Non-pharmaceutical Interventions to Contain a Pandemic In this lecture we will be discussing non-pharmaceutical interventions to contain an avian influenza pandemic.

Learning Objectives Describe individual and community level non-pharmaceutical interventions Understand how and when to use non-pharmaceutical interventions Describe the factors involved in deciding to use non-pharmaceutical interventions The learning objectives for this lecture are to describe the various non-pharmaceutical interventions that are available, to understand how and when to use non-pharmaceutical interventions might be useful, and to describe the factors involved in deciding to use non-pharmaceutical interventions.

Session Outline Non-pharmaceutical Interventions (NPI) Types of interventions Legal authorities and ethical framework Factors that affect when to use Implementation of NPI Evaluation Scaling back We will begin this session by describing the types of non-pharmaceutical containment measures, how they are used, and why they are used. Then we will discuss the legal authority needed to use non-pharmaceutical interventions, and some of the ethical issues that are involved. Next, we will cover factors or triggers that affect when non-pharmaceutical should be used and implemented, some of the logistics involved in implementing these measures, and the impact they may have on the affected groups such as fear, and the social and psychological impact. We will conclude with considerations for the evaluation and effectiveness of non-pharmaceutical containment measures, and when to scale back or stop.

Complete Containment Unlikely Without intervention, expect international spread in 1 month and U.S. cases in 1 to 2 months. This next slide is a slide that may be useful in some but not all circumstances and country settings--you will need to be the judge of when and for what audiences this slide may be appropriate and effective. This slide illustrates in a visually striking way how a pandemic influenza virus might spread globally if early identification and rapid response using standard public health measures and interventions are unsuccessful in preventing transmission and containing the spread of influenza virus locally. This US modeling exercise shows the theoretical spread of influenza virus that begins in Asia, as depicted by the red dots. Without any interventions, we can expect international spread in 1 month, and spread to the US and Us cases in 1 to 2 months. The green dots represent persons who have developed immunity to the disease, or who have succumbed to it. This model predicts that even if complete containment is unlikely, interventions would still be useful in delaying international spread by approximately one month—which could still have important implications in reducing overall morbidity and mortality from an influenza pandemic. Interventions may still delay international spread by 1 month

Potential Tools in Our Toolbox Our best countermeasure – vaccine – will probably be unavailable during first wave of pandemic Antiviral treatment may improve outcomes but will have only modest effects on transmission Antiviral prophylaxis may have more substantial effects on reducing transmission Non-pharmaceutical interventions may reduce and delay transmission, and may decrease health and human impact In terms of interventions, there are numerous tools in our public health tool box. At our current capacity, our best countermeasure, vaccine, will probably be unavailable during the first wave of an influenza pandemic. Antiviral treatment, which was discussed in the previous lecture, may improve outcomes but will have only modest effects on reducing or preventing transmission, and antiviral prophylaxis may have more substantial effects on reducing transmission. In addition to pharmaceutical interventions, modeling also predicts that non-pharmaceutical interventions may reduce and delay transmission, and may decrease the health and human impact of an influenza pandemic.

Non-pharmaceutical Interventions 1. Delay disease transmission and outbreak peak 2. Decompress peak burden on healthcare infrastructure 3. Diminish overall cases and health impacts Daily Cases #1 #2 #3 Days since First Case Pandemic outbreak: No intervention With intervention Modeling suggest that the implementation of non-pharmaceutical interventions can work in three ways to mitigate the overall effects of an influenza pandemic, and to shift and alter the overall shape of the epidemic curve, as illustrated in this slide. First, NPIs can delay disease transmission and the timing of the outbreak peak. Second, they can decompress and lower the peak burden on healthcare infrastructure, and third they can diminish overall cases and therefore health impacts.

Overview of NPI Individual level Isolation Quarantine Infection control Community level Quarantine of groups/sites Measures to increase social distance School closures Business and market closure Cancellation of events Movement restrictions Infection control NPI can be conceptualized, categorized, and discussed as individual and community level interventions. Isolation and quarantine will be the focus of the individual level interventions, and we will also mention infection control practices and the use of personal protective equipment. Quarantine of groups and sites, and social distancing measures will be the focus of the community level NPI. We will discuss each of these separately and in more depth.

