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Decision-Making and Situation Assessment During a Rapid Containment Operation

Decision-Making and Situation Assessment During a Rapid Containment Operation. Learning Objectives. Discuss when to implement an RC strategy. Describe factors affecting the assessment. Describe responsibilities during a containment operation.

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Decision-Making and Situation Assessment During a Rapid Containment Operation

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  1. Decision-Making and Situation Assessment During a Rapid Containment Operation

  2. Learning Objectives • Discuss when to implement an RC strategy. • Describe factors affecting the assessment. • Describe responsibilities during a containment operation. • Formulate the information needed to decide whether a containment operation should be implemented.

  3. Overview of Presentation • Critical factors for decision-making • Decision-making process • Types of data needed for situation assessment and monitoring • Duration of containment operation

  4. Rapid Response:Routine Public Health Action • Relies on early detection of cases • Initial local investigation • Standard control measures to prevent further transmission • Notification of national authorities and WHO

  5. Rapid Containment:Extraordinary Public Health Action • Must be considered if investigation suggests that local outbreak may be the start of a pandemic • The outcome of the containment operation will have global effects • Likely to require measures beyond rapid response: • extensive international assistance to affected country • increased coordination of communication • RC of an influenza pandemic has never been tried before

  6. Rapid Containment • RC is based on existing routine response mechanisms • Both RC and RR are conducted by the same people • Failed containment operation • Lead to spread of pandemic virus • Trigger pandemic response plans and other actions such aspossibly halting seasonal vaccine production and switching to pandemic vaccine production and administration

  7. Rapid response and containment

  8. Rapid Response and Containment: Continuum of Activities Rapid containment 100% Rapid response 0% Situation worsening

  9. Containment is Time Sensitive • Mathematical modelling indicates “window of opportunity” to act is very short • May have ~ 3 weeks to start antivirals and public health measures after Index Cluster is detected • Detection, investigation and reporting of first cases must happen quickly

  10. Rapid Containment Cannot Be “Business as Usual” No of cases per day Start containment Country and WHO assess 30 Results from WHO lab Specimen to WHO lab Results from national lab Specimen to national lab Initial investigation 20 Report to local office Detection of Index Cluster Start of Index Cluster Onset of first case 10 Too Late to Contain? 1 10 20 30 Days after first case

  11. Response and ContainmentMust Happen Quickly No of cases per day 30 Start containment Country and WHO assess 20 Results from national lab Specimen to national lab Results from WHO lab Initial investigation Specimen to WHO lab Report to local office Detection of cluster Onset of first case Start of cluster Possible to contain? 10 1 10 20 30 Days after first case

  12. Key Questions to Address • Is there compelling evidence to suggest that a novel influenza virus has gained the ability to spread easily from person to person and initiate and sustain outbreaks in the community? • If so, are there compelling reasons why a containment operation should not go forward?

  13. Factors affecting Assessment (1) Virological factors • Laboratory evidence of a novel virus critical • Certain features may suggest a newly advanced adaptation to humans • Mix of avian and human genes • Increased number of mutations Photo provided by CDC

  14. Factors affecting Assessment (2) Epidemiologic factors • Efficient and sustained human-to-human transmission such as • 5 or more cases closely related in time or space • 2 or more generations of transmission • Clinical severity is not an important consideration • Early cases could be “mild” • Severe illness is more likely to be detected Photo provided by WHO

  15. Factors affecting Assessment (3) Operational and logistical factors • Size of the Index Cluster • Time since first cases became ill • Geographical characteristics of the area (e.g. accessibility, natural boundaries) • Ability to ensure basic infrastructure and essential services • General security situation • Willingness of the country to decide, lead and manage • International resources and support

  16. Decision-Making Process • WHO and national authorities will jointly assess all available information • WHO will consult with external experts and provide advice to the country • Additional field assessments will be done if information insufficient to make a decision

  17. Responsibilities during Containment Operation Country • Makes ultimate decision to launch • Responsible for leading and managing the operation WHO • Continues to assess, advise and suppport • Requests and coordinates international assistance • Deploys global antiviral stockpile Formal declaration of a public health emergency of international concern (PHEIC) does not need to be in place

  18. When Containment is not recommended • Novel influenza virus could not be confirmed • Not operationally feasible, including for security reasons, to rapidly implement at the necessary level • National authorities do not support the operation • Virus has already spread too far and containment no longer feasible

  19. Containment feasibility?Location and Number of Cases • Multiple locations • Large number of cases • One location • Limited number of cases • One location • Large number of cases

  20. Containment Feasibility?Setting and Population Density • Urban area • High population density • Rural area • Low population density

  21. Situation Assessment and Monitoring: What Types of Data Are Needed? • Epidemiologic data • Virological data • Containment measures • Healthcare utilization and capacity • Essential infra-structure needs

  22. Epidemiologic and Virological Data • Number and location of cases and deaths • Trends over time • Age-specific attack rates and case fatality rates • Clinical parameters (e.g. illness characteristics, complications, severity) • Evidence of antiviral resistance • Molecular characterization and evolution

  23. Containment Measures Antivirals • Compliance and refusals • Number and type of adverse events Measures to reduce influenza transmission • General level of compliance • Degree of movement in and out of Containment Zone • Number of persons in isolation and quarantine

  24. Healthcare and Essential Services • Do people have access to the medical care they need? • General and Intensive Care hospital beds • Essential medicines, respirators, personal protective equipment • Do healthcare facilities have adequate numbers of staff? • Status of • Food, water and sanitation supplies • Transport • Telecommunications • Security

  25. Duration of Containment

  26. Challenges • Detection, investigation, notification, and assessment must happen rapidly • Advance planning necessary for data collection and management • Getting real-time information • Getting the right information • Continuous assessment and monitoring required • Guide decisions to change strategy or stop

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