Pandemic Influenza

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2 “We feel that the opportunity for the (Influenza) virus to make adaptive changes is real. The pandemic risk is great, the timing is unpredictable and the severity is uncertain.” Dr Margaret Chan, Director General W.H.O. As Representative of the Director-General for Pandemic Influenza 2005


PANDEMIC A pandemic is a worldwide epidemic caused by a novel virus that affects most or all age groups within a period of months. It may be viewed as hundreds of large epidemics occurring in many different countries at the same time. A pandemic may occur if three conditions are met: a new influenza virus emerges (such as avian influenza H5N1); the virus infects humans (this has occurred with H5N1, although it is still relatively rare); the virus spreads efficiently and in a sustained manner from human to human.


WHY PREPARE? Impact of a novel pandemic influenza virus on developing world populations – Overcrowding Poor access to basic health-care services Limited or no access to hospitals High prevalence of malnutrition High incidence/prevalence of other communicable diseases


WHY PREPARE? Logistic challenges Lack of adequate surveillance/early warning systems Poor links to national disease surveillance systems Possible exclusion from national influenza preparedness and response activities Lack of trained and equipped staff


UNDERSTANDING TRANSMISSION The transmission of human influenza viruses is thought to occur largely through exposure to respiratory droplets at distances of less than 1–2 m, through direct inhalation. Large-particle (>5 m) respiratory droplet transmission is common among close contacts (within 1 m) and likely to account for the majority of transmission.


CLOSE CONTACT WITH A CASE IS - intimate contact (within 1 m) providing care living in the same household direct contact with respiratory secretions (saliva droplets of a suspected case, coughing or sneezing), body fluids and/or excretions (e.g. faeces ).


INFECTIOUS PERIOD The infectious period of seasonal human influenza is approximately up to 5 days from the onset of illness in adults The infectious period in children may be 10 days or more The duration of viral replication, and hence possible infectiousness, is longer with A(H5N1) and perhaps other novel virus infections, and may extend up to 2–3 weeks A small proportion of patients may be infectious just before symptoms appear.


ATTACK RATES Available data from previous pandemics and from seasonal human influenza studies suggest an attack rate of 15–35% This may be higher in densely populated sites, for example up to 50–60%, as crowding may facilitate the transmission of influenza viruses.

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Period Phase Definition Inter-Pandemic 1 No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low. 2 No new influenza virus subtypes have been detected in humans. However, a circulated animal influenza virus subtype poses a substantial risk of human disease. Pandemic Alert 3 Human infection(s) with a new subtype but no human-to-human spread, or at most rare instances of spread to a close contact. 4 Small cluster(s) with a new subtype but no human-to-human transmission but spread is highly localized suggesting that the virus is not well adapted to humans. 5 Larger clusters(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk). Pandemic 6 Increased and sustained transmission in general population. WE ARE CURRENTLY IN THE PANDEMIC ALERT PERIOD UNDER PHASE 4 (AUGUST 27, 2008).

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Early Warning System :

Early Warning System Application of simplified case definitions adapted to the local circumstances at community and health-care facility levels will promote: Early detection of initial cases/clusters or deaths, during the pandemic alert period (WHO phases 3–5). The first indication of human cases of avian influenza or the start of a pandemic may be sick health-care workers or an increase in the number of patients with unexplained acute respiratory illness and fever or pneumonia of unknown origin.

Early warning system:

Early warning system A cluster of 3 or more sick people or deaths, with onsets of illness within 7 –1 0 days of each other, and who live within a defined geographical area with unexplained moderate to severe acute respiratory illness Unexplained: clinical, epidemiological, or laboratory evaluation does not determine a cause or etiological agent, such as a routine community-acquired pneumonia. Moderate-to-severe respiratory illness : temperature > 38 °C, and either cough or shortness of breath or difficulty breathing, with or without clinical or radiological evidence of pneumonia.

If the above case/cluster definition is met :

If the above case/cluster definition is met during the pandemic alert period (WHO phases 3–5), a history of :- travel to or residence in an area affected by avian influenza outbreaks in birds or other animals direct contact with dead or sick birds or other animals in an affected area; close contact with a person (living or deceased) with unexplained severe acute respiratory illness; possible occupational exposure , through employment as an animal culler, veterinarian, laboratory worker or health-care worker.

