Country Situation: Preparedness for Avian/Pandemic Influenza in India By DR Shashi khare NICD Delhi.

1. Country Situation: Preparedness for Avian/Pandemic Influenza in India By DR Shashi khare NICD Delhi. Avian/Pandemic Influenza Preparedness In India Dr. Shashi Khare NICD Delhi.

2. Influenza Pandemic • An influenza pandemic (global epidemic) occurs when a new virus subtype appears, against which no one is immune. • Several simultaneous epidemics worldwide with large numbers of cases and deaths. • Spreads rapidly around the world in view of global transport and urbanization.

3. Pandemic Influenza Uniqueness • Will last much longer than most other emergency events with “waves” of influenza activity separated by months • Reduced availability of Health-care workers and first responders • Limited resources because of widespread influenza pandemic

4. Consequences of the Influenza Pandemic Livelihoods • Income loss due to market changes High illness & potentially higher death rates Overstretched health facilities Disproportionate impact on vulnerable groups Human Health Higher public anxiety Increased demand for governance & security Reduced capacity due to absence and illness Governance & Security Deterioration of coping & support mechanisms Interruption in public services Quarantine policies Social & Humanitarian Needs Trade & commerce disruptions Labour shortages Interruption of regular supply systems Economic Systems

5. Current phase Definition of WHO Pandemic Phases Note: 2005 definitions simplify and replace 1999 definitions • Pre-Pandemic Period Phase 1 – no avian virus poses a significant risk to human Phase 2 – new avian virus poses a risk to human • Pandemic Alert Period Phase 3 – but no human-to-human transmission Phase 4 – limited human-to-human transmission Phase 5 – human-to-human spread, larger clusters, but still localized • Pandemic Period Phase 6 – Transmission sustained, global spread  Human infection

6. Pandemic Preparedness - Strategies • Planning activities started in 2004 • Highest Political commitment • National Consultation • Multi sectoral involvement • Knowledge gap filled through WHO guidelines

7. WHO Strategies Objectives according to the different periods • Pre-Pandemic Period 1 – Reduce opportunities for human infection 2 – Strengthen the early warning system • Pandemic Alert Period 3 – Contain or delay spread at the source • Pandemic Period 4 – Reduce morbidity, mortality, and social disruption 5 – Conduct research to guide response measures 6 - Minimise the impact of pandemic

8. FAO/OIE AVIAN INFLUENZA CONTROL WHO COUNTRIES SURVEILLANCE WHO PANDEMIC PREPAREDNESS ANTIVIRAL GLOBAL STOCKPILE RESEARCH / INDUSTRY VACCINE DEVELOPMENT WHO Strategy Actions according to the different phases • Pre-Pandemic Period • Pandemic Alert Period • Pandemic Period

9. Global Strategy Agreed Nov 2005 1 Stop influenza in animals through stamping out the disease at the place where the infection starts 2 Prevent emergence of pandemic by limiting human exposure; • if pandemic does start, contain it quickly; • if containment is not possible, mitigate pandemic consequences. 3 Countries in lead: Support from Global Partnership

10. Pandemic preparedness: interventions • Pharmaceutical: use of antiviral drugs, vaccine & escalated medical services • Non-Pharmaceutical: personal Hygiene, PPE, travel restriction, social distancing, quarantine & risk communication Multisectoral & community Cooperation Requires strong leadership & Support of Govt.

11. GETTING PREPARED 1 • GOALS • Early Detection, Investigation and Confirmation, Containment • STRATEGIES • Social distancing, personal protection, movement restriction, maintenance of essential infrastructure • Systematic use of anti-viral therapy (oseltamivir) • Rapid development and equitable distribution of effective vaccines (Major controversy: will poor countries have access)

12. GETTING PREPARED 2 • APPROACH • Plan to mitigate effects of pandemic on Local Communities: Economies, Governance, Basic Needs, Border Movements • Build Resilience through high level of popular awareness, understanding and engagement • Government reaching out to and working with Private Entities and Voluntary Bodies • Government and voluntary bodies preparing for large scale Humanitarian Relief

