High-Level Isolation: A Landscape Analysis of Global Capabilities and Opportunities to Advance the Field

High-level isolation units (HLIUs) have been established by countries to provide safe and optimal medical care for patients with high-consequence infectious diseases. We aimed to identify global high-level isolation capabilities and determine gaps and priorities of global HLIUs, using a multiple method approach that included a systematic review of published and gray literature and a review of Joint External Evaluations and Global Health Security Index reports from 112 countries. A follow-up electronic survey was distributed to identified HLIUs. The landscape analysis found 44 previously designated/self-described HLIUs in 19 countries. An additional 33 countries had potential HLIUs; however, there were not enough details on capabilities to determine if they fit the HLIU definition. An electronic survey was distributed to 36 HLIUs to validate landscape analysis findings and to understand challenges, best practices, and priorities for increased networking with a global HLIU cohort; 31 (86%) HLIUs responded. Responses revealed an additional 30 confirmed HLIUs that were not identified in the landscape analysis. To our knowledge, this was the first mapping and the largest ever survey of global HLIUs. Survey findings identified major gaps in visibility of HLIUs: while our landscape analysis initially identified 44 units, the survey unveiled an additional 30 HLIUs that had not been previously identified or confirmed. The lack of formalized regional or global coordinating organizations exacerbates these visibility gaps. The unique characteristics and capabilities of these facilities, coupled with the likelihood these units serve as core components of national health security plans, provides an opportunity for increased connection and networking to advance the field of high-level isolation and address identified gaps in coordination, build an evidence base for HLIU approaches, and inform HLIU definitions and key components.

Assessment of the Preparedness and Planning of Academic Emergency Departments in India During the COVID-19 Pandemic: A Multicentric Survey

Objective:

Emergency medicine being a young specialty in India, we aimed to assess the level of disaster preparedness and planning strategies among various academic emergency departments (EDs) across India during the coronavirus disease 2019 (COVID-19) pandemic.

Methods:

A cross-sectional multicentric survey was developed and disseminated online to various academic EDs in India and followed up over a period of 8 wk. All results were analyzed using descriptive statistics.

Results:

Twenty-eight academic emergency medicine departments responded to the study. Compared with pre-COVID period, COVID-19 pandemic has led to 90% of centers developing separate triage system with dedicated care areas for COVID suspected/infected in 78.6% centers with nearly 70% using separate transportation pathways. Strategizing and executing the Institutional COVID-19 treatment protocol in 80% institutes were done by emergency physicians. Training exercises for airway management and personal protective equipment (PPE) use were seen in 93% and 80% centers, respectively. Marked variation in recommended PPE use was observed across EDs in India.

Conclusions:

Our study highlights the high variance in the level of preparedness response among various EDs across India during the pandemic. Preparedness for different EDs across India needs to be individually assessed and planned according to the needs and resources available.

Qualitative Research: Institutional Preparedness During Threats of Infectious Disease Outbreaks

Background

As demonstrated during the global Ebola crisis of 2014-2016, healthcare institutions in high resource settings need support concerning preparedness during threats of infectious disease outbreaks. This study aimed to exploratively develop a standardized preparedness system to use during unfolding threats of severe infectious diseases.

Methods

A qualitative three-step study among infectious disease prevention and control experts was performed. First, interviews (n = 5) were conducted to identify which factors trigger preparedness activities during an unfolding threat. Second, these triggers informed the design of a phased preparedness system which was tested in a focus group discussion (n = 5) were conducted to identify which factors trigger preparedness activities during an unfolding threat. Second, these triggers informed the design of a phased preparedness system which was tested in a focus group discussion (n = 5) were conducted to identify which factors trigger preparedness activities during an unfolding threat. Second, these triggers informed the design of a phased preparedness system which was tested in a focus group discussion (.

