mitigating the impact of pandemic (h1n1): options for public health measures dr li ailan...
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Mitigating the Impact of Pandemic (H1N1):Options for Public Health Measures
Dr Li AilanCommunicable Disease Surveillance & Response (CSR)
WHO Western Pacific Regional Office (WPRO)
3rd Meeting of the National Influenza Centres in the Western Pacific and South-East Asia Regions
18-20 August 2009, Beijing, China
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Outline Outline Outline Outline
What options are available for public health interventions?
What have countries prepared for non-pharmaceutical interventions?
What actual public health measures have been applied or being implemented in response to pandemic (H1N1) 2009?
Conclusion
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Primary Strategies for Combating Influenza Primary Strategies for Combating Influenza
Pharmaceutical interventions – Use of matched vaccines – Use of effective antiviral drugs
Non-pharmaceutical interventionsNon-pharmaceutical interventions – Individual and household level public health
measures– Societal level public health measures,
including social distancing
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Goals of Public Health Intervention Goals of Public Health Intervention
Delay outbreak peak
Delay spread and shift an epidemic curve to the right side
– to reduce peak burden on health care facilities (e.g. hospitals)
– to “buy time” for other measures (e.g. vaccination)
Reduce morbidity and mortality through reducing the total number of cases
1
2
3
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Public Health Measures Available (theoretically) at national and community level
Public Health Measures Available (theoretically) at national and community level
1. Individual/household measuresPersonal protective measuresIsolation & quarantineInfection prevention and control in the home settingUse of masks in the community setting
2. Societal measures, including social distancingSuspension of classes and child care programmesAdjusting or changing work patternsRestriction of public or mass gatheringsDomestic travel advisories and restrictions
1. Individual/household measuresPersonal protective measuresIsolation & quarantineInfection prevention and control in the home settingUse of masks in the community setting
2. Societal measures, including social distancingSuspension of classes and child care programmesAdjusting or changing work patternsRestriction of public or mass gatheringsDomestic travel advisories and restrictions
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Public Health Measures Available (theoretically) at the international border
Public Health Measures Available (theoretically) at the international border
1. International travel and screeningHealth advice and alerts to travellersHealth declaration formTemperature screening On-board identification of suspected travellersInternational travel advisory, restriction, border closure?
2. Management of symptomatic & exposed travellersSymptomatic travellers (isolation & treatment…)Exposed travellers (quarantine…)
1. International travel and screeningHealth advice and alerts to travellersHealth declaration formTemperature screening On-board identification of suspected travellersInternational travel advisory, restriction, border closure?
2. Management of symptomatic & exposed travellersSymptomatic travellers (isolation & treatment…)Exposed travellers (quarantine…)
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Key considerations Key considerations
Decision on public health measures based on risk assessment, especially severity and potential impact
Public health measures should be evidence-based whenever possible
Countries should balance the benefits against the costs and potential consequences
Need to be tailored to suit country or local context
Planning, coordination and communication is essential
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Comparative risk of outbreaksComparative risk of outbreaks
Transmissibility
Low High
Severity of Disease
(Morbidity &
Mortality)
High
Low
H5N1SARS
1918 Pandemic
Pandemic (H1N1) 2009?
Seasonal Flu
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Possible strategies based on risk categoryPossible strategies based on risk category
Transmissibility
Low High
Severity of Disease
(Morbidity &
Mortality)
High
Low
Aiming at preventing disease importation and containing the virus
Aiming at rapid containment at the early stage, and mitigating the impacts, if containment not possible
Routine public health measures without additional aggressive interventions
Aiming at reducing transmission and mitigating impact with focus on vulnerable population
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Matching cost and consequences of interventions with risk level
Matching cost and consequences of interventions with risk level
Cost s and Consequences
Lev
el o
f R
isk
More acceptable interventions
Less acceptable interventions
SARS
Seasonal Influenza
New H1N1???
1918 pandemic virus or worse
E.g. Isolation & quarantine
E.g. Travel restriction
E.g. Respiratory hygiene
F B
A
C
E
D
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Options for interventions: Decision MatrixOptions for interventions: Decision Matrix
OptionsBenefitsLimitations & consequence
Decision(Yes/No/wait)
School School closureclosure
Reducing transmission among children and decreasing spread to the community
Acceptable in some countries
high social & economic cost
Second consequences
Need alternative childcare programme
Absenteeism of working parents, including HCWs
Educational continuity?
