions as
indicated
 Task 2: Increase capacity of the
community and local health leaders to
design/redesign and implement of health
services

46.  Task 3: Utilise the referral system
established by the lead health authority
 Task 4: Whenever possible, base health
services and interventions on
scientifically sound methods
 Task 5: Utilise technologies that are
appropriate and socially and culturally
acceptable

47. Essential tasks: Post-emergency
phase
 Task 1: Ensure equity
 Task 2: Utilise an inter-sector approach
 Task 3: Expand health promotion and
prevention services

48. Challenges for
Epidemiologists

49. Applying epidemiologic methods in the context of:
 Physical destruction
 Public fear
 Social disruption
 Lack of infrastructure for data collection
 Time urgency
 Movement of populations
 Lack of local support and expertise

50. Selecting study designs:
 Cross-sectional:
Studies of frequencies of deaths, illnesses, injuries,
adverse health affects
Limited by absence of population counts
 Case-control:
Best study to determine risk factors, eliminate
confounding, study interactions among multiple
factors
Limited by definition of specific outcomes, issues of
selection of cases & controls
 Longitudinal:
Studies document incidence and estimate magnitude
of risk Limited by logistics of mounting a study in a
post-disaster environment and subject follow-up

51.  Need standardized protocols for data collection
immediately following disaster
 Need standardized terminology, technologies, methods
and procedures
 Need operational research to inventory medical
supplies and determine
1) actual needs,
2) local capacity,
3) needs met by national/international communities
 Need evaluation studies to determine efficiency and
effectiveness of relief efforts and emergency
interventions

52. Challenges for Epidemiologists
 Need databases for epidemiologic research based
on existing disaster information systems
 Need to identify injury prevention interventions
 Need to improve timely and appropriate medical
care following disaster (search & rescue,
emergency medical services, importing skilled
providers, evacuating the injured)
 Need measures to quickly reestablish local health
care system at full operating capacity soon after
disaster

53. Challenges for Epidemiologists
 Need uniform disaster-related injury definitions
and classification scheme
 Need investigations of disease transmission
following disasters and public health measures to
mitigate disease risk
 Need to study problems associated with massive
influx of relief supplies and relief personnel
 Need cost-benefit and cost-effectiveness analyses

54. Role of Hospitals in Disasters/PHE
Hospitals are central to provide emergency
care when a disaster strike the society.

55. What constitutes a disaster/PHE for a
hospital?
 Whenever a hospital or a health care facility is confronted
by a situation where it has to provide care to a large
number of patients in limited time, which is beyond its
normal capacity, constitute a disaster for the said hospital.
 In others words when the resources of the hospitals are
over-whelmed beyond its normal capacity and additional
contingency measure are required to control the event, the
hospital can be said to be in a disaster situation.

56. Assessment of the capacity of a hospital to respond to a
given emergency situation can be assessed by the following
two ways:
 Hospital Treatment Capacity (HTC), is defined as the
number of casualties that can be treated in the hospital in
an hour and is usually calculated as 3% of total number of
beds
 Hospital Surgical Capacity (HSC) is Hospital Surgical
Capacity (HSC) the number of seriously injured patients
that can be operated upon within a 12-hour period i.e.
HSC= Number of operation rooms x 7x 0.25 operations/12
hrs.

57. According To WHO: The Mass Casualty Emergencies
can be categorized in one of the following ways:
A. Based on the
Number of
Casualties
( for 1000
bedded 30 hospital)
Category 1 : Up to thirty patients
belonging to a single accident or
any other emergency, coming to a
Category 2: Thirty to fifty patients
hospital casualty at one time.
Category 3: More than fifty patients

58. Categorisation Of Patients Based on TYPE OF
CASUALTIES:
 Category A: Patients in critical condition
 Category B: Patients in serious but not life threatening
condition
 Category C: Walking , but wounded.

59. Categorization of the CONTINGENCY PLAN into
three classes :
 Class A: The plan can be put into practice without
any disruption to the normal and routine work of the
institution.
 Class B:The plan can be put into practice with minor
disruption to the day to day functioning of the hospital
and with some readjustments. The plan may be
upgraded to C if the numbers of casualties increase.
 Class C:There would be definite disruption of routine
work. Major readjustments would be required in
hospital
functioning, inpatient treatment, duty arrangements

60. Organization of Health Delivery System in
Disaster/ Emergency situations
Pre-Hospital Management:: To render first aid to
victims at the spot of disaster and their transportation to
nearby
hospital as an essential part of life saving measures.
a) First aid Parties & Posts(static and mobile)
b) Ambulance service
c) Mobile Surgical Units.
Emergency Hospital Organization
a) Emergency Hospital Services (including critical care
facilities)
b) Emergency Surgical Services
c) Emergency Transfusion Services

61. CONCLUSION
 The absence of a clear definition of PHEP makes it
difficult to determine whether the nation is better prepared
to respond to a bioterrorist attack or major disease
outbreak now than it was nearly a decade ago.
 Moreover, without an agreed-upon definition,
policymakers and other stakeholders will continue to
struggle to determine what it will take to get ready for
such attacks and outbreaks , as well as how to prioritize
future investments.

62.  The definition presented here provides a concise, broadly
applicable vision of what a prepared community looks like,
along with a short list of actionable and measurable steps
for attaining that vision.
 At the most general level, the definition and action-oriented
elements can help provide a set of shared terms
for discussion among various governmental and
nongovernmental actors about what exactly is involved in
enhanced community preparedness.

63. THANK
YOU