Transcript Slide 1
Country Situation:
Avian/Pandemic
Influenza
Preparedness
Preparedness In
for
India
Avian/Pandemic Influenza in
India
By
DR Shashi khare
Dr. Shashi Khare
NICD Delhi.
NICD Delhi.
Influenza Pandemic
• An influenza pandemic
(global epidemic) occurs
when a new virus
subtype appears, against
which no one is immune.
• Several simultaneous
epidemics worldwide
with large numbers of
cases and deaths.
• Spreads rapidly around
the world in view of
global transport and
urbanization.
Pandemic Influenza Uniqueness
• Limited resources
because of widespread
influenza pandemic
300
Bombay
Madras
Calcutta
200
150
100
50
0.
19
. 10
.
2.1
1.
16
. 11
.
30
. 11
.
14
. 12
28
. 12
.
5.1
7.9
21
.9
24
.8
10
.8
27
.7
13
.7
0
29
.6
deaths/1000
250
15
.6
• Reduced availability of
Health-care workers
and first responders
Influenza -Weekly Death Rate in India 1918
1.6
• Will last much longer
than most other
emergency events with
“waves” of influenza
activity separated by
months
Week ending
Consequences of the Influenza Pandemic
Livelihoods
• Income
loss due to market changes
Human Health
• High illness & potentially higher death rates
• Overstretched health facilities
• Disproportionate impact on vulnerable groups
Governance &
Security
• Higher public anxiety
• Increased demand for governance & security
• Reduced capacity due to absence and illness
Social &
Humanitarian Needs
Economic Systems
• Deterioration of coping & support mechanisms
• Interruption in public services
• Quarantine policies
• Trade & commerce disruptions
• Labour shortages
• Interruption of regular supply systems
Definition of WHO Pandemic Phases
Note: 2005 definitions simplify and replace 1999 definitions
• Pre-Pandemic Period
Phase 1 – no avian virus poses a significant risk to
human
Phase 2 – new avian virus
a risk
to human
poses
Human
infection
• Pandemic Alert Period
Current
phase
Phase 3 – but no human-to-human transmission
Phase 4 – limited human-to-human transmission
Phase 5 – human-to-human spread, larger clusters,
but still localized
• Pandemic Period
Phase 6 – Transmission sustained, global spread
Pandemic Preparedness - Strategies
• Planning activities started in 2004
• Highest Political commitment
• National Consultation
• Multi sectoral involvement
• Knowledge gap filled through WHO
guidelines
WHO Strategies
Objectives according to the different periods
• Pre-Pandemic Period
1 – Reduce opportunities for human infection
2 – Strengthen the early warning system
• Pandemic Alert Period
3 – Contain or delay spread at the source
• Pandemic Period
4 – Reduce morbidity, mortality, and social disruption
5 – Conduct research to guide response
measures
6 - Minimise the impact of pandemic
WHO Strategy
Actions according to the different phases
•
Pre-Pandemic Period
FAO/OIE
AVIAN INFLUENZA CONTROL
RESEARCH / INDUSTRY
VACCINE DEVELOPMENT
Pandemic Period
PANDEMIC
PREPAREDNESS
WHO
ANTIVIRAL GLOBAL STOCKPILE
•
COUNTRIES
Pandemic Alert Period
SURVEILLANCE
•
WHO
Global Strategy Agreed Nov 2005
1 Stop influenza in animals through
stamping out the disease at the place
where the infection starts
2 Prevent emergence of pandemic by
limiting human exposure;
• if pandemic does start, contain it quickly;
• if containment is not possible, mitigate
pandemic consequences.
3 Countries in lead: Support from Global
Partnership
Pandemic preparedness: interventions
• Pharmaceutical:
use of antiviral drugs, vaccine
& escalated medical services
• Non-Pharmaceutical:
personal Hygiene, PPE, travel
restriction, social distancing,
quarantine & risk
communication
Multisectoral
&
community
Cooperation
Requires
strong leadership
&
Support
of Govt.
