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Clinical management of influenza and other acute respiratory illness in resource-limited settings: learning from the influenza pandemic (H1N1) 200920–21 October 2010 – Geneva Switzerland

WHO/HSE/GIP/DAC/2011.3

© World Health Organization 2011

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WHO/HSE/GIP/DAC/2011.3

Management of acute respiratory illness in resource-limited settings | i

Contents

Acknowledgements ii

Abbreviations and acronyms iii

1 Background 1

2 The meeting 22.1 Objectives 2

2.2 Outcomes 2

2.3 Agenda 3

2.4 Participants 3

3 National experience 43.1 Disease activity and impact on health-care systems 4

3.2 Clinical epidemiology 6

3.3 Clinical care 10

3.4 National systems and response 13

3.5 Communication 17

4 Key challenges of implementing clinical guidance 184.1 Country needs assessment questionnaire 18

4.2 Developing clinical guidance in resource-limited settings 20

4.3 Development of deployable kits of medical supplies and devices to manage hospitalized ARI in resource-limited settings 21

4.4 Infection prevention and control 23

5 WHO approach: training to improve patient care at all levels 245.1 Home-based care for pandemic influenza 24

5.2 Community case management during an influenza outbreak training package 25

5.3 Hospital-based training 25

5.4 Critical care training 26

5.5 Promoting oxygen use for pneumonia treatment 27

6 WHO action points 30

ii | Management of acute respiratory illness in resource-limited settings

Annex 1 Agenda 31

Annex 2 List of participants 36

Annex 3 Oral statement on declarations of interest 42

Annex 4 Country questionnaire proforma 44

Annex 5 Calculation table for disposables and pulse oximetry for 100 severe pneumonia cases 47

Tables

Table 1 South Africa (H1N1) 2009 fatality comorbidities 8Table 2 South Africa HIV fatality comorbidity data 8Table 3 Clinical outcome of (H1N1) patients by time of initiation of antiviral therapy, Argentina 12Table 4 Requirements needed to strengthen treatment of acute respiratory illness, as identified by different countries 19

Figures

Figure 1 The 2009 influenza pandemic: key lessons learnt from countries 5Figure 2 Argentina pandemic (H1N1) 2009 mortality rates according to age and gender 7Figure 3 Severe acute respiratory illness surveillance – incidence of infection of pandemic (a) (H1N1) 2009 and (b) H3N2 by HIV status, Soweto, South Africa 9Figure 4 Streptococcus pneumoniae and influenza detection rates and total number of samples by week, South Africa, 2009 11Figure 5 Early and effective primary care can forestall progression to severe disease 14Figure 6 Bed status during surge of pandemic (H1N1) 2009 cases, Mongolia, 2010 16

AcknowledgementsThis document was prepared by Paula Lister, Justin Ortiz and Kathryn Sauven under the coordination of Nikki Shindo of the World Health Organization (WHO) Global Influenza Programme.

We would like to acknowledge the essential contributions of the participants at the technical meeting, and of WHO departments, including Health Action in Crisis/Emergency Preparedness and Capacity Building (HAC/EPC), Human Immunodeficiency Virus/Systems Strengthening and HIV (HIV/SSH), Family and Community Health Cluster/Child and Adolescent Health and Development (FCH/CAH) and Health Security and Environment/Global Alert and Response (HSE/GAR). We would also like to acknowledge other members of the Supporting Patient Care team of the WHO pandemic influenza functional response structure.

The report was reviewed by Dr Iryna Bobrova, Dr Rosa Bologn, Dr Bin Cao, Dr Tawee Chotpityasunondh, Dr Santiram Dhakal, Dr Lena Napolitano, Dr Enkhtur Shonkhuuz, Dr Jagdish Chander Suri and Dr Juno Thomas.

We would also like to acknowledge the support in this project of WHO staff: Vincent Ahove, Sylvie Briand, Meena Nathan Cherian, John Conly, Janet Diaz, Hien Doan, Sergey Eremin, Michelle Gayer, Madhu Ghimire, Sandra Gove, Benido Impouma, Matthew Lim, Joshua Mott, Lulu Muhe, Naoko Obara, Heather Papowitz, Charles Penn, Susan Piazza, Shamim Ahmad Qazi, Pilar Ramon-Pardo, Yu Togawa and Mari-Helene Vannson.

The final document was further strengthened by written comments, critiques and technical editing of previous drafts from Anna Bowman, Hilary Cadman, Rebecca Harris and Tim Nguyen. This project was supported in part by a grant from the United States Agency for International Development (USAID) and Japan.

Management of acute respiratory illness in resource-limited settings | iii

Abbreviations and acronymsAIDS acquired immunodeficiency syndrome

ARDS acute respiratory distress syndrome

ARI acute respiratory infection

CAP community-acquired pneumonia

CHW community health worker

ETAT emergency triage assessment and treatment

GIP Global Influenza Programme (of WHO)

HCW health-care worker

HIV human immunodeficiency virus

ICU intensive care unit

ILI influenza-like illness

IMAI integrated management of adolescent and adult illness

IMCI integrated management of childhood illness

IPC infection prevention and control

IRDT influenza rapid diagnostic test

MOH ministry of health

NGO nongovernmental organization

NIV noninvasive ventilation

RSV respiratory syncytial virus

SARI severe acute respiratory illness

SARS severe acute respiratory syndrome

TB tuberculosis

UNICEF United Nations Children’s Fund

WHO World Health Organization

1 | Management of acute respiratory illness in resource-limited settings

1 Background

Pandemic (H1N1) 2009, the first influenza pandemic of the 21st century, reached all parts of the world within a year, causing epidemics of varying magnitude. During the pandemic period, the World Health Organization (WHO) received reports of over 18 000 laboratory-confirmed deaths due to infection with the virus; however, the actual death toll is likely to have been much higher1. The hospitalization rate was highest in children under 5 years of age, and particularly in those under 1 year of age. In contrast to seasonal influenza epidemics, most of the deaths from the 2009 influenza pandemic occurred in those under 60 years of age, up to half of whom had previously been healthy.

Since the start of the 2009 influenza pandemic, WHO has been supporting countries in the area of patient care. For countries with limited resources, WHO has developed information and training materials for several levels of health care – at home and in the community, and in district and tertiary hospitals. Information on the pandemic disease was collected through WHO networks, including the network of clinicians at the front line. The training materials were developed based on existing WHO guidelines and manuals (e.g. Hospital care for children2), complemented with information specific to pandemic (H1N1) 2009.

In early August 2010, the Director General of WHO announced that the world was moving into the post-pandemic period. During this period, however, the pandemic (H1N1) 2009 virus is expected to continue to circulate globally and cause disease among susceptible populations, especially in countries that did not go through the full (H1N1) 2009 epidemic. Learning lessons from the pandemic (H1N1) 2009 experiences can help to strengthen health-care systems against future epidemics of influenza and of other epidemic-prone acute respiratory infections (ARIs).

To address resource constraints in low- and middle-income countries, the following points – raised by those attending the First Africa Flu Alliance meeting held in Morocco in June 20103 – were considered when developing strategies to improve care of patients with ARI:

� further develop nurse-led primary care in communities through ARI training and the development of care and diagnostic kits;

� increase knowledge of influenza in the population through, for example, the mass media, community health workers (CHWs) and social mobilization campaigns;

� strengthen pneumonia care in hospitals through in-service training, delivery of equipment as a package (e.g. oxygen, masks and pulse oximeter) and strategic planning that emphasizes funding and human resources.

1 http://www.who.int/csr/disease/swineflu/notes/briefing_20091222/en/index.html2 http://whqlibdoc.who.int/publications/2005/9241546700.pdf3 The First Africa Flu Alliance Meeting was hosted by the WHO Global Influenza Programme. Plans to reduce influenza burden in

Africa were discussed by health authorities, health partners and international health agencies. The meeting report is available at http://www.who.int/csr/disease/influenza/2010_06_3_afa_mtg_marrakesh_morocco.pdf (accessed March 2011)

http://www.who.int/csr/disease/swineflu/notes/briefing_20091222/en/index.html

http://whqlibdoc.who.int/publications/2005/9241546700.pdf

http://www.who.int/csr/disease/influenza/2010_06_3_afa_mtg_marrakesh_morocco.pdf

Management of acute respiratory illness in resource-limited settings | 2

2 The meeting

This document reports on a meeting convened by WHO in October 2010 titled Clinical management of influenza and other acute respiratory illnesses in resource-limited settings: Learning from (H1N1) 2009 influenza pandemic.

2.1 ObjectivesThe overall goal for the meeting was to contribute to improved clinical management of influenza and other ARI at all levels of health care during community transmission of pandemic influenza. Specific objectives developed to achieve the overall goal were to:

� review lessons learnt for the diagnosis and management of influenza from settings where resources are limited;

� list key challenges of implementing clinical guidance in resource-limited settings, and use this information for the further development of country-specific action items, to improve clinical management of influenza at all or at focused levels of health care;

� introduce WHO information materials and training curricula to the participants, and assess whether any of these can fit into the action items identified by the above-mentioned exercise;

� engage donors and funding agencies to support the countries through implementation of the action items or provision of resources.

2.2 OutcomesBased on the objectives listed above, the outcomes of the meeting would be:

� a meeting report (this document) that summarizes:

– key lessons learnt in the management of pandemic (H1N1) 2009 from resource-limited settings;

– key challenges of implementing clinical guidance in resource-limited settings;

– country-based needs analysis to improve clinical management of influenza at all or at focused levels of health care during community spread of pandemic influenza;

� a list of prioritized action items for future coordinated capacity building activities, agreed upon by the participating partner agencies;

� agreement on the next steps.


The knowledge acquired through the meeting will be reflected in WHO training materials and used in:

� the development of national or local plans to improve health-care preparedness during a surge of sick people with ARI, and clinical management of ARI;

� community awareness raising activities during transmission of pandemic influenza or other epidemic-prone ARI.

2.3 AgendaOn Day 1 experts summarized key features of pandemic (H1N1) 2009, and eight countries presented their experiences of the pandemic. This was followed by a session on promoting oxygen use for pneumonia treatment, and introductory presentations on WHO training curricula and a country needs survey that participants completed at the meeting. On Day 2, the meeting was divided into working groups to discuss a range of practical issues to improve current clinical and community care training packages and their implementation. The full agenda is given in Annex 1.

2.4 ParticipantsFifty participants, predominately from resource-limited countries, were invited to the meeting. Participants from the WHO African Region were given priority, due to the high burden of ARI in the region and the need to align with the outcomes of the First Africa Flu Alliance meeting. The international experts participating in the meeting were invited to share their knowledge in relevant technical areas, and of good practices for the diagnosis and clinical management of influenza and its severe complications.

Participants included representatives from ministries of health, national authorities in patient care or health systems, public health policy makers and clinicians from developing countries; clinical experts; and representatives of nongovernmental organizations (NGOs) and of bilateral and multilateral funding and donor agencies. Also in attendance were WHO staff from WHO Headquarters, Regional Offices and Country Offices. A list of participants is given in Annex 2. Participants were asked to complete a written declaration of interest before the meeting. An oral statement of declaration of interest was read at the start of the meeting; it noted that no conflicts of interest were identified (Annex 3).

The meeting was organized by the WHO Global Influenza Programme (GIP), in collaboration with other members of the Supporting patient care team of WHO pandemic influenza functional response structure from several WHO clusters – Health Security and Environment, Health Action in Crises, HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), TB (tuberculosis) and Neglected Tropical Diseases, and Family and Community Health.


