NIC Role during a pandemic and NIC contingency plan Wenqing Zhang MD Global Influenza Programme, WHO

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NIC Role during a pandemic and NIC contingency
planWenqing Zhang MDGlobal Influenza
Programme, WHO HQTHE 3rd MEETING OF
NATIONAL INFLUENZA CENTRES IN THE WESTERN PACIFIC
AND SOUTH EAST ASIA REGIONS18-20 August 2009
Beijing China
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Key GISN documents related to NICs

• NIC TOR
• Stable for long-term, "glue" and "lubricant" of a
  Network
• Seasonal influenza surveillance and support to
  WHO vaccine virus process
• Detection of emerging virus
• Minimum technical requirement to become a GISN
  member
• NIC Role in monitoring and responding to the
  threat of human influenza
• Precise roles of NICs during all the different
  stages of pandemic preparedness and response
• WHO recommendation - implementation depending on
  national authorities
• NOT to replace NIC TOR
• NIC Contingency plan development guidance
• Guidance to prepare for pandemic response
• Laboratory surveillance and response guidelines
  during a pandemic under development
• Guidance to respond during a pandemic
• - A package for NICs -

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NIC role during a pandemic
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Pandemic preparedness and response phases
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Structure of recommendation of NIC role

• Consistent with the WHO guidance Pandemic
  Influenza Preparedness and Response
• Planning and coordination
• Situation monitoring and assessment
• Reducing the spread of disease and
• Communications.
• All recommended activities intended to continue
  in higher phases unless replaced

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During a period of high alert WHO phase 4

• Definitions
• Phase 4 H-2-H transmission able to sustain at
  community-level
• Not necessarily mean a pandemic is to take place
• NIC objectives
• Early detection of novel virus infection in
  humans
• Geographically assisting the decision making of
  rapid containment
• If rapid containment operation undertaken,
  enhanced surveillance in place
• Assisting WHO and national authorities on
• Pandemic risk assessment
• Development/update of vaccine viruses,
  diagnostics etc

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During a period of high alert WHO phase 4

• Planning and coordination
• Affected countries
• Rapid containment
• Whether or not to mount
• If yes, assisting national authority an enhanced
  surveillance system
• Ensuring continuity of lab surveillance
• Sampling strategy developed, reviewed, adjusted
• Selection criteria developed jointly with WHO for
  sending representative specimens to CCs during
  rapid containment operation
• All countries
• Implementation/adjustment of surge capacity plans
• Reviewing lab diagnostic strategy
• Be aware of and taking actions to any new WHO
  surveillance criteria
• Measures in place to protect lab workers

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During a period of high alert WHO phase 4

• Situation monitoring and assessment
• Affected countries
• Testing and sharing of specimens
• Representative cases for testing time
  sequential symptom geographical location
  potential epi history
• Testing characterization alert to variant
• Timely shipping all/selective specimens/virus
  isolates to WHO CCs
• Supporting the effective clinical management of
  infection
• Continuing monitor susceptibility of antivirals
  to emerging virus strains
• Rapid sharing of information significant of
  public health with WHO and national authorities
• All countries
• Assistance to national authorities -
  systematically organizing specimen testing
• Advice to the country on lab testing algorithms
  and surveillance criteria
• Testing specimens from all suspected cases

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During a pandemic WHO phases 5-6

• Definitions
• Phase 5 novel virus established H-2-H
  transmission at community level in at least 2
  countries in one WHO region
• Phase 6 in addition, at least one other country
  in another WHO region
• NIC objectives
• Affected countries
• Assisting national authorities on mitigating
  pandemic impact
• Monitoring the evolution of the novel virus
• Countries not yet affected
• Support detection of start of a pandemic to
  trigger interventions
• All countries
• Assisting WHO and national authorities on
• Pandemic risk assessment
• Development/update of vaccine viruses,
  diagnostics etc

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During a pandemic WHO phases 5-6

• Planning and coordination
• Review lab components of national plan and
  implementation as required
• Periodic review to sustain NIC diagnostic
  functioning
• Adjustment of sampling/testing strategy
• Be aware of update of guidance on biosafety
  requirements, specimen collection, storage and
  transport and selection of viruses to CCs

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During a pandemic WHO phases 5-6

• Situation monitoring and assessment
• Affected countries
• Adjustment of lab surveillance from individual
  case diagnosis to overall monitoring
• Monitoring the percentages of novel virus and
  seasonal viruses co-circulating
• Adequate surveillance assist WHO/GISN monitoring
  antigenic evolution and antiviral susceptibility
• Timely sharing representative viruses/specimens
  with WHO
• Timely sharing findings of public health
  significance with WHO, national authorities and
  general public
• Unaffected countries
• Update of plans/strategies developed based on
  gained experience from affected countries
• Maximizing surveillance for rapid detection of
  first cases

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After a pandemic

• Unknown of one wave or multiple waves
• NIC objectives
• Review and recovery
• Rebuilding NIC capacity, immediately
• Ready for "next" wave

