Health Interventions, Tools, & Modules

For Humanitarian Organizations & Local Partners

For Pandemic Influenza Preparedness
At Household & Community Levels in Developing Countries
Health Working Group

Humanitarian Pandemic Preparedness (H2P) Initiative

(IFRC, CORE Group, AED, InterAction, UN, USAID)

February 9, 2009 Draft

(Revisions after the Dec. 11, 2008 draft are highlighted in yellow)
 CONTENTS

I. General Approach
II. Interventions & Tools
III. Modules

I. GENERAL APPROACH

• For an introduction to avian & pandemic flu, please see: Avian Influenza
Frequently Asked Questions, WHO, Revised 5 December 2005:
www.who.int/csr/disease/avian_influenza/avian_faqs/en/index.html.
• For H2P pandemic planning assumptions (“Preparing for Which
Pandemic?”), and for more information on H2P health interventions, please see
www.coregroup.org/h2p/.
• For a more detailed list of key pandemic flu planning assumptions, please see
sections III – VII of: www.savethechildren.org/publications/technical-
resources/avian-flu/aifipp/Flu_Assumptions_Matrix.doc & CIDRAP, Univ. of
Minnesota, Pandemic Influenza Overview (regularly updated)
www.cidrap.umn.edu/cidrap/content/influenza/panflu/biofacts/panflu.html

The Health Technical Working Group is supporting two categories of health

interventions:

• Those that are fairly specific to pandemic flu, such as non-pharmaceutical

interventions (NPIs) to reduce person-to-person flu transmission, &
• Those that are more general, such as interventions to reduce the indirect
health impacts of a pandemic.

Interventions to reduce indirect impacts, such as moving case management of

childhood illness from health facilities to the community (CCM, as described by
WHO, see below) have substantial potential benefits that extend well beyond
pandemic periods. For example, CCM (community case management of childhood
illness) is an important strategy (even during inter-pandemic periods!) to increase
access to & use of life-saving case management services in areas of high under-five
mortality & poor access to existing services. So in many settings, there is a strong
rationale for implementation of CCM at scale now, & for H2P advocacy & support for
implementation of CCM at scale as soon as possible.

On the other hand, although it is desirable for H2P & local partners to conduct
planning workshops in as many districts as feasible, as soon as possible, in as many
H2P countries as possible, there are good reasons for expecting that much pandemic-
specific planning at district & community levels (such as planning for implementation
of NPIs & home care) will happen only after being “triggered” by a higher threat of
imminent pandemic onset (such as WHO declaration of sustained human-to-human
transmission – new WHO Phase 41) than is the case now, during Phase 3. Levels of
funding & in-country perceptions of the importance (compared to the many other
competing priorities) of pandemic-specific district-level planning now, at scale, may
make it unlikely that effective planning workshops will be held in a high percentage
of the 500 or so districts in Ethiopia, for example, or even in most of the 75 districts of
Nepal. Where workshops are conducted, district-level government & other local
partners are likely to send lower level staff to participate, given the

1 www.who.int/csr/disease/influenza/PPWGupdate_WHOWebVersion.pdf

comparatively low level of importance now accorded to pandemic flu. Given the high
levels of turnover of district-level staff in many countries, it is likely that many staff
who participate in workshops in the near future will have been transferred long before
the pandemic-specific plans need to be implemented. Therefore, a focus of pandemic-
specific health-related activities will be to develop “off-the-shelf” fully prepared &
deployed capacity among several in-country partners at national & sub-national
levels, to rapidly roll out district-level planning & training for community
interventions in as many NGO/RC/partner work sites as possible, with minimal
support from outside these sites. This will initially involve work with global partners
to identify, revise, and/or develop generic guidelines for developing countries, & then
adaptation of these guidelines for use in each country. This will include the definition
of triggers (e.g. WHO declaration of Phase 4, following sustained person-to-person
transmission resulting in community outbreaks in one or more countries) for
implementation of these interventions at scale during the few weeks that the vast
majority of all communities will have before the arrival of the first pandemic wave in
their geographic area. The idea is to train national & district-level community health
program managers & other key partner staff, through national/sub-national-level
workshops, & district-level workshops to the extent that this is feasible, in what they
should do differently during a pandemic – focusing on a few changes to existing
programming which could be achieved in only a few days training of existing
community health workers (CHWs) & community leaders, following notification of
the triggering event. Planning will also ensure that NGOs & local partners will have
required pre-approval & support to rapidly implement planned actions. In each of the
selected countries, partners will test/drill the implementation of these interventions
from national level down to selected communities in as many districts as feasible, &
incorporate results into the country-level plans. Materials for district-level workshops
& community-level testing in the near future should be based on a scenario of likely
imminent local arrival of a severe pandemic wave (local outbreak) following a recent
triggering event (such as WHO declaration of Phase 4, following evidence of
sustained person-to-person transmission in another country). Materials based on this
scenario will be more useful once this triggering event has actually occurred (in the
future), & more interesting for workshop participants now, in Phase 3, than materials
& workshop curricula designed for a much less imminent threat now during Phase 3.
Health interventions are grouped below into modules, based on criteria such as the
target group (family members, CHWs, community leaders, etc.), complexity of the
intervention, current state of global guidance, & expected duration of the process of
in-country adaptation. (Please see Section III, below.) II. INTERVENTIONS &
TOOLS