3 National experience

All presenters reported that the pandemic (H1N1) 2009 highlighted the limitations of clinical care delivery within their countries (Argentina, Bhutan, India, Mongolia, South Africa, Thailand, Ukraine, United States of America). Although the overall disease impact differed, all presenters noted challenges to the pandemic clinical response in their countries. The main lessons learnt from the presentations are given in Figure 1.

3.1 Disease activity and impact on health-care systems

Summary points

� The disease impact of pandemic (H1N1) 2009 varied among countries.

� Some countries experienced intense surges of pandemic cases, which stressed health-care systems.

� Some countries experienced high incidence of ARI caused by non-pandemic influenza aetiologies (e.g. influenza H3N2 or B, and respiratory syncytial virus [RSV]) back-to-back with the pandemic influenza circulation; this had implications for resource allocation and aetiology-specific clinical guidelines.

Pandemic influenza timing and intensity

Presenters reported that their countries experienced one or two peaks of pandemic influenza cases between April 2009 and October 2010.

Several countries experienced sudden pandemic influenza disease activity over a relatively short period of time in 2009, as outlined below.

Argentina experienced an intense, concentrated surge of hospitalized patients from mid-June to early July 2009, during which time 10–20% of admitted patients required intensive care.

Mongolia experienced a similar intense surge of cases. The first surge was caused by pandemic (H1N1) 2009; it occurred early in the 2009–2010 season, from mid-October to November 2009. This was followed by a second peak, caused by influenza B virus, in January–February of 2010. The second peak was most notable in Ulaanbaatar city, where over 1000 patients were admitted to hospital with severe ARI; three quarters of these patients were under 5 years of age.

In Thailand, a first wave of influenza-like illness (ILI) patients comprised mostly the “worried well”. A subsequent wave resulted in a substantial number of hospitalized ARI cases (four times greater than seen during a typical influenza season), which stressed hospital surge capacity. During this second wave, Thailand experienced the same number of influenza cases within a period of 2 months that it had over the previous 4 years.


Figure 1. The 2009 influenza pandemic: key lessons learnt from countries

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ARDS, acute respiratory distress syndrome; ARI, acute respiratory infection; HCW, health-care worker; HIV, human immunodeficiency virus; MODS, multiple organ dysfunction syndrome


Impact on national health-care systems

In several countries, the pandemic had a substantial impact on health-care delivery. Argentina, India, Mongolia, Thailand and Ukraine all reported that the number of ARI cases during peak pandemic influenza activity burdened national health-care systems. While some countries (e.g. Argentina) experienced a short period of elevated disease activity, others (e.g. India) had sustained, lower level disease activity. Both scenarios resulted in stressed health-care systems. An additional burden on health-care delivery was reported by Ukraine, where 60 000 health-care workers (HCWs) experienced ARI between the beginning of the pandemic and April 2010, and there were 42 HCW deaths.

Impact of seasonal influenza and other infections

Pandemic (H1N1) 2009 was not the only influenza virus causing disease during the pandemic. As mentioned above, Mongolia, which experienced high pandemic morbidity, found that influenza B was implicated in most of the hospitalized and outpatient cases in early 2010 (i.e. during the second peak). Likewise the reports from India, Thailand and Ukraine indicated that a high proportion of patients with ARI/ILI tested negative for pandemic (H1N1) 2009 but still required medical attention. When influenza circulation is known in the community, negative test results must be interpreted with caution.1 A high proportion of these patients had confounding or coinfecting illnesses such as malaria, dengue, chikungunya, RSV or seasonal influenza. South Africa reported that similar numbers of cases of pandemic (H1N1) 2009 and H3N2 were seen in 2009. These experiences reinforced the need for robust and timely laboratory testing to inform disease surveillance and clinical care.

3.2 Clinical epidemiology

Summary points

� High hospitalization rate in young children and increased death rate in non-elderly adults were common in the countries represented.

� Risk factors for severe disease were similar to those of seasonal influenza (including pregnant women), while varying percentages of otherwise healthy persons were reported both in hospitalized and fatal cases.

� Chronic respiratory diseases and HIV infection were highlighted as comorbidities of significant importance.

Age groups affected

Globally, the highest attack rates for pandemic (H1N1) 2009 were reported among children and young adults. The hospitalization rate was highest in the youngest paediatric age group (particularly in those <1 year of age), and the death rate was highest among non-elderly adults, followed by infants under 1 year of age.2 This finding was common among the countries represented in the meeting.

In Argentina, a retrospective study3 of paediatric admissions in Buenos Aires during the pandemic found that the rate of hospitalization (20.9/100 000) was twice that seen during the preceding influenza season (10.3/100 000), and that the overall death rate was 10 times higher during the 2009 pandemic (1.1/100 000) than during the 2007 influenza season (0.1/100 000 population; no paediatric deaths associated with seasonal influenza were reported in 2008). During the pandemic, most deaths were caused by refractory hypoxaemia in infants under 1 year of age (death rate, 7.6/100 000).

1 See Clinical management of human infection with pandemic (H1N1) 2009: revised guidance at http://www.who.int/csr/resources/publications/swineflu/clinical_management/en/index.html and Use of influenza rapid diagnostic tests at http://apps.who.int/tdr/svc/publications/tdr-research-publications/rdt_influenza

2 Writing committee of the WHO consultation on clinical aspects of pandemic (H1N1) 2009 influenza. ‘Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection’. The New England Journal of Medicine, 2010, 362:1708–19

3 Libster R et al. Pediatric hospitalizations due to influenza in 2010 in Argentina. The New England Journal of Medicine, 2010, 362:45–55

http://www.who.int/csr/resources/publications/swineflu/clinical_management/en/index.html


http://apps.who.int/tdr/svc/publications/tdr-research-publications/rdt_influenza

http://apps.who.int/tdr/svc/publications/tdr-research-publications/rdt_influenza


While young children had the highest frequency of influenza A(H1N1)pdm09 virus infection in Argentina, the highest mortality occurred among those 50–59 years of age. Among children, however, mortality was highest in the youngest age group (0–4 years).

Figure 2. Argentina pandemic (H1N1) 2009 mortality rates according to age and gender

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N (total deaths) = 578 Notes: The circles show the highest rates in both the paediatric and adult populations Source: Ministerio de Salud, Presidencia de la Nación, Argentina

Similarly, in 2009, in one study in Soweto1 – an urban area of Johannesburg, South Africa –highest severe acute respiratory illness (SARI) incidence rates were observed in the group 0–4 years of age, for both (H1N1) 2009 and H3N2, with higher SARI hospitalization incidence for H3N2 confirmed cases.2

Notably, in Bhutan, the overwhelming majority of severe cases occurred within educational establishments in children and young adults, whereas the general Bhutan adult population had minimal disease.

Risk factors for severe disease

In countries that reported severe disease, it was normally found among traditional influenza high-risk groups, including those with chronic underlying disease and pregnant women. In one Argentinean hospital, 66% of admitted children had comorbidities; this compares with 34% in the previously mentioned Buenos Aires study. Underlying medical condition was more common in older children than in patients under 1 year of age. The average age of children hospitalized with underlying illness was considerably higher (50 months) than the average age of those who had been previously healthy (13 months). Among adults, most countries noted the greatest risk of severe pandemic influenza disease among those with chronic comorbid conditions, particularly chronic respiratory disease. In South Africa, pregnancy (2nd or 3rd trimester) or puerperium, HIV, obesity and active TB were all associated with higher risk of death from pandemic (H1N1) 2009.

South Africa presented data suggesting that HIV infection was associated with a substantial risk for severe pandemic influenza disease, and that HIV combined with other comorbidities greatly increased the risk of severe outcomes (Table 1). The prevalence of HIV (20%)3 among deaths from pandemic (H1N1) 2009 was higher than that expected in the general population (10%).

1 Lower middle class populated urban area (Wikipedia http://en.wikipedia.org/wiki/Soweto)2 Cohen et al. Elevated incidence of hospitalisation for seasonal and pandemic influenza in HIV-infected individuals, South Africa, 2009.

Poster session presented at: Options for the Control of Influenza VII; 3–7 September 2010; Hong Kong SAR, China3 Among 93 fatal cases investigated in 2009, 40 were tested for HIV infection and 19 were positive. The figure of 20% was derived by assuming

that all untested fatalities (i.e. 19/93) were negative for HIV.

http://en.wikipedia.org/wiki/Soweto


Table 1. South Africa (H1N1) 2009 fatality comorbidities

Factor Frequency of factor/ number tested (%)

HIV infected 19/40 tested (48%)

Pregnant or puerperium

– of total cases 27/93 (29%)

– of women of childbearing age (15–49 years) 27/46 (59%)

No comorbidities 21/87 (24%)

Diabetes 12/86 (14%)

Obesity 18/87 (21%)

Cardiac disease 7/85 (8%)

Active tuberculosis 9/86 (10%)

Asthma 5/86 (6%)

HIV, human immunodeficiency virus Source: J Thomas, National Institute for Communicable Diseases, South Africa

Of the HIV-positive pandemic (H1N1) 2009 fatalities, most had dual underlying risk conditions (Table 2). Pregnant HIV-infected women comprised 58% of all HIV-infected fatalities. Of the 19 HIV-infected pandemic (H1N1) 2009 fatalities, 4 had active TB. In South Africa, there were also probable cases of vertical transmission of pandemic influenza,1 which was thought to have caused the death of two mother–child pairs, with one mother HIV-negative, the other HIV-positive.

Table 2. South Africa HIV fatality comorbidity data

Factor Number of cases

Pregnancy

– additional comorbidities

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•ActiveTBwithCOPD

•Asthma

– on HAART

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•CCFwithCOPD

•ActiveTB

– on HAART

8/19 total HIV infected (42%)

1

1

1

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1

CCF, congestive cardiac failure; COPD, chronic obstructive pulmonary disease; HAART, highly active antiretroviral treatment; HIV, human immunodeficiency virus; TB, tuberculosis Source: J Thomas, National Institute for Communicable Diseases, South Africa

1 A probable vertical transmission of pandemic (H1N1) 2009 virus has been also reported from Thailand. Dulyachai W et al. Perinatal pandemic (H1N1) 2009 infection, Thailand. Emerging Infectious Diseases, 2010, 16:343–4


In the Soweto study, HIV-infected patients showed higher incidence of SARI with pandemic (H1N1) virus infection than HIV-negative patients in all age groups. This phenomenon was also found with H3N2 virus infection, except for the age group 0–4 years. If controlled for age, influenza virus associated SARI incidence was five times higher in HIV-infected patients for both pandemic (H1N1) and H3N2 viruses, and the risk was highest in ages 25–44 years (Figure 3).

Figure 3. Severe acute respiratory illness surveillance – incidence of infection of pandemic (a) (H1N1) 2009 and (b) H3N2 by HIV status, Soweto, South Africaa

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CI, confidence interval; HIV, human immunodeficiency virus; MH, Mantel-Haenszel; RR, relative risk a Reporting period 9 February to 23 December 2009; results until end of epidemiologic week (2009) 52 Source: Cohen C et al. Elevated incidence of hospitalisation for seasonal and pandemic influenza in HIV-infected individuals, South Africa, 2009. Poster session presented at: Options for the Control of Influenza VII; 2010 Sep 3–7; Hong Kong SAR, China


3.3 Clinical care

Summary points

� Pandemic (H1N1) 2009 made obvious the limitations and capacity of critical care services in all countries.

