United Nations
B H U T A N
Contingency Plan
For a Human Influenza Pandemic
Update: September 2006
coordinated/prepared by:
Ms. Sunita Giri, Mr. Phintsho Dorji, and Dr. Ei Kubota
UNCT Avian and Human Influenza Focal Points
Email: ;
Table of Content
Page
A.Introduction……………………………………………………………………….……..3
B. Background Information………………………………………….……….…… … 3
C. Medical Intervention………………………………………………………………… 4
1. Vaccines
1.1 Vaccine against Seasonal Influenza ………………………………….……….…. 5
1.2 Pneumoccocal vaccine …………………………………….……….……….……. 5
1.3 Vaccine against pandemic influenza ……………………..………………….…… 5
2. Antiviral
2.1 Prophylaxis……………………………………………………………………..… 5
2.2 Treatment ……………………………………………………………….……...…. 6
2.3 Stockpiling Tamiflu...... 6
3. Antipyretics, antibiotics and medical supplies………………………………..……. 6
4. Personal Protective Equipment and masks…………………………………..….. 7
5. Medical Care………………………………………………………………….……. 7
6. Evacuations…………………………………………………………………..…….. 7
D. Non-medical Intervention…………………………………………….…….……… 7
1. Workplace…………………………………………………………………….……… 8
1.1 Maintenance of programmes and operation………………………………………. 8
1.2 UN coordination with Government………………………………………………… 8
1.2 AI Preparedness status for Bhutan &UN…………………………………………. 9-10
2. Meetings……………………………………………………………………….….. 11
3. International travel………………………………………………………….…… 11
4. Early departure/relocation of staff……………………………………….……… 11
4.1 Early departure…………………………………………………………………. 11
4.2 Confinement to duty station residence ………………………………………… 11
4.3 Relocation……………………………………………………………………… 11
5. Method of relocation……..………………………………………………….…… 11
6. Necessary measures for remaining staff…………..……………………….…… 11
7. Deceased staff……………………………………………………………….…… 12
E. Communication…………………………………………………………………… 12
F. Implementing the AI Contingency Plan……………………………………… 13
List of Annexes
- Table of Implementation: UN-Bhutan Contingency Plan for AI pandemic……. 14-18
- Procurement Plan for AI………………………………………………………... 19-21
- Risk and threat analysis and mitigation action…………………………………. 22-14
- Summary of programme continuity………………………………………………25
- Personal Protective Equipment Kit (PPE)…………………………………………...... 26
- Guideline for use of vaccines and antiviral drugs…………………………… …..27
- Health Advisory on Self Protection for travel to/through
or living in outbreak regions………………………………………………… …..28
- UN-Bhutan AI Pandemic Management Team……………………………… …...29
- ToR of UN-Bhutan AI Pandemic Management Team……………………………30-32
- List of UNCT and AI focal points…………………………………………..33
- List of Security Focal Persons for AI Contingency Plan……………………34
- List of UN Health Team……………………………………………………. 34
- List of number of UN staff and dependents…………………………………35
- List of Essential staff with critical functions………………………………...36-38
- Proposed priority groups for pandemic vaccine…………………………….. 39
- List of 6-week supplies to be stocked………………………………………..40-43
- Communication Plan…………………………………………………………44
- List of UN physicians & medical facilities…………………………………..45
- Individual AI Pandemic Preparedness Check list…………………………….46
- Table indicating updates to the AI Plan………………………………………47-48
A. Introduction
In drawing up this contingency plan, the United Nations Medical Services Staff Contingency Plan Guidelines for an Influenza Pandemic, dated 10 October 2005 was used as the model. The plan has been subsequently updated based on the revised guidelines provided by the UN Medical Services dated 01 March 2006 and the inter-agency review comments sent on 20 July 2006. The draft National Influenza Pandemic Preparedness Plan, Bhutan, 30 September 2005 and the Contingency Plan for the Avian Influenza Pandemic, Lao PDR were also consulted. In the process of developing the plan, all UN agencies in Bhutan, UN Security Management Team, Chairpersons of UN Staff Associations, one UN physician and the Ministry of Health focal person for the National Preparedness Plan were consulted.
