1. SPANISH PLAN FOR THE PREPARATION AND RESPONSE TO AN INFLUENZA PANDEMIC Dr. Carmen Amela Heras Public Health National Direction Ministry of Health and Consumption Madrid, Spain

2. General Objectives Reduce the impact of the pandemic on the population’s health Take measures to reduce the transmission of the virus and protect the population. Guarantee that the response and the measures adopted correspond with UE and OMS recommendations in each phase.

4. National Plan Key Elements 1.Organizational structure and coordination 2.Epidemiologic and virological vigilance 3.Prevention and control measures Vaccines, Antiviral, and Non pharmaceutical intervention measures 4.Health system response, and 5.Communication

5. Organizational and Coordination Structure National Executive Committee for the prevention, control and follow up of the epidemiological evolution of the influenza virus (RD 1131/2003) - Operative Group of the Executive Committee - Technical Coordination Group - Scientific Committee - Public Health Committee - Subcommittees or work groups

7. Response to the sanitary emergency services Epidemiological and virological vigilance Antiviral and vaccines Communication National Plan. Work Groups. (Subcommittees) The objective is for all the Autonomous Communities to have their own plan, in which they place special emphasis on the emergency response. With Representation in the Autonomous Communities

8. Approved Protocols Detection, by sanitary professionals, of suspicious cases of the bird flu in humans Infection control measures in sanitary centers Actions that would be taken in the case of people that work in farms or could be exposed to infected birds. Definition of priority groups for the supply of antivirals. Instructions for use for intervention with oseltamivir following exposure to the influenza virus A/H5N1. Recommendations for travelers that are moving towards affected countries and other exterior sanitary measures. Protocol for action when passengers arrive in Spain (via air or sea)

9. Public Health Measures Will help retrace diffusion, but will not avoid the Pandemic. Isolation Closing of Institutions Personal Security Travel restrictions Restrictions for celebrating large reunions Organic Law of Special Measures in Public Health Matters 3/1996 0f 14 th of April, articles 2 and 3. The Litigious-Administrative Court authorizes the measures that the sanitary authorities consider urgent and necessary for health.

10. Scenarios, Consequences and Measures in the PANDEMIC ALERT PHASE ARRIVAL OF INFECTED BIRDS ARRIVAL OF PERSONS THAT ARE INFECTED OR SUSPECTED INCREASE IN THE RISK OF DIFUSSION ANIMALS -ANIMALS ANIMALS - HUMANS INCREASE IN SOCIAL UNREST RISK OF TRANSMISSION FROM HUMAN TO HUAMN Coordinated vigilance and control methods Agriculture – Environment - Sanitation Towns Communication Strategies Trust in the Ability of the Authorities to Respond Action protocol before a Dangerous Aerial transmission disease (PAETAP)

11. Vigilance: algorithm suspicious case PATIENT REPORTING SUSPICOUS INFLUENZA SYMPTOMS Fever (> 38°C) Respiratory symptoms: Cough Or Difficulty Breathing Any other very serious disease without an alternative diagnosis EPIDEMOLOGICAL HISTORY History of travel to areas affected by bird flu2 in the last 7 days. Close contact (at a distance of touching or talking) with other cases of severe respiratory disease or Unexplained death in a patient coming from an affected area http://www.who.int/csr/don/2005 or Being part of a group of workers with severe respiratory disease without other alternative diagnosis. or Work in a laboratory with accidental exposure to the influenza virus A/H5 or Work or have been in close contact during the last 7 days with birds in a corral, or live or dead animals (or thier products) that could have been exposed to the highly pathogenic bird flu virus A/H5. and Close contact (1 meter) with domestic birds live or dead, wild birds or pigs. SUSPICIOUS CASE

