UNITED NATIONS MEDICAL SERVICES STAFF CONTINGENCY PLAN GUIDELINES FOR AN INFLUENZA PANDEMIC

Transcription

1 UNITED NATIONS MEDICAL SERVICES STAFF CONTINGENCY PLAN GUIDELINES FOR AN INFLUENZA PANDEMIC UN System Medical Directors 1 March 2006 (1 st update since 5 October 2005)

2 Table of Contents Preface A. Introduction B. Background information C. Pandemic Preparedness Plan Phase Phase Phase Phase Annex 1 A. Medical Interventions B. Non-Medical Interventions C. Communication Annex 2 Template for the Contingency Plan for Pandemic Procurement Annex 3 Personal protective equipment kit (PPE) for medical and paramedical staff, and other staff whose critical functions entail high-risk exposure Annex 4 Health advisory on self protection for travel to/through or living in outbreak regions.. 26 Annex 5 Protecting yourself and others against respiratory illness Annex 6 Proposed priority groups for pandemic vaccine Annex 7 Use of personal protective equipment kit Annex 8 List of 6-week supplies to be stocked Page 25 1 March 2006 Page 2

3 PREFACE The UN Medical Directors, with technical input from WHO experts, created this document in order to provide a contingency plan template for the health and safety of worldwide UN staff and their families. These Guidelines provide a plan to ensure preparedness for a timely, consistent and coordinated response across the UN organizations to a possible global threat of an Influenza pandemic, thereby minimizing the effects of such a pandemic. This is the first revision since these Guidelines were initially released on 6 October This update incorporates a policy change from departure/early departure to recommending confinement to the duty station residence in the event of a pandemic as an alternative which would help prevent staff safety from being compromised by exposure to pandemic influenza. The new recommendation, upon the advice of WHO, is that staff should be instructed to stay in their duty station residence during a pandemic wave and that staff themselves should ensure they have sufficient emergency food supplies, water, prescribed medication, medical kits and other essentials to last six weeks (as listed in Annex 8), until the wave has passed. This is due to the fact that increasing the movement of people may contribute to spreading influenza which would not be wise from a public health perspective. Also, leaving the duty station may not be logistically feasible since airlines may shut down and countries may close their borders even to their own nationals returning from a pandemicaffected area and therefore, departure from the duty station may not be in the interest of staff safety. It may also not be desirable from a programmatic perspective, in light of the impact this would have on UN operations. One option to help facilitate operational continuity is for staff to work from home when a pandemic strikes and this option should be explored during the present phase (Phase 3). Secondly, this version of the Guidelines incorporates answers and clarifications to all questions posed by management in duty stations worldwide in response to the version issued on 6 October Thirdly, we incorporated further information on this subject as it has evolved since October This document remains a living document and as new research and information comes to light, it will be incorporated into future updates. Lastly, Annexes 2 and 3 have been modified and Annex 6 has been expanded. Two new Annexes have been added, one on how to use personnel protective equipment (Annex 7) and the other listing the supplies to be stocked for six weeks (Annex 8). The former Annexes 7 and 8 in the document issued on 6 October 2005 have been removed. 1 March 2006 Page 3

4 A. Introduction The purpose of this plan is to protect the health of the staff and their dependents. A timely and effective response across the UN system will enable the Organizations to fulfill their mandates to the member states. Differences amongst the Organizations, and from location to location, may require local adaptation or modification of these guidelines. The plan primarily addresses the needs of field duty stations; each UN Headquarters should develop its own plan with the relevant Emergency Management Groups. This contingency plan further develops the "WHO Health and Medical Services Contingency Plan for an Influenza Pandemic, dated 30 May 2005 and this plan, United Nations Medical Services Staff Contingency Plan Guidelines for An Influenza Pandemic of 5 October This subject was initially addressed during the Medical Directors meeting in Vienna in April 2005 where the draft WHO contingency plan for their own staff and dependants was reviewed and eventually finalized by WHO on 30 May To facilitate the initial stages of planning, an informal Working Group was established represented by the Department of Safety and Security, the United Nations Medical Directors Group, WHO technical experts, FAO, UNICEF, WFP and DPKO. As a result of the Working Group decisions, this document was prepared by the UN Medical Directors Group with technical input from WHO. This preparedness plan sets out measures and actions required of UN Medical Services, UN Resident Coordinators, UN Country Management Team, Crisis Management Team, UN Designated Officials, UN Security Management Teams, individual agencies and staff members to determine and implement, on an inter-agency basis at the country level, the appropriate preparations and precautions. B. Background information Influenza is a viral respiratory disease affecting humans and certain animals. Normally, people are infected only by human influenza viruses and not animal influenza viruses. Clinical disease ranges from infection with no symptoms to mild nonspecific illness to many different life threatening complications, including pneumonia. On occasion, animal influenza viruses, or influenza viruses containing genes from animal influenza viruses can begin to infect people. When a completely new strain of influenza virus emerges among human populations, and has the ability to spread easily from person to person, the virus can spread world wide within months (and perhaps weeks) leading to higher levels than usual of mortality and severe illness. In this situation, all age groups are vulnerable to infection, and there can be disruption to all sectors of society. Such a situation is called an influenza pandemic." Pandemics are different from usual influenza seasons and happen relatively infrequently. 1 March 2006 Page 4