The purpose of this contingency plan is to ensure appropriate preparations and precautions for a timely and well coordinated response across the UN Organizations in the event of an influenza pandemic in Bhutan. The overall objective of this plan is to minimize the impact of an influenza pandemic on the UN staff and their dependents. At the same time, the UNCT will work closely with the Government to support the national preparedness plan to deal with an avian influenza outbreak.
The United Nations Country Team in Bhutan consists of UNDP, UNFPA, WFP, FAO, UNICEF and WHO. As of August 2006, the total number of national and international staff and their dependents is 357; 16 international staff with 20 dependents and 73 national staff with 248 dependents (see annex 13). All UN staff is stationed within Thimphu city.
The plan outlines specific measures and actions required of the UN AI pandemic management team, individual agencies and staff members in supporting an effective response.
This contingency plan was endorsed by the UNCT members on 12 December 2005.
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. On occasion, animal influenza viruses (influenza viruses containing genes from animal influenza viruses) can begin infecting 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 or weeks leading to high levels of morbidity and mortality. In this situation, all age groups are vulnerable to infection, and there can be disruption of all sectors of the society. Such a situation is called influenza “pandemic." Pandemics are different from usual influenza seasons.
There is currently rising concern that an avian (bird) influenza virus known as influenza A (H5NI ) 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 21st Century. The possibility of the H5N1 virus gaining ability to conduct efficient and sustained human-to-human transmission must be considered quite "real" but at the same time it is also not certain. Therefore it is impossible to predict where and when or if at all, an outbreak of the Avian Influenza may occur.
If an influenza pandemic virus were to appear again similar to the one in 1918, even taking into account the advances in medicines since then, unparalleled tolls of illness and death could be expected. Air travel may hasten the spread of a new virus and decrease time for preparing interventions. Health care systems could be rapidly over burdened, economies strained and social order disrupted. Although it is not feasible to halt the spread of a pandemic virus, it should be possible to minimize its consequences through advanced preparation to meet the challenge.
If an influenza pandemic occurs in Bhutan, we could expect the following to happen:
· Given the current situation of high mobility, poor practice of "respiratory etiquette" eg. “doma spitting” and poor hand washing practice among the general population, the pandemic virus may spread rapidly (particularly in the urban towns), leaving little or no time to prepare.
· The already over taxed national referral hospital at Thimphu will be overwhelmed and unable to respond to the needs of the UN staff and dependents.
· Vaccines, antiviral agents and antibiotics to treat secondary infections will be in short supply. It will take several months or longer before any effective pandemic vaccine becomes widely available.
· For international UN staff, the window period for evacuation is likely to be narrow.
Borders may close quickly to prevent the spread of the virus.
· Essential community services are likely to be disrupted and also supply of basic food commodities coming in from India may be disrupted due to closing down of borders.
Once the H5NI virus gains 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. In some respects, given the dispersed nature of human settlements in most parts of Bhutan and entry routes into the country that can be easily closed and well monitored, Bhutan maybe in a slightly better position to contain the pandemic if it should occur.
C. Medical Interventions
Unlike the situation in many other countries, the UN in Bhutan does not have in-house UN physicians or a UN dispensary. In the event of influenza pandemic in Bhutan, the doctors currently identified as “UN physicians” at JDWNRH will be over whelmed catering to the needs of the general population, bearing in mind that there are only three hospitals (JDWNRH, IMTRAT hospital, RBA hospital) in Thimphu. It will not be feasible for the “UN physicians” to provide advice and basic health services exclusively for the UN staff. Their role will be limited to providing specialist services in the event of serious illness and complications and in the decision making for medical evacuation out of the country.
Therefore, the following measures have been put in place:
· UNCT has mobilized a “UN health/medical team” from amongst staff and dependents, where possible, with medical background
· All vaccines, antivirals, antibiotic and other medicines and supplies will be centrally stored in this dispensary. Antivirals and vaccines to be kept under lock.
1. Vaccines
1.1. Vaccines against Seasonal Influenza
There is a vaccine available to protect against seasonal human influenza. This vaccine will not protect against a pandemic influenza strain but it will protect against seasonal influenza which, at a time of pandemic could be mistaken as being caused by the pandemic virus. Such a situation would cause unnecessary anxiety and result in misuse of limited antiviral drugs.
The UNCT will procure seasonal influenza vaccines for all the UN staff and their dependents and administer them through the temporary UN dispensary. All staff have been consulted based on which orders will be placed.
