Atika BERRY, MD, MpHCommunicable 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

1920 1940 1960 1980 2000

H1N1

H2N2

H3N2

1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”

20-40 million deaths 1-4 million deaths 1-4 million deaths

Characteristics of The Three Pandemics of The 20th Century (*)Pandemic (date & common name

Area of emergence

Influenza A virus subtype

Estimated case fatality rate

Estimated mortality 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 “Hong Kong

Flu”

Southern China H3N2 < 0.2% 1-4 m

All age groups

(*) Adapted from European Centre for Disease Prevention and Control, Pandemics of the 20 th century, October 2008

The VirusThe Virus

Human

Influenza VirusSwine Flu Virus

Pig to pig transmission &

pig to human transmission

Human to human transmission

(& Human to pig transmission?)

What can be happening now?What can be happening now?

Communicable Disease Surveillance, Forecasting and Response, CSR/EMRO)

??

Viral Reassortment

Reassortment in pigs

Reassortment in humans

Pandemic Influenza Virus

Cumulative Number of Confirmed Swine-Origin Flu Cases in The World

Country Cases DeathsAustria 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 PhasesWHO Pandemic Phases

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 3a:cases outside LebanonPhase 3b: cases including Lebanon

-Phase 4. Small cluster(s) with limited human-to-human transmission but spread is highly localized.Phase 4a: cases outside LebanonPhase 4b: cases including Lebanon

-Phase 5: Larger cluster(s) of human-to-human transmission Phase 5a: cases outside LebanonPhase 5b: cases including Lebanon

Pandemic period-Phase 6. Pandemic: increased and sustained transmission in general population.

Roles and Responsibilities in Preparedness and Response

A- National preparedness and response as a whole-of-society responsibility:

Government LeadershipHealth sector (public, private, NGO’s)Non-health sectors (electrical, water, business…)Communities, individuals, and families

B- Coordination under IHR (2005)

5-6 Pandemic PhasesPhase 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

Phases 5-6

PLANNING AND COORDINATIONProvide leadership and coordination to

multisectorial resources to mitigate the societal and economic impacts

SITUATION MONITORING AND ASSESSMENT

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

COMMUNICATIONSContinue 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)

TransparencyContinuous 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) 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 dropletsfall on peoplesurfaces 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 diseaseUpdate 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: 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 periodImplement 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 levelsImplement & adjust the triage system as necessaryEnhance infection control practices in healthcare & laboratory

settings & distribute PPE in accordance with national planProvide medical & non-medical support for patients & their contacts

in households & alternative facilities if neededProvide social & psychological support for health care workers,

patients & communitiesImplement corpse management procedures as necessary

Containment measures at this point are not effective.

Isolation Precautions

Source: Rosie Sokas, MD MOH UIL at Chicago

Droplet precautions: Droplet precautions: Surgical MasksSurgical Masks

N-95 Filtering Masks

Personal Protective Equipment(PPE)

National Actions During Phases 5-6:CommunicationsRegularly 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 sectorsCommunicate transparently and with a consistent message with the

public and local health care providers.Consider declaring state of emergencies in the affected areas. 

Antivirals- OseltamivirTreatment 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 & coordinationDetermine the need for additional resources &capacities during possible

future pandemic wavesBegin rebuilding essential servicesAddress psychological impacts of the pandemic, especially on the health

workforceConsider offering assistance to countries with ongoing pandemic activityReview the status & replenish national, local and household stockpiles &

suppliesReview & revise national plans

B- Situation monitoring & assessmentActivate the surveillance activities required to detect subsequent pandemic

wavesEvaluate 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 accordinglyContinue with vaccination programmes in accordance with national

plans, priorities, and vaccine availability

D- Continuity of health care provisionEnsure that health care personnel have the opportunity for rest &

recuperationRestock medications & supplies & service & renew essential equipmentReview and, if necessary, revise pandemic preparedness & response

plans in anticipation of possible future pandemic wavesRevise 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 pandemicCommunicate 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