13. GETTING PREPARED 3 • PROCEDURES • Robust information systems established • Protocols developed for use of stockpiles, emergency operations • Civil society, NGOs, local government, Private Sector synchronized • Systems for disseminating information to public via media developed and tested • Continuity plans for different entities simulated and lessons applied • Concept for putting multiple plans into practice, together, developed and put to test

14. Need for preparedness • Reduction of transmission of the pandemic virus strain • To decrease cases, hospitalizations and deaths • Maintenance of essential services • Reduction of economic and social impact

15. Pandemic Preparedness - Strategies Planning activities started in 2004 Highest Political commitment National Consultation Multi-sectoral involvement Knowledge gap filled through WHO guidelines

16. Multisectoral Approach • Involvement of government sector at many levels, and people with various specialties: • Policy development, legislative review and drafting • Animal health • Public health • Patient care • Laboratory diagnosis, research & development • Risk communication • Disaster management

17. Multiple Sectors involved(1) • Human Health: Contain the pandemic Medicines, Commodities, Equipment, R and D, Patient Care, Lab services • Financial Services: Keeping financial systems going Banking (cash and settlements), financial regulation, risk management and insurance • Utilities, Personal Services: Electricity, Water, Food, Telecoms, Postal services, Retailing (Catering for the needs of the most vulnerable) • Transportation– Logistics, Business, Leisure: Supply systems Air, sea, rail; Ports; Pilgrimages; Sports and other events; Tourism

18. Multiple Sectors involved(2) • Government, Security, Military: Public Services, Rule of law, Judiciary and Correction, Private Security, respect for rights • Information Management: Transparency Strategic communication; Broadcast and print; Good use of internet • Environment and hygieneBiosecurity: Cleaning, Maintenance, refuse management, wildlife • Food and Livestock Production Growing, Processing, Marketing and Distribution of animal meat for human consumption

19. Preparedness for Avian/ pandemic influenza in India

20. National Scenario India-7th largest country areawise 2nd most populated (1 billion+ popn.) High Population Density in urban settings Major poultry sector- ranks among the top 5 nations in egg production in the world 1,00,000 wet lands

21. National Scenario (contd) Falls on the route of two major flyways of migratory birds AI entrenched in SEA 1918 outbreak killed 7 million people with one of the highest CFR An influenza pandemic would have substantial impact on the growing economy .

22. Preparedness for AI in India • Inter Ministerial Task Force & Joint Monitoring Group • Contingency Plan finalised • Training of RRTs • Stockpiling of drugs, PPE & critical care equipments • Laboratory strengthening & Networking – ICMR & IDSP Labs • Surveillance for seasonal influenza • International Partnership on Avian & Pandemic Influenza (IPAPI) Meet – 4-6 December 2007, New Delhi • Risk communication

23. Legal and Institutional Frame work • National Disaster Management Act-2005. • National Disaster Management Authority established 2006. • National Crisis Management Committee. • National Influenza Pandemic Committee. • Inter-ministerial Task Force for Sectoral Co-ordination. • Joint Monitoring Group for monitoring. • National Task Force on Communications in I& B ministry • Technical Committee for Laboratory Strengthening, vaccines, Import of poultry Products etc.

24. Operational Frame-work • Ministry of Health: Nodal Ministry for Biological Disasters at National level including AI • Dept of Animal Husbandry: focal point for Animal Health • State Health and Animal Husbandry Departments: nodal agencies in states to operationalize State plans • District authority: implementing agency at grass root level • Disaster Management Authorities: National, State and District level

25. Proposed AI Lab network Referred samplesProvides Resources IDSP

26. Risk Communication UNICEF with MOHFW has developed material targeted at three communication clusters: preventing an outbreak controlling an outbreak emergency response to pandemic. Communication tools have been identified and creative ideas being further refined

27. IEC MATERIAL

28. Situation of AI Outbreak in INDIA

29. Avian Influenza Outbreaks in India No human case reported in India

30. Avian Influenza Outbreaks in Poultry, India - 2008 Dated: 17 December 2008 Map not to scale

32. Human surveillance in affected area • Micro planning at block level (house to house activity ) - 0-3 KM daily • 3-10 KM bi-weekly • Screening of PUI /suspect at each level • Surveillance worker to medical officer • Medical officer to RRT members • Mechanism for collection and transportation of human sample (s) • Surveillance workers • Protective equipment • chemoprophylaxis

