Influenza Preparedness in the Iran Petroleum Industry Health Organization

1
Influenza Preparedness in theIran Petroleum
Industry Health Organization

• Bijan Hamidi, MD MPH
• Director of Strategic Studies and Performance
  Analysis office
• Member of the Disaster Task Force
• Secretary of the Influenza Epidemic Preparedness
  Task Force
• Petroleum Industry Health Organization (PIHO),
  Iran

World Conference on Disaster Management Toronto,
Canada June 2006
A deeper look into the process raher than the
input
2
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 ME, Research and documentation 39

Wherever needed, additional information is
brought in the notes sheet
3
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

4
Note Original map from FAO, cases around Iran
added later.
5
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

6
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

7
Petroleum Industry Health Organization (PIHO)
www.piho.ir

• Is directly responsible for the health services
  of the Ministrys 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

8
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

9
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.

10
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

11
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

12
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

13
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

14
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

15
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

16
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!

17
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

18
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

19
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

20
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 ME, research and documentation

21
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

22
(No Transcript)
23
Phases and specific priorities
Back to the components page

• 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,)

24
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

25
Case definitions
Back to the components page
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
26
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

27
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

28
Sample action sheet
Back to the components page
Specialists 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 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 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

30
Task Force main responsibilities
Back to the components page

• 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

31
Influenza expert team
Back to the components page

• 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

32
Specialized Medical Teams
Back to the components page

• 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

33
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

34
Objectives of the capacity assessment
Back to the components page

• 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

35
Intrasectoral and Intersectoral Coordination
Back to the components page

• 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

36
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

37
Surveillance Objectives
Back to the components page

• 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

38
Trainings and mock drills
Back to the components page

• 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.

39
Operations Monitoring Evaluation, Research and
Documentation
Back to the components page

• 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

40
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.Hhamidi_at_piho.orghamidib_at_gm
  ail.comMobile (98) 912 387 3488Office (98)
  21 8894 2060