Influenza Pandemic - Literature review Example

Border Control Measures Border control measures are usually considered as an essential ingredient of the Australian Government’s plans to delay the arrival or minimise the spread of a virus with pandemic potential and may be implemented early in the development of a pandemic overseas (Department of Health and Ageing 2009). Border control measures are a non-pharmaceutical intervention usually deployed as part of a wider national plan to slow down the development of a pandemic in Australia (Kotsimbos et al 2010). They are entailed in the Australian Health Management Plan for Pandemic Influenza (AHMPPI), such as FLUBORDERPLAN in 2008. Border control measures are usually initiated at the second or DELAY phase of an influenza pandemic in the event of a declaration by the World Health Organization (WHO) of an imminent influenza pandemic due to the emergence of a new influenza virus strain for which there is no immunity and which can cause serious disease among humans and is easily spread from human to human (Kotsimbos et al 2010, Department of Health and Ageing 2009). There are several approaches under border control measures applied by the Australian Government to detect infected arriving passengers at airports and other ports of entry. These include non-automatic pratique which requires commanders of incoming international flights to declare the health status of all people on board prior to arrival in Australia (Kelly et al 2011). Other approaches included in flight announcements by pilots to encourage self reporting of ill health or respiratory symptoms by passengers (Appuhamy et al 2009). In addition, airline staff- both pilots and crew are also required to identify passengers with respiratory symptoms. Passengers are also required to complete Health Declaration Cards where they report current symptoms (Department of Health and Ageing 2009). Screening measures include the use of thermal screening using infra-red cameras at designated international airports and clinical nursing presence at designated international airports to identify and contain the threat of influenza. Border workers are also provided with personal protective equipment such as goggles, face masks and surgical gloves to minimize the risk of exposure to the virus due to close contact with infected people where social distancing is not practical (Department of Health and Ageing 2009). Additional measures included travel restrictions through exit screening for persons intending to travel outside Australia, quarantining of incoming international travellers from regions affected by pandemic influenza and the cleaning and disinfection of aircraft and airport surfaces (Kelly et al 2011, Roth and Henry 2011). Guidelines around the use of border measures during an Influenza Pandemic The Australian Government’s guidelines on the use of border control measures are outlined by the AHMPPI and the Commonwealth of Australia Government (COAG) in the National Action Plan for Human Influenza Pandemic. The guidelines, such as those published in FLUBORDERPLAN: The National Pandemic Influenza Airport Border Operations Plan 2008 by the Australian Government Department of Health and Ageing (2009a), outlines the various roles and responsibilities of the Commonwealth Government border agencies, state or territory government agencies and the health and airline sectors to respond to the threat or actual transmission of pandemic influenza in Australia. The National Pandemic Influenza Airport Border Operations Plan 2008 outlines the hierarchical chain of command in declaration of the initiation or deployment of border control measures. Once an imminent pandemic is declared by the WHO and communicated to the Chief Medical Officer (CMO), the CMO sets off a consultative process with the Minister of Health and Ageing who in turn recommends the up-scaling of the Australian pandemic phase to DELAY OS4 to the Prime Minister. The PM then convenes the National Pandemic Emergency Committee and after activating border control measures, notifies the Governor General of the up scaling to DELAY OS4 who then authorizes the Australian Government access to emergency powers under the Quarantine Act 1908 (Department of Health and Ageing 2009). FLUBORDERPLAN outlines some of the guidelines in the use of border control measures during an influenza pandemic. In the case of a reported sick traveller on board via non automatic pratique, the aircraft is met by nursing and quarantine services staff on landing and the patient is isolated for processing and possible quarantine. Other travellers on board the flight with the sick passenger are then contained within the aircraft. In case the sick passenger meets the Communicable Diseases Network of Australia’s (CDNA) definition for influenza, the other patients are assessed for symptoms and those identified as coming into contact with the sick passenger are quarantined and provided with alcohol hand rub, surgical masks and flu information. The guidelines also outline procedures for processing patients via thermal screening and Health Declaration Cards (HDC). In the event of disclosure of symptoms and or detection of elevated skin temperature levels, travellers are escorted by quarantine staff to nurses for assessment and quarantine processing dependent on displaying CDNA definitions of influenza. In essence, the guidelines dictate that any traveller who either displays symptoms through screening or comes into contact with infected travellers must be dully accessed and subjected to quarantine processing (Department of Health and Ageing 2009a). The guidelines on border control measures also stipulate standards for the CDNA influenza screening and assessments, the use of appropriate safety equipment and procedures by border nurses to reduce or eliminate exposure to the influenza virus, the training or