Which recommendations are considered essential for outbreak preparedness by first responders?

Since 1940, the frequency of outbreaks and the diversity of infectious disease pathogens have increased significantly [1, 2]. Most outbreaks are successfully dealt with at the local or regional level, but some have the propensity to become epidemics. Outbreaks trigger anxiety in the general population and require prompt and adequate actions from healthcare organizations and healthcare professionals [3]. Healthcare organizations have to deal with an increased number of (potentially) infected patients and have to accommodate new procedures and algorithms that interfere with daily routines. Moreover, professionals with various backgrounds of expertise need to work together in a coordinated way to respond to the outbreak [4]. Unfortunately, recent outbreak evaluations show that outbreak response is often suboptimal; there is considerable room for improvement [5, 6].

For healthcare organizations preparedness is considered essential to respond quickly and effectively to outbreaks in order to minimize the spread of pathogens and to reduce the number of infected persons. Preparedness requires an operational mindset focused on the development of formal procedures and guidelines in all preparedness phases, even during the period when there is no threat or outbreak. Many studies conclude that while at the national level preparedness guidelines and procedures are often in place, regional healthcare organizations are not always fully prepared [7‐9]. It is a challenge for first responders to optimally prepare for outbreaks. The process of outbreak preparedness is time consuming and costly for healthcare organizations and asks for a shared responsibility of various actors in the field [10]. Therefore it is important that preparedness activities are efficient and effective, i.e. actually contribute to a better response. There are, however, no widely accepted standards for optimal outbreak preparedness for first responders as -due to the infrequency and the acute nature of outbreaks- there is little systematic evidence linking preparedness activities to response outcomes [10, 11].

This lack of clear and agreed upon standards does not guide first responders in optimal preparedness. The CDC [12], ECDC [13] and RAND corporation [14] developed tools to support preparedness planners and assess the level of preparedness. These tools, however, are intended primarily for public health organizations and are not specifically aimed at first responders, or focus solely on quality improvement without quality measurement, or focus on an influenza pandemic only.

Previously, we systematically reviewed the scientific preparedness literature and generated a series of 80 generic recommendations representing optimal outbreak preparedness for first responders originating from industrialized countries (low and middle income country settings were excluded) (Huis, A., Belfroid E., Klein Breteler, J., van Steenbergen, J., Hulscher, M. Defining and improving healthcare system's preparedness for infectious disease outbreaks: a systematic review identifying generic key recommendations and their connections to continuous quality improvement. Submitted). First responders were defined as organizations which are directly involved in providing healthcare during an infectious disease outbreak (including primary-, secondary-, tertiary- and home and community care providers), or indirectly involved in providing healthcare services during an outbreak (including local health departments, and clinical diagnostic laboratories). In the current study we aim to capture the views of first responders on the relevance of each recommendation as a criterion for high quality preparedness. Furthermore, we aim to identify those recommendations that have the highest urgency to be implemented from the perspective of the first responders. We compare two expert groups, the ECDC National Focal Points for preparedness and response, and authors of important papers on outbreak preparedness.

We chose a multistep approach using a Delphi procedure [15] to select a set of key recommendations representing high quality infectious disease preparedness from a first responder’s perspective. Recommendations extracted from scientific literature (Huis, A., Belfroid E., Klein Breteler, J., van Steenbergen, J., Hulscher, M. Defining and improving healthcare system's preparedness for infectious disease outbreaks: a systematic review identifying generic key recommendations and their connections to continuous quality improvement. Submitted) were prepared for the questionnaire round (step 1), see Fig. 1. The recommendations were presented to a national panel (step 2) in order to pilot the questionnaire, clarify the wording, and condense the number of recommendations resulting in an amended questionnaire. The amended questionnaire was presented to two international expert panels (step 3), the ECDC National Focal Points for preparedness and response, and authors of important papers on outbreak preparedness. The results from these two international expert panels were compared to gain insight into their perspectives. Formal ethical approval from a medical ethical committee was not required for this research in the Netherlands since it does not entail subjecting participants to medical treatment or imposing specific rules of conduct on participants. All the experts consented to participate in the study and were aware that their responses would be used for research purposes.

In this study infectious disease experts selected a set of key recommendations representing high quality preparedness and specified which ones should be given the highest urgency when preparing for a future crisis.

Several attempts have been made to develop recommendations for outbreak preparedness [11‐14]. These recommendations differ in perspective, number of healthcare organizations the recommendations apply to, type of healthcare organization and, level of detail and specificity. Our key recommendations, in contrast to the existing recommendations, are specifically developed from the perspective of first responders to guide them in selecting relevant preparedness activities for their organization, and not from a regional or national perspective. When aggregating this information at regional level, policy makers can map the strengths and weaknesses of the region as a whole and decide upon specific interventions to improve overall preparedness.

