Health Interventions For Pandamic Influenza Preparedness

Health Interventions, Tools, & Modules For Humanitarian Organizations & Local Partners For Pandemic Influenza Preparedness At Household & Community Levels in Developing Countries Health Working Group Humanitarian Pandemic Preparedness (H2P) Initiative (IFRC, CORE Group, AED, InterAction, UN, USAID) February 9, 2009 Draft (Revisions after the Dec. 11, 2008 draft are highlighted in yellow)

CONTENTS I. II. III.

General Approach Interventions & Tools Modules

I. GENERAL APPROACH • For an introduction to avian & pandemic flu, please see: Avian Influenza Frequently Asked Questions, WHO, Revised 5 December 2005: www.who.int/csr/disease/avian_influenza/avian_faqs/en/index.html. • For H2P pandemic planning assumptions (“Preparing for Which Pandemic?”), and for more information on H2P health interventions, please see www.coregroup.org/h2p/. • For a more detailed list of key pandemic flu planning assumptions, please see sections III – VII of: www.savethechildren.org/publications/technicalresources/avian-flu/aifipp/Flu_Assumptions_Matrix.doc & CIDRAP, Univ. of Minnesota, Pandemic Influenza Overview (regularly updated) www.cidrap.umn.edu/cidrap/content/influenza/panflu/biofacts/panflu.html The Health Technical Working Group is supporting two categories of health interventions: • Those that are fairly specific to pandemic flu, such as non-pharmaceutical interventions (NPIs) to reduce person-to-person flu transmission, & • Those that are more general, such as interventions to reduce the indirect health impacts of a pandemic. Interventions to reduce indirect impacts, such as moving case management of childhood illness from health facilities to the community (CCM, as described by WHO, see below) have substantial potential benefits that extend well beyond pandemic periods. For example, CCM (community case management of childhood illness) is an important strategy (even during inter-pandemic periods!) to increase access to & use of life-saving case management services in areas of high under-five mortality & poor access to existing services. So in many settings, there is a strong rationale for implementation of CCM at scale now, & for H2P advocacy & support for implementation of CCM at scale as soon as possible. On the other hand, although it is desirable for H2P & local partners to conduct planning workshops in as many districts as feasible, as soon as possible, in as many H2P countries as possible, there are good reasons for expecting that much pandemic-

specific planning at district & community levels (such as planning for implementation of NPIs & home care) will happen only after being “triggered” by a higher threat of imminent pandemic onset (such as WHO declaration of sustained human-to-human transmission – new WHO Phase 41) than is the case now, during Phase 3. Levels of funding & in-country perceptions of the importance (compared to the many other competing priorities) of pandemic-specific district-level planning now, at scale, may make it unlikely that effective planning workshops will be held in a high percentage of the 500 or so districts in Ethiopia, for example, or even in most of the 75 districts of Nepal. Where workshops are conducted, district-level government & other local partners are likely to send lower level staff to participate, given the 1 www.who.int/csr/disease/influenza/PPWGupdate_WHOWebVersion.pdf comparatively low level of importance now accorded to pandemic flu. Given the high levels of turnover of district-level staff in many countries, it is likely that many staff who participate in workshops in the near future will have been transferred long before the pandemic-specific plans need to be implemented. Therefore, a focus of pandemicspecific health-related activities will be to develop “off-the-shelf” fully prepared & deployed capacity among several in-country partners at national & sub-national levels, to rapidly roll out district-level planning & training for community interventions in as many NGO/RC/partner work sites as possible, with minimal support from outside these sites. This will initially involve work with global partners to identify, revise, and/or develop generic guidelines for developing countries, & then adaptation of these guidelines for use in each country. This will include the definition of triggers (e.g. WHO declaration of Phase 4, following sustained person-to-person transmission resulting in community outbreaks in one or more countries) for implementation of these interventions at scale during the few weeks that the vast majority of all communities will have before the arrival of the first pandemic wave in their geographic area. The idea is to train national & district-level community health program managers & other key partner staff, through national/sub-national-level workshops, & district-level workshops to the extent that this is feasible, in what they should do differently during a pandemic – focusing on a few changes to existing programming which could be achieved in only a few days training of existing community health workers (CHWs) & community leaders, following notification of the triggering event. Planning will also ensure that NGOs & local partners will have required pre-approval & support to rapidly implement planned actions. In each of the selected countries, partners will test/drill the implementation of these interventions from national level down to selected communities in as many districts as feasible, & incorporate results into the country-level plans. Materials for district-level workshops & community-level testing in the near future should be based on a scenario of likely imminent local arrival of a severe pandemic wave (local outbreak) following a recent

