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Pandemic Influenza Preparedness and Response: A WHO Guidance Document. Geneva: World Health Organization; 2009.

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Pandemic Influenza Preparedness and Response: A WHO Guidance Document.

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5RECOMMENDED ACTIONS BEFORE, DURING AND AFTER A PANDEMIC

The goal of planning and coordination efforts is to provide leadership and coordination across sectors.

This section provides specific actions to be taken by national authorities and WHO. The new WHO pandemic phases and a summary of recommended actions for each phase are presented in Table 4. Recommendations are grouped by pandemic phases and the five components of preparedness and response which are the following:

TABLE 4. SUMMARY TABLE OF RECOMMENDED ACTIONS.

TABLE 4

SUMMARY TABLE OF RECOMMENDED ACTIONS.

  1. planning and coordination
  2. situation monitoring and assessment
  3. reducing the spread of disease
  4. continuity of health care provision
  5. communications.

The goal of planning and coordination efforts is to provide leadership and coordination across sectors. One important aspect is to integrate pandemic preparedness into national emergency preparedness frameworks.

The goal of situation monitoring and assessment is to collect, interpret, and disseminate information on the risk of a pandemic before it occurs and, once under way, to monitor pandemic activity and characteristics. To assess if the risk of a pandemic is increasing, it will be important to monitor the infectious agent, its capacity to cause disease in humans, and the patterns of disease spread in communities. It is important to collect data on influenza viruses, the genetic changes taking place and consequent changes in biological characteristics, and to rapidly investigate and evaluate outbreaks. Once a pandemic influenza virus begins to circulate, it will be vital to assess the effectiveness of the response measures.

Reducing the spread of disease will depend significantly upon increasing the “social distance” between people. Measures such as individual/household level measures, societal-level measures and international travel measures, and the use of antivirals, other pharmaceuticals, and vaccines will be important.

Individual/household level measures include risk communication, individual hygiene and personal protection, and home care of the ill and quarantine of contacts. Societal-level measures are applied to societies or communities rather than individuals or families. These measures require a behavioural change in the population, multiple sector involvement, mobilization of resources, strong communication, and media support.

International travel measures aim to delay the entry of pandemic disease into not-yet-affected countries and will have an impact on international traffic and trade. Countries should balance reducing the risks to public health and avoiding unnecessary interference with international traffic and trade.

The use of pharmaceutical interventions to prevent or treat influenza encompasses a range of approaches. Additionally, the successful prevention and treatment of secondary or pre-existing conditions will be a key factor in many settings for reducing the overall burden of illness and death.

During a pandemic, health systems will need to provide health-care services while attending to the influx of patients with influenza illness. Planning for surge capacity in health-care facilities will help determine the extent to which the existing health system can expand to manage the additional patient load. Health-care facilities will need to maintain adequate triage and infection control measures to protect health-care workers, patients, and visitors.

The goal of communications before and during a pandemic is to provide and exchange relevant information with the public, partners, and stakeholders to allow them to make well informed decisions and take appropriate actions to protect health and safety and response and is a fundamental part of effective risk management. Communications should be based on the five principles outlined in WHO's outbreak communications planning guide:25 planning; trust; transparency; announcing early; and listening. Given the complex risks and perceptions associated with an influenza pandemic, communication strategies that simply disseminate outbreak information and recommendations will be insufficient. The scope and complexity of the task demands frequent, transparent, and proactive communication and information exchange with the public, partners, and other stakeholders about decision making, health recommendations, and related information. In addition to the suggested actions which follow below, countries are encouraged to develop core risk communication capacities such as those described in the WHO outbreak communication planning guide. By developing a solid foundation for pandemic influenza communications, Member States would also strengthen communication response systems for any public health emergency that may arise.

Core elements of pandemic influenza communication are:

  • to maintain and build public trust in public health authorities before, during and after an influenza pandemic;
  • to support coordination and the efficient use of limited resources among local, national, regional and international public health partners;
  • to provide relevant public health information to the public; to support vulnerable populations having the information they need to make well-informed decisions;
  • to take appropriate actions to protect their health and safety; and
  • to minimize social and economic disruption.

A. PHASES 1-3

Actions taken during pandemic Phases 1-3 are aimed at strengthening pandemic influenza preparedness and response capacities at global, regional, national and sub-national levels.

