REPUBLIC OF ESTONIA
MINISTRY OF SOCIAL AFFAIRS
INFLUENZA PANDEMIC PREPAREDNESS PLAN
Prepared by Kuulo Kutsar MD, PhD Advisor in Epidemiology Health Protection Inspectorate
Revised
August 2005 December 2005 April 2006 July 2007
TALLINN 1
2004
CONTENTS
ABBREVIATIONS AND ACRONYMS.................................................................................. 6 1. FACTORS INFLUENCING INFLUENZA PANDEMIC.................................................. 7 PREPAREDNESS .................................................................................................................... 7 1.1 Definition of influenza pandemic.................................................................................. 7 Influenza case definition........................................................................................................ 7 1.2 Pandemic influenza viruses .......................................................................................... 7 1.3 Experience from earlier influenza pandemics............................................................... 8 1.4 Influenza complications of medical-economic importance ........................................... 9 1.5 Health system expenses for ensuring influenza pandemic preparedness .....................10 1.6 Arrangement of influenza surveillance ........................................................................11 2. MAIN COMPONENTS OF THE INFLUENZA PANDEMIC PREPAREDNESS PLAN .............................................................................................................................................12 3. MAIN INDICATORS FOR ENSURING INFLUENZA PANDEMIC PREPAREDNESS .............................................................................................................................................12 1. Risk analysis for ensuring influenza pandemic preparedness......................................12 2. Chain of command and management ..........................................................................13 3. Communications ..........................................................................................................13 3.1 Communication to the public ........................................................................................13 3.2 Communication to the cooperation partners ..................................................................13 4. Legal acts .....................................................................................................................13 5. Influenza pandemic preparedness action plan .............................................................14 6. Influenza surveillance..................................................................................................14 7. Laboratory investigation of influenza cases .................................................................15 8. Epidemiological investigation of influenza outbreaks..................................................16 9. Clinical management of influenza patients..................................................................17 10. Management of infection control by health service providers ......................................17 11. Prevention of influenza transmission among the population .......................................17 11.1 Health protection activities..........................................................................................17
11.1.1 Personal hygiene requirements ............................................................................................17 11.1.2 Prevention of infection spread among the population..........................................................18 11.1.3 Quarantine and social distancing ........................................................................................18 11.1.4 Restriction or banning of travelling or trade .......................................................................18
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Influenza vaccination ..................................................................................................18
12.1 Influenza risk groups...............................................................................................................19 12.2 Seasonal influenza vaccination ...............................................................................................20 12.3 Pandemic influenza vaccination..............................................................................................20
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Prevention and treatment of influenza .........................................................................20 Functioning of vitally important services.....................................................................21
14.1 Health care system ..................................................................................................................21 14.1.1 Family doctor activities........................................................................................................21 14.1.2 Emergency medical service ..................................................................................................21 14.1.3 Active care hospitals ............................................................................................................22 14.2 Other vitally important services ..............................................................................................22
15. Influenza post-pandemic period...................................................................................23 4. COOPERATION PARTNERS FOR ENSURING INFLUENZA PANDEMIC PREPAREDNESS ..............................................................................................................23
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5. MOBILIZATION OF RESOURCES ................................................................................24 6. INFLUENZA PANDEMIC PREPAREDNESS PHASES AND LEVELS........................25 7. RESPONSIBILITIES OF THE REPUBLIC OF ESTONIA AS A EUROPEAN UNION MEMBER STATE IN ENSURING INFLUENZA PANDEMIC PREPAREDNESS ......27 7.1 Planning and coordination ..........................................................................................27 7.2 Situation monitoring and assessment...........................................................................27 7.3 Prevention and spread containment.............................................................................28 7.4 Arrangement of communication ..................................................................................29 8. INFLUENZA PANDEMIC PREPAREDNESS ACTION PLAN .....................................29 Influenza inter-pandemic period...........................................................................................29 Phase 1..................................................................................................................................29 1. Planning and coordination ..............................................................................................29 2. Situation monitoring and assessment...............................................................................30 3. Prevention and containment............................................................................................30
3.1 Procurement and stockpiling of vaccines, antivirals, personal protective equipment ..............30
4. Health care system response ...........................................................................................31
4.1 Availability of health care and ambulance service ...................................................................31 4.2 Management of health protection activities ..............................................................................31 4.3 Management of logistics............................................................................................................31
5. Communications.............................................................................................................32 Phase 2..................................................................................................................................32 1. Planning and coordination ..............................................................................................32 2. Situation monitoring and assessment...............................................................................33
2.1 Surveillance of influenza and influenza-like illnesses:..............................................................33 2.2 Influenza laboratory surveillance .............................................................................................33
3. Prevention and containment............................................................................................33
3.1 Procurement and stockpiling of vaccines, antivirals and personal protective..........................33 equipment ........................................................................................................................................33
4. Health care system response ...........................................................................................33
4.1 Availability of health care and ambulance service ...................................................................33 4.2 Management of health protection activities ..............................................................................34 4.3 Management of logistics............................................................................................................34
5. Communications.............................................................................................................34 Influenza pandemic alert period ...........................................................................................34 Phase 3..................................................................................................................................34 1. Planning and coordination ..............................................................................................35 2. Situation monitoring and assessment...............................................................................35 3. Prevention and containment............................................................................................35 4. Health care system response ...........................................................................................35 5. Communications.............................................................................................................36 Phase 4..................................................................................................................................36 1. Planning and coordination ..............................................................................................36 2. Situation monitoring and assessment...............................................................................37 3. Prevention and containment............................................................................................37 4. Health care system response ...........................................................................................37 5. Communications.............................................................................................................38 Phase 5..................................................................................................................................38 Level 1-3............................................................................................................................38 1. Planning and coordination ..............................................................................................38 2. Situation monitoring and assessment...............................................................................38 3. Prevention and containment............................................................................................39 4. Health care system response ...........................................................................................39
