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Targeting influenza in Africa: strategic actions for assessing the impact of the disease and for developing control measures (WHO, June 3 2011, edited)
[Source: World Health Organization, Weekly Epidemiological Record, full PDF document, (LINK). Extract, edited.]
Weekly epidemiological record / Relev? ?pid?miologique hebdomadaire
3 june 2011, 86th year / 3 juin 2011, 86e ann?e - No. 23, 2011, 86, 233?240 - http://www.who.int/wer
Targeting influenza in Africa: strategic actions for assessing the impact of the disease and for developing control measures
Background
The impact of influenza on the African continent is not fully understood. However, available information indicates that seasonal influenza may cause significant morbidity and mortality. For example, in 2002 an influenza outbreak in Madagascar had a case-fatality rate of 3% compared with <0.1% seen during other seasonal influenza epidemics.(1) The majority of deaths occurred in young children. Similarly, also in 2002, high case-fatality rates (3.5%) among children aged <5 years were observed during an outbreak in the Democratic Republic of the Congo.(2)
Pneumonia is a major cause of death in Africa, particularly among children aged <5 years. Given that influenza is one of the important causes of childhood pneumonia, populations in Africa may benefit from strategies aimed at preventing and controlling influenza.
Since 2006, the highly pathogenic avian influenza A(H5N1) virus has been circulating in poultry on the continent and has caused infections in humans, especially in Egypt. Since the emergence of the pandemic influenza A (H1N1) 2009 virus, a number of African countries have provided regular updates to WHO on its spread. However, the impact of the pandemic on the continent has been difficult to assess, which indicates there is a need to strengthen surveillance systems.
These events have stimulated many African countries to improve their preparedness for an influenza pandemic and strengthen their capacity for influenza surveillance. Despite these achievements, there is still heterogeneity in the levels of existing capacity, and the quality and performance of surveillance systems within and between countries.(3)
The need for collaborative actions in Africa
The absence of adequate information, lack of awareness of the disease, and competing public health priorities have posed great challenges to understanding the impact of influenza in Africa and to determining appropriate control measures. Considerable gaps have been observed in the geographical coverage of surveillance systems and the resources available to support them, as well as the integration, utilization and expansion of existing systems. Furthermore, the coordination of activities by different technical agencies, networks and countries is not optimal; for example, similar activities may be undertaken in the same country by several international agencies.
To approach these challenges, WHO has established the Africa Flu Alliance to facilitate discussion, coordination and interaction among researchers, donors and funding agencies, and public health professionals on the African continent and worldwide, in order to focus on the burden that influenza and other acute respiratory diseases cause in Africa. The first meeting of the Africa Flu Alliance (held in Marrakesh, Morocco, in June 2010)(3) was attended by international stakeholders and representatives from African countries; participants at the meeting developed a road map of interventions and policies to help coordinate the activities necessary to improve understanding of the epidemiology and burden of the disease.
A road map of actions to reduce the influenza burden
In order to better target influenza in Africa, the following strategic actions were identified by the meeting?s participants as being necessary to help gain an understanding of the disease?s impact and to develop control measures.
Gather and organize existing knowledge on influenza to better understand the disease in Africa
Data on influenza in Africa are limited. Four main areas for improvement have been identified to help stakeholders gather and better organize existing knowledge.
1. Countries should actively collate existing data, and use findings from other countries to complement data from their own country. There are a number of data sources that could be used in addition to data collected through epidemiological and laboratory surveillance ? for example, data gained from educational and training workshops; data aggregated and used for mathematical modelling; data from national health information systems, including vital statistics; and data derived from clinical management and case management. All of these types of data could be used to gain a better understanding of the disease.
2. Experts in each country should be encouraged to publish their data. To encourage the exchange of data, activities should include hosting writing workshops and regional conferences, and establishing national forums.
3. Countries should make data accessible by identifying and developing communication platforms for timely data sharing ? for example, in online journals, through teleconferences with experts or web-based platforms; and by developing mechanisms to encourage countries to obtain feedback from existing international databases, such as WHO?s FluNet4 and FluID.(5)
4. Each country should strengthen coordination within its own borders to make better use of data from surveillance systems and other sources, such as government ministries and academia.