PHASES 1-3PLANNING AND COORDINATION

WHO ACTIONSNATIONAL ACTIONS
  • Provide technical support to Member States in the preparation of national pandemic preparedness plans.26
  • Provide leadership in coordinating the prioritized activities for epidemic and pandemic preparedness.27
  • Advocate new partnerships with organizations of the United Nations system, bilateral development agencies, nongovernmental organizations, and the private sector.28
  • Facilitate and encourage the operability of national pandemic plans through preparedness activities, including exercises.
  • Establish and activate a cross-governmental, multi-agency national pandemic preparedness committee that meets regularly.
  • Assess capacities and identify priorities for pandemic preparedness planning and response at national and sub-national levels.
  • Advise sub-national governments on best practices in pandemic planning; monitor and evaluate the operability and quality of their plans.
  • Develop, exercise, and periodically revise national and sub-national influenza pandemic preparedness and response plans in close collaboration with human and animal health sectors and other relevant public and private partners with reference to current WHO guidance.
  • Establish, as needed, full legal authority and legislation for all proposed interventions.
  • Anticipate and address the resources required to implement proposed interventions at national and sub-national levels including working with humanitarian, community-based, and non-governmental organizations.
  • Develop an ethical framework to govern pandemic policy development and implementation.29
  • Integrate pandemic preparedness and response plans into existing national emergency preparedness and response programmes.
  • Provide to public and private sectors the key assumptions, guidance and relevant information to facilitate their pandemic business continuity planning.
  • Identify and address trans-border issues, including interoperability of plans across borders.
  • Consider providing resources and technical assistance to resource-poor countries with foci of influenza activity.
  • Participate, when possible, in regional and international pandemic preparedness planning initiatives and exercises.
26

Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003

27

Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003.

28

Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003.

29

Ethical considerations in developing a public health response to pandemic influenza (WHO/CDS/EPR/GIP/2007.2), World Health Organization, 2007.

PHASES 1-3SITUATION MONITORING AND ASSESSMENT

WHO ACTIONSNATIONAL ACTIONS
  • Collect, synthesize, and disseminate information on the global human influenza situation in collaboration with partners.
  • Provide guidance and tools for detection, investigation, rapid risk assessment, reporting and ongoing evaluation of clusters of influenza-like illness.
  • Provide support to countries with human cases of influenza caused by viruses with pandemic potential to assist in establishing facts and fully characterizing cases.
  • Develop tools to estimate seasonal and pandemic influenza disease burden.30
  • Establish joint initiatives for closer collaboration with national and international partners, including FAO and OIE in the early detection, reporting and investigation of influenza outbreaks of pandemic potential, and in coordinating research on the human-animal interface.31
  • Establish global case definitions for reporting by countries of human cases of influenza caused by viruses with pandemic potential.
  • Strengthen the Global Influenza Surveillance Network and other laboratories to increase capacity for influenza surveillance.32
  • Provide diagnostic reagents to national influenza reference centres for identification of the new strain.
  • Coordinate collection and testing of strains for possible vaccine production and antiviral susceptibility.
  • Develop national surveillance systems to collect up-to-date clinical, virological, and epidemiological information on trends in human infection with seasonal influenza viruses, which will also help to estimate additional needs during a pandemic.
  • Detect animal31,33 and human infections with animal influenza viruses, identify potential animal sources of human infection, assess the risk of transmission to humans, and communicate this information to WHO and relevant partners.
  • Detect and investigate unusual clusters of influenza-like respiratory illness or deaths and assess for human-to-human transmission.
  • Characterize and share both animal and human influenza virus isolates and associated information with relevant international agencies, such as WHO, FAO and OIE, to develop diagnostic reagents, candidate vaccine viruses, and monitor antiviral resistance.
  • Strengthen the national laboratories in influenza diagnostic capabilities.
30

Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003.

31

Resolution WHA 58.5 Strengthening pandemic influenza preparedness and response. In: Fifty-eighth World Health Assembly, Geneva 16-25 May, 2005 (WHA58/2005/REC/1).

32

Resolution WHA 58.5 Strengthening pandemic influenza preparedness and response. In: Fifty-eighth World Health Assembly, Geneva 16-25 May, 2005. (WHA58/2005/REC/1).

33

Using current FAO and OIE guidelines: Avian influenza and the virus that causes it(ftp://ftp​.fao.org/docrep​/fao/010/a0632e/a0632e02.pdf accessed 8 October 2008), Terrestrial Animal Health Code 2008, Article 10.4.29, Surveillance strategies (http://www​.oie.int/eng​/normes/mcode/en_index.htm accessed 8 October 2008).

