Facilitator’s Manual FOREWORD The emergence of an avian influenza strain capable of infecting humans has served as a strong reminder of humankind’s vulnerability to another pandemic. Successful control and containment of a pandemic will be dependent on early recognition of the first instances of human-to-human transmission with timely detection and rapid response. Timely detection will only be accomplished by increasing the sensitivity of surveillance systems at all levels. One strategy for reaching such an increase is the involvement and training of healthcare workers to engage their efforts in the notification of signal events that may indicate the emergence of a new pathogen with pandemic potential. This training package aims at providing such training and at offering tools to facilitate the response by healthcare facilities in a situation where the demand for services surpasses their operating capacity. This training package draws upon the growing body of knowledge on influenza, and attempts to consolidate it in an easy-to-use format for healthcare workers. The materials included in this training package have been designed as a generic guideline that requires adaptation to country specificities. Of particular importance is the inclusion of country- specific procedures for the immediate notification of such signal events. While this material has been developed with influenza in mind, the capacities that will be reinforced by the tools provided in this training package will serve for the detection, notification, and response to any disease with epidemic potential. The strengthening of such basic public health capacities will be fundamental in the implementation of the new International Health Regulations. It is hoped that this material will be of assistance to national programs tasked with the challenging but necessary task of preparing for a possible influenza pandemic. Health Surveillance, Health Systems and Services Area (HSS) Disease Prevention and Control Area (HSD) Pan American Health Organization ~Agenda coordination meeting ~Summary of the course ~Participants Profile ~Pre/Pos test ~Course evaluation COORDINATION MEETING We propose the holding of a preliminary meeting with national counterparts to go over the materials and review the presentations. The presentation review will be of particular importance when the presentations will be given by national counterparts. This time will be an opportunity to adapt the material to national specificities. The coordination meeting is also an opportunity to define who will be taking over the practical demonstrations and who will be the national facilitators for the case studies at the end of each day of the course. It is of the utmost importance that, if available, the following professionals from the ministry of health participate in this coordination meeting: the person(s) charged with respiratory disease surveillance, the person(s) charged with health services delivery; the person(s) charged with laboratory diagnosis of influenza; the person(s) coordinating communications in the pandemic preparedness process; and the person or commission charged with infection control. The following topics should be discussed: 1. General introduction of the strategy 1.1. Implementation of the Nationwide enhanced surveillance 1.2. Preparation of health services 1.3. Implementation of the International Health Regulations 2. Sub-national replication of the course 3. Suggested profile of the participants 4. Definition of next steps 5. Presentation of the course agenda 6. Definition of facilitators for case studies 7. Review of the presentations that will be delivered by national counterparts: 7.1. National Influenza Pandemic Preparedness Plan 7.2. Information flows of the national surveillance system 7.3. Laboratory 7.3.1. Laboratory tests 7.3.2. Sample taking and shipment 7.3.3. Practical demonstration of sample taking 7.4. Infection Control 7.4.1. ABC 7.4.2. Specific precautions for SARI 7.5. Communication 7.5.1. Risk Communication 7.5.2. National communications strategy for a pandemic Summary of the course for Health Establishments Preparedness for Clusters or Unusual or Unexpected Cases of SARI Purpose of the course To strengthen the capacity of the health facilities to detect and to respond rapidly to one or more cases of unusual or unexpected severe acute respiratory infection (SARI), including those caused by human influenza. General Objetive Part I - Prepare healthcare workers for detection and early management of a unusual case or cluster of SARI within healthcare facilities thus enabling the early identification of emerging agents and their investigation and control on a timely manner.. Part II – Provide tools for improvement of the response by healthcare facilities in a situation of SARI cases that exceed their capacity in order to achieve adequate and efficient care. Methodology: The content of the training package is based on the Generic Protocol for Influenza Surveillance developed by PAHO and Centers for Disease Prevention and Control of the United States (CDC) (4), on WHO guidelines, and on scientific articles from peer-reviewed journals. The packed was designed for a training course for a group 40 people. The course consists of short presentations from 20 to 30 minutes, followed by a discussion of each topic. The material presented will be supplemented with exercises, case studies, practical demonstrations, and simulations where participants will be separated into smaller work groups of 5 to 8 people. It is important to emphasize that the course is aimed at healthcare workers whose work include the inpatient treatment of patients with SARI. Profile of participants: This course is meant for healthcare workers, particularly those at healthcare facilities where patients are admitted. This includes all healthcare workers that treat patients, such as nurses, physicians, laboratory personnel, etc. The course also contains components directed to the management and coordination of health services, so the course should involve medical coordinators and managers. As the first course is meant to train future trainers, it is essential to have the participation of those charged with surveillance at the national and sub-national level, as well as those responsible for rapid response teams for the field investigation of possible outbreaks. We include a proposal for a breakdown of the participants’ profiles by categories for the first, train-the-trainers course. PART I ‐ Detection and Management of SARI Objetives: That healthcare workers in every facility be capable of detecting on a timely basis: 9 Unusual or unexpected SARI cases; 9 Clusters of SARI 9 Excess cases of SARI. That healthcare workers in every facility be capable of responding on a timely basis to: 9 Carry out effective case management while observing infection control standards 9 Report such events immediately to corresponding sub-national and/or national authorities for the mobilization of rapid response teams according to the mechanisms established in the country. 9 Collect adequate samples from these cases and appropriately ship them to the laboratory in a timely manner. 9 Know the International Health Regulations 2005 and their role in its implementation Time Topic 1st DAY 8:00-8:30 Registration and Opening 8:30-9:15 Pre Test with 36 questions 9:15-9:30 Introduction, objectives, and presentation of the methodology 9:30-10:15 Influenza Basics Objective: To present characteristics of the influenza virus, of seasonal influenza, avian influenza in humans, and pandemic influenza 10:15-10:30 Break 10:30-11:00 International Health Regulations (IHR-2005) Objective: To confer knowledge about the International Health Regulations and the necessary basic competencies defined there for surveillance and response. 11:00-11:30 Influenza Pandemic and Preparedness Objective: To present pillars for pandemic preparedness 11:30-12:00 National Influenza Pandemic and Preparedness Objective: To present country advances in preparing for a pandemic. This presentation should be given by the person closely involved with the pandemic preparedness process in the given country. This presentation can be consolidated with the presentation before it, for the interest of time, provided both topics are presented by national counterparts. 12:00-13:30 Lunch 13:30-14:10 Generic Protocol for Influenza Surveillance (GPIS) Objective: To familiarize participants with the basic concepts and case definitions proposed by the GPIS, including sentinel surveillance and nationwide enhanced surveillance of influenza. The presentation of the GPIS should be followed by a presentation of the routine reporting system and information flows for each country. This second presentation should be given by those responsible for the surveillance of respiratory diseases at the national level. 14:10-15:15 Nationwide Enhanced Surveillance Objective: Make healthcare workers aware of the need to notify unusual and unexpected events. Specifically, train in the early detection of SARI triggers for the notification, investigation, sampling, and management of cases. 15:15-15:30 Break 15:30-17:30 Surveillance exercises The group will be divided in three to five groups and three real events will be presented, each unexpected or unusual due to different characteristics (if more than three groups are conformed, some groups will be reviewing the same event). The groups should be moderated by national counterparts, and the discussion should include aspects of what makes the event unusual or unexpected,