Considerations for Non-Pharmaceutical Interventions Limited evidence to evaluate NPI for influenza Observation and modeling Tailor NPI to each locality’s situation NP interventions likely useful in delaying spread of disease, and should be used in coordination with other interventions Before we begin our discussions of NPI, we should state that there has not been much substantive research in the area of non-pharmaceutical interventions. Only a few studies that involve modeling (not real data) have been done, otherwise all our information is from historical accounts, such as the 1918 epidemic and SARS, and simple observation. Therefore the recommendations presented here only reflect the current thinking on non-pharmaceutical interventions. These recommendations will continue to evolve as we learn more about the effectiveness of the interventions. WHO recommends tailoring non-pharmaceutical interventions to your specific situation. There are different recommendation depending on the pandemic phase the country is in, the pattern of transmission occurring in the country and the severity and extent of illness. The importance of non-pharmaceutical interventions is that they may successfully delay the spread of disease, while vaccine development or other response measures are being actively pursued—and they should be used in coordination with other interventions.

Overview of NPI Individual level Isolation Quarantine Infection control Community level Quarantine of groups/sites Measures to increase social distance School closures Business and market closure Cancellation of events Movement restrictions Infection control With that introduction, we can begin to discuss individual level NPIs.

Definitions Isolation Quarantine Either can be voluntary or mandatory Separation and restricted movement of ill persons with contagious disease Often in a hospital setting Primarily individual level Quarantine Separation and restricted movement of well persons presumed exposed Often at home, may be designated residential facility or hospital Applied at the individual or community level Either can be voluntary or mandatory It is always important to be sure that your students understand the definitions of isolation and quarantine, and that both can be implemented in a voluntary or mandatory manner. It is always preferable to implement these measures in a voluntary manner, and WHO recommends using the least restrictive measures possible. However, your country an dlocalities should also have a plan and resources identified to enforce these measures if necessary. Isolation is the separation and restricted movement of ill persons with contagious disease. It is most often undertaken in a hospital setting, although it could theoretically occur anywhere where appropriate medical treatment could be provided, and it is primarily used on an individual level.

Isolation Isolate severe and mild cases Location of isolation (eg home, hospital) depends on several factors Do not wait for lab confirmation Plan for large number of severe cases Provide medical and social care In order to reduce transmission of disease from known cases, isolation of ill persons with either mild or severe disease is recommended. The location of isolation be it in the household or in a healthcare facility will depend on a number of factors, such as: the severity of illness of the particular patient, the number of affected persons, the domestic setting in which the patient resides, the number of contacts s/he has and the likelihood the patient will comply to the isolation order. Current recommendations, advise isolating patients at ALL phases of the pandemic, however, as the number of cases increase isolation becomes more difficult. Therefore, it is critical that government authorities prepare in advance for a large number of severe cases. In addition, it is important not to wait for lab confirmation of disease prior to recommending isolation measures. Such a delay would likely contribute to the further spread of disease. When asking patients to voluntarily isolate themselves, it is important that they fully understand the reasons for this request. Getting patients to comply with isolation measures can be difficult, so public information that clearly explains the necessity for this action is critical. Involuntary isolation of symptomatic persons may be necessary as well. In these cases, enforcement must be considered. It is vital to consider and the provision of medical and social care (such as food and water) to cases.

Definitions Isolation Quarantine Either can be voluntary or mandatory Separation and restricted movement of ill persons with contagious disease Often in a hospital setting Primarily individual level Quarantine Separation and restricted movement of well persons presumed exposed Often at home, may be designated residential facility or hospital Applied at the individual or community level Either can be voluntary or mandatory In contrast to isolation, quarantine is the separation and restricted movement of well persons presumed exposed to a contagious disease. It can often occur at home, but may also be performed in a designated residential facility or hospital. It can be applied at either the individual or group and community level.