PHASES 1-3REDUCING THE SPREAD OF DISEASE

WHO ACTIONSNATIONAL ACTIONS
  • Promote agreements for international technical assistance and resource mobilization to resource-poor countries with foci of influenza activity.
Preventing human influenza infection from animals
  • Activate joint mechanisms for actions with other organizations (e.g. FAO, OIE) to control disease in animals and to implement prevention measures.
  • Encourage dissemination of information on spread in animals and interspecies transfers.
Individual/societal level measures
  • Provide guidance on measures to reduce the spread of influenza disease (social distancing and use of pharmaceuticals) and develop tools to estimate their public health value.34
  • Periodically reassess and modify recommended interventions in consultation with appropriate partners, including those not in the health-care sector, regarding acceptability, effectiveness and feasibility.
Antivirals
  • Develop principles to guide national recommendations for use of antivirals (for prophylaxis and treatment).
  • Manage WHO strategic global stockpile of antivirals and develop standard operating procedures for rapid deployment.
  • Increase global antiviral availability by using UN/WHO mechanisms such as the prequalification programme35 and the Essential Medicines List.36
Vaccines
  • Develop principles to guide national recommendations for use of seasonal and pandemic vaccines.
  • Support strain characterization and development and distribution of vaccine prototype strains for possible vaccine production.
  • Review and update WHO recommendations for pandemic vaccine use.
  • Provide technical support, capacity building and technology transfer for influenza vaccines and diagnostics to developing countries.37
  • Formulate mechanisms and guidelines to promote fair and equitable distribution of pandemic influenza vaccines.38
  • Manage an international stockpile of H5N1 vaccine for use in countries in need.
  • Identify, regularly brief, and train key personnel to be mobilized as part of a multisectoral expert response team for animal or human influenza outbreaks of pandemic potential.
Preventing human influenza infection from animals39
  • Reduce infection risk in those involved in responding to animal outbreaks (education and training regarding the potential risk of transmission; correct use of personal protective equipment; making antivirals available if indicated by the risk assessment).
  • Recommend measures to reduce human contact with potentially infected animals.
  • Control potentially contaminated environments such as wet markets and ponds with free grazing ducks.
  • In conjunction with animal health authorities, establish national guidance on food safety, safe agricultural practices, and public health issues related to influenza infection among animals.<br
Individual / household level measures
  • Promote hand and respiratory hygiene.40
  • Develop infection control guidance for household settings.41
  • Develop plans to provide necessary support for ill persons isolated at home and their household contacts.
Societal level measures
  • Establish protocols to suspend classes, especially in the event of a severe pandemic or if there is disproportionate or severe
  • Promote development of mitigation strategies for public and private sector workplaces (such as adjusting working patterns and practices).
  • Promote reduction of unnecessary travel and overcrowding of mass transport systems.
  • Develop a framework to facilitate decision-making for cancellation/restriction of mass gatherings at the time of the pandemic.42
International travel measures
  • Develop capacities for emergency public health actions at designated points of entry in accordance with IHR (2005) Annex 1 B.2.
Antivirals and other pharmaceuticals
  • Estimate and prioritize antiviral requirements for treatment and prophylaxis during a pandemic.
  • Develop mechanisms and procedures to select, procure, stockpile, distribute, and deliver antivirals based on national goals and resources.
  • Plan for the increased need for antibiotics, antipyretics, hydration, oxygen, and ventilation support within the context of national clinical management strategies.
  • Assess effectiveness and safety of antiviral therapy using standardized protocols when possible.
Vaccines
  • For countries not using seasonal influenza vaccine, document the disease burden and economic impact of seasonal influenza and develop a national vaccine, policy if indicated.43
  • For countries using seasonal influenza vaccine, work to increase seasonal influenza vaccine coverage levels of all high risk people. 44
  • Establish goals and priorities for the use of pandemic influenza vaccines.45
  • Develop a deployment plan to deliver pandemic influenza vaccines to national distribution points within seven days from when the vaccine is available to the national government.46
  • Consider the feasibility of using pneumococcal vaccines as part of the routine immunization program in accordance with WHO guidelines.47
34

Resolution WHA 58.5 Strengthening pandemic influenza preparedness and response. In: Fifty-eighth World Health Assembly, Geneva 16-25 May, 2005 (WHA58/2005/REC/1).

35

Prequalification. World Health Organization (http://www​.who.int/hiv​/amds/prequalification/en/ accessed 11 February, 2009).

36

Essential medicines list and WHO model formulary. World Health Organization (http://www​.who.int/selection_medicines​/list/en/ accessed 11 February 2009).

37

Resolution WHA 58.5 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-eighth World Health Assembly, Geneva 16-25 May, 2005 (WHA58/2005/REC/1).

38

Resolution WHA 60.28 Pandemic influenza preparedness: sharing of influenza viruses and access to vaccines and other benefits In: Sixtieth World Health Assembly, Geneva 14-23 May, 2007 (WHASS1/2006-WHA60/2007/REC/1)

39

Avian influenza: guidelines, recommendations, descriptions. World Health Organiztion (http://www​.who.int/csr​/disease/avian_influenza​/guidelinestopics/en/index.html accessed 11 February, 2009).

40

Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO Interim Guidelines. Geneva, World Health Organization 2007. (WHO/CDS/EPR/2007.6).

41

Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO Interim Guidelines. Geneva, World Health Organization 2007. (WHO/CDS/EPR/2007.6).

42

Communicable disease alert and response for mass gatherings. Geneva, World Health Organization, 2008 (WHO/HSE/EPR/2008.8).

43

Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003.

44

Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003.

45

Currently there are no WHO recommendations either supporting or opposing the stockpiling of new influenza vaccines for use either prior to a pandemic or during its early stages.

46

Guidelines for the deployment of a pandemic influenza vaccine (to be published in 2009). World Health Organization 2009.

47

Pneumococcal conjugate vaccine for childhood immunization - WHO position paper. Weekly Epidemiological Record, No. 12, 2007, 82:93-104.