Results

Four preparedness phases were identified: preparedness phase green is a situation without the presence of the infectious disease threat that requires centralized care, anywhere in the world. Phase yellow is an outbreak in the world with some likelihood of imported cases. Phase orange is a realistic chance of an unexpected case within the country, or unrest developing among population or staff; phase red is cases admitted to hospitals in the country, potentially causing a shortage of resources. Specific preparedness activities included infection prevention, diagnostics, patient care, staff, and communication. Consensus was reached on the need for the development of a preparedness system and national coordination during threats.

Conclusions

In this study, we developed a standardized system to support institutional preparedness during an increasing threat. Use of this system by both curative healthcare institutions and the (municipal) public health service, could help to effectively communicate and align preparedness activities during future threats of severe infectious diseases.

Exit and Entry Screening Practices for Infectious Diseases among Travelers at Points of Entry: Looking for Evidence on Public Health Impact

A scoping search and a systematic literature review were conducted to give an insight on entry and exit screening referring to travelers at points of entry, by analyzing published evidence on practices, guidelines, and experiences in the past 15 years worldwide. Grey literature, PubMed. and Scopus were searched using specific terms. Most of the available data identified through the systematic literature review concerned entry screening measures at airports. Little evidence is available about entry and exit screening measure implementation and effectiveness at ports and ground crossings. Exit screening was part of the World Health Organisation's (WHO) temporary recommendations for implementation in certain points of entry, for specific time periods. Exit screening measures for Ebola Virus Disease (EVD) in the three most affected West African countries did not identify any cases and showed zero sensitivity and very low specificity. The percentages of confirmed cases identified out of the total numbers of travelers that passed through entry screening measures in various countries worldwide for Influenza Pandemic (H1N1) and EVD in West Africa were zero or extremely low. Entry screening measures for Severe Acute Respiratory Syndrome (SARS) did not detect any confirmed SARS cases in Australia, Canada, and Singapore. Despite the ineffectiveness of entry and exit screening measures, authors reported several important concomitant positive effects that their impact is difficult to assess, including discouraging travel of ill persons, raising awareness, and educating the traveling public and maintaining operation of flights from/to the affected areas. Exit screening measures in affected areas are important and should be applied jointly with other measures including information strategies, epidemiological investigation, contact tracing, vaccination, and quarantine to achieve a comprehensive outbreak management response. Based on review results, an algorithm about decision-making for entry/exit screening was developed.

'Tiny Iceland' preparing for Ebola in a globalized world

Background: The Ebola epidemic in West Africa caused global fear and stirred up worldwide preparedness activities in countries sharing borders with those affected, and in geographically far-away countries such as Iceland.

Objective: To describe and analyse Ebola preparedness activities within the Icelandic healthcare system, and to explore the perspectives and experiences of managers and frontline health workers.

Methods: A qualitative case study, based on semi-structured interviews with 21 staff members in the national Ebola Treatment Team, Emergency Room at Landspitali University Hospital, and managers of the response team.

Results: Contextual factors such as culture and demography influenced preparedness, and contributed to the positive state of mind of participants, and ingenuity in using available resources for preparedness. While participants believed they were ready to take on the task of Ebola, they also had doubts about the chances of Ebola ever reaching Iceland. Yet, factors such as fear of Ebola and the perceived stigma associated with caring for a potentially infected Ebola patient, influenced the preparation process and resulted in plans for specific precautions by staff to secure the safety of their families. There were also concerns about the teamwork and lack of commitment by some during training. Being a ‘tiny’ nation was seen as both an asset and a weakness in the preparation process. Honest information sharing and scenario-based training contributed to increased confidence amongst participants in the response plans.

Conclusions: Communication and training were important for preparedness of health staff in Iceland, in order to receive, admit, and treat a patient suspected of having Ebola, while doubts prevailed on staff capacity to properly do so. For optimal preparedness, likely scenarios for future global security health threats need to be repeatedly enacted, and areas plagued by poverty and fragile healthcare systems require global support.

Ebola Preparedness in the Netherlands: The Need for Coordination Between the Public Health and the Curative Sector

Context:

During the Ebola outbreak in West Africa in 2014-2015, close cooperation between the curative sector and the public health sector in the Netherlands was necessary for timely identification, referral, and investigation of patients with suspected Ebola virus disease (EVD).