GETTING PREPARED 1
• GOALS
– Early Detection, Investigation and Confirmation,
Containment
• STRATEGIES
– Social distancing, personal protection,
movement restriction, maintenance of essential
infrastructure
– Systematic use of anti-viral therapy (oseltamivir)
– Rapid development and equitable distribution of
effective vaccines (Major controversy: will poor
countries have access)
GETTING PREPARED 2
• APPROACH
– Plan to mitigate effects of pandemic on Local
Communities: Economies, Governance, Basic
Needs, Border Movements
– Build Resilience through high level of popular
awareness, understanding and engagement
– Government reaching out to and working with
Private Entities and Voluntary Bodies
– Government and voluntary bodies preparing for
large scale Humanitarian Relief
GETTING PREPARED 3
• PROCEDURES
– Robust information systems established
– Protocols developed for use of stockpiles,
emergency operations
– Civil society, NGOs, local government, Private
Sector synchronized
– Systems for disseminating information to public
via media developed and tested
– Continuity plans for different entities simulated
and lessons applied
– Concept for putting multiple plans into practice,
together, developed and put to test
Need for preparedness
• Reduction of transmission of the
pandemic virus strain
• To decrease cases, hospitalizations and
deaths
• Maintenance of essential services
• Reduction of economic and social impact
Pandemic Preparedness - Strategies
• Planning activities started in 2004
• Highest Political commitment
• National Consultation
• Multi-sectoral involvement
• Knowledge gap filled through WHO guidelines
Multisectoral Approach
• Involvement of government sector at many
levels, and people with various specialties:
Policy development, legislative review
and drafting
Animal health
Public health
Patient care
Laboratory diagnosis, research &
development
Risk communication
Disaster management
Multiple Sectors involved(1)
• Human Health: Contain the pandemic
Medicines, Commodities, Equipment, R and D,
Patient Care, Lab services
• Financial Services: Keeping financial systems going Banking
(cash and settlements), financial regulation,
risk management and insurance
• Utilities, Personal Services:
Electricity, Water, Food, Telecoms, Postal services,
Retailing (Catering for the needs of the most vulnerable)
• Transportation– Logistics, Business, Leisure: Supply systems
Air, sea, rail; Ports; Pilgrimages; Sports and other events;
Tourism
Multiple Sectors involved(2)
• Government, Security, Military:
Public Services, Rule of law, Judiciary and Correction,
Private Security, respect for rights
• Information Management:
Transparency Strategic communication; Broadcast and
print; Good use of internet
• Environment and hygiene Biosecurity:
Cleaning, Maintenance, refuse management, wildlife
• Food and Livestock Production
Growing, Processing, Marketing and Distribution of
animal meat for human consumption
Preparedness
for
Avian/ pandemic influenza in
India
National Scenario
• India-7th largest country
areawise
• 2nd most populated (1 billion+
popn.)
• High Population Density in
urban settings
• Major poultry sector- ranks
among the top 5 nations in egg
production in the world
• 1,00,000 wet lands
National Scenario (contd)
• Falls on the route of two
major flyways of migratory
birds
• AI entrenched in SEA
• 1918 outbreak killed 7 million
people with one of the
highest CFR
• An influenza pandemic would
have substantial impact on
the growing economy .
Preparedness for AI in India
• Inter Ministerial Task Force
& Joint Monitoring Group
• Contingency Plan finalised
• Training of RRTs
• Stockpiling of drugs, PPE &
critical care equipments
• Laboratory strengthening &
Networking – ICMR & IDSP
Labs
• Surveillance for seasonal
influenza
• International Partnership on
Avian & Pandemic Influenza
(IPAPI) Meet – 4-6
December 2007, New Delhi
• Risk communication
Legal and Institutional Frame work
•
•
•
•
•
•
•
•
National Disaster Management Act-2005.
National Disaster Management Authority established
2006.
National Crisis Management Committee.
National Influenza Pandemic Committee.
