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 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) Credit: US National Museum of Health and Medicine 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: 1.Can affect animals and birds on a large scale 2.Can affect humans and cause severe disease 3.But still can not be transmitted from human- to-human

7. How to control/prevent pandemic influenza? 1.Containment of potential human pandemics at the source 2.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. Delay of 4 days reduce the probability of eliminating a large epidemic of a new pandemic virus to: – 1.5 –R 0 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 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

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 1.The success of any strategy for containing an emerging pandemic virus is strictly TIME DEPENDENT. 2.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 1.Recognition of the event: –Epidemiological and virological signals –Steps of initial investigation 2.Verifying the event: –Risk assessment –Immediate control measures 3.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 1.Early detection, and rapid response 2.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 2006 Influenza 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. Municipality: –How many human resources are needed? –… Short cut of human resources was observed and prolonged field activities Lebanon: Influenza H7N7 risk Tyr caza, March-April 2006

20. 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? –… Lebanon: Influenza H7N7 risk Tyr caza, March-April 2006

21. How to avoid containment delay? 1.Be prepared 2.Visualize risky areas 3.Have centrally available information and maps to decide on strategy and needed resources 4.Save time and act rapidly

22. Avian Influenza Preparedness using GIS tool 1.Preparedness tool 2.Visualization of risky areas 3.Decision tool 4.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: 1.Specify a 3km radius zone from the index case and control its movements at entry and exit 2.Control (destroy) all poultry in the security zone (3km radius) 3.Detect poultry cases in a 7km radius zone with enhanced veterinarian surveillance 4.Detect human cases in affected areas 5.Prepare health structures to manage human cases 6.Close community gathering places 7.Rise public and professional awareness

25. 1.Quarantine - Security and Surveillance zones: ActorQuestionsParameters Q1MI/FSI What are the limits of the security and surveillance zones? Q2MI/FSI What are the needed resources to quarantine the security zone? Needed quarantine resources / km (Human, equipment, financial, information) Q3MI/FSI What are the suitable places for the entry/exit check points? Criteria for suitable places for check points Q4All What are the needed resources at the entry/exit check points? Needed resources / check point (Human, equipment/material, financial, information)

26. 1.Quarantine - Security and Surveillance zones: algorithm Buffer 3km Buffered Zone 3km Select Road-based Security Zone Security zone IndexCase Buffer 7km Buffered Zone 7km Select Roads-based Surveillance Zone Roads Surveillance zone FSI Report: Needed Quarantine resources FSI Report: Suitable Entry/exit check points All Report: Needed Resources at check points Spatial map Q1 Q2Q3Q4 Suitable places For checkpoints Suitable check points

27. ActorQuestionsParameters Q1MOA What are target farms and backyards for poultry stamping out? What are the target poultry population for stamping out? Q2MOA What are the needed resources for rapid and adequate stamping out? Needed resources for adequate stamping out ( backyard, traditional & modern farm) Q3MOA What are the needed resources for farms disinfections? Needed farms disinfections resources Q4MOA What are the suitable places for disposal carcasses and infective material without water contamination? Criteria for suitable places for carcasses burial without water contamination Q5MOA/ MF What are the needed resources for farms compensation? Compensation / poultry species, type and age 2. Destroy poultry in 3km radius zone

28. 2. Destroy poultry in 3km radius zone: algorithm FarmsDataBase Select within Security Zone Target Farms in security zone MOA Report: Needed stamping resources MOA Report: Target Farms in Security Zone MOA Report: Compensation estimations Water resources Land Use Suitability place for burial Suitable Places for carcasses burial Spatial map MOA Report: Needed Disinfections resources Security zone Farms including slaughterhouses and poultry live markets Q1 Q5 Q3Q2 Q4

29. ActorQuestionsParameters Q1MOA What are the targeted farms and backyards for active surveillance? Q2MOA What are the targeted wild birds itinerary for active surveillance? Q3MOA What the needed resources for active surveillance, specimens collection and transportation? Needed resources for active surveillance, specimens collection and transportation / surveillance point 3. Detect poultry cases in a 7km radius zone: questions

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

31. ActorQuestionsParameters Q1MOH What are targeted HEALTH STRUCTURES for enhanced and active surveillance? Q3MOH What are targeted FARMS for active human surveillance? Q4MOH What are targeted HOUSEHOLDS for active human surveillance? Q5MOH What the needed resources for active surveillance, specimens collection and transportation? -Needed resources for active surveillance, health monitoring, specimens collection and transportation -Needed resources for antiviral prophylaxis 4. Detect human cases in affected area:

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

33. ActorQuestionsParameters Q1MOH What are targeted health structures for case referral? Criteria for reference health structures Q2MOH What are targeted health structures for training on case management and infection control? Criteria for training health structures Q3MOH What are needed resources for training on cases management and infection control? Needed resources for training on cases management and infection control / site Q4MOH What are needed resources for protecting, monitoring and ensure prophylaxis for care providers? Needed resources for protecting, monitoring and ensure prophylaxis / person 5. Prepare health structures to manage human cases:

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

35. Actor Questions Q1All What are targeted community gathering places for closure? Q2All What are needed resources to ensure closure of targeted community gathering places? 6. Close community gathering places:

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