5 There is currently rising concern that an avian or bird influenza virus, known as influenza A (H5N1) or simply as "H5N1," which is circulating widely among birds primarily in Asia but now parts of Europe, may gain the ability to spread easily from person to person and lead to the first influenza pandemic of the 21 st Century. Many of the prerequisites for the start of an influenza pandemic appear to be in place but the virus still has not gained the ability to conduct efficient and sustained human-to-human transmission. The possibility that the H5N1 virus will gain this ability must be considered quite "real" but also is not certain. If an influenza pandemic appears, the following additional considerations will be important to understand and incorporate into additional local planning efforts: Given the high level of global travel, the pandemic virus may spread to much of the world within weeks to months, leaving little or no time to prepare. In all three 20 th Century pandemic, substantially more young people died from pandemic influenza than normal when compared with regular influenza seasons. In the 1918 pandemic, the highest death rates and the largest total numbers of deaths occurred in previously healthy young adults. These patterns suggest that the next pandemic could have a substantial impact on the workforce. Vaccines and antiviral agents for pandemic influenza, as well as antibiotics to treat secondary infections will be in short supply initially, while distribution of available supplies is likely to be unequal. It will take several months or longer before any effective pandemic vaccine becomes widely available. Many if not most medical facilities will be overwhelmed by patients. Moreover, the health care workforce is likely to be reduced because health care workers will also become ill and will also stay home to care for ill family members. For weeks at a time, significant shortages of personnel may occur, disrupting essential community services. UN staff, depending on the mandate of their organization may be required to continue their critical functions. Once the virus has gained the ability to spread easily among people, then no country or region can be considered a low-risk area for infection. In essence, there will be no "safe havens" from potential exposure to the virus. More background information on influenza is available on WHO web site at in particular, the Fact sheet on Avian Flu and the Frequently Asked Questions booklet. 1 March 2006 Page 5

6 C. Pandemic Preparedness Plan WHO's revised global influenza preparedness plan and related national plans are based on the concept of pandemic phases, which facilitates preparedness planning. Although activity levels are expected to vary from region to region at any point in time, a pandemic phase will be designated for the world. Each phase is associated with international and national actions. The UN Medical Services contingency plan adapts this framework to the UN organizational level. I. INTER-PANDEMIC PHASES: Phase 1: no novel influenza A virus subtypes have been detected in humans. An influenza A virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low. Phase 2: No novel influenza A virus subtypes have been detected in humans; however, a circulating animal influenza A virus subtype poses a substantial risk of human disease II. PANDEMIC ALERT: Phase 3: human infection(s) with a novel subtype, but no human to human spread, or at most rare instances of spread to a close contact. We are currently in Phase 3. Phase 4: small cluster(s) with limited human to human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. Phase 5: larger cluster(s) but human to human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk). Depending on the available information at the time, it may be difficult to make a rapid and meaningful distinction between phases 4 and 5. III. PANDEMIC Phase 6: increased and sustained transmission in general population. MEDICAL ACTIONS: Actions recommended independent of Pandemic Phase Seasonal influenza vaccination is recommended for staff and dependants who are at high risk of complications from influenza or who will be travelling internationally. If supplies allow, it is also be made available to all other UN personnel and their dependents. 1 March 2006 Page 6

7 Pneumococcal vaccination is recommended for staff and dependents who are at high risk of complications from pneumococcal infections (See International Travel and Health, WHO, 2005 pp 110/112). The following table shows the implementation of the UN Medical Services contingency plan for an influenza pandemic. Actions are intended to continue through progressive phases unless they are superseded by the actions of a higher phase. If an up scaling designation skips a phase, actions in the skipped phase should also be implemented, unless they are superseded by the actions in the higher phase. UN Agencies will continuously monitor the development and availability of a specific pandemic influenza vaccine and will procure vaccine for staff and dependents as soon as possible. PHASE 3: Human infection(s) with a novel subtype, but no human to human spread, or at most rare instances of spread to a close contact ACTION RESPONSIBILITY PLANNING AND COORDINATION Brief relevant officials of the UN organizations on present situation, possible outcomes and related resource requirements Convene regular meetings of the UN Agencies Technical Working Group Identify members and functions for a Crisis Management Team (CMT) at organizational level Identify members and functions for a Crisis Management Team (CMT) both at HQ and country level Assess preparedness status and identify gaps and develop plans to address these gaps UN Steering Committee UN Medical Directors UN Agencies participating in the Technical Working Group UN Senior Coordinator for Avian and Human Influenza Respective organizations UN Country Team and above-mentioned working group at the Headquarters level CMT at country and Headquarter levels 1 March 2006 Page 7

8 ACTION Identify critical functions and the associated staff needed to maintain those functions (usually not more than 10% of staff). The defined critical functions will vary to some extent among Organizations due to differences in their mandate. Those functions specific to the mandate must be defined by the individual organizations, however, for all organizations they should include the following: Physical security of staff Medical care of staff Maintenance of computers and telephone services Ability to communicate with other Organizations and Governments Maintenance of Utilities (electricity, water and sanitation) Ability to make important operational and policy decisions related to the pandemic Ability to make important operational and policy decisions related to critical operations and programs continuity RESPONSIBILITY All UN Agencies both at Headquarters and country level MEDICAL INTERVENTIONS Pandemic Vaccines Antivirals Antipyretics Prioritize and identify the groups who will receive the Pandemic Vaccine once it becomes available (Annex 6) Stockpile Oseltamivir (Tamiflu) to treat 30% or more of staff and dependants. In addition, stockpile enough Oseltamivir to provide prophylaxis for 6 weeks primarily for staff needed and identified to maintain critical functions with high risk of exposure. As finances permit, all HQ medical services of the UN System should consider purchasing additional Oseltamivir to cover requests from affected regions for use for other reasons (Annex 2). Such as paracetamol are usually readily available. However, staff members should be encouraged to stock enough for their own needs. UN Administration at each duty station and UN physicians: UN Medical Services UN/DPKO civilian clinics UN Dispensaries UN examining physicians (UNEPs) selected for this purpose. As above Headquarters medical services of the UN System and respective Administration Individual staff members 1 March 2006 Page 8