PHASES 1-3CONTINIUITY OF HEALTH CARE PROVISION

WHO ACTIONSNATIONAL ACTIONS
  • Provide guidance for appropriate infection control, laboratory biosafety and clinical management in health care and social settings, and in care facilities.
  • Establish regional clinical advisory network for timely distribution and collection of important clinical information, identify knowledge gaps, and develop standardized clinical protocols.
  • Assist national health care delivery authorities in identifying priority needs and response strategies, and assessing preparedness (e.g. through developing checklists, model pandemic preparedness plans, training and table-top exercises).
  • Develop guidance for remote, resource-poor communities on home-based care of patients during an influenza pandemic.
  • Identify priorities and response strategies for public and private health care systems for triage, surge capacity, and human and material resource management.
  • Review and update continuity of health care provision strategies at national and sub national levels.
  • Develop strategies, plans, and training to enable all health care workers, including community level workers, to respond during animal outbreaks and a pandemic.
  • Develop case-finding, treatment, and management protocols, and algorithms.
  • Develop national infection control guidance.48
  • Estimate and plan for procurement and distribution of personal protective equipment for protection of workers.49
  • Develop and implement routine laboratory biosafety and safe specimen-handling and shipping policies and procedures.50
  • Explore ways to provide drugs and medical care free of charge (or cover by insurance) to encourage prompt reporting and treatment of human cases caused by an animal influenza virus or virus with pandemic potential.
  • Develop the capacity for the rapid deployment of diagnostic tests once available.
  • Assess health system capacity to detect and contain outbreaks of human influenza disease in hospital settings.
48

Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO Interim Guidelines. Geneva, World Health Organization 2007. (WHO/CDS/EPR/2007.6).

49

Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO Interim Guidelines. Geneva, World Health Organization 2007. (WHO/CDS/EPR/2007.6).

50

Collecting, preserving and shipping specimens for the diagnosis of avian influenza A(H5N1) virus infection, Guide for field operations. World Health Organization 2006 (WHO/CDS/EPR/ARO/2006.1).

PHASES 1-3COMMUNICATIONS

WHO ACTIONSNATIONAL ACTIONS
  • Update national and international authorities, other partners/stakeholders, and the public, with current information on risks, sources, personal safety, and ways of mitigation of influenza pandemics.
  • Maintain formal communication channels among Member States, other international organizations, key stakeholders, and technical/professional associations to facilitate information sharing and coordination.
  • Increase the familiarity of news media with WHO activities, operations, and decision-making related to influenza and other epidemic-prone diseases.
  • Develop feedback mechanisms to identify emerging public concerns, address rumours, and correct misinformation.
  • Support Member States' communication efforts during a pandemic by providing material and technical guidance.51
  • Establish an emergency communications committee with all necessary standard operating procedures to ensure a streamlined, expedited dissemination of communications products.
  • Update leadership and other relevant sectors regarding global and national pandemic influenza risk status.
  • Build effective relations with key journalists and other communications channels to familiarize them with influenza and pandemic related issues.
  • Develop effective dialogue and listening mechanisms with the general public.
  • Develop effective communication strategies and messages to inform, educate, and communicate with individuals and families so they are better able to take appropriate actions before, during, and after a pandemic.
  • Initiate public health education campaigns in coordination with other relevant authorities on individual-level infection control measures.
  • Increase public awareness of measures that may be available to reduce the spread of pandemic influenza.
  • Create messages and feedback mechanisms targeted towards hard-to-reach, disadvantaged, or minority groups.
  • Test communications procedures through exercises.
  • Update communications strategies as feedback from the general public and stakeholder organizations is collected and analysed.
51

World Health Organization Outbreak Communication Planning Guide. World Health Organization 2008. ISBN 978 92 4 159744 9.

B. PHASE 4

An important goal during WHO pandemic Phase 4 is to contain the new virus within a limited area or delay its spread to gain time to implement interventions, including the use of vaccines.

PHASE 4PLANNING AND COORDINATION

WHO ACTIONSNATIONAL ACTIONS
  • Consult with the affected country and external experts on the decision to launch a rapid containment operation.
  • Provide ongoing advice to the affected country on the management of the containment operation.
  • Coordinate the international response to rapid containment, including the deployment of international field teams as requested and necessary.
  • Mobilize and dispatch resources (e.g. antivirals from the global stockpile, other materials and logistics) for rapid containment.
  • Mobilize financial resources for a rapid containment operation as needed and encourage the provision of international assistance to resource-poor countries.
  • Initiate planning and actions to switch from seasonal to pandemic vaccine production.
FOR AFFECTED COUNTRIES
  • Direct and coordinate rapid pandemic containment activities in collaboration with WHO to limit the spread of human infection.
  • Activate national emergency and crisis committee(s) and national command, control, and coordination mechanisms for emergency operations.
  • Activate procedures to access and mobilize additional human and material resources.
  • Deploy operational and logistics response teams.
  • Identify needs for international assistance.
  • Designate special status as needed (such as declaring a state of emergency) to facilitate rapid containment interventions.
  • Provide regular updates on the evolving situation to WHO as required under IHR (2005) and to other partners to facilitate coordination of response.
  • Encourage cross-border collaboration with surrounding countries through information sharing and coordination of responses.
  • Activate pandemic contingency plans for all sectors as deemed critical for the provision of essential services.
  • Finalize preparations for a possible pandemic including procurement plans for essential pharmaceuticals.
COUNTRIES NOT YET AFFECTED
  • Finalize preparations for a possible pandemic by activating internal organizational arrangements within the command-and-control mechanism and mobilizing staffing surge capacity in critical services.
  • Respond, if possible, to requests for international assistance organized by WHO.