Establish and adapt surveillance for influenza
Most countries in Africa do not have an influenza surveillance system that incorporates both disease surveillance and laboratory testing. Some countries have only a partial system. Due to competing public health needs, establishing a new, vertically integrated surveillance system focused on a single disease, such as that needed for influenza, will be difficult for many resource-limited countries. Countries need to establish, adapt and integrate influenza surveillance into the African context;(5) strategic areas in which work should be conducted include:
1. standardizing surveillance approaches ? that is, countries should adapt and use WHO influenza protocols and standardized case definitions, tools and reporting forms;
2. improving influenza surveillance by evaluating existing systems and considering the lessons learnt from evaluations;
3. linking influenza surveillance with surveillance for other diseases (for example, for polio); finding ways to motivate health-care workers to collate information and use appropriate tools to collect information on influenza;
4. promoting collaboration among different laboratories to increase capacity ? for example, among veterinary laboratories and public health laboratories; supporting the development of national laboratory capacity; supporting the development of regional confirmatory or reference laboratories; promoting the twinning of laboratories that have more capacity with those that have less so they can learn from each other; and promoting collaboration among epidemiological units and technical laboratory units;
5. promoting reporting to FluNet(4) and FluID(5) by Member States in order to improve information sharing; promoting equity and transparency in data-sharing for mutual benefit; safeguarding data ownership; considering jointly publishing data from WHO and the Africa Flu Alliance to acknowledge contributions made by different countries; and providing feedback to those that report data.
Improve patient care
Collecting data alone will not engage people in Africa where the disease has not been recognized as a major health threat, thus benefits to the population need to be explicit and immediate. As common approaches are used to care for pneumonia patients, access to antiviral medicines, antibiotics and other therapies (such as the use of oxygen) will facilitate the treatment of patients with influenza and its complications, as well as other pneumonias, and will prevent severe consequences.
Many countries on the African continent, however, either have no access or only limited access to these resources. Strengthening the capacity of health-care systems to respond to influenza outbreaks and epidemics will eventually benefit the management of all respiratory infections. Improving access to health care, increasing the knowledge and skills of health-care staff, and improving resources for health-care workers are technical areas that should be targeted for improvement. A focused approach was emphasized aiming at:
1. further developing nurse-led primary care in communities by providing training in diagnosing and treating acute respiratory infections;
2. increasing the knowledge of the population about the disease ? for example, through the mass media, community health workers and social mobilization campaigns; and
3. strengthening pneumonia care in hospitals by providing in-service training, delivering equipment as a package (for example, oxygen, masks, pulse oximeters) and emphasizing strategic planning for funding and maintaining human resources.
Resource constraints will need to be considered when trying to make improvements to the care of patients, and distinct approaches will need to be adopted in countries with weak health-care systems, in those with functioning systems but insufficient resources, and in countries with functioning systems and resources.
Ensuring access to care encompasses ensuring access to both technologies and treatments.
Introduce and adapt prevention and control policies
Policies for prevention and control should reflect African needs and realities, and must be tailored to reflect the heterogeneity of countries in Africa (for example, in terms of climate, culture and language); they should also be adaptable so that they can be modified as conditions change. Four areas to be targeted for improvement were identified.
1. Countries should establish systems for regional collaboration during emergencies ? for example, by establishing a regional stockpile of antiviral medicines and vaccines, and ensuring the availability of emergency funds.
2. Countries should work to ensure that communication, advocacy and the management of behavioural change are integral parts of implementing evidence-based policies. For example, the uptake of vaccines and immunization programmes are sometimes hampered by inadequate or inaccurate information circulating among the public, and communication needs to target all levels of society, including the general public, community leaders, politicians and academic centres.
3. Countries should evaluate their experience with the recent pandemic A(H1N1) 2009 virus and adapt their pandemic preparedness plans accordingly. The evaluation should measure the impact of interventions.
4. Countries should integrate and create links among influenza prevention and control strategies and other health programmes and intervention strategies ? for example, with the Integrated Disease Surveillance and Response strategy for surveillance and with the WHO global immunization vision and strategy(6) for vaccination.
They should also consider including the private health-care sector and other public sectors in such efforts.
Next steps for the Africa Flu Alliance
Participants at the meeting(7) requested that WHO coordinate and promote the objectives and future activities of the alliance. Future activities will include mapping existing capacities, and projects in the Africa Flu Alliance?s road map. WHO and members of the alliance will emphasize the implementation of strategic actions ? for example, by organizing a meeting on the clinical management of influenza patients in resource-limited settings and workshops to provide opportunities to exchange information and knowledge. The road map will be used as a monitoring tool for the implementation of actions defined by the alliance.
