EPIDEMIC AND PANDEMIC EVENTS PREPAREDNESS IN MINISTRY OF HEALTH HOSPITALS, JEDDAH, 2017, A CROSS SECTIONAL STUDY

Received: 08 September 2017 Final Accepted: 10 October 2017 Published: November 2017 Background: Recently various epidemic and pandemic events have been occurred worldwide with negative impacts on health, economic and social aspects of life. Health care workers are at high risk for acquiring any epidemic virus, which can threaten their lives. Objective: This study was conducted to assess concerns, perceived impacts, and HCWs preparedness for epidemic and pandemic events in MOH hospitals in Jeddah for 2017 Methods: A structured self-administered questionnaire was prepared to assess the concerns, perceived impacts, and HCW preparedness for epidemic and pandemic events in MOH hospitals. Results: The majority realized that their profession incurred them the risk of exposure to infection, occupational exposure to infection was accepted as part of professional duty in >60% of our sampled HCWs. The minority of HCWs would dismiss to keep taking care of their patients and would think to quit their work during epidemic and pandemic events. Conclusions: There is a need to enhance human resources capacities through psychosocial support and comprehensive training programs for epidemic and pandemic preparedness and response.

Training drills are also crucial to improve HCW performance for preparedness during epidemic and pandemic events. Immersive simulation education can be used to assess the experiences of participants. In one study, most participants acquired more knowledge after training exercises (14) . Infection prevention and mass vaccination training in the US recommended more pre-event training to achieve effective points of dispensing (POD) (15)(16) . Different modalities of the training program were used, and various preparedness aspects were implemented. Findings showed a significant improvement associated with these training programs (17)(18)(19)(20) . We conducted this study to assess concerns, perceived impacts, and HCWs preparedness for epidemic and pandemic events in MOH hospitals in Jeddah for 2017.

Subjects and Methods:-Study setting:-
This study was conducted in MOH hospitals in Jeddah, which is the main port of entry to Makkah and is regarded as one of the largest places of mass gathering in the world. The hospitals included five general adult hospitals and two paediatric hospitals.

Study design and Population:-
This descriptive cross-sectional survey was conducted from 1 June to end of August 2016 in Jeddah. The study population comprised all accessible HCWs who were working at the seven MOH hospitals in Jeddah, were direct clinical care providers (physicians, nurses, pharmacists, laboratory technicians, and other clinical support staff), and consented to participate. Sample size:-Sample size was calculated for an alpha of 0.05, based on a 71.6% overall prevalence of perceived preparedness among HCWs, taken from a study conducted in Singapore in 2006 about concerns and preparedness for an avian influenza pandemic among HCWs (21) . The total population of the MOH hospitals in Jeddah was 8126 HCWs (22) .The sample size was 305 HCWs, which was estimated using OpenEpi version 3.03a. We added 20% of potential unresponsive participants.
Sampling technique:-Sstratifiedd random sampling was conducted to select the study sample of HCWs from the different included hospitals. The stratification was according to the type of job titles, for instance, doctors, nurses, and clinical support staff. Subsequently, a random sample was included in each stratum using proportional allocation technique.

Study tools:-
A structured self-administered questionnaire was prepared to assess the concerns, perceived impacts, and HCW preparedness for epidemic and pandemic events in MOH hospitals. The questionnaire was adopted from an original survey of concerns and preparedness for an avian influenza pandemic in Singapore in 2006 (21) , and was formulated according to our objective. It consisted of five sections, each including some questions. The five sections were independent variables, which were as follows: 1. Demographic data 592 2. Work-related concerns of HCWs 3. Non-work-related concerns of HCWs 4. Perceived impact on the personal life and work of HCWs 5. HCW preparedness for epidemic and pandemic events The dependent variable was the degree of HCW preparedness.

Data collection technique:-
We distributed questionnaires to the respondents who agreed to participate in the study after explaining the purpose of the survey and clarifying precautions about the questionnaire. The surveyed participants anonymously filled the self-administered questionnaires, which we collected afterwards.

Data entry and statistical analysis:-
After data collection, the data were revised, coded, and entered using statistical software IBM SPSS version 20. The given graphs were constructed using Microsoft Excel. All statistical analyses were performed using two-tailed tests and an alpha error of 0.05. A P value ≤0.05 was considered statistically significant. In descriptive statistics, Frequencies and percentages were used to describe the frequency of each category for categorical data. Mean with standard deviation was used to describe scale data.
Pilot study:-A pilot study was conducted in one hospital to assure feasibility. Consequently, the study needed more human resources to assist in data collection.
Ethical considerations:-This study was approved by the Ethics Review Committee No. (H-02-J-002) and date 4-4-1438 H .All participants provided written informed consent. All collected data were kept confidential and were not disclosed except for the study's purpose. Table 1 demonstrates that nearly samples were selected according to the weight of the population from different hospitals for representativeness. Response rate was 93.7%. More than half of the sample population (53.6%) were aged <30 years, while only 2.9% were >50 years. Moreover, 59.5% of the included HCWs were females, and 40% were males. Regarding marital status, most of the sample were married (53.1%), while 40% comprised single staff. For educational level, 48.1% of the included HCWs had bachelor degree followed by 28.7% with diploma while those with post graduate degrees composed 23.2% of the sample. Considering the job title, 36.7% were nurses, followed by doctors (31.8) and laboratory staff (12.5%), while other jobs constituted only about 18%. Work related concerns regarding epidemic and pandemic events:- Table 2 shows that among work-related concerns regarding epidemic and pandemic event items, the highest agreement rate was for feeling of risk exposure, which was recorded among 77.8% of HCWs, followed by being afraid of falling into the epidemic or pandemic attack (71.7%) and accepting the risk of contracting infection as part of the job (61.5%).

