Influenza: Haiti Pre-decision Brief for Public Health Action

Key recommendations

Because of the limited resources for shipping, storing, and administering vaccine during the current rebuilding phase in Haiti, decisions about implementing an influenza immunization program should be made based on its likely benefits compared with the likely benefits of other public health interventions. Because no data are available on the burden of influenza disease in disaster recovery settings, widespread influenza vaccination is generally a lower priority. If influenza vaccines are made available, resources permitting, vaccination campaigns should ideally start before increases in influenza activity occur. The 2009 H1N1 vaccine, Southern Hemisphere 2010 seasonal influenza vaccine, or 2010-11 Northern Hemisphere seasonal influenza vaccine should be administered in accordance with WHO recommendations.
Appropriate hand washing and respiratory hygiene is encouraged for prevention of many infectious diseases, although the effectiveness of these measures in preventing influenza-specific transmission is limited.
Surveillance for influenza is recommended to monitor trends in influenza activity and change in patterns of disease severity. Strengthening syndromic surveillance by using World Health Organization (WHO) – Pan American Health Organization (PAHO) case definitions for influenza-like illness (ILI) and Severe Acute Respiratory Illness (SARI) is advised.
Increased specimens collection and laboratory testing should be promoted when possible, especially for hospitalized or severe cases. Laboratory support or testing capacity is available via Caribbean Epidemiology Center (CAREC) and CDC. A subset of influenza positive samples should be sent to CDC’s Influenza Division to assess antigenic characteristics and antiviral susceptibility.
In the event that influenza activity is detected, measures should be taken to provide influenza antiviral treatment to persons with ILI who have severe illness or who are in a group at high risk of influenza-related complications, especially pregnant women, the elderly, children younger than 2 years, and those with chronic conditions, like asthma.

1. What was the situation in Haiti before the earthquake?

First cases of 2009 H1N1 influenza were reported in Haiti on July 15, 2009 (WHO-PAHO). The last Haiti epidemiologic report, week 42, had a total of 91 laboratory confirmed cases of 2009 H1N1. Specimens have also tested positive for seasonal influenza A and B strains in lesser numbers (WHO-PAHO). Since the earthquake, no laboratory data nor deaths due to 2009 H1N1 influenza have been reported (as of April 26, 2010). The CAREC Surveillance Report for influenza indicates that 2009 H1N1 has declined in the region since the beginning of 2010.
Haiti is a recipient country for WHO pandemic influenza vaccine donation. Haiti has been assigned but not received one million doses from WHO. WHO is awaiting country confirmation to determine the best time to send this vaccine (WHO-PAHO) based on capacity to properly store it until administration.

2. What is the likelihood of cases/outbreaks of this disease developing in the near future?

Currently, 2009 H1N1 continues to be the predominant influenza virus strain reported in the Caribbean and tropical zones of the Americas (CAREC/WHO-PAHO), although levels of circulation are low and level of herd immunity unknown. WHO-PAHO Weekly Regional Updates for 2009 H1N1 have reported unchanged or decreasing trends in acute respiratory disease overall for the Caribbean region since epidemiology week 13. However, increased levels of ILI were reported in nearby Jamaica, but at low intensity of acute respiratory disease and low impact on healthcare services (PAHO Regional Update, April 26, 2010).

It is likely that increases in 2009 H1N1 activity or outbreaks from other strains of influenza will occur in Haiti in the coming months or year, but the timing and severity of a future influenza outbreak is not known. The risk of influenza-associated outbreaks in Haiti is difficult to assess; however, displaced populations – especially in crowded settings – are at increased risk of influenza and other respiratory infections that are spread through close contact.

3. Should an influenza outbreak occur, how would it be detected?

Currently, limited syndromic surveillance of acute respiratory illness is conducted in Haiti. Fifty-two sentinel sites in Haiti report syndromic surveillance data to the Haiti Ministry of Health. The Internally Displaced Persons Surveillance System (IDPSS) collects daily reports from ambulatory healthcare providers. The country remains on immediate alert for the rainy season (PAHO EOC SitRep24). But the capacity to test for influenza among persons with respiratory illness is limited. Guidelines for surveillance can be obtained from PAHO.
Haiti currently has the capacity for diagnosis of influenza by both real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) and immuno-fluorescence assay antibody (IFA). IFA testing for other respiratory pathogens is also available (WHO-PAHO).
Rapid Influenza Diagnostic Tests (RIDT) are commercially available tests for point-of-care influenza diagnostic testing, but have moderate to low sensitivity for detecting 2009 H1N1 and other influenza viruses. Therefore, RIDTs are not optimal for making individual patient treatment decisions or as the sole test used for influenza surveillance purposes. Use of these tests may provide useful information regarding presence of influenza in a resource-limited setting where other more sensitive testing is not available. If RIDTs are used and detect influenza activity, these results can be used to help to inform influenza antiviral treatment of persons living in the area who present for care with influenza-like illnesses.

4. What options for public health action should be considered in the event of an influenza outbreak?

In the event of an increase in ILI, investigation should include laboratory testing for influenza. If influenza is confirmed, review of infection control measures and controls, treatment algorithms and antiviral supplies, and potential for influenza vaccination efforts should be performed and modified as appropriate. Public education should emphasize appropriate self-care, caregiving, and indications for seeking medical treatment.
As resources become available and initial priorities are met, an influenza vaccination program should be considered targeting healthcare workers and persons at high risk for severe disease or death.
Availability of influenza antiviral medications in Haiti is limited to approximately 30,000 courses. Oseltamivir and Zanamivir are not currently listed on the Inter-Agency Emergency Health Kits (IEHK) drug list. Plans for the rapid distribution of available antivirals to appropriate patients should be made to ensure treatment is initiated within 48 hours following onset of illness. Non-governmental organizations that provide care in displaced populations should be advised to keep an inventory of their antiviral stockpile and to promptly initiate treatment of patients with respiratory infections who are hospitalized or are identified as at high risk for influenza-related complications once influenza activity is detected in their area. Usage rates should be regularly monitored, and acquisition of antiviral medications should be considered if inventory falls low or if surveillance data indicate a significant increase in severe respiratory disease due to influenza. People with mild symptoms but who are at higher risk for severe illness or death (e.g., pregnant women, infants and young children, and those with chronic lung disease such as asthma or chronic obstructive pulmonary disease [COPD]) should be considered for early, empiric treatment with antiviral medications.

Useful links and references:

CDC. Vaccine Information for Clinicians and Health Care Professionals. Available at: http://www.cdc.gov/h1n1flu/vaccination/professional.htm.

CDC. H1N1 flu: Infection Control, Available at http://www.cdc.gov/h1n1flu/infectioncontrol.

WHO. Global Alert and Response, available at: http://www.who.int/csr/disease/swineflu/guidance/vaccines/en/index.html.

WHO. Guidance documents on pandemic (H1N1) 2009. Available at http://www.who.int/csr/disease/swineflu/guidance/en/index.html

Emergency Preparedness and Response

Emergency Preparedness & Response

Influenza: Haiti Pre-decision Brief for Public Health Action

Key recommendations

1. What was the situation in Haiti before the earthquake?

2. What is the likelihood of cases/outbreaks of this disease developing in the near future?

3. Should an influenza outbreak occur, how would it be detected?

4. What options for public health action should be considered in the event of an influenza outbreak?

Useful links and references:

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