� Participants from resource-limited settings reported that access to medical supplies were limited in their countries.

� Often, physicians were unable to determine the risk of disease progression among patients with ARI or laboratory-confirmed influenza.

� Some participants did not have access to WHO’s clinical guidance for treatment of influenza or ARI.

� Participants reported challenges with translating knowledge of infection prevention and control (IPC) into practice.

� The diagnosis of pandemic (H1N1) 2009 virus infection was often challenging in resource-limited settings.

� A number of countries reported bacterial coinfection or secondary bacterial pneumonia at presentation, particularly among patients requiring hospital admission and those with HIV.

� Participants from several countries noted that their country experienced appreciable incidence of ARI during pandemic (H1N1) 2009 that was not caused by the pandemic influenza virus.

� A delay in the initiation of medical care and antiviral therapy (e.g. with oseltamivir) was associated with increased severity of disease in several countries.

Clinical care delivery

Participants from resource-limited settings noted that health centres in their countries had insufficient resources to deliver ARI treatment during the influenza pandemic. They reported that access to supplies such as antibiotics, antivirals, oxygen, pulse oximeters and mechanical ventilators were limited in their countries. At the primary care level, a common concern was that physicians were unable to determine the risk of disease progression among patients with ARI or laboratory-confirmed influenza. Several participants noted that pneumonia severity clinical prediction scores (e.g. CURB-651) appeared to be inadequate triage tools in their settings, making decisions difficult about whom to hospitalize or refer for higher level of care.

Participants expressed a need for increased awareness of WHO guidelines and training materials at the WHO Country Offices, as well as among community clinicians. There was a preference for the development of influenza-specific guidelines over general ARI management guidelines. On the other hand, for management of severe ARI, the value of a syndromic approach to clinical guidance was raised.

Despite the limitations and capacity of critical care services in some countries, participants reported success treating the most critically ill patients. China and India managed to avoid endotracheal intubation in pandemic influenza patients with acute respiratory distress syndrome (ARDS) by using noninvasive ventilation (NIV).2 Some participants reported modest success with salvage therapies for hypoxaemic respiratory failure (notably prone positioning, recruitment manoeuvres and advanced ventilatory techniques). None of the participants had access to nitric oxide or extracorporeal membrane oxygenation (ECMO) therapies. Other participants from low-income countries reported severe shortages of medical oxygen and the essential health technologies necessary to manage critically ill patients requiring mechanical ventilation. India and Uganda both highlighted critical care service training needs; this is further discussed in Section 5.4.

1 http://www.aafp.org/fpm/2006/0400/fpm20060400p41-rt2.pdf2 Bai L et al. Clinical features of pneumonia caused by influenza A (H1N1) virus in Beijing, China. Chest 2010; e-pub 10–1036

http://www.aafp.org/fpm/2006/0400/fpm20060400p41-rt2.pdf


Infection prevention and control

According to national response plans, some countries set up dedicated triage and treatment services to deliver care to those with mild illness. Such services prevented their entry into mainstream services, and therefore reduced the risk of transmission of infection to other patients and HCWs. Thailand’s outdoor “one-stop fever clinics”, which incorporated practical hand-washing and mask-wearing promotion, and dispensing of pharmaceuticals onsite, further facilitated IPC. This practice was feasible in mild climates but was not considered practicable in cold climates, such as Mongolia.

Participants reported challenges with translating IPC knowledge into practice; India reported that HCWs were reluctant to use surgical masks for routine contact, and instead favoured N95 masks, even though these were unnecessary.

Bacterial coinfection

Bacterial coinfection at presentation or secondary bacterial pneumonia (particularly due to Streptococcus pneumoniae) was reported by a number of countries. South Africa reported surges in cases of S. pneumoniae coincident with influenza activity (Figure 4). Additionally, HIV patients were found to have a higher incidence of S. pneumoniae-influenza coinfection (58%) than infection with influenza alone (44%). Argentina reported concurrent bacterial pneumonia in 10% of paediatric admissions, with a handful of cases of empyema; 22% of hospitalized patients in one Argentinean hospital had bacterial coinfections.

Figure 4. Streptococcus pneumoniae and influenza detection rates and total number of samples by week, South Africa, 2009

0

Num

ber o

f sam

ples

Det

ectio

n ra

te (%

)

Epidemic week

20

40

60

7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

80

100

120

140

0

10

20

30

40

50

60

Respiratory and blood specimans Respiratory specimans only SP In�uenza

SP, Streptococcus pneumoniae Source: J Thomas, National Institute for Communicable Diseases, South Africa

Diagnostic test limitations

The diagnosis of pandemic (H1N1) 2009 virus infection was often challenging in resource-limited settings. In most countries, reverse transcriptase polymerase chain reaction (RT-PCR) was used; however, results were not available in a timely fashion for use in clinical decision-making (one country participant reported results taking a month to be available).


Some countries attempted to use influenza rapid diagnostic tests (IRDTs) for screening of hospitalized ARI patients. While acknowledging that IRDTs vary in their sensitivity and specificity, and are generally suboptimal for diagnosis of pandemic (H1N1) 2009, participants emphasized the contribution to health care that improved IRDTs would have in resource-limited settings. It was again emphasized that clinicians should not rely on the test result alone, but need to use clinical judgement, taking into account the epidemiological situation. In the meantime, strengthening country clinical laboratory capacities would aid diagnosis of influenza and would potentially strengthen diagnostic capability for other respiratory infections.

India reported that nearly one third of high-risk patients testing positive for pandemic (H1N1) 2009 virus infection were afebrile. Such a finding confounds the use of high body temperature in clinical specimen collection criteria for pandemic influenza, thus expanding the number of laboratory tests to be performed and the number of patients who may require empiric antiviral therapy.

Drug therapy, antiviral use and availability

WHO clinical management guidance on pandemic (H1N1) 2009 virus infection1 recommends the use of antiviral therapy for patients with severe or progressive clinical illness and those at high risk of developing severe or complicated illness.

A delay in the initiation of medical care and antiviral therapy was associated with increased severity of disease in several countries. Argentina presented data from a small cohort of patients that showed greater incidence of adverse outcomes in patients who experienced a delay in starting on antiviral therapy (Table 3). This was a challenge in some countries where limited central stores of oseltamivir were deployed only after patients tested positive for pandemic influenza virus (occurring often days after specimen collection). In some hospitals, ministry of health officials would not permit use of oseltamivir in people who had a laboratory-confirmed diagnosis but had experienced symptoms for more than 2 days, because of perceptions that antiviral therapy would not be useful after such a delay. In addition, countries reported limited supplies of paediatric and parenteral antiviral formulations, resulting in challenges to the management of children and those with critical illness.

Table 3. Clinical outcome of (H1N1) patients by time of initiation of antiviral therapy, Argentina

Clinical outcome, treatment or intervention

>48 hours

N = 48 (45%)

<48 hours

N = 57 (55%)OR (95%CI) P

Pneumonia 20 (66.6) 10 (33.3) 3.35 (1.26–9.16) 0.006

ICU admission 17 (68) 8 (32) 3.35 (1.86–10) 0.01

Length of hospitalization (median, days) 11 (IQR: 6.5–17) 7 (IQR: 4–11) – 0.006

Oxygen supplementation 42 (61.7) 26 (38.2) 8.07 (2.75–26) 0.0001

Mechanical ventilation (%) 15 (68.2) 7 (31.8) 3.28 (1.09–10.5) 0.002

Antibiotic use 34 (48.6) 36 (51.4) 1.41 (0.57–3.52) 0.4

Death 4 (66.6) 2 (33.3) 2.5 (0.33–28) 0.28

CI, confidence interval; ICU, intensive care unit; IQR, interquartile range; OR, odds ratio Source: Bologna R, Medicinia Infantil 2009: 285–291

1 Clinical management of human infection with pandemic (H1N1) 2009: revised guidance at http://www.who.int/csr/resources/publications/swineflu/clinical_management/en/index.html



Participants witnessed many instances of irrational or inappropriate pharmacotherapy for patients with pandemic (H1N1) 2009 influenza, including irrational combinations of antibacterial medications and use of high-dose steroids for the management of acute lung injury – a condition that has not been shown to improve with steroid therapy. Participants were reminded of WHO guidance regarding the use of corticosteroids, which state that these should be avoided in treating severely ill patients with pandemic (H1N1) 2009 influenza unless indicated for another reason.

Delay in seeking medical care

Several countries reported that severe disease was often associated with a delay in seeking medical care. Among the many reasons cited for late presentation to health clinics or health posts were financial obstacles, decreased availability of primary care, difficulty assessing patients at the primary care level and preferential use of traditional healers. For example, in India, preferential use of traditional healers delayed presentation of patients to health-care facilities. Ukraine also reported late initiation of therapy early in the pandemic, although this improved after a November 2009 WHO mission, which emphasized early antiviral treatment of influenza patients. Several countries identified issues with poor assessment of patients at primary care level, lack of access to pulse oximetry and supplemental oxygen, and delay in referral to tertiary care.

3.4 National systems and response

Summary points

� Most countries reported inadequacies in intensive care or high-dependency care capacities.

� Some countries used patient categorization for efficient patient management, and prioritized use of resources during the 2009 pandemic.

� Focusing efforts on primary care may have prevented progression of cases to severe disease.

� The use of decentralized “fever clinics” minimized the entry of infected patients into the main health systems, improving hospital infection control.

� National and international clinical networks were activated to exchange real-time information and best practice in diagnosing and treating patients.

� Adjustment of dose of antiviral therapy for young children was challenging; also, many countries had difficulty in procuring parenteral antivirals.

� In many countries, surge capacity was exceeded.

Patient categorization and resource rationalization

Many encouraging examples of national systems were developed in response to the pandemic, to strengthen capacity to respond to high disease burden. Thailand, with recent experience from severe acute respiratory syndrome (SARS) and avian influenza A (H5N1), responded to the pandemic by establishing one-stop fever clinics. Triaging of patients and categorization of patients into severe and mild disease, with further categorization of the mild group into vulnerable and nonvulnerable subgroups, worked well. This rationalized treatment helped to ensure that nonvulnerable patients with mild disease (who were in the majority) received symptomatic treatment and advice, but no antiviral therapy unless symptoms deteriorated or persisted for more than 48 hours. Similarly, this group of patients were not tested for pandemic (H1N1) 2009, to limit laboratory testing. India and Mongolia also described a system of antiviral prioritization, in line with WHO guidelines. Unlike the early containment response to the pandemic in developed countries, antiviral prophylaxis was not given to contacts of cases in resource-limited countries other than in India (where high-risk contacts were given prophylaxis). India and Thailand also rationalized the sampling and testing for influenza A (H1N1) 2009 virus of severely ill patients or symptomatic vulnerable groups.


Focusing care and resources at the primary care setting, and early initiation of treatment for vulnerable groups and those with severe disease, was mentioned repeatedly as a strategy that would make the best use of resources and reduce progression of disease (Figure 5). India was the only country to mention the development of intensive care units (ICUs) at district level, and mobile ICUs. India and Thailand mentioned the use of CHWs during the pandemic response. India reported that health-care personnel were initially inadequately trained to respond to the pandemic; however, training systems were developed to address this need. India and Thailand also both had clear guidelines for home-based care, and used these to good effect.