HCWs Demographic Characteristics:-
Non-work-related concerns regarding epidemic and pandemic event:- Table 3 For non-work-related concerns regarding epidemic and pandemic event items, 73.8% of HCWs agreed on concern for their work colleagues, followed by agreement on the right of close people to worry for their health (73.5%) and on being most concerned for their parents (71.4%). The least agreed on items included the statement that 'people close to the staff would be worried as they may get infected by me' (61.8%) and the high risk of infection for close people (64.7%).  Table 4 clarifies that the agreement for all items was relatively low: 58.9% of HCWs agreed that they have increased workload, while 57.4% agreed on feeling more stressed. Moreover, 44% were afraid of telling their families about the risk they were exposed to, and they told that they have to do work not normally done by them. Only 17.5% told that 'people would avoid my family members because of my job', while 25% avoided telling other people about the nature of their job. Table 5 demonstrates that about 75% of HCWs agreed on the presence of an infection control committee and infection control team at their hospitals, and 72% told that their hospitals informed them for vaccinations. Furthermore, about 60% told that they received training and adequate PPE and understood their benefits. Discussion:-Concerns, perceived impacts, and HCW preparedness for epidemic and pandemic events:-In this study, most HCWs perceived that their job might endanger them and they may become ill. This is analogous to previous studies where the respondent staff felt at risk of contracting the infection at workplaces and had a sense of potential sickness during work (23)(24)(25) .

Preparedness for epidemic and pandemic events:-
Although the majority realized that their profession incurred them the risk of exposure to infection, occupational exposure to infection was accepted as part of professional duty in >60% of our sampled HCWs. Besides increased apprehension of HCWs to contracting infection, the minority of HCWs would dismiss to keep taking care of their patients and would think to quit their work during epidemic and pandemic events. These findings are consistent with previous studies conducted in Singapore, Egypt, and Indonesia (23,24,26) .
Our study showed that those with paramedical jobs had higher work concern than physicians and nurses. The low level of concern among physicians could be attributed to their level of knowledge, continued medical education for case management, scientific dependability, and clinical training compared with other HCWs, along with possible previous experience of similar events. Furthermore, marital status contributed to the increase in HCWs' concern.
Since the emergence of MERS-CoV, 31% of reported cases have been related to healthcare facilities, 19.6% of which have been reported in HCWs (27) . The increased number of affected HCWs has made their colleagues increasingly concerned about them. Besides, it was noted that HCWs were concerned for their family members and vice versa. This fits with the findings of other studies (23,26,28).
Excess workload and exhausted work could be two factors which troubled more than half of the HCWs in our study. This was more obvious in a similar study conducted in Egypt, the rate of which was almost 90% (23) .
During the pandemic and epidemic events that had occurred, social ostracism experienced by HCWs and their family was a prominent finding in previous studies, including a study conducted in Singapore in 2006 (63.5% and 51.9%, respectively) (21) , another study in 2007 (57.1% and 46.4%) (24) , and a study in Egypt during the H1N1 pandemic in 2009 (52.8% and 30.6%) (23) . However, our study revealed little concern on social ostracism among HCWs and their family regarding epidemic and pandemic events (24.5% and 17.5%, respectively), which is identical to the results of a study on avian influenza in South Jakarta (26) .
During the early outbreak of MERS-CoV, some secondary and tertiary hospitals in Saudi Arabia were overwhelmed and disrupted. This was, to some extent, due to breaks in infection control practices of the hospitals combined with unpreparedness of HCWs, worsened by insufficient PPE and lack of preparedness training , (29) .
On average, we found that most HCWs were aware about the presence of infection control committees and infection control staff in their hospital. Approximately more than two-thirds of the participants commented that they were recommended to take the required vaccination; this high proportion was the result of Saudi MOH's mandate that all HCWs should receive annual influenza vaccination (30) . Even though these results differ from some earlier studies, the results of one study in 29 European Union countries indicated that most European countries recommend influenza vaccination. However, HCW vaccination was still low. Our results are consistent with those in the US in 2014-2015, whereas vaccination coverage was 96.0% among HCWs working in healthcare facilities where 596 vaccination was mandated (31) . Additionally, there is evidence to suggest that mandatory influenza vaccination policies could increase influenza vaccination coverage (32)(33)(34) .
The WHO has provided a framework of preparedness plans to ensure that countries worldwide are effectively prepared to respond to pandemic influenza. Approximately 103 countries currently do not have influenza pandemic preparedness plans, or these plans are not publicly available. Only 11 countries have revised and disseminated their national pandemic preparedness plans after 2014 [35][36] . Saudi Arabia published their pandemic preparedness plan before 2009, with no update so far. These were consistent with our results showing insufficient information about an epidemic and pandemic preparedness plan, wherein less than half of HCWs were not aware whether their hospital had a pandemic preparedness plan. However, these findings are contrary to studies in Singapore and Egypt that reported high values in both institutional and personal preparedness (23)(24) . A study in Indonesia had findings similar with our findings (26) .

Conclusion:-
Based on our findings, the majority of HCWs have some concerns about epidemic and pandemic events. In addition, their poorly preparedness for managing these events in their hospitals. We suggest to enhance human resources capacities through psychosocial support and comprehensive training programs for epidemic and pandemic preparedness and response.