triggering event (such as WHO declaration of Phase 4, following evidence of sustained person-to-person transmission in another country). Materials based on this scenario will be more useful once this triggering event has actually occurred (in the future), & more interesting for workshop participants now, in Phase 3, than materials & workshop curricula designed for a much less imminent threat now during Phase 3. Health interventions are grouped below into modules, based on criteria such as the target group (family members, CHWs, community leaders, etc.), complexity of the intervention, current state of global guidance, & expected duration of the process of in-country adaptation. (Please see Section III, below.) II. INTERVENTIONS & TOOLS 1. Non-pharmaceutical interventions (NPIs) to reduce transmission at household & community levels: Includes respiratory etiquette, hand washing, social distancing of adults & children, & voluntary isolation of the ill (and voluntary quarantine of the exposed, if the pandemic is severe). Some of these NPIs require substantial pre-pandemic planning & would only be implemented in a moderate and/or severe pandemic, & thus depend on a pandemic severity index (not yet available from WHO), while others require less pre-pandemic planning & would be recommended even for mild pandemics. (Please see Section III, below.) Tools: As far as we know, detailed guidance on how to implement community-level NPIs, along with a pandemic severity index, are not yet available for developing country settings. (WHO may release draft guidance related to these issues in the near future. See: Revision of the Pandemic Influenza Preparedness Guidance - An Update on the Drafting Process, 16 July 2008: www.who.int/csr/disease/influenza/PPWGupdate_WHOWebVersion.pdf) Currently available tools include: • Recommendations for nonpharmaceutical public health interventions, WHO 2005 checklist: Annex 1 of the WHO Global Influenza Preparedness Plan: www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_200 5_5/en/, • Nonpharmaceutical Interventions for Pandemic Influenza, National and Community Measures, WHO Writing Group, Emerging Infectious Diseases, January 2006 (literature review & summary recommendations): www.cdc.gov/ncidod/EID/vol12no01/pdfs/05-1371.pdf, • February 2007 interim US strategy for community mitigation (Detailed howto guidance on NPIs & severity index): www.pandemicflu.gov/plan/community/mitigation.html.

• Non-Pharmaceutical Interventions for Use By Developing Countries During a Human Influenza Pandemic, CDC & USAID (Undated January 2008 5 page document) • Module I Content: Household Mitigation, H2P Health Working Group draft document (at: www.coregroup.org/h2p/) (These tools may be an adequate basis for starting country-level adaptation in developing countries.) 2. Home- & community-based care of those ill with influenza: Home-based care refers to the guidance given to families on caring for household members ill with an influenza-like illness. Community-based care refers to community & CHW activities to advise & support families on home-based care, & care for families unable to care for themselves (due to concurrent illness among all of a household’s potential care-givers or household resource constraints). www.who.int/diseasecontrol_emergencies/HSE_EPR_DCE_2008_3rweb.pdf), notes that, "During a pandemic, extremely high numbers of patients presenting to the health-care facility will necessitate home treatment for large numbers of infected patients," & that, "All health-care workers, caregivers & patients should be provided with information, in the local language, regarding the illness & symptoms, mode of transmission, treatment & possible consequences" (but the document fails to provide any guidance on home care, beyond infection prevention). During the next pandemic, the vast majority of all ill persons around the world will be cared for in their own places of residence. Pandemic influenza preparedness & mitigation in refugee & displaced populations: WHO guidelines for humanitarian agencies, May 2008 ( WHO/UNICEF: Informal discussion on behavioural interventions for the next influenza pandemic, 12-14 December 2006, Bangkok: Summary and recommendations (www.unicef.org/influenzaresources/files/WHO_UNICEF_API_Mtg_Bangkok_Dec_ 06.pdf) notes that, “pandemic preparedness which emphasizes what can be done locally regardless of access to vaccines or antiviral drugs is crucial to enable citizens to take appropriate action to protect themselves & their families, before, during & after a pandemic in order to reduce transmission & minimize illness & death, as well as social & economic disruption.” Although this document does not describe the content of home care, it provides a strong rationale for the importance of it: • “Health services will be overwhelmed & will be unable to cope with demand. • “Anti-virals may not be available.

