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Outbreaks of infectious diseases during peacetime or in disaster/war-related conditions, may most often need an effective crisis management in the hospital. The emergency preparedness in hospitals may vary within, and between countries, dependent on endemic and epidemic conditions, capacity, knowledge and economy. Lack of preparedness may result in a high risk of disease burden and death and cause a high economic impact on the health care.
KeywordsHigh-risk microbes Lassa/Ebola/SARS/MERS/Nipah/avian influenza and other viruses Anthrax/pest/cholera/diphtheria and other bacteria Emergency Preparedness Crisis management Infection control Isolation Disinfection
- Protect the healthcare institution and the society in general:
Against spread of infection during outbreak of unusually infectious and universal very dangerous disease
Unusually high number in the society of transmitted contagious disease in peacetime, in disasters, and when the country is in war or when war threatens
Have an emergency plan for how to act in situations of such outbreaks.
All persons responsible for the emergency plan and for implementation of the plan
Determined by epidemic situation and the type of infectious agent
The hospital’s management/crisis management in cooperation with the emergency response team for infection control supervises the work at the hospital in cooperation with national health authorities and county governor [1, 2, 3, 4, 5, 6, 7].
The Directorate for Social Security and Preparedness is responsible for the national risk image and for follow-up. (DSB, Norway 2014)
Law on Health and Social Preparedness for Infectious Diseases may be present and implemented in some countries, like in Norway .
81.4 Practical Measures 
Epidemiological conditions—concerning infectious diseases:
81.4.1 “Normal” Conditions
Globally, there are endemic and epidemic conditions that may vary by time, localisation and use of antibiotics and still be perceived as “normal” for this actual country [65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77]. Special infections, like resistant microbes, are increasing in most countries in the world, and WHO made in 2017 a priority list of 12 families of bacteria (“nightmare” bacteria) that agency experts say “pose the greatest threat to human health and kill millions of people every year” (WHO 27 Feb 2017) . In 2017 CDC identified more than 220 samples of these “nightmare” bacteria containing unusual resistance genes in the United States and more than 1400 isolates from clinical samples of 32 states during the first 9 months of 2017 [66, 67, 68, 69, 70]. The endemic and epidemic conditions of these resistant bacteria vary between countries and are associated with risk of deaths, a high disease burden and death and an overall economic impact, reducing the gross domestic product (GDP) up to 1.6% .
Resistant microbes usually follow patients and personnel with “import status” (from other countries or areas with endemic conditions) and are caught early in the process by good routines and preliminary investigations [52, 53, 73, 74, 75, 76, 77]. Import routines (testing for MRSA, ESBL, CRE, CP, VRE, TBC, etc.) work usually well at the hospital, both for patients and for personnel (MRSA and TBC) [52, 53, 71, 72, 73, 74, 75]. Resistant microbes create even larger problems in primary care.
Healthcare professionals are generally exposed to infection if relevant precautions are not used. About 5–10% of MRSA-exposed healthcare persons may be infected or carriers with MRSA, and 10–20% of infected may need treatment, long-term sick leave, etc. [74, 75, 76] Screening of healthcare contacts of patients infected with carbapenemase-producing, very resistant bacteria with super-resistant genes in the United States found that one in ten was colonized with these bacteria .
Annual norovirus epidemics occupy the isolation capacity and lead to high sickness absence among infected healthcare professionals. Winter epidemics of RS virus and rotavirus in infants and flu outbreaks in all age groups occur each year. These are normal epidemiological conditions.
81.4.2 Sporadic Outbreak of Serious Infectious Disease: Import Disease
Preparedness measures depend on the agent, extent and rate of development. As a rule, such infections are far from most countries in Europe, such as SARS, bird flu and Ebola, and are usually taken care of where they occur. It may rarely lead to import, for example, Ebola-infected healthcare personnel transported to actual homeland for treatment, in 2014.
81.4.3 Disasters: Natural or Inflicted—and Bioterrorism
The hospital emergency preparedness plan/disaster plan must be available and followed after adaptation to the current situation.
A number of natural disasters lead to increased risk of outbreaks of serious epidemics in society such as earthquakes; floods; tsunami in holiday paradises; earth, stone or clay landslides; snow avalanches; extreme heat; radiation damage; hurricane/tornado; fire over large areas; volcanic eruptions; explosions; etc. The disasters may cause a heavy load on the healthcare system in general . This may happen in own country or harm own citizens abroad [1, 3, 4, 12].
War-related or disaster-related measures at terrorist attacks against the population often cause major damage and spread of infections due to a paralysed infrastructure. Bioterrorism, for example, by anthrax can cause uncontrolled epidemic outbreaks in the population; see separate chapter.