Principles of Quarantine Used when resources are available to implement and maintain Provide essential services and care for those in quarantine Used in combination with other interventions Surveillance, diagnosis, treatment, and preventive interventions Used only as long as necessary Does not have to be absolute to be effective Quarantine is almost an ancient public health tool, which has been rarely used in the past century. It was, however, recently used during the 2003 global SARS epidemic—and this experience has helped us to outline some of the general guiding principles to follow if implementation of quarantine is considered warranted and needed. First, quarantine should be used only when there are resources available to implement and maintain it in a manner which protects those under quarantine—governments should be prepared to provide essential services and care to those sin quarantine. Second, quarantine should be used in combination with other interventions such as surveillance, diagnosis, treatment, and other preventive interventions. Third, quarantine should be used only as long as necessary, and lastly, it does not have to be absolute to be effective. Modeling has shown that even partially implemented or “leaky” quarantine measures can have effect on decreasing disease transmission.

Principles of Quarantine Implementation requires clear understanding of roles and legal authority at all levels Implementation requires coordinated planning by many partners Public health authorities, health-care providers, emergency response teams, law enforcement, and transportation authorities Implementation requires trust and participation of the general public Effective risk communication, support and coordination with community groups We have also learned that implementation requires clear understanding of roles and legal authority ata all levels of government, and that implementation requires coordinated planning by many partners. Lastly, and perhaps most importantly, implementation of quarantine is dependant upon the trust and participation of both those placed under quarantine and the general public. To gain this trust, government and health officials will need to have developed effective risk communication messages and social mobilization techniques to gain the support and coordinatino of community groups.

Quarantine Identification of contacts Interview and medical exam Contact tracing and follow-up Becomes difficult as case load increases Essential during rapid response phase In order to recommend quarantine measures to the right people, we must identify all significant contacts of cases. Contacts are those exposed to the case. Defining exposure to the case is a critical first step. As discussed in Module 8, this involves interviewing the contacts and doing a medical examination, which includes temperature measurement. Those who meet the case definition should be isolated and treated as cases. Contact tracing involves getting a list of people the sick individual potentially exposed to the virus. Each of the individuals on the list must then be contacted. This can be a time and labor intensive activity. After the contact has been found, it is necessary to follow-up with him/her several days later to see if symptoms have developed. Given that contact tracing and follow-up requires lots of staff time, after the number of contacts increases this will no longer be feasible. However, it is essential to identify all contacts while performing rapid containment activities.

Quarantine Regular health monitoring is essential part of quarantine and rapid containment Conduct frequent health checks for high risk groups (e.g. household contacts of suspected cases) Self-health monitoring and reporting Fever telephone hotlines and clinics While the exposed people are being quarantined, active monitoring of their health occurs regularly and is an essential part of the rapid containment effort. Self-health monitoring and reporting are also recommended. Information that is easy to access and understand about signs and symptoms must be provided in order for self-health monitoring to be effective. Fever telephone hotlines and fever clinics may prove helpful as well. This was true during the SARS outbreak. Fever clinics and hotlines are another way for exposed persons to monitor their own health. Beyond self-health monitoring, daily or every-other-day health checks should be conducted for some high risk groups. Health checks will likely be a critical feature of a rapid containment effort. For example, daily health checks of household contacts of suspected cases would be a good idea. In general daily health checks of the entire population are not an effective use of limited resources.

Infection Control Infection Control Hand hygiene Cough etiquette Facemasks Cleaning and disinfection of surfaces Infection control measures such as hand washing, cough etiquette, disinfecting surfaces, the use of masks and other PPE are NPIs can be applied at both the individual and community levels. These topics are covered thoroughly in Module 6. so, I will just pass through these next slides quickly.