Most countries reported inadequacies in intensive care or high-dependency care capacities. Centralization of intensive care facilities allowed Mongolia and Thailand to focus their intensive care efforts and to optimize resource allocation.

Figure 5. Early and effective primary care can forestall progression to severe disease

Early supportive care may reduce complications and ITU referrals

Good/ early supportive care

Intensivetherapy

Intensivetherapy

Poor/ latesupportive care

High mortalityImproved survival

ITU, intensive treatment unit

Syndromic versus specific influenza guideline approach

Most countries used a syndromic approach in managing high case loads of ARI patients during the peaks of pandemic (H1N1) 2009. Thailand used a generic influenza syndromic approach to clinical care that expedited triage and gave appropriate advice to those with non-life threatening illness ((H1N1) 2009 or otherwise) while identifying those with severe disease or at risk of developing severe disease. Thailand did, however, restrict prescription of antiviral therapy to doctors, to ensure appropriate and rational use of antiviral stocks. Thailand’s syndromic approach extended to their community-acquired pneumonia (CAP) guidelines, adding an antiviral to their CAP treatment protocol in 2009 (third generation cephalosporin + macrolide + antiviral). Bhutan also used existing pneumonia treatment guidelines to good effect.


Other countries (India, Mongolia and Saudi Arabia) requested more influenza-specific clinical guidelines, especially in relation to admission or discharge criteria.

Advisory groups

Several countries responded to the overwhelming disease burden and public mistrust by establishing clinical advisory working groups (Mongolia) and seeking assistance from specialist visiting WHO teams (Mongolia and Ukraine).

Clinical networks

Both the national and international clinical networks were effective in disseminating key guidance for the diagnosis and treatment of patients. In Ukraine, conference calls among clinicians conveyed messages and clinical management recommendations nationwide. Clinicians who had managed severely ill pandemic (H1N1) 2009 patients in one area of Ukraine educated their colleagues who had yet to see such cases in their areas. Country participants reported appreciation for WHO guidance for health communications during the pandemic, but some acknowledged challenges in adapting generic health communications plans that were already in place before the pandemic onset.

The WHO mission to Mongolia made 10 recommendations, the most notable of which were to translate infection control knowledge into practice, and to centralize intensive care. Ukraine found that advice from the WHO mission helped to improve clinical outcomes. This included advice to reduce polypharmacy and steroid use, to initiate antiviral therapy more promptly, to use pulse oximetry and adequate oxygen therapy, and to prioritize treatment of high-risk individuals.

Both Mongolia and Ukraine described how WHO missions helped to allay public concerns about the pandemic in their countries. In Mongolia, the WHO mission visited several tertiary, district and provincial hospitals and primary care facilities, to observe care and to hold discussions with HCWs about clinical management. They provided rapid recommendations to the ministry of health about how clinical management could be improved. The mission was successful in that it returned credibility to the national health system. Similarly, in Ukraine, a WHO mission was credited for effective clinical care recommendations, improved public trust and improved clinical outcomes.

Drug procurement

Young children were at increased risk of severe disease with high attack rates, but antiviral therapy dose adjustment by weight posed a challenge.1 Thailand had difficulties accessing manufactured oseltamivir suspension due to cost (about $40/bottle). Their solution was to manufacture their own oral suspension using oseltamivir capsules, thus reducing the inconvenience and the cost per treatment. The “homemade” oseltamivir suspension created by hospital pharmacists was at a concentration that was easier to use (10mg/ml) than the commercially available formulation (12mg/ml), and was found to be stable in a refrigerator for 10 days. Multiple sources of pharmaceuticals, together with national manufacturing of antiviral drugs, can improve access to antiviral therapy and potentially reduce procurement costs. Both India and Ukraine produce their own generic oseltamivir. Difficulty with procurement of parenteral antivirals was reported by many countries.

1 A report of review of extemporaneous preparations of oseltamivir is provided by WHO as Annex 8 of the WHO Guidelines for pharmacological management of pandemic (H1N1) 2009 influenza and other influenza viruses at http://www.who.int/csr/resources/publications/swineflu/h1n1_use_antivirals_20090820/en/index.html

http://www.who.int/csr/resources/publications/swineflu/h1n1_use_antivirals_20090820/en/index.html


Surge capacity

Surge capacity was an issue of concern for many countries. Several countries described how their surge capacity was exceeded. Typically, countries addressed surge capacity issues by increasing beds in hospitals. In some Indian hospitals, patients had to share beds, with patients lying head-to-toe. In Mongolia surge capacity was exceeded, as demonstrated by Figure 6. Frustrating Mongolia’s hospital surge planning was the cold climate, which did not allow space to triage patients out of doors.

Figure 6. Bed status during surge of pandemic (H1N1) 2009 cases, Mongolia, 2010a

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1/1–7/1 8/1–15/1 16/1–23/1 25/1–1/2 2/2–9/2 10/2–17/2 18/2–25/2 26/2–3/3

Maximum capacity Surge capacity Weekly average of patients

Bed

capa

city

Date

a Weekly data from January to February 2010 Source: S Enkhtur, State Maternal and Child Health Research Center, Mongolia


3.5 Communication

Summary point

� Communicating effectively with the public is critical for a successful pandemic response.

Several countries reported increased numbers of “worried well” during the early days of the pandemic, and a later shift towards a belief that the pandemic virus was benign. During the first wave of the pandemic, Bhutan and Thailand both had high numbers of worried well seeking assessment and reassurance. In Bhutan, the media attributed paediatric deaths to vaccination against pandemic (H1N1) 2009, leading to substantial challenges in gaining public trust. Bhutan addressed these issues through advocacy in educational institutions, where most cases were arising, and dissemination of information through village heads back to remote areas. Some countries, including India and Thailand, found that CHWs were an excellent resource for dissemination of public health messages. Mongolia used television media to address fears and promote key educational messages, which helped to improve trust in the pandemic response.

Participants recommended that communications be strengthened throughout health-care systems, from government level to CHWs, to make it easier to ensure that any training materials disseminated are of the appropriate level and consistent. Rapid communication tools can also be used for effective dissemination of health education messages and improving the speed of communication with HCWs at all levels. Medical anthropologists familiar with a region can assist tremendously with community messaging; they can also develop draft materials in response to a crisis.


4 Key challenges of implementing clinical guidance

4.1 Country needs assessment

Summary points

� The survey of participants identified significant gaps in the ability of health workers to diagnose and manage ARI, with a resultant delay in initiation of treatment.

� The survey also identified areas where lack of resources has weakened the treatment of ARI.

� Two key areas for improvement were identified – training and resource mobilization.

The survey

WHO asked participants to complete a questionnaire (given in Annex 4) designed to identify:

� the area and level of health care where support was needed to strengthen the treatment of ARI;

� the nature of support needed (e.g. equipment, training and financial support).

Participating countries and territories

Participating countries and territories were Argentina, Bhutan, China, Ethiopia, Ghana, Hong Kong SAR, India, Indonesia, Kenya, Malawi, Mongolia, Nigeria, Philippines, South Africa, Thailand and Uganda.

Analysis of responses to the questionnaire

Twenty-three responses were obtained from 16 countries. Nineteen responders were actively involved in treating ARI patients (83%). Also, 19 responders (83%) worked at a national or tertiary level, while the remainder worked at a district (2; 9%) or regional level (2; 9%).

In considering the overall adequacy of health systems in their country, 20 participants (87%) felt they had a functioning health system but had insufficient resources to deliver ARI treatment in their country; 3 participants (13%) felt their country had a functioning health system with sufficient resources; none of the participants felt their country had a weak or poorly functioning health system.

Significant weaknesses in ARI treatment among 16 participant countries or territory included:

� deficiencies in the diagnosis of ARI;

� nonuniversal application of simple care measures;

� lack of provision of information to patients treated at home;

� lack of resources such as oxygen and antiviral medication;

� lack of surge capacity and other strategic health-care system planning.

All countries identified a need for HCW training, but varied on the level of health care at which training was required (i.e. home based, community based, in hospital or in critical care). Some countries requested training in all areas.


Countries varied in their resource needs, with some requiring all resources (including oxygen and essential basic medicines), and others having fewer needs.

Table 4, below, lists the requirements for strengthening ARI treatment, as identified by each of the participating countries.

Table 4. Requirements needed to strengthen treatment of acute respiratory illness, as identified by different countries

Country

Training

Basic essential

medicines

Oxygen and

supplies

Laboratory supplies

ARI kit

Comm

unity care

IMA

I and IM

CI

Critical care

IPC

Laboratory

Argentina x x x

Bhutan x x x x x x x x x

China x x x x x x x x x

Ethiopia x x x x x x x x x

Ghana x x x x x x x x x

HK SAR x x x x x

India x x

Indonesia x x xa

Kenya x x x x x x x xa x

Malawi x x x x

Mongolia x x x x x x x x

Nigeria x x x x x x x x x

Philippines x x x x x x x x x

South Africa x x xa xa x

Thailand xa xa

Uganda x x x x x x x x x

ARI, acute respiratory illness; HK SAR, Hong Kong Special Administrative Region; IMAI, integrated management of adolescent and adult illness; IMCI, integrated management of childhood illness; IPC, infection prevention and control a Not all the participants from the country checked the box.

Conclusion from the country needs assessment

Early recognition and early, good supportive care to patients with ARI can reduce the severity of disease, and the subsequent burden of severely and critically ill patients on health-care systems; it can also reduce mortality within populations. In every health-care system, treatment of ARI is strengthened by attention to these aspects of care.

The survey identified significant gaps in the ability of health workers to diagnose and manage ARI in some countries, with a resultant delay in initiation of treatment. It also identified areas where lack of resources has weakened the treatment of ARI among the countries assessed. Countries identified two key areas for improvement – training and resource mobilization.


Based on the findings of the survey, training in the following key areas of clinical management and in processes or systems (outlined in the points below) should be adapted locally:

� assessment and recognition of ARI, and progression to severe disease;

� home-based , community-based, primary and critical health care;

� surge planning;

� adaptation and application of appropriate national guidance;

� identification of resource needs;

� prioritization of resources;

� strategic planning to support training and resource programmes.

New equipment, medicines and treatments must be supported with appropriate guidance for their use, and appropriate training for HCWs who will use them.

4.2 Developing clinical guidance in resource-limited settings

Summary points

� Generic guidance based on clinical syndromes (e.g. ARI) is needed and can build on established guidance and good practice. Such guidance needs to be adapted when outbreaks occur.

� Generic guidance should have a “whole of health-care system” approach.

� The community, including CHWs, is essential in implementation of clinical guidance.

� Clinical guidance should be evaluated for compliance and effectiveness, using implementation assessment tools.

� In resource-limited settings, where it may be difficult to implement WHO guidance in its entirety, it will be necessary to set priorities.

Syndromic or generic guidance

The development of syndromic or generic guidance for clinical syndromes (e.g. ARI) is useful in resource-limited settings. Multiple diseases with overlapping symptoms (e.g. malaria and dengue) can make the diagnosis of influenza difficult, especially in areas with limited diagnostic capacity. Many health systems will already have guidance in place to treat these infections. Therefore, influenza guidance should supplement and build on any established guidance, rather than supplanting it. Syndromic or generic guidance prevents the development of multiple, disease-specific guidance that can create confusion. It also ensures that patients are treated according to clinical syndromes and allows early, empiric treatment of a differential diagnosis, deferring confirmation of a specific infection. Early definitive diagnosis may be hampered by lack of access to laboratory testing, particularly if there are no reliable, sensitive point-of-care tests. In addition, paucity of local surveillance can make the infectious cause of ARI outbreaks uncertain, and therefore make it difficult to know when to treat patients “according to the pandemic guidance”.

