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Beverley Herbert,
RGON, RM, Adv Dip Nursing, MCNA (NZ)
Member of the MOH National Emerging Novel Infectious Diseases (ENID)
Clinical Action Plan Project (NECAP)
Although the focus of highly contagious emerging diseases has shifted
lately from the SARS virus to the Bird flu/Avian flu, with the potential
for "species hopping", the threat of new infections remains
to the forefront. January 2004 saw the Ministry of Health release a discussion
document on the National Clinical Action Plan for Emerging Infectious
Diseases. The following outlines the responsibilities, for the health
sector, to deal with infections that are highly contagious.
During an emerging infectious disease-related emergency, the health sector's
response will be based on the co-ordinated incident management system
(CIMS). CIMS is New Zealand's model for the command, control and co-ordination
of emergency response. It is intended to provide a structure allowing
the multiple agencies or units involved in an emergency to work together
as a team.
The key feature of CIMS is control. Control operates horizontally and
involves the co ordination of actions across various agencies or units.
In an emergency situation, a single incident controller is designated
to control the response and task various units and agencies with carrying
out actions. During the SARS crisis it became apparent that there were
gaps and inconsistencies in the ability for accurate information to be
distributed through the primary and secondary sector in a timely fashion.
Ministry of Health response team
In the event of an emerging infectious disease-related emergency, the
Ministry of Health will establish a single emergency response team under
the CIMS structure comprising members of the Public Health, Clinical Services,
DHB Funding and Performance, and Corporate and Information Directorates,
and others as appropriate.
District Health Board response team
Each DHB will also base its response on the CIMS structure. It will designate
an incident controller to be responsible for managing the response across
its district. The DHB incident controller may be a Medical Officer of
Health or another individual from outside the hospital setting, but must
be able to communicate with and develop strategies in conjunction with
hospital-based services.
To organise the clinical response of primary and secondary care during
an emerging infectious disease-related emergency, a team should be established
with membership including representation from at least:
- Public health/Medical Officer of Health
- DHB emergency planning
- Emergency department
- Infection control
- Intensive care
- Medical/infectious disease/respiratory specialities
- Nursing
- Occupational Safety and Health
- Primary Care providers
- Ambulance
- Hospital management
- DHB funding
- Communications.
Primary care
DHBs will be responsible for establishing and maintaining communication
networks with all primary care providers in their respective districts.
DHBs must be able to contact GP practices in their region through fax,
email and phone. These local networks will be used to forward detailed,
locality-specific information, advice and guidelines to primary care practitioners.
DHBs should also maintain communication links with ambulance services
and primary care providers such as nurse-led clinics, pharmacists, dentists
and others. In areas where Primary Health Organisations (PHOs) have been
established, they should act as the conduit through which DHBs pass communications
to GP and other primary care services. PHOs must retain updated contact
details of all services within their organisation.
In the event of an emerging infectious disease-related emergency all
primary care practices need to have the following minimum capabilities.
- Contact details for advice about, and referral of, suspect patients.
- Access to updated clinical information on the emerging infectious
disease including case definition and management and treatment guidelines.
- Appropriate visible signage advising patients and others of any restrictions
or required actions.
- Access to appropriate personal protective equipment for staff, including
receptionists.
- Availability of infection control review of facilities.
- Availability and accessibility of infection control training.
DHBs will have overall accountability for ensuring that primary care
practices are provided with appropriate advice, guidelines, and access
to training. Practices themselves will be responsible for providing signage
(though content should be based on national-level advice) and basic personal
protective equipment (such as gloves and masks) to their staff. Where
supplementary or additional equipment and supplies are necessary, these
will be made available to primary care services
Community-based assessment centres
Planning for the establishment of community-based assessment centres will
need to vary according to local circumstances. Possible arrangements include:
- facility: accident and medical clinic, designated GP practice, facility
associated with hospital campus or facility arranged with local government
or Civil Defence;
- staffing: rostered GPs and practice nurses, public health nurses,
emergency department staff, other private sector nurses.
There should be planning for at least one primary care assessment centre
in every major or medium-sized metropolitan centre. DHBs and primary care
practitioners will need to undertake this planning collaboratively, and
the participation of GPs is imperative for a successful process. DHBs
will have the responsibility for initiating such planning.
Fundamental to an effective response to any emergency is the capacity
for communication in an accurate and timely manner between people involved
in the response. All DHBs must have a communications function that allows
the receipt, supply and distribution of information through a single point
of contact, on a 24-hour, seven-day basis.
Infection Control
Ensuring infection control is practiced effectively underlies all other
actions.
International evidence from the SARS crisis indicates that proper application
of standard precautions, as well as contact and droplet precautions, is
effective in preventing the further transmission of the disease. Since
the greatest risk of disease transmission is from undetected cases, it
is imperative that health care workers practice good infection control
in their everyday work.
Guidelines for hospital infection control in relation to SARS patients
were developed by the World Health Organization and the US Centers for
Disease Control and Prevention. All health care providers should ensure
that clinical staff are familiar with these guidelines which are available
at the following locations.
- US Centers for Disease Control and Prevention: http://www.cdc.gov/ncidod/sars/ic.htm#healthcare
- World Health Organization: http://www.who.int/csr/sars/infectioncontrol/en/
In addition, the following are key requirements of primary and secondary
services with regard to infection control.
- All DHBs must include infection control services in their response
team in the event of an emerging infectious disease-related emergency.
- DHBs should have appropriate staffing levels within their infection
control services, which will allow for secondment at short notice into
emerging infectious disease-related activities such as widespread specific
staff education.
- All hospital-based services should have policies relating to standard
precautions, use of personal protective equipment, hand hygiene and
patient isolation (including the cleaning of isolation rooms and waste
disposal).
- Infection control practitioners must provide routine education/training
regarding the basic principles of infection control to all hospital-based
staff including medical, allied health, and support staff (e.g., orderlies,
cleaners).
- Provision should be made for additional specific education programmes/sessions
to be developed and undertaken during an emerging infectious disease-related
emergency.
- All primary care, ambulance and community-based services should be
able to provide evidence that standard precautions are routinely practiced
and that appropriate procedures exist to manage patients that require
separation from others.
- All primary care, ambulance and community-based providers must have
access to infection control training.
Conclusion
The last major pandemic was 'Spanish flu' in 1918-1919, which killed 40
million people worldwide. There were also outbreaks in 1957 in China and
1967 in Hong Kong. Influenza viruses are highly unstable and if there
are animal and human strains circulating at the same time, they could
'meet' and give rise to a new influenza virus to which humans would have
little, if any, protective immunity.
For a number of years the MOH and the WHO have predicted an influenza
pandemic and therefore early detection and sound surveillance systems
are key for slowing the spread of a pandemic. Although the WHO believe
the global spread of the virus can at best be slowed down, it is estimated
that it could travel around the world in four to eight months. As with
the SARS outbreak the lead time was relatively short especially as travel
hastened the spread. Although vaccines are the main defence, it may take
months to develop and produce ones to target new strains. Our best defence
is to be prepared for such events: it is a matter of when it will happen,
and not if.
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