• “Minimizing the number of caretakers will in turn minimize the exposure of other family members to the virus. • “Knowing how to care for sick people at home may reduce the severity of illness or complications & increase their chances of survival. • “May help reduce panic when communities feel confident in handling a situation requiring self-care or home-based care of someone who has fallen ill. • “Severe complications need to be treated by appropriate health personnel.” (Knowledge of which complications to seek care for can promote appropriate care seeking & reduce the burden on health services due to inappropriate care seeking.) Additional reasons for the importance of guidance on home care include: • Over-utilization of health services due to the lack of guidance on home care will lead to crowding & influenza transmission at health facilities. • The inadequacy of current IMCI, ARI, & pneumonia guidelines: Although influenza is an acute respiratory infection, & flu may be referred to as “severe respiratory illness,” as influenza diagnosis will likely be unavailable in many settings, IMCI & ARI guidelines focus on the identification of children with pneumonia for prompt treatment with antibiotics, not on home care. (Guidelines for diarrhea may be more comparable to what is needed for pandemic flu: a focus on home care, especially hydration, along with information on when to seek care outside the home.) • Health workers with whom our organizations are working around the world will be asked for & expected to provide basic guidance on home care during the next pandemic. • The importance of adequate hydration for those ill with influenza: Dr. Grattan Woodson (see below) believes that prevention & treatment of dehydration in those ill with the flu will save more lives than any other intervention during the next flu pandemic. Dr. Woodson’s 17-page guide on influenza home care (which goes well beyond what might be included in generic guidance for families in developing countries, but much of which might be considered for guidance on community-based care) includes advice on: • Identification & treatment of dehydration • Treatment of adults with fever • Treatment of chills & body aches & pains • Treatment for sore throat, nasal/sinus/ear congestion, cough, chest pain, & headache • Treatment of nausea, vomiting, diarrhea, & abdominal pain

• Diet & exercise • How to keep children with flu comfortable • Dehydration in children • Treating children for cough, runny nose, fever, nausea, vomiting, & diarrhea • Pandemic psychology Tools: There is a growing body of literature on home care for flu, from & for North American jurisdictions (including government of the province of Alberta, the state of Massachusetts, & the American Red Cross, along with those cited below). The focus of guidance in these is very similar, with differences mainly in the level of detail. However, as far as we know, there is a complete lack of any guidance of this kind for developing country settings. Generic home care guidance for local adaptation in developing country settings is an important gap which urgently needs to be addressed. Currently available: • The gold standard on home care may be Good Home Treatment of Influenza by Grattan Woodson, MD, FACP: www.birdflumanual.com/ or www.fluwikie.com/pmwiki.php?n=Consequences.PandemicPreparednessGuide s#Woodson • Among the abbreviated versions, one of the best is that of Seattle/King County (in Washington state): www.kingcounty.gov/healthservices/health/preparedness/pandemicflu/care.asp x (These tools, written for North American settings, appear less than adequate for starting country-level adaptation in developing countries.) 3. Reduce indirect health impacts (Continue to treat potentially fatal diseases, such as pneumonia, malaria, diarrhea, AIDS, & TB, under conditions of disrupted health services). Local planning for continuity of key services, an important intervention which cuts across sectors, will likely be an important component of this intervention. Tools: • Reducing excess mortality from common illnesses during an influenza pandemic: WHO guidelines for emergency health interventions in community settings, October 2008. (This includes recommendations for modification of existing health services, such as providing 12 weeks supply of medications to HIV & TB patients & focusing on only life-saving interventions, & recommendations for moving case management of childhood pneumonia,

