SWAZILAND HPAI PLAN – ZERO DRAFT

1.0.Introduction

Highly Pathogenic Avian Influenza (HPAI) is an infectious disease due to type A influenza virus strains. This disease mainly affects wild and domestic birds but has in rare occasions crossed the species barrier to infect humans and other mammals. So far, about 200 people have been infected with HPAI of the H5N1 subtype, the agent responsible for ongoing outbreaks of HPAI, and half of those have already died. It is believed that the relatively low number of human infections registered up to now will significantly increase if the HPAI virus transforms and acquires the ability to easily transmit among humans.

Such an event will trigger a pandemic human influenza with the potential to reach all countries of the World within a short period of time. It is anticipated that the pandemic human influenza will have serious consequences on national health care delivery systems, economy and trade, essential infrastructural services, travel inside and outside the country, governance and state of law, food security, capacity for humanitarian assistance, etc…

It is for this reason that all countries are strongly urged to give priority to the development of national plans for HPAI and human pandemic threat preparedness and response. Swaziland has taken this matter very seriously by appointing different coordination committees tasked to constantly assess the situation and advise on the appropriate courses of action to take at different phases of HPAI epidemic and/or human influenza pandemic. This document will focus on what the health sector is planning to do in collaboration with other Government sectors, NGOs, and other partners.

2.0. Background

HPAI has not yet been identified in any country of the sub-region. But, given the rapid spread of ongoing HPAI outbreaks mainly through migratory birds movements and importation of birds, the situation can change any time. Better understanding of the risks of introduction of HPAI, the possible routes of its transmission to birds and humans, and the legal and institutional arrangements for disease prevention and control in humans and in animals, becomes therefore an important element to consider in drafting plans for HPAI and human pandemic influenza threat preparedness and response in Swaziland.

2.1. Risks of introduction of HPAIin Swaziland

The Ministry of Agriculture and Cooperatives (MOAC) has identified several possible routes of introduction of HPAI in Swaziland including importation of commercial birds, pet birds, migratory birds, and waterfowls. For further details refer to the MOAC Avian Flu plan.

2.2. Risks of transmission of HPAI once introduced into Swaziland

There are different ways by which HPAI virus can spread to susceptible birds. The Ministry of Agriculture and Cooperatives (MOAC) has identified the following as potential modes of transmission in Swaziland: uncontrolled bird movement, mixing between wild and domestic bird species, fomites, feeds, and waste products. For additional information, refer to the MOAC Avian Flu plan.

2.3. Possible routes of transmission of HPAI to humans

The current state of knowledge about the infectiousness of Avian Influenza virus stipulates that this virus does not easily transmit from birds to humans and as yet there is no evidence of efficient human-to-human transmission of Avian Influenza virus.

Experience from Southest Asian countries where the first human cases were reported supports that close contact with dead or sick birds is the principal source of infection with Avian Influenza virus. The current belief is that the majority of cases were infected during the slaughtering, defeathering, butchering and preparation for consumption of infected birds. In a few cases, exposure to chicken droppings when children played in an area frequented by free-ranging poultry is thought to have been the source of infection.

For Avian Influenza control purposes, it is assumed that certain groups of people are particularly at high risk for getting infected even tough few cases have been detected among them. These groups include commercial poultry workers, workers at lively poultry markets, cullers, veterinarians, and health staff caring for patients without adequate protective equipment.

Of great significance for developing countries with fewer commercial poultry farms, most cases of Avian Influenza have occurred in rural and periurban households where small flocks of poultry are kept.

In the case of Swaziland, there are some practices which can contribute to increased risk of HPAI transmission to humans. They include collection of sawdust for bedding and replenishment of beddings in commercial production systems, cleaning of chicken stalls, keeping chicks in the same house with humans for warming, exposure to bird droppings especially when used in gardening as fertilizer, methods of chicken slaughtering in abattoirs and other places without protection, selling of roasted chicken along the streets, and unsupervised sale of eggs.

2.4. Policy and legal framework for HPAI preparedness and response

As mentioned earlier, the virus responsible for HPAI outbreaks has the potential to transform and become easily transmissible among humans with increased morbidity and mortality as result. Taking into account this human dimension of the HPAI threat, efforts in the health sector are geared towards preventing HPAI transmission to humans, controlling it, and mitigating its impact in the context of the Public Health Act of 1969. The following sections highlight some provisions of the Act which are relevant to public health interventions to be undertaken if HPAI is introduced in Swaziland and affects humans and/or when a human influenza pandemic is declared.