Inter-ministerial Task Force for Sectoral Coordination.
Joint Monitoring Group for monitoring.
National Task Force on Communications in I& B
ministry
Technical Committee for Laboratory Strengthening,
vaccines, Import of poultry Products etc.
Operational Frame-work
• Ministry of Health: Nodal Ministry for Biological
Disasters at National level including AI
• Dept of Animal Husbandry: focal point for
Animal Health
• State Health and Animal Husbandry
Departments: nodal agencies in states to
operationalize State plans
• District authority: implementing agency at
grass root level
• Disaster Management Authorities: National,
State and District level
Proposed AI Lab network
Referred samples
Provides Resources
IGMC Shimla
CRI Kasauli
SGPGI Lucknow
Reference Lab.
IPM Hy d era ba d
Refer enc e La b.
IDSP
NIV, Pune
NIC
National Lab.
NICD
ManipalMed College
NIMHANS Bangalore
Reference Lab.
National Lab.
J IPMER Po nd ich er ry
Ha ffkines Mum ba i
Reference Lab.
BJ Med College
Ahmedabad
Reference Lab.
Risk Communication
• UNICEF with MOHFW has
developed material targeted
at three communication
clusters:
– preventing an outbreak
– controlling an outbreak
– emergency response to
pandemic.
• Communication tools have
been identified and creative
ideas being further refined
IEC MATERIAL
Situation of AI Outbreak in INDIA
Avian Influenza Outbreaks in India
Year
Affected States
2006
Maharashtra
Gujarat
Madhya Pradesh
Manipur
2007
2008- 09
Tripura, Assam,
West Bengal contd..
2009
Sikkim
No human case
reported in India
Avian Influenza Outbreaks in Poultry, India 2008
Dated: 17 December 2008
North
Tawang
Dhemaji
East Kameng
Sikkim
Sikkim
Sikkim
NEPAL
BHUTAN
Darjeeling
Darjeeling
Darjeeling
Jalpaiguri
59
59
59
Supaul
Araria
Bihar
Bihar
Bihar
Begusarai
DINAJPUR
DINAJPUR
DINAJPUR
DINAJPUR
DINAJPUR
DINAJPUR
Banka
Mon
Mokokchung
KURIGRAM
KURIGRAM
KURIGRAM
KURIGRAM
KURIGRAM
KURIGRAM
RANGPUR
RANGPUR
RANGPUR
Wokha
Nagaon
Nagaland
Nagaland
Nagaland
Dimapur
West Khasi Hills
JOYPURHAT
JOYPURHAT
JOYPURHAT
JOYPURHAT
JOYPURHAT
JOYPURHAT
NAOGAON
NAOGAON
NAOGAON
BAGURA
BAGURA
BAGURA
BAGURA
BAGURA
BAGURA
Phek
Kohima
Meghalaya
Meghalaya
Meghalaya
West
Garo Hills
North Cachar Hills
East Khasi Hills
South Garo Hills
Fresh Outbreaks
Nov-Dec 2008
Tuensang
Karbi Anglong
Jaintia Hills
JAMALPUR
JAMALPUR
JAMALPUR
