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