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5. Communications.............................................................................................................39 Level 4 ...............................................................................................................................40 1. Planning and coordination ..............................................................................................40 2. Situation monitoring and assessment...............................................................................40
2.1 Surveillance of pandemic influenza and influenza-like illnesses...............................................40 2.2 Influenza laboratory surveillance .............................................................................................40
3. Prevention and containment............................................................................................40
3.1 Final procurement and stockpiling of needed antivirals, antimicrobials and...........................40 personal protective equipment ........................................................................................................40
4. Health care system response ...........................................................................................41
4.1 Availability of health care, intensive care and ambulance services..........................................41 4.2 Management of health protection activities ..............................................................................41 4.3 Management of logistics............................................................................................................41
5. Communications.............................................................................................................41 Influenza pandemic period....................................................................................................41 Phase 6..................................................................................................................................41 Level 1-2............................................................................................................................42 1. Planning and coordination ..............................................................................................42 2. Situation monitoring and assessment...............................................................................42
2.1 Surveillance of influenza and influenza-like illnesses ...............................................................42 2.2 Influenza laboratory surveillance .............................................................................................42
3. Prevention and containment............................................................................................43
3.1 Management of antivirals, vaccines, antimicrobials and personal protective ..........................43 equipment stocks .............................................................................................................................43
4. Health care system response ...........................................................................................43
4.1 Availability of health care, intensive care, mechanical ventilation and ambulance .................43 services 43 4.2 Management of health protection/public health activities ........................................................43 4.3 Management of logistics............................................................................................................43
5. Communications.............................................................................................................44 Level 3 ...............................................................................................................................44 1. Situation monitoring and assessment...............................................................................44
1.1 Surveillance of influenza and influenza-like illnesses ...............................................................44 1.2 Influenza laboratory surveillance .............................................................................................44
2. Prevention and containment............................................................................................44
2.1 Management of antivirals, antimicrobials, vaccines.................................................................44
3. Health care system response ...........................................................................................45
3.1 Availability of health care, intensive care, mechanical ventilation and ambulance .................45 services 45 3.2 Management of public health activities.....................................................................................45 3.3 Management of logistics............................................................................................................45
4. Communications.............................................................................................................45 Level 4 ...............................................................................................................................45 1. Situation monitoring and assessment...............................................................................45
1.1 Pandemic influenza surveillance...............................................................................................45 1.2 Laboratory surveillance ............................................................................................................46
2. Prevention and containment............................................................................................46
2.1 Management of vaccines, antivirals during first wave..............................................................46
3. Health care system response ...........................................................................................46
3.1 Availability of health care and ambulance services during first wave......................................46 3.2 Management of health protection activities ..............................................................................46 3.3 Management of logistics............................................................................................................47
4. Communications.............................................................................................................47
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Level 5 ...............................................................................................................................47 1. Situation monitoring and assessment...............................................................................47
1.1 Pandemic influenza surveillance...............................................................................................47 1.2 Influenza laboratory surveillance .............................................................................................47
2. Prevention and containment............................................................................................47
2.1 Management of vaccines and antivirals....................................................................................47
3. Health care system response ...........................................................................................48
3.1 Availability of health care, intensive care and ambulance services..........................................48 3.2 Management of health protection activities ..............................................................................48 3.3 Management of logistics............................................................................................................48
4. Communications.............................................................................................................48 Post-pandemic period............................................................................................................48 1. Planning and coordination ..............................................................................................48 2. Situation monitoring and assessment...............................................................................49
2.1 Surveillance of influenza ...........................................................................................................49 2.2 Laboratory surveillance ............................................................................................................49
3. Prevention and containment............................................................................................49
3.1 Management of vaccines, antivirals, antimicrobials and personal protective ..........................49 equipment ........................................................................................................................................49
4. Health care system response ...........................................................................................49
4.1 Availability of health care, intensive care and ambulance services..........................................49 4.2 Management of health protection/public health activities ........................................................50 4.3 Management of logistics............................................................................................................50
5. Communications.............................................................................................................50 9. RECOMMENDATIONS AND PROBLEMS TO BE RESOLVED..................................50 10.REFERENCE DOCUMENTS ...........................................................................................52 11.FUNCTIONAL APPENDICES OF THE PLAN...............................................................53