Seasonal Vs Pandemic:

Seasonal Vs Pandemic unusual distribution by age group (e.g. younger age group, previously healthy); severe illness in adults in the absence of chronic disease; disease affecting health-care workers; excess deaths.

Planning for 10,000 Population:

Planning for 10,000 Population

Key measures:

Key measures Containment Zone: Use of antiviral drugs for treatment and prophylaxis; Movement restrictions in and out of the Containment Zone Use of additional non-pharmaceutical interventions. Key measures in both Containment and Buffer zones: Surveillance and laboratory testing; Containment communications.

Report , separate and Burn:

Report , separate and Burn REPORT Report unusual sickness/death among poultry. Report and seek treatment SEPARATE POULTRY new stock kept apart for 2 weeks; from wild birds; from each other by species; from living areas; from children. BURN AND/OR BURY DEAD BIRDS SAFELY.


WHAT WE NEED TO DO? Reduce human exposure to H5N1 Strengthen the early warning system Intensify rapid containment operations Build surge capacity to cope with a pandemic Accelerate vaccine development and expansion of production capacity


INDIA NIPC NCDC DAHD RRT activities Surveillance activities Reporting Case Management Public health measures Communication




GUIDELINES FOR CULLERS Animal Husbandry Department will identify cullers. Training to cullers will be provided by Animal Husbandry Department Animal Husbandry Dept will provide them chemoprophylaxis and PPE. Once culled they will dispose off PPE as waste management guidelines (Annexure –III) in a designated area. They will take shower after each culled session. They will be isolated in a separate place away from human dwelling for 10 days after last culling. Regular health check-up of cullers for development of signs (including temperature charting twice daily) and symptoms of Influenza till 10 days after last culling would be done by RRT. In the event of any suspected case among cullers during the quarantine period, it would be treated in the nearest identified health facility. Infection control practices would be followed as per WHO Guidelines.




MILITARY & PANDEMIC PREPAREDNESS Military – often neglected in Pandemic preparedness planning at national level Military is often the first agency to be called in case of most humanitarian crisis/disaster Unclear understanding of its role in pandemic


MILITARY ROLE SARS Containment Nipah virus Avian Influenza


MILITARY STRENGTHS Organizational structure – clear command Rapid mobilization & deployment Self sufficient in logistics Medical units designed for field deployment Expansion & contingency capacity integral to military planning


MILITARY STRENGTHS Can be deployed in remote areas Presence over a large geographical area Known for its professional approach & mission oriented work culture Multi – trade personnel available


ROLE OF MILITARY MEDICAL – Screening centres, field hospital & wards, investigation, surveillance & reporting ADMINISTRATIVE – Culling ops, Traffic, Transport, quarantine, restriction of movement, relief ops, disposal of dead, order and discipline, supplies of essential goods

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JAKARTA, March 2 (Reuters) - The Indonesian military will help in the fight against bird flu as part of the country's efforts to stamp out the disease that has killed 63 people, the bird flu national committee said on Friday. The military will set up bird flu treatment centres at two army hospitals to ensure wider access to medical care people infected with the virus, the committee said in a statement. In addition, the military will also support national and regional bird flu control efforts in remote areas in the sprawling archipelago, which has the world's highest human death toll from the virus. "The military will also work closely in developing Indonesia's contingency plan for a possible pandemic by holding regular simulation and field exercises," Bayu Krisnamurthi , the head of the committee, said. Indonesian military to help fight bird flu 02 Mar 2007 - Reuters

Pig slaughter begins in Malaysia :

Pig slaughter begins in Malaysia Malaysian soldiers have begun shooting thousands of pigs in an attempt to control the spread of the Japanese encephalitis virus, which has killed up to 50 people. Officials say more than 300,000 pigs will be destroyed over a 10-day period in villages in the south-western state of Negri Sembilan. Soldiers on pig-alert Sunday, March 21, 1999 Published by BBC News

Army drafted to help chicken cull Sunday, January 25, 2004 – CNN News :

Army drafted to help chicken cull Sunday, January 25, 2004 – CNN News BANGKOK, Thailand (AP) -- Hundreds of soldiers wearing safety masks, rubber gloves and protective caps fanned out across a central Thai province on a mission to bury chickens believed to be carrying bird flu.

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