1. Non-pharmaceutical interventions (NPIs) to reduce transmission at

household & community levels: Includes respiratory etiquette, hand washing,
social distancing of adults & children, & voluntary isolation of the ill (and
voluntary quarantine of the exposed, if the pandemic is severe). Some of these
NPIs require substantial pre-pandemic planning & would only be implemented
in a moderate and/or severe pandemic, & thus depend on a pandemic severity
index (not yet available from WHO), while others require less pre-pandemic
planning & would be recommended even for mild pandemics. (Please see
Section III, below.)

Tools: As far as we know, detailed guidance on how to implement community-level

NPIs, along with a pandemic severity index, are not yet available for developing
country settings. (WHO may release draft guidance related to these issues in the near
future. See: Revision of the Pandemic Influenza Preparedness Guidance - An Update
on the Drafting Process, 16 July 2008:
www.who.int/csr/disease/influenza/PPWGupdate_WHOWebVersion.pdf) Currently
available tools include:

• Recommendations for nonpharmaceutical public health interventions, WHO

2005 checklist: Annex 1 of the WHO Global Influenza Preparedness Plan:
www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_200
5_5/en/,
• Nonpharmaceutical Interventions for Pandemic Influenza, National and
Community Measures, WHO Writing Group, Emerging Infectious Diseases,
January 2006 (literature review & summary recommendations):
www.cdc.gov/ncidod/EID/vol12no01/pdfs/05-1371.pdf,
• February 2007 interim US strategy for community mitigation (Detailed how-
to guidance on NPIs & severity index):
www.pandemicflu.gov/plan/community/mitigation.html.
 • Non-Pharmaceutical Interventions for Use By Developing Countries During a
Human Influenza Pandemic, CDC & USAID (Undated January 2008 5 page
document)
• Module I Content: Household Mitigation, H2P Health Working Group draft
document (at: www.coregroup.org/h2p/)

(These tools may be an adequate basis for starting country-level adaptation in

developing countries.)

2. Home- & community-based care of those ill with influenza: Home-based

care refers to the guidance given to families on caring for household members
ill with an influenza-like illness. Community-based care refers to community &
CHW activities to advise & support families on home-based care, & care for
families unable to care for themselves (due to concurrent illness among all of a
household’s potential care-givers or household resource constraints).

www.who.int/diseasecontrol_emergencies/HSE_EPR_DCE_2008_3rweb.pdf), notes
that, "During a pandemic, extremely high numbers of patients presenting to the
health-care facility will necessitate home treatment for large numbers of infected
patients," & that, "All health-care workers, caregivers & patients should be provided
with information, in the local language, regarding the illness & symptoms, mode of
transmission, treatment & possible consequences" (but the document fails to provide
any guidance on home care, beyond infection prevention). During the next pandemic,
the vast majority of all ill persons around the world will be cared for in their own
places of residence. Pandemic influenza preparedness & mitigation in refugee &
displaced populations: WHO guidelines for humanitarian agencies, May 2008 (

WHO/UNICEF: Informal discussion on behavioural interventions for the next

influenza pandemic, 12-14 December 2006, Bangkok: Summary and
recommendations
(www.unicef.org/influenzaresources/files/WHO_UNICEF_API_Mtg_Bangkok_Dec_
06.pdf) notes that, “pandemic preparedness which emphasizes what can be done
locally regardless of access to vaccines or antiviral drugs is crucial to enable citizens
to take appropriate action to protect themselves & their families, before, during &
after a pandemic in order to reduce transmission & minimize illness & death, as well
as social & economic disruption.” Although

this document does not describe the content of home care, it provides a strong
rationale for the importance of it:

• “Health services will be overwhelmed & will be unable to cope with demand.
• “Anti-virals may not be available.
 • “Minimizing the number of caretakers will in turn minimize the exposure of
other family members to the virus.
• “Knowing how to care for sick people at home may reduce the severity of
illness or complications & increase their chances of survival.
• “May help reduce panic when communities feel confident in handling a
situation requiring self-care or home-based care of someone who has fallen ill.
• “Severe complications need to be treated by appropriate health personnel.”
(Knowledge of which complications to seek care for can promote appropriate
care seeking & reduce the burden on health services due to inappropriate care
seeking.)

