Pandemic Influenza Preparedness Planning Review

Previous Findings on Pandemic Influenza Preparedness Planning

Question:

Literature review on pandemic influenza national preparedness plans ( history, how closely they follow WHO guidance documents, usefulness, policy planning for influenza).
 

Influenza viruses achieve pandemic proportion once they spread rapidly leading to worldwide pandemics. Increase in awareness of threat caused by pandemic influenza on public health over the last few years has led to growing focus on “pandemic influenza preparedness planning” (PIPP) (Holloway et al., 2014). Such plans were made earlier but failed as it paid less attention to the requirements of the disadvantaged (World Health Organization, 2015). It is difficult to completely eradicate the influenza virus as it has many subtypes and all of them exist in aquatic birds. Moreover, it is difficult to predict the occurrence of next pandemic and severity of a disease. Flood or any other disaster-related planning taking place at the local scale may not be very robust in its response towards pandemic influenza that can impact the public health infrastructure. Every country must be able to strike a balance between preparedness and risk which is a challenge in planning for pandemic influenza. Planners and policy-making bodies should be capable to wisely allocate resources by making a realistic estimate of the pandemic outcomes. It will ensure that the heath care needs on the daily basis are not shortchanged.

In this literature review, the author aims to analyze the previous findings of these plans along with WHO guidance documents. The review will identify how closely the countries follow these guidelines and what are its benefits and usefulness. In this paper, there will be an emphasis on policy planning for influenza. Further, it will highlight the theoretical models behind pandemic influenza planning. It will also address the questions that if pandemic plans address modeling needs of researchers to make projections and forecasts. 

In 2003, the re-emergence of cases related to avian H5N1 triggered global efforts to support countries for increasing their capacity to detect novel influenza viruses (Iskander et al., 2013). In 2004, the “United States Centers for Disease Control and Prevention” (CDC) announced to help countries in enhancing their surveillance capacity (Fineberg, 2014). CDC through its bilateral cooperative agreements, with 12 countries has identified cases of H5N1 (Moen et al., 2014).

According to Shimabukuro & Redd, (2014) the aim of this agreement was to enhance epidemiology, surveillance, and laboratory infrastructure required for influenza detection. These provide the countries with training, funding and technical assistance to identify the gaps in surveillance and infrastructure and address them accordingly (Jonas & Warford, 2014). The states having established national influenza center (NIC) are only eligible to enter the CDC agreement provided they agree to share essential data and samples with the “WHO Global Influenza Surveillance and Response System” (GISRS) (Mei et al., 2013).

According to World Health Organization, (2013) the reports of “International Health Regulations”, 2013 the preparedness plan of the world is not accurate enough to mitigate health events of public. Therefore, multisectoral collaboration is required to overcome the threat. In 2013, WHO issued ‘Pandemic Influenza Risk Management' a guidance document to update and replace about response related to pandemic influenza preparedness. 

WHO Guidance Documents and Analysis

It aims to develop plans related to threats to public health. The concept it holds is that there should be a risk-based approach to managing public health emergencies.

• WHO supports and helps to meet IHR obligations by maintaining the strength of core capacities.
• It also governs policies by providing the ethical framework.
• It strengthens the GISRS and improves the laboratories for surveillance and diagnostics
• It promotes the production capacity globally for pandemic vaccines with the help of “Global Action Plan for Influenza Vaccines” (Cox et al., 2014)

According to Sun et al., (2014) the WHO recommendations, the PIPP will be maintained in line with “Pandemic Influenza Risk Management WHO Interim Guidance” and be revised by the member states. It also includes “National Pandemic Influenza Vaccine Deployment Plan” to be integrated with national PIPP. It recommends a perfect collaboration and coordination between stakeholders and other government sectors whose specific responsibilities are defined in NIPP. The plan also needs to include emerging hazards due to infectious diseases (Meeyai et al., 2013).

According to Uyeki & Cox, (2013) the WHO/ SEARO advocates and supports the countries to improve their emergency operation centers. WHO disseminates messages related to public health through media, press conference, and its websites. It is also responsible for providing financial and technical resources for implementing the “new WHO interim guidance”. Technical support of WHO includes:

• To improve the surveillance and data collection related to clinical, epidemiological and virological data. It helps to assess the "human-to-human transmission and the epidemiological situation."
• influenza-like illness risk assessment
• Interventions to reduce the disease spread (Stein et al., 2012)

WHO provides its member states updated guidance related to laboratory biosafety, infection prevention, and control, clinical management in health-care facilities, use of antiviral and home-based care, use of seasonal and pandemic vaccines (Bandayrel et al., 2013). Overall WHO facilitates the development of a system for impact assessment and its tool consists of guidelines, training and dedicated team for this purpose.