border nurses and the financing of costs associated with deployment of border nurse which are reimbursed by state governments. Literature Review on the Effectiveness of Border Control Measures There is scientific evidence to prove that border control measures are potentially effective in delaying the entry of pandemic virus to any country. Roth and Henry (2011) identify movement through air travel as a major facilitating factor in influenza transmission. This suggests that control measures on major airports would be effective in delaying the entry of pandemic influenza into Australia. Cowling et al (2010) estimated that border control measures would only have short term delays in local transmission for countries which implemented border control as opposed to those that did not. The AHMPPI and the Department of Health and Ageing (2009) claim that border control measures deployed in Australia such as FLUBORDERPLAN are based on current epidemiology available of pandemic influenza and can be used as an effective non-pharmaceutical intervention to slow down or delay the entry of pandemic influenza virus into Australia (Waterer et al 2010, Department of Health and Ageing 2009). However, Bell (2006) and Samaan et al (2004) had indicated that border control measures had not been very effective in delaying the onslaught of similar viral diseases drawing from Australia’s experience with SARS in 2004. Other medical authors and experts such as Collignon (2009), Aledort et al (2007) and Bradt and Epstein (2010) questioned the use of border control measures despite the lack of sufficient and conclusive evidence of its effectiveness in delaying the entry of pandemic influenza into Australia. Kelly et al (2011) and Mathews et al (2007) have pointed out that the use of border control measures such as FLUBORDERPLAN was not based on a current understanding of influenza epidemiology and was unsupported by a sufficient number of predictive modelling studies which included asymptomatic infections- or infections with suppressed symptoms. Kelly et al (2011) also point to a gap in border detection of pandemic HINI infections due to the high incidence of afebrile or asymptomatic infections which cannot be detected by the screening techniques employed in border control measures such as thermal scanning or core temperature measurements. The cost effectiveness of border control measures has also been questioned by Appuhamy et al (2009) as they required significant investment in public health resources but had very low pick-up or detection rates (Kelly et al 2011, Waterer et al 2010). Despite criticism of the lack of a sufficient evidence basis for border control as a measure to delay or control the entry of pandemic influenza in Australia, border control is by nature a short term measure which can significantly stall viral entry from overseas while longer term measures such as vaccination and primary health care are prepared (Kotsimbos et al 2010). As indicated by Roth and Henry (2011) and the Department of Health and Ageing, border control measures such as FLUBORDERPLAN are a temporal stage and part of a wider strategic plan to control pandemic influenza and it serves an important role in preparation for more concrete and effective interventions. Benefits of using border measures The use of border measures is one of the efficient means of delaying the entry of the pandemic influenza A (H1N1) in Australia. Border measures help in the identification of potential cases of the pandemic prior to any contact (Appuhamy et al, 2010). Once the pandemic is identified in other areas, it is essential to employ pre-border measures and at-border measures as this helps to delay the entry of the pandemic into the country in the longest time possible. This in turn provides the Australian government with sufficient time to prepare and implement effective measures aimed at curbing this pandemic in order to protect the Australian population. Scientific research studies show that the use of a combination of pre-border and at-border measures can help in the delay of the virus entry into Australia (Department of Health and Ageing, 2010). Border measures are among the control measures that if implemented effectively and early enough can help to slow down the spread of the pandemic in Australia. These measures also help to raise awareness for people who are of travelling it also helps to deter infected individuals from travelling (Department of Health and Ageing, 2010). The quarantine and identification of infected persons at the point of entry helps to delay the transmission of the influenza in Australia. Border measures incorporate screening, health declaration, temperature checks and the observation of symptoms from passengers. Some studies show that these measures help in the delay of transmission by seven to twelve days (Takemi et al, 2010). Border measures can also help to lower rates of morbidity that occur as a result of the pandemic influenza A (H1N1). A study conducted by McLeod et al (2008) illustrates that in 1918 and 1919 border measures used in Australia helped to reduce the rates of morbidity. McLeod observes that Australia managed to successful to use marine time quarantine to delay in the introduction of the H1N1 virus in Australia in 1918-1919.However, other countries neighbouring Australia like New Zealand did not employ any border measures. In New Zealand the H1N1 virus was first detected in October 1918, in Australia the virus was detected in January 1919. It is estimated that the death rates in Australia were lower than in New Zealand mainly because the entry of the virus was delayed through border measures (McLeod et al, 2008). Disadvantages of using border measures Border measures cannot be used to keep the H1NI virus out of Australia indefinitely. Before the 2009 H1N1 virus pandemic, some studies suggested that border measures