Additional reasons for the importance of guidance on home care include:

• Over-utilization of health services due to the lack of guidance on home care

will lead to crowding & influenza transmission at health facilities.
• The inadequacy of current IMCI, ARI, & pneumonia guidelines: Although
influenza is an acute respiratory infection, & flu may be referred to as “severe
respiratory illness,” as influenza diagnosis will likely be unavailable in many
settings, IMCI & ARI guidelines focus on the identification of children with
pneumonia for prompt treatment with antibiotics, not on home care.
(Guidelines for diarrhea may be more comparable to what is needed for
pandemic flu: a focus on home care, especially hydration, along with
information on when to seek care outside the home.)
• Health workers with whom our organizations are working around the world
will be asked for & expected to provide basic guidance on home care during the
next pandemic.
• The importance of adequate hydration for those ill with influenza: Dr. Grattan
Woodson (see below) believes that prevention & treatment of dehydration in
those ill with the flu will save more lives than any other intervention during the
next flu pandemic.

Dr. Woodson’s 17-page guide on influenza home care (which goes well beyond what
might be included in generic guidance for families in developing countries, but much
of which might be considered for guidance on community-based care) includes advice
on:

• Identification & treatment of dehydration

• Treatment of adults with fever
• Treatment of chills & body aches & pains
• Treatment for sore throat, nasal/sinus/ear congestion, cough, chest pain, &
headache
• Treatment of nausea, vomiting, diarrhea, & abdominal pain
 • Diet & exercise
• How to keep children with flu comfortable
• Dehydration in children
• Treating children for cough, runny nose, fever, nausea, vomiting, & diarrhea
• Pandemic psychology

Tools: There is a growing body of literature on home care for flu, from & for North
American jurisdictions (including government of the province of Alberta, the state of
Massachusetts, & the American Red Cross, along with those cited below). The focus
of guidance in these is very similar, with differences mainly in the level of detail.
However, as far as we know, there is a complete lack of any guidance of this kind for
developing country settings. Generic home care guidance for local adaptation in
developing country settings is an important gap which urgently needs to be addressed.
Currently available:

• The gold standard on home care may be Good Home Treatment of Influenza
by Grattan Woodson, MD, FACP: www.birdflumanual.com/ or
www.fluwikie.com/pmwiki.php?n=Consequences.PandemicPreparednessGuide
s#Woodson
• Among the abbreviated versions, one of the best is that of Seattle/King
County (in Washington state):
www.kingcounty.gov/healthservices/health/preparedness/pandemicflu/care.asp
x

(These tools, written for North American settings, appear less than adequate for
starting country-level adaptation in developing countries.)

3. Reduce indirect health impacts (Continue to treat potentially fatal diseases,

such as pneumonia, malaria, diarrhea, AIDS, & TB, under conditions of
disrupted health services). Local planning for continuity of key services, an
important intervention which cuts across sectors, will likely be an important
component of this intervention.

Tools:

• Reducing excess mortality from common illnesses during an influenza

pandemic: WHO guidelines for emergency health interventions in community
settings, October 2008. (This includes recommendations for modification of
existing health services, such as providing 12 weeks supply of medications to
HIV & TB patients & focusing on only life-saving interventions, &
recommendations for moving case management of childhood pneumonia,
 diarrhea, & malaria to the community level before and/or during a pandemic.)
www.who.int/diseasecontrol_emergencies/common_illnesses2008_6.pdf

Tools for continuity of key services:

• Pandemic Preparedness Planning for US Businesses with Overseas

Operations, 4 pages, Jan. 5, 07
(www.pandemicflu.gov/plan/business/businessoversea.html),
• Government of New Zealand pandemic flu Business Continuity Planning
Guide, October 2005, remains an excellent 68-page resource with practical
tools (www.med.govt.nz/irdev/econ_dev/pandemic-planning/business-
continuity/planning-guide/index.html);
• Pandemic influenza preparedness & mitigation in refugee & displaced
populations, WHO guidelines for humanitarian agencies, May 2008,
(www.who.int/diseasecontrol_emergencies/HSE_EPR_DCE_2008_3rweb.pdf);
• Avian & Pandemic Influenza Planning Assumptions, & Westport /
Washington Summary Preparedness Matrix, Save the Children (US),
(www.savethechildren.org/publications/technical-resources/avian-flu/aifipp/19-
Flu_Planning_Assumptions_Matrix112706.doc)

(These tools may be an adequate basis for starting in-country planning for continuity
of key services.)