Infection Control Practices and Personal Protective Equipment Hand washing Destroys the influenza (eg, H5N1) virus, when done properly Results in fewer upper respiratory infections Soap and water effective Handwashing stations in public places Handwashing is the most practical form of infection control. When done properly, it destroys the H5N1 virus, which results in fewer people getting upper respiratory infections due to the virus. Soap and water are effective in destroying the virus. An aggressive infection control program in the community will have handwashing stations available in public places, such as restaurants or train and bus stations. References: WHO Writing Group. Emerg Inf Dis 2006;12:88-94 *WHO SEARO: Simple public health interventions for Avian Influenza

Infection Control Practices and Personal Protective Equipment Cough etiquette Should be routine for everyone Another infection control practice is “cough etiquette”, or covering your mouth when you cough with a tissue, your arm, or a mask. Here is an example of public information on universal hygiene behaviors. This type of behavior should be encouraged and routine for everyone.

Infection Control Practices and Personal Protective Equipment Face Masks Recommended for symptomatic persons and persons seeking care for respiratory illness in high risk areas (waiting rooms) Consider use when caring for ill persons in the community Consider use among high risk populations, and exposed persons (poultry workers, market workers) PPE should be used in health care facilities Masks would be recommended for people who are symptomatic, or who are seeking care for respiratory symptoms in high-risk areas such as waiting rooms. Masks can also be used by people taking care of ill persons in their homes or the community. In the event of a threat of widespread influenza, the use of face masks by the public might be considered, particularly for those who have been exposed to avian influenza, or who are part of a high risk population such as working with poultry on farms or in markets. Remember from the Infection Control module that PPE should always be used to protect against influenza risk in healthcare facilities.

Infection Control Practices Cleaning and disinfecting surfaces Reduces transmission via fomites Use household cleaning products such as alcohol and chlorine bleach In hospitals clean rooms daily or more If poultry is ill, cleaning of pens recommended Since AI virus can live on surfaces for several hours, disinfecting surfaces is an effective way to reduce transmission of disease. The use of common household cleaning products such as bleach and alcohol are effective. More information on the proper use of these substances is available in the WHO infection control guidelines for healthcare facilities. In hospital settings, rooms should be cleaned at least daily and surfaces that are commonly touched, should be cleaned more often. In addition, if your poultry has been infected with AI, it is important to thoroughly clean the pens to prevent further spread of disease. More information available from WHO. Source: Advice for people living in areas affected by bird flu, 8 Nov 2004

Community Level Infection Control During the SARS outbreak there were community-level campaigns to promote infection control, including hand washing, cough etiquette, cleaning, disinfection and wearing of masks by ill person and members of the general public.

Overview of NPI Individual level Isolation Quarantine Infection control Community level Quarantine of groups/sites Measures to increase social distance School closures Business and market closure Cancellation of events Movement restrictions Infection control Next, we will discuss community level NPI such as quarantine of groups and site and measures to increase social distance in a bit more detail, and also mention infection control at the community level.

Quarantine of Groups or Sites Household or community quarantine Evidence or suspicion of human-to-human transmission Monitor for illness and provide essential services and medical care Cordon sanitaire Barrier that restricts travel in and out of an area Helpful in closed settings (military barracks, dormitories) May be impractical in some settings During a containment effort, it may be necessary to quarantine exposed groups or sites in the community. Primarily this refers to a household or group of households in a situation where human-to human transmission is suspected or has been documented. Assume a case has been diagnosed in household A. Members of household B are relatives of the case and had spent time with him/her a few days prior to illness. Members of household B should be quarantined promptly. Quarantined households should be monitored for illness and provided with medical care just as quarantined individuals. An extension of the community quarantine concept, is known as Cordon sanitare, which refers to a barrier designed to prevent disease from spreading by preventing ill and exposed persons from mixing with other parts of society. For example, it might be necessary to prevent population flight from affected areas and from having those suspected of infection from entering unaffected areas. It might also be used as a strategy in which groups are closed off from the surrounding society in an effort to protect the community and prevent illness from being introduced widely. It may particularly helpful to manage people in closed settings such as military barracks or dormitories. However, this strategy may be impractical in most settings, thus it is generally NOT recommended by WHO.