9 Antibiotics Medical Supplies ACTION Sources of antibiotics able to treat secondary bacterial infections on an out-patient basis in 10% or more of UN staff and their dependents should be identified. If such a supply is not available or is considered unreliable, the antibiotics should be stockpiled (Annex 1 and 2). Procure stocks of: Surgical masks in numbers sufficient to provide all staff and dependants with 2 masks per day for 6 weeks. Enough Personal Protective Equipment (PPE) including N95 masks, gloves and gowns (Annex 3) for two changes per day for 6 weeks for medical and paramedical staff when in direct contact with ill patients or those staff whose critical functions involve high risk of exposure. Where local supplies are not sufficient consider procuring one set of needles and syringes per staff member and dependent. Thermometers should be procured by all staff members RESPONSIBILITY UN Country Management Team and UN Physicians/designated UNEPs at each duty station UN Country Management Team and UN Physicians/designated UNEPs at each duty station should estimate needs and request the appropriate amounts. Staff member responsibility to buy thermometers NON MEDICAL INTERVENTIONS Familiarize with national preparedness plan and inform the UNCT Familiarize with UN Medical Services Contingency Plan for Influenza Pandemic Identify hospitals in the country and region where critically ill staff may be sent and develop specific plans for facilitating their rapid hospitalization, for example via a Memorandum of Understanding Prepare contractual agreements with outpatient and hospital-based health care providers who will help prepare for the implementation of local plans and to care for ill UN staff. Providers to be paid for at a reasonable and customary rate for the location and time services are rendered WHO Resident Representative All Country Management Teams, Crisis Management Teams, UN Designated Officials, UN Security Management Teams, UN Physicians/designated UNEPs and Staff Counselors CMT at the duty station at the country level; UN Physicians/designated UNEPs at the duty station at the country level; CMT at country level UN Physician at the duty station at the country level 1 March 2006 Page 9

10 COMMUNICATION ACTION Develop plans for creating local auxiliary outpatient care clinics for UN staff and their dependents that are designed to reduce the risk of nosocomial influenza infection ( fever clinics ) for the distribution of simple surgical masks for the distribution of PPE Communicate the UN preparedness plan to all Organizations and Country Offices Provide health travel advisory (Annex 4) Disseminate periodic advice on personal hygiene (Annex 5). Information on case management and Infection Control Guidelines to Health Care Worker (HCW) and WHO/FAO experts (See Case Management Guidelines); RESPONSIBILITY CMT at country level UN Medical Director/UNDSS UN Medical Directors in consultation with WHO Country Representatives UN Medical Directors UN Clinics UN Dispensaries Designated UNEPs UN Medical Directors PHASE 4: Small cluster(s) with limited human to human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans PLANNING AND COORDINATION ACTION Declare Pandemic Alert Phase 4 Implement Crisis Management Team at UN System Level for countries with clusters Implement Crisis Management Team at Organizational Level Convene regular meetings of UN Medical Directors Group WHO UNCT/DO RESPONSIBILITY Headquarters Field Administration and Security UN Medical Services UN Medical Director Convene regular meetings of UN Agencies Technical Working Group Staff should be advised to prepare for staying at home for 6 weeks by stocking supplies (Annex 8) UN Senior Coordinator for Avian and Human Influenza Designated Officials Individual UN Agencies at country level Staff members 1 March 2006 Page 10

11 ACTION RESPONSIBILITY MEDICAL INTERVENTIONS Pandemic Vaccine As in Phase 3 See Phase 3 Antivirals As in Phase 3 See Phase 3 Antipyretics As in Phase 3 See Phase 3 Antibiotics As in Phase 3 See Phase 3 Medical Supply As in Phase 3 See Phase 3 NON MEDICAL INTERVENTIONS COMMUNICATION Distribute surgical masks to staff and dependents in countries with clusters according to the plan Distribute PPE to medical and paramedical staff in countries with clusters according to the plan Distribute PPE to staff required to carry out critical functions with risk of high exposure in countries with clusters Conduct dry runs of fever clinics to make sure they can be implemented and operated smoothly when needed Confirm contractual medical care agreements with health care providers and facilities Issue health and travel advisory for affected countries Inform staff of local healthcare arrangements Issue advice on personal protection and hygiene Distribute guidelines on management of suspected/probable cases at fever clinics. Individual UN Agencies in the countries with clusters UN Medical Services UN Clinics UN Dispensaries Contracted Healthcare Providers at country level Individual UN Agencies in the countries with clusters UN Medical Services UN Clinics UN Dispensaries Contracted Healthcare Providers at country level CMT at country level UN Medical Directors in consultation with WHO Individual UN Agencies at country level UN Medical Services UN Clinics UN Dispensaries Contracted Healthcare Providers at country level As above 1 March 2006 Page 11

12 PHASE 5: Larger cluster(s) but human to human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk). PLANNING AND COORDINATION ACTION Declare Pandemic Alert Phase 5 Staff should be instructed to stay in their duty station residences, having ensured that they have sufficient food, water, prescribed medication and supplies, medical kits and other essentials to last 6 weeks, until a pandemic wave has passed. [Such supplies are listed in Annex 8.] When UN staff is working in settings with very weak medical infrastructure, when there is a potentially severe shortage of essential services, or when responses to the pandemic might lead to a marked reduction in security cover for UN staff, relocation within the duty station might be necessary. WHO RESPONSIBILITY Secretary General on advice from the UN Steering Committee Designated Officials Individual UN Agencies MEDICAL INTERVENTIONS Treatment Treatment to be provided by the preidentified healthcare providers as necessary following case management guidelines Pandemic Vaccine As in Phases 3 and 4 (Annex 6) As above Antivirals Antipyretics Provide antivirals within 48 hours to symptomatic persons who meet the clinical case definition criteria in accordance to Case Management Guidelines to be provided later Provide antivirals primarily to those staff whose critical functions involve high risk of exposure for prophylaxis (Annex 1) To be taken in accordance with Case Management Guidelines UN Medical Services UN Clinics UN Dispensaries Contracted Healthcare Providers As above As above As above Antibiotics Use as required As above Medical supply Advise use of surgical masks and PPE already distributed in Phase 4 in accordance with Case Management Guidelines Individual UN Agencies NON MEDICAL INTERVENTION Fever Clinics to become operational as needed. UN Medical Directors UN Clinics UN Dispensaries Contracted Healthcare Providers 1 March 2006 Page 12

