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PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE. Atika BERRY, MD, MpH Communicable Diseases Dpt, MOH 02 May 2009. Introduction.

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pandemic influenza preparedness and response


Atika BERRY, MD, MpH

Communicable Diseases Dpt, MOH

02 May 2009


The development of an Influenza pandemic can be considered as the result of the transformation of an animal influenza virus into a human influenza virus. At the genetic level, pandemic influenza viruses may arise through:

  • Genetic reassortment: genes mix between animal and human influenza viruses
  • Genetic mutation: genes change in an animal influenza virus
circulating influenza strains and pandemics in the 20 th century
Circulating Influenza Strains and Pandemics in The 20thCentury

1968: “Hong Kong Flu”

1918: “Spanish Flu”

1957: “Asian Flu”

20-40 million deaths

1-4 million deaths

1-4 milliondeaths




1920 1940 1960 1980 2000

characteristics of the three pandemics of the 20 th century
Characteristics of The Three Pandemics of The 20th Century (*)

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


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

What can be happening now?


Influenza Virus

Swine Flu Virus

Pig to pig transmission &pig to human transmission

Human to human transmission

(& Human to pig transmission?)



Viral Reassortment

Reassortment in humans

Reassortment in pigs

Pandemic Influenza Virus

cumulative number of confirmed swine origin flu cases in the world
Cumulative Number of Confirmed Swine-Origin Flu Cases in The World

As of 06:00 GMT, 1 May 2009, 11 countries have officially reported 331 cases of influenza A(H1N1) infection. (Ref:

who classification of pandemic phases
WHO classification of pandemic phases

Pandemic alert period

-Phase 3. Human infections with a new subtype, but no or very limited human-to-human spread.

Phase 3a:cases outside Lebanon

Phase 3b: cases including Lebanon

-Phase 4. Small cluster(s) with limited human-to-human transmission but spread is highly localized.

Phase 4a: cases outside Lebanon

Phase 4b: cases including Lebanon

-Phase 5: Larger cluster(s) of human-to-human transmission

Phase 5a: cases outside Lebanon

Phase 5b: cases including Lebanon

Pandemic period

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

roles and responsibilities in preparedness and response
Roles and Responsibilities in Preparedness and Response

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

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

B- Coordination under IHR (2005)

5 6 pandemic phases
5-6 Pandemic Phases
  • Phase 5:human to human spread of the virus into at least two countries in one WHO region. It is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.
  • During Phase 5-6, actions shift from preparednessto response.The goal of recommended actions is to reduce the impact of the pandemic on society
national actions during phases 5 6 planning and coordination
National Actions During Phases 5-6:Planning and Coordination
  • Activation of the Government Leadership (Multisectorial resources coordination) in order to:

- Finalize preparations for an imminent pandemic (activation of crisis committees, and national command and control systems

- Update national guidance and recommendations (according to WHO recommendations and taking into account information from affected countries)

  • Transparency
  • Continuous collaboration with WHO
national actions during phases 5 6 situation monitoring and assessment 1
National Actions During Phases 5-6:Situation Monitoring and Assessment(1)

Pandemic Disease Surveillance:

  • Enhance surveillance, increase preparedness:

- Elaborate a national case definition,

- Designate a RRT at the Mohafaza level,

- Detailed epidemiological investigation of the case

- Undertake a comprehensive assessment of the earliest

cases of pandemic influenza,

- Contact tracing for the two weeks prior to onset of


- Follow-up contacts for fever and cough for one week,

- Active case search to find any additional cases…)

  • Document the evolving pandemic (geographical spread, trends and impact)
  • Document any changes in epidemiological & clinical features of the pandemic virus
  • Provide the appropriate laboratory kit (RHUH)
  • Take appropriate laboratory specimens and share the specimen with WHO reference laboratories
  • Report probable, suspected and confirmed cases to the WHO.
national actions during phases 5 6 situation monitoring and assessment 2
National Actions During Phases 5-6:Situation Monitoring and Assessment(2)

Monitoring and Assessment of the Impact of the Pandemic:

  • Monitor essential health related ressources (medical supplies; antivirals, vaccines and other pharmaceuticals, health care worker availability, hospital occupancy/availability; use of alternative health facilities, lab materials stocks; and mortuary capacity)
  • Monitor and assess national impact (workplace and school absenteeism, regions affected)
  • Assess the uptake & impact of implemented mitigated measures
  • Forecast economic impact of the pandemic, if possible

Big droplets

fall on people

surfaces bed clothes

Courtesy of CDC

national actions during phases 5 6 reducing the spread of the disease 1
National Actions During Phases 5-6:Reducing the Spread of the Disease (1)

Phase 5a:

  • Be prepared to implement planned interventions to reduce the spread of pandemic disease
  • Update recommendations on the use of planned interventions based on experience and information from affected countries
  • Implement distribution and deployment plans for pharmaceuticals, and other resources as required
  • Consider implementing entry screening at international borders
national actions during phases 5 6 reducing the spread of the disease 2
National Actions During Phases 5-6:Reducing the Spread of the Disease (2)