A whole of health-care system approach is vital for the development of clinical guidance, to ensure involvement of all levels of care, including the community. It is essential to have high-level support for the development of a generic approach to clinical guidance. The generic approach reduces the work load, by overcoming the need to produce multiple, condition-specific guidelines that overlap. Health-care systems should actively develop networks – horizontally between neighbouring facilities, and vertically through all layers to and from regional and national centres. Such networks would support and enhance surge capacity.


� Horizontal networks can provide mutual aid.

� Vertical networks can:

– provide clinical expertise “downwards” using teleconferences, telemedicine and web casts;

– allow for the real-time collection of clinical data “upwards” from front-line clinicians to centralized experts;

– allow for communication of CHW clinical surveillance (e.g. for the numbers of ILI seen weekly).

The community is essential in the implementation of clinical guidance. For example, such guidance may be the only source of information for some CHWs, who have a key role in public health education, prevention of infection, early recognition of disease, assessment of severity of disease and management of home-based care. Therefore, the guidance should be comprehensive (e.g. it should include infection control guidance). Clinical guidance should:

� support the key role of CHWs as a link between home-based and hospital-based care, and in public health education, particularly in IPC;

� support training of CHWs in the early recognition of ARI and management of mild cases;

� emphasize the importance of frequent reassessment and provision of information to the patient, and the referral of more complicated cases.

Consideration should be given within clinical guidance to the potential roles that community volunteers could play.

The clarity of clinical guidance can benefit from testing in sample populations before publication. To review compliance, evaluation of published guidance should be considered. Training materials, training assessment tools and implementation assessment tools or “benchmarks standards” should be considered when adapting clinical guidance, to measure compliance over time.

WHO’s clinical management guidance for pandemic (H1N1) 2009 was developed with evidence from settings that were mainly in developed countries and thus were not resource limited. Although the guidance considers feasibility in resource-limited settings, it needs to be tested for its efficacy in such circumstances. Health systems of different countries vary in their quality and performance; also, there may be variations in different areas within countries in terms of levels of service. It may not be feasible for countries with limited resources to implement WHO guidance in its entirety; therefore, prioritization will be needed.

To help in the development of priorities, adapted clinical guidance should include a hierarchy of the effectiveness of different aspects of treatment and care. Guidance should also provide information on alternatives where possible. Information on high-risk groups is essential.

4.3 Development of deployable kits of medical supplies and devices to manage hospitalized ARI in resource-limited settings

Summary points

� During the 2009 influenza pandemic, WHO produced draft documents with lists of recommended medical supplies and health technologies to manage hospitalized patients with ARI.

� Training and appropriate systems must be put into place before the implementation of any technology in a health-care system.

� Priority should be given to concurrent introduction of medical oxygen, pulse oximetry, and consumables such as masks and tubing. For most settings, there is no single generic (one size fits all) solution to a hospital’s oxygen needs.


During the 2009 influenza pandemic, WHO was asked by Member States to assist with the identification and procurement of necessary medical supplies and devices for the hospital management of influenza patients. WHO consulted individual experts and professional societies to develop basic lists of minimal recommended respiratory care supplies and devices to manage hospitalized patients with ARI. The ultimate goal was to design and produce kits of supplies that could be rapidly deployed for outbreaks of severe ARI to resource-limited settings.

A number of key challenges in the development of ARI kits were identified, as outlined below:

� Before a new technology is introduced, there is a critical need to implement training and systems to identify failure of the technology.

� Improving access to health technology and supplies is critical if countries are to improve capacity to care for severe ARI.

� Training and appropriate systems must be put into place before the implementation of any technology in a health-care system, and ARI kits should not be deployed without adequate guidance or training on their use.

� In the United Kingdom, early warning systems have been shown to support ward nurses in their response to deteriorating patients. Similar systems could be adopted as adjuncts to ARI kits, to ensure that there is no over-reliance on the technology to forestall deterioration of ARI patients.

� Priority should be given to concurrent introduction of medical oxygen, pulse oximetry, and consumables such as masks and tubing, as outlined below.

Medical oxygen

Oxygen is available in many forms, including concentrators, liquid oxygen, canisters and industrial formulations; each form has benefits and drawbacks. Particular needs within the hospital require different oxygen sources. For most settings, there is no one generic (i.e. one size fits all) solution to a hospital’s oxygen needs.

Pulse oximetry

WHO guidance on pulse oximetry for hypoxaemia was last published in 20031 and needs to be updated, especially considering advances in technology. Pulse oximetry is most useful in settings where oxygen is available; there is limited benefit in diagnosing hypoxia when oxygen is not available to treat it. This technique is also useful as a point-of-care diagnostic to assist with decisions about whether to hospitalize or refer to a higher level of care, regardless of oxygen availability.

Consumables

There was limited discussion at the meeting about components of consumable products (e.g. masks and tubing) that would be included in WHO ARI kits. Wherever possible, such items should be disposable, and guidance should emphasize this fact, given issues relating to infection control and patient safety.

Additional components

ARI kits could also include drugs and supplies necessary to treat comorbidities (e.g. salbutamol for asthma exacerbation and antibacterials for pneumonia). Participants also suggested the inclusion of stethoscopes and sphygmomanometers. A list of items that could be included in such a kit is given in Annex 5.

1 http://www.who.int/surgery/collaborations/Oxygen_Meeting_Report_Geneva_2003.pdf

http://www.who.int/surgery/collaborations/Oxygen_Meeting_Report_Geneva_2003.pdf


4.4 Infection prevention and control

Summary points

� Countries reported an erosion in quality and quantity of IPC training.

� Countries encouraged the idea of recommending IPC training for all HCWs, and ensuring appropriate use of personal protective equipment when resources are limited.

� Research is required on the relative efficacy of alternative methods used in resource-limited settings (e.g. scarves used as masks).

WHO has published interim guidelines for IPC of acute respiratory disease in health care.1 These guidelines have been evaluated in the clinical setting using a survey taken before and after publication of the guidelines. Overall, outcome measures have indicated some positive trends and some significant changes in relevant IPC practices in the hospitals studied. Lessons learnt from this evaluation process have been used to assist the development of a standard IPC guideline, which is currently in development.

Identified challenges include the practical handling of masks in relation to multiple usage, prioritization of use in resource-limited settings, cost and procurement, and acceptability of surgical versus N95 masks.

Countries have experienced erosion in both the quality and quantity of IPC training given to trainee medical professionals. There is a risk of potential harm to the patient and the HCW if risk of transmission is wrongly assessed. Therefore, IPC training should be strengthened for HCWs at all levels of the health system. It was suggested that IPC guidance be incorporated into clinical guidelines, together with implementation tools. There are research gaps in IPC ‘best practice’ when essential supplies (e.g. water, soap and surgical masks) are missing.

The pandemic highlighted the value of clinical networks; these need to include IPC staff, because these staff do not always have the forum to share knowledge. To further overcome these challenges, more training is needed.

1 http://www.who.int/csr/resources/publications/swineflu/WHO_CDS_EPR_2007_6/en/index.html

http://www.who.int/csr/resources/publications/swineflu/WHO_CDS_EPR_2007_6/en/index.html


5 WHO approach: training to improve patient care at all levels

WHO developed training for the provision of good health care at different levels during a pandemic. These include training packages on patient care at home, district hospital, critical care and community-based care.

5.1 Home-based care for pandemic influenza

Summary points

� Cultural perceptions of illness can have significant impacts on public health outcomes.

� WHO developed a home-based patient care package for the prevention and treatment of influenza for people living in remote, resource-limited communities.

� The findings of anthropological research have been applied in the design of the package, to overcome potential sociocultural obstacles to the acceptance and implementation of key health messages.

� The home-based care messages have been designed so that they can be adapted to different cultural settings.

� The approach has been field tested in Egypt, Lao People’s Democratic Republic, Sierra Leone and Tajikistan. An evaluation has been carried out in Sierra Leone and is underway in Ecuador.

In 2009, WHO developed a care package for the prevention and treatment of influenza for people living in remote, resource-limited communities receiving home-based care. The package was prepared to meet the need for information on influenza at the household and community level in resource-limited community settings. In developing the package, WHO used the findings of anthropological research to overcome potential sociocultural obstacles to the acceptance and implementation of key health messages.

The care package was designed to provide countries with key messages on infection prevention and care of patients with influenza. It also includes guidance on cultural adaptation of these messages for implementation; the aim being that users will adapt the key messages to create feasible, user-friendly and culturally acceptable messages for specific social and cultural contexts. The approach has been field tested in Egypt, Lao People’s Democratic Republic, Sierra Leone and Tajikistan. An evaluation has been carried out in Sierra Leone and is underway in Ecuador.

The package is targeted at ministries of health, NGOs and other health partners involved in the development and implementation of community health care projects.


5.2 Community case management during an influenza outbreak training package

Summary points

� CHWs play a key role in responding to emergencies.

� Communication channels need to be maintained from the ministry of health (MOH) through to CHWs to use their potential in early warning capabilities.

� CHWs can complement integrated management of childhood illness/integrated management of adolescent and adult illness (IMCI/IMAI) as it follows a similar flowchart algorithm style.

� CHWs need continual support beyond initial training: supplies, logistics, continued training.

The community is often the first responder in emergencies, including those caused by disease outbreaks. CHWs can be the front-line health workers during an outbreak of communicable disease or other emergencies, alleviating the strain and demand on HCWs in hospitals, clinics and other institutions when the health system is overwhelmed or disrupted. They can also improve access to measures for the prevention and treatment of epidemic diseases and other common illnesses (including severe pneumonia), and help in implementing public health programmes and ensuring community participation, due to their close links to the community. Therefore, communication channels from the MOH through to CHWs need to be maintained, to make best use of the early warning capabilities of CHWs.

Training materials are being developed for CHWs to ensure that they are ready to provide health services to communities in conjunction with home-based care and other levels of care. The package is intended to train CHWs to manage common symptoms of ILI such as cough or difficulty in breathing, fever and diarrhoea, and to continue critical services during an emergency such as a disease outbreak. This training approach complements IMCI/IMAI because it follows a similar flowchart algorithm style.

The target audience to be trained using this package is CHWs:

� with previous experience in both patient care and health education;

� having mid-level information about patient care; for example, able to provide medication such as antimalarial drugs, antibiotics or oral rehydration salts (ORS);

� who have previously participated in training courses from organizations such as WHO or the United Nations Children’s Fund (UNICEF) in topics such as IMCI.

After completion of training with this package, it is recommended that CHWs receive continual support in the form of supplies, logistics and continued training.

5.3 Hospital-based training

Summary points

� IMCI training material is useful at the country level.

� For further implementation of the training, additional resources are required for resource-limited settings.

� Access to the training could be improved by making it available in multiple languages.


In the past few years, training materials and established courses for the management of childhood illnesses have been used in over 100 countries. Integrated clinical management of the severely ill child from emergency presentation through to the first level of hospital care has reduced childhood mortality. A similar approach has been used in the development of training materials and courses for hospital-based care for adults and adolescents (IMAI).

Materials for IMCI include the paediatric “emergency triage assessment and treatment (ETAT) course” and “severe pneumonia training”, and for IMAI they include the adult “quick check course” and “management of severe respiratory distress and septic shock module”.

