1. Mitigating the Impact of Pandemic (H1N1): Options for Public Health Measures Dr Li Ailan Communicable Disease Surveillance & Response (CSR) WHO Western Pacific Regional Office (WPRO) 3 rd Meeting of the National Influenza Centres in the Western Pacific and South-East Asia Regions 18-20 August 2009, Beijing, China

2. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) OutlineOutline 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

3. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Primary Strategies for Combating Influenza Pharmaceutical interventions –Use of matched vaccines –Use of effective antiviral drugs Non-pharmaceutical interventions Non-pharmaceutical interventions –Individual and household level public health measures –Societal level public health measures, including social distancing

4. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) 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

5. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Public Health Measures Available (theoretically) at national and community level 1. Individual/household measures  Personal protective measures  Isolation & quarantine  Infection prevention and control in the home setting  Use of masks in the community setting 2. Societal measures, including social distancing  Suspension of classes and child care programmes  Adjusting or changing work patterns  Restriction of public or mass gatherings  Domestic travel advisories and restrictions 1. Individual/household measures  Personal protective measures  Isolation & quarantine  Infection prevention and control in the home setting  Use of masks in the community setting 2. Societal measures, including social distancing  Suspension of classes and child care programmes  Adjusting or changing work patterns  Restriction of public or mass gatherings  Domestic travel advisories and restrictions

6. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Public Health Measures Available (theoretically) at the international border 1. International travel and screening  Health advice and alerts to travellers  Health declaration form  Temperature screening  On-board identification of suspected travellers  International travel advisory, restriction, border closure? 2. Management of symptomatic & exposed travellers  Symptomatic travellers (isolation & treatment…)  Exposed travellers (quarantine…) 1. International travel and screening  Health advice and alerts to travellers  Health declaration form  Temperature screening  On-board identification of suspected travellers  International travel advisory, restriction, border closure? 2. Management of symptomatic & exposed travellers  Symptomatic travellers (isolation & treatment…)  Exposed travellers (quarantine…)

7. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) 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

8. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Comparative risk of outbreaks Transmissibility Low High High Low Severity of Disease (Morbidity & Mortality) H5N1 SARS 1918 Pandemic Pandemic (H1N1) 2009? Seasonal Flu

9. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Possible strategies based on risk category Transmissibility Low High  Aiming at rapid containment at the early stage, and mitigating the impacts, if containment not possible  Aiming at preventing disease importation and containing the virus High Low Severity of Disease (Morbidity & Mortality)  Aiming at reducing transmission and mitigating impact with focus on vulnerable population  Routine public health measures without additional aggressive interventions

10. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Matching cost and consequences of interventions with risk level Cost s and Consequences Level of Risk 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 FB A C E D

11. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Options for interventions: Decision Matrix Decision (Yes/No/wait) Limitations & consequence BenefitsOptions high social & economic cost Second consequences Need alternative childcare programme Absenteeism of working parents, including HCWs Educational continuity? Reducing transmission among children and decreasing spread to the community Acceptable in some countries School closure Comments & guidance: -Must weight the benefits of reducing transmission against economic and social costs -Decision based on local situation and context (“case-by-case”)… -…

12. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) 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

13. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Pandemic Preparedness Assessment 2009: Public Health Measures at International Borders

14. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Pandemic Preparedness Assessment 2009: Individual/Household level Measures

15. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Pandemic Preparedness Assessment 2009: Societal level Measures

16. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Responding 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

17. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) 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 closure Length of closure varied: mostly 7-14 days

18. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) School closure in Japan (May 2009) 17 May : Schools closed, in Osaka 17 May: Schools closed Hyogo Prefecture Source: NIID, Japan

19. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) School closure in Japan (June 2009) Schools and Kindergartens in Fukuoka were closed on 7 June Source: NIID, Japan

20. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Conclusion The potential benefits of public health measures should be carefully balanced against their potentially significant social and economic costs – “one size will not fit all” Decision based on assessed situation and local context. No standard, single combination of measures will fit all countries – “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

21. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) 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/tec h_guidance.htm http://www.wpro.who.int/health_topics/h1n1/tech/tec h_guidance.htm

22. Communicable Disease Surveillance and Response (CSR) WHO Western Pacific Regional Office (WPRO) Acknowledgement  Dr Takeshi Kasai, Regional Advisor, CSR/WPRO  Dr Nobuhiko Okabe, NIID, Japan  Ms Qiu Yi Khut, CSR/WPRO  Ms Katie Harrigan, CSR/WPRO