diarrhea, & malaria to the community level before and/or during a pandemic.) www.who.int/diseasecontrol_emergencies/common_illnesses2008_6.pdf Tools for continuity of key services: • Pandemic Preparedness Planning for US Businesses with Overseas Operations, 4 pages, Jan. 5, 07 (www.pandemicflu.gov/plan/business/businessoversea.html), • Government of New Zealand pandemic flu Business Continuity Planning Guide, October 2005, remains an excellent 68-page resource with practical tools (www.med.govt.nz/irdev/econ_dev/pandemic-planning/businesscontinuity/planning-guide/index.html); • Pandemic influenza preparedness & mitigation in refugee & displaced populations, WHO guidelines for humanitarian agencies, May 2008, (www.who.int/diseasecontrol_emergencies/HSE_EPR_DCE_2008_3rweb.pdf); • Avian & Pandemic Influenza Planning Assumptions, & Westport / Washington Summary Preparedness Matrix, Save the Children (US), (www.savethechildren.org/publications/technical-resources/avian-flu/aifipp/19Flu_Planning_Assumptions_Matrix112706.doc) (These tools may be an adequate basis for starting in-country planning for continuity of key services.) 4. Other interventions being considered: (a) Early Warning / Surveillance? (of suspected flu in humans – critical for triggering local implementation of NPIs & triggering training for household & community-based care): Whether or not we would do surveillance, or at what level we would work at, would depend heavily on the country. Community based surveillance is applicable almost anywhere in the world given that surveillance has not trickled down to the community level thus far. For many SE Asian countries, national level surveillance protocols have been established. Elsewhere, this could be a key preparedness intervention at the national level. Tools for national level work: • WHO is working on a community health worker monitoring form to collect very simple data during an influenza pandemic. • WHO guidelines for investigation of human cases of avian influenza A(H5N1) • WHO case definitions for human infections with influenza A(H5N1) virus • WHO guidelines for global surveillance of influenza A/H5 (All can be found at www.who.int/csr/disease/avian_influenza/guidelines/en/)

• International Health Regulations (www.who.int/csr/ihr/en/) • PAHO-CDC Generic Protocol for Influenza Surveillance (www.amro.who.int/English/AD/DPC/CD/flu-snl-gpis.pdf) • A very good example of national public health surveillance protocol for human cases of avian flu (and identifying clusters, etc) is PATH’s work in the Ukraine. “Surveillance & Control of Human Cases of Avian Influenza” Provisional Guidelines for Public Health Services in Ukraine (www.path.org/publications/details.php?i=1484) • There is something similar being worked on for Africa • CDC is also working on standardizing reporting forms • For community level work, CARE has programs & materials for activities in 5 countries, but community level surveillance is highly specific to context – creating a generic handbook is difficult & a lot of adaptation is needed. (http://icarenews.care.org/avianflu.html) (b) Psycho-social? Woodson has a section on this. (c) Communications • WHO outbreak communication guidelines (2005): www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/index.html (d) Others? • Community guidance to families on home stockpiling? (The October 2008 WHO draft guidance for web-based review notes that, “during a pandemic, it is important for households to consider storing food and daily medicines at home.”) The H2P Food Security Working Group is addressing this issue. • Handling of bodies? • Preparedness for first level health facilities? • Lines of succession for critical roles in communities? III. MODULES Health interventions are grouped into modules, based on criteria such as the target group (family members, CHWs, community leaders, etc.), complexity of the intervention, current state of global guidance, & expected duration of the process of in-country adaptation. In some countries, it may be feasible to adapt Module I content comparatively rapidly, & test/train for this down to the communitylevel, while adaptation & testing/training for Module II proceeds more gradually. In some settings, it may be appropriate to present how other countries have addressed Module II interventions, at district and/or local-level workshops, & seek input from workshop participants on how they would adapt & implement these interventions in their area, even before adaptation has been completed at national level. Important findings from district & local workshops should inform adaptation & revision of

guidelines & training materials at national level. Module I. Household Mitigation Criteria: (a) Focused at family / household level (b) Minimum/basic interventions (c) Focused on communications & behavior change (d) Not requiring a pandemic severity index (interventions for all pandemics, irrespective of severity) (e) Fairly generalizable across countries/settings – requiring little in-country adaptation (f) Not requiring extra supplies / drugs from outside the community (g) Can be implemented by a broad range of community volunteers without detailed planning by community leaders Content: i. What is pan flu ii. Transmission iii. What families can do to reduce transmission (respiratory etiquette, hand washing, keeping your distance from others, & voluntary isolation of the ill) iv. Signs v. Home care vi. Care seeking outside the home vii. Community communications to promote & support families in the above Main Challenges: • Lack of home care guidance for developing country settings Examples of Materials: • WHO/UNICEF: Informal discussion on behavioural interventions for the next influenza pandemic, 12-14 December 2006, Bangkok: Summary and recommendations www.unicef.org/influenzaresources/files/WHO_UNICEF_API_Mtg_Bangkok_ Dec_06.pdf • Seattle/King County on home care (& on reducing transmission at family level): www.kingcounty.gov/healthservices/health/preparedness/pandemicflu/care.asp x • Module I Content: Household Mitigation, H2P Health Working Group draft document at www.coregroup.org/h2p/. (WHO is working on a generic

