1. text WHO Global Influenza Programme NIC Role during a pandemic and NIC contingency plan Wenqing Zhang MD Global Influenza Programme, WHO HQ THE 3rd MEETING OF NATIONAL INFLUENZA CENTRES IN THE WESTERN PACIFIC AND SOUTH EAST ASIA REGIONS 18-20 August 2009 Beijing China

2. text 2 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 2 WHO Global Influenza Programme l NIC TOR – Stable for long-term, "glue" and "lubricant" of a Network Seasonal influenza surveillance and support to WHO vaccine virus process Detection of emerging virus – Minimum technical requirement to become a GISN member l NIC Role in monitoring and responding to the threat of human influenza – Precise roles of NICs during all the different stages of pandemic preparedness and response – WHO recommendation - implementation depending on national authorities – NOT to replace NIC TOR l NIC Contingency plan development guidance – Guidance to prepare for pandemic response l Laboratory surveillance and response guidelines during a pandemic – under development – Guidance to respond during a pandemic - A package for NICs - Key GISN documents related to NICs

3. text WHO Global Influenza Programme NIC role during a pandemic

4. text 4 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 4 WHO Global Influenza Programme Pandemic preparedness and response phases

5. text 5 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 5 WHO Global Influenza Programme Structure of recommendation of NIC role l Consistent with the WHO guidance: Pandemic Influenza Preparedness and Response – Planning and coordination – Situation monitoring and assessment – Reducing the spread of disease; and – Communications. l All recommended activities intended to continue in higher phases unless replaced

6. text 6 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 6 WHO Global Influenza Programme During a period of high alert – WHO phase 4 l Definitions – Phase 4: H-2-H transmission able to sustain at community-level Not necessarily mean a pandemic is to take place l NIC objectives – Early detection of novel virus infection in humans Geographically – assisting the decision making of rapid containment If rapid containment operation undertaken, enhanced surveillance in place – Assisting WHO and national authorities on: Pandemic risk assessment Development/update of vaccine viruses, diagnostics etc

7. text 7 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 7 WHO Global Influenza Programme l Planning and coordination – Affected countries Rapid containment –Whether or not to mount –If yes, assisting national authority an enhanced surveillance system Ensuring continuity of lab surveillance –Sampling strategy developed, reviewed, adjusted –Selection criteria developed jointly with WHO for sending representative specimens to CCs during rapid containment operation – All countries Implementation/adjustment of surge capacity plans Reviewing lab diagnostic strategy Be aware of and taking actions to any new WHO surveillance criteria Measures in place to protect lab workers During a period of high alert – WHO phase 4

8. text 8 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 8 WHO Global Influenza Programme l Situation monitoring and assessment – Affected countries Testing and sharing of specimens –Representative cases for testing: time sequential; symptom; geographical location; potential epi history … –Testing; characterization; alert to variant –Timely shipping all/selective specimens/virus isolates to WHO CCs Supporting the effective clinical management of infection –Continuing monitor susceptibility of antivirals to emerging virus strains –Rapid sharing of information significant of public health with WHO and national authorities – All countries Assistance to national authorities - systematically organizing specimen testing Advice to the country on lab testing algorithms and surveillance criteria Testing specimens from all suspected cases During a period of high alert – WHO phase 4

9. text 9 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 9 WHO Global Influenza Programme During a pandemic – WHO phases 5-6 l Definitions – Phase 5: novel virus established H-2-H transmission at community level in at least 2 countries in one WHO region – Phase 6: in addition, at least one other country in another WHO region l NIC objectives – Affected countries Assisting national authorities on mitigating pandemic impact Monitoring the evolution of the novel virus – Countries not yet affected Support detection of start of a pandemic to trigger interventions – All countries Assisting WHO and national authorities on: –Pandemic risk assessment –Development/update of vaccine viruses, diagnostics etc

10. text 10 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 10 WHO Global Influenza Programme During a pandemic – WHO phases 5-6 l Planning and coordination – Review lab components of national plan and implementation as required – Periodic review to sustain NIC diagnostic functioning – Adjustment of sampling/testing strategy – Be aware of update of guidance on biosafety requirements, specimen collection, storage and transport and selection of viruses to CCs

11. text 11 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 11 WHO Global Influenza Programme During a pandemic – WHO phases 5-6 l Situation monitoring and assessment – Affected countries Adjustment of lab surveillance from individual case diagnosis to overall monitoring Monitoring the percentages of novel virus and seasonal viruses co-circulating Adequate surveillance assist WHO/GISN monitoring antigenic evolution and antiviral susceptibility Timely sharing representative viruses/specimens with WHO Timely sharing findings of public health significance with WHO, national authorities and general public – Unaffected countries Update of plans/strategies developed based on gained experience from affected countries Maximizing surveillance for rapid detection of first cases

12. text 12 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 12 WHO Global Influenza Programme After a pandemic l Unknown of one wave or multiple waves l NIC objectives – Review and recovery Rebuilding NIC capacity, immediately Ready for "next" wave

13. text 13 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 13 WHO Global Influenza Programme After a pandemic l Post-peak period – Continuing virological surveillance to support WHO on: Percentage of novel virus detections among all influenza virus circulating Vaccine virus update Antiviral susceptibility Diagnostics update Pandemic risk assessment – Capacity restore – Gap/lesson/experience review – Possible research studies l Possible new wave – Same as that for phases 5-6