Training is aimed at building on established good practice, identifying systems and knowledge gaps, and ensuring a systems approach to support the emergency treatment of patients. The training is designed for HCW and ancillary or support staff who may contribute to the improved performance of the emergency team, and for hospital administrators. Additional resources are required for implementation in resource-limited settings.

The training packages are modular and can therefore be adapted to the needs of the health-care facility or be used in refresher training through specific modules relevant to an infectious disease outbreak. The newer IMAI training materials and courses are still being evaluated with field tests;1 they need to be made available in multiple languages.

5.4 Critical care training

Summary points

� Pandemic influenza critical care training has been developed for clinicians in tertiary hospitals with sufficient resources to manage septic shock and hypoxic respiratory failure.

� It is important to consider how best to recommend any therapy developed and validated in high-resource settings for tertiary hospitals in low- and middle-income countries.

WHO has developed pandemic influenza critical care training modules for tertiary hospital clinicians. Unlike the IMAI modules, which were developed for resource-limited hospitals, the critical care training materials were developed for a target audience of clinicians with sufficient resources to manage septic shock and hypoxic respiratory failure. These modules reflect international standards of care, where WHO guidance is not available. The objectives of the course are to train participants to be able to describe how to provide safe and quality critical care to patients with any of the following:

� severe pneumonia;

� acute lung injury or ARDS;

� septic shock associated with severe influenza infection or CAP.

Training is modular and conducted over 3 days. The approach is comprehensive, with clinical training encompassing patient arrival to the hospital through to their care in the ICU. The materials include a compact disc (CD) with PowerPoint modules, lecture scripts and instructions for the interactive exercises.

1 The IMAI material can be accessed through the IMAI website: www.who.int/hiv/capacity/en

http://www.who.int/hiv/capacity/en


At the meeting, there was much discussion of how best to recommend any therapy developed and validated in high-resource settings for tertiary hospitals in low- and middle-income countries. For example, the group discussed the potential for NIV to forestall mechanical ventilation for ARDS. Although NIV has not been demonstrated to be better than mechanical ventilation for the management of ARDS in developed countries, participants reported good outcomes with NIV in their hospitals during the pandemic (most notably in China and India). If mechanical ventilation is associated with poor outcomes in some developing settings, participants argued, then perhaps NIV should be considered as an alternative.

Participants made additional recommendations about content for the training course, including mechanical ventilation in general (not just for the management of ARDS) and NIV. It was strongly recommended that the modules be adaptable to fit local needs and medical cultures.

5.5 Promoting oxygen use for pneumonia treatment

Summary points

� Hypoxaemia is a common and major cause of mortality.

� Accurate detection of hypoxaemia and timely oxygen therapy improve survival of patients with severe pneumonia.

� Misperceptions about oxygen treatment (e.g. cost) are common in developing countries.

� Investment in oxygen systems to improve the diagnosis and management of hypoxaemia should be part of health system support.

� Global awareness of the need to increase the availability of oxygen systems is necessary.

WHO presented information about hypoxaemia risks, identification and therapy, and summarized organizational efforts to improve patient access to medical oxygen worldwide.

Hypoxaemia epidemiology

Pneumonia is the most common cause of hypoxaemia worldwide. It is estimated that 11–20 million children are admitted to hospitals for treatment of pneumonia each year. Of these cases, 13–38% experience hypoxaemia, and the condition contributes to 1.5 million deaths.1 Other common causes of hypoxaemia include birth asphyxia, sepsis and low birth weight in the neonatal period and for adults; and exacerbation of chronic obstructive pulmonary disease such as acute asthma exacerbation, sepsis, cardiac failure, major trauma, obstetric emergencies and anaesthesia.

Pneumonia with hypoxaemia (as determined by below normal oxyhaemoglobin saturation) is associated with increased risk of death. The pulse oximeter – an inexpensive and noninvasive device – can help clinicians to risk-stratify patients with respiratory disease, and make decisions about location, type and intensity of therapies. Incorporation of pulse oximeters in medical practice can save lives by identifying patients who would benefit from oxygen therapy; it can also save resources by avoiding unnecessary use of oxygen.

1 UNICEF, WHO. Pneumonia: the forgotten killer of children. 2006. http://whqlibdoc.who.int/publications/2006/9280640489_eng.pdf (accessed 18 Nov. 2011).

http://whqlibdoc.who.int/publications/2006/9280640489_eng.pdf


Identification of hypoxaemia

Pulse oximetry is a noninvasive and accurate diagnostic test that detects 20–30% more hypoxaemia cases than physical examination alone.1 Many different categories of pulse oximeters are available, with a wide range of functionality and cost. WHO has conducted reviews of pulse oximeters for use in resource-limited settings, and can provide guidance to Member States considering purchasing the devices for clinical use.2

Oxygen treats hypoxaemia

Among hypoxaemic patients, oxygen therapy decreases mortality due to pneumonia. Ideally, all patients at risk should have their oxygen saturation assessed early in their clinical evaluation, and should then start therapy if hypoxaemia is present. In practice, oxygen is often given for the following oxygen saturation values:3

� <90% at sea level where oxygen supplies are sufficient

� 80–90% for pre-term neonates

� <85% at altitude (>2500 m) or where oxygen supplies are limited.

The major sources of medical oxygen are compressed gas oxygen cylinders, oxygen concentrators and large storage piped oxygen systems. Oxygen delivery methods should be safe, simple, effective and inexpensive. Delivery devices include nasal prongs, head boxes and face masks. Optimal hospital oxygen systems should include all of the following:

� pulse oximetry for detecting and monitoring hypoxaemia

� reliable oxygen sources

� continuous power supply

� oxygen tubing and delivery mechanism

� clinical protocols for use of oxygen

� training and supervision

� regular maintenance and spare parts.

Challenges in delivering oxygen

A recent review4 outlined several misperceptions about oxygen therapy in developing countries; including the belief that:

� the burden of hypoxaemia is low and does not justify a public health approach

� oxygen therapy is needed by only a narrow group of patients

� there is a lack of evidence of oxygen effectiveness

� oxygen therapy is palliative

� oxygen therapy is expensive

� oxygen therapy is complicated.

1 Duke T, Subhi R, Peel D and Frey B. Pulse oximetry: technology to reduce child mortality in developing countries. Annals of Tropical Paediatrics, 2009, 29:165–175.

2 WHO, Informal consultation on clinical use of oxygen. Meeting report, 2–3 October 2003. http://www.who.int/surgery/collaborations/Oxygen_Meeting_Report_Geneva_2003.pdf (accessed 21 Nov. 2011)

3 Subhi R, Smith K, Duke T. When should oxygen be given to children at high altitude? A systematic review to define altitude-specific hypoxaemia. Archives of Disease in Childhood, 2009, 94:6–10.

4 The Union Oxygen Systems Working Group, The International Journal of Tuberculosis and Lung Disease, 2010, 14:1362–1368.




These beliefs are clearly incorrect; however, they remain as substantial challenges to the widespread use of oxygen therapy worldwide.

In addition, there are systemic issues in many hospitals that pose challenges to appropriate oxygen therapy. These include ineffective triage, lack of availability of oxygen source and supplies, and failure to use oxygen appropriately. System-wide investments are necessary for sustainable implementation of oxygen therapy. Such investments include suitable hospital administrative policies, allocation of resources, equipment and supply maintenance, patient monitoring, staff training and development of technical capacity for maintenance and repair.

Oxygen availability

Oxygen is on the WHO list of essential medicines, but is not always available in hospitals. WHO and its collaborators have conducted surveys of oxygen availability and use in low- and middle-income countries. In a survey of 132 facilities in eight low- and middle-income countries in Asia and Africa, medical oxygen was reported to be always available (21%), sometimes available (33%) and never available (11%).1 Another survey in 231 facilities from 12 sub-Saharan African countries found that 44% of facilities had access to any oxygen source, and 34% had access to supplies such as face masks and tubing to deliver oxygen to patients.2 Aware of the decreased access to oxygen therapy in many low- and middle-income country hospitals, the International Union Against Tuberculosis and Lung Disease has recently called on the international community to action to address this health-care inequity.3

WHO efforts to improve access to medical oxygen

WHO has developed several guidelines and supportive tools to assist clinicians with use of appropriate oxygen therapy. These include clinical guidelines via:

� IMCI;

� integrated management for emergency and essential surgical care;

� pandemic influenza emergency guidelines for the management of patients with severe respiratory distress and shock in district hospitals in resource-limited settings;

� IMAI (currently under development).

WHO has also produced an oxygen training video and oxygen assessment tool for clinicians. With regard to durable medical devices, WHO has developed specifications for oxygen concentrators and pulse oximeters, and has conducted field trials of different oxygen concentrator models.

1 Kushner AL, Cherian MN, Noel, L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective. Archives of Surgery, 2010, 145(2):154–9.

2 Belle J, Cohen H, Shindo N, Lim M, Velazquez-Berumen A, Ndihokubwayo JB, Cherian M. Influenza preparedness in low-resource settings: a look at oxygen delivery in 12 African countries. Journal of Infection in Developing Countries, 2010, 4(7):419–24.

3 Duke T et al. Oxygen is an essential medicine, The International Journal of Tuberculosis and Lung Disease, 2010;14(11):1362–8.


6 WHO action points

Five action points were proposed at the end of the meeting, as follows:

1. Develop a meeting report.

2. Follow up the country-specific needs with WHO Regional Offices and Country Offices and partners, including exploration of funding sources.

3. Compile lessons learnt from countries – consider publishing in a peer-reviewed journal as a meeting proceeding.

4. Ensure that key messages and comments are sent to the relevant WHO in-house partners (e.g. those dealing with IMAI, IMCI and patient safety).

