Using Geographical Information System tool in containing influenza pandemic threats

1. Using Geographical Information System tool in containing influenza pandemic threats Republic of Lebanon Ministry of Public Health Epidemiological Surveillance Program Nada Ghosn, MD

2. Influenza: seasonal, pandemic, avian

3. Human influenza • Seasonal influenza: • Annual outbreaks due to minor changes in the surface of the influenza viruses • Human have partial immunity due to previous infections. • Pandemic influenza: (الجائحة) • Global and worldwide severe epidemic • Due to major change • No human have partial of fully immunity against infection because it is a completely new virus.

4. Latest Influenza pandemics Credit: US National Museum of Health and Medicine 1918: “Spanish Flu” 20-40 million deaths A(H1N1) 1957: “Asian Flu” 1-4 million deaths A(H2N2) 1968: “Hong Kong Flu” 1-4 million deaths A(H3N2) Next? “XX Flu” millions deaths A(H5N1)?

5. Animal influenza • Avian influenza • Highly Pathogenic Avian Influenza (HPAI) • Low Pathogenic Avian Influenza • Outbreaks of new avian influenza • Increase the risk of a human pandemic • Through the merging of animal and human influenza viruses.

6. Influenza virus H5N1 • The new H5N1 avian influenza is a potential candidate for pandemic influenza: • Can affect animals and birds on a large scale • Can affect humans and cause severe disease • But still can not be transmitted from human-to-human

7. How to control/prevent pandemic influenza? Containment of potential human pandemics at the source Containment of HPAI in animals at the source

8. Pandemic Influenza modeling:Time factor Any delay will reduce the probability of eliminating large epidemics in humans

9. Probability of eliminating a large epidemic using social and geographical targeting prophylaxis, varying with the delay (0-4 days) from case detection to prophylaxis for the 5-km radius policy • Delay of 4 days reduce the probability of eliminating a large epidemic of a new pandemic virus to: • <50% for a virus with R0=>1.5 • R0 quantifies the transmissibility of pathogen Source: Ferguson, Derek, Cummings, Cauchemaz, Fraser, Riley, Meeyai, Lamsiiriithaworn, Burke. Strategies for containing an emerging influenza pandemic in Southeast Asia. Nature. Vol. 437. 8 September 2005

10. Containment pandemic influenza WHO plan:time factor The success of any strategy for containing an emerging pandemic virus is strictly TIME DEPENDENT

11. WHO pandemic influenza plan • The success of any strategy for containing an emerging pandemic virus is strictly TIME DEPENDENT. • Objectives of containment strategy • To stop, or at least to slow, the spread of pandemic influenza at the source of its emergence in order to reduce global morbidity and mortality Source: WHO pandemic influenza draft protocol for rapid response and containment. 30 May 2006

12. WHO pandemic influenza plan • Recognition of the event: • Epidemiological and virological signals • Steps of initial investigation • Verifying the event: • Risk assessment • Immediate control measures • Containing the event: • Decision to launch a containment operation • Phase 1 - standard measures to reduce transmission: case management, infection control, antiviral treatment, intensified surveillance, contact tracing, monitoring contacts for signs of illness • Phase 2 - exceptional measures: voluntary quarantine, social distancing, mass antiviral prophylaxis Source: WHO pandemic influenza draft protocol for rapid response and containment. 30 May 2006

13. Containment avian influenza FAO plan:Time factor Timely reporting and timely response

14. FAO Recommendations • Early detection, and rapid response • The main measures to prevent, control and eradicate HPAI are: • Effective disease surveillance for early detection and reporting • Enhanced biosecurity of poultry farms • Control of movement of birds and products • Changes to industry practices to reduce risk • Rapid, humane destruction of infected poultry and poultry at high risk of infection (stamping out) • Disposal of carcasses and potentially infective material in a biosecure and environmentally manner • Proper use of vaccine Source: FAO - 2005

15. Containment factors: available information Available information can reduce delay in conducting response measures

16. Lebanon, March-April 2006Influenza H7N7 risk Tyr caza

17. Lebanon: Influenza H7N7 risk Tyr caza, March-April 2006 • MOA: • What is the area size? • What are the target farms? • What are the target birds size? • … • Collecting data was time consuming (>2 days) and has delayed the stamping out measures