Measures to Increase Social Distance Social Distancing School closure Business and market closure Cancellation of public gatherings Movement restrictions Increasing social distance is the goal of many community level non-pharmaceutical interventions. Social distancing measures aim to reduce the opportunities for disease transmission by reducing the amount of contact people have with each other. Some examples of measures which can increase social distance include school closures, business and market closures, cancellation of public gatherings and events, and movement restrictions. Modeling studies have shown social distancing measures to be effective in containing the spread of disease, especially when combined with other methods.

Closure of Schools and Facilities Should be implemented early Especially useful if high morbidity among children Business and market closures Access to and availability of necessities Economic considerations Similarly, in a rapid response to a presumed Avian Influenza cluster, closure of schools will also most likely be a key part of a successful pandemic containment effort. The risk of infection and illness among children is likely to be decreased if schools are closed. If there has been significant morbidity and mortality among children this may help slow the spread of disease. Anecdotal reports suggest that community influenza outbreaks may be limited by closing schools. Results of mathematical modeling also suggest a reduction of overall disease, especially when schools are closed early in the outbreak. If school closures are enforced, parents should ensure that children are not gathering in large numbers outside the school setting. During the first wave of the Asian influenza pandemic of 1957-1958, the highest attack rates were seen in school aged children. This has been attributed to their close contact in crowded settings. One study found that during an influenza outbreak, school closures were associated with significant decreases in the incidence of viral respiratory diseases among children aged 6-12 years. In making a decision to close businesses and market places, officials must consider how people will access basic necessities such as food and water. In addition, if businesses and factories are closed will availability of basic items be effected? A large economic impact may also be felt. In general these social distancing measures are disruptive and may cause distress and discomfort to the population. These considerations must be weighed against the potential benefits of using social distancing measures.

Cancellation of Events Population measures to increase social distance and reduce mixing Discourage mass gatherings such as festivals and sporting events Impact on economy Cultural significance In a rapid response to a presumed Avian Influenza cluster, preventing ill or exposed persons from exposing others while attending public gatherings will likely be a key part of a successful pandemic containment effort. During an established pandemic, when making a decision to cancel events, the impact on the economy needs to be balanced with the ability to effectively protect the public through such means. Health officials must also keep in mind the importance of the event to the public and its cultural significance. During the 1957-1958 influenza pandemic, a WHO expert panel found that spread of disease within some countries followed public gatherings, such as conferences and festivals. This panel also observed that in many countries the pandemic broke out first in camps, army units and schools; suggesting that the avoidance of crowding may be important in reducing the peak incidence of an epidemic.

Movement Restrictions Another population measure to increase social distance and reduce mixing Restrictions on public transportation and public gatherings Voluntary or involuntary work holidays Things to consider Effectiveness Implementation Alternative infrastructure Early, rapid response may be key to successful containment effort There are several ways to restrict movement of the population. When considering doing something like restricting public transportation, public gatherings or recommending a work holiday, health officials should consider the potential effectiveness of these measures, how they can most effectively be implemented, and how to maintain critical supplies and infrastructure while limiting community interaction. For example, when public transportation is cancelled, other modes of transportation must be provided for emergency medical services and medical evaluation. In an early, rapid response to a presumed cluster of Avian Influenza, preventing ill or exposed persons from leaving the affected area may be a key part of a successful pandemic containment effort.

Legal Authorities and Ethical Framework The next session is about the legal authority to implement non-pharmaceutical interventions, and the ethical framework for doing so in the context of public health.

Legal Authorities Health officials have legal authority Laws differ by country Review existing laws prior to pandemic Some questions to consider: Which agency has legal authority? Under what conditions can authority be used? How is quarantine/isolation enforced? Consequences for violation? In most countries public health officials have the legal authority to enforce isolation/quarantine measures, however, the laws are different for each country. Prior to a pandemic phase, officials should review laws to ensure consistency across provincial governments and sufficient powers are given to public health. Specific legal issues to consider for your country are: -Which agency has this legal authority to enforce isolation, quarantine and other social distancing measures? -Under what conditions can this authority be used? -How are quarantine & isolation enforced? Some nations may use law enforcement (police force or military), while others the judicial system. -What are the consequences for violating quarantine? Other things to consider are cross-border legal issues and coordination between national and provincial governments. Please adapt this content to your country’s specific situation by providing specific answers to these questions for your country. Note: Please adapt this content to your country