JAMALPUR
JAMALPUR
JAMALPUR
Godda
Pakur 35
35
35
East Garo Hills
20
20
20
English
Bazar
Sahibganj
Outbreak
April - June 2008
58. Ranaghat - II
62. Kurseong
63. Bijanbari
LALMONIRHAT
LALMONIRHAT
LALMONIRHAT
LALMONIRHAT
LALMONIRHAT
LALMONIRHAT
South
South
South
Dinajpur
Dinajpur
Dinajpur
21
21
21
49
49
49
Lakhisarai
Jamui
Chirang
Chirang
Chirang
Chirang
Chirang
Chirang
Barpeta
Barpeta
Barpeta
Nalbar
Nalbar
Darrang
Nalbar
Nalbar
Nalbar
Sidli Chirang
Pachim
Bongaigaon
Bongaigaon
BongaigaonBajali
Nalbari
Nalbari
Nalbari
Nalbari
Boitamari
Bezera
Morigaon
Hajo
Kamrup
Kamrup Metro
Metro
Metro
Kamrup
Metro
Kamrup
Kamrup
Metro
Dhubri
Kamrup
Kamrup
Guwahati
Kamrup
Goalpara
Gobardhana
Rampur
Rani
Ri Bhoi
NILPHAMARI
NILPHAMARI
NILPHAMARI
NILPHAMARI
NILPHAMARI
NILPHAMARI
Malda
Malda
Malda
Bhagalpur
Munger
Sibsagar
Jorhat
Sonitpur
A
A S
S S
S A
A M
M
40
40
40
THAKURGOAN
THAKURGOAN
THAKURGOAN
THAKURGOAN
THAKURGOAN
THAKURGOAN
Purnia
Katihar
Fresh Outbreak
in WB, Dec 2008
Khagaria
41
41
41
PANCHAGHARH
North
Dinajpur
Madhepura
Fresh outbreak Assam
Nov-Dec 2008
Dibrugarh
Dibrugarh
Dibrugarh
Lakhimpur
Kokrajhar
Cooch
Cooch
Cooch
Behar
Behar
Behar
Kishanganj
Darbhanga
Samastipur
Arunachal
Arunachal
Arunachal Pradesh
Pradesh
Pradesh
62
62
62
62
62
62
63
63
63
63
63
63
Madhubani
Dibrugarh
West Kameng
East
SHERPUR
Senapati
NETROKONA
NETROKONA
NETROKONA
NETROKONA
NETROKONA
NETROKONA
SUNAMGANJ
Cachar
SYLHET
SYLHET
SYLHET
SYLHET
SYLHET
SYLHET
Ongoing Outbreaks in
Bangladesh since 2007
Ukhrul
Tamenglong
Karimganj
Manipur
Manipur
03
03
03
Manipur
Hailakandi
MOULVI
MOULVI BAZAR
BAZAR
BAZAR
MOULVI
BAZAR
MOULVI
MOULVI
BAZAR
RAJSHAHI
RAJSHAHI
RAJSHAHI
48
48
48
RAJSHAHI
RAJSHAHI
05
Churachandpur
05
09
09 10
09
10
1005
Giridih
HABIGANJ
NATORE
NATORE
NATORE
NATORE
NATORE SIRAJGANJ
13 08
13
08 61
61
North
Kolasib
08
61
12
12 13
12
TANGAIL
TANGAIL
TANGAIL
KISHOREGANJ
MYMENSINGH
TANGAIL
TANGAIL
TANGAILMYMENSINGH
MYMENSINGH
Deoghar
Dumka
MYMENSINGH
MYMENSINGH
06
06
57
57 Tripura
06
57
Murshidabad
Murshidabad
Murshidabad
GAZIPUR
GAZIPUR
GAZIPUR
GAZIPUR
GAZIPUR
Jharkhand
Jharkhand Jamtara
54
54
36
36
36
14
14 54
Jharkhand
14
PABNA
PABNA
PABNA
PABNA
PABNA
PABNA
04
04
04
56
56
56
07
07
07
27
27
West Tripura
NARSINGDHI
NARSINGDHI
27
B.
B. Baria
Baria
Baria
NARSINGDHI
47
47
B.
Baria
NARSINGDHI
NARSINGDHI B.
47
B.