13 ACTION Home confinement of symptomatic persons in affected countries i.e. seven days since resolution of fever. This information will be updated as evidence related to the pandemic virus becomes available. To ensure containment at early stage, it is encouraged that family members of a symptomatic person do not come to work. Defer all non- critical meetings in affected countries and prohibit or postpone any UN activities requiring mass gatherings Defer all non- critical travel Defer all travel of UN staff presenting with influenza-like symptoms RESPONSIBILITY UN physicians/contracted Healthcare Providers Country Representatives Staff and dependents DO Country Representatives CMT at country level UN Medical Directors As per health and travel advisories from UN Medical Directors UN Country Management Team and UN physicians/contracted Healthcare Providers COMMUNICATION Inform staff of travel restrictions UN Medical Directors UN Clinics UN Dispensaries Contracted Healthcare Providers Security Services Travel Sections/Units Reinforce personal protection and hygiene guidelines(annex 5) Update and disseminate infection control guidelines for cases and exposure to cases Organizations keep their staff regularly informed and updated on developments UN Medical Directors UN Clinics UN Dispensaries Contracted Healthcare Providers As above Country Representatives CMT at country level 1 March 2006 Page 13

14 PHASE 6: Increased and sustained transmission in the general population. ACTIONS RESPONSIBILITY PLANNING AND COORDINATION MEDICAL INTERVENTIONS Declare Pandemic Phase 6 Acquisition of pandemic vaccine and planning of staff vaccination once the vaccine becomes available Crisis Management Teams to meet regularly Treatment to be provided by the preidentified healthcare providers as necessary following case management guidelines Provide antivirals as prophylaxis primarily to staff who perform critical functions with high risk of exposure Vaccinate with pandemic vaccine according to priority groups already identified (Annex 6) WHO UN Medical Directors UN Clinics UN Dispensaries Contracted Healthcare Providers CMT at country, headquarters level and organizational levels UN Medical Directors UN Clinics UN Dispensaries Contracted Healthcare Providers As above As above NON MEDICAL INTERVENTIONS As in Phase 5 See Phase 5 COMMUNICATION As in Phase 5 See Phase 5 Note: Actions in Phase 6 may be superseded by the actions of the National Health Authorities and must be adapted accordingly. 1 March 2006 Page 14

15 1. Vaccines 1.1 Vaccine against seasonal influenza Annex 1 A. Medical Interventions There is a vaccine available each year to protect against seasonal human influenza. This vaccine is recommended primarily for staff and dependants who are at high risk of complications from influenza or who will be traveling internationally. If supply allows it can also be made available to all other UN personnel and their dependents. Influenza vaccine can also be a highly cost-effective countermeasure against seasonal influenza. In most years the northern and southern hemisphere vaccines are identical or very similar. Persons living in the northern hemisphere should be vaccinated with the northern hemisphere vaccine while those living in the southern hemisphere should be vaccinated with the southern hemisphere vaccine. For those living in equatorial regions vaccinations will be with the vaccine locally available at that time. Vaccination programmes should be commenced once the vaccine for the appropriate hemisphere becomes available. In the northern hemisphere this will generally be in October and November and in the southern hemisphere from March to May. Travelers are advised to have the vaccine of the hemisphere where they are based. While seasonal influenza vaccine will not protect against a pandemic strain and does not provide protection against the many other viruses that can cause respiratory illnesses, widespread use of seasonal influenza vaccines may be very helpful in a pandemic situation. Any reduction in seasonal influenza cases due to use of seasonal influenza vaccine will reduce the possibility that a case of seasonal influenza might be mistaken for a case of pandemic influenza, thereby reducing unnecessary worry and actions. 1.2 Pneumococcal vaccine Pneumococcal vaccine should be considered for people at particular risk for the bacterial pneumonia complication of influenza, including those 65 years of age or older, those with heart failure, emphysema, diabetes mellitus, alcoholism, or chronic liver disease, and those who are otherwise immune compromised. (For more information, please refer to the WHO International Travel and Health booklet). Persons who meet these criteria are advised to contact their usual healthcare providers. No stockpile is recommended. 1.3 Vaccine against pandemic influenza If a new pandemic virus strain emerges, there will be a focused effort by public health authorities and manufacturers worldwide to develop, distribute and administer an effective and specific pandemic vaccine. However, the process is complicated and will take a number of months before a vaccine would be available. Currently, vaccines against the influenza virus A/H5N1 are being developed and tested but these vaccines are not yet available for general or widespread use. 1 March 2006 Page 15

16 Moreover, the current vaccine containing a recent H5N1 virus may or may not be effective against a future H5N1 strain, if such a strain emerges with the ability to spread easily among people. WHO will closely follow the development, protective effect and safety of both the A/H5N1 and any other new pandemic vaccine and will make recommendations on its use as soon as the product is available. If deemed appropriate based on safety and efficacy, WHO will also contact manufacturers beforehand to arrange the procurement of the vaccine in advance of its need. Under the best of circumstances, given the global population size and limited production capacity for influenza vaccine, any pandemic vaccine will initially be in short supply. Demand will far exceed availability. Priority recipients will include those involved with direct clinical contact with patients, those staff required to maintain critical functions, and those at particularly high risk of serious complications, such as the elderly and those with chronic diseases, please refer to Annex 6. Such priority lists, as developed, will have to be compatible with recommendations made for the international community at the time the vaccine becomes available. UN Medical Services will follow WHO recommendations. However, it is also anticipated that more detailed priority lists may be developed at national and local levels that will inevitably reflect some differences in terms of local preferences. 2. Antivirals In recent years, new anti-viral agents to prevent or treat influenza infections have been developed. Two classes of drugs are available (the M2 inhibitors such as amantadine and rimantadine and the neuraminidase inhibitors such as Oseltamivir and Zanimivir). These drugs have been licensed for the prevention and treatment of human seasonal influenza in some countries. However, initial analysis of viruses isolated from the recent human cases of A/H5N1 indicates that many of these viruses currently are resistant to the M2 inhibitors. In addition, only the neuraminidase inhibitors have been shown, in animal laboratory tests, to be effective against influenza virus A/H5N1. There is extremely little real world clinical experience with use or effectiveness of antiviral drugs against H5N1 viral infections in humans. Among the neuramindase inhibitors, the only drug easily deliverable (orally in capsules/suspension) is Oseltamivir, known in its only commercial form as Tamiflu ). At this time, limited evidence suggests that Tamiflu can reduce the duration of viral replication and improve prospects of survival, provided they are administered within 48 hours following symptom onset. Other antivirals, such as amantadine, have not shown effectiveness against A/H5/N1 in laboratory settings, but could potentially have some effectiveness against another new emerging strain. The following provides guidance on use of Oseltamivir for prophylaxis and treatment: 2.1 Prophylaxis Antiviral drugs used for prophylaxis are given to people who are not infected and who are not ill. The purpose of prophylaxis is to try and prevent the development of severe pandemic disease in people who are potentially exposed to pandemic influenza. Oseltamivir can be offered to selected staff needed and identified to maintain critical functions. The current prophylactic regimen is one tablet of 75mg per day. The upper limits for safe use of 1 March 2006 Page 16