Several patterns emerge when analyzing the final set. Firstly, the selected recommendations do not focus on psychosocial aspects of outbreak preparedness, such as ‘childcare for employees’ and ‘mental support for employees’. Recommendations regarding psychosocial aspects have been rejected in step 2. The international expert panels in step 3 had the option to add new recommendations but no recommendation regarding psychosocial aspects was added to the list. During large outbreaks, these aspects are highly important to ensure employees work attendance and commitment to sustained efforts, while possibly finding themselves at risk of acquiring and transmitting the disease to their family and friends [16]. We assume these recommendations were rejected because the expert panel mainly consisted of doctors and policy makers who tend to focus on the organizational and medical aspects of preparedness, rather than the conditions that facilitate health care professionals to attend work. Literature shows that psychosocial needs need to be taken into account [17‐20]. More research is needed to determine the specific needs of healthcare workers during outbreaks and the corresponding preparedness activities. Secondly, we found a high level of consistency (49 recommendations) in the selection of relevant commendations from the initial set, by both panels. This shows that almost all preselected recommendations were considered important by our experts teams. Thirdly, both panels endorsed the importance of the preparedness for triage, a key component of outbreak response. Both groups agreed that healthcare organizations need to have triage protocols. The way to prepare for triage was, however, rather different for both panels. While the National Focal Points considered the supra institutional development of triage protocols, the inclusion of an ethical framework in the protocol and regional tuning of the protocols relevant key recommendations, the preparedness experts rejected them. Contrarily, the key recommendation on objective criteria to activate and stop triage protocols was rejected by the National Focal Points but accepted by the preparedness experts. This reflects a longstanding debate on triage protocols. It is practically impossible to predict what situations might develop in an outbreak so it can be rather challenging to develop universal triage protocols beforehand. On the other hand, triage is a very political sensitive topic. It can thus be useful to consider a variety of aspects in detail beforehand and incorporate them in a triage protocol. There is no literature available that provides a sufficient evidence base to develop key recommendations regarding triage [21].

Considering the ‘most urgent recommendations’ there are five recommendations that are selected by both expert groups. This is a strong signal that those five recommendations have a high urgency. Organizations have to develop a generic plan, which is flexible to allow for changes to reflect new developments during a specific outbreak. Furthermore, they should work together and tune their respective plans. Also the staff protection and infection control measures are considered urgent by both groups. In addition training of all designated professionals is considered urgent. It is not surprising these five recommendations were selected. The preparedness plan, training and exercises and infection control measures receive a great deal of attention in the preparedness literature, implying there is a general consensus that these elements are important (Huis, A., Belfroid E., Klein Breteler, J., van Steenbergen, J.,Hulscher, M. Defining and improving healthcare system's preparedness for infectious disease outbreaks: a systematic review identifying generic key recommendations and their connections to continuous quality improvement. Submitted).

In addition, we found several differences in the ‘most urgent recommendations’ selected meaning that not all recommendations are equally important for the different groups. Differences between both groups in the selected’10 most urgent’ can presumably be explained by the different perspectives of both respondent groups. The National Focal Points selected several recommendations about the development of the preparedness plan and other formal procedures. The preparedness experts selected the more practical recommendations. When improving outbreak preparedness it is impossible to focus on the total set of recommendations because of the size of the set, so it makes sense to concentrate on the most urgent recommendations. The differences between both groups show us that the background and perspective of the professional is very influential in the choice for the most urgent recommendations. Therefor it is very important that all relevant stakeholders from the region are included in outbreak preparation so that no perspectives are left out.

Our study has several limitations. Firstly, we realize that our data concern only rich industrialized countries and the recommendations therefore are not easily applicable to low income countries with completely different context, infrastructure, priorities and resources. However, we concentrated on the wealthy counties as they have the possibilities, research, and experts to achieve the highest preparedness standards. A similar systematic approach should be used (systematic review and expert consensus procedure) to select recommendations for low- and middle-income countries. Secondly, the aim of the study was to develop a set of recommendations for the first local response in an outbreak situation. Although we urged the international experts to fill out the questionnaire from that perspective, we realize that these might be biased to more managerial aspects. However, we observed high similarity between the selected items by the “true first responders” in the Dutch panel with those of the international experts of “quasi first-responders”. Another limitation is the focus on outbreaks and not all hazard preparedness. We did so because outbreaks require unique recommendations because of the transferable potential of pathogens and an all hazard approach would miss, for outbreaks specific, relevant recommendations. One of the strengths of our study is the inclusion of a wide variety of experts in the field of outbreak preparedness. All our respondent groups (n = 14, n = 14 and n = 8) contained a sufficient number of participants as compared to the recommended 7–15 number of participants [15]. The national panel consisted of a wide variety of disciplines involved in outbreak preparedness. The panel of the National Focal Points on preparedness and response covered the entire European Union and the respondent panel of the preparedness experts had a worldwide coverage including different specialties and experienced respondents.

We present a set of generic recommendations, including a prioritization of the most urgent ones. When preparing for the next crises, these can provide the basis for frontline organizations to guide decisions on how and where to start, as well as to identify weaknesses. Outbreak preparedness requires a solid scientific base. While this field of research is rather new, more efforts are needed to provide systematic evidence on high quality preparedness, ideally linking it to outbreak response outcomes.