Comments & guidance:
-Must weight the benefits of reducing transmission against economic and social costs
-Decision based on local situation and context (“case-by-case”)…
-…
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Pandemic Preparedness Assessment 2009 Pandemic Preparedness Assessment 2009
Annual assessment of pandemic preparedness was conducted in May-June, using the WHO WPRO and CDC Joint Assessment Tool
A supplementary questionnaire on public health measures was added in this “readiness” survey
– Is this public health measure included in your national response plan?– Did you apply or consider applying this measure?– What is your trigger to start and stop the public health intervention?
The questionnaire was distributed to collect data from 17 countries and areas, 15 (88%) responded to the survey
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Pandemic Preparedness Assessment 2009: Public Health Measures at International Borders
Pandemic Preparedness Assessment 2009: Public Health Measures at International Borders
A. Public Health Measures at International Borders
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Health alerts fortravellers
Health declarationform/card
Passenger screening Management ofsymptomatic travellers
Management ofexposed travellers
Public Health Measure
% o
f 'Y
es' R
esp
on
se f
rom
Mem
ber
Sta
tes
In Pandemic Response Plan?
Conduct / consider activities?
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Pandemic Preparedness Assessment 2009: Individual/Household level Measures
Pandemic Preparedness Assessment 2009: Individual/Household level Measures
B. Individual / Household Level Public Health Measures
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hand and respiratoryhygiene
Isolation of ill people Quarantine of contacts Infection prevention &control for home
caregivers
Use of masks incommunity settings
Public Health Measure
% o
f 'Y
es' R
esp
on
se f
rom
Mem
ber
Sta
tes
In Pandemic Response Plan?
Conduct / consider activities?
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Pandemic Preparedness Assessment 2009: Societal level Measures
Pandemic Preparedness Assessment 2009: Societal level Measures
C. Societal Level Public Health Measures
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Closure of school and child-care facilities
Restriction/cancellation ofpublic or mass gatherings
Adjusting or changing w orkpatterns
Domestic travel advisories,restrictions, other measures
Public Health Measure
% o
f 'Y
es
' R
es
po
ns
e f
rom
Me
mb
er
Sta
tes
In Pandemic Response Plan?
Conduct / consider activities?
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Responding to Pandemic (H1N1) 2009Responding to Pandemic (H1N1) 2009
Based on risk assessment, most countries with community transmission have shifted from “containment” efforts to “mitigation” strategies
Robust risk assessment help ensure appropriate public health measures are planned and implemented.
Public health interventions have been dynamic in the region with most countries and areas implemented
– relatively “aggressive” border measures including passengers’ screening– personal hygiene behaviour interventions – school closures at the early stage of outbreaks
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Example: School closure Example: School closure
At the early stage of Pandemic (H1N1) 2009, the large proportion of school children and young adults affected
School closure measure has been most frequently used as compared with other social level measures
Many countries used school closure measures in the Asia Pacific Region, including Australia, China, Japan, Malaysia, New Zealand, the Philippines, Singapore and Thailand…
Types of measures varied: from “real” school closure or class dismissal, from “proactive” or “reactive” approach…
Length of closureLength of closure varied: mostly 7-14 days
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
School closure in Japan (May 2009) School closure in Japan (May 2009)
0
5
10
15
20
25
30
35
府内その他
A中学高等学校 :87例:44例
17 May : Schools closed, in Osaka17 May: Schools closed Hyogo Prefecture
Source: NIID, Japan
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
School closure in Japan (June 2009) School closure in Japan (June 2009)
Schools and Kindergartens in Fukuoka were closed on 7 June
Source: NIID, Japan
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Conclusion Conclusion
The potential benefits of public health measures should be carefully balanced against their potentially significant social and economic costs
Decision based on assessed situation and local context. No standard, single combination of measures will fit all countries – – “one size will not fit all”“one size will not fit all”
Available information indicated some public health measures have helped slow down the spread of the virus
Need for continuing planning, monitoring and evidence
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Interim guidance available Interim guidance available
Mitigating the impact of pandemic (H1N1) 2009: Options for public health measures
Responding to pandemic (H1N1) 2009: Options for interventions at international points of entry
http://www.wpro.who.int/health_topics/h1n1/tech/tech_guidance.htm
Communicable Disease Surveillance and Response (CSR)WHO Western Pacific Regional Office (WPRO)
Acknowledgement Acknowledgement
Dr Takeshi Kasai, Regional Advisor, CSR/WPRO
Dr Nobuhiko Okabe, NIID, Japan
Ms Qiu Yi Khut, CSR/WPRO
Ms Katie Harrigan, CSR/WPRO