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ABBREVIATIONS AND ACRONYMS
ECDC EHIF EISS EC EU EMEA LG MoD MoEAC WHO OIE MoA SAM MoF MoIA MoSA IHD HCB HPI HSP UT MoFA VFB EWRS GR European Centre for Disease Control Estonian Health Insurance Fund European Influenza Surveillance Scheme European Commission European Union European Agency for the Evaluation of Medicinal Products Local Government Ministry of Defence Ministry of Economic Affairs and Communications World Health Organization International Office for Epizootics Ministry of Agriculture State Agency of Medicines Ministry of Finance Ministry of Interior Affairs Ministry of Social Affairs Institute for Health Development Health Care Board Health Protection Inspectorate Health Service Provider University of Tartu Ministry of Foreign Affairs Veterinary and Food Board Early Warning and Response System Government of the Republic
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1. FACTORS INFLUENCING INFLUENZA PANDEMIC PREPAREDNESS
1.1 Definition of influenza pandemic A pandemic is called an extremely enormous influenza epidemic spread widely across the state borders occupying many countries and continents and accompanied by a high rate of morbidity and mortality of the people. At the level of contemporary knowledge it is not possible to predetermine the emerging of an influenza pandemic and avoid its development. An influenza pandemic threat occurs in case when • A new influenza virus subtype appears which has not before circulated in a human population, • A new influenza virus subtype active transmission from human to human finds confirmation and • A new influenza subtype has a high human pathogenicity. Influenza case definition Clinical description Clinical picture with compatible characteristics (a severe onset, high fever, headache and muscular pain, cough). Laboratory criteria for diagnostics Possible diagnosis. • High titer of A- or B-influenza virus antibodies in a blood serum sample. Confirmed diagnosis. • Detection of influenza antigen or influenza virus specific RNA, • Isolation of influenza virus from clinical investigation material or • Demonstration of a specific 4-fold antibody response to influenza A- or B-virus in pair sera. Case classification Possible case • An influenza compatible case which is epidemiologically linked with a confirmed diagnosis case Confirmed case • A laboratory confirmed compatible influenza case. 1.2 Pandemic influenza viruses First of all influenza A viruses have a pandemic capacity. The influenza viruses with such capacity may emerge first through profound change of antigenic structure of the virus during several years and secondly, as the result of recombination of human influenza virus with avian or animal influenza virus. In both cases the human immune system is defenceless with regard to a new antigenic type of virus for which reason the human pathogenicity and spread capability are especially high. The influenza virus with pandemic capacity appears into circulation, as a rule, unexpectedly for which reason at the first stage of epidemic or pandemic a new antiviral is absent. Close communication between the different countries, extensive and fast travelling, but also the urbanization and overpopulation contribute to the spread of a pandemic-capable influenza virus. 7
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1.3 Experience from earlier influenza pandemics It is possible to prevent the pandemic influenza virus spread through a quick isolation of an infected influenza patient in hospital or at home, medical monitoring and restricting close contacts and public communication of the influenza patient, public communication on pandemic prevention and control measures. Effective clinical, laboratory/virology and epidemiological surveillance system is an important element of pandemic influenza preparedness. Serological studies are required to determine the immune structure and actual immunity state. In arranging influenza surveillance, ensuring the preparedness for pandemic and communication with WHO and EC/ECDC the National Influenza Centre is of crucial importance. The National Influenza Centre should have a laboratory/virology base that is able to detect the appearance of new and pandemic viruses in circulation: - to isolate influenza viruses - to perform genetic subtyping of influenza viruses - to investigate the drug resistance of new and pandemic influenza virus strains - to approbate fast diagnostic methods of a new strain of the influenza virus - to accomplish the tasks of the influenza reference laboratory or mediate ordering this service • Immunization and a prophylactic use of antivirals are important tools for prevention and control of influenza epidemic/pandemic. • According to the data of WHO the development of a new pandemic influenza virus subtype vaccine takes minimum 5-6 months and maximum 8-10 months. Therefore during this period for the protection of the population and risk groups reserves of influenza antivirals, preferably those basing on neuraminidase inhibitors should be stockpiled. Antivirals suppressing neuraminidase have an antiviral effect of typical influenza viruses as well as human/avian H5N1 and H7N7 influenza viruses. Probably antiviral medications basing on neuraminidase inhibitors have an antiviral effect also in case of new mutating strains of influenza virus • Immunization against pneumococcal infection reduces essentially pneumonia morbidity and consequent mortality. • At the national level in case of suspected human threat of avian influenza contamination epidemiological and laboratory/virological surveillance should be accomplished in cooperation with the veterinary service • Government should develop effective pandemic influenza preparedness system on the basis of the action plan. • The estimated duration of an influenza pandemic is 6-8 weeks. Estimated losses of health care field during an influenza pandemic • 50% of doctors and nurses will fall ill • The waiting time of a patient for an outpatient visit will be extended at least to 15 hours • Approximately 95% of population health care need falls to outpatient health care system 8
Efficacy of influenza seasonal vaccine Healthy adults – 70%-90% Elderly adults – reduces complications and deaths 70%85% and hospitalization frequency 25%-50% Estimated indicators for population morbidity and mortality during an influenza pandemic • Morbidity during a seasonal influenza epidemic is 5%-15% of the population and 40%-50% of the elderly people • In the USA an annual seasonal influenza average mortality is 7.5 – 23.0 cases per 100 000 population and among the elderly persons over 65 years of age 30-150 cases per 100 000 population • USA seasonal influenza and pneumonia mortality has been 9.4% (2004) Pandemics Morbidity Number of deaths per 1000 population 1.1%-2.2% 6.45 0.04-0.11% 0.59 0.12-0.31%% 0.74 Mortality
Spanish influenza H1N1 (1918-1919) 25-30% Asian influenza H2N2 (1957-1958) 30-80% Hong Kong influenza H3N2 (1968-1969) 15-40%
1.4 Influenza complications of medical-economic importance Influenza is an acute respiratory viral infection which often causes severe respiratory and non-respiratory system complications with high mortality. Influenza complications increase the workload of the providers of health services and treatment costs. Due to influenza complications the loss of workforce and working hours are very high as the treatment of severe complications may last for several weeks or they may also end fatally. Influenza complications and fatal cases develop mainly in young children, elderly people aged over 65 years and immunodeficient persons for the reason of which those groups of population belong to the influenza risk groups. The most frequent influenza complications are a damage of the respiratory system – first of all pneumonia (bacterial, viral or mixed bacterial-viral etiology), cardiovascular diseases (myocarditis, pericarditis, fibrillation of ventricles, exacerbation of chronic heart diseases), muscular damage (myositis, rhabdomyolysis), damages of the central nervous system (encephalitis, transversal myelitis) and Reye syndrome (complex damage of liver and central nervous system). The economic loss of influenza epidemic in the developed countries is estimated 10-60 million USD per one million population. The ability of a state and its health care system to cope with a biological health hazard, among them with an influenza pandemic, depends to a great extent how comprehensively the state has prepared to combat them and protect the population. The preparedness capacity for an influenza pandemic is determined by the existence of a comprehensive plan and its timely and coordinated implementation. Proceeding from the above-said the objectives of the realization of the influenza pandemic preparedness plan are as follows:
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Health protection of the population of the state and sustaining its working capacity Prevention of catastrophic social and economic results of an influenza pandemic and avoidance of social-economic losses Warrant mutual supportive cooperation with EC, WHO and interested countries Warrant timely preparedness of all sectors of the health system and response capacity to influenza pandemic Determine the responsibilities and functions of MoSA, its administrative institutions, health service providers and cooperation partners for realization of the preparedness plan Avoid or minimize panic and fear among the population, health service providers and functionally important cooperation partners Warrant normal living and working activity under the conditions of the pandemic or minimize its harmful disorders due to high influenza morbidity and mortality Rational use of resources and means of the country during the pandemic to minimize the high morbidity and fatal complications To warrant the influenza pandemic preparedness the interdependency of the extent of morbidity, loss of workforce and prejudice of vital activity of the population are taken into account: • In case the influenza epidemic/pandemic morbidity is 10% of total working-capable population, it causes an essential load to functioning and vital activity of the population of the country • In case the influenza epidemic/pandemic morbidity is 25% of the total working capable population, in addition to the above-said, additional great difficulties arise in meeting the daily needs of the population and ensuring normal everyday life; the health care system is deeply overburdened and the availability of health services is minimum. • In case influenza epidemic/pandemic morbidity is 50% of the total working-capable population, a catastrophic situation develops in the country.
