influenza preparedness in the iran petroleum industry health organization

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Influenza Preparedness in theIran Petroleum Industry

Health OrganizationBijan Hamidi, MD MPHDirector of Strategic Studies and Performance Analysis officeMember of the Disaster Task ForceSecretary of the Influenza Epidemic Preparedness Task ForcePetroleum Industry Health Organization (PIHO), Iran

World Conference on Disaster ManagementToronto, Canada

June 2006

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Layout of the presentation Iran and the Ministry of Petroleum 3 PIHO and its Mandate 7 Impact of AF at the ministerial, national and global levels 9 Challenges faced 15 Development of a plan 18 General overview of the plan 20 Phases 21 Case definitions 24 ToRs 26 Task Force and the liaisons 29 Experts team 31 specialized Medical Teams 32 Organization Capacity Assessment 33 Coordination 35 Surveillance 36 Training 38 Program M&E, Research and documentation 39

Wherever needed, additional information is brought in the notes sheet

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Iran Located in the Middle East, joining

South Asia to the Europe More than 1.6 million sq km, 12000 sq

km of water and almost 2500 km of coastline

Mostly hot dry climate, but also sub-tropical in the North

Dense poultry population in the North and West part of the country

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Note: Original map from FAO, cases around Iran added later.

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Petroleum Industry (1)

Iran economy depends heavily on the petroleum industry

Oil makes up to 80% of the country exports, 4th exporter of oil to the world

Oil, gas and petrochemical plants and firms, are the major industries in the country

More than 360 companies and 270 major industrial sites

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Petroleum Industry (2)

Almost 100,000 work in the Ministry of Petroleum and another 60,000 in the associated companies

Most of these employees work in remote, oil and natural gas reach areas in South and South West of the country

Industrial plants including refineries and petrochemical firms are all around the country

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Petroleum Industry Health Organization (PIHO) www.piho.ir

Is directly responsible for the health services of the Ministry’s employees and their families in the operational sites and also in the cities

Operates at the national level; 20 regional offices in the country

9 hospitals, 19 dayclinics and polyclinics, more than 60 family clinics and 100 occupational health centers, all around the country

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Petroleum Industry Health Organization (2)

More than 5,500 employees All the specialty and sub-specialty curative

services But the focus is on the preventive and

emergency care, especially in the operational sites

Also provides services to the local communities in remote areas of the country

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The hovering threat If a full scale AF pandemic occurs,

leading to an epidemic in Iran, lasting for 4 months…

With an estimated attack rate of 30% in the first 3 to 4 months,

And a work absence rate of at least 25% at each point in the time…

Total work time lost will reach to 8,000 man-years and …

With 2% mortality, the work-force lost will be more than 8,700 man-years.

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Impact of possible AF pandemic to the industry (1)

This will be equal to 330 m USD just based on average salaries and compensation rates

The 16,700 years of work force lost during the epidemic period is equal to 17% of the annual work force

This is expected to cause at least 10% (400,000 m BPD) reduction in Iran oil production equivalent to 3.12 b USD loss for the 4 months pandemic period based on present oil production and price rates1

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Impact of possible AF pandemic to the industry (2)

This losses excludes: Cost of reduction in petrochemical and gas

production capacity Cost of social disruption due to oil

production and distribution failure Cost of health system failure due to

system overload Cost of psychological and sociological

trauma

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Global impact Following the Arabs – Israel war and the Arabs

oil embargo in 1973, a net 4 m barrels/day reduction in oil production led to 400% increase in the oil price1

If a direct relation is supposed, the oil production reduction in Iran per se, if not compensated, may contribute to 40% increase in global oil price

Still in another more optimistic scenario, decrease in Iran oil production may contribute to 12% increase in global oil price2

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Impact of possible AF pandemic in PIHO (1)

With hospital admission rate of 50 percent and mortality rate of 2 percent:

PIHO is estimated to face 5-7 fold increase in hospital admissions and more than 25 fold increase in mortalities

This sharp increase in health services demand, is along with at least 30 percent reduction in health work force

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Impact of possible AF pandemic to PIHO (2)

This sharp increase in health services demand, is along with at least 30 percent reduction in health work force

Leading to a complete disaster state in health care services

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Challenges faced in PIHO Sensitizing PIHO top level managers

and development of a consensus within the organization for resource mobilization

Awareness raising and sensitizing the petroleum Minister and Boards of Directors of companies and firms

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Awareness raising and sensitization (1)

Turned out to be the major challenge Financial resources needed for key

preparedness actions (i.e. vaccination, stockpiling of medications and education of the population) was the major factor contributing to the decision makers unwillingness for commitment

Awareness raising was particularly found to be inadequate when a key decision maker in the ministry wrote on the letter requesting support for the plan that “it seems unnecessary”!