home/community based care document to guide local NGOs, faith-based organizations, & communities. We hope that this WHO guidance will soon render this draft H2P document unnecessary.) • Training curricula, H2P Health Working Group draft documents Module II. Community Mitigation Criteria: (a) Focused on community-level / community-wide activities (b) Requires more detailed planning by community leaders (c) Requires a pandemic severity index (interventions for moderate / severe pandemics) (d) Requires substantial in-country adaptation (e) Also (as in Module I) not requiring extra supplies / drugs from outside the community Content (additional to that of Module I, education of families on prevention & home care): i. What communities can do to reduce transmission: Social distancing of adults and children, such as dismissing classes (KG – university), closing child care centers, reducing out-of-school mixing of children and students, reducing nonessential travel and overcrowded transport, and other measures to limit public crowding, gathering, mixing, or contacts (such as closing, cancelling, restricting, or modifying: sports events, worship services, theatres, funerals, weddings, parties, and/or workplace practices). ii. Infection prevention for CHWs iii. Community support (incl. care, food, water) for families unable to care for themselves (due to illness among all of the household’s potential care-givers or household resource constraints). iv. Continuity of care for selected health conditions, if feasible (such as providing 12 weeks supply of medications to HIV & TB patients, & focusing on life-saving interventions, such as treatment of malnutrition, safe delivery, and essential newborn care) v. Early warning and other information (on pandemic onset and approaching wave - keeping communities informed regarding numbers, location, and severity of cases; and on the best sources of information and guidance.) vi. Addressing community perceptions and concerns. vii. ? Psycho-social support? viii. ? Handling of bodies? ix. ? Lines of succession for critical roles in communities? Main Challenges (additional to those of Module I):

• Lack of guidance for developing country settings on a pandemic severity index & on how to implement community-level NPIs • Need for substantial in-country adaptation & approval process Examples of Materials: • February 2007 interim US strategy for community mitigation (NPIs): www.pandemicflu.gov/plan/community/mitigation.html, • For community-based care: Woodson: www.birdflumanual.com/ or www.fluwikie.com/pmwiki.php?n=Consequences.PandemicPreparednessGuide s#Woodson • For continuity of care for selected health conditions: Reducing excess mortality from common illnesses during an influenza pandemic: WHO guidelines for emergency health interventions in community settings, October 2008: www.who.int/diseasecontrol_emergencies/common_illnesses2008_6.pdf Module III. Community Case Management (CCM) Criteria: (a) Requires substantial extra supplies / drugs from outside the community (b) Requires more extensive training & support of CHWs to master new skills. Content: i. Moving case management of pneumonia, diarrhea, and/or malaria to the community level (by CHWs) before and/or during a pandemic. (The H2P HWG suggests that, if CCM is permitted in country, that pandemic preparedness activities include planning for the continuity of drug supplies to CHWs, and consider whether or not CHWs should receive guidance and antibiotics to treat pneumonia in older children &/or adults. This is important because a high percentage of pandemic flu-related mortality is expected to be due to secondary bacterial pneumonia. If CCM is NOT permitted: Consider meeting with WHO & UNICEF to consider advocacy with MOH for permission to introduce CCM.) Main Challenges: • Funding & logistics: Need for substantial extra supplies / drugs from outside the community (particularly in those areas where this is implemented only after news related to possible pandemic onset). • Time & resources (following news of the triggering event) for more extensive training & supervision of CHWs to master new skills (particularly in those

areas where this is implemented only after news related to possible pandemic onset). • Need for substantial in-country adaptation & approval process (unless CCM is already permitted). Examples of Materials: • Reducing excess mortality from common illnesses during an influenza pandemic: WHO guidelines for emergency health interventions in community settings, October 2008: www.who.int/diseasecontrol_emergencies/common_illnesses2008_6.pdf