Transcript PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE

Atika BERRY, MD, MpH
Communicable Diseases Dpt, MOH
02 May 2009
Introduction
The development of an Influenza pandemic can be
considered as the result of the transformation of an animal
influenza virus into a human influenza virus. At the
genetic level, pandemic influenza viruses may arise
through:
 Genetic reassortment: genes mix between animal and
human influenza viruses
 Genetic mutation: genes change in an animal influenza
virus
Circulating Influenza Strains and
Pandemics in The 20th Century
1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”
20-40 million deaths
1-4 million deaths
1-4 million deaths
H3N2
H2N2
H1N1
1920
1940
1960
1980
2000
Characteristics of The Three Pandemics
of The 20th Century (*)
Pandemic
(date &
common
name
Area of
emergence
Influenza A
virus
subtype
Estimated
Estimated
case fatality mortality
rate
worldwide
Age groups
most
affected
1918-1919
“Spanish Flu”
Unclear
H1N1
2-3%
20-50 m
Young
adults
1957-1958
“Asian Flu”
Southern
China
H2N2
< 0.2%
1-4 m
Children
1968-1969
Southern
“Hong Kong
China
H3N2
< 0.2%
1-4 m
Flu”
(*) Adapted from European Centre for Disease Prevention and Control, Pandemics of the 20th century, October 2008
All age
groups
The Virus
Communicable Disease Surveillance, Forecasting and Response, CSR/EMRO)
What can be happening now?
Human
Swine Flu Virus
Influenza Virus
Human to human
transmission
(& Human to pig
transmission?)
?
Pig to pig
transmission &
pig to human
transmission
Viral Reassortment
Reassortment in
humans
Reassortment in pigs
Pandemic Influenza
Virus
Cumulative Number of Confirmed Swine-Origin Flu
Cases in The World
Country
Cases
Deaths
Austria
1
0
Canada
34
0
Germany
3
0
Occupied Palestinian Territories
2
0
Netherlands
1
0
New Zealand
3
0
Mexico
156
9
Spain
13
0
Switzerland
1
0
United Kingdom
8
0
US
109
1 (Texas)
Total
331
10
As of 06:00 GMT, 1 May 2009, 11 countries have officially reported 331 cases of
influenza A(H1N1) infection. (Ref: www.WHO.int)
WHO Pandemic Phases
WHO classification of pandemic phases
Pandemic alert period
-Phase 3. Human infections with a new subtype, but no or very limited human-tohuman spread.
Phase 3a:cases outside Lebanon
Phase 3b: cases including Lebanon
-Phase 4. Small cluster(s) with limited human-to-human transmission but spread is
highly localized.
Phase 4a: cases outside Lebanon
Phase 4b: cases including Lebanon
-Phase 5: Larger cluster(s) of human-to-human
transmission
Phase 5a: cases outside Lebanon
Phase 5b: cases including Lebanon
Pandemic period
-Phase 6. Pandemic: increased and sustained transmission in general population.
Roles and Responsibilities
in Preparedness and Response
ANational preparedness and response as a whole-ofsociety responsibility:
 Government Leadership
 Health sector (public, private, NGO’s)
 Non-health sectors (electrical, water, business…)
 Communities, individuals, and families
BCoordination under IHR (2005)
5-6 Pandemic Phases
 Phase 5: human to human spread of the virus into at least two
countries in one WHO region. It is a strong signal that a
pandemic is imminent and that the time to finalize the
organization, communication, and implementation of the
planned mitigation measures is short.
 During Phase 5-6, actions shift from preparedness to
response. The goal of recommended actions is to reduce the
impact of the pandemic on society
Preparedness Components & Actions
During Phases 5-6
Preparedness Components and
Actions
PLANNING AND COORDINATION
SITUATION MONITORING AND
ASSESSMENT
Phases 5-6
Provide leadership and coordination to
multisectorial resources to mitigate the societal
and economic impacts
Actively monitor and assess the evolving
pandemic and its impacts and mitigation
measures
REDUCING THE SPREAD OF THE
DISEASE
Implement individual, societal, and
pharmaceutical measures
CONTINUITY OF HEALTH CARE
PROVISION
Implement contingency plans for health
systems at all levels
COMMUNICATIONS
Continue providing updates to general public
and all stakeholders on the state of pandemic
and measures to mitigate risk
National Actions During Phases 5-6:
Planning and Coordination
 Activation of the Government Leadership (Multisectorial
resources coordination) in order to:
- Finalize preparations for an imminent pandemic (activation
of crisis committees, and national command and control
systems
- Update national guidance and recommendations (according
to WHO recommendations and taking into account
information from affected countries)
 Transparency
 Continuous collaboration with WHO
National Actions During Phases 5-6:
Situation Monitoring and Assessment(1)
Pandemic Disease Surveillance:
 Enhance surveillance, increase preparedness:
- Elaborate a national case definition,
- Designate a RRT at the Mohafaza level,
- Detailed epidemiological investigation of the case
- Undertake a comprehensive assessment of the earliest
cases of pandemic influenza,
- Contact tracing for the two weeks prior to onset of
symptoms,
- Follow-up contacts for fever and cough for one week,
- Active case search to find any additional cases…)
 Document the evolving pandemic (geographical spread, trends and impact)
 Document any changes in epidemiological & clinical features of the pandemic virus
 Provide the appropriate laboratory kit (RHUH)
 Take appropriate laboratory specimens and share the specimen with WHO reference
laboratories
 Report probable, suspected and confirmed cases to the WHO.