PHASE 4SITUATION MONITORING AND ASSESSMENT

WHO ACTIONSNATIONAL ACTIONS
  • Provide support to national authorities and facilitate assessment of the extent of human-to human transmission with on-site evaluation.
  • Refine case definition for global reporting.
  • Recommend strategies for national authorities to enhance vsurveillance in affected areas.
  • Coordinate collection and testing of specimens and/or strains to develop diagnostic reagents, prototype vaccines, and for antiviral susceptibility.
  • Coordinate with national authorities to monitor containment measures.
FOR AFFECTED COUNTRIES
  • Enhance surveillance to rapidly detect, investigate, and report new cases and clusters.52
  • Collect specimens for testing and virological characterization using protocols and procedures developed in collaboration with WHO.
  • Share specimens and/or strains to develop diagnostic reagents and prototype vaccines and for antiviral susceptibility.
  • Collect more detailed epidemiological and clinical data as time and resources permit.53
  • To the extent possible, monitor compliance, safety, and effectiveness of mitigation measures and share findings with the international community and WHO.
FOR COUNTRIES NOT YET AFFECTED
  • Enhance virological and epidemiological surveillance to detect possible cases and clusters, especially if sharing extensive travel or trade links with affected areas.
  • Report any suspect cases to national authorities and WHO.
52

WHO Interim planning guidance for rapid containment of the initial emergence of pandemic influenza. (http://www​.who.int/csr​/disease/avian_influenza​/guidelines/draftprotocol​/en/index.html accessed 10 February 2009).

53

WHO Interim planning guidance for rapid containment of the initial emergence of pandemic influenza. (http://www​.who.int/csr​/disease/avian_influenza​/guidelines/draftprotocol​/en/index.html accessed 10 February 2009) and WHO Global Surveillance for Pandemic Influenza, World Health Organization 2009 (to be published 2009 http://www​.who.int/csr​/disease/influenza/).

PHASE 4REDUCING THE SPREAD OF DIEASE

WHO ACTIONSNATIONAL ACTIONS
  • Assist the affected country in undertaking rapid pandemic containment operations coordinating international collaboration.
  • Dispatch antivirals from the WHO stockpile to the affected country, to be used in rapid containment operations.
  • Develop up-to-date vaccine prototype strains.
  • Collaborate with national authorities in determining possible use of a potentially effective vaccine during rapid containment operations.
  • Update guidance for optimal use of pandemic vaccines when available.
ALL COUNTRIES
International travel measures
  • Consider implementing exit screening as part of the early global response (i.e. first few affected countries).54
  • Provide advice to travellers.
AFFECTED COUNTRIES
  • Undertake rapid pandemic containment55 operations in collaboration with WHO and the international community.
  • Request and distribute antivirals from the WHO global stockpile and/or other national or regional stockpiles for treatment of cases and prophylaxis of all persons in the designated areas.
  • Consider deploying pandemic vaccine if available.
  • Implement individual/household and societal-level disease control measures.56
  • Limit all non-essential movement of persons in and out of the designated containment area(s) and implement screening procedures at transit points.
COUNTRIES NOT YET AFFECTED
  • Reassess the capacity to implement mitigation measures to reduce the spread of pandemic influenza.
  • Distribute stockpiles of pharmaceuticals and other materials according to national plans.
  • Use appropriate individual/household disease control measures for suspect cases and their contacts.57
54

If exit screening is implemented, it should be considered as a time-limited intervention and the isolation and treatment of cases and quarantine of contacts resulting from screening must be carried out in accordance with IHR (2005).

55

WHO Interim Protocol: Rapid operations to contain the initial emergence of pandemic influenza. (http://www​.who.int/csr​/disease/avian_influenza​/guidelines/draftprotocol/en/in dex.html accessed 8 October 2008).

56

Recommended interventions to reduce the spread of disease during pandemic influenza. World Health Organization 2009 (to be published 2009 http://www​.who.int/csr​/disease/influenza/).

57

Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO Interim Guidelines. Geneva, World Health Organization 2007. (WHO/CDS/EPR/2007.6).

PHASE 4CONTINUITY OF HEALTH CARE PROVISION

WHO ACTIONSNATIONAL ACTIONS
  • Coordinate and support collection of clinical data to reassess clinical management guidelines and protocols.
  • Update guidelines for clinical management and infection control as necessary.
  • Update guidelines for biosafety in laboratories as necessary.
AFFECTED COUNTRIES
  • Provide guidance to health-care workers to consider influenza infection in patients with respiratory illness and to test and report suspect cases.
  • Implement appropriate infection control measures and issue personal protective equipment as needed.
  • Activate contingency plans for responding to the possible overload of health and laboratory facilities to deal with potential staff shortages.
  • Activate alternative strategies for case isolation and management as needed.
COUNTRIES NOT YET AFFECTED
  • Activate pandemic contingency planning arrangements for the health sector.
  • Advise health-care workers to consider the possibility of influenza infection in patients with respiratory illness, especially those with travel or other contact with persons in the affected country(ies).

