Infection Prevention Control (IPC)

IPC data were extracted by thematic analysis, ^{Reference Tartari, Allegranzi and Ang1,Reference Bazeyo, Bagonza and Halage10,Reference Al-Shareef, Alsulimani and Bojan11,Reference Ungchusak, Sawanpanyalert and Hanchoworakul19,Reference Mortelmans, Gaakeer and Dieltiens25,Reference Mortelmans, Van Boxstael, De Cauwer and Sabbe27,Reference Anathallee, Curphey and Beeching29,Reference Grundmann30} as an important factor considered in some articles, which consisted of decontamination, dead body management, laundry, catering, as well as individual and mass isolation. Measures carried out by staff (such as hand washing and use of PPE), and proper isolation of patients (based on the type of illness) affect the performance of hospitals and health centers responding to infectious disasters. ^{Reference Munoz-Price, Arheart and Mills34,Reference Carlos, Capistrano and Tobora35}

Our study showed that challenges confronting IPC around the world are in categories such as access to individual and mass isolation, decontamination measures, hospitalization facilities for patients with highly infectious diseases, biological waste disposal, isolated rooms with ≥ 12 air changes per hour, implementing IPC guidelines on the handling of laboratory samples, infection control in food preparation and hospital cleansing and laundries, access to alcohol and gloves, and managing dead bodies.

Risk Perception

Risk perception of infectious disasters is one of the components of the proper preparedness and performance of health systems. Appropriate risk perception is a determining factor in disaster risk reduction implementations. Risk perception was extracted as one of the effective themes influencing hospital preparedness and response ^{Reference Almutairi, Alodhayani and Moussa12,Reference Mortelmans, Van Boxstael, De Cauwer and Sabbe27} but only 71% of Belgian hospitals were considered to be at risk of Chemical, biological, radiological and nuclear (CBRN) events. ^{Reference Mortelmans, Van Boxstael, De Cauwer and Sabbe27} In Saudi Arabia, all physician and nurse participants had high levels of concern about hemorrhagic fever, so they adhered to strict standard measures for infection control. ^{Reference Almutairi, Alodhayani and Moussa12} The threat of an epidemic may be frightening, particularly when it causes community collapse due to over-estimation of the risk, or vice-versa (inadequate follow-up and widespread epidemics by under-estimation). ^{Reference Bonneux and Van Damme36}

Planning

The sub-themes identified were: preparedness plans for recovery period (recovery announcement, human rehabilitation), programs for special groups, agreements, guidelines, and protocols. ^{Reference Tartari, Allegranzi and Ang1,Reference Al-Shareef, Alsulimani and Bojan11,Reference Ungchusak, Sawanpanyalert and Hanchoworakul19-Reference Droogers, Ciotti and Kreidl23,Reference Paganini, Borrelli and Cattani26-Reference Dell’Era, Hugli and Dami28,Reference Keeble32,Reference Zoutman, Ford, Melinyshyn and Schwartz33} Some necessary plans included educational programs, contamination prevention, rapid communication, individual and mass quarantine, and rapid diagnostic tests. ^{Reference Grundmann30,Reference Lin, Peng and Tsai37} It should be considered that real preparedness is much different from the existence of a plan.

Essential Support Services

Essential support services are considered to be a basic element for proper preparedness and performance during biological disasters that include surge capacity measures, PPE, appropriate masks, and isolation facilities. ^{Reference Anathallee, Curphey and Beeching29,Reference Wilson and Ridgway38-Reference Stockley, Constantine and Orr41} In our study, essential support services were a major theme, that included the following sub-themes: equipment, separate entrances to wards, ventilation, ambulance, high specialty hospitals, PPE, and surge-capacity. ^{Reference Tartari, Allegranzi and Ang1,Reference Al-Shareef, Alsulimani and Bojan11,Reference Kao, Ko and Guo13,Reference Forrester, Pillai and Beer15,Reference Ungchusak, Sawanpanyalert and Hanchoworakul19,Reference Li, Huang and Zhang21,Reference Mortelmans, Gaakeer and Dieltiens25,Reference Mortelmans, Van Boxstael, De Cauwer and Sabbe27,Reference Anathallee, Curphey and Beeching29} Our review has shown that there is a wide range of equipment coverage around the world.