Baria
Tripura
Tripura
Aizawl
Birbhum
Birbhum
34
34
34
Tripura
MANIKGANJ
MANIKGANJ
23
MANIKGANJ
Dhanbad
KUSHTIA
KUSHTIA
23
MANIKGANJ
MANIKGANJ
KUSHTIA
KUSHTIA
KUSHTIA
31
31 Birbhum
DHAKA
DHAKA
31
DHAKA
DHAKA
DHAKA
22
22
22 23
Mamit
17
17
17
02
02
02
24
NARAYANGANJ
NARAYANGANJ
24
NARAYANGANJ
NARAYANGANJ
NARAYANGANJ
11
11 18
55
55
18
18 24
11
55
16
16
16
32
32
32
CHUADANGA RAJBARI
RAJBARI
RAJBARI
RAJBARI
South
RAJBARI
RAJBARI
Bokaro
Mizoram
Mizoram
37
37
Mizoram
37
15
15
15
Tripura
28
28
28
43
43 01
43
COMILLA
01
19
19
01
19
29
29
29 JHENAIDAH
JHENAIDAH
JHENAIDAH
MUNSHIGANJ
MUNSHIGANJ
MUNSHIGANJ
MUNSHIGANJ
MUNSHIGANJ
25
25
25
Outbreak
39
39
39
MAGURA
MAGURA
MAGURA
MAGURA
MAGURA FARIDPUR
Serchhip
June 2008
Burdwan
Burdwan
Burdwan
Purulia
Purulia
Purulia
58
58
CHANDPUR
CHANDPUR
CHANDPUR
58
CHANDPUR
CHANDPUR
CHANDPUR
42
42
55. Bishalgarh
42
Bankura
Bankura
Bankura
Nadia
Nadia
Nadia
BANGLADESH
Imphal
Imphal
Imphal
2007
2007
2007
Chandel
MYANMAR
Saraikela
Bengal
West
West
West Bengal
Bengal
East Singhbhum
(Jamshedpur)
hbhum
sa)
Midnapore
Midnapore
Midnapore
West
West
West
38
38
38
Hooghly
Hooghly
Hooghly
52
52
52
24
24
24 Parganas
Parganas
Parganas
50
50
50
North
North
North
Howrah
Howrah
Howrah
44
44
51
51
5144
Kolkata
45
45
45
Midnapore
East
Mayurbhanj
Balasore
Map not to scale
46
46
46
26
26
26
24
24
24 Parganas
Parganas
Parganas
South
South
South
JESSORE
JESSORE
JESSORE
JESSORE
JESSORE
JESSORE
GOPALGANJ
GOPALGANJ
GOPALGANJ
GOPALGANJ
GOPALGANJ
GOPALGANJ
BARISAL
BARISAL
BARISAL
BARISAL
BARISAL
BARISAL
SATKHIRA
SATKHIRA
SATKHIRA
SATKHIRA
SATKHIRA
SATKHIRA
NOAKHALI
NOAKHALI
NOAKHALI
NOAKHALI
NOAKHALI
NOAKHALI
KHULNA
KHULNA
KHULNA
KHULNA
KHULNA
KHULNA
BARGUNA
BARGUNA
BARGUNA
BARGUNA
BARGUNA
BARGUNA
Lunglei
RANGAMATI
BHOLA
BHOLA
BHOLA
BHOLA
BHOLA
BHOLA
PATUAKHALI
PATUAKHALI
PATUAKHALI
PATUAKHALI
PATUAKHALI
PATUAKHALI
56. Mohanpur
57. Salema
KHAGRACHARI
PEROJPUR
BAGERHAT
FENI
FENI
FENI
FENI
FENI
FENI
CHITTAGONG
Lawngtlai
Tinsukia
Tirap
Human surveillance in affected area
• Micro planning at block level (house to house activity )
- 0-3 KM daily
– 3-10 KM bi-weekly
• Screening of PUI /suspect at each level
– Surveillance worker to medical officer
– Medical officer to RRT members
• Mechanism for collection and transportation of human
sample (s)
• Surveillance workers
– Protective equipment
– chemoprophylaxis
Selected public health measures
• Bird Handlers /Cullers
– Use of Personal Protection Equipment
– Chemoprophylaxis with Oseltamivir
– Daily health check up
• Quarantine
– During culling
– Post culling period
Institutional set up
• Identification of designated institution
– Block Primary Health Center with isolation facility
– Referral sub-divisional /district hospital with facility
for critical care (27 such hospital are already set)
– ID hospital at state level with facility for critical care
• Capacity building of human resources
– 54 nos of state RRT trained by GoI
– 1st and 2nd line of state RRT allocated for each district
• Arrangement of transport facility for shifting of patient.