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After a pandemic

• Post-peak period
• Continuing virological surveillance to support
  WHO on
• Percentage of novel virus detections among all
  influenza virus circulating
• Vaccine virus update
• Antiviral susceptibility
• Diagnostics update
• Pandemic risk assessment
• Capacity restore
• Gap/lesson/experience review
• Possible research studies
• Possible new wave
• Same as that for phases 5-6

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After a pandemic

• Post-pandemic period
• Same as that for post-peak period
• In particular on the proportions of circulating
  influenza viruses which will become seasonal
  influenza viruses

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Summary NIC role

• NICs most likely the primary source of expertise
  in surveillance and response to influenza
  epidemics and pandemics
• Triggering many of the well-planned interventions
  depending on NICs' effective functioning
• Proved by the recent H1N1 event
• GISN WHO coordinated efforts on
  laboratory/virological surveillance, preparedness
  and response
• Significant contribution to response to routine
  and emerging influenza problem
• NICs are the backbone
• NIC role in all different phases interlinked
• Influenza, at its core, a virus problem
• Respect to science and nature
• Working as a team globally
• Science and knowledge key to success

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NIC contingency plan
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Why a NIC contingency plan

• Lab response/service - a key and indispensible
  component of overall national/global response
• Significantly increased level of demand for lab
  service expected
• and proved by recent response
• Most likely exceed routine NIC operations
• Ensuring effectiveness and continuity of NIC
  functioning
• Political and institutional commitment needed
• Coordination from high-level e.g. from MoH
• Need planning in advance

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How to develop a NIC contingency plan

• Assessment on anticipated surge level that will
  be put on the NIC
• Identification of the actions and resources
  needed to establish and maintain the required
  "surge capacity"
• Ensuring the availability of premises, staff and
  equipment
• Stockpiling supplies
• Testing strategies, protocols and algorithms
• Lab biosafety and transport of specimens
• Data management
• Communication

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Ensuring the availability of premises, staff and
equipment

• Availability of lab and office space
• Extra lab and office needed during a pandemic
• Helpful to transfer lab diagnostic technologies
  to other labs
• Additional freezer space needed during a pandemic
• If BSL3 lab available, priority reserved for
  flu-related work
• Availability of trained staff
• Adequate training in advance
• Engaging workers in other labs possibly
• Less-well-trained staff could assist with task
  e.g. tracking specimens, preparing specimen
  collection kits etc
• NIC to keep a full list of available staff and
  their relevant training
• A plan of work shifts and backup personnel in
  place
• Medical surveillance plan in place
• Equipment
• Should have a back-up power source
• Other back-up equipment e.g. biosafety cabinet,
  PCR machines, incubators either purchased in
  advance or sourced from other labs
• Increased storage capacity
• NIC to keep an updated inventory of all lab
  equipment

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Stockpiling supplies

• Stockpiling reagents
• Not all have long shelf life, and delivery of
  supplies might be long lead-time
• In general, a stockpile sufficient for at least 3
  months of current NIC activity could be a good
  strategy
• NICs may wish to establish networks and reach
  agreement on the exchange of reagents in order to
  meet short needs
• Stockpiling of/access to antiviral drugs
• In coordination with MoH/occupational health
• Stockpiling of PPE

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Testing strategies, protocols and algorithms

• Testing strategy
• should be based on national strategies for
  pandemic surveillance and the capabilities and
  resources of the lab
• Lead-up and early stages, every specimens to be
  tested
• While virus widespread, selection criteria for
  specimens to be tested should be established and
  applied
• Testing protocols
• Each protocols must be thoroughly validated
  before being put into routine use
• To be agreed upon with epidemiologists and
  network members
• Testing algorithms
• In line with national and global pandemic
  surveillance strategies

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Laboratory biosafety and transport of specimens

• Lab biosafety and biosecurity
• Biosafety cabinet
• Understanding and training on practice at
  appropriate biosafety levels
• Seasonal vaccination among lab workers
• Transport of specimens in-country
• Possible disruption of or refusal by routine
  transport system
• SOP in place with coordination from high level
  national authorities
• Transport of specimens to reference labs and WHO
  CCs
• WHO guidelines on specimens/virus shipping
  followed
• International transport arranged according to
  IATA regulations
• Import/export permits obtained in advance
• Personnel handling shipping trained

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Data management

• Conventional filing of forms and results
• At the very minimum and essential
• and be maintained to provide back-up if
  electronic systems down
• Electronic systems
• Best use existing systems to avoid additional
  duplicated work
• As simple as possible to keep key information
• Remaining possibility to expand the system

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Communications

• Successful NIC response has to be team work
• A robust communication network established in
  advance
• MoH, national lab network, WHO, WHO CCs, NICs,
  other partners
• GISN communication platform for timely and
  informal communications
• FluNet reporting lab surveillance findings

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Summary NIC contingency plan

• Lab surge capacity is anticipated and inevitable
• The better planned/prepared,
• the less chaos in a lab handling pouring in
  specimens and under pressing stress
• the better continuity of NIC quality service
• Individual NICs individual plans
• Commitments from MoH and host institution is key
• "NIC contingency plan" not just another document
• Reassurance to success of national and global
  pandemic response
• Protection of NIC staff precious asset of a
  country
• Take actions!

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