Pandemic Flu: A Scottish framework for responding to an influenza pandemic

6 INTER-PANDEMIC AND PANDEMIC ALERT PERIODS: THE NEED FOR EARLY DETECTION AND ALERT

6.1 International collaboration to give early warning

An influenza pandemic is by definition an international event expected to affect most countries. International collaboration offers the best opportunity for early warning, mitigating the impact and gaining public confidence in the response by:

• sharing information and research
• rapid identification and alert
• timely surveillance to monitor international spread
• sharing epidemiological information to inform national policies
• achieving coherent, though not necessarily harmonised, national responses and public information for use before and during a pandemic
• considering the effects of national policies on neighbouring and other countries and
• learning from each other.

Scotland will participate as the UK continues to develop and strengthen its international networks, working with the World Health Organization ( WHO), the European Union ( EU) and other bilateral and multinational groups. In particular, Scotland will work within a UK framework where the UK will:

• work to improve WHO and EU influenza surveillance
• support a UK-based WHO Collaborating Centre
• work within the framework of the International Health Regulations
• work collaboratively to develop and support the work of the European Centre for Disease Prevention and Control in improving the detection and control of communicable diseases in Europe
• work to improve the EU early warning and response system

WHO has defined phases in the evolution of a pandemic that allow a stepwise escalation in planning and response proportionate to the risk from the first emergence of a novel influenza virus (see table 1 in section 5.2). This global classification is used internationally.

6.2 National arrangements for early detection and alert

During the inter-pandemic and pandemic alert periods, clinicians, and the public, need to remain vigilant in order to identify individuals with a possibly unusual influenza (or other respiratory virus) infection - whether arising in the UK or imported. This must be supported by the laboratory capacity and capability to identify a new virus promptly. Close collaboration is also required with animal health surveillance, to assess the risks of a new mammal or bird influenza virus crossing species.

6.2.1 Clinical recognition - Health Protection Scotland

In liaison with the Health Protection Agency ( HPA), Health Protection Scotland ( HPS) maintains WHO phase-specific algorithms on its website for the investigation, management and reporting of those patients for whom clinicians and virologists should maintain heightened awareness as being more likely to acquire or import novel influenza viruses. These would normally include patients with respiratory illness who have recently returned from an area affected by outbreaks of a novel virus in animals or humans, poultry workers, contacts of people with known avian influenza, or unusual outbreaks of respiratory disease in, for example, a healthcare setting. Decisions on whether, and how, to investigate such patients should be taken in consultation with the local NHS Board Health Protection Teams (who will normally discuss with an expert in HPS). As alert levels increase, the Scottish Government in liaison with HPS will reinforce the need for heightened awareness and provide relevant information to health professionals and the public.

6.2.2 Laboratory diagnosis

The UK has a network of regional laboratories capable of providing a specialist diagnostic service for influenza A, influenza B and the most likely pandemic influenza subtype (currently H5). Any new or unusual virus identified in Scotland is sent to the National Influenza Reference Laboratory at the HPA Centre for Infections, Colindale, for detailed characterisation. The Centre will also develop diagnostic reagents if necessary, validate any new diagnostic tests, roll out new tests as appropriate, and undertake antiviral susceptibility testing. The HPA will immediately inform the Department of Health ( DH), if a new influenza virus from a human infection is confirmed. DH will then inform the Scottish Government and HPS.

6.2.3 Capacity and capability

Should it be required, the HPA Centre for Infections will be able to draw on the expertise, resources and containment facilities at the HPA Centre for Emergency Preparedness and Response at Porton Down, including the Special Pathogens Reference Unit on a UK wide basis.

6.2.4 Liaison with veterinary laboratories

Through its existing links with HPA Centre for Infections and the HPA National Influenza Reference Laboratory, HPS will be updated regarding developments at the Veterinary Laboratory Agency, including over laboratory diagnostic methods on a UK wide basis.

6.2.5 Domestic preparation

Domestic preparations in Scotland in the inter-pandemic and pandemic alert periods should particularly focus on developing surge capacity in health and community care, preparing measures to ensure wider business continuity and to maintain essential services and supplies in a pandemic scenario. Health priorities include the management of seasonal influenza, participating in UK wide arrangements to facilitate the development, manufacture and supply of a specific vaccine, maintaining adequate supplies of essential pharmaceutical and other materials, developing an ethical framework to underpin planning and improving hygiene awareness amongst the general population. Regular joint reviews, testing and exercising of business continuity and response plans across all sectors throughout this period are critical to the robustness and resilience of Scotland's response.

6.3 Inter-Pandemic Alert Period - WHO Phases 1 and 2

The inter-pandemic years provide opportunities to improve knowledge, refine policies, build capacity and prepare the population for the likely emergence of an influenza pandemic. Efforts will also focus on contributing to multinational efforts to reduce the opportunities for a new influenza virus to emerge, developing capability for effective surveillance and detection in every country and improving domestic preparations in all sectors to address the threat.

