Transcript Mitigating the Impact of Pandemic (H1N1): Options for Public Health Measures Dr Li Ailan Communicable Disease Surveillance & Response (CSR) WHO Western Pacific Regional.

Mitigating the Impact of Pandemic (H1N1):
Options for Public Health Measures
Dr Li Ailan
Communicable Disease Surveillance & Response (CSR)
WHO Western Pacific Regional Office (WPRO)
3rd Meeting of the National Influenza Centres
in the Western Pacific and South-East Asia Regions
18-20 August 2009, Beijing, China
Outline
 What options are available for public health interventions?
 What have countries prepared for non-pharmaceutical
interventions?
 What actual public health measures have been applied or
being implemented in response to pandemic (H1N1) 2009?
 Conclusion
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Primary Strategies for Combating Influenza
 Pharmaceutical interventions
– Use of matched vaccines
– Use of effective antiviral drugs
 Non-pharmaceutical interventions
– Individual and household level public health
measures
– Societal level public health measures,
including social distancing
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Goals of Public Health Intervention
 Delay outbreak peak
1
 Delay spread and shift an
epidemic curve to the right side
– to reduce peak burden on health
care facilities (e.g. hospitals)
– to “buy time” for other measures
(e.g. vaccination)
 Reduce morbidity and mortality
through reducing the total
number of cases
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
2
3
Public Health Measures Available (theoretically)
at national and community level
1. Individual/household measures
Personal protective measures
Isolation & quarantine
Infection prevention and control in the home setting
Use of masks in the community setting
2. Societal measures, including social distancing
Suspension of classes and child care programmes
Adjusting or changing work patterns
Restriction of public or mass gatherings
Domestic travel advisories and restrictions
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Public Health Measures Available (theoretically)
at the international border
1. International travel and screening
Health advice and alerts to travellers
Health declaration form
Temperature screening
On-board identification of suspected travellers
International travel advisory, restriction, border closure?
2. Management of symptomatic & exposed travellers
Symptomatic travellers (isolation & treatment…)
Exposed travellers (quarantine…)
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Key considerations
 Decision on public health measures based on risk
assessment, especially severity and potential impact
 Public health measures should be evidence-based
whenever possible
 Countries should balance the benefits against the
costs and potential consequences
 Need to be tailored to suit country or local context
 Planning, coordination and communication is essential
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Comparative risk of outbreaks
Transmissibility
Low
Severity of High
Disease
High
H5N1
SARS
(Morbidity
&
Mortality)
1918 Pandemic
Pandemic (H1N1) 2009?
Low
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Seasonal Flu
Possible strategies based on risk category
Transmissibility
Low
Severity of High
Disease
Aiming at preventing
disease importation and
containing the virus
Aiming at rapid
containment at the early
stage, and mitigating the
impacts, if containment not
possible
Routine public health
measures without additional
aggressive interventions
Aiming at reducing
transmission and mitigating
impact with focus on
vulnerable population
(Morbidity
&
Mortality)
Low
High
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Matching cost and consequences of
interventions with risk level
More acceptable interventions
1918
pandemic
virus or
worse
C
A
D
B
E
Level of Risk
SARS
New H1N1
???
Seasonal
Influenza
F
Less acceptable interventions
E.g. Respiratory
hygiene
E.g. Isolation &
quarantine
Cost s and Consequences
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
E.g. Travel
restriction
Options for interventions: Decision Matrix
Options
School
closure
Benefits
Reducing transmission
among children and
decreasing spread to the
community
Acceptable in some
countries
Limitations &
consequence
Decision
(Yes/No/wait)
high social & economic cost
Second consequences
Need alternative childcare
programme
Absenteeism of working
parents, including HCWs
Educational continuity?
Comments & guidance:
-Must weight the benefits of reducing transmission against economic and social costs
-Decision based on local situation and context (“case-by-case”)…
-…
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Pandemic Preparedness Assessment 2009
 Annual assessment of pandemic preparedness was conducted
in May-June, using the WHO WPRO and CDC Joint
Assessment Tool
 A supplementary questionnaire on public health measures was
added in this “readiness” survey
– Is this public health measure included in your national response plan?
– Did you apply or consider applying this measure?