play a very limited role in delaying the transmission of the virus. These studies estimate that border screen help in delaying the spread of the virus for only one to two weeks (Ferguson et al, 2006). There is inconclusive and limited evidence showing that border measures are effective in the control of the transmission of diseases. In 2009, Australia implemented a combination of several border measures in a bid to detect infected passengers. Border measures such as thermal scanning, health declaration cards and the observation of patients with respiratory symptoms among many other measures were used. Although the number of passengers who were screened was not confirmed, it is estimated that ten thousands of passengers were screened. Out of this numbers, only four cases were confirmed (Appuhamy et al, 2010). Despite the fact that these measures were carried out, cases of H1N1 pandemic were reported in Australia. It is difficult for border measures such as thermal scanning, the observation of patients with respiratory symptoms and other screening methods to identify H1N1 symptoms. This is mainly because a considerable proportion of the H1N1 viruses are afebrile or completely asymptomatic thus it is impossible to detect using border measures (Gerrard et al, 2009; Miller et al, 2010). Moreover, the use of border control measures to control the spread of H1N1 virus exposes personnel working at the airport or other entry to risk of getting the infection. Challenges in the implementation and use of border measures As a result of increased number of people traveling to and from Australia using different forms of transportation, the use of border measures to control the spread of any pandemic can be an expensive undertaking ( WHO, 2009). The effective implementation of these measures requires that the necessary screening technologies and materials are purchased and that personnel in working in airports or other border entry points are effectively trained. In addition border measures necessitate the investment of considerable public and clinical health resources. Apparently, this is a costly undertaking. Moreover, border control measures have limited effectiveness in a country like Australia which has porous border. Due to the high scale of air transport, efficient border control measures would necessitate unrealistic rates of detection so as to limit or delay transmission (Wood et al 2007; Nishiura et al. 2009). Recommendations Despite the fact that there is limited evidence showing the effectiveness of border measures in delaying and controlling the transmission of the H1N1 pandemic , border control measures should still be incorporated in the Australian Health Management Plan for Pandemic Influenza (AHMPPI). The use of border measures is a stepping stone towards addressing the H1N1 pandemic. Without border measures the transmission of H1N1 virus may intensify (McLeod et al, 2008). Nevertheless, there is need for major improvements during the implementation and use of border measures to delay and control the transmission of the H1N1 virus. Foremost, it is essential to conduct a comprehensive evaluation of the pandemic and how it can be detected easily so as to avoid transmission. The detection or identification of the H1N1 virus is one of the key challenges that affect the effectiveness of border measures. This is mainly because the H1N1 viruses are afebrile or completely asymptomatic thus it is impossible to detect using border measures (Gerrard et al, 2009; Miller et al, 2010). It is therefore, essential for extensive research and evaluation to be conducted in order to determine the mechanisms that can be used to detect the virus. There is need to incorporate a wide range of technological resources for screening in order to enhance the effectiveness of border control measures. The efficiency of the existing screening measures is limited due to increased number of people traveling. Therefore, the Australian government should invest in a wide range of technological resource so as to improve the effectiveness of border control measures. In addition to this, there is need to institute extensive training programs that are geared towards equipping personnel working in airports and other entry points with the relevant skills needed to use and implement effective border control measures (WHO, 2009). Conclusion Border control measures are part of the Australian Government’s plans to delay the arrival and minimise the spread of a virus with pandemic potential and is often implemented early in the development of a pandemic overseas (Department of Health and Ageing 2009). Some studies show that border control measures are potentially effective in delaying the entry of pandemic virus to any country. However, some studies show that border measures cannot be used to keep the H1NI virus out of Australia indefinitely. These studies estimate that border screen help in delaying the spread of the virus for only one to two weeks (Ferguson et al, 2006). In order to enhance the effectiveness of border control measures, there is need to conduct a comprehensive research on how pandemics can be detected easily so as to avoid transmission. Furthermore, there is need to incorporate a wide range of technological resources for screening in order to enhance the effectiveness of border control measures (WHO, 2009). References Appuhamy, R., Beard, F., Phung, H., Selvey, C., Birrell, F. & Culleton, T., (2010). The changing phases of pandemic (H1N1) 2009 in Queensland: an overview of public health actions and epidemiology. The Medical Journal of Australia 192 (2): 94-97. Australian Government, Department of Health and Ageing. (2010).Australian Health Management for Pandemic influenza (2009). Retrieved on October 25, 2011 from Australian Government Department of Health and Ageing, (2009a). 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