1.5 Health system expenses for ensuring influenza pandemic preparedness • Procurement and ensuring influenza vaccine, pneumococcal vaccine and antiviral medicines for the risk groups, strategically and operatively important officials performing professional tasks and for the population (point 11.1). • Implementation of the influenza pandemic preparedness plan: - Ensuring the preparedness of the health system, implementation of ordinary and additional measures (personal protective equipment, lungs ventilation devices etc) for the health staff providing active care; - Ensuring the preparedness of the health protection/public health system, necessary ordinary and additional measures (establishment of the National Influenza Centre, introduction and financing of the influenza sentinel surveillance system, designation of the influenza reference laboratory, carrying out sero-epidemiological surveys and building a laboratory complex of biosafety level 3.
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1.6 Arrangement of influenza surveillance MoSA has designated HPI as the public health institution responsible for surveillance management. In accordance with the regulation of the Government of 27.11.2003 No 297 “The Act for Prevention and Containment of Communicable Diseases” influenza epidemiological, clinical and laboratory/virology surveillance is carried out routinely year-round and enhanced surveillance during the influenza seasonal rise – from week 40 to week 20 of the following year (from October to May). The influenza case definition serves as a basis for influenza surveillance (point 1.1). Estonia participates in the EISS surveillance system of the EC/ECDC and World Health Organization communicable disease surveillance system. Influenza clinical surveillance is managed by family doctors, infectious disease consultants and other specialists. In practice, laboratory surveillance is managed only by the HPI Central Laboratory Virology Laboratory and TU Clinics United Laboratory Virology Laboratory and epidemiological surveillance by HPI and its regional and county institutions. The most important phase in early detection of a new pandemic influenza virus is influenza virological surveillance. For diagnosing influenza during the period other than epidemic/pandemic a rapid method or serological investigation are used both of which do not detect appearance of an influenza virus subtype with a new antigenic structure into circulation. Therefore the MoSA will have to establish a requirement that during the influenza seasonal epidemic rise (from October to May) virological laboratories should investigate samples, one of which would be performed by a rapid method (RT-PCR) and would isolate viruses on tissue culture and determine the antigenic structure of the isolated virus and perform genetic identification. At the time when highly pathogenic human/avian influenza virus will emerge into circulation and its isolation on the tissue culture is most probable, the isolation of influenza virus on the tissue culture may be carried out in a virology laboratory with biosafety level 3 or 4. If a virological laboratory corresponding to the required safety level is absent in Estonia, the HPI will organize dispatching a positive sample to the WHO or ECDC influenza reference laboratory for identification the virus, determining the antigenic structure and genotyping. The surveillance of influenza complications and mortality rate due to its complications are not organized routinely in Estonia. In organizing the influenza pandemic preparedness the MoSA should introduce both the surveillance of influenza complications and mortality, however, at present it is proceeded from the data of the Death Register. Additionally it is necessary to collect the following data for planning the health care system pandemic preparedness: • mortality caused by influenza and pneumonia; • mortality of children caused by influenza; • data of hospitalization of adults and children caused by influenza.
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2. MAIN COMPONENTS OF THE INFLUENZA PANDEMIC PREPAREDNESS PLAN
The main components for the determination of the influenza pandemic preparedness are as follows: • Divide the influenza pandemic preparedness and response activities into phases and levels in accordance with ECDC and WHO standpoints; • Determine responsibilities of Estonia as an EU member state in integrated influenza pandemic prevention and control activities; • Determine influenza surveillance strategy, pandemic prevention and control and management coordination; • Communication plan and strategy; • Pandemic influenza preparedness Action plan. As an EU member state, Estonia participates in EC Communicable Diseases Surveillance Network activities and in the development of influenza pandemic preparedness in accordance with the enactments of EC Decision 2119/98/EC and in early information and quick response system activities in accordance with the enactments of EC Decision 200/57/EC and activities of EC Public Health Preparedness and Response Planning Commission (PRPG). To control effective implementation of the influenza pandemic preparedness plan progress surveillance indicators will be established and a relevant instruction will be developed. The influenza pandemic preparedness plan represents an inter-sectoral dynamic document the functionality of which will be checked through training and which will be amended on a regular basis.
3. MAIN INDICATORS FOR ENSURING INFLUENZA PANDEMIC PREPAREDNESS
1. Risk analysis for ensuring influenza pandemic preparedness • Acknowledge the importance and objectives of influenza preparedness at the national level • Ensure financing of implementation of influenza pandemic preparedness measures • The impact of an influenza pandemic on the state economy, social services, health care system, other vitally important services and health status of the population is assessed • The potential impact of use of antivirals and (pandemic) influenza vaccine on the population and risk groups is assessed • The needs of the population exposed to influenza pandemic (health services, the availability of economic and social services) are determined and their assurance are assessed • The operational capacity of the health care system is assessed
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The operational capacity of the health protection/public health system is assessed The national legislation capacity to support epidemic/pandemic activity is assessed
2. Chain of command and management • Chain of command, operational structure of the management system and decisionmakers are designated • Every designated person knows his/her operational tasks and area of responsibility in accordance with the action plan of the institution • Standard guidelines in accordance with operational functions are developed 3. Communications 3.1 Communication to the public • Information/communication plans to the public are developed • Communication target groups are determined • Communication channels are determined • To develop a national influenza pandemic Internet website • To ensure competence of the information to be communicated to the public • At every level to use spokesmen for communicating with the public • To hold regular press conferences 3.2 Communication to the cooperation partners • The information service of MoSA coordinates the communication of the cooperation partners • MoSA has a communication scheme with the cooperation partners • MoSA has defined communication key areas 4. Legal acts • Assessment of functionality of the Emergency Preparedness Act and the Communicable Diseases Prevention and Control Act and regulations developed on their basis to support the activities in implementing influenza pandemic prevention, control and preparedness • Assessment of functionality of valid legal acts in the conditions of influenza pandemic in epidemiological indications in the following fields: - restriction of travelling or movement of the people; - closing of children's and educational institutions; - banning of public gatherings; - isolation of infected persons; - establishment of quarantine; - restriction or banning of international trade; - compulsory vaccination and antiviral treatment/prophylaxis of the risk groups; - admittance of new vaccines and antivirals having no sale licence in Estonia in the shortest time; Conformity of the Estonian epidemic/pandemic control legal acts with the International Health Regulations, version of 2005.