Legal Authorities Mandatory vs. voluntary restrictions Administrative communication & coordination Define who will make decisions about which NPI to use Define who will be responsible for implementation and enforcement Rapid response teams, MOH and WHO should communicate regularly and coordinate activities When assessing legal authority to implement some of these measures consider if the restrictions are mandatory or voluntary. If the suggestion for voluntary work holidays for those exposed to AI are not being followed, officials may consider making the work holiday a mandatory one. Government powers for a voluntary restriction are much more difficult to enforce. Regardless voluntary restrictions can be very effective. Administrative communication and coordination across government agencies is critical. Within your country you must identify which agency will make the decisions about which NPI will be undertaken. Similarly the government agency responsible for implementing and enforcing the NPI must be clearly identified. The local rapid response team, working with the ministry of health should communicate with WHO on a regular basis. Regular communications should be scheduled to ensure all parties are aware of each other’s tasks and responsibilities Adapt to your country by indicating which agencies will do what and how interaction between rapid response teams, MOH and WHO will occur. Note: Please adapt this content to your country

Ethical Issues Several ethical issues will arise Discuss prior to pandemic phase Ethical issues include: Restriction of individual freedom Lost wages Compensation for mandatory isolation and quarantine Many ethical issues will arise from the use of non-pharmaceutical interventions. Having discussions about what they might be and how to handle them prior to the epidemic may be helpful. Ethical issues that may arise include restriction of individual freedom; lost wages or lack of means to support oneself/family, and if quarantined or isolated individuals should be compensated appropriately. Similarly lost business revenue due to business closures may also require compensation.

Triggers for Non-Pharmaceutical Interventions There are several factors specific to your local situation to consider when deciding which non-pharmaceutical interventions to use.

Contextual Factors Current pandemic phase Local public health and emergency infrastructure Community understanding Most importantly, the current pandemic phase or a shift in the pandemic phase will trigger the use of NPIs. Specific WHO recommendations for use of NPIs by pandemic phase will be presented shortly. Implementation of NPI can only be carried out with the appropriate local public health and emergency infrastructure. Local government officials would have to ensure basic infrastructure such as water, food, shelter and security were available for those affected by the containment operation. Lastly ensuring that the community understands the need for such interventions is critical. Messages should be distributed with the principals of risk communication in mind. Review module 7 for more information.

Outbreak-Specific Factors Geographic extent Area small enough that containment would be logistically possible Supply of food, shelter, medical care etc to affected area Pandemic potential Presence of clusters in defined area over short period of time Outbreak specific factors can also influence your country’s decision to implement NPIs such as quarantine and social distancing measures. Such measures are recommended when the geographic area of affected persons is small enough that containment would be logistically possible. More specifically, the size of the affected community should allow for adequate supplies of food and shelter, and the provision of medical care and emergency services. In addition, the pandemic potential of the virus must be considered. The detection of clusters indicating human-to-human transmission, is likely to be the most important epidemiological signal of a transition to a new pandemic phase. An increase in the number of cases in a defined area over a short period of time should trigger containment activities and use of exceptional measures.

Recommendations for NPI Phase 3 (Current) Phase 4 & 5 (Rapid response) Phase 6 (Pandemic) Isolation Yes Quarantine No Possibly Identification of contacts Health monitoring Cordon sanitaire Facility closure, movement restrictions, cancellation of events WHO provides these recommendations for when to use which NPI. However, this should not be seen as a rigid guideline, rather as your local situation evolves the decisions about what interventions to use should be made. Isolation of symptomatic patients is recommended to limit transmission in any pandemic phase. The use of quarantine measures might be useful in the early phases of the spread of influenza, when a rapid response is underway, but is of uncertain usefulness in the pandemic phase. Identifying contacts and monitoring contacts’ individual health is a useful way to find, isolate, and treat influenza cases early on. However once disease becomes widespread or pandemic, enough people will be ill that this measure will no longer be practical. Cordon sanitaire might have limited usefulness in the rapid response phase of influenza spread, but is otherwise logistically difficult and hard to enforce. Closing facilities or events and limiting travel could be a useful measure at any time, depending on the local situation, as this will prevent large numbers of people from having the opportunity to gather and pass around the virus.