  • Section 3 enlists notifiable diseases under category (a) and category (b). There is a provision that this list be updated from time to time as deemed necessary. The list of notifiable diseases needs to be amended to include Highly Pathogenic Avian Influenza.
  • According to section 4, the occupier of the premises in an urban area or a medical practitioner who attends to a person suffering from a notifiable disease has the responsibility of reporting the case to the nearest medical officer of health within 24 hours of occurrence.
  • Section 6 covers control of entry or departure in or out of the country by affected person (s) as well as medical examinations.

Section 25 empowers medical officer of health/ health inspector to enter any place to investigate a disease at any reasonable time and to do all that is required.

  • Section 6 empowers the medical officer of health to place under surveillance a person infected with a notifiable disease.
  • Section 7 empowers the medical officer of health to extract samples from the body of the infected person for analysis.
  • Section 5 provides for the obligatory reporting by any medical officer who comes across a communicable disease of public health significance.

2.5. Organizational framework for HPAI preparedness and response

Previous experience with epidemics in the country has shown that better coordination of interventions and collaboration with stakeholders and partners is the key to successful prevention and control of epidemics.

The structural organization of HPAI preparedness and response chain of command reflects this spirit and heavily relies on already existing structures at national, regional, sub-regional, and community levels. In addition, a Cabinet Committee and a National Multi-sectoral Steering Committee will soon be established to oversee the planning process and the implementation of HPAI prevention and control interventions in birds and in humans.

Several meetings of National and Regional Epidemic Task Forces have already taken place to assess the risks of introduction of HPAI and its spread in Swaziland, and the country needs in order to control it once introduced in the country, minimize transmission to humans, and cope with the human influenza pandemic threat. Figure 1 presents the organizational structure for HPAI preparedness and response in hierarchical order.

Figure 1. Hierarchy of the HPAI prevention and control coordination

2.6. Major thematic areas of the National HPAI preparedness and response plan

2.6.1. Advocacy & Coordination

Effective response to HPAI and pandemic human influenza requires strong political commitment. National authorities must be sensitized on the threat posed by HPAI and they must play a leading role in all efforts aimed at mobilizing communities for HPAI preparedness and response. That is why it is strongly suggested that a Cabinet Committee be formed to coordinate the national HPAI preparedness and response at the highest level, advocate for the creation of a conducive legal environment for disease prevention and control, and lobby for adequate financial support from Government, key partners, regional and international institutions.

2.6.2. Risk communication

Experience with other major diseases such as HIV/AIDS has shown that knowledge about risk factors for transmission of a deadly disease is important but not sufficient to prevent behavioural practices putting people at high risk. Communication strategies aimed at behaviour change will play a major role in preventing infection of humans from birds. A multi-sectoral communication subcommittee has been set up to develop a HPAI communication strategy document.

2.6.3. Surveillance & Laboratory

Epidemic detection and disease monitoring will require the strengthening of existing surveillance systems and structures at national, regional, sub-regional, and community levels. Laboratory capacity also needs to be strengthened through procurement of equipment and reagents, and training of laboratory staff on HPAI laboratory diagnostic procedures. Formal collaboration with a WHO accredited regional or international laboratory will also be established for diagnostic confirmation and virus subtyping.

2.6.4. Pandemic influenza containment in humans

Vaccination against pandemic influenza virus is the first line of defense in preventing the spread of pandemic influenza. Unfortunately, an effective vaccine will not be available for several months after the emergence of a pandemic influenza virus. In the meanwhile, antivirals such as tamiflu will be recommended for prophylaxis but for only selected groups of people. Quarantine of affected communities with restriction of movement will also be envisaged if the infection is localized.

2.6.5. Case Management & Impact mitigation

Treatment with antivirals such as tamiflu is the mainstay for the treatment of HPAI. Adequate stocks of this drug need to be kept at strategic points for rapid deployment along with broad-spectrum antibiotics to treat bacterial complications of viral influenza. PPE kits are needed to protect high risk groups, e.g. health and agricultural workers caring for HPAI cases, and HPAI specific infection control guidelines must be available in all health facilities to reduce risk of human exposure.