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5. Influenza pandemic preparedness action plan • Influenza pandemic preparedness phase multi-sectoral action plan is developed, approved by the Government and is compulsory for all partners • According to the action plan activities and responsible executors are designated in every phase and level 6. Influenza surveillance According to the influenza preparedness plan influenza surveillance is: a) routine surveillance in the inter-pandemic period; b) enhanced surveillance (beginning with phase 2 of preparedness alert period; c) pandemic surveillance in the pandemic period. Routine surveillance in the inter-pandemic period The objective of a routine surveillance is: 1. to determine the intensiveness of seasonal influenza epidemic process; 2. to collect data for implementation of the influenza immunization plan; 3. early detection of unusual clusters and outbreaks, potentially caused by a new subtype of influenza virus; 4. communication to ECDC EWRS and participation in WHO Global Influenza Surveillance Network. The methods of a routine surveillance are: • Clinical and laboratory identification of influenza and influenza-like diseases in accordance with influenza definition and case reporting • Implementation of influenza clinical and virological surveillance sentinel-system • Detection of unusual acute respiratory disease death cases in the population • Detection of unusual acute respiratory disease death cases in health care institutions • Surveillance of group morbidity and unusual disease cases in institutions/enterprises • Monitoring of antivirals and antimicrobials purchase frequency • Influenza reference laboratory activity • National Influenza Centre which arranges influenza surveillance in the country and coordinates cooperation with WHO, EC and other, first of all veterinary avian influenza surveillance system, international organizations and neighbouring countries Enhanced surveillance (beginning with phase 2 preparedness alert period) In case group diseases with epidemic/pandemic potential or restricted outbreaks occur in Estonia or the countries having with Estonia close travelling or trade links, enhanced influenza surveillance is established – thus beginning with influenza pandemic preparedness alert period phase 2. Surveillance methods in addition to the routine methods are: • The data of the veterinary service of unusual death cases among wild/domestic birds or detection of avian influenza virus in the bird population
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Reports on unusual respiratory diseases or death cases among the workers of poultry farms, slaughterhouses and the veterinary system Reports on unusual respiratory diseases or death cases among the risk group health care workers, staff of influenza laboratories or mortuaries Monitoring of travellers arriving from influenza epidemic/pandemic or avian influenza risk regions Monitoring of media reports and rumours
Surveillance in the pandemic period The indicators of the pandemic period surveillance are: data collection with a view to use and distribution of resources, monitoring morbidity/mortality and characterizing epidemic process and making an adequate decision. The methods of influenza pandemic surveillance are: • Data collection on hospitalization of patients and disease-suspicious persons • Data collection on mortality of patients and disease-suspicious persons • Data collection on absenteeism from work/educational institutions • Data collection on use of pandemic influenza vaccine and immunisation coverage • Monitoring of side-effects of influenza vaccine • Monitoring of pneumococcal immunisation and vaccine side-effects • Monitoring of use and side-effects of influenza antivirals • Identification of pandemic influenza etiology, a selective laboratory diagnostics is performed 7. Laboratory investigation of influenza cases Tasks of a virology laboratory • Influenza laboratory minimum diagnostics capacity includes implementation of virus isolation and subtyping, immunofluorescence or RT-PCR methods. Commercial quick tests for determining influenza virus antigen are not sufficiently sensitive and specific. They do not ensure subtyping of a virus and for this reason they are not recommended for confirmation of a clinical diagnosis. Those testing sets may be used in absence of other methods only for investigation of influenza outbreaks. • The guidelines for sampling, maintaining and transporting of patient's material are developed and they are available for the health service providers (HSP) • MoSA recognizes as the leading laboratory for influenza laboratory diagnostics HPI Central Laboratory Virology Laboratory • HPI organizes transportation of highly infectious samples for investigation to WHO or ECDC reference influenza laboratories. By the power of attorney of MoSA, HPI has concluded cooperation agreement with a BSL-4 virology laboratory of the Swedish Communicable Diseases Institute. • Designated by MoSA virology laboratories are able to increase diagnostic capacity in the initial pandemic period when the number of diagnostic samples is greatest
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The designated virology laboratories determine in time the need for diagnostics, equipment and additional staff, their training and additional financing. MoSA guarantees covering the preparedness expenses of the laboratories The designated virology laboratories keep non-investigated samples (pharynx secretum, blood serum, etc.) that are investigated during the post-pandemic period MoSA has concluded agreements with WHO and ECDC reference laboratories for additional investigation of samples, isolation of influenza virus, subtyping or genotyping Virology laboratories assist HSP in interpretation of the results of laboratory investigations Virology laboratories investigate the development of antivirals resistance to influenza virus MoSA guarantees financing of the National Influenza Centre at the HPI. The National Influenza Centre should be recognized by WHO MoSA designates the National Influenza Reference Laboratory and finances its activities The tasks of the Influenza Reference Laboratory The Influenza Reference Laboratory verifies identified influenza viruses, in case of need types, subtypes and genotypes them The Influenza Reference Laboratory transports in case of need the patient's material containing influenza virus or identified influenza viruses to WHO or EC reference laboratory, following the guidelines of the International Air Transport Association (IATA) for packaging and transporting infectious materials
8. Epidemiological investigation of influenza outbreaks The objective of epidemiological investigation of influenza outbreaks is identification of the source of infection, mode of virus spread and tracking of contacts, monitoring of changes of epidemic process and planning of preventive and control measures • HPI establishes the number of trained epidemiologists required for accomplishment of epidemiological investigations and epidemic control measures in the conditions of an influenza pandemic and for work on the state border • HPI applies to MoSA for increasing the number of epidemiologists and financing the posts • MoSA guarantees financing of the 24/7 work schedule of duty-epidemiologists and EWRS • Identification of possible human-to-human transmission of a new influenza subtype and its source • Development of guidelines for epidemiological management of close contacts of the influenza patient, medical monitoring, isolation, observation of hygiene requirements, communication • Updating of epidemiological investigation and reporting documents in accordance with the needs of the influenza pandemic preparedness • In case of existence of epidemiological and clinical indication the influenza case definition will be reviewed