17 Oseltamivir as prophylaxis are unknown. However, it is assumed that based on past pandemics and epidemics that in local areas, the duration of elevated risk of exposure to the pandemic virus in an area will be several weeks. In this document, to aid planning efforts, this period has been defined as 6 weeks because Oseltamivir is licensed for up to six weeks of continuous use for prophylaxis. Use of antiviral drugs for prophylaxis is extremely resource consuming. Therefore, pre-exposure prophylaxis should be limited to maintenance of critical functions of an Organization. 2.2 Treatment (a) Of ill persons: In symptomatic patients suspected of having pandemic influenza, Oseltamivir can be administered as treatment. Current recommendations for treatment, based on treatment against seasonal influenza, are is two 75 mg. capsules a day (total of 150 mg. per day) for 5 days. There are no data for use for children below the age of 1 year. Oral suspension for children can be given to children up to 40 kg after which the adult dosage can be used (ref: product information). For maximum effect, the drug should be started within 48 hours of the onset of symptoms (the greatest effect being demonstrated if taken within 12 hours). During a pandemic situation, the possibility to test an individual patient for influenza infection will be extremely limited and therefore decision about whether to treat or not will depend upon clinical findings (refer to Case Management Guidelines). Moreover, current recommendations on the amount and duration of treatment may change as more information becomes available about the effectiveness of dosages of antiviral drugs against pandemic influenza. (b) Post-exposure prophylaxis/treatment: This is, at present, considered for a very restricted group of professionals who have been exposed to Avian Influenza virus H5N1, such as animal health experts or WHO virologists. 3. Stockpiling Oseltamivir If a pandemic is declared it is very likely that all stocks of medicine useful against influenza, particularly Oseltamivir, will be in very high demand and rapidly exhausted. Therefore UN offices must be prepared and stockpile some Oseltamivir. The amount of Oseltamivir stockpiled by the UN system at the country level is based on the following considerations: 1. Based on past epidemics, a reasonable overall attack rate (i.e., the number of new symptomatic illnesses per 100 persons over one year) for pandemic influenza will be 30%. 2. Since some people who will develop symptoms will not have pandemic influenza but may have colds or other respiratory infections, some of the may be used treating non-pandemic illnesses. 3. Organizations at the country level will have to use for prophylaxis to maintain critical functions further increasing the required supply. Based on these considerations, UN offices each should stockpile enough Oseltamivir to provide for a 5-day course of treatment for approximately 30 % or more of all their staff and their dependants. 1 March 2006 Page 17

18 In addition, enough Oseltamivir should be stockpiled by the specific UN organizations to provide prophylaxis for 6 weeks primarily for all persons who are needed to maintain critical functions with high risk of exposure. Antivirals will become a very valuable commodity during a pandemic as there will not be sufficient production to meet the full demand and therefore plans should be developed for their secure storage locally. This place should be dry with a temperature below 30 degrees. Under these conditions the shelf life is expected to be at least 5 years. Stocks of medications should be under the responsibility of the UN Medical Service physician at the duty station. In their absence, the organizations representatives should hold the Oseltamivir stockpile and make the drug available to pre-identified contracted physicians who will be in charge of specific decisions about the use of antiviral drugs since Oseltamivir is a prescription drug and should not be self medicated. Specific criteria for prescription of Oseltamivir will be distributed to all healthcare providers. These measures should be replicated in the sub offices. Oseltamivir is at present not available in sufficient amounts to cover the requirements of the contingency plan; it will be supplied as orders are filled by the manufacturer(s). 4. Antipyretics Antipyretic such as paracetamol will be indicated as in most febrile diseases to relieve pain and control fever. Aspirin is contraindicated in those suspected of having influenza under the age of 12 and in those with known contraindications. Antipyretics are widely available and no particular stockpile is recommended. 5. Medical Supplies. UNCT s and responsible medical personnel should consider availability of syringes and needles and stockpile one set per staff member and dependent, if not available in sufficient quantities locally or if supplies are unreliable. 6. Antibiotics As influenza can be complicated by secondary bacterial infection of the lungs, antibiotics could be life saving. Availability of antibiotics suitable for outpatient use and targeted to pulmonary bacterial infection should be ascertained and if not available in sufficient amounts during a pandemic situation then consideration should be given towards stockpiling enough to treat pneumonia in approximately 10% of staff and dependents (see Annex 2 for procurement details). The goal of providing rapid outpatient antibiotic treatment is to reduce the number of cases of severe secondary bacterial infection requiring treatment in a hospital facility. The appropriate antibiotics are specified in the procurement plan (Annex 2). Note should be taken of the expiry date and unused antibiotics should be donated to local healthcare facilities in good time for use and restocked accordingly. 1 March 2006 Page 18