Objective:

In this study, we evaluated experiences in preparedness among stakeholders of both curative and public health sectors to formulate recommendations for optimizing preparedness protocols. Timeliness of referred patients with suspected EVD was used as indicator for preparedness.

Design:

In focus group sessions and semistructured interviews, experiences of curative and public health stakeholders about the regional and national process of preparedness and response were listed. Timeliness recordings of all referred patients with suspected EVD (13) were collected from first date of illness until arrival in the referral academic hospital.

Results:

Ebola preparedness was considered extensive compared with the risk of an actual patient, however necessary. Regional coordination varied between regions. More standardization of regional preparation and operational guidelines was requested, as well as nationally standardized contingency criteria, and the National Centre for Infectious Disease Control was expected to coordinate the development of these guidelines. For the timeliness of referred patients with suspected EVD, the median delay between first date of illness until triage was 2.0 days (range: 0-10 days), and between triage and arrival in the referral hospital, it was 5.0 hours (range: 2-7.5 hours). In none of these patients Ebola infection was confirmed.

Conclusions:

Coordination between the public health sector and the curative sector needs improvement to reduce delay in patient management in emerging infectious diseases. Standardization of preparedness and response practices, through guidelines for institutional preparedness and blueprints for regional and national coordination, is necessary, as preparedness for emerging infectious diseases needs a multidisciplinary approach overarching both the public health sector and the curative sector. In the Netherlands a national platform for preparedness is established, in which both the curative sector and public health sector participate, in order to implement the outcomes of this study.

Ebola in the Netherlands, 2014-2015: costs of preparedness and response

The recent epidemic of Ebola virus disease (EVD) resulted in countries worldwide to prepare for the possibility of having an EVD patient. In this study, we estimate the costs of Ebola preparedness and response borne by the Dutch health system. An activity-based costing method was used, in which the cost of staff time spent in preparedness and response activities was calculated based on a time-recording system and interviews with key professionals at the healthcare organizations involved. In addition, the organizations provided cost information on patient days of hospitalization, laboratory tests, personal protective equipment (PPE), as well as the additional cleaning and disinfection required. The estimated total costs averaged €12.6 million, ranging from €6.7 to €22.5 million. The main cost drivers were PPE expenditures and preparedness activities of personnel, especially those associated with ambulance services and hospitals. There were 13 possible cases clinically evaluated and one confirmed case admitted to hospital. The estimated total cost of EVD preparedness and response in the Netherlands was substantial. Future costs might be reduced and efficiency increased by designating one ambulance service for transportation and fewer hospitals for the assessment of possible patients with a highly infectious disease of high consequences.

Monitoring travellers from Ebola-affected countries in New South Wales, Australia: what is the impact on travellers?

Background

Amidst an Ebola virus disease (EVD) epidemic of unprecedented magnitude in west Africa, concerns about the risk of importing EVD led to the introduction of programs for the screening and monitoring of travellers in a number of countries, including Australia. Emerging reports indicate that these programs are feasible to implement, however rigorous evaluations are not yet available. We aimed to evaluate the program of screening and monitoring travellers in New South Wales.

Methods

We conducted a mixed methods study to evaluate the program of screening and monitoring travellers in New South Wales. We extracted quantitative data from the Notifiable Conditions Information Management System database and obtained qualitative data from two separate surveys of public health staff and arrivals, conducted by phone.

Results

Between 1 October 2014 and 13 April 2015, public health staff assessed a total of 122 out of 123 travellers. Six people (5%) developed symptoms compatible with EVD and required further assessment. None developed EVD. Aid workers required lower levels of support compared to other travellers. Many travellers experienced stigmatisation. Public health staff were successful in supporting travellers to recognise and manage symptoms.

Conclusion

We recommend that programs for monitoring travellers should be tailored to the needs of different populations and include specific strategies to remediate stigmatisation.