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9. Clinical management of influenza patients • Influenza patients and influenza-suspicious persons are hospitalized preferably at home (in case of extreme need in the facilities of alternative hospitalization) and necessary health services are ensured for them by general practitioners and emergency medical service; • Influenza patients in a serious general condition, with unstable vital functions and dangerous complications are hospitalized, if possible, in the infection departments, in increasing the number of such patients to the departments of a general, central or regional hospital temporarily adapted for the treatment of influenza patients, implementing infection control requirements; • HSP-s ensure taking a sample from an influenza patient or influenza-suspected person, its fast and safe packaging in accordance with requirements and fast transportation to the designated virology laboratory (necessary up to the development of the pandemic), • HSP-s ensure an effective clinical investigation, among them hospitalization for identifying indicators and meeting the treatment guidelines. 10. Management of infection control by health service providers • Hospitals adapt infection control regulations/guidelines taking into consideration the peculiarities of the new highly pathogenic subtype of influenza virus for preventing the spread in the facility and coordinate them with HPI local offices; • HPI local offices counsel in introduction of alternative hospitalization facilities for implementing expedient infection control requirements; • Hospitals train for infection control temporarily employed staff; • HSP implements effective personal protective equipment; • HSP provides influenza vaccination for the health care workers belonging to a risk group; • If indicated, a HSP ensures preventive influenza antiviral treatment of the risk group health care workers. 11. Prevention of influenza transmission among the population 11.1 Health protection activities • All partners of implementation of Influenza Pandemic Preparedness Plan know the legal framework for implementation of health protection activities • HPI communicates the population about the expected usefulness of the implemented health protection measures, however, also about possible modest efficacy • In implementing health protection measures ECDC and WHO recommendations are followed 11.1.1 Personal hygiene requirements • HPI communicates to the population on the measures for preventing droplet infection • HPI makes the measures for preventing droplet infection available for the population on an Internet website
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11.1.2 Prevention of infection spread among the population • Communication to the population on human/avian influenza modes and risk groups • Information material on prevention of human/avian influenza infection is developed for the population • Information material on prevention of human/avian influenza infection is developed for professional risk groups (workers of poultry farms and slaughterhouses, veterinary workers, etc.) • Information material on prevention of human/avian influenza infection is developed for the persons travelling to the risk regions and persons arriving from avian influenza risk regions • Influenza immunization and antiviral prevention plans for the population under risk are developed and implemented • Guidelines for influenza infection spread prevention in children's and educational institutions, hostels, nursing homes, defence forces and prisons are developed 11.1.3 Quarantine and social distancing • Ensure legal framework for closing children's, educational and cultural institutions • Ensure legal framework for banning mass gatherings • Ensure imposition of quarantine and for the people in quarantine legal framework for provision of health and social services, among them catering and psychological aid • Ensure legal framework for forced treatment and isolation • Ensure legal framework for identification, isolation and referring to treatment of persons been in contact with potentially infected persons 11.1.4 Restriction or banning of travelling or trade • Ensure restriction/banning of travelling or trade in epidemiologic indications in accordance with the Estonian and EC legal enactments and International Health Regulations (2005); • Coordinate restriction/banning of travelling or trade with GR, MoIA, MoFA, international transport companies and tourist agencies. 12. Influenza vaccination • Influenza vaccine is a cost-effective vaccine. Vaccination makes it possible to prevent high morbidity and mortality in the seasonal spread period as well as during an influenza outbreak/pandemic. As a rule, seasonal vaccination of the population takes place annually just before the beginning of the seasonal rise period. In Estonia the influenza vaccination is self-paid or is paid by the employer. Estonia does not have the national influenza vaccination program that should be developed taking into consideration influenza pandemic hazard. The production of a new influenza subtype specific vaccine will start at the initial period of an influenza pandemic when the mentioned virus is isolated and identified. The production of a new vaccine requires five to six months for which 18
reason during the first wave of influenza pandemic a new specific effective vaccine is most probably absent. Therefore the influenza vaccination may begin with an essential “delay”. To procure and deliver a new pandemic influenza vaccine as early as possible MoSA should conclude a procurement agreement with a potential manufacturer in time. 12.1 Influenza risk groups The safety link of an influenza pandemic chain is formed by influenza risk group people with a compromised immune system. Fast spread of a new influenza virus subtype among the people of influenza risk groups may in a short time release influenza epidemic/pandemic with a high morbidity and mortality. Therefore the people of influenza risk groups should be annually vaccinated. The most vulnerable persons of the influenza risk groups are: • Persons aged 65 or older (total number ~ 240 000), among them the persons having anaemia, chronic disorders of the pulmonary, cardiovascular, renal or metabolic system (first of diabetes mellitus) (~ 110 500) • Adults aged 18 18-64 years and young children (aged >6 months) having anaemia, chronic disorders of the pulmonary, cardiovascular renal or metabolic system (first of all diabetes mellitus) (~ 157 000) • Children and adolescents aged 6 months – 17 years (~ 265 000) • People with compromised immune system including immunosuppression caused by medications (~ 2000) and HIV-positive persons (~ 6000) • Pregnant women (~ 14 000) • Close contacts of the persons belonging to risk groups During an influenza epidemic/pandemic on epidemiological indications all persons carrying out operative and strategically important occupational tasks should be vaccinated: • Health care workers (physicians, nurses, emergency medical aid workers) (~ 14 000) • Health protection officials (~160) • Rescue workers, policemen, border guard, workers of detention institutions, etc. (~ 10 500) • Customs officials (~500) • Defence force (~5000) • Migration and Citizenship Board (~ 10), etc. In case of avian influenza danger in epidemiological indications endangered persons due to the character of their work: belong to influenza vaccination • Poultry farm workers (~200) • Veterinary workers (~100) As the most life-endangering complication of influenza is pneumonia development as the result of pneumococcal infection, ensuring influenza pandemic preparedness also the people belonging to the risk group of pneumococcal infection – infants, the people aged
