Text WHO Global Influenza Programme NIC Role during a pandemic and NIC contingency plan Wenqing...

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WHO Global Influenza Programme

NIC Role during a pandemic and

NIC contingency plan

Wenqing Zhang MDGlobal Influenza Programme, WHO HQ

THE 3rd MEETING OF NATIONAL INFLUENZA CENTRES IN THE WESTERN PACIFIC AND SOUTH EAST ASIA REGIONS

18-20 August 2009 • Beijing China

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Epidemic and Pandemic Alert and Response - WHO Global Influenza Programme

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NIC TOR– Stable for long-term, "glue" and "lubricant" of a Network

• Seasonal influenza surveillance and support to WHO vaccine virus process• Detection of emerging virus

– Minimum technical requirement to become a GISN member

NIC Role in monitoring and responding to the threat of human influenza– Precise roles of NICs during all the different stages of pandemic preparedness and

response– WHO recommendation - implementation depending on national authorities– NOT to replace NIC TOR

NIC Contingency plan development guidance– Guidance to prepare for pandemic response

Laboratory surveillance and response guidelines during a pandemic – under development

– Guidance to respond during a pandemic

- A package for NICs -

Key GISN documents related to NICs

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NIC role during a pandemic

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Pandemic preparedness and response phases

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Structure of recommendation of NIC role

Consistent with the WHO guidance: Pandemic Influenza Preparedness and Response

– Planning and coordination

– Situation monitoring and assessment

– Reducing the spread of disease; and

– Communications.

All recommended activities intended to continue in higher phases unless replaced

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During a period of high alert – WHO phase 4

Definitions– Phase 4: H-2-H transmission able to sustain at community-level

• Not necessarily mean a pandemic is to take place

NIC objectives– Early detection of novel virus infection in humans

• Geographically – assisting the decision making of rapid containment• If rapid containment operation undertaken, enhanced surveillance in place

– Assisting WHO and national authorities on:• Pandemic risk assessment • Development/update of vaccine viruses, diagnostics etc

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Planning and coordination– Affected countries

• Rapid containment– Whether or not to mount– If yes, assisting national authority an enhanced surveillance system

• Ensuring continuity of lab surveillance– Sampling strategy developed, reviewed, adjusted– Selection criteria developed jointly with WHO for sending representative specimens

to CCs during rapid containment operation

– All countries• Implementation/adjustment of surge capacity plans• Reviewing lab diagnostic strategy• Be aware of and taking actions to any new WHO surveillance criteria• Measures in place to protect lab workers


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Situation monitoring and assessment

– Affected countries• Testing and sharing of specimens

– Representative cases for testing: time sequential; symptom; geographical location; potential epi history …

– Testing; characterization; alert to variant – Timely shipping all/selective specimens/virus isolates to WHO CCs

• Supporting the effective clinical management of infection– Continuing monitor susceptibility of antivirals to emerging virus strains– Rapid sharing of information significant of public health with WHO and national

authorities

– All countries• Assistance to national authorities - systematically organizing specimen testing• Advice to the country on lab testing algorithms and surveillance criteria• Testing specimens from all suspected cases


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During a pandemic – WHO phases 5-6

Definitions– Phase 5: novel virus established H-2-H transmission at community level

in at least 2 countries in one WHO region

– Phase 6: in addition, at least one other country in another WHO region

NIC objectives– Affected countries

• Assisting national authorities on mitigating pandemic impact• Monitoring the evolution of the novel virus

– Countries not yet affected• Support detection of start of a pandemic to trigger interventions

– All countries• Assisting WHO and national authorities on:

– Pandemic risk assessment – Development/update of vaccine viruses, diagnostics etc

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Planning and coordination– Review lab components of national plan and implementation as

required

– Periodic review to sustain NIC diagnostic functioning

– Adjustment of sampling/testing strategy

– Be aware of update of guidance on biosafety requirements, specimen collection, storage and transport and selection of viruses to CCs

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Situation monitoring and assessment

– Affected countries• Adjustment of lab surveillance from individual case diagnosis to overall

monitoring • Monitoring the percentages of novel virus and seasonal viruses co-circulating• Adequate surveillance assist WHO/GISN monitoring antigenic evolution and

antiviral susceptibility• Timely sharing representative viruses/specimens with WHO• Timely sharing findings of public health significance with WHO, national

authorities and general public

– Unaffected countries• Update of plans/strategies developed based on gained experience from affected

countries• Maximizing surveillance for rapid detection of first cases

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After a pandemic

Unknown of one wave or multiple waves

NIC objectives– Review and recovery

• Rebuilding NIC capacity, immediately

• Ready for "next" wave

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After a pandemic Post-peak period

– Continuing virological surveillance to support WHO on:• Percentage of novel virus detections among all influenza virus circulating