14. text 14 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 14 WHO Global Influenza Programme After a pandemic l Post-pandemic period – Same as that for post-peak period In particular on the proportions of circulating influenza viruses – which will become seasonal influenza viruses …

15. text 15 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 15 WHO Global Influenza Programme Summary – NIC role l NICs most likely the primary source of expertise in surveillance and response to influenza epidemics and pandemics l Triggering many of the well-planned interventions depending on NICs' effective functioning – Proved by the recent H1N1 event l GISN – WHO coordinated efforts on laboratory/virological surveillance, preparedness and response – Significant contribution to response to routine and emerging influenza problem – NICs are the backbone l NIC role in all different phases interlinked l Influenza, at its core, a virus problem – Respect to science and nature – Working as a team globally l Science and knowledge – key to success

16. text WHO Global Influenza Programme NIC contingency plan

17. text 17 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 17 WHO Global Influenza Programme Why a NIC contingency plan l Lab response/service - a key and indispensible component of overall national/global response l Significantly increased level of demand for lab service expected – … and proved by recent response – Most likely exceed routine NIC operations l Ensuring effectiveness and continuity of NIC functioning – Political and institutional commitment needed – Coordination from high-level e.g. from MoH l Need planning in advance

18. text 18 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 18 WHO Global Influenza Programme How to develop a NIC contingency plan l Assessment on anticipated surge level that will be put on the NIC l Identification of the actions and resources needed to establish and maintain the required "surge capacity" – Ensuring the availability of premises, staff and equipment – Stockpiling supplies – Testing strategies, protocols and algorithms – Lab biosafety and transport of specimens – Data management – Communication

19. text 19 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 19 WHO Global Influenza Programme Ensuring the availability of premises, staff and equipment l Availability of lab and office space – Extra lab and office needed during a pandemic Helpful to transfer lab diagnostic technologies to other labs – Additional freezer space needed during a pandemic – If BSL3 lab available, priority reserved for flu-related work l Availability of trained staff – Adequate training in advance – Engaging workers in other labs possibly – Less-well-trained staff could assist with task e.g. tracking specimens, preparing specimen collection kits etc – NIC to keep a full list of available staff and their relevant training – A plan of work shifts and backup personnel in place – Medical surveillance plan in place l Equipment – Should have a back-up power source – Other back-up equipment e.g. biosafety cabinet, PCR machines, incubators either purchased in advance or sourced from other labs – Increased storage capacity – NIC to keep an updated inventory of all lab equipment

20. text 20 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 20 WHO Global Influenza Programme Stockpiling supplies l Stockpiling reagents – Not all have long shelf life, and delivery of supplies might be long lead- time – In general, a stockpile sufficient for at least 3 months of current NIC activity could be a good strategy – NICs may wish to establish networks and reach agreement on the exchange of reagents in order to meet short needs l Stockpiling of/access to antiviral drugs – In coordination with MoH/occupational health l Stockpiling of PPE

21. text 21 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 21 WHO Global Influenza Programme Testing strategies, protocols and algorithms l Testing strategy – should be based on national strategies for pandemic surveillance and the capabilities and resources of the lab – Lead-up and early stages, every specimens to be tested – While virus widespread, selection criteria for specimens to be tested should be established and applied l Testing protocols – Each protocols must be thoroughly validated before being put into routine use – To be agreed upon with epidemiologists and network members l Testing algorithms – In line with national and global pandemic surveillance strategies

22. text 22 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 22 WHO Global Influenza Programme Laboratory biosafety and transport of specimens l Lab biosafety and biosecurity – Biosafety cabinet – Understanding and training on practice at appropriate biosafety levels – Seasonal vaccination among lab workers l Transport of specimens in-country – Possible disruption of or refusal by routine transport system – SOP in place with coordination from high level national authorities l Transport of specimens to reference labs and WHO CCs – WHO guidelines on specimens/virus shipping followed – International transport arranged according to IATA regulations – Import/export permits obtained in advance – Personnel handling shipping trained

23. text 23 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 23 WHO Global Influenza Programme Data management l Conventional filing of forms and results – At the very minimum and essential – and be maintained to provide back-up if electronic systems down l Electronic systems – Best use existing systems to avoid additional duplicated work – As simple as possible to keep key information – Remaining possibility to expand the system

24. text 24 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 24 WHO Global Influenza Programme Communications l Successful NIC response has to be team work l A robust communication network established in advance – MoH, national lab network, WHO, WHO CCs, NICs, other partners l GISN communication platform for timely and informal communications l FluNet reporting – lab surveillance findings

25. text 25 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 25 WHO Global Influenza Programme Summary – NIC contingency plan l Lab surge capacity is anticipated and inevitable l The better planned/prepared, – the less chaos in a lab handling pouring in specimens and under pressing stress – the better continuity of NIC quality service l Individual NICs individual plans l Commitments from MoH and host institution is key l "NIC contingency plan" not just another document – Reassurance to success of national and global pandemic response – Protection of NIC staff – precious asset of a country l Take actions!

26. text 26 Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme text 26 WHO Global Influenza Programme