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65 years or older, immunosuppressed people, chronic cardiovascular and pulmonary patients are vaccinated. In case of epidemic/pandemic belong to influenza vaccination strategically important persons (government leaders, essential representatives of energetic, food and water management sectors, etc.) on whom depends the functioning of the society (~ …). 12.2 Seasonal influenza vaccination • HSP-s and other institutions as employers having influenza risk groups vaccinate the workers belonging to influenza risk groups • Ensure high coverage of influenza vaccination of the workers belonging to a risk group • Arrange surveillance of side-effects of influenza vaccine 12.3 Pandemic influenza vaccination • Under the conditions of a pandemic for achieving an adequate immune level one person should be vaccinated with two doses of pandemic vaccine • MoSA ensures a possibly early procurement of influenza vaccine on the account of resources of the state budget • MoSA arranges transport, storage and distribution of pandemic influenza vaccine • HPI arranges cold chain handling of pandemic influenza vaccine • Priority risk groups for vaccination are determined (in case of avian influenza – workers of poultry farms, slaughterhouse, veterinary service, processors of broiler carcasses, health care and health protection workers, rescue, police and other workers of vital operative services • Outline accomplishment of vaccination of priority risk groups • Outline accomplishment of vaccination of other risk groups and the population • Outline establishment of vaccination centres, their supply with workers and training of temporary staff • Ensure safety of vaccination • Arrange surveillance of side-effects of pandemic influenza vaccine • Assess efficacy of pandemic influenza vaccine 13. Prevention and treatment of influenza Influenza antivirals are used for influenza prevention as well as treatment in an early phase of influenza infection. Influenza preventive treatment is used first of all for the people of a risk group (point 12.1). Influenza antivirals decrease influenza virus discharge from the organism of an infected person. In the initial phase of influenza pandemic they help to decrease essentially morbidity and mortality. Antivirals do not compete with an inactivated influenza vaccine. • MoSA develops antivirals use strategy during an influenza epidemic/pandemic and ensures its implementation • SAM ensures in the condition of an influenza pandemic the legal availability of medications and vaccines having or not having a sale licence in the country, reviewing the applications for sale licences and import or introduction permits by way of exception • MoSA arranges procurement, transportation, storage and distribution of antivirals
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MoSA arranges surveillance of use and assessment of efficacy, development of drug resistance and adverse effects HCB develops influenza prevention and treatment guidelines
14. Functioning of vitally important services All vitally important services should function during an influenza pandemic, of which the most important is the health care system. 14.1 Health care system The basic task of the health care system during an influenza pandemic is the provision of health care services for the influenza patients and sustaining of provision of health care services in a required amount for the other patients requiring emergency medical aid. The greatest workload falls on the outpatient part of the health care system (up to 98% patients need outpatient treatment) 14.1.1 Family doctor activities • Family doctors carry out an active informative work among the population before an influenza outbreak (various events and personal contacts with the persons entered into their register) on influenza prevention, nursing an influenza patient, infection safety measures and distribute corresponding information material; • In preparing for an influenza pandemic family doctors participate in professional advanced training, work through and make preparations for the implementation of influenza related guidelines; • Family doctors take an active part in influenza pandemic preparedness training; • Family doctors are supplied with necessary personal protective equipment and arrange their work following maximally infection safety requirements; • Family doctors and persons working together with them are influenza vaccinated; • Family doctors ensure the provision of services for the population during an influenza pandemic on all weekdays making appropriate reorganization of their work routine; • During an influenza pandemic family doctors arrange outpatient treatment of influenza patients and identification of patients requiring hospitalization and referring them for treatment; • During an influenza pandemic family doctors give recommendations for nursing an influenza patient; • Family doctors monitor influenza diseases of the people entered into their register and inform about this the local institution of the Health Protection Inspectorate; • In case of a disease of the family doctor the other health care workers working together with the family doctor continue provision of services in accordance with their qualification and the family doctor finds with the social and health department of the county government an opportunity for an expedient replacement during his/her disease. 14.1.2 Emergency medical service • For operating in case of an influenza pandemic, emergency medical service develops preparedness plans for accomplishment of tasks given it by the Health 21
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Care Board, coordinates those with the Health Care Board and arranges training to check them; In preparing for an influenza pandemic, emergency medical service participates in professional advanced training, works through and makes preparations for the implementation of guidelines; Emergency medical service takes an active part in influenza pandemic preparedness training; Emergency medical service workers are vaccinated against influenza; Emergency medical service has sufficient supplies of medical means for acting in the conditions of an influenza pandemic, it is supplied with required personal protective equipment and disinfection facilities; Emergency medical service is prepared to provide life saving service to the patients having influenza or influenza complications and in case of indications transport them to the corresponding intensive care hospital/ward.