Surveillance

There are reports of the implementation and use of modern and multipurpose surveillance systems. There have been monitoring reports of symptoms in specific times and regions, syndromic surveillance systems, pre-diagnostic and non-specific criteria monitoring, and health behavior spectrum monitoring. ^{Reference Kman and Bachmann42} Surveillance execution is an important element in appropriate preparedness and performance. ^{Reference Ungchusak, Sawanpanyalert and Hanchoworakul19,Reference Li, Huang and Zhang21,Reference Moen, Kennedy, Cheng and MacDonald24}

In 36 European countries, routine influenza surveillance was evaluated as appropriate. ^{Reference Moen, Kennedy, Cheng and MacDonald24} An extensive study in 125 hospitals, across 45 countries, showed that 68% of hospital staff who were engaged in the management of hemorrhagic fever patients were aware of surveillance system and notification processes. Guidelines for suspected cases were available in 70% of hospitals. ^{Reference Tartari, Allegranzi and Ang1} In the early days of the largest Ebola epidemic in Africa, no surveillance system was available. ^{Reference Forrester, Pillai and Beer15}

Laboratory

While an appropriate response to biological disasters requires access to laboratory facilities, only 3 studies had evaluated this theme as an aspect of preparedness. ^{Reference Ungchusak, Sawanpanyalert and Hanchoworakul19,Reference Li, Huang and Zhang21,Reference Hui, Jian-Shi and Xiong22,Reference Reilly and Markenson52}

Vulnerable Groups

The vulnerable groups are more susceptible than the general population, even during a natural and uncomplicated disaster. They also have more needs, and will be even greater in complex disasters such as biological events, but as only 3 countries had considered it as an element of preparedness, ^{Reference Naik, Vagi, Uzicanin and Dopson43-Reference Cohen, Tamrakar and Lowe50} it was one of the issues mentioned the least in the field of disaster management.

Education, Exercise, and Evaluation

Review of articles in the field of biological disaster response reveals the impact of education and exercise. ^{Reference Djalali, Della Corte and Segond51,Reference Reilly and Markenson52} Hospitals will not have the appropriate response capacity without effective education. ^{Reference Reilly and Markenson52} This theme was extracted after thematic analysis, including the sub-themes of: staff education, patient education, vulnerable group training, and community training. Education is one of the challenges of infectious disaster management. Education gaps were clear during the Ebola epidemic in East Africa. ^{Reference Kratochvil, Evans and Ribner53} The current systematic review showed 11 articles had studied the issue, suggesting the importance and frequency of theme as an element of biological disaster preparedness and response. ^{Reference Tartari, Allegranzi and Ang1,Reference Bazeyo, Bagonza and Halage10-Reference Almutairi, Alodhayani and Moussa12,Reference Forrester, Pillai and Beer15,Reference Ungchusak, Sawanpanyalert and Hanchoworakul19,Reference Li, Huang and Zhang21,Reference Hui, Jian-Shi and Xiong22,Reference Paganini, Borrelli and Cattani26,Reference Grundmann30,Reference Keeble32,Reference Zoutman, Ford, Melinyshyn and Schwartz33}

Human Resource

The number of health care workers drops when biological disasters occur, similar to influenza pandemics. ^{Reference Rutkow, Paul, Taylor and Barnett54-Reference Balicer, Barnett and Thompson57} Although the degree to which motivation and the number of available workers decrease in biological disasters varies from country to country, the level of motivation is lower for biological disasters than other disasters. ^{Reference Forrester, Pillai and Beer15,Reference Du, Suo and Jia16,Reference Barnett, Levine and Thompson56} One of the main extracted themes was human resources, including sub-themes of access to an infectious diseases specialist, a counseling Psychologist, and volunteers. ^{Reference Tartari, Allegranzi and Ang1,Reference Forrester, Pillai and Beer15,Reference Li, Huang and Zhang21,Reference Mortelmans, Gaakeer and Dieltiens25} Deficiency of specialist human resources, including infectious disease specialists, psychiatrists, and epidemiologists, was observed in several studies.

