Interventions to Contain Cluster of Human AI Cases

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Interventions to Contain Cluster of Human AI Cases

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Interventions to Contain Cluster of Human AI Cases:

Interventions to Contain Cluster of Human AI Cases

WHO Cluster Definition:

WHO Cluster Definition Two or more cases epidemiologically linked At least 1 laboratory confirmed case Other cases Laboratory-confirmed, or Unexplained deaths linked epidemiologically to a confirmed case (probable case) Countries can use their own definitions

Approach:

Approach Phase wise approach Management of human case of avian influenza (Phase-3) Managing a cluster of human cases (Phase 4) Managing a pandemic- Large number of human cases of influenza caused by a novel virus (Phase 5 & 6)

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Phase-wise Intervention

Goal of Rapid Response and Containment:

Goal of Rapid Response and Containment “To ensure rapid detection and investigation of clusters of cases, closely related in time and place, and ensure immediate international/national intervention aimed at preventing the emergence of a fully transmissible pandemic virus or delaying its international spread.” Source: WHO strategic action plan for pandemic influenza 2006-2007

Modeling Studies: Possible to Contain Emerging Virus in Southeast Asia:

Modeling Studies: Possible to Contain Emerging Virus in Southeast Asia Antivirals would need to reach a sizeable proportion of affected persons (80%-90%) Accompanied by rapid and effective implementation of non-pharmaceutical measures (i.e., isolation, quarantine, movement restriction) Over a very short period of time (days to 3 weeks) Source: WHO strategic action plan for pandemic influenza 2006-2007

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1 10 20 30 Day after first case Onset of first case Start of cluster 30 20 10 Detection of cluster Report to local office Initial investigation Specimen to national lab Results from national lab Investigation of MO Specimen to WHO lab Results from WHO lab Notification to WHO Implementation of containment Cases/day Containment is Time Sensitive

Enabling Factors:

Enabling Factors Probably just enough time to implement strategy if Rapid investigation by national team No reliance on international team to trigger strategy No waiting for definite diagnosis/virus characterization Investigators prepared to take steps towards containment Close collaboration with relevant authorities and WHO Continuous risk assessment Scaling up without delay

Containment Strategy: Key Assumptions:

Containment Strategy: Key Assumptions Virus will not be highly transmissible Emergence will be geographically circumscribed Initial clusters will be rapidly detected and reported Antivirals will be rapidly mobilised and administered Population movement will be restricted

Cluster Containment Strategy Options (Phase-4/5):

Cluster Containment Strategy Options (Phase-4/5) Targeted/functional approach Relies on identification of cases and contacts “Manageable number of cases” Geographical approach Focuses on persons within radius (0-10 km) of each case Focuses on persons in an “administrative region” or other conveniently defined area/“containment zone”

Critical Actions for Rapid Response and Containment:

Critical Actions for Rapid Response and Containment Early warning signal detection Initial investigation and control measures Notification and assessment Containment decision and strategy Implementation of containment measures Monitoring and evaluation Population movement restriction

Early Warning Signals:

Early Warning Signals Early warning signals suggest that the virus is acquiring the capacity for efficient human-to-human transmission Signals include Epidemiological: Clusters of ILI or SARI cases closely related in time and place, involving chains of transmission sustained over time Clusters involving healthcare workers/unusual age groups Virological: Isolation of an untypable reassorted virus; virus with mutations indicative of adaptation to humans

Initial investigation:

Initial investigation Case interview Laboratory testing Contact tracing Active case finding

Initial Cluster Containment Measures:

Initial Cluster Containment Measures Initial Cluster Containments Measures Isolate cases Quarantine contacts Community quarantine Social distancing measures Port/airport/border control Antiviral drugs Social mobilisation

Notification & Assessment:

Notification & Assessment Notification National authorities WHO Assessment Diagnostic confirmation Needs assessment

Components of Operational Plan (Phase 4-5):

Components of Operational Plan (Phase 4-5) Micro Plan Surveillance, contact tracing Laboratory preparedness and diagnostics Early case detection and management Infection control practices in health facilities/community Pharmaceutical interventions Non-pharmaceutical interventions (e.g. isolation, quarantine) Risk communication Logistics Media management Social mobilisation Data monitoring

Operational Plan:

Operational Plan Identifies the roles and responsibilities of all stakeholders Ministry of Health/DGHS/EMR National Institute of Communicable Diseases Indian Council of Medical Research Central Government Hospitals Other Central Ministries: Home Affairs/Civil Aviation/ Information and Broadcasting State Health Department/Medical Education District Health Authorities Block Administrative Authorities

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Demarcation of Containment and Buffer Zone (0-5 and 5-10 Km area) 5 km 5 km

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Surveillance Active house to house Surveillance in Containment and Buffer zone Surveillance workers at higher risk hence to be protected using PPE Contact tracing Prophylaxis of close contacts Identification of close contacts by active case finding and contact tracing Prophylaxis of household and family contacts Health monitoring of close contacts Treatment of contacts become symptomatic

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Laboratory Support National Institute of Virology, Pune and National Institute of Communicable Diseases, Delhi are the apex laboratories Sixteen additional laboratories to test samples. Identify the laboratory attached to the State Have stock of viral transport medium Refer to the guidelines on sample collection, storage and transportation Initially all cases need to be tested. Subsequently when the community spread is established, samples from cases need to be tested based on a sampling framework Know the flights and their timings to send samples to designated labs Know the contact details of the nodal person of the identified laboratory

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Early Case Detection and Management Identified health facilities have isolation wards conforming to WHO guidelines Facilities for respiratory and ventilatory management Staff on chemoprophylaxis Treatment of suspected, probable and confirmed cases Strict infection control practices

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Infection Control Practices To be followed in community settings and hospital settings Surveillance workers need to use triple layered surgical mask Medical personnel treating the patient need to wear full complement of PPE N-95 respirator advocated in all aeorosol generating procedures and situations were splashing of blood or body fluids are expected. Droplet and contact precautions in all settings

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Pharmaceutical Interventions Mass Chemoprophylaxis/Targeted Chemoprophylaxis Chemoprophylaxis of all persons in the containment zone with oseltamivir – geographical approach In targeted approach, only close family and social/community contacts are provided chemoprophylaxis Approach depends on the oseltamivir stockpile In either approach, contact tracing as per guidelines to be done in buffer zone and beyond Supply chain management of oseltamivir for mass chemoprophylaxis needs to be in place

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Non-pharmaceutical Interventions Individual level Contact and droplet precautions Community level Social Distancing measures School closure Quarantine and isolation Risk communication

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Risk communication Communicate risk in clear terms Media strategy Flu-wise campaign Flu-care campaign Media Plan Use print and visual media in regional language and/or local vernacular Social mobilisation-self help groups/commuity volunteers/AWW/ASHA/school teachers

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Logistic support Oseltamivir PPE Other medical supplies for supportive therapy Hand sanitisers/disinfectants

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Media Management Only identified person would speak to media Fully knowledgeable about the facts/figures Regular press briefing and press releases

Components of Operational Plan for Cluster Containment:

Components of Operational Plan for Cluster Containment Command and Control Unified command Identified nodal person 24x7 control room Number circulated widely

Cluster Containment Would be Planned and Implemented if::

Cluster Containment Would be Planned and Implemented if: Virus is not efficiently transmitting, clusters and limited in terms of time, place, person Population demarcated by natural or artificial boundaries Legal instruments available to support it Enough human and material resource (PPE, oseltamivir) are available Community informed of the risk and involved in implementing the micro plan Essential services are maintained

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