19 7. Personal Protective Equipment (PPE) Personal protective equipment kits which include N95 masks provide a high degree of protection against infection if fitted properly and are appropriate for persons who are at unusually high risk of infection. Instructions for use are attached as Annex 7. Currently during Phase 3 only specific UN professional groups will require PPE as per Annex 3 (for example, field investigators who are investigating outbreaks from FAO and WHO). Once a pandemic has started PPE will be provided to all staff who perform critical functions with a high risk of exposure. Please note that all items in the PPE kits are disposable except for the goggles which should be cleaned/ decontaminated after every use e.g. with soap and water. Simple Surgical Masks Suspected cases should wear a simple surgical mask in order to limit the spread of the virus into the air through coughing, speech, and fomites. In the event of a pandemic it is anticipated that many staff will request masks as they may provide some sense of security although are no guarantee for protection. As a result masks may be in short supply and it is recommended that UN offices consider stockpiling disposable surgical masks to be able to respond to the initial demand. Such use should not be encouraged but probably also cannot be prohibited. Recommendation: ideal stockpile is an average of 2 simple surgical masks per person per day for 6 weeks for all UN staff and dependants. 8. Medical Care and Medical Evacuation Each country team, in cooperation with the appropriate government offices, should now in phase 3, identify the most appropriate local healthcare facilities to treat UN staff and dependents in case of an influenza pandemic. A plan should be developed locally detailing how ill UN staff and dependents will be transported and admitted to the facility if necessary. Each UNCT should designate healthcare providers (UN physicians, dispensary physicians, preidentified contracted healthcare providers) who will be responsible for out patient triage, case management of UN staff and liaison with the identified facilities. The preidentified contracted healthcare providers should initially each receive a basic stock of Oseltamivir for 10 treatments, PPE and simple surgical masks to be replenished as needed. The healthcare providers must plan for the increased number of outpatients by identifying additional space. From WHO Pandemic Phase 5 and until the pandemic alert has been officially declared over, all UN staff remaining in the country should check their body temperature at least once daily and notify the 1 March 2006 Page 19

20 UN physician on duty of any respiratory symptoms such as cough or any fever (temperature above or equal to 38 C) by phone. If symptomatic they should be seen by either the designated UN physician or another health care provider and told to abstain from going to work if appropriate. Requests for medical evacuation of severe cases that cannot be dealt with locally will be dealt with according to the established rules and regulation on the subject. However note that Medical evacuation in the event of a pandemic may not be possible due to public health regulations and the extraordinary logistic difficulties. B. Non-Medical Interventions All UN staff and their dependants will have to follow the public health measures taken by the national authorities, particularly those relevant to social gatherings (e.g. schools, cinemas, public transportation etc.). General recommendation regarding "respiratory etiquette" (cover your mouth when you cough) and hand washing or hand decontamination with alcohol hand rub should be emphasized. 1. Workplace During Phase 3, Agency Heads will need to define as soon as possible the critical functions for their Organization and the staffing needed to maintain such functions. All functions, especially those that are critical, should be assessed for their telecommuting potential (working from home with ICT support). Any staff member who becomes ill should be asked to practice isolation and to stay home for 7 days after the resolution of fever (or longer if the case is complicated). In addition he/she should, as soon as possible, start a course of Oseltamivir and wear a simple surgical mask when meeting other people. In the early phases of a pandemic (phase 4 and early phase 5), in order to contain the possible spread of infection, persons who have been exposed to a known case of pandemic influenza should be asked to practice quarantine and to stay home for the period of 7 days to cover the maximum incubation period. Later, as pandemic infections become more common, the request for voluntary quarantine may be dropped since it would no longer be effective or practical. If a staff member has a relative or someone else at home suspected of being affected by pandemic influenza, he/she should be allowed to abstain from going to work to provide care for that person. 2. Meetings If a pandemic is declared all international and other large meetings should be postponed. 1 March 2006 Page 20

21 3. International Travel Influenza is an airbourne disease and is readily transmittable by droplets. Viral excretion may also occur during the incubation period (which may be relatively short). Therefore it is unlikely that travel restrictions and other social distancing efforts, can stop the spread of influenza, however, these steps may help slow down the spread of an influenza pandemic. Early in the pandemic, slowing down the spread of the influenza pandemic virus could buy precious time for vaccine development and access to other essential supplies. UN Offices are required to strictly follow WHO recommendations at the time of the outbreak. 4. Confinement to duty station residence in the event of a pandemic As an alternative to departure that would help prevent staff safety from being compromised by exposure to pandemic influenza, and as advised by WHO, staff should be instructed to stay in their duty station residence. Staff members should also ensure that they have sufficient emergency food supplies, water, prescribed medication, medical kits and other essentials to last 6 weeks (such supplies are listed in Annex 8), until a pandemic wave has passed. This is due to the fact that increasing the movement of people may contribute to spreading influenza which would not be wise from a public health perspective. Also, leaving the duty station may not be logistically feasible since airlines may shut down and countries may close their borders even to their own nationals returning from a pandemic-affected area and therefore, departure from the duty station may not be in the interest of staff safety. Departure from the duty station may also not be desirable from a programmatic perspective, in light of the impact this would have on UN operations. One option to help facilitate operational continuity is for staff to work from home when a pandemic strikes and would need to be further explored. 5. Relocation of staff within country While it was agreed that the overarching policy direction should now be for staff to remain confined to their duty stations and/or residences in the event of a pandemic, further work is needed to agree on the additional support and services that will be required by the concerned staff. Where this support is not forthcoming, deviations from the policy (i.e. relocation) may be indicated. For example, when UN staff are working in settings with very weak medical infrastructure, when there is a potential severe shortage of essential services, or when responses to the pandemic might lead to a marked reduction in security cover for UN staff, relocation might be necessary. DPKO indicated that this is of particular importance for those who depend on the protection of United Nations troops and those who are assigned to remote locations. 6. Repatriation of Remains Repatriation of deceased staff due to pandemic influenza could be delayed and will necessarily follow guidelines developed by the UN during the pandemic. Mortuary bags should be stockpiled where not locally available for 3% of international staff and their dependents. 1 March 2006 Page 21