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Awareness raising and sensitization (2)

A campaign for awareness raising was started Among many activities, the following were

particularly found to be useful: Participation in the Ministry of Petroleum Council of

Deputies and meetings of Boards of Directors of the companies to discuss the threat and the consequences, face to face

Discussing the ongoing preparedness activities in other countries and industries

Bringing facts, reports and continuous news updates to the attention of the managers

And very interesting of all raising concerns in the families of the employees during daily clinical visits

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Planning process For different reasons (noteworthy of all, lack of

adequate resources) the focus of the planning was on the process rather than the input

The planning process was initiated in June 2005 and a team was organized for this

The first draft was submitted in August The plan was continuously improved by subsequent

discussions and consultations; now in its fifth version

An orientation and training workshop (ToT) for the regions liaisons was conducted in November

Subsequent orientation workshops were conducted for the heath care workers in the regions

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Objectives and expected outcomes

To reduce the avoidable causes of mortality and morbidity (in the population covered) due to possible epidemic of influenza in the country

To improve efficiency and effectivity of health interventions in a frenzy state of soaring demand and to avoid confusions

To ensure business continuity and reduce workforce absenteeism and loss

To contribute to the national and global efforts to control the pandemic

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Components of the plan Actions phase definitions Case definitions ToRs and job descriptions Influenza Task Force Experts team Specialized Medical Teams Organization Capacity Assessment Intrasectoral and intersectoral coordination Surveillance Training Operations M&E, research and documentation

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Actions phase definitions To get a clear view of what to do when To avoid unnecessary actions and avoid

delays in actions to be taken Three phases were defined based on WHO 3

periods, 6 phases to address specific needs of the organization

According to this definitions, we are (were?) in the first phase

The distinction between phase 2 and 3 will be official confirmation of the first human case in the country

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Phases and specific priorities

Phase I Awareness raising and development of consensus Planning and organization Risk assessment Development of intersectoral and intrasectoral coordination mechanisms Vaccination and stockpiling of antiviral and other medicines and

consumables Training and capacity building Medical examinations on return from abroad

Phase II Broadening of vaccination Enhanced surveillance activities Regular meetings of TF and Expert team Level one safety administrative regulations (limitations on public gatherings,

reporting symptoms, …) Phase III

Provision of curative care Control measures for the Epidemic Level two safety administrative regulations (social gatherings banned,

meetings frequency and participation reduced to the minimum, out of office working,…)

Back to the components page

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Case definitions An absolute need to reasonably identify and assign

cases so that to Avoid over-reactions and at the same time, life threatening

delays in appropriate actions to be taken The traditional categorization of the cases into

suspected and definite cases in the surveillance systems, appeared to be insufficient to address the bursting nature of flu epidemic coarse

Before a case is diagnosed as a suspicious case to be reported, it may be assigned as a case to be closely followed up by local staff if certain sign and symptoms are observed

At the same time the definition of cases, extremely depends on the phases of the epidemic/ pandemic

In the surveillance and health care system, these cases are treated appropriately

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Case definitions

Case

Phase I(increased prevalence in

the poultry; no or limited human cases)

Phase II(Increased human cases with

evidence of man to man transfer)

Phases III(Identification of first

case in the country)

Under observation(By the local physician)

High grade fever with positive auscultations and radiology

FUO with positive clinical findings

Travel outside of the country in the past 7 days or close contact with a definite case

Suspicious(should be report to the next level

of care)

Above sign and symptoms with travel outside of the country in the past 7 days

Either of the following criteria

- FUO with recent (7 days) travel to the countries with prevalent bird or human cases

- High grade fever, cough and dyspnea

High grade fever with close contact or inhabitants of cities with prevalent cases

Definite case(Generally a definite case is

define on positive serologic findings as recommended by CDC/ WHO but in phase III, more liberalism in diagnosis is warranted)

High grade fever with either of:

- Positive A/H5 culture- Positive PCR for

A/H5- Positive IFA for H5

Ag- 4 fold increase in H5

specific Ab titer

Same as left High grade fever, cough, dyspnea, close contact (as defined) or inhabitant of cities with prevalent human cases plus:

- High grade fever or- Positive pulmonary

radiology


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Terms of Reference and job descriptions

The key factor to ensure a swift and effective health response is clear and specific actions for health staff, either the managers or the staff directly involved in patient care

This also depends on the phase of the epidemic

These ToRs are developed for GPs and Family Physicians, specialists, Directors of the regional offices, Hospital directors, Directors of the occupational health centers, regional directors of occupational health, regional flu liaisons, the organization deputies, members of the flu Task Force and even the President of the organization

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Overview of individuals main tasks

GPs and family physicians to be involved in direct observation and care of the cases,

Specialists to provide specific care, especially to the critical cases

Managers at all levels to take care of the staff safety and health, and to ensure and monitor coordinated, supported response

Occupational health managers to be directly involved in care of the employees regarding public health issues at work and absenteeism

Regional Flu liaisons to ensure vertical information sharing, situation reporting, and performance monitoring in the regions

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Sample action sheetSpecialists Phase I Phase II Phase II

General tasks - Specific chemotherapy- Feed back to the GPs and Family Physicians in the referral system chain and to technically supervise

then- Planning and conducting training activities if necessary, at any point

Should be observed

cases

- Palliative treatment and antibiotic therapy in case of superimposed bacterial infections