• Vaccine virus update

• Antiviral susceptibility

• Diagnostics update

• Pandemic risk assessment

– Capacity restore

– Gap/lesson/experience review

– Possible research studies

Possible new wave

– Same as that for phases 5-6

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After a pandemic Post-pandemic period

– Same as that for post-peak period

• In particular on the proportions of circulating influenza viruses – which will become seasonal influenza viruses …

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Summary – NIC role NICs most likely the primary source of expertise in surveillance and response to

influenza epidemics and pandemics

Triggering many of the well-planned interventions depending on NICs' effective functioning

– Proved by the recent H1N1 event

GISN – WHO coordinated efforts on laboratory/virological surveillance, preparedness and response

– Significant contribution to response to routine and emerging influenza problem

– NICs are the backbone

NIC role in all different phases interlinked

Influenza, at its core, a virus problem– Respect to science and nature

– Working as a team globally

Science and knowledge – key to success

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NIC contingency plan

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Why a NIC contingency plan

Lab response/service - a key and indispensible component of overall national/global response

Significantly increased level of demand for lab service expected

– … and proved by recent response

– Most likely exceed routine NIC operations

Ensuring effectiveness and continuity of NIC functioning

– Political and institutional commitment needed

– Coordination from high-level e.g. from MoH

Need planning in advance

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How to develop a NIC contingency plan

Assessment on anticipated surge level that will be put on the NIC

Identification of the actions and resources needed to establish and maintain the required "surge capacity"

– Ensuring the availability of premises, staff and equipment

– Stockpiling supplies

– Testing strategies, protocols and algorithms

– Lab biosafety and transport of specimens

– Data management

– Communication

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Ensuring the availability of premises, staff and equipment

Availability of lab and office space– Extra lab and office needed during a pandemic

• Helpful to transfer lab diagnostic technologies to other labs– Additional freezer space needed during a pandemic– If BSL3 lab available, priority reserved for flu-related work

Availability of trained staff– Adequate training in advance– Engaging workers in other labs possibly– Less-well-trained staff could assist with task e.g. tracking specimens, preparing specimen

collection kits etc– NIC to keep a full list of available staff and their relevant training– A plan of work shifts and backup personnel in place– Medical surveillance plan in place

Equipment– Should have a back-up power source– Other back-up equipment e.g. biosafety cabinet, PCR machines, incubators either purchased in

advance or sourced from other labs– Increased storage capacity– NIC to keep an updated inventory of all lab equipment

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Stockpiling supplies

Stockpiling reagents

– Not all have long shelf life, and delivery of supplies might be long lead-time

– In general, a stockpile sufficient for at least 3 months of current NIC activity could be a good strategy

– NICs may wish to establish networks and reach agreement on the exchange of reagents in order to meet short needs

Stockpiling of/access to antiviral drugs

– In coordination with MoH/occupational health

Stockpiling of PPE

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Testing strategies, protocols and algorithms

Testing strategy

– should be based on national strategies for pandemic surveillance and the capabilities and resources of the lab

– Lead-up and early stages, every specimens to be tested

– While virus widespread, selection criteria for specimens to be tested should be established and applied

Testing protocols

– Each protocols must be thoroughly validated before being put into routine use

– To be agreed upon with epidemiologists and network members

Testing algorithms

– In line with national and global pandemic surveillance strategies

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Laboratory biosafety and transport of specimens

Lab biosafety and biosecurity

– Biosafety cabinet

– Understanding and training on practice at appropriate biosafety levels

– Seasonal vaccination among lab workers

Transport of specimens in-country

– Possible disruption of or refusal by routine transport system

– SOP in place with coordination from high level national authorities

Transport of specimens to reference labs and WHO CCs

– WHO guidelines on specimens/virus shipping followed

– International transport arranged according to IATA regulations

– Import/export permits obtained in advance

– Personnel handling shipping trained

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Data management

Conventional filing of forms and results– At the very minimum and essential

– and be maintained to provide back-up if electronic systems down

Electronic systems– Best use existing systems to avoid additional duplicated work

– As simple as possible to keep key information

– Remaining possibility to expand the system

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Communications

Successful NIC response has to be team work

A robust communication network established in advance– MoH, national lab network, WHO, WHO CCs, NICs, other partners

GISN communication platform for timely and informal communications

FluNet reporting – lab surveillance findings

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Summary – NIC contingency plan

Lab surge capacity is anticipated and inevitable

The better planned/prepared,

– the less chaos in a lab handling pouring in specimens and under pressing stress

– the better continuity of NIC quality service

Individual NICs individual plans

Commitments from MoH and host institution is key

"NIC contingency plan" not just another document

– Reassurance to success of national and global pandemic response

– Protection of NIC staff – precious asset of a country

Take actions!

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