33. Selected public health measures • Bird Handlers /Cullers • Use of Personal Protection Equipment • Chemoprophylaxis with Oseltamivir • Daily health check up • Quarantine • During culling • Post culling period

34. Institutional set up • Identification of designated institution • Block Primary Health Center with isolation facility • Referral sub-divisional /district hospital with facility for critical care (27 such hospital are already set) • ID hospital at state level with facility for critical care • Capacity building of human resources • 54 nos of state RRT trained by GoI • 1st and 2nd line of state RRT allocated for each district • Arrangement of transport facility for shifting of patient. • Arrangement for sending clinical samples.

35. IEC Materials used during Outbreak Interpersonal communication with the community members Leaflets containing essential messages Posters & Handbills Audio / Video CD’s & Short films for circulation through local cable channels Public messages through ‘news dailies’ Information through DOHFW website IEC materials prepared in collaboration with UNICEF CD containing TV clippings and short film for circulation through local cable channel

36. Lessons Learnt • Inadequate inter-sectoral coordination • Problem in total destruction of backyard poultry • Surveillance of infection in poultry/birds to detect early focus – need strengthening • Quarantine – difficulty in operationalization • Infection control practices – use of PPE in hot & humid atmosphere • IEC – need strengthening Unsafe practices IEC material

37. AI/ PI Plans • National Pandemic Preparedness Plan • Contingency plan for managing avian influenza in poultry • Contingency Plan for management of human cases of avian influenza

38. AI/ PI Plans: Objectives • International, National, State & District Level co-ordination. • Identification of roles & responsibilities of all stake holders. • Prevent /delay entry of novel virus • Stamp out the disease if appearing in small clusters • Institutionalizing mechanism for developing sufficient quantity of vaccines. • Availability of adequate quantity of anti-viral drugs

39. Critical Issues in the Pandemic Plan • Sectoral Coordination • Surveillance • Augmenting critical care • Stockpiling of drugs • Management of Mass casualties • Disposal of dead bodies • Border/ Port/ Airport Control • Imposing trade and travel restrictions

40. India’s Pandemic Preparedness plan Scenario 2- India involved We have to face it ?

41. Estimated Time Frame? It would be unrealistic for any state/ country to consider that it could prepare and implement a detailed and comprehensive pandemic plan in weeks, or even months. Time is now Start preparing

42. Balanced Approach – the best Strategies that employ all aspects of the preparedness will have the greatest likelihood of success • Building healthy public policy • Creating healthy environments • Strengthening community action • Building personal skills • Reorienting health services Maintain significant investment in research and effective intervention strategies.

43. Action springs not from thought, but from a readiness for responsibility G.M.Trevelyan (1876-1962)

44. Actions to be taken at Industry Level 3 main aspects of preparedness at industrial level • Information & Technology • Infrastructure • People / Employee

45. Information & Technology • Strengthened the key communication services such as email etc.. • Increased capacity for employees to work from home • Enhancement of Remote conferencing( eg: 24x7 outbreak monitoring cell NICD) • Distance / elearning platform for educating employees on behavior during pandemic should be incorporated by all industries It is important to build and test redundancy during non pandemic times.

46. Infrastructure • Workplace preparedness • Protocols on social distancing • Protocols on seating inside the office to ensure a distance of minimum one meter from next employee • Closure of common areas, meeting rooms, cafeteria etc • Wash rooms with proper ventilation with doors opening inside • Identification / equipping employee quarantine room in each location • Protocols on “Deep” cleaning of workplace • Training employees to maintain respiratory hygiene at workplace

47. People / Employee In the services business people are the most critical resource, during a pandemic the dependency on critical resources will increase multi-fold • Identification of critical skills • Procured supply of Personal Protective Equipment • Protocols on Self evaluation mechanism for employees • Methodology for identification of Backup resources • Work from home Strategy • Distribution of IEC material to the employees

48. Long wait for vaccine Influenza epidemic, New York, 1947. Times photograph Prevention is easy…. • but where is the vaccine Thank You