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Reducing Excess Mortality from Common Illnesses During an Influenza Pandemic: WHO Guidelines for Emergency Health Interventions in Community Settings. Geneva: World Health Organization; 2008.

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Reducing Excess Mortality from Common Illnesses During an Influenza Pandemic: WHO Guidelines for Emergency Health Interventions in Community Settings.

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Introduction

Background

An influenza pandemic occurs when an influenza virus that is efficiently transmissible from person to person appears, against which the human population has limited or no immunity. On average, three pandemics per century have been documented since the 16th century, occurring at intervals of 10–50 years. In the 20th century, pandemics occurred in 1918, 1957 and 1968. The 1918 pandemic is estimated to have killed more than 40 million people in less than one year. The 1957 and 1968 pandemics were milder, but many countries nevertheless experienced strains on health-care resources. Given the unpredictable behaviour of influenza viruses, neither the timing nor the severity of the next pandemic can be predicted with certainty. If an influenza pandemic virus were to appear again similar to the one that struck in 1918, even taking into account the advances in medicine since then, unparalleled tolls of illness and death could be expected (1). An influenza pandemic has the potential to cause considerable morbidity and mortality for a concentrated period of around 8–12 weeks, with recurrence in waves over 2–3 years.

Communicable diseases are currently the leading cause of preventable deaths worldwide, disproportionately affecting resource-poor settings. Pandemic influenza would add to already unacceptable levels of morbidity and mortality from diarrhoea, malaria, pneumonia, malnutrition, HIV/AIDS and tuberculosis, in addition to causing high maternal and neonatal death rates. A few key conditions cause 90% of deaths from communicable diseases: pneumonia (3.9 million deaths per year); diarrhoeal diseases (1.8 million); and malaria (1.2 million). Malnutrition is a significant contributing factor to this mortality (2).

During a pandemic, these illnesses are likely to increase in resource-poor settings where chronically strained health systems would face even higher patient volumes, severe resource constraints, and absenteeism of critical staff. Therefore strategies are needed to address pandemic influenza within the broad range of health needs, while acknowledging current resource limitations.

Rationale

In resource-poor settings, pandemic preparedness efforts are best directed broadly, to address not just one potential new illness but also those illnesses currently posing an urgent threat to communities. For example, an integrated preparedness approach might address pneumonia caused by pandemic influenza within a broader framework that focuses on reducing mortality from the common illnesses (e.g. pneumonia, diarrhoea, malaria) responsible for the highest disease burdens.

In addition, existing public health programmes, such as those for tuberculosis, HIV/AIDS, chronic diseases, nutrition and reproductive health, should prioritize activities in order to maintain a minimum level of service during a pandemic, and should assist patients by preparing for a temporary interruption of care and/or supplies.

Many aspects of health-care delivery during an influenza pandemic may be undertaken at the household and community levels. Services provided in the community may help fill gaps during an emergency, reduce demand for health facility-based services, limit exposure to influenza within the facilities and, perhaps most importantly, are more likely to be accessible to patients. A strengthened community-based approach to common illnesses can benefit communities before, during and after an influenza pandemic.

A supportive policy environment is required to ensure that these measures are in place well before the onset of an influenza pandemic.

Objectives

  • To provide strategies for prevention and treatment, at the community and household levels, of the most likely contributors to mortality from common illnesses during an influenza pandemic.
  • To provide recommendations to support a minimum level of continuity for priority public health programmes during a pandemic.

These guidelines are designed primarily for community-level programming in resource-poor settings (urban, semi-urban and rural) but are applicable to a wide range of situations.

Intended audience and purpose

These guidelines are intended for use by government officials including staff of the ministry of health, nongovernmental organizations (NGOs) involved in health-related activities, Red Cross/Red Crescent societies and United Nations (UN) agencies. Recommendations may be used as a strategic framework for public health authorities, the private sector, health system planners and policy-makers, to approach the care of common illnesses in communities prior to and during a pandemic. They may also be used as the basis for designing public information campaigns promoting behaviours to reduce the risk of transmission in the home as well as encouraging home-based management of certain common conditions.

These guidelines do not contain specific guidance for treatment of patients, but do describe the technical prioritization and decision-making rationale needed to facilitate the training and preparation of community health responders. In areas where community health providers do not exist, these guidelines may be used to advocate for their establishment.

Key principles

  • These guidelines comprise recommendations for the management of selected conditions during an influenza pandemic estimated to last 8–12 weeks, occurring in recurrent waves over 2–3 years.
  • The prioritization of key interventions is based on the potential for mortality reduction in the community. These interventions together should constitute a minimum recommended package to be adapted to local needs and requirements.
  • The recommended actions should build on existing national community health programmes, services and resources that will shift to an “emergency mode” for the duration of the pandemic.
  • Treatment guidelines for acute illnesses are adapted from existing WHO guidelines; existing national guidelines should be respected.
  • During a severe influenza pandemic, the over-treatment of illnesses by health providers (resulting from the presumptive treatment of disease syndromes) for a finite time period (8–12 weeks) is anticipated and accepted.
  • Practices such as completion of childhood immunizations and antenatal care interventions (tetanus toxoid vaccination, intermittent preventive treatment for malaria, iron and folic acid supplementation, etc.) should be strengthened prior to an influenza pandemic. Implementation of these interventions will be challenging during an influenza pandemic owing to the scarcity of resources (e.g. health staff, medical supplies) and a temporary reduction of these activities is likely.
  • Existing human resources at the community level may be trained to function as community health responders (CHRs), in order to address emergency community health needs during an influenza pandemic.
  • These guidelines should be considered as an integral part of the community component of the national pandemic preparedness plan (PPP), and should be integrated into other pandemic preparedness activities.
  • Implementation of a community-based strategy, identification of community health responders and training should begin immediately at all levels, to complement national PPPs.
  • Triggers for full implementation in response to a pandemic should be determined by local factors (e.g. available resources and local epidemiology of the influenza virus) in accordance with national policy.
Copyright © World Health Organization 2008.

All rights reserved.

Bookshelf ID: NBK179283
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