According to Reidy et al., (2015) all the member states (Nepal, Bhutan, Myanmar, Maldives, Indonesia, Sri Lanka, Thailand, and Timor-Leste) were ready with their NIPP during the 2009 pandemic hit. It was found that the plan was helpful in fighting the infectious diseases.

Figure: Risk assessment and recovery

(Source: Jonas & Warford,  2014)

Wangchuk et al., (2013) investigated that Thailand had sophisticated response system and developed its "self-learning business continuity plan online". Bangladesh laid its focus on reliable surveillance systems including information sharing system. It acts as the platform for monitoring the severity of influenza. According to Influenza, (2012) Sri Lanka showed the usefulness of “web-based influenza-like illness” and “severe acute respiratory infection surveillance systems”.

All the member states showed the high level of "political commitment" and described the response structures for pandemic preparedness (World Health Organization, 2015). According to Chowell & Viboud, (2013) all these countries have committees for facing national level emergencies such as “Prime Minister's Committees” (Williams et al., 2014).  Johnson et al., (2015) studied that Timor-Leste has "National Commission for Epidemic Control" which is powerful command structure supplemented with military support, working groups and civil societies.

According to Bhatia, (2013) all the member states have “Ministry of Health” help in organizing response at a national level. Jonas & Warford, (2014) described that Indonesia highlights the significance of "coordination spreading to sub-national levels" by the presence of "influenza outbreak command post” at provincial, district and central levels. Some countries such as Nepal, Bhutan have integrated the disaster management plan in the NIPP. (Azziz-Baumgartner et al., 2012) Criticized that most of the member states have implemented the “vaccine deployment plan” only in 2009 pandemic situation. Some of these countries like Nepal still suffer from an absence of skilled staff, decreased capacity for isolation spaces, inability to sustain the plateau level of response from the teams. They thus are unable to completely follow the WHO guidance documents (Chowdhury et al., 2016).

Policy Planning and Theoretical Models for Pandemic Influenza

Polansky et al., (2016) analyzed that some of the countries shifted from their priorities as a result of fatigue that followed after 2009 pandemic. Dewar & Robinson (2014) investigated that in almost all the member states the NIPP is reviewed but in Bangladesh and Nepal, the NIPP is revised but has not received approval from the higher levels.   Bastien et al., (2012) identified that some of these countries are experiencing the problem with "Risk communication" which was not entirely integrated into preparedness plan. There is a dilemma that to what extent media should be involved in information sharing as there are no guidelines related to it provided by NIPP. The other challenges faced by these countries as identified by (Charania et al., 2014) are: lack of zeal, interest, competence, cooperation between government sectors, decreased capacity for assessment of severity.

Uyeki & Cox, (2013) investigated that all the member states shared influenza viruses with GISRS and contributed towards sharing benefits by working with important private and public institutions and also continue its support of GISRS.

Reidy et al., (2015) explored the benefit of WHO guidance document and stated that it is useful in sharing the “PIP biological materials” such as influenza vaccine, pharmaceutical manufacturers and diagnostic, research and academic institutions” which are outside of GISRS. The other benefits are partnership contribution (Manufacturers using “WHO GISRS”, diagnostics and influenza vaccine contribute to WHO on the annual basis) which in turn helps in overall improvement of "global pandemic influenza preparedness" and response. The other factors of usefulness are

• Building surveillance capacity
• Establishment of antiviral vaccination
• Stockpiling of interpandemic vaccine
• Improvement of laboratory equipment (Jonas & Warford, 2014) 

In response to the spread of diseases like influenza, some significant health advances have taken place globally. WHO has issued a new policy named "Pandemic Influenza Risk Management" which guides on preparedness, understanding the dynamic of the disease and risk management of influenza (World Health Organization, 2015). WHO has taken initiative for Pandemic Influenza Preparedness Plan in Kathmandu, Nepal. The purpose of the program was to make the nation prepared for diseases management according to the guidance of WHO (Sanford et al., 2016). The primary objective of this program was to review to the current trend of the influenza pandemic in South-East Asia region and recommend new WHO guidance plan for the development of national preparedness plan in pandemic influenza (World Health Organization, 2015). The WHO member states (Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) updated their experience on preparedness (Hirve et al., 2016). The session addressed different approaches developed by each country to check increased rate of influenza (Forster, 2014).