4. Other interventions being considered:

(a) Early Warning / Surveillance? (of suspected flu in humans – critical for
triggering local implementation of NPIs & triggering training for household &
community-based care): Whether or not we would do surveillance, or at what level we
would work at, would depend heavily on the country. Community based surveillance
is applicable almost anywhere in the world given that surveillance has not trickled
down to the community level thus far. For many SE Asian countries, national level
surveillance protocols have been established. Elsewhere, this could be a key
preparedness intervention at the national level. Tools for national level work:

• WHO is working on a community health worker monitoring form to collect

very simple data during an influenza pandemic.
• WHO guidelines for investigation of human cases of avian influenza
A(H5N1)
• WHO case definitions for human infections with influenza A(H5N1) virus
• WHO guidelines for global surveillance of influenza A/H5

(All can be found at www.who.int/csr/disease/avian_influenza/guidelines/en/)

 • International Health Regulations (www.who.int/csr/ihr/en/)
• PAHO-CDC Generic Protocol for Influenza Surveillance
(www.amro.who.int/English/AD/DPC/CD/flu-snl-gpis.pdf)
• A very good example of national public health surveillance protocol for
human cases of avian flu (and identifying clusters, etc) is PATH’s work in the
Ukraine. “Surveillance & Control of Human Cases of Avian Influenza”
Provisional Guidelines for Public Health Services in Ukraine
(www.path.org/publications/details.php?i=1484)
• There is something similar being worked on for Africa
• CDC is also working on standardizing reporting forms
• For community level work, CARE has programs & materials for activities in
5 countries, but community level surveillance is highly specific to context –
creating a generic handbook is difficult & a lot of adaptation is needed.
(http://icarenews.care.org/avianflu.html)

(b) Psycho-social? Woodson has a section on this. (c) Communications

• WHO outbreak communication guidelines (2005):

www.who.int/csr/resources/publications/WHO_CDS_2005_28/en/index.html

(d) Others?

• Community guidance to families on home stockpiling? (The October 2008

WHO draft guidance for web-based review notes that, “during a pandemic, it is
important for households to consider storing food and daily medicines at
home.”) The H2P Food Security Working Group is addressing this issue.
• Handling of bodies?
• Preparedness for first level health facilities?
• Lines of succession for critical roles in communities?

III. MODULES Health interventions are grouped into modules, based on criteria
such as the target group (family members, CHWs, community leaders, etc.),
complexity of the intervention, current state of global guidance, & expected duration
of the process of in-country adaptation. In some countries, it may be feasible to adapt
Module I content comparatively rapidly, & test/train for this down to the community-
level, while adaptation & testing/training for Module II proceeds more gradually. In
some settings, it may be appropriate to present how other countries have addressed
Module II interventions, at district and/or local-level workshops, & seek input from
workshop participants on how they would adapt & implement these interventions in
their area, even before adaptation has been completed at national level. Important
findings from district & local workshops should inform adaptation & revision of
guidelines & training materials at national level. Module I. Household Mitigation
Criteria:

(a) Focused at family / household level

(b) Minimum/basic interventions
(c) Focused on communications & behavior change
(d) Not requiring a pandemic severity index (interventions for all pandemics,
irrespective of severity)
(e) Fairly generalizable across countries/settings – requiring little in-country
adaptation
(f) Not requiring extra supplies / drugs from outside the community
(g) Can be implemented by a broad range of community volunteers without
detailed planning by community leaders

Content:

i. What is pan flu

ii. Transmission
iii. What families can do to reduce transmission (respiratory etiquette, hand
washing, keeping your distance from others, & voluntary isolation of the ill)
iv. Signs
v. Home care
vi. Care seeking outside the home
vii. Community communications to promote & support families in the above

Main Challenges:

• Lack of home care guidance for developing country settings

Examples of Materials:

• WHO/UNICEF: Informal discussion on behavioural interventions for the next

influenza pandemic, 12-14 December 2006, Bangkok: Summary and
recommendations
www.unicef.org/influenzaresources/files/WHO_UNICEF_API_Mtg_Bangkok_
Dec_06.pdf
• Seattle/King County on home care (& on reducing transmission at family
level):
www.kingcounty.gov/healthservices/health/preparedness/pandemicflu/care.asp
x
• Module I Content: Household Mitigation, H2P Health Working Group draft
document at www.coregroup.org/h2p/. (WHO is working on a generic
 home/community based care document to guide local NGOs, faith-based
organizations, & communities. We hope that this WHO guidance will soon
render this draft H2P document unnecessary.)
• Training curricula, H2P Health Working Group draft documents

Module II. Community Mitigation Criteria:

(a) Focused on community-level / community-wide activities

(b) Requires more detailed planning by community leaders
(c) Requires a pandemic severity index (interventions for moderate / severe
pandemics)
(d) Requires substantial in-country adaptation
(e) Also (as in Module I) not requiring extra supplies / drugs from outside the
community

Content (additional to that of Module I, education of families on prevention & home

care):

i. What communities can do to reduce transmission: Social distancing of adults

and children, such as dismissing classes (KG – university), closing child care
centers, reducing out-of-school mixing of children and students, reducing non-
essential travel and overcrowded transport, and other measures to limit public
crowding, gathering, mixing, or contacts (such as closing, cancelling,
restricting, or modifying: sports events, worship services, theatres, funerals,
weddings, parties, and/or workplace practices).
ii. Infection prevention for CHWs
iii. Community support (incl. care, food, water) for families unable to care for
themselves (due to illness among all of the household’s potential care-givers or
household resource constraints).
iv. Continuity of care for selected health conditions, if feasible (such as
providing 12 weeks supply of medications to HIV & TB patients, & focusing
on life-saving interventions, such as treatment of malnutrition, safe delivery,
and essential newborn care)
v. Early warning and other information (on pandemic onset and approaching
wave - keeping communities informed regarding numbers, location, and
severity of cases; and on the best sources of information and guidance.)
vi. Addressing community perceptions and concerns.
vii. ? Psycho-social support?
viii. ? Handling of bodies?
ix. ? Lines of succession for critical roles in communities?

Main Challenges (additional to those of Module I):

 • Lack of guidance for developing country settings on a pandemic severity
index & on how to implement community-level NPIs
• Need for substantial in-country adaptation & approval process

Examples of Materials:

• February 2007 interim US strategy for community mitigation (NPIs):

www.pandemicflu.gov/plan/community/mitigation.html,
• For community-based care: Woodson: www.birdflumanual.com/ or
www.fluwikie.com/pmwiki.php?n=Consequences.PandemicPreparednessGuide
s#Woodson
• For continuity of care for selected health conditions: Reducing excess
mortality from common illnesses during an influenza pandemic: WHO
guidelines for emergency health interventions in community settings, October
2008: www.who.int/diseasecontrol_emergencies/common_illnesses2008_6.pdf

Module III. Community Case Management (CCM) Criteria:

(a) Requires substantial extra supplies / drugs from outside the community
(b) Requires more extensive training & support of CHWs to master new skills.

Content:

i. Moving case management of pneumonia, diarrhea, and/or malaria to the

community level (by CHWs) before and/or during a pandemic. (The H2P HWG
suggests that, if CCM is permitted in country, that pandemic preparedness
activities include planning for the continuity of drug supplies to CHWs, and
consider whether or not CHWs should receive guidance and antibiotics to treat
pneumonia in older children &/or adults. This is important because a high
percentage of pandemic flu-related mortality is expected to be due to secondary
bacterial pneumonia. If CCM is NOT permitted: Consider meeting with WHO
& UNICEF to consider advocacy with MOH for permission to introduce
CCM.)

Main Challenges:

• Funding & logistics: Need for substantial extra supplies / drugs from outside
the community (particularly in those areas where this is implemented only after
news related to possible pandemic onset).
• Time & resources (following news of the triggering event) for more extensive
training & supervision of CHWs to master new skills (particularly in those
 areas where this is implemented only after news related to possible pandemic
onset).
• Need for substantial in-country adaptation & approval process (unless CCM is
already permitted).

Examples of Materials:

• Reducing excess mortality from common illnesses during an influenza

pandemic: WHO guidelines for emergency health interventions in community
settings, October 2008:
www.who.int/diseasecontrol_emergencies/common_illnesses2008_6.pdf