12. Fever> 38°C + Respiratory symptoms (cough or difficulty breathing) Fever> 38°C + Respiratory symptoms (cough or difficulty breathing) Very serious disease Without an alternative diagnosis Very serious disease Without an alternative diagnosis Visit to areas affected By bird flu in the last 7 days Visit to areas affected By bird flu in the last 7 days Close contact (<1m.) with domestic Birds, live or dead, wild birds and pigs Close contact (<1m.) with domestic Birds, live or dead, wild birds and pigs Close contact (<1m.) with severe respiratory disease or unexplained death in a patient that comes from an Affected area Close contact (<1m.) with severe respiratory disease or unexplained death in a patient that comes from an Affected area Do you work in a laboratory Do you work in a laboratory Have You been exposed to the Virus A/H5 Have You been exposed to the Virus A/H5 SUSPICIOUS CASE SUSPICIOUS CASE YES NO Are you part of a group of sanitary workers with severe respiratory disease without an alternative diagnosis Are you part of a group of sanitary workers with severe respiratory disease without an alternative diagnosis Do you work or have been in close contact during the last 7 days with birds in a corral, or live or dead animals (or their products) that could have been exposed to the highly pathogenic bird flu virus A/H5. Do you work or have been in close contact during the last 7 days with birds in a corral, or live or dead animals (or their products) that could have been exposed to the highly pathogenic bird flu virus A/H5. NO NO CASE DO NOT MOVE THE PATIENT WITHOUT EXPESS ORDERS FROM CICU 900.161.161 Patient barrier measures: Surgery mask and hygienic measures Patient isolation measures. The patient will be confined in the examination room or a room. Personal protection measures: Use personal protection equipment and hygiene measures. Patient barrier measures: Surgery mask and hygienic measures Patient isolation measures. The patient will be confined in the examination room or a room. Personal protection measures: Use personal protection equipment and hygiene measures. ADOPT GENERAL PROTECTION MEASURES ADOPT GENERAL PROTECTION MEASURES CALL CICU CALL CICU UPDATED FEBRUARY 20, 2006 Coordination and alert: algorithms

13. Basic Points PAETAP CASECASE NO CASENO CASE Laboratory Vigilance Protocol PANDEMIC COORDINATION CENTER CICU PANDEMIC COORDINATION CENTER CICU SANITARY PROFESSIONALS AVOID TRANSMISSIONRAPID AND EFFICIENT WARNING ADEQUATE AND SECURE ASSISTANCE CONTROL AND PROTECTION MEASURES DISSEMINATION PROTOCOL COMMUNICATION STRATEGIES TIMELY DETECTION OF A SUSPICIOUS CASE SELF PROTECTION BARRIER MECHANISMS HYGIENE ISOLATION INFROMATION FLOW AND COMMAND CONCISE AND PREESTABLISHED CONTACT MANAGEMENT ISOLATION VIGILANCE PROTOCOLS ASSISTANCE SERVICES PRIMARY ATTENTION SPECIALIZED ATTENTION EXTRA HOSPITAL EMERGENCIES TIMELY COMMUNICATION INFORMATION FLOW CHARTS COORDINATION CENTERS

15. Evaluation of Risk

17. Risk evaluation. Asiatic region compared to Europe. EuropeAsia Geographic Extension Located in more limited areas Scattered throughout Asia Endemnicity Not endemicEndemic Management of animals Good. Industrial exploitation. Little hygiene in the majority of the homemade pens Available resources and technical ability More resources and better capacity Limited resources and capacity

18. Simulation: Common Ground The exercise simulated an Influenza pandemic in Europe that affected all the member States, Objectives of the Exercise Evaluate the execution of the national plans of the Member States; Improve compatibility and interoperability of the plans of the member States; Examine the role and availability of control measures. Determine the availability and convenience of the contention measures and Examine the role of the European Commission during an influenza pandemic

19. Messages The threat of a pandemic has not increased significantly due to the detection of the virus in Europe. All countries have to be prepared for the arrival of A/H5N1. The bird flu virus A/H5N1 is a great problem for animal health At this time it is assumed that it is a low risk for human health –The people at risk are those that have close contact with infected birds and their products –Even in them the risk of infection is low but the disease is serious We cannot forget that the influenza has a tendency to change and surprise!

20. Communication of the Risk - Confusion about the types of flu “I could swear I just heard my egg sneeze”