18. Lebanon: Influenza H7N7 risk Tyr caza, March-April 2006 • MOI • What is the target area? • What is the area targeted for quarantine? • What is the perimeter? • How many human resources are needed? • …

19. Lebanon: Influenza H7N7 risk Tyr caza, March-April 2006 • Municipality: • How many human resources are needed? • … • Short cut of human resources was observed and prolonged field activities

20. Lebanon: Influenza H7N7 risk Tyr caza, March-April 2006 • MOPH: • What are the exposed persons targeted for health monitoring ad active surveillance? Professionals, farms, households… • What are the health structures in place for case referral and case management? • What are the needed resources? • …

21. How to avoid containment delay? Be prepared Visualize risky areas Have centrally available information and maps to decide on strategy and needed resources Save time and act rapidly

22. Avian Influenza Preparednessusing GIS tool Preparedness tool Visualization of risky areas Decision tool Save time

23. If Influenza A/H5N1 virus appears in Lebanon • All response measures aim to: • Prevent the spread of the virus • Contain the virus at the source (focus)

24. If Influenza A/H5N1 virus appears in Lebanon • Response measures include: • Specify a 3km radius zone from the index case and control its movements at entry and exit • Control (destroy) all poultry in the security zone (3km radius) • Detect poultry cases in a 7km radius zone with enhanced veterinarian surveillance • Detect human cases in affected areas • Prepare health structures to manage human cases • Close community gathering places • Rise public and professional awareness

25. Quarantine - Security and Surveillance zones:

26. Quarantine - Security and Surveillance zones:algorithm Roads Spatial map Q1 Security zone Suitable check points Buffered Zone 3km Select Road-based Security Zone Suitable places For checkpoints Buffer 3km IndexCase Q1 Surveillance zone Buffered Zone 7km Select Roads-based Surveillance Zone Buffer 7km Q2 Q3 Q4 FSI Report: Needed Quarantine resources FSI Report: Suitable Entry/exit check points All Report: Needed Resources at check points

27. 2. Destroy poultry in 3km radius zone

28. 2. Destroy poultry in 3km radius zone: algorithm Q1 Q2 Q3 MOA Report: Needed stamping resources MOA Report: Needed Disinfections resources MOA Report: Target Farms in Security Zone Security zone Q5 Q1 MOA Report: Compensation estimations Target Farms in security zone Select within Security Zone FarmsDataBase Water resources Q4 Suitable Places for carcasses burial Land Use Suitability place for burial Spatial map Farms including slaughterhouses and poultry live markets

29. 3. Detect poultry cases in a 7km radius zone: questions

30. 3. Detect poultry cases in a 7km radius zone: algorithm Q1 MOA Report: Target Farms in Surveillance zone FarmsDataBase Q1 Target Farms in surveillance zone Q2 Select within Surveillance Zone MOA Report: Target wild birds surveillance Surveillance zone Q2 Target migratory Birds itinerary Proximity Migratory birds itinerary Q3 MOA Report: Needed surveillance resources Index Case Farms including slaughterhouses and poultry live markets

31. 4. Detect human cases in affected area:

32. 4. Detect human cases in affected area: algorithm Q1 Q1 Target Health structures for surveillance MOH Report: Target Health Stru. for active surveillance Security zone Surveillance zone Target poultry workers MOH Report: Target Poultry workers for active surveillance Health Structures Q3 Q3 Target households MOH Report: Target Households for active surveillance Target Farms in security zone Proximity Q4 Q4 Spatial Map (building blocks) Q5 MOH Report: Needed Surveillance resources Population Q5 MOH Report: Needed Anti-viral prophylaxis resources

33. 5. Prepare health structures to manage human cases:

34. 5. Prepare health structures to manage human cases:algorithm Q1 Health Structures Q1 Reference Health structures MOH Report: Reference Health structures Patient transport services Q1 Q1 MOH Report: Reference patient transport service Reference Transport services Security zone Surveillance zone Suitability & Proximity Q3 Q2 MOH Report: Needed resources for training on case management and infection control Target health structures for training Spatial Map (building blocks) Population Q4 MOH Report: Needed resources for protecting care providers and antiviral prophylaxis

35. 6. Close community gathering places:

36. 6. Close community gathering places: algorithm Target Schools for closure Report: Target schools Security zone Surveillance zone Target Common places for closure Report: Target Common places Proximity Spatial Map (building blocks) Schools Report: Needed resources to ensure Closure implementation Community gathering places