Implementation of NPI In order to effectively implement these NP interventions, several issues must be considered.

Coordination Governmental and non-governmental organizations (NGO) must work together Help spread health messages Get community buy-in for interventions Assist directly with health monitoring, medical care etc. Pre-event planning is key to successful implementation Although this will be specific to your country, working with non-governmental organizations will enhance the effectiveness of government to implement some of these measures. NGOs can be helpful in spreading health related messages, they can also assist in contacting community leaders to get buy-in and in some cases they may even be able to assist directly. For example, some community groups may volunteer to assist with health monitoring or providing necessities to quarantined and isolated groups. Within each country and province, health officials can determine which NGOs they should work with. Note: Please adapt this content to your country

Concurrent Measures Combining measures reduces spread more than using only 1 measure Early implementation is essential NPI can delay spread of disease, allowing time for vaccine development and other response measures It has been shown that combining measures is more effective at reducing spread of disease then using just 1. The importance of non-pharmaceutical interventions is that they can delay spread of disease, allowing time for vaccine development and other response measures. Thus combining measures may enhance effectiveness.

Logistics and Security Work with local police/military Logistics requires significant planning Logistical and security issues Isolation Quarantine of individuals or groups Measures to increase social distance There will be many logistical and security challenges to implementing some of these interventions. Assessing and handling the challenges will be very specific to your country’s situation. In general health officials will have to work with their local police or military to ensure security as they try to implement some of these non-pharmaceutical interventions. In addition, working out logistics will require significant planning ahead to implement the intervention. It is recommended that planning begin soon. A few examples to consider are movement restrictions and quarantine. As discussed previously there are several logistical issues associated with quarantining groups or areas. If the quarantined population feels unfairly targeted, there may be rioting or civil unrest. Ensuring people do not go to work or school when the facilities are closed will require a security presence at all the closed facilities. Note: Please adapt this content to your country

Risk Communication Clear consistent messages Wide spread delivery One source for official information Prevention of incorrect information Given that some of these NP measures may appear drastic to the population, wide spread panic may ensue upon calling for these measures. Therefore risk communication is critical. There should be only 1 source for official health information. Always tell the public why the measures are important and how they will protect the public. Messages should be clear and consistent and spread broadly. Try to reach a majority of the population with the messages. Incorrect information should be prevented from circulating widely. If it does begin to circulate, efforts must be made to counter it quickly. Review information from module 7 about risk communications for more details.

Psychological and Social Impact Explain why measures are necessary Provide updates on when ban will be lifted Hotlines to answer questions Health officials must be aware of the potentially serious psychological and social impact some of these measures may have on the population. For example, in a quarantine or isolation situation, some people may feel very anxious about loss of income, and accessibility to food and water. Others may feel depressed if they are unable to see friends and family. Some steps can be taken to lessen the social and psychological impact of non-pharmaceutical interventions, such as making sure people understand why the measures are necessary, providing continual updates on when government officials will lift the measures and providing telephone hotlines to answer questions. Telephone hotlines can also serve as a place for citizens to get their voices heard and feel like officials are listening to them.

Health Monitoring and Medical Care Self-health monitoring may reduce burden on hospitals and clinics Hotlines to answer questions about signs and symptoms Effective medical care requires well trained staff Ensure health care providers are available Self-health monitoring could be helpful in some situations. Sufficient information must be sent to the population in order for it to be effective. Hotlines to answer the public’s questions about signs and symptoms may reduce the burden on clinics and hospitals. Health monitoring and medical care is a critical part of implementing isolation and quarantine. Health care providers must have the most up-to-date information about AI. Officials must ensure that there are as many providers available as possible. Contingency plans are necessary in the event of health care providers becoming ill, or not coming to work due to family illness or fear of illness.