22 C. Communication The threat of an influenza pandemic will create a high demand for information both within the UN and from external partners. It will be vital to coordinate the information that is circulated by headquarters, regional and country offices. A country communication plan, in association with headquarters and the regional offices, needs to be prepared to rapidly provide appropriate information to all UN staff. This should identify who is responsible for coordinating UN information and communications. Clear internal and external communication will be essential to rapidly deal with rumors and anxieties. All UN medical personnel providing health care to UN staff should be adequately briefed on the contingency plan for influenza pandemic and be provided with the available medical guidelines. The UN Medical Services Staff Contingency Plan Guidelines for Pandemic Influenza has been provided to all relevant levels of the UN system and the input received has been incorporated into this first update. As new evidence comes to light and further feedback is received from those involved in its implementation, further updates will be issued. 1 March 2006 Page 22

23 Annex 2 TEMPLATE FOR THE CONTINGENCY PLAN FOR PANDEMIC PROCUREMENT Action Quantity Unit cost (in US dollars) $ Notes Seasonal human flu vaccines Pandemic strain vaccines Antivirals: Treatement Tamiflu (Oseltamivir) For staff and dependants who are at high risk for complications from influenza or who will be travelling internationally. If supplies allow it can also be made available to all other UN personnel and their dependents. For Proposed Priority Groups for Pandemic Vaccine refer to Annex 6 A 5-day treatment course for 30% of staff and their dependents. * Increase by 10% for a cushion. (10 capsules per course) 7.3/dose 7.3 Single dose syringe N/A /pack of 10 capsules Not expected to be available for at least 6 months after the pandemic virus has been isolated 16.4 Treatment Antivirals: Prophylaxis Tamiflu (Oseltamivir) One tablet per day for 6 weeks primarily for healthcare workers and those performing critical functions with high risk of exposure (42 capsules/person) Prophylaxis Syringes and needles ** IF SUCH A SUPPLY IS NOT AVAILABLE OR IS CONSIDERED UNRELIABLE, CONSIDER STOCKPILING THE FOLLOWING SYRINGES One set of syringes and needles per staff member and dependent 12.0/pack of 100 (half 5 ml and half 10ml syringes with 23G and 21G needles) 0.12 Need to order in blocks of 100 at minimum * For purposes of prophylaxis and treatment, staff and their dependants denotes all staff members and their recognized dependents and all other individuals who have a direct contractual relationship with the organization and their recognized dependents. ** To ensure injection safety, if injectibles have to be used at the local facilities, this stockpile is not specific for pandemic. 1 March 2006 Page 23

24 Action Quantity Unit cost (in US dollars) $ Notes IF SUCH A SUPPLY IS NOT AVAILABLE OR IS CONSIDERED UNRELIABLE, THE FOLLOWING ANTIBIOTICS SHOULD BE STOCKPILED Antibiotics Amoxicillin (500 mg) + Clavulanic Acid (125 mg) Antibiotics (fuoroquinolone) Ciprofloxacin Antibiotics Azithromycin 1 course of 30 tablets for 7.5% of staff population 1 course of 20 tablets for 2.5% of the staff population 1 course of 5 tablets for 2.5% of staff population Available as blister 10x5 tablets (30 tablets per course: US$ 4.50) Available as 100 tablets/bottle or blister 10x mg tablet: (20 tablets per course US$ 0.56) Available as 6 caps/bottle (Cipla, India: US$ 1.08) 4caps/bottle (Durbin, U.K.: US$ 23.08) 500 mg tablet once per day for five days $4.50 Oral drug to be used for secondary (bacterial) pneumonia good for S. pneumonia $0.56 Oral drug to be used for secondary (bacterial) pneumonia if not responding to Augmentin good for H. Influenza but may not be good for S. pneumonia $1.08 $23.08 Taken once per day for five days Staph and S. pneumonia and also for those allergic to or not responding to amoxicillin. Note should be taken of the expiry date and unused antibiotics should be donated to local healthcare facilities in good time for use and restocked accordingly. Repatriation of bodies of deceased international staff and family members (mortuary bags) 3% of international staff population When local availability is not sufficient PPE Kit For health workers and those performing critical functions with high risk of exposure $50.00 (This unit cost is less from the previous quote of $130.07) $50.00 The cost of one kit with supplies to cover 2 changes for 42 days is $ as per Annex 3. Simple Surgical masks Sub-total Shipping Contingency fund TOTAL 2 per day per staff and dependents x 42 days Packing, freight, insurance ply 1 March 2006 Page 24

25 Annex 3 PERSONAL PROTECTIVE EQUIPMENT KIT (PPE) FOR MEDICAL AND PARAMEDICAL STAFF, AND OTHER STAFF WHOSE CRITICAL FUNCTIONS ENTAIL HIGH-RISK EXPOSURE * This is an average supply that has been worked out for this category of staff, calculating 2 changes per day for each person for 6 weeks. Item Description Unit Quantity Per day Quantity for 6 weeks Unit price in USD Total cost for 6 weeks in USD 1 Protective goggles, polycarbonate, reusable Each 3 N/A $8.00 $ Face mask grade P2 (or N95), disposable BX/ $0.49 $ single use gloves, small, anatomically shaped, latex, non-sterile 4 Single use gloves, medium, anatomically shaped, latex, non-sterile PAIR $0.06 $25.20 PAIR $0.06 $ Single use gloves, large, anatomically shaped, latex, non-sterile, PAIR $0.06 $ Single use plastic apron, EACH 2 84 $0.07 $ Rubber Gloves (reusable for environmental cleaning PAIR 10 N/A $3.00 N/A 8 Coverall, disposable, non sterile EACH 2 84 $5.38 $ Alcohol rub disinfectant ** Dangerous goods UN code 1987, Class 3 bottle/ 1000ml 1 N/A $8.25 $ Disposable bag for bio-hazardous waste 1 bag per day for 6 weeks. 11 Disposal bag for bio hazardous waste, small, with Bio-Hazard print, polypropylene 1 bag per day for 6 weeks EACH 1 42 bags EACH 1 42 bags N/A $0.35 $ bags N/A $0.35 $ bags Total US$ * This PPE kit is not adequate for veterinarian purposes including for culling. ** This should be procured locally to avoid problems with shipping of dangerous goods. If it cannot be supplied locally, order separately. Alternatively, chlorhexidine gluconate 4% solution in bottles of 250 ml each (that means 4 bottles per kit to equal the liter requirement per kit), could be procured. 1 March 2006 Page 25

