1. Non-Pharmaceutical Interventions to Face the Pandemic Dr John J. Jabbour Senior Epidemiologist IHR/CSR/DCD WHO/EMRO INTERCOUNTRY MEETING ON AVIAN INFLUENZA AND PREPAREDNESS FOR HUMAN PANDEMIC INFLUENZA EMRO, CAIRO, EGYPT, 28-30 NOVEMBER 2005

2. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 2 Outline Why non-pharmaceutical interventions? What are the non-pharmaceutical interventions? Limitations Challenges

3. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 3 Why non-pharmaceutical intervention? Given the problems of : inadequate vaccine supplies and the uncertain role of antiviral drugs, Several efforts have been made to determine whether non-pharmaceutical interventions could mitigate the initial impact of a pandemic

4. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 4 Why non-pharmaceutical intervention? the principal protective tools pending the augmentation of vaccine supplies. In resource-poor settings, non- pharmaceutical interventions may be the main line of defense throughout the first wave of a pandemic. The effectiveness of most of these interventions has not, however, been tested under the unique conditions of a pandemic.

5. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 5 The effectiveness of many interventions depends on: the behavior of the virus as determined by its: pathogenicity, principal mode of transmission (droplet or aerosol), concentration in different age groups, duration of virus shedding susceptibility to antiviral drugs.

6. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 6 Example If children are the most severely affected age group, or play a major role in transmission, then health authorities should make decisions about: the effectiveness of school closure, travel measures (children travel less frequently than adults) and quarantine (children cannot be separated from their parents).

7. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 7 Selection of appropriate measures Driven by questions of feasibility, which are closely linked to: costs, ease of implementation within existing infrastructures, likely acceptability to the public, and potential to cause social and economic disruption.

8. Non-pharmaceutical Interventions

9. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 9 Public health information, communication Information for public on risks and risk avoidance (tailored to target population) Information for professionals (Guidelines) Advice on universal hygiene behavior Preparatory information on next phase

10. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 10 Measures to reduce risk that cases transmit infection Confinement: Confine cases (mild and severe) as appropriate to local situation (provide medical and social care, face masks): Severity of illness depends on prior experience with related variants symptomatic persons exposed person: undertake risk assessment considering: evidence of human-to-human transmission; closeness of contact; frequency of exposure persons seeking care (respiratory illness) in risk

11. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 11 Measures to reduce risk that contacts transmit infection Tracing and follow-up of contacts (Not feasible once pandemic starts) Self-health monitoring and reporting if ill Voluntary quarantine (home confinement) of healthy contacts; provide medical and social care Advise contacts to reduce social interaction Advise contacts to defer travel to unaffected areas Provide contacts with antiviral prophylaxis

12. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 12 Measures to increase social distance Voluntary home confinement of symptomatic persons Closure of schools (including pre-school, higher education) in conjunction with other measures (limiting after-school activities) to reduce mixing of children Population-wide measures to reduce mixing of adults (furlough non-essential workers, close workplaces, discourage mass gatherings) Masks in public places

13. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 13 Disinfection measures Hand-washing Household disinfection of potentially contaminated surfaces Widespread environmental disinfection Air disinfection

14. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 14 Measures for persons entering or exiting an infected area within the country Advise to avoid contact with high-risk environments (infected poultry farms, live poultry markets) Recommended deference of non-essential travel to affected areas Restrict travel to and from affected areas Disinfection of clothing, shoes, or other objects of persons exiting affected areas

15. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 15 Influenza Surveillance Influenza surveillance network with NAMRU-3 (Expansion and guidelines) Active search surveillance for persons coming from affected areas Distribute proper information to travelers for self reporting Facilitate the installation of proper communication means for data reporting Health facilities Laboratories Build analytical capacities at national levels capable of producing reports quickly

16. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 16 Laboratory Skills Guidelines: sample collection, biosafety, etc. Building capacities: Consultants Training of national staff Link to reference laboratory for virus isolation and information-sharing Laboratory surveillance networking

17. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 17 Limitations Pandemic influenza is considered far more difficult to control than SARS: Influenza A viruses are much more contagious than the SARS corona virus The incubation period is shorter and the virus can be spread prior to the onset of symptoms Fever checks and border screenings will not be able to detect people in the incubation period who have no symptoms While SARS remained largely confined to hospital settings, pandemic influenza will rapidly and widely spread within the community

18. JJ/IHR/CSRCommunicable Disease Surveillance, Forecast & Response Unit 18 Challenges Select the appropriate non-pharmaceutical measure Strengthen human and animal health surveillance systems Enhance inter-sectoral collaboration Improve laboratory capacities for detecting and isolating the virus Ability to produce and disseminate guidelines and educational material to the health professionals and the public Ability to share and update information quickly among all concerned parties