Evaluation Limited evidence about NP interventions currently exists Opportunity to add to the body of evidence Create evaluation plan prior to pandemic Number of cases prevented Unforeseen positive and negative impact Currently there is very little scientific evidence about the effectiveness of NP interventions. This may be an opportunity to add to the body of evidence and improve our use of these interventions. An evaluation plan for each of the non-pharmaceutical interventions can be created prior to the pandemic. An evaluation plan helps develop ideas about what types of things are important to measure and in what detail. A few general questions to ask of the intervention are: How many cases were prevented? What were the unforeseen negative and positive impacts of the intervention? Should it be recommended to other nations or for other epidemics?

Scaling Back What requirements are necessary prior to scaling back? Number of new cases Spread of disease to surrounding areas In order to scale back on the intervention measure, officials will have to decide when they feel the spread of disease has been effectively contained. Some things to look at on the population level are the number of new cases being reported in the population and if disease has spread to surrounding areas.

Summary NPI likely useful in delaying and reducing disease transmission, and may decrease health and human impact NPI should be used in coordination with other interventions, and early implementation is crucial All measures should be implemented within context of local situation In conclusion we have reviewed individual and community level non-pharmaceutical interventions. NPI are likely useful in delaying and reducing disease transmission, and may decrease health and human impact. To be most effective, NPI should be used in coordination with other interventions, and implemented early. Always keep in mind that these interventions must be planned, implemented and evaluated within the local context.

Discussion on individual and community level interventions Interactive Exercise 1 Discussion on individual and community level interventions We will break out into groups to further explore the individual and community level interventions we just discussed. See Exercise 1, Module 9 NPI Facilitator guide / Trainee Activities. Note: With a smaller group, this exercise can be done immediately following the slides on individual and community level interventions.

Interactive Exercise 2 Group discussion about legal, ethical, social and psychological aspects of NP interventions We will have a group discussion to highlight of some of the legal, ethical, social and psychological aspects of non-pharmaceutical interventions in your area. See Exercise 2, Module 9 NPI Facilitator guide / Trainee Activities. Note: With a smaller group, this exercise can be done immediately following the slides on legal authority and ethical framework

Role playing with individual and community-level interventions Interactive Exercise 3 Role playing with individual and community-level interventions This role play exercise will give you the opportunity to discuss the most practical NPI to take in a situation, and to attempt explaining interventions that must or should be taken to different groups. See Exercise 3, Module 9 NPI Facilitator guide / Trainee Activities.

References WHO Writing Group. Emerg Inf Dis 2006;12:88-94. WHO SEARO: Simple public health interventions for Avian Influenza WHO WPRO: Advice for people living in areas affected by bird flu, 8 Nov 2004 http://www.wpro.who.int/NR/rdonlyres/04FA6993-8CD1-4B72-ACB9-EB0EBD3D0CB1/0/Advice10022004rev08112004.pdf Flu Pandemic Mitigation: Social Distancing. GlobalSecurities.org, Sept 2005. http://www.globalsecurity.org/security/ops/hsc-scen-3_flu-pandemic-distancing.htm Centers for Disease Control and Prevention (2004).  Fact Sheet:  Isolation and Quarantine.  Division of Global Migration and Quarantine, National Center for Infectious Diseases.  http://www.cdc.gov/ncidod/dq/index.htm Center for Law and the Public's Health (Dec. 2001).  The Model State Emergency Health Powers Act. http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf

Glossary Isolation Quarantine Social Distancing Cordon Sanitaire The physical separation and confinement of an individual or groups of individuals who are infected or reasonably believed to be infected with a contagious disease. Isolated people may be cared for in their homes, hospitals, or other designated healthcare facilities Quarantine Physical separation and confinement of an individual or groups of individuals who are or may have been exposed to a contagious disease and who do not show signs or symptoms. Social Distancing Measures taken to reduce the opportunity for the spread of infection by decreasing contact and gatherings among people Cordon Sanitaire Derived from the French for quarantine line. Barrier designed to prevent disease from spreading by preventing ill and exposed persons from mixing with other parts of society