26 Annex 4 HEALTH ADVISORY ON SELF PROTECTION FOR TRAVEL TO/THROUGH OR LIVING IN OUTBREAK REGIONS The following recommendations are directed to UN staff and their recognized dependents travelling to/through or living in areas where avian influenza A (H5N1) outbreaks among poultry or human H5N1 cases have been reported. These recommendations may be revised as more information becomes available. To minimize the possibility of infection, observe precautions to safeguard your health. Specifically, travelers should avoid touching live or dead poultry (e.g., chickens, ducks, geese, pigeons, quail) or any wild birds or their feces, and avoid settings where H5N1- infected poultry may be present, such as commercial or backyard poultry farms and live poultry markets. Do not eat uncooked or undercooked poultry or poultry products, including dishes made with uncooked poultry blood. As with other infectious illnesses, one of the most important preventive practices is careful and frequent hand washing. Cleaning your hands often, using either soap and water (or waterless, alcohol-based hand rubs when soap is not available and hands are not visibly soiled), removes potentially infectious materials from your skin and helps prevent disease transmission. When preparing food: Separate raw meat from cooked or ready-to-eat foods. Do not use the same chopping board or the same knife for preparing raw meat and cooked or ready-to-eat foods. Do not handle either raw or cooked foods without washing your hands in between. Do not place cooked meat back on the same plate or surface it was on before it was cooked. All foods from poultry, including eggs and poultry blood, should be cooked thoroughly. Egg yolks should not be runny or liquid. Because influenza viruses are destroyed by heat, the cooking temperature for poultry meat should reach 70 C (158 F). Wash egg shells in soapy water before handling and cooking, and wash your hands afterwards. Do not use raw or soft-boiled eggs in foods that will not be cooked. After handling raw poultry or eggs, wash your hands and all surfaces and utensils thoroughly with soap and water. If you believe you might have been exposed to avian influenza, take the following precautions: 1 March 2006 Page 26

27 Monitor your health for 10 days. If you become ill with fever and develop a cough or difficulty breathing, or if you develop any illness during this 10-day period, consult a health-care provider. Before you visit a health-care setting, tell the provider the following: 1) your symptoms 2) if you have had direct poultry contact, and 3) where you traveled. Do not travel while sick, and limit contact with others as much as possible to help prevent the spread of any infectious illness. 1 March 2006 Page 27

28 Annex 5 PROTECTING YOURSELF AND OTHERS AGAINST RESPIRATORY ILLNESS Respiratory illnesses like influenza are spread by coughing, sneezing or contaminated hands. To help stop the spread of microorganisms, Cover the nose and mouth when coughing or sneezing Use a tissue and dispose of it after use in the waste. Clean your hands after coughing or sneezing Wash with soap and water or Clean with alcohol-based hand cleaner. If using a surgical mask, dispose of it carefully after use and wash hands. Be careful with respiratory secretion (e.g. coughing and sneezing) when around other people. It may be best to avoid contact with individuals at risk (small children or those with underlying or chronic illnesses such as immune- suppression of lung disease) until respiratory symptoms have resolved. For staff in high-risk situations see Annex 7 1 March 2006 Page 28

29 Annex 6 PROPOSED PRIORITY GROUPS FOR PANDEMIC VACCINE Proposed Priority groups for pandemic vaccine: Group 1. Health professionals (healthcare providers and relevant public health specialists e.g. WHO/FAO) 2. Staff performing critical functions with high risk of exposure 3. Remaining staff performing critical functions 4. Persons at high risk of severe or fatal outcomes following influenza infection staff and dependents with high risk medical conditions immunocompromised >65 years of age children between 6 23 months of age pregnant women 5. Children 24 months to 18 years 6. Healthy adults Even though the recommended priority groups are determined, they will be continually revised in light of new information that is learnt about the pandemic virus. When sufficient pandemic influenza vaccine is available, the entire staff population will be offered vaccination. 1 March 2006 Page 29

30 Annex 7 USE OF PERSONAL PROTECTIVE EQUIPMENT KIT If full personal protective equipment needs to be worn, please note the following. The order for putting on personal protective equipment is not important, however, for practicality, the following sequence is given as an example: When required, wear boots / or shoe covers with trousers tucked inside Wear a mask (N95 or equivalent). This should be correctly fitted ensuring a good face seal Mould the nose piece to the shape of your nose. Ensure there is a correct seal. Wear a gown Wear an impermeable apron if splashes of blood or body fluids are expected Wear a cap Wear protective eye wear / goggles (reusable, wash with water and detergent after every use) Wear gloves with gown sleeve cuff tucked into glove Removing personal protective equipment. The key principle when removing personal protective equipment is that the wearer should avoid contact with respiratory secretions and other contaminants. Mask should be kept on until all other PPE is removed. Hands should be washed or decontaminated with 70% alcohol solution once all PPE has been removed. 1 March 2006 Page 30

31 The following is an example of how to remove personal protective equipment: Remove gloves. Remove gown/apron. Remove goggles and cap. Remove boots (if worn). Remove mask. Do not touch face Wash hands or decontaminate hands using 70% alcoholic hand-rub. Full personal protective equipment using coverall instead of a surgical gown Hood of coverall Coverall (Reference: WHO. Practical Guidelines for Infection Control in Health Care Facilities, WHO, 2004.) 1 March 2006 Page 31