5. Develop standard guidelines, and monitoring and evaluation programmes.


Annex 1 Agenda

Day 1 – Pandemic (H1N1) 2009 influenza Wednesday 20 October 2010

08:30–9:00 Registration

Session 1: Opening and Introduction – Plenary

09:00–9:05 Welcome, opening remarks and objectives

(Speaker: Sylvie Briand, Head, Global Influenza Programme)

09:05–9:15 Housekeeping arrangements: Declaration of Interest, meeting folder content and distribution of questionnaire

(Speaker: Nikki Shindo)

9:15–9:30 Influenza and burden of disease


Session 2: Overview of Pandemic (H1N1) 2009 – Plenary

9:30–9:50 Clinical, virological and epidemiological features of H1N1 pandemic influenza

(Speaker: Tim Uyeki)

9:50–10:10 Clinical management of H1N1: an all level approach to prevention, diagnosis and treatment

(Speaker: Kevin Rooney)

10:10–10:20 Other topical severe influenza treatment modalities

(Speaker: David Hui)

10:20–10:40 Questions and answers

10:40–10:50 Refreshment break


Session 3: Lessons learnt – Country experiences

10:50–11:00 Introduction to the session

(Chair: Matthew Lim)

11:00–11:50 Panel discussion

Thailand: Tawee Chotpitayasunondh

Argentina: Rosa Bologna

South Africa: Juno Thomas

United States: Lena Napolitano

11:50–12:00 Summary of lessons

(Rapporteur: Tim Uyeki)

12:00–13:00 Group picture and lunch break

Session 4: Challenges in pneumonia patient care during influenza pandemic – Country experiences

13:00–13:10 Setting the scene – Clinical management of acute respiratory diseases

(Chair: Gail Thomson)

13:10–14:00 Panel discussion

Bhutan: Santiram Dhakal

India: JC Suri

Mongolia: Enkhtur Shonkhuuz

Ukraine: Iryna Bobrova

14:00–14:10 Summary of challenges

(Rapporteur: Jamie Montoya)

Session 5: Promoting oxygen use for pneumonia treatment

14:10–14:20 Global survey on oxygen availability

(Speaker: Meena Cherian)

14:20–14:35 Optimizing oxygen in resource-limited settings

(Speaker: Shamim Qazi)

14:35–14:50 Challenges of delivering oxygen therapy in resource-limited settings

(Speaker: Janet Diaz)

14:50–15:00 Discussion

(Facilitator: Simon Mardel)

15:00–15:20 Refreshment break

Day 1 – Pandemic (H1N1) 2009 influenza continued Wednesday 20 October 2010


Session 6: Introduction to WHO approach – improving patient care at all levels

15:20–15:35 Introduction: Summary of training developed by WHO

(Speaker: Nikki Shindo, Facilitator: Rebecca Harris)

15:35–15:45 Home-based patient care

(Speaker: Anna Bowman)

15:45–15:55 Community case management

(Speaker: Marie-Helene Vannson)

15:55–16:05 IMAI district hospital training

(Speaker: Sandy Gove)

16:05–16:15 IMCI/ETAT

(Speaker: Lulu Muhe)

16:15–16:25 Tertiary hospital critical care training

(Speaker: Janet Diaz)

16:25–16:55 Promoting oxygen use (WHO video)

(Speakers: Shamim Qazi /Simon Mardel)

16:55–17:00 Closing remarks for Day 1 and information on Day 2


19:00–21:00 Networking dinner

Day 1 – Pandemic (H1N1) 2009 influenza continued Wednesday 20 October 2010


Day 2 – Improving patient care for acute respiratory illness and pandemic influenza Thursday 21 October 2010

Session 7: Introduction to training and mini-training sessions

9:00–9:20 Introduction to morning sessions


9:20–12:00 Clinical working group I – parallel session

IMAI Quick Check and Management of severe respiratory distress and septic shock; IMCI ETAT and Severe pneumonia training

(Facilitators: Hillary Cohen/Lulu Muhe; Rapporteur: Paula Lister)

9:20–12:00 Clinical working group II – parallel session

Infection prevention and control in health-care facilities

(Facilitators: Sergey Eremin and John Conly; Rapporteur: Rebecca Harris)

9:20–12:00 Clinical working group III – parallel session

Critical care mini training

(Facilitator: Janet Diaz; Rapporteur: Justin Ortiz)

9:20–12:00 Community working group – parallel session

Introduction to “Community case management during an influenza outbreak” training course for community health-care workers

(Facilitators: Heather Papowitz, Marie-Helene Vannson; Rapporteur: Kathryn Sauven)

12:00–13:30 Lunch break

Session 8: Group work

13:30–13:40 Introduction to afternoon sessions


13:40–15:00 Community working group – parallel session

Home-based care for pandemic influenza

(Facilitators: Anna Bowman, Julienne Anoko; Rapporteur: Kathryn Sauven)

13:40–15:00 Clinical working group I – parallel session

Developing clinical guidance in resource-limited settings

(Facilitator: Michelle Gayer; Rapporteur: Paula Lister)

13:40–15:00 Clinical working group II – parallel session

Developing an ARI kit for resource-limited countries

(Facilitator: Simon Mardel; Rapporteur: Justin Ortiz)


Session 9: Meeting conclusion and way forward

15:00–16:00 Feedback from working groups

(Facilitator: Sylvie Briand)

16:00–17:00 Identifying country needs – Findings from country needs assessment survey

(Facilitator: Paula Lister)

17:00–17:20 Action points and way forward


17:20–17:30 Close of meeting

(Speaker: Sylvie Briand)

Day 2 – Improving patient care for acute respiratory illness and pandemic influenza continued Thursday 21 October 2010


Annex 2 List of participants

Country and territory participants

Dr Dagnew Tadesse AbeyMinistry of HealthPO Box 1234 Addis AbabaEthiopia

Mr Humphreys MasukuChief Environmental Health OfficerMinistry of HealthPO Box 30377Capital City, Lilongwe 3Malawi

Dr Prince AgbenoheviPrincipal Medical Officer and Public Health PhysicianMilitary Hospital, AccraIndependence Ave. AccraGhana

Dr David MeyaInfectious Disease Institute, Makerere University The College of Health SciencesSchool of MedicinePO Box 7072KampalaUganda

Dr Sami Al HajjarHead, Pediatric Infectious DiseasesAssociate ProfessorKing Faisal Specialist Hospital and Research CenterDepartment of PediatricsPO Box 3354, Riyadh 11211Saudi Arabia

Dr Jaime MontoyaExecutive DirectorPhilippine Council for Health Research and DevelopmentGeneral Santos AvenueBicutan, TaguigPhilippines

Dr Afua Asabea AmoabengMedical OfficerUniversity of Ghana, Legon HospitalPO Box LG 25LegonGhana

Dr David MutongaHead, Division of Disease Surveillance and ResponseMinistry of Public Health and Sanitation Afya House, Cathedral RoadPO Box 30016, NairobiKenya

Dr William AmpofoNoguchi Memorial Institute for Medical ResearchCollege of Health SciencesUniversity of GhanaPO Box LG 581LegonGhana

Dr Lena NapolitanoProfessor of SurgeryUniversity of Michigan Health SystemRoom 1C421 University Hospital1500 East Medical Center DriveAnn Arbor, MI 48109–0033United States of America

Dr Musa Kalamullah BabashaniAminu Kano Teaching HospitalZaria Road PMB 3452KanoNigeria

Dr Julienne Ngoundoung AnokoSocioanthropologistMarcelo Usera 57 2 Izq28026 MadridSpain


Dr Frew BensonCluster ManagerCommunicable Diseases and National Focal Point for International Health RegulationsCivitas Building, Andries Street, PretoriaSouth Africa

Dr Michael OchogaCoordinatorFMOH Asokoro District Hospital2 Cassandra St. MaitamaAbujaNigeria

Dr Iryna BobrovaHead of Consultative PolyclinicMinistry of HealthClinic of L.V. Gromashevskiy Institute of Epidemiology and Infectious Diseases23, I.Mazepy Street, 01015 KyivUkraine

Dr Nyeko Margaret OkelloPrincipal Medical OfficerMulago HopistalPO Box 7051KampalaUganda

Dr Rosa BolognaHead, Hospital Nacional de Pediatria J.P. GarrahanServicio de InfectologiaCombate de los Pozos 18811245 Buenos AiresArgentina

Dr Bernard Toliva OparPrincipal Medical OfficerMinistry of HealthPO Box 7272KampalaUganda

Dr Bin CaoBeijing Chao-Yang HospitalBeijing Institute of Respiratory MedicinePO Box 100020BeijingChina

Mr Wayne RamkrishnaMinistry of HealthCivitas Building Andries StreetPretoriaSouth Africa

Dr George Chitope-MwaleDirector of Clinical ServicesMinistry of HealthPO Box 30377Capital City, Lilongwe 4Malawi

Dr Kevin RooneyLead Clinician in Critical CareRoyal Alexandra HospitalCorsebar RoadPaisley PA2 9 PNUnited Kingdom

Dr Tawee ChotpityasunondhPediatric Infectious Disease SpecialistQueen Sirikit National Health Institute of Child Health420/8 Rajvithi Road RajtheviBangkokThailand

Dr Enkhtur ShonkhuuzMaternal and Child Health Research CenterChildren’s Internal Clinical HospitalBayangol DistrictUlaanbaatar 210624Mongolia

Dr Hillary CohenAttending PhysicianMaimonides Medical Center965 48th Street, BrooklynNew YorkUnited States of America

Dr Jagdish Chander SuriHead of the DepartmentRoom No 404, Ward-32 2nd Floor, Casualty BuildingDepartment of Pulmonary Critical Care & Sleep MedicineVMMC & Safdarjang Hospital, New Delhi 110029India


Dr Santiram DhakalGeneral Duty Medical OfficerMinistry of HealthTrashigang HosptialTrashigangBhutan

Dr Milliyon Wendabeku TeklewoldeEarly Warning and Response Team ExpertMinistry of HealthN/Lafto Sub City, Kebele 03/05, House 1101Addis AbabaEthiopia

Dr Ndeye Mery Dia BadianeCentre Hospitalier National Universitaire de Fann(University of Dakar Fann Hospital)Avenue Cheikh Anta DiopDakarSenegal

Dr Juno ThomasHeadOutbreak Response UnitNational Institute for Communicable DiseasesPrivate Bag X4, Sandringham 2131South Africa

Dr Sardikin GiriputroDirectorMinistry of HealthJI Sunter Permai RayaJakarta Utara 14340Indonesia

Dr Gail ThomsonConsultant in Infectious DiseasesHealth Protection AgencyPorton Down, SalisburyWiltshire, SP4 0JGUnited Kingdom

Dr Bukar A. GremaAminu Kano Teaching HospitalZaria Road P M B 3452KanoNigeria

Dr Tim UyekiDeputy Chief, Epidemiology and Prevention BranchUS Centers for Disease Control and Prevention (CDC)Mail-Stop A–20, 1600 Clifton Road, N.E. AtlantaGeorgia 30333United States of America

Dr David HuiProfessor & Head of Division of Respiratory MedicineDirector of Stanley Ho Center for Emerging Infectious DiseasesThe Chinese University of Hong KongPrince of Wales Hospital30–32 Ngan Shing Street, Shatin, NTHong Kong SARChina

Dr Helen Van der PlasSenior Specialist & Senior LecturerUniversity of Cape TownG16/63, New Main BuildingGroote Schuur Hospital Observatory7925 Cape TownSouth Africa

Dr Henderson Munene IrimuChief Medical SpecialistHead, RIDD/HIV/TB care and treatmentKenyatta National Hospital (KNH)Nairobi 00202Kenya

Dr Catherine Weil-OlivierProfessor of PediatricsUniversity Paris VII28 rue Parmentier92200, Neuilly sur SeineFrance


Dr Simon MardelSenior Lecturer in Global HealthConsultant in Emergency MedicineHumanitarian and Conflict Response InstituteEllen Wilkinson BuildingUniversity of ManchesterManchester M13 9PLUnited Kingdom

ObserversDr Marie-Claude BottineauPaediatrics, Neonatology & Vaccine AdvisorMédecins Sans FrontièresRue de Lausanne 78Case Postale 116Geneva 21Switzerland

Dr Amy GinsburgProgram for Appropriate Technology in Health (PATH)PO Box 900922Seattle, WA 98109United States of America

Ms Anaïs ColombiniEconomic and Financial Studies ManagerAgence de Médecine Préventive Ferney-VoltaireIHF – immeuble JB Say13 Chemin du Levant01210 Ferney-VoltaireFrance

Dr Frederick HaydenWellcome TrustGibbs Building215 Euston RoadLondon NW1 2BEUnited Kingdom

Ms Cécile DuperrayAgence de Médecine Préventive Paris25–28 rue du Dr. Roux75724 PARIS cedex 15France

Dr Christoph SteffenProject CoordinatorAgence de Médecine Préventive Ferney-VoltaireIHF – immeuble JB Say13 chemin du Levant01210 Ferney-VoltaireFrance