The result could be a massive destruction or paralysis of infrastructure such as water and sewage, energy supply, transport system, access to food and water, healthcare systems, broken hospitals and communications networks, etc.
In such statements it is important to have both disaster plans and infection control plans in place, like the examples published from CDC [54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 78, 79, 80, 81, 82].
The director at the hospital has overall responsibility and determining authority and leads the emergency group.
The emergency group shall advise on unusually large outbreaks, particularly dangerous microbes, in an uncontrollable epidemic and in disasters/state of war/suspected biological sabotage.
The emergency group shall be adviser before, during and after the situation described above and shall propose preventive measures and guidelines in the current situation.
Infection control leader coordinate the infection protection according to what is determined, in the same way as under normal conditions.
Under normal circumstances, the emergency group meets once a year with ongoing updating of the action plan. The director summon for the meeting.
In case of epidemic outbreak, particularly dangerous microbe or uncontrollable situation, the director summons the hospital’s disaster leader in cooperation with the infection control leader for emergency group meetings. The group meets so often it is necessary to come up with updated recommendations and measures.
81.4.4 Suggestions to Members of the Emergency Response Group
184.108.40.206 Permanent Members
The director (manager)
Assistant hospital director
Head of disaster committee or equivalent (deputy head)
Head of Infection Control Department (coordinator for disease prevention) 
Head of the Department of Infectious Diseases
Head of the Department of Medical Microbiology
Head of the Department for Internal Service, prehospital service (ambulances), etc.
Hospital medical officer
220.127.116.11 Situational Members
Head of the department(s) with the problem(s), external participants from the state and municipal health authorities, safety overseer, HR representative.
81.4.5 Work Tasks at Situation of Increased Preparedness
- Competent infection control personnel (hygiene nurses, infection control doctor, epidemiologist, etc.) are available and can provide advice and guidance as well as carry out preparatory control measures regarding:
Isolation regime and routines for the actual patient group
Written infection control procedures for patients, personnel and visitors
Personnel access to and use of personal protection equipment (PPE)
Control of isolates (air pressure and function)
Patient logistics, to avoid spreading to other patients
General infection control at the hospital, including cleaning and disinfection
Other prophylactic measures such as vaccines and drugs
Special measures for infection-exposed persons and especially susceptible persons (patients, personnel and visitors)
Infection isolates: A written updated overview must be available for all types of isolates and single rooms at the hospital. The required number and quality must be calculated. The isolates must be routinely checked for ventilation and negative pressure—by the technically responsible at the hospital.
Cohort treatment and mobilization: There should be a feasible plan for cohort treatment of patients that have the same diagnostic type of infection, mobilization and relocation of other patients and an escalation plan for more beds in cooperation with other hospitals, health institutions, etc.
Competent hospital staff (doctors, nurses, cleaners, porters, ambulance staff, service units, etc.) must be available for the appropriate infection control work, in addition to treatment staff. Resources must be considered.
Infection control equipment should be available and sufficient (respirators, tight-fitting goggles, double gloves, infection gown, cap/hood, coverings of the head/neck, room-bound shoes/shoe coverings, decontamination equipment/machines and chemical disinfectants, including hand disinfectants) and in accordance with the actual infectious agent (see isolation procedures).
Vaccines that are currently preventive should be made available from defined stocks within a certain time limit (flu, rabies, anthrax, plague, smallpox, diphtheria, tetanus, polio, BCG, haemorrhagic viruses, etc.).
Drugs and specific immunoglobulins should be made available from defined stocks as needed.
The escalation plan must be available for further treatment and isolation of patients and exposed personnel, including healthcare professionals.
The Norwegian biotechnology community has warned about inadequate preparedness—easy to spread disease and hazardous agents in drinking water, air or food . This is a well-known phenomenon for many other countries. Biosafety level 4 is the strictest level of safety where dangerous infection is identified and worked on. Nonetheless, infection occurs, and biologically dangerous and living agents have—by misunderstanding—been sent from such laboratories . Work in high-risk laboratories is complicated and not everyone is equally well-trained .
There is a great variety in Europe in terms of quality of how high risk-infected patients become isolated [86, 87]. Checklists for infection control at high-level isolation have been designed and tested for five special units in Europe: in France, Germany, Italy, England (London) and Sweden (Linköping) . The isolation unit was checked for separate entry for healthcare personnel and infected patient, safety control and security personnel, constant power and throughput autoclaves. The isolation room was checked for internal communication system, negative air pressure indicators, self-closing doors and separate/private bathroom/toilet. It is also checked for medical technical devices for intensive treatment and diagnostics and infection control procedures such as the use of PPE, hand hygiene, disinfection and waste management, external and internal transport, training in infection control and postmortem treatment .
Guidance for outbreak response and incident management is recently made for acute care hospitals in the United States .
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