National Actions During Phases 5-6:
Situation Monitoring and Assessment(2)
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Monitoring and Assessment of the Impact of the
Pandemic:
Monitor essential health related ressources (medical
supplies; antivirals, vaccines and other pharmaceuticals,
health
care
worker
availability,
hospital
occupancy/availability; use of alternative health facilities,
lab materials stocks; and mortuary capacity)
Monitor and assess national impact (workplace and school
absenteeism, regions affected)
Assess the uptake & impact of implemented mitigated
measures
Forecast economic impact of the pandemic, if possible
Big droplets
fall on people
surfaces bed clothes
Courtesy of CDC
National Actions During Phases 5-6:
Reducing the Spread of the Disease (1)
Phase 5a:
 Be prepared to implement planned interventions to reduce
the spread of pandemic disease
 Update recommendations on the use of planned
interventions based on experience and information from
affected countries
 Implement distribution and deployment plans for
pharmaceuticals, and other resources as required
 Consider implementing entry screening at international
borders
National Actions During Phases 5-6:
Reducing the Spread of the Disease (2)
Phase 5b:
A- Individual/household level measures:
 Advice people with ARI to stay at home & minimize their contact with household
members & others
 Advice household contacts to minimize their level of interaction outside home &
to isolate themselves at the first sign of any symptoms of influenza
 Provide infection control guidance for household caregivers according to WHO
guidance
B- Social level Measures:
 Implement social distancing measures
 Encourage reduction of travel and crowding of the mass transport system
 Assess and determine if cancelation, restriction, or modification of mass gathering
is indicated
National Actions During Phases 5-6:
Reducing the Spread of the Disease (3)
Phase 5b (contd)
C- International travel measures:
 Consider implementing exit screening as part of the early global response
 Provide advice to travelers
D- Pharmaceuticals measures:
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Distribute antivirals, and other medical supplies in accordance with national plans
Implement vaccine procurement plans
Plan for vaccine distribution &accelerate preparation for mass vaccination campaigns
Modify/adapt antiviral & vaccine strategies based on monitoring & surveillance
information
 Implement medical prophylaxis campaigns for antivirals &/or vaccines according to
priority status & availability in accordance with national plans
 Monitor safety and efficacy of pharmaceutical interventions to the extent possible &
monitor supply
National Actions During Phases 5-6:
Continuity of Health Care Provision (1)
Phase 5a:
 Prepare to switch to pandemic working arrangements
 Ministry of public health and health care institutions should
plan ahead for the surge activities in this period
 Implement pandemic vaccine procurement plans.
 Prioritization of antiviral use based on availability and
effectiveness.
National Actions During Phases 5-6:
Continuity of Health Care Provision (2)
Phase 5b:
 Implement pandemic contingency plans for full mobilization of
health systems, facilities, & workers at national & sub-national levels
 Implement & adjust the triage system as necessary
 Enhance infection control practices in healthcare & laboratory
settings & distribute PPE in accordance with national plan
 Provide medical & non-medical support for patients & their contacts
in households & alternative facilities if needed
 Provide social & psychological support for health care workers,
patients & communities
 Implement corpse management procedures as necessary
Containment measures at this point are not effective.
Isolation Precautions
Droplet precautions: Surgical
Masks
Source: Rosie Sokas, MD MOH UIL at
Chicago
N-95 Filtering Masks
Personal Protective Equipment
(PPE)
National Actions During Phases 5-6:
Communications
 Regularly update the public on what is known & unknown about the
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pandemic disease, including transmission patterns, clinical severity,
treatment & prophylaxis options
Provide regular communications to address societal concerns, such as
the disruption to travel, border closures, schools, or the economy or
society in general
Regularly update the public on sources of emergency medical care,
resources for dealing with urgent non-pandemic health care needs, &
resources for self-care of medical conditions
Provision of written information to all related sectors
Communicate transparently and with a consistent message with the
public and local health care providers.
Consider declaring state of emergencies in the affected areas.
Antivirals- Oseltamivir
 Treatment is 75 mg twice a day for 5 days.
 Prophylaxis is 75 mg once a day for 7 days after last
exposure.
 Prophylaxis:
 High risk exposure (household contacts)
 Moderate risk (unprotected very close exposure to sick
animals; HCW with unprotected exposure to patients)
 Low risk exposure: no need for prophylaxis unless
activation of exceptional measures.
Importance of the Early Treatment
Pandemic Waves (1918-1919)
The Post-Peak Period (1)
A- Planning & coordination
 Determine the need for additional resources &capacities during possible
future pandemic waves
 Begin rebuilding essential services
 Address psychological impacts of the pandemic, especially on the health
workforce
 Consider offering assistance to countries with ongoing pandemic activity
 Review the status & replenish national, local and household stockpiles &
supplies
 Review & revise national plans
B- Situation monitoring & assessment
 Activate the surveillance activities required to detect subsequent pandemic
waves
 Evaluate the resources needed to monitor the subsequent waves
The Post-Peak Period (2)
C- Reducing the spread of the disease:
 Evaluate the effectiveness of the measures used & update guidelines,
protocols, & algorithms accordingly
 Continue with vaccination programmes in accordance with national
plans, priorities, and vaccine availability
D- Continuity of health care provision
 Ensure that health care personnel have the opportunity for rest &
recuperation
 Restock medications & supplies & service & renew essential equipment
 Review and, if necessary, revise pandemic preparedness & response
plans in anticipation of possible future pandemic waves
 Revise case definitions, treatment protocols, & algorithms as required
The Post-Peak Period (3)
E- Communications:
 Regularly update the public & other stakeholders on any
changes to the status of the pandemic
 Communicate to the public on the ongoing need for
vigilance & disease-prevention efforts to prevent any
upswing in disease levels
 Continue to update the health sector on new information
or other changes that affect disease status, signs &
symptoms, or case definitions, protocols & algorithms
Thank you