Scientists believe that avian or bird viruses played a significant role in each of the influenza pandemics that occurred in the last century and that it is highly probable that the next pandemic will emerge from an animal reservoir. Expanding and improving co-ordination and co-operation between the organisations responsible for human and animal health is therefore an important objective. Through the Department for International Development and Department for the Environment, Food and Rural Affairs, the UK government works with international agencies to support a range of veterinary and social strategies - particularly improved animal husbandry, veterinary control and education - in potential source countries and to strengthen veterinary and human health services related to the control of avian influenza. It also supports WHO and EU initiatives to improve the capacity to detect and monitor the emergence of a novel virus in those parts of the world with poorly developed health surveillance systems.

Individuals should keep themselves informed, adopt good hygiene measures and ensure that they are routinely vaccinated for seasonal influenza and pneumonia if they have been identified as being in a high risk group.

6.4 Pandemic Alert Period - WHO Phases 3-5

WHO will continue to inform its Member States of any change in alert phase. As international phases change, the Government will monitor developments, reassess national risk and review preparedness arrangements at all levels across each sector. The general aim is to accelerate, consolidate and test preparedness efforts, as outlined above, before phase 4 and be fully prepared to initiate and implement response actions at any phase thereafter.

The initial UK response depends significantly on the location of an incident or outbreak and the extent of travel or trade connections with that region. Should a case, cases or outbreak originate in the UK, the overriding priority will be to halt, limit or slow the spread. If outside the UK, the priorities would include:

• supporting the efforts of the WHO and governments to limit or control the spread of infection
• maintaining international liaison
• providing advice and information to UK citizens or travellers abroad
• initiating domestic measures to increase vigilance and alerting the NHS to look for and investigate any illness that might be due to the virus in the UK
• reviewing the likely efficacy of any possible travel or other restrictions and making UK policy clear
• reviewing possible opportunities for vaccine development
• securing access to vaccine supplies and other pharmaceuticals and non-consumable supplies as they become available
• providing information that builds public awareness and understanding
• reviewing all response arrangements.

Individuals should listen to Government advice, adopt good hygiene measures and ensure that they are routinely vaccinated for seasonal influenza and pneumonia if they have been identified as being in a high risk group.

6.4.1 Phase 4

At phase 4 all organisations in Scotland should review business/service continuity arrangements, consider initiating measures to enhance and preserve essential supplies and finalise plans for pre-distribution of any stockpiled items. Expert groups should convene to review emerging information, provide advice on adjustments in response strategies and make recommendations in respect of optimal clinical practices. Steps to prepare and inform the public will be accelerated, with particular emphasis on enhancing understanding, explaining the likely issues and limitations, describing how essential services will respond and advising on self and community help. Information messages will also emphasise the importance of staying at home if ill, taking sensible precautions, adopting good hygiene habits and identifying friends or relatives who may be able to provide assistance and support during the pandemic.

Individuals should listen to Government advice, adopt good hygiene measures and ensure that they are routinely vaccinated for seasonal influenza and pneumonia if they have been identified as being in a high risk group. They should consider how they and their families might prepare for events such as school closures, shortages and travel constraints. This could include considering support from and to friends and neighbours. Steps should be taken to ensure continuing care for any existing health conditions and supplies kept of normal home remedies.

6.4.2 Phase 5

At phase 5 response plans must be ready for instant implementation and activated when required. National and local co-ordination and communication arrangements should be activated, the influenza information line established and arrangements for the development and supply of a specific vaccine reviewed. Health departments will be monitoring the development and emerging epidemiology of the pandemic and considering proportionate response measures including the implementation of service restrictions to allow healthcare organisations to finalise preparations, adjust working practices and release capacity in preparation for a pandemic.

Individuals should listen carefully to public announcements with advice and instructions. They should familiarise themselves with local arrangements for accessing health and community care support and antivirals. Advertising campaigns and a door to door leaflet drop will be implemented with messages emphasising that people should maintain essential activities as far as possible and explaining how services will operate and how they should be accessed. Symptomatic patients should stay at home and seek assistance via the national influenza hotline. They should be prepared to describe symptoms, give basic personal details and carefully note and follow clinical advice and instructions.

6.5 Preventing a pandemic's initial development

Theoretical modelling suggests that it may be possible to contain (or at least slow) the spread of infection from rural parts of the country of origin at source providing the virus is detected early, area quarantine and stringent social distancing measures are quickly applied and prophylactic antiviral medicines are given promptly to the 50,000 people nearest to the original source. WHO has established an antiviral stockpile for this purpose, but the success of such measures depends critically on early detection, the effectiveness of local planning and response in parts of the world where such systems are not well developed. Although that continues to improve, there can be little certainty that a containment policy would succeed, but even if it fails to contain the outbreak completely, it might delay spread by about a month giving others more time to prepare.

Should the virus originate in the UK, then rapid detection, isolation and treatment of sufferers, the application of stringent containment measures and the use of antiviral prophylaxis for all close contacts may possibly contain or limit its spread. However, if the virus enters the UK through travellers from infected areas such internal containment efforts are considered unlikely to succeed due to the large number of seed cases expected.