- All the previous actions - Antiviral therapy- Follow up of the cases at

home with strict isolation procedures

- Follow up of all cases after two days

- Education of the victim family and reassurance

Upon observation of a suspicious

case

- All the previous actions - Routine reporting to the Director

of the Health center/ hospital with c.c to the region flu liaison

- Lab request for definite diagnosis if necessary

- Specific chemotherapy- Reporting to the Director of

the Health center/ hospital with c.c to the region flu liaison

- Implementing strict isolation procedures if hospitalization is needed

- Lab request for definite diagnosis if necessary

- All the previous actions- Patients should not be

transferred to other health centers as much as possible

- Lab request for definite diagnosis only if necessary to control the epidemic

Upon observation of a definite

case

- Specific chemotherapy- Hospitalization (preferably in (ICU)

and transfer if there is no ICU bed and patient condition permits

- All the previous actions - All the previous actions


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Influenza epidemic preparedness and response Task Force

A task force is formed as the highest body to govern the preparedness and response of the organization

The President of the organization works as the head of the TF. The secretary is in charge of the coordination and follow up of the issues (members listed in the slide note sheet)

All the members have clear and specific ToRs

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Task Force main responsibilities

To ensure health staff safety against influenza while in service

Governing, leadership, coordinating, prioritizing, and decision making during flu preparedness and response

Trend analysis and predicting short and long term effects of the pandemic on the petroleum industry

Providing resources and taking care of the gaps Coordination with the national partners in the

preparedness and response Accountability against the Ministry of Petroleum and

informing the media


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Influenza expert team Is the technical and consultative body

of the Flu TF Members include distinguished experts

in infectious. Pulmonary and ICU specialists, Internists, Pediatricians, anesthesiologists and epidemiologists.

One of their main tasks is to develop ICU and hospital admission policies appropriate at each point of the crisis


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Specialized Medical Teams Designed to act upon observation of first

cases (in all the hospitals) Specially trained and fully protected to work

as the first line of inpatient care for influenza cases

When cases are abandoned and involvement of the whole medical staff is required, teams are increased and they are divided into that teams, later may work as supervisors and specialized care givers


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Capacity assessment of the Regional Offices

A major component of risk assessment A detailed form was developed to assess the

situation of the 20 regions regarding: Vaccination and population education capacities Outpatient and inpatient capacities at regular times and in

case of surge in demands (Isolated and ICU beds, ventilators,…)

Human resources with related expertise Logistic capacities, transportation, storage, communications,

public relations Level of coordination with local MoH, and other partners Capacities for indirect services (outsourcing) Resources in the industry that can be mobilized in case of

crises situations

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Objectives of the capacity assessment

Particularly directed to identify strengths and weaknesses based on the plan

So that gaps are recognized, prioritized and addressed accordingly

Fine tuning of the plan based on realities on the ground

And to assess managerial capacities to handle crises situations


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Intrasectoral and Intersectoral Coordination

Success in achieving the goals of the plan could only be viewed in terms of effective intrasectoral and intersectoral partnership

The priority of the global and national actions to the components of this plan is emphasized and encouraged to be respected, unless a gap or failure is noticed

Close collaboration of PIHO Regional Offices with local MoH and other partners is encouraged and emphasized in the plan

Rigorous coordination meetings and information exchange is mandatory with all the partners


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Surveillance The hallmark of a quick, effective,

dynamic response to a variety of possible scenarios during an epidemic

Designed to be effective and at the same time as simple as possible so that it can be managed during a crisis and chaos situation

Forms developed for registering and report of different cases by related staff

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Surveillance Objectives To monitor the epidemiologic situation of the

epidemic and if needed to consider change of phases Early diagnosis and secondary prevention of

Influenza cases Follow up of the cases for health outcomes

evaluation and monitoring of efficacy of medical interventions

To reflect case load and burden of disease for appropriate managerial decisions

Timely identification of shortage of resources and broadening gaps in the services in the Regions

Documentation


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Trainings and mock drills Capacity building among health care workers

and even managers is the main factor to ensure automatic appropriate reactions to the rapidly evolving situation in crises

For this reason, extensive efforts was put on preparing training material, holding workshops at the national and regional levels, encouraging participation in online training courses and most important of all for planning mock drills.


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Operations Monitoring & Evaluation, Research and Documentation

As a integral part of the plan, specific measures are taken to ensure appropriate monitoring and documentation so that lessons are not missed

A major responsibility of the communication and Media Officer in the Task Force is arrange for appropriate documentation of the whole preparedness and response activities

The real situation will provide the best opportunity to test the efficacy of the plan to improve in continuously, if only we do not miss the lessons


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Thank you for your time

All the plan document is in the process of translation into English and will be launched on the organization site at: www.piho.ir/en/

The author welcomes recommendations and exchange of information and experience, Bijan Hamidi, M.D M.P.H

[email protected]@gmail.comMobile: (+98) 912 387 3488Office: (+98) 21 8894 2060

influenza preparedness in the iran petroleum industry health organization

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