There was risk-based planning to encourage member states to develop right plans by global risk assessment study done by WHO. WHO extended its technical cooperation in Bhutan for the period of 2014-2018. This is the fourth WHO Country Cooperation Strategy developed with the collaboration of Ministry of Health, national agencies, important stakeholders and health partners like United Nations for contributing to the health sector in Bhutan. This partnership is crucial for the improvement in the health of Bhutan citizens. Their target is to sustain Millenium Development Goals and increasing ways of prevention, monitoring and treatment of pandemic diseases like influenza (Dhingra et al., 2014). The unified goal is to reduce morbidity, mortality and achieving access to affordable health care service. For attaining the target of Millenium Development Goal, they have developed plans for strengthening prevention approaches. WHO has provided important funding to Bhutan to give technical support for management of pandemic influenza. WHO has provided assistance to the Ministry of Health for mobilizing additional resources for global health initiatives. The set priorities will help in the development of health risk management plan in the next five years. This unified support will harmonize support towards achieving national health goal for Bhutan (Crichton, 2015).

Influenza Detection and Surveillance

Other member states are also involved in the initiatives for managing the spread of influenza worldwide. Each member country described the challenges and best practices needed in their country to administer the pandemic influenza (Mei et al., 2013). Bangladesh stressed the need for reliable surveillance system monitor the severity of influenza disease through analyzing laboratory capacity and special surveillance in hospitals (World Health Organization, 2015). The health ministry of Sri Lanka suggested implementation of web-based influenza illness system. Many member countries suggested a need for identification of hazards, cross-border preparation plan and vaccine deployment plan for the disease. WHO helped in preparing response structure for pandemic preparedness. It provided support from political powers for fighting the pandemic (World Health Organization, 2015). In all the member states, Ministry Of Heath was involved in supporting national emergency committee, and they have played a role in raising nation level awareness through coordination of different sectors (Van Kerkhove et al., 2012).

According to Lässig and Łuksza, a fitness model is derived for haemagglutinin that predicts the viral population evolution from one year to another. In this model, two factors, deleterious mutations outside the epitopes and adaptive epitope changes are used to identify the strain’s fitness (Handel et al., 2013). Fitness components of the strains are concluded in the given circulating year through using the data of population-genetic of all past strains (Bull & Lauring, 2014). In the following year, the frequency of descendent strains is predicted from frequency and fitness of each strain. The researcher can map the adaptive history of influenza spread by using this fitness model (Sugita et al., 2013). This model also helps in selecting principle methods for vaccine selection (Łuksza & Lässig, 2014).

In a structured population, Sander had utilized a discrete-time, stochastic simulation model of influenza spread to compare different intervention strategies through their effectiveness. One publication is made to compare the predictions of the model with other research models. According to this model, a population was selected, which contains people communicating in known contact groups (Sander et al., 2009). As per the researcher, this model helps in stimulating the stochastic spread of influenza. It was assumed that each in the population meets people from neighborhood or households or people from larger community or neighborhood (Pybus et al., 2013). In this present population, it was observed that adults are in contact with workgroups and households, school-age children attend high, middle and elementary school, and preschool children attend larger day-care centers or small playgroups (Kolmanovskii & Myshkis, 2013). An infected individual after receiving treatment in this population modifies the other healthy outcomes, like hospitalization, pneumonia, bronchitis due to the spread of influenza. This model will help the researchers to stratify the population in an account of risk and age status. The age groups consist of older adults (65 years), younger adults (19–64 years old), children (5–18 years), and children (0–4 years) (Malosh et al., 2014). Younger adults are further stratified into low and high risk. While, High-risk adults have underlying chronic conditions, like, metabolic disease, respiratory or cardiovascular, that increases the risk of mortality, hospitalizations, pneumonia, bronchitis, etc.

Multisectoral Collaboration for Pandemic Preparedness

The occurrence of Influenza pandemics has found in the history, and it is associated with excess substantial morbidity and mortality. Wu and Cowling used the mathematical model of this infectious disease to permit the quantitative analysis of epidemic processes to depend on the underlying biological mechanisms (Wu & Cowling, 2011). In the past years, this model was used to know pandemic planning by allowing detailed assumptions of spreading rate of influenza and effectiveness of those alternative control strategies. During influenza pandemic of 2009, mathematical models were utilized to track the spreading rate of the virus, predict the time duration of the pandemic and analysis of the influence of large-scale vaccination (Wu & Cowling, 2011). This model has contributed substantially to pandemic influenza preparedness. To control this pandemic, this model is used as a real time tool. Recently, the use of this model is limited due to lack of necessary surveillance information such as serological data (Ernsting et al., 2013). This mathematical model provides a beneficial layout to interpret and analyze surveillance data of influenza pandemic. 

Conclusion

The literature review has given a clear concept about the NIPP and the models in a planning process. There is a need of addressing issues faced by some of the member states like providing adequate funds for purchasing the large amount of PPE. As there is still a persistent threat of pandemic influenza, all the member states should have properly planned response system and hence increase their efforts for improvement and better preparedness.  

References

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National Pandemic Influenza Vaccine Deployment Plan

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Policy planning for influenza