– What is your trigger to start and stop the public health intervention?
 The questionnaire was distributed to collect data from 17
countries and areas, 15 (88%) responded to the survey
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Pandemic Preparedness Assessment 2009:
Public Health Measures at International Borders
A. Public Health Measures at International Borders
% of 'Yes' Response from Member States
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Health alerts f or
travellers
Health declaration
f orm/card
Passenger screening
Management of
symptomatic travellers
Public Health Measure
Management of
exposed travellers
In Pandemic Response Plan?
Conduct / consider activities?
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Pandemic Preparedness Assessment 2009:
Individual/Household level Measures
B. Individual / Household Level Public Health Measures
% of 'Yes' Response from Member States
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Hand and respiratory
hygiene
Isolation of ill people
Quarantine of contacts
Inf ection prevention &
Use of masks in
control f or home
community settings
caregivers
In Pandemic Response Plan?
Public Health Measure
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Conduct / consider activities?
Pandemic Preparedness Assessment 2009:
Societal level Measures
C. Societal Level Public Health Measures
% of 'Yes' Response from Member States
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Closure of school and childcare f acilities
Restriction/cancellation of
public or mass gatherings
Adjusting or changing w ork
patterns
Public He alth M e asure
Domestic travel advisories,
restrictions, other measures
In Pandemic Response Plan?
Conduct / consider activities?
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Responding to Pandemic (H1N1) 2009
 Based on risk assessment, most countries with community
transmission have shifted from “containment” efforts to
“mitigation” strategies
 Robust risk assessment help ensure appropriate public health
measures are planned and implemented.
 Public health interventions have been dynamic in the region with
most countries and areas implemented
– relatively “aggressive” border measures including passengers’ screening
– personal hygiene behaviour interventions
– school closures at the early stage of outbreaks
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Example: School closure
 At the early stage of Pandemic (H1N1) 2009, the large proportion
of school children and young adults affected
 School closure measure has been most frequently used as
compared with other social level measures
 Many countries used school closure measures in the Asia Pacific
Region, including Australia, China, Japan, Malaysia, New Zealand,
the Philippines, Singapore and Thailand…
 Types of measures varied: from “real” school closure or class
dismissal, from “proactive” or “reactive” approach…
 Length of closure varied: mostly 7-14 days
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
School closure in Japan (May 2009)
17 May: Schools closed Hyogo Prefecture
17 May : Schools closed, in Osaka
30
35
25
30
学校閉鎖
20
兵庫県（神戸市
以外）
神戸市
15
25
20
15
10
10
5
5
0
0
5/1
5/8
5/15
5/22
Source: NIID, Japan
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
府内その他 ：44例
A中学高等学校 ：87例
School closure in Japan (June 2009)
Schools and Kindergartens in Fukuoka were closed on 7 June
18
16
14
12
その他
10
渡航歴あり
Source: NIID, Japan
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
06月30日
06月28日
06月26日
06月24日
06月22日
06月20日
06月18日
06月16日
06月14日
06月12日
06月10日
06月08日
06月06日
板小
06月04日
0
06月02日
板中
05月31日
2
05月29日
その他小学校
05月27日
4
05月25日
宮竹幼稚園
05月23日
6
05月21日
幼児
05月19日
8
Conclusion
 The potential benefits of public health measures should be
carefully balanced against their potentially significant
social and economic costs
 Decision based on assessed situation and local context.
No standard, single combination of measures will fit all
countries – “one size will not fit all”
 Available information indicated some public health
measures have helped slow down the spread of the virus
 Need for continuing planning, monitoring and evidence
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Interim guidance available
 Mitigating the impact of pandemic (H1N1) 2009:
Options for public health measures
 Responding to pandemic (H1N1) 2009: Options for
interventions at international points of entry
http://www.wpro.who.int/health_topics/h1n1/tech/tec
h_guidance.htm
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)
Acknowledgement
 Dr Takeshi Kasai, Regional Advisor, CSR/WPRO
 Dr Nobuhiko Okabe, NIID, Japan
 Ms Qiu Yi Khut, CSR/WPRO
 Ms Katie Harrigan, CSR/WPRO
Communicable Disease Surveillance and Response (CSR)
WHO Western Pacific Regional Office (WPRO)