PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE

1
PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE

• Atika BERRY, MD, MpH
• Communicable Diseases Dpt, MOH
• 02 May 2009

2
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

3
Circulating Influenza Strains and Pandemics in
The 20th Century
1968 Hong Kong Flu
1918 Spanish Flu
1957 Asian Flu
20-40 million deaths
1-4 million deaths
1-4 million deaths
H3N2
H2N2
H1N1
1920 1940 1960 1980 2000
4
Characteristics of The Three Pandemics of The
20th Century ()
() Adapted from European Centre for Disease
Prevention and Control, Pandemics of the 20th
century, October 2008
5
(No Transcript)
6
(No Transcript)
7
The Virus
8
What can be happening now?
Human Influenza Virus
Swine Flu Virus
Pig to pig transmission pig to human
transmission
Human to human transmission ( Human to pig
transmission?)
?
9
Viral Reassortment
Reassortment in humans
Reassortment in pigs
Pandemic Influenza Virus
10
Cumulative Number of Confirmed Swine-Origin Flu
Cases in The World
As of 0600 GMT, 1 May 2009, 11 countries have
officially reported 331 cases of influenza
A(H1N1) infection. (Ref www.WHO.int)
11
WHO Pandemic Phases
12
WHO classification of pandemic phases

• Pandemic alert period
• -Phase 3. Human infections with a new subtype,
  but no or very limited human-to-human spread.
• Phase 3acases 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.

13
Roles and Responsibilities in Preparedness and
Response

• A- National preparedness and response as a
  whole-of-society responsibility
• Government Leadership
• Health sector (public, private, NGOs)
• Non-health sectors (electrical, water, business)
• Communities, individuals, and families
• B- Coordination under IHR (2005)

14
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

15
Preparedness Components Actions During Phases
5-6
16
National Actions During Phases 5-6Planning 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

17
National Actions During Phases 5-6Situation
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.

18
National Actions During Phases 5-6Situation
Monitoring and Assessment(2)

• 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

19
Big droplets fall on people surfaces bed clothes
Courtesy of CDC
20
National Actions During Phases 5-6Reducing 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

21
National Actions During Phases 5-6Reducing 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

22
National Actions During Phases 5-6Reducing 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
• 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

23
National Actions During Phases 5-6Continuity 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.

24
National Actions During Phases 5-6Continuity 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.

25
Isolation Precautions
26
Droplet precautions Surgical Masks
27
N-95 Filtering Masks
28
Personal Protective Equipment (PPE)
29
(No Transcript)
30
(No Transcript)
31
National Actions During Phases 5-6Communications

• Regularly update the public on what is known
  unknown about the 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. 

32
(No Transcript)
33
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.

34
Importance of the Early Treatment
35
Pandemic Waves (1918-1919)
36
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

37
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

38
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

39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43

• Thank you