Clinical Management of Patients

In this study, and based on thematic analysis, clinical management of patients was one of the extracted themes in facing biological disasters. ^{Reference Tartari, Allegranzi and Ang1,Reference Li, Huang and Zhang21,Reference Hui, Jian-Shi and Xiong22,Reference Mortelmans, Van Boxstael, De Cauwer and Sabbe27,Reference Grundmann30} This theme included sub-themes of access to distribution and storage of drugs and vaccines, and treatment of patients. The results of our study showed that clinical management of specific patients (chronic renal failure patients in need of hemodialysis), diagnostic guidelines, patient tracking, reserves of vaccines and antibiotics, and other pharmaceutical resources are problematic in some research.

Risk Communication

During intentional or unintentional outbreaks of infectious diseases, communication, information, and guidance are often the most important public health tools in risk management. ^{Reference World Health58} Effective communication reduces response time in disasters. ^{Reference Mosquera, Melendez and Latasa59}

It was determined by our research that the following items had encountered some problems: sharing specific information (such as free bed numbers and hospital capacity), training programs, answering frequent asked questions, visual tools for personal protection exercises and educational videos, and intra-hospital communication mechanisms. In African countries, even telephone interference had led to inefficient management in the Ebola pandemic. ^{Reference Tartari, Allegranzi and Ang1,Reference Kao, Ko and Guo13,Reference Forrester, Pillai and Beer15,Reference Ungchusak, Sawanpanyalert and Hanchoworakul19,Reference Moen, Kennedy, Cheng and MacDonald24,Reference Grundmann30}

Budget

In spite of the high cost of preparedness and performance measures during infectious disasters, proper budgets are not usually allocated. Researches show that a lack of financial resources acts as a major obstacle to proper preparedness. ^{Reference Mortelmans, Van Boxstael, De Cauwer and Sabbe27} The amount of funding varies according to each country’s context. Our study found that in Switzerland, the lack of national funds for enhancing disaster preparedness is one of the main causes of hospital vulnerability to chemical, biological, radiological, nuclear, and burn threats. ^{Reference Dell’Era, Hugli and Dami28} Funding for biological defense has been increasing in the United States since 2000, ^{Reference Grundmann30} but budget strategies for hospital preparedness should be prioritized and rationally reviewed. ^{Reference Keeble32} 70% of hospitals in Ontario, Canada had not received adequate funding for influenza epidemics. ^{Reference Zoutman, Ford, Melinyshyn and Schwartz33} At the beginning of the largest Ebola epidemic in east Africa, health care worker salaries were not paid due to the lack of budget. ^{Reference Forrester, Pillai and Beer15}

Coordination

Good evidence of the coordination and command of infectious epidemics has been seen in Taiwan. The Epidemic Command Center is responsible for managing infectious epidemics. Unified command and appropriate coordination has been implemented by: determining 6 geographic areas in the country; designating a respondent hospital, a support hospital, and mass isolation sites such as public spaces or determined hospitals in each area; and connecting all of them to the Center of Infectious Epidemics Control. The above mentioned system can be a model for controlling epidemics and other infectious disasters worldwide. ^{Reference Kao, Ko and Guo13}

Infectious disasters differ from other disasters in many respects, such as drug supply, vaccines, and special equipment like PPE; so their management requirements include Memoranda of Agreement (MOA), Memoranda of Understanding (MOU), and cooperative planning with other hospitals, health centers, government, local authorities, and support providers. Coordination with foreign organizations (respondent and supportive) as well as national inter-disciplinary coordination can improve management. ^{Reference Avery and Zabriskie-Timmerman60}

Limitations

The limitation of our research was that methodology of studies was not similar. The tools used in different studies were also not similar.