Due to increased demand for health care services, it is anticipated that admission capacity in many facilities will be quickly exceeded and human resources to care for patients will not meet the need. The health planning unit must devise strategies for dealing with this situation. One possible option is to establish temporary treatment centers in communities.

Food and other items of daily living will also be in great demand in heavily affected areas. There will therefore be a need to mobilize a humanitarian relief response in those areas. Collaboration with other Government sectors and partners will play a critical role.

2.6.6. CapacityBuilding& Logistics

As mentioned before, current health institutions and structures do not have adequate capacity to deal with the threat of HPAI and pandemic human influenza. A lot of technical and financial support needs to be mobilized to fill the gaps.

Particular attention needs to be paid to provision of adequate means of transport and communication, coordination of the procurement of different medical and laboratory supplies.

2.7. Description of the national HPAI preparedness and response plan

Efficient use of scarce national resources requires that the health sector response to mount against HPAI and the human influenza pandemic be adapted to the level of threat for human health. It therefore makes sense that the objectives of the health sector response be defined according todifferent threat scenarios that the country might be faced with.In this regard, there are three phases to consider: the pre-epizootic phase, i.e. before HPAI is introduced in the country; the epizootic phase, i.e. after HPAI has been introduced in the country; and the pandemic phase, i.e. after emergence or introduction of a pandemic human influenza virus.

2.7.1. Objectives

General Objective

  • To prevent transmission of HPAI to humans, control its spread and mitigate the impact of human influenza pandemic.

Pre-epizootic objectives

  • Create public awareness about HPAI and human pandemic influenza threat
  • Enhance national HPAI preparedness and response coordination capacity

Epizootic objectives

  • Reduce opportunities for human exposure to HPAI
  • Strengthen surveillance systems and laboratory diagnostics
  • Improve capacity for case management

Pandemic objectives

  • Reinforce communication and health promotion
  • Contain or delay human infection at source
  • Reinforce capacity for surveillance and reporting
  • Minimize mortality through case management

2.7.2. Activities

To achieve the objectives of the health sector response we propose a series of activities which mainly fall under the major thematic areas outlined above. A complete workplan with a timeframe, a budget, and monitoring indicators is presented in Annex 1.

Enhance national HPAI preparedness and response coordination capacity

  • Review and update policy and legal documents pertaining to disease control
  • Form coordination committees for HPAI preparedness and response
  • Sensitize members of coordination committees on HPAI prevention and control
  • Establish collaboration mechanisms with relevant stakeholders and partners

Create public awareness about HPAI and human pandemic influenza threats

  • Establish an HPAI communication task team
  • Develop an HPAI communication strategy document
  • Develop appropriate messages for different target groups
  • Train health workers on the communication strategies
  • Disseminate HPAI health information through the mass media and other channels

Reduce opportunities for human exposure to HPAI infection / pandemic influenza

  • Reinforce communication and health promotion
  • Ensure strict application of food safety measures in public and commercial places
  • Monitor availability of disinfectants and sanitizers, PPE, and proper disposal of bird waste products at high risk premises
  • Supervise burial of dead bodies

Strengthen surveillance systems and laboratory diagnostics

  • Orient NETF and RETFs on HPAI surveillance tools and reporting channels
  • Develop a database and a daily feedback bulletin for HPAI at national level
  • Adapt HPAI laboratory diagnostic procedures
  • Upgrade the National Reference Laboratory to screen for HPAI
  • Train laboratory staff on specimen collection, handling, and testing
  • Procure reagents and lab supplies for HPAI diagnosis
  • Establish a memorandum of understanding with an external lab for confirmation

Improve capacity for HPAI case management and impact mitigation

  • Adapt HPAI case management guidelines
  • Train health workers on HPAI case management
  • Stockpile antivirals, antibiotics, antipyretics, and PPE kits at central level
  • Train health workers on HPAI infection control guidelines
  • Develop a protocol for proper disposal of dead bodies
  • Upgrade capacity for admission at hospitals and health centers
  • Establish alternative treatment facilities in communities
  • Develop a humanitarian relief plan

Contain or delay human infection at source

  • Provide isolation units in hospitals and health centers with supplies
  • Provide temporary community treatment centers with supplies
  • Distribute antivirals, PPE kits, and other medicine commodities to end-users
  • Provide support to affected people in quarantined areas

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