PHASE 4COMMUNICATIONS

WHO ACTIONSNATIONAL ACTIONS
  • Update national and international authorities, other partners, stakeholders, and the public on global epidemiological situation, disease characteristics, and the containment efforts.
  • Issue updates on the effectiveness of various public health measures as data become available.
  • Coordinate and disseminate relevant public health messages using various channels (WHO website, published material, press conferences, and the media).
  • Work with partners to promote consistent messages.
FOR ALL COUNTRIES
  • Activate communications mechanisms to ensure widest possible dissemination of information.
  • Update and disseminate “Talking Points” so that all spokespeople convey consistent information.
  • Conduct frequent and pre-announced public briefings through popular media outlets such as the web, television, radio, and press conferences to counter panic and dispel rumours.
FOR AFFECTED COUNTRIES
  • Regularly communicate via established mechanisms:
    • what is known and not known about the virus, the state of the outbreak, use and effectiveness of measures and likely next steps;
    • the importance of limiting all non-essential movement of persons in and out of the designated containment area(s) and relevant screening procedures at transit points;
    • the importance of compliance with recommended measures to stop further spread of the disease;
    • how to obtain medicines, essential services and supplies in the containment area(s).
  • Gather feedback from the general public, vulnerable populations and at-risk groups on attitudes towards the recommended measures and barriers affecting their willingness or ability to comply. Incorporate the findings into communication and health education campaigns targeted to the specific groups.
  • Collaborate with surrounding countries on information sharing.

C. PHASES 5-6

During Phases 5-6 (pandemic), actions shift from preparedness to response at a global level. The goal of recommended actions during these phases is to reduce the impact of the pandemic on society.

PHASES 5-6PLANNING AND COORDINATION

WHO ACTIONSNATIONAL ACTIONS
  • Encourage international assistance to resource-poor countries and/or seriously affected countries.
  • Interact with international organizations and agencies inside and outside of the health sector to coordinate interventions.
AFFECTED COUNTRIES
  • Maintain trust across all agencies and organizations and with the public through a commitment to transparency and credible actions.
  • Designate special status as needed, such as declaring a state of emergency.
  • Provide leadership and coordination to multisectoral resources to mitigate the societal and economic impact of a pandemic.
  • Work for rational, ethical, and transparent access to resources.
  • Assess if external assistance is required to meet humanitarian
COUNTRIES NOT YET AFFECTED
  • Finalize preparations for an imminent pandemic, including activation of crisis committee(s) and national command and control systems.
  • Update, if necessary, national guidance and recommendations taking into account information from affected countries.

PHASES 5-6SITUATION MONITORING AND ASSESSMENT

WHO ACTIONSNATIONAL ACTIONS
  • Coordinate the assessment and monitoring of the disease characteristics and severity, and provide guidance accordingly.
  • Monitor the global spread of disease and possible changes in epidemiological, clinical, and virological aspects of infection, including antiviral drug resistance.
  • Support affected Member States as much as possible in confirming the spread of human infections and assessing the epidemiological situation.
AFFECTED COUNTRIES
Pandemic disease surveillance58
  • Undertake a comprehensive assessment of the earliest cases of pandemic influenza.
  • Document the evolving pandemic including geographical spread, trends, and impact.
  • Document any changes in epidemiological and clinical features of the pandemic virus.
  • Maintain adequate virological surveillance to detect antigenic and genetic changes, as well as changes in antiviral susceptibility and pathogenicity.
  • Modify national case definitions and update clinical and laboratory algorithms for diagnosis, as necessary.
Monitoring and assessment of the impact of the pandemic
  • Monitor essential health-related resources such as: medical supplies; antivirals, vaccines and other pharmaceuticals; health care worker availability, hospital occupancy/availability; use of alternative health facilities, laboratory material stocks; and mortuary capacity.
  • Monitor and assess national impact using criteria such as workplace and school absenteeism, regions affected, groups most affected, and essential worker availability.
  • Assess the uptake and impact of implemented mitigation measures.
  • Forecast economic impact of the pandemic, if possible.
58

Global surveillance during an influenza pandemic, World Health Organization 2009 (http://www​.who.int/csr​/disease/swineflu/guidance​/surveillance​/WHO_case_definition​_swine_flu_2009_04_29.pdf).