PP006 Ebola In The Netherlands: Costs Of Preparedness And Response

INTRODUCTION:

Between December 2013 and April 2016, an unprecedented epidemic of Ebola Virus Disease (EVD) took place. This epidemic urged countries all over the world to be prepared for the possibility of having an EVD patient (1). Besides morbidity and mortality of the disease, containment efforts also have economic consequences for society. In this study, costs of preparedness for and response to EVD made by the Dutch health system were estimated.

METHODS:

We used an activity-based costing method in which cost of personnel time targeted at preparedness, and response activities was based on a time recording system and interviews with key professionals of the organizations involved. In addition, patient days of hospitalizations, laboratory tests, personal protective equipment (PPE), as well as costs for additional cleaning and disinfection were acquired via the organizations. All costs are expressed at the 2015-euro price level.

RESULTS:

The estimated total costs of EVD preparedness and response in the Netherlands were averaged at EUR14.1 million, ranging from EUR7.6 to EUR24.9 million. There were thirteen possible cases clinically evaluated and one confirmed case, admitted through an international evacuation request, corresponding to approximately EUR1 million per case (2). Preparedness activities of personnel, especially of all ambulance care services and hospitals that could possibly receive a case, and expenditures on PPE, were the main cost drivers.

CONCLUSIONS:

The estimated total cost of EVD preparedness and response in the Netherlands was substantial. Costs made by healthcare organizations were higher than among public health organizations (3). Designating one ambulance care service and fewer hospitals for the assessment of possible patients with viral hemorrhagic fever or other highly infectious disease of high consequence might improve efficiency and reduce future costs. The experiences and collaboration of healthcare organizations that managed patients with possible EVD can serve as a valuable resource for future outbreaks of other highly infectious diseases.

Ebola outbreak preparedness planning: a qualitative study of clinicians' experiences

Objectives

The 2014–15 Ebola outbreak in West Africa highlighted the challenges many hospitals face when preparing for the potential emergence of highly contagious diseases. This study examined the experiences of frontline health care professionals in an Australian hospital during the outbreak, with a focus on participant views on information, training and preparedness, to inform future outbreak preparedness planning.

Study design

Semi-structured interviews were conducted with 21 healthcare professionals involved in Ebola preparedness planning, at a hospital in Australia.

Methods

The data were systematically coded to discover key themes in participants' accounts of Ebola preparedness.

Results

Three key themes identified were: 1) the impact of high volumes of—often inconsistent—information, which shaped participants' trust in authority; 2) barriers to engagement in training, including the perceived relative risk Ebola presented; and finally, 3) practical and environmental impediments to preparedness.

Conclusions

These clinicians' accounts of Ebola preparedness reveal a range of important factors which may influence the relative success of outbreak preparedness and provide guidance for future responses. In particular, they illustrate the critical importance of clear communication and guidelines for staff engagement with, and implementation of training. An important outcome of this study was how individual assessments of risk and trust are produced via, and overlap with, the dynamics of communication, training and environmental logistics. Consideration of the dynamic ways in which these issues intersect is crucial for fostering an environment that is suitable for managing an infectious threat such as Ebola.

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Outbreak communication needs to be rigorously controlled for consistency and transparency at all levels.

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Risk perception is influenced by lack of trust in the communication provided.

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Assessment of training effectiveness and feasibility for outbreak threats should include frontline clinicians.

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Dynamics of communication and mistrust can strongly influence the ability of an organisation to implement best practice.

Lassa fever: another threat from West Africa

Lassa fever, a zoonotic viral infection, is endemic in West Africa. The disease causes annual wide spread morbidity and mortality in Africa, and can be imported by travelers. Possible importation of Lassa fever and the potential for the use of Lassa virus as an agent of bioterrorism mandate clinicians in Israel and other countries to be vigilant and familiar with the basic characteristics of this disease. The article reviews the basis of this infection and the clinical management of patients with Lassa fever. Special emphasis is given to antiviral treatment and infection control.