• Arrangement for sending clinical samples.
IEC Materials used during Outbreak
• Interpersonal communication with the community
members
• Leaflets containing essential messages
• Posters & Handbills
• Audio / Video CD’s & Short films for
circulation through local cable channels
• Public messages through ‘news dailies’
• Information through DOHFW website
• IEC materials prepared in collaboration with UNICEF
• CD containing TV clippings and short film for
circulation through local cable channel
Lessons Learnt
•
Inadequate inter-sectoral
coordination
•
Problem in total destruction
of backyard poultry
•
Surveillance of infection in
poultry/birds to detect early
focus – need strengthening
•
Quarantine – difficulty in
operationalization
•
Infection control practices –
use of PPE in hot & humid
atmosphere
•
IEC – need strengthening
Unsafe practices
IEC material
AI/ PI Plans
• National
Pandemic
Preparedness Plan
• Contingency plan for
managing
avian
influenza in poultry
• Contingency Plan for
management
of
human cases of avian
influenza
AI/ PI Plans: Objectives
• International, National, State & District Level
co-ordination.
• Identification of roles & responsibilities of all
stake holders.
• Prevent /delay entry of novel virus
• Stamp out the disease if appearing in small
clusters
• Institutionalizing mechanism for developing
sufficient quantity of vaccines.
• Availability of adequate quantity of anti-viral
drugs
Critical Issues in the Pandemic Plan
•
•
•
•
•
•
•
•
Sectoral Coordination
Surveillance
Augmenting critical care
Stockpiling of drugs
Management of Mass casualties
Disposal of dead bodies
Border/ Port/ Airport Control
Imposing trade and travel restrictions
India’s Pandemic Preparedness plan
Scenario 2- India involved
We have to face it
?
Estimated Time Frame?
It would be unrealistic for any state/
country to consider that it could prepare
and implement a detailed and
comprehensive pandemic plan in weeks, or
even months.
Time is now
Start preparing
Balanced Approach – the best
Strategies that employ all
aspects of the preparedness
will have the greatest
likelihood of success
– Building healthy public
policy
– Creating healthy
environments
– Strengthening community
action
– Building personal skills
– Reorienting health services
Maintain significant
investment in research and
effective intervention
strategies.
Action springs not from thought,
but from a readiness for responsibility
G.M.Trevelyan (1876-1962)
Actions to be taken at Industry Level
3 main aspects of preparedness at industrial level
• Information & Technology
• Infrastructure
• People / Employee
Information & Technology
• Strengthened the key communication services such as email
etc..
• Increased capacity for employees to work from home
• Enhancement of Remote conferencing( eg: 24x7 outbreak
monitoring cell NICD)
• Distance / elearning platform for educating employees on
behavior during pandemic should be incorporated by all
industries
It is important to build and test redundancy during non pandemic
times.
Infrastructure
• Workplace preparedness
Protocols on social distancing
Protocols on seating inside the office to ensure a
distance of minimum one meter from next employee
Closure of common areas, meeting rooms, cafeteria etc
Wash rooms with proper ventilation with doors opening
inside
Identification / equipping employee quarantine room in
each location
Protocols on “Deep” cleaning of workplace
Training employees to maintain respiratory hygiene at
workplace
People / Employee
In the services business people are the most critical resource, during a
pandemic the dependency on critical resources will increase multifold
•
Identification of critical skills
•
Procured supply of Personal Protective Equipment
•
Protocols on Self evaluation mechanism for employees
•
Methodology for identification of Backup resources
•
Work from home Strategy
•
Distribution of IEC material to the employees
Thank You
Long wait for
vaccine
Influenza epidemic,
New York, 1947.
Times photograph
•
Prevention is easy….
but where is the vaccine