PHASES 5-6REDUCING THE SPREAD OF DISEASE

WHO ACTIONSNATIONAL ACTIONS
  • Consider and issue any new or revised Temporary Recommendations under IHR (2005), including advice from Emergency Committee as appropriate.59
  • Facilitate assessment of interventions and update recommendations if needed.
  • Facilitate assessment of antiviral susceptibility, effectiveness, and safety.
  • Make recommendations for pandemic vaccine composition60 and switch to pandemic vaccine production if not previously done.
  • Facilitate development of national guidelines for national authorities to conduct targeted vaccination campaigns if pandemic vaccine is available.
ALL COUNTRIES
International travel measures
  • Take into account WHO guidance and information when issuing international travel advisories and health alerts.
AFFECTED COUNTRIES
Individual/household level measures
  • Advise people with acute respiratory illness to stay at home and to minimize their contact with household members and others.
  • Advise household contacts to minimize their level of interaction outside the home and to isolate themselves at the first sign of any symptoms of influenza.
  • Provide infection control guidance for household caregivers61 taking into account the WHO guidance.62
Societal level measures
  • Implement social distancing measures as indicated in national plans, such as class suspensions and adjusting working patterns.
  • Encourage reduction in travel and crowding of the mass transport system.63
  • Assess and determine if cancellation, restriction, or modification of mass gatherings is indicated.64
International travel measures
  • Consider implementing exit screening as part of the early global response (i.e. first few affected countries).65
  • Provide advice to travellers.
Pharmaceutical measures
  • Distribute antivirals, and other medical supplies in accordance with national plans.
  • Implement vaccine procurement plans.
  • Plan for vaccine distribution and accelerate preparations for mass vaccination campaigns.
  • Modify/adapt antiviral and vaccine strategies based on monitoring and surveillance information.
  • Implement medical prophylaxis campaigns for antivirals and/or vaccines according to priority status and availability in accordance with national plans.
  • Monitor safety and efficacy of pharmaceutical interventions to the extent possible and monitor supply.
COUNTRIES NOT YET AFFECTED
  • 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.66
59

Assuming a PHEIC has been determined to be occurring as defined by IHR (2005)

60

Especially if non-pandemic strains are still circulating.

61

If medical masks are available and the training on their correct use is feasible, they may be considered for symptomatic persons and susceptible caregivers in household settings when close contact can not be avoided.

62

Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO Interim Guidelines. Geneva, World Health Organization 2007. (WHO/CDS/EPR/2007.6)

63

Symptomatic people should self-isolate and avoid using public transport. There is, however, insufficient evidence to date to either support or oppose the closure or restriction of mass transport systems as a measure to reduce disease transmission in the community.

64

If a country decides to cancel, restrict or modify all or certain mass gatherings, this decision should be based on the nature of the gathering and on local disease levels, and should only be implemented once the disease is present in the community.

65

If exit screening is implemented, it should be considered as a time-limited intervention and the isolation and treatment of cases and quarantine of contacts resulting from screening must be carried out in accordance with IHR (2005).

66

If entry screening is implemented, it should be considered as a time-limited intervention and the isolation and treatment of cases and quarantine of contacts resulting from screening must be carried out in accordance with IHR (2005).

WHO recognizes individual country considerations will affect national decisions, but, in general, does not encourage:

  • pandemic-related international border closures for people and/or cargo;
  • general disinfection of the environment during a pandemic;
  • the use of masks in the community by well persons;
  • the restriction of travel within national borders during a pandemic, with the exception of a globally led rapid response and containment operation, or in rare instances where clear geographical and other barriers exist;

PHASES 5-6CONTINUITY OF HEALTH CARE PROVISION

WHO ACTIONSNATIONAL ACTIONS
  • Coordinate response with other international organizations.
  • Provide guidance to national authorities in assisting clinicians in recognition, diagnosis, and reporting of cases and other critical issues as needed.
  • Implement pandemic contingency plans for full mobilization of health systems, facilities, and workers at national and sub-national levels.
  • Implement and adjust the triage system as necessary.
  • Enhance infection control practices in healthcare and laboratory settings and distribute personal protective equipment in accordance with national plans.
  • Provide medical and non-medical support for patients and their contacts in households and alternative facilities if needed.
  • Provide social and psychological support for health-care workers, patients, and communities.
  • Implement corpse management procedures as necessary.
FOR COUNTRIES NOT YET AFFECTED
  • Prepare to switch to pandemic working arrangements.

PHASES 5-6COMMUNICATIONS

WHO ACTIONSNATIONAL ACTIONS
  • Update national authorities, other partners and stakeholders, and the public on global situation, trends, epidemiological characteristics, and recommended measures.
  • Continue to work with partners to promote consistent messages.
  • Regularly update the public on what is known and unknown about the pandemic disease, including transmission patterns, clinical severity, treatment, and 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, and resources for self-care of medical conditions.

D. THE POST-PEAK PERIOD

The overall goal of actions during the post-peak period is to address the health and social impact of the pandemic, as well as to prepare for possible future pandemic waves.

THE POST-PEAK PERIODPLANNING AND COORDINATION

WHO ACTIONSNATIONAL ACTIONS
  • Identify lessons learned for immediate application, as well as for future needs.
  • Determine the need for additional resources and capacities during possible future pandemic waves.
  • Begin rebuilding of essential services.
  • Address the psychological impacts of the pandemic, especially on the health workforce.
  • Consider offering assistance to countries with ongoing pandemic activity.
  • Review the status of and replenish national, local, and household stockpiles and supplies.
  • Review and revise national plans.

THE POST-PEAK PERIODSITUATION MONITORING AND ASSESSMENT

WHO ACTIONSNATIONAL ACTIONS
  • Assist countries in estimating national impact.
  • Continue global situation monitoring for global spread and national trends.
  • Review lessons learned and make adjustments in surveillance guidelines and tools for countries.
  • Assess and monitor the type and pathogenicity of circulating influenza viruses.
  • Activate the surveillance activities required to detect subsequent pandemic waves.
  • Evaluate the resources needed to monitor subsequent waves.