Dr Sabine FlessenkaemperTechnical AdvisorPandemic Preparedness InitiativeGerman Technical Cooperation (GTZ)Postfach 518065726 EschbornGermany


WHO ConsultantsDr Janet DiazWorld Health Organization20, Avenue AppiaCH-1211 GenevaSwitzerland

Dr Justin OrtizSenior Fellow, Pulmonary & Critical Care MedicineUniversity of Washington Medical Center1959 N.E. Pacific, Campus Box 356522Seattle WA 98195–6522United States of America

Dr René GerretsUniversity of AmsterdamSpinhuisOudezijds Achterburgwal 1851012DK AmsterdamNetherland

Dr Kathryn Sauven3A Wray CrescentLondon N4 3LNUnited Kingdom

Dr Paula ListerPaediatric & Neonatal IntensivistGreat Ormond Street Hospital for ChildrenNHS TrustGreat Ormond StreetLondon WC1N 3JHUnited Kingdom

WHO Regional and Country OfficesDr Vincent AhoveWHO Ghana Country Office

Dr Joshua MottWHO Europe Regional Office

Dr Madhu GhimireWHO South-East Asia Regional Office

Dr Pilar Ramon-PardoWHO Region of the Americas and Pan American Health Organization

Dr Benido ImpoumaWHO Africa Regional Office

WHO SecretariatDr Sylvie BriandGlobal Influenza Programme

Dr Matthew Lim*Biorisk Reduction for Dangerous Pathogens

Ms Anna Bowman*Secretariat of the meetingGlobal Influenza Programme

Dr Lulu Muhe*Newborn and Child Health and Development

Dr Meena Nathan CherianClinical Procedures

Dr Heather Papowitz*Emergency Preparedness and Capacity Building


Dr John ConlyInnovation and Translational Research for Epidemics

Dr Charles Penn*Global Influenza Programme

Dr Sergey Eremin*Biorisk Reduction for Dangerous Pathogens

Dr Shamim Ahmad Qazi*Newborn and Child Health and Development

Dr Michelle Gayer*Disease Control in Humanitarian Emergencies

Dr Nahoko Shindo*Secretariat of the meetingGlobal Influenza Programme

Dr Sandra Gove*Capacity Building and HIV

Dr Mari-Helene Vannson*Global Influenza Programme

Ms Rebecca Harris*Global Influenza Programme

* Members of the H1N1 Supporting Patient Care team


Annex 3 Oral statement on declarations of interest This annex provides the text of the statement that was read out at the start of the meeting.

We now turn to the matter of declarations of interest. There are many participants in this meeting, attending in different capacities: experts attending in their personal capacity and representatives of governments, national agencies or institutions, international organizations and nongovernmental organizations.

In accordance with WHO policy, the Secretariat reviewed and assessed the declarations submitted by participants participating in this meeting in their personal expert capacity. They are:

� Dr Rosa Bologna

� Dr Tawee Chotpityasunondh

� Dr Hillary Cohen

� Dr Santiram Dhakal

� Dr Sardikin Giriputro

� Dr David Hui

� Dr Simon Mardel

� Dr Jaime Montoya

� Dr Lena Napolitano

� Dr Julienne Ngoundoung Anoko

� Dr Kevin Rooney

� Dr Juno Thomas

� Dr Gail Thomson

� Dr Tim Uyeki

� Dr Helen Van der Plas

� Dr Catherine Weil-Olivier

In order to be as transparent as possible, we are now going to disclose to you the interests that were declared by some of these participants and we request that each person confirm that these declarations are still correct and up to date.

Represented by Interest declared

Tawee ChotpityasunondhHas declared grants received by his research unit from US CDC, US NIH and Sanofi-pasteur to conduct influenza related research.

Sardikin GiriputroHas declared grants received by his research unit from WHO to conduct influenza related research.

Juno ThomasReceived travel grants from Sanofi-pasteur and US CDC to participate in influenza related meetings.

US CDC, United States Center for Disease Control and Prevention; US NIH, United States National Institutes of Health; WHO, World Health Organization

After review and assessment, none of these interests were determined to present a conflict with the objectives of this meeting.


Participants also include representatives of the following Member States, national agencies or institutions, international organizations and nongovernmental organizations:

� China

� Ethiopia

� Ghana

� India

� Indonesia

� Kenya

� Malawi

� Mongolia

� Nigeria

� Saudi Arabia

� Senegal

� South Africa

� Uganda

� Ukraine

� Agence de Médecine Préventive

� German Technical Cooperation

� Médecins Sans Frontières

� Program for Appropriate Technology in Health (Wellcome Trust

These representatives are not here to assess or give advice as independent experts, but rather to represent the views of their organizations. Their declared interests, if any, have therefore been assessed accordingly.

As a further measure to ensure transparency the meeting report will contain an Annex on Declarations of Interest which will reflect the subject as we have just covered it.

Unless there are any questions related to this matter I propose that we proceed with the agenda of the meeting.


Annex 4 Country questionnaire proforma

Ad-hoc clinical management needs assessment questionnaire

Version 1.4

Purpose

The purpose of the questionnaire is to quickly assess needs in clinical management and care from country participants in order to stimulate discussion and further action during the WHO meeting “Clinical management of influenza and other acute respiratory illness in resource-limited settings: learning from the influenza pandemic (H1N1) 2009”.

Interviewee

Country participants at the meeting.

Objectives

� Identify at which health-care level/area support is needed.

� Identify which kind of support (material/goods, training, financial, etc.) is needed.

Assessment process

Questionnaire will be distributed in the morning on Day 1 of the meeting.

Questionnaire to be collected after lunch Day 1.

Analysis by WHO / consultant Day 1.

Results presented on Day 2 of meeting.


Questions

1. Please categorize the overall health/clinical care system in your country by checking one box:

� Country with weak health systems

� Country with functioning health systems but insufficient resources

� Country with functioning health systems and resources

2. Please prioritize the area where you think support is mostly needed in your country (check 1 box):

� Improving access to health care

� Increase knowledge and skills of health-care staff

� Improve health worker resources to equipment and supplies (e.g. oxygen and delivery methods)

3. Please check box if this applies to your hospital, primary care clinic or community-based outreach service in your country:

Health-care workers are being trained/able and provided equipment to:

� Diagnose ARI (including rapid tests for influenza and/or X-rays, or clinically through assessment and classification of illness)

� Treat ARI patient with

– Antibiotics

– Antivirals

– Oxygen / O2

– Supportive care such as hydration and antipyretics

� Manage surge capacity with increased number of patients with respiratory illnesses during a pandemic

� Provide information on home care to patient and family

4. In order to strengthen ARI / pneumonia care (at hospitals, primary care clinics and outreach services) we need more:

� In-service training / guidelines

– IMAI Quick Check and Management of Severe Respiratory Distress and Septic Shock and IMCI ETAT and Severe Pneumonia Training

– Infection prevention and control in health-care facilities

– Critical care training

– Community Case Management training course for Community Healthcare Workers

– Laboratory training


� Equipment and supplies

– basic essential medicines

– oxygen supplies, e.g. masks, pulse oxymeter, patient delivery/interface, etc.

– laboratory supplies (diagnostic or clinical)

– ARI kit

� Strategic planning (funding, human resources, etc.)

� Preparedness planning for surge capacity of all resources in the event of a pandemic or other event that can cause the health facility to become overwhelmed or cause service disruption

� (something else, please specify)

5. Please let us know any other needs that can help to improve ARI / pneumonia care in hospitals, primary care clinics and outreach services on a routine or emergency basis.

6. Demographics

� Your country:

� In which health-care level are you mainly working (tick one)?

– National

– Regional

– District

� Are you treating ARI / pneumonia patients?

– Yes

– No


Annex 5 Calculation table for disposables and pulse oximetry for 100 severe pneumonia cases

The table below lists the requirement for disposables and pulse oximetry for 100 severe pneumonia cases, plus additional materials and cost margins to cover maternal and child health.

Signage and documents Number

Unit cost

(US$)Total cost

Essential for acute

respiratory distress

syndrome (ARDS)

adolescent and adult

SUBCOST Kit B

Essential additions

for district general

hospital (DGH) unmet

obstetric and child

health needs SUBCOST Kit C

No smoking signs caution oxygen (symbols)

20 5 100 Yes 100

Wall chart of ages, flows, devices and FiO2 (symbols)

10 5 50 Yes 50

Wall chart of safety advice and contraindications

10 5 50 Yes 50

Manual use of pulse oximetry 10 5 50 Yes 50

Manual use of O2 concentrator or cylinders

2 10 20 Yes 20

Advice manual for engineers and managers

2 10 20 Yes 20

Monitoring charts 200 0.25 50 Yes 50

Consumables Number

Unit cost

(US$)Total cost

Essential for acute


syndrome (ARDS)


SUBCOST Kit B

Essential additions



obstetric and child


Nasal cannulae Infant 10 4 40 Yes 40

Nasal cannulae Child 10 4 40 Yes 40

Nasal cannulae Adult 50 4 200 Yes 200

Oxygen mask Child 10 4 40 Yes 40

Oxygen mask Adult 20 4 80 Yes 80

Non-rebreathing mask Child 10 8 80 Yes 80


Consumables continued Number

Unit cost

(US$)Total cost

Essential for acute


syndrome (ARDS)


SUBCOST Kit B

Essential additions



obstetric and child


Non-rebreathing mask Adult 100 8 800 Yes 800

Suction catheters Neonate 10 2 20 Yes 20

Suction catheters Neonate 10 2 20 Yes 20

Suction catheters Infant 10 2 20 Yes 20

Suction catheters Infant 10 2 20 Yes 20

Suction catheters Child 10 2 20 Yes 20

Suction catheters Child 10 2 20 Yes 20

Suction catheters Adult 10 2 20 Yes 20

Suction catheters Adult 10 2 20 Yes 20

Catheters for newborn oxygen (nasopharyngeal)

10 2 20 Yes 20

Catheters for infant oxygen (nasopharyngeal)

10 2 20 Yes 20

Bubble humidifiers 10 10 100 Yes 100

Oxygen tubing 100 2 200 Yes 200

Oxygen mask with nebuliser

Child 20 4 80 Yes 80

Oxygen mask with nebuliser

Adult 20 4 80 Yes 80

Foot powered suction and maintenance kit

100 1 100 Yes 100

Straps to secure cylinders 30 5 150 Yes 150

The items above in teal may be moved from this kit

Essential for ARDS

adolescent and adult SUBCOST

Essential additions for DGH unmet

obstetric and child health

needs SUBCOSTKit B+C TOTAL

USD 2530 USD 2370 USD 160


Pulse oximetry Number

Unit cost

(US$)Total cost

Essential for acute


syndrome (ARDS)


SUBCOST Kit B

Essential additions



obstetric and child


Essential for TRIAGE ONLY in DGH SUBCOST Kit A

Pulse oximeter battery powered

5 150 750

Spare probes Adult 5 50 250

Spare probes Child 5 50 250

Spare probes Infant 5 50 250

Hand held sensor to verify oxygen source

1 200 200

1700

Feedback to

Dr Simon Mardel [email protected] Senior Lecturer in Global Health, Manchester University

mailto:[email protected]

Global Influenza Programme, World Health Organization

20 Avenue Appia, CH-1211 Geneva 27, Switzerland | Fax +41 22 791 48 78 | Email [email protected]

mailto:[email protected]

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