1.2 Pneumococcal vaccine
Pneumococcal vaccine will be considered for people at particular risk of 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.
The UNCT will procure pneumococcal vaccines with a single dose syringe for 10% of staff and dependents. Each agency will draw up a list of pneumococcal vaccine recipient and forward to the “UN health team”.
1.3 Vaccine against pandemic influenza
Although a vaccine against the influenza virus A/H5N1 is currently being developed in the hope that it will be effective against the emerging pandemic strain, it is not yet available, nor is there any guarantee that it would be effective against a human strain.
WHO will monitor the development of any new pandemic vaccine and make recommendations as soon as the product is available. The UNCT will follow the recommendations.
It is expected that any new pandemic vaccine will initially be in short supply as the demand will be far greater than the supply. Therefore, as per the UN Medical Services Staff Contingency Plan Guidelines for an Influenza Pandemic, each agency will draw up list of priority recipients. Priority recipients include those involved with direct clinical contact with patients, those staff required to maintain essential functions, and those at particularly high risk of serious complications, such as the elderly and those with chronic diseases.
2. Antivirals
In recent years, new anti-viral agents to prevent or treat influenza infections have been developed.
Among them, oseltamivir, also known as Tamiflu is widely used to treat influenza. Tamiflu is used to treat those with flu symptoms as well as to reduce the chances of getting the flu if there is a flu outbreak.
2.1 Prophylaxis
Use of antiviral drugs for prophylaxis is extremely resource consuming, therefore it is recommended that Tamiflu be offered as a prophylactic only to essential staffs that are needed to maintain essential functions of the UN agencies and technical staff involved in pandemic out break control and field investigations.
The current prophylactic regimen is one tablet of 75mg per day for 6 weeks. The upper limits for safe use of Tamiflu as prophylaxis is not known, however, the 6 weeks limit is based on experience of past pandemics that usually last several weeks.
2.2 Treatment
In patients with flu like symptoms suspected of having pandemic influenza, Tamiflu should be administered in a dose of two 75 mg. capsules a day (dose for adults is 150 mg/day) for 5 days. For maximum effect, the drug should be started within 48 hours of onset of symptoms. During a pandemic situation, the possibility to test individual patients for influenza infection will be limited and therefore treatment should be given immediately if possible.
With regard to post exposure treatment, during a wide spread pandemic it will not be feasible to give post-exposure treatment to non-ill contacts. For most people it will not be known if they were “exposed” to the pandemic influenza and moreover, in most situations, it is expected that most Tamiflu will be used to treat persons with symptoms.
2.3. Stockpiling Tamiflu
If a pandemic is declared it is very likely that all stocks of medicine useful against influenza, particularly Tamiflu will be in very high demand. Taking into account elements such as the epidemiology of past pandemics, the likely attack rate and WHO recommendations, the UNCT will procure a basic stockpile allowing for a 5-day course of Tamiflu treatment for 40% of all staff and dependents and Tamiflu as prophylaxis for staff performing essential duties.
During a pandemic antiviral will become extremely valuable, therefore they would have to be stored in a secure place (under lock) in the temporary dispensary in the UN house and the stock security will be the responsibility of the “UN medical team”. Overall, the Resident Coordinator will be responsible to ensure proper utilization of the stockpile of medications.
Prior to the development of this contingency plan, UN agencies have already processed procurement of Tamiflu as shown in the table below.
Tamiflu procurement status as of August 2006
Agency / Staff coverage / Remarks1 / UNDP / 30 % / Order under process with HQ
2 / UNICEF / 100% / Stock already received
3 / WHO / 30% / As WHO is in the Ministry of Health, it will use the Ministry’s stock if required. WHO-SEARO also remain ready to cover the staff in the country office should such a contingency arise.
4 / WFP / 100% / Stock already received
5 / UNV / 30% / Included with UNDP procurement
6 / UNFPA / 100% / Has requested UNFPA head quarter to supply
7 / FAO / 100% / FAO Headquarter in Rome is procuring for all FAO country Offices.
3. Antipyretics, antibiotics and medical supplies
Given the particular situation of Bhutan with limited numbers of private pharmacies, no local production of medicines and assuming that government facilities will be overwhelmed in the event of influenza pandemic, antipyretic, antibiotics and basic medical supplies will be in very short supply. Therefore, UNCT will have to stockpile these supplies.