THE POST-PEAK PERIODREDUCING THE SPREAD OF DISEASE

WHO ACTIONSNATIONAL ACTIONS
  • Facilitate evaluation of interventions.
  • Evaluate the effectiveness of the measures used and update guidelines, protocols, and algorithms accordingly.
  • Continue with vaccination programmes in accordance with national plans, priorities, and vaccine availability.

THE POST-PEAK PERIODCONTINUITY OF HEALTH CARE PROVISION

WHO ACTIONSNATIONAL ACTIONS
  • Update guidance to national authorities to optimize use of scarce facilities.
  • Ensure that health-care personnel have the opportunity for rest and recuperation.
  • Restock medications and supplies and service and renew essential equipment.
  • Review and, if necessary, revise pandemic preparedness and response plans in anticipation of possible future pandemic wave(s).
  • Revise case definitions, treatment protocols, and algorithms as required.

THE POST-PEAK PERIODCOMMUNICATIONS

WHO ACTIONSNATIONAL ACTIONS
  • Regularly update the public and other stakeholders on any changes to the status of the pandemic.
  • Urge Member States, partners, and other stakeholders to make adjustments to their communications plans and systems.
  • Regularly update the public and other stakeholders on any changes to the status of the pandemic.
  • Communicate to the public the ongoing need for vigilance and 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 and symptoms, or case definitions, protocols and algorithms.

E. THE POST-PANDEMIC PERIOD

The goal of activities during the post-pandemic period is to address the long-term health and social impact of the pandemic, as well as to restore normal health and social functions.

THE POST-PANDEMIC PERIODPLANNING AND COORDINATION

WHO ACTIONSNATIONAL ACTIONS
  • Facilitate implementation of lessons learned for immediate application, as well as for future needs.
  • Evaluate the effectiveness of specific responses and interventions and share findings with the international community.
  • Review the lessons learned and apply to national emergency preparedness and response programmes.
  • Revise national and sub-national pandemic preparedness and response plans.

THE POST-PANDEMIC PERIODSITUATION MONITORING AND ASSESSMENT

WHO ACTIONSNATIONAL ACTIONS
  • Report on the global situation.
  • Review lessons learned and make adjustments in surveillance guidelines and tools for countries.
  • Collect and analyse available data to evaluate the epidemiological, clinical, and virological characteristics of the pandemic.
  • Review and revise situation monitoring and assessment tools for the next pandemic and other public health emergencies.
  • Resume seasonal influenza surveillance incorporating the pandemic virus subtype as part of routine surveillance.

THE POST-PANDEMIC PERIODREDUCING THE SPREAD OF DISEASE

WHO ACTIONSNATIONAL ACTIONS
  • Provide technical support to Member States, as requested, to evaluate the impact of the pandemic on the country and the effectiveness and impact of interventions utilized during the pandemic.
  • Conduct a thorough evaluation of individual, household, and societal interventions implemented.
  • Conduct a thorough evaluation of all the pharmaceutical interventions used, including:
    • antiviral effectiveness, safety, and resistance; and
    • vaccine coverage, effectiveness, and safety.
  • Review and update relevant guidelines as necessary.
  • Continue with vaccination programmes in accordance with national plans, priorities, and vaccine availability.

THE POST-PANDEMIC PERIODCONTINUITY OF HEALTH CARE PROVISION

WHO ACTIONSNATIONAL ACTIONS
  • Utilize existing clinical networks to review clinical information and effectiveness and safety of clinical interventions; advise on knowledge gaps and research needs.
  • Review and revise relevant guidance.
  • Collect and analyse available data to evaluate the response of the health system to the pandemic.
  • Review the lessons learned and share experiences with the international community.
  • Amend plans and procedures to include lessons learned.
  • As needed, provide psychosocial services to facilitate individual and community-level recovery.

THE POST-PANDEMIC PERIODCOMMUNICATIONS

WHO ACTIONSNATIONAL ACTIONS
  • Evaluate communications response during previous phases; review lessons learned.
  • Ensure that lessons learned are incorporated into revised and improved communications plans of all stakeholders, ready for use in the next pandemic/major public health event.
  • Continue to work with Member States to increase the effectiveness of national communications activities.
  • Publicly acknowledge the contributions of all communities and sectors.
  • Communicate to the public and other stakeholders the lessons learned about the effectiveness of responses during the pandemic and how the gaps that were discovered will be addressed.
  • Encourage stakeholders across all sectors, public and private, to revise their pandemic and emergency plans based upon the lessons learned.
  • Extend communications planning and activities to cover other epidemic diseases and use the principles of risk communications to build the capacity to dialogue with the public on all health matters of potential concern to them.
  • Improve and adjust communications plan in readiness for the next major public health event.

Footnotes

25

World Health Organization Outbreak Communication Planning Guide. World Health Organization 2008. ISBN 978 92 4 159744 9.

Copyright © 2009, World Health Organization.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications - whether for sale or for noncommercial distribution - should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e- mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK143063

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