Phase 5b:

A- Individual/household level measures:

  • Advice people with ARI to stay at home & minimize their contact with household members & others
  • Advice household contacts to minimize their level of interaction outside home & to isolate themselves at the first sign of any symptoms of influenza
  • Provide infection control guidance for household caregivers according to WHO guidance

B- Social level Measures:

  • Implement social distancing measures
  • Encourage reduction of travel and crowding of the mass transport system
  • Assess and determine if cancelation, restriction, or modification of mass gathering is indicated
national actions during phases 5 6 reducing the spread of the disease 3
National Actions During Phases 5-6:Reducing the Spread of the Disease (3)

Phase 5b (contd)

C- International travel measures:

  • Consider implementing exit screening as part of the early global response
  • Provide advice to travelers

D- Pharmaceuticals measures:

  • Distribute antivirals, and other medical supplies in accordance with national plans
  • Implement vaccine procurement plans
  • Plan for vaccine distribution &accelerate preparation for mass vaccination campaigns
  • Modify/adapt antiviral & vaccine strategies based on monitoring & surveillance information
  • Implement medical prophylaxis campaigns for antivirals &/or vaccines according to priority status & availability in accordance with national plans
  • Monitor safety and efficacy of pharmaceutical interventions to the extent possible & monitor supply
national actions during phases 5 6 continuity of health care provision 1
National Actions During Phases 5-6:Continuity of Health Care Provision (1)

Phase 5a:

  • Prepare to switch to pandemic working arrangements
  • Ministry of public health and health care institutions should plan ahead for the surge activities in this period
  • Implement pandemic vaccine procurement plans.
  • Prioritization of antiviral use based on availability and effectiveness.
national actions during phases 5 6 continuity of health care provision 2
National Actions During Phases 5-6:Continuity of Health Care Provision (2)

Phase 5b:

  • Implement pandemic contingency plans for full mobilization of health systems, facilities, & workers at national & sub-national levels
  • Implement & adjust the triage system as necessary
  • Enhance infection control practices in healthcare & laboratory settings & distribute PPE in accordance with national plan
  • Provide medical & non-medical support for patients & their contacts in households & alternative facilities if needed
  • Provide social & psychological support for health care workers, patients & communities
  • Implement corpse management procedures as necessary

Containment measures at this point are not effective.


Droplet precautions: Surgical Masks

Source: Rosie Sokas, MD MOH UIL at Chicago

national actions during phases 5 6 communications
National Actions During Phases 5-6:Communications
  • Regularly update the public on what is known & unknown about the pandemic disease, including transmission patterns, clinical severity, treatment & prophylaxis options
  • Provide regular communications to address societal concerns, such as the disruption to travel, border closures, schools, or the economy or society in general
  • Regularly update the public on sources of emergency medical care, resources for dealing with urgent non-pandemic health care needs, & resources for self-care of medical conditions
  • Provision of written information to all related sectors
  • Communicate transparently and with a consistent message with the public and local health care providers.
  • Consider declaring state of emergencies in the affected areas. 
antivirals oseltamivir
Antivirals- Oseltamivir

Treatment is 75 mg twice a day for 5 days.

Prophylaxis is 75 mg once a day for 7 days after last exposure.


High risk exposure (household contacts)

Moderate risk (unprotected very close exposure to sick animals; HCW with unprotected exposure to patients)

Low risk exposure: no need for prophylaxis unless activation of exceptional measures.

the post peak period 1
The Post-Peak Period (1)

A- Planning & coordination

  • Determine the need for additional resources &capacities during possible future pandemic waves
  • Begin rebuilding essential services
  • Address psychological impacts of the pandemic, especially on the health workforce
  • Consider offering assistance to countries with ongoing pandemic activity
  • Review the status & replenish national, local and household stockpiles & supplies
  • Review & revise national plans

B- Situation monitoring & assessment

  • Activate the surveillance activities required to detect subsequent pandemic waves
  • Evaluate the resources needed to monitor the subsequent waves
the post peak period 2
The Post-Peak Period (2)

C- Reducing the spread of the disease:

  • Evaluate the effectiveness of the measures used & update guidelines, protocols, & algorithms accordingly
  • Continue with vaccination programmes in accordance with national plans, priorities, and vaccine availability

D- Continuity of health care provision

  • Ensure that health care personnel have the opportunity for rest & recuperation
  • Restock medications & supplies & service & renew essential equipment
  • Review and, if necessary, revise pandemic preparedness & response plans in anticipation of possible future pandemic waves
  • Revise case definitions, treatment protocols, & algorithms as required
the post peak period 3
The Post-Peak Period (3)

E- Communications:

  • Regularly update the public & other stakeholders on any changes to the status of the pandemic
  • Communicate to the public on the ongoing need for vigilance & disease-prevention efforts to prevent any upswing in disease levels
  • Continue to update the health sector on new information or other changes that affect disease status, signs & symptoms, or case definitions, protocols & algorithms