14.1.3 Active care hospitals • For operating in case of an influenza pandemic active care hospitals develop preparedness plans for accomplishment of tasks given them by the Health Care Board, coordinate those with the Health Care Board and arrange training; • Active care hospitals arrange their staff training and for checking the preparedness level of their staff; • Active care hospitals have a directive for operating in the conditions of a pandemic; • Active care hospitals are prepared to restructure their bed occupancy; • Active care hospitals are prepared to hospitalize, isolate and treat and ensure active care for the patients having influenza or influenza complications; • Active care hospitals ensure infection control and prevention of hospital infection spread; • Active care hospitals ensure in hospitalization of influenza and other extraordinary patients observance of hospital care indications; • Health care staff of an active care hospital is influenza-vaccinated; • Active care hospitals arrange a rational use of health care workers and in case of diseases (absence) of the staff inter-hospital replacement; • Health care workers of active care hospitals are provided with the personal protective equipment, they are ensured possibly infection-safe working conditions; safe working conditions are provided for continuous functioning of the other essential staff; • Active care hospitals have sufficient supplies of medications, among them antibiotics for treatment of influenza complications; • The withdrawal/neutralization system of contagious biological waste is prepared for functioning in pandemic conditions. • 14.2 Other vitally important services • Local governments arrange burial of dead bodies
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Local governments develop influenza epidemic/pandemic preparedness and action plan They complete the required staff and arrange its replacement They arrange epidemic/pandemic preparedness training for the staff They provide the staff with personal protective equipment and arrange vaccination.
15. Influenza post-pandemic period After fading of influenza pandemic a recovery period begins in the country. • Health care and other vital systems develop operative recovery plans • Health care and other vital systems restore the activities in accordance with their customary structure and statutes • MoSA arranges an analysis of efficacy and drawbacks of influenza pandemic activities and replacement of spent resources and its financing plan • GR arranges an assessment of the socioeconomic impact and the results • MoSA ensures psychological and social support to the population
4. COOPERATION PARTNERS FOR ENSURING INFLUENZA PANDEMIC PREPAREDNESS
• • • • • • • • • • • • • • • • • • • • • • Ministry of Social Affairs Ministry of Interior Affairs Ministry of Finance Ministry of Agriculture Ministry of Foreign Affairs Ministry of Justice Ministry of Defence Ministry of Education and Research Ministry of Economic Affairs and Communication Health Care Board Health Protection Inspectorate Estonian Health Insurance Fund Health Service Providers Virology/microbiology laboratories diagnosing influenza and its complications Blood centres County governments State Agency of Medicines Medicine manufacturers Veterinary and Food Board Companies importing medicines Pharmacies European Commission - Surveillance Network of Communicable Diseases
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- ECDC - EISS - EMEA ● World Health Organization - Global Influenza Surveillance Network ● World Organization for Animal Health (OIE)
5. MOBILIZATION OF RESOURCES
● For the development of influenza pandemic preparedness MoSA arranges an analysis of required costs and submitting an application to the Government of the Republic for financing, among them: ● formation of additional permanent structures (National Influenza Centre, authorized influenza reference laboratory and stockpile of strategic vaccines); ● establishment of influenza sentinel surveillance system; ● finding, training and remuneration of additional work force managing temporary and permanent structures; ● procurement of influenza and other vaccines for mass vaccination of the population and risk groups; ● procurement of influenza medications for conducting treatment/prophylaxis of the population and risk groups; ● accomplishment of sero-epidemiological surveys (financing, arrangement of blood sera collection, supply with diagnostics, arrangement of research); ● provision of health care workers and health protection officials with personal protective equipment; ● life insurance arrangement/financing of health care workers and health protection officials working in infection danger; ● provision of active care hospitals with lung ventilation devices; ● creation of permanent epidemic containment fund for financing influenza pandemic/epidemic preparedness, prevention activities and epidemic control measures; ● establishment of a virology laboratory of biosafety level 3 (BSL-3) on the basis of the Virology Laboratory of HPI; ● routine annual seasonal influenza vaccination of risk group persons and starting public (MoSA) financing of this program; ● MoSA arranges an analysis of additional expenditures occurring during the influenza pandemic and submitting an application for their financing to the Government of the Republic; ● MoSA arranges an analysis of required costs to restore the state of vital systems corresponding to the pre-pandemic situation and submitting an application for their compensation to the Government of the Republic; ● the costs for provision of health care services are financed from the budget of health insurance, in case of need changing the agreements and financing principles of the corresponding year;
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● the costs of the emergency medical service and uninsured persons are financed during an influenza pandemic from the state budget; ● The Government of the Republic finances the costs that are connected with creation of preparedness, additional activity costs during an influenza pandemic and costs required for restoring the health care system.
6. INFLUENZA PANDEMIC PREPAREDNESS PHASES AND LEVELS
The Republic of Estonia follows in the development and implementation of Influenza Pandemic Preparedness Plan phases and levels recommended by the World Health Organization and recognized by the European Commission/ECDC with a view to implementation and cooperation coordination. Influenza inter-pandemic period Phase 1 Phase 1: No new influenza virus human pathogenic subtypes are circulating in the world and no disease cases caused by them are registered. The infection risk of the people with human-pathogenic subtype of the avian influenza virus circulating in birds/animals is in reality existent. Level 1: No new influenza virus subtypes have been detected in humans in Estonia. Estonia has no extensive travel/tourism or commercial links with the countries where the infection risk of the people with a human-pathogenic subtype of avian influenza virus circulating in birds/animals is existent. Phase 2: No infection with a new influenza virus subtype has been detected in humans in the world. The infection risk of the people with human-pathogenic subtype of the avian influenza virus is in reality existent. Level 1: No new influenza virus subtypes have been detected in humans in Estonia. Estonia has no extensive travel or commercial links with the countries where the infection risk of the people with a human-pathogenic subtype of avian influenza virus circulating in birds/animals is existent. Level 2: Estonia has extensive travel/tourism or commercial links with the countries where the infection risk of the people with a human pathogenic subtype of avian influenza virus circulating in birds/animals is existent. Phase 3: Human infections with a new influenza virus subtype occur in single cases, but the new virus subtype is not transmitted from a human to human or as an exception is transmitted from an infected person to a close contact person. Level 1: No human infection single cases with a new influenza virus subtype occur in Estonia. Estonia has no extensive travel or commercial links with the countries where single cases of human infection with a new virus subtype occur. Level 2: Estonia has extensive travel/tourism or commercial links with the countries where single cases of human infection with a new virus subtype occur. Level 3: Single cases of infection with a new subtype of influenza virus occur in Estonia.
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Phase 4: Small local limited-extent clusters (with up to 25 cases and duration of up to two weeks) influenza virus outbreaks occur in one or several inter-connected geographic regions. The number of infected persons (Ro) is 0