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1 See No. 46, 2002, pp. 381?386.
2 See No. 1/2, 2003, p. 1.
3 Report of the 1st Africa Flu Alliance Meeting: 3?4 June 2010, Marrakesh, Morocco. Geneva, World Health Organization, 2010 (WHO/HSE/GIP/DAC/2011.1). (Also available from (LINK).)
4 FluNet. Geneva, World Health Organization, 2011 ((LINK), accessed May 2011).
5 FluID. Geneva, World Health Organization, 2010 ((LINK), accessed May 2011).
6 Global immunization vision and strategy. Geneva, World Health Organization, 2010 ((LINK), accessed February 2011).
7 See Annex III, in reference 3 for a full list of participants.
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Weekly epidemiological record / Relev? ?pid?miologique hebdomadaire
3 june 2011, 86th year / 3 juin 2011, 86e ann?e - No. 23, 2011, 86, 233?240 - http://www.who.int/wer
Targeting influenza in Africa: strategic actions for assessing the impact of the disease and for developing control measures
Background
The impact of influenza on the African continent is not fully understood. However, available information indicates that seasonal influenza may cause significant morbidity and mortality. For example, in 2002 an influenza outbreak in Madagascar had a case-fatality rate of 3% compared with <0.1% seen during other seasonal influenza epidemics.(1) The majority of deaths occurred in young children. Similarly, also in 2002, high case-fatality rates (3.5%) among children aged <5 years were observed during an outbreak in the Democratic Republic of the Congo.(2)
Pneumonia is a major cause of death in Africa, particularly among children aged <5 years. Given that influenza is one of the important causes of childhood pneumonia, populations in Africa may benefit from strategies aimed at preventing and controlling influenza.
Since 2006, the highly pathogenic avian influenza A(H5N1) virus has been circulating in poultry on the continent and has caused infections in humans, especially in Egypt. Since the emergence of the pandemic influenza A (H1N1) 2009 virus, a number of African countries have provided regular updates to WHO on its spread. However, the impact of the pandemic on the continent has been difficult to assess, which indicates there is a need to strengthen surveillance systems.
These events have stimulated many African countries to improve their preparedness for an influenza pandemic and strengthen their capacity for influenza surveillance. Despite these achievements, there is still heterogeneity in the levels of existing capacity, and the quality and performance of surveillance systems within and between countries.(3)
The need for collaborative actions in Africa
The absence of adequate information, lack of awareness of the disease, and competing public health priorities have posed great challenges to understanding the impact of influenza in Africa and to determining appropriate control measures. Considerable gaps have been observed in the geographical coverage of surveillance systems and the resources available to support them, as well as the integration, utilization and expansion of existing systems. Furthermore, the coordination of activities by different technical agencies, networks and countries is not optimal; for example, similar activities may be undertaken in the same country by several international agencies.
To approach these challenges, WHO has established the Africa Flu Alliance to facilitate discussion, coordination and interaction among researchers, donors and funding agencies, and public health professionals on the African continent and worldwide, in order to focus on the burden that influenza and other acute respiratory diseases cause in Africa. The first meeting of the Africa Flu Alliance (held in Marrakesh, Morocco, in June 2010)(3) was attended by international stakeholders and representatives from African countries; participants at the meeting developed a road map of interventions and policies to help coordinate the activities necessary to improve understanding of the epidemiology and burden of the disease.
A road map of actions to reduce the influenza burden
In order to better target influenza in Africa, the following strategic actions were identified by the meeting?s participants as being necessary to help gain an understanding of the disease?s impact and to develop control measures.
Gather and organize existing knowledge on influenza to better understand the disease in Africa
Data on influenza in Africa are limited. Four main areas for improvement have been identified to help stakeholders gather and better organize existing knowledge.
1. Countries should actively collate existing data, and use findings from other countries to complement data from their own country. There are a number of data sources that could be used in addition to data collected through epidemiological and laboratory surveillance ? for example, data gained from educational and training workshops; data aggregated and used for mathematical modelling; data from national health information systems, including vital statistics; and data derived from clinical management and case management. All of these types of data could be used to gain a better understanding of the disease.
2. Experts in each country should be encouraged to publish their data. To encourage the exchange of data, activities should include hosting writing workshops and regional conferences, and establishing national forums.
3. Countries should make data accessible by identifying and developing communication platforms for timely data sharing ? for example, in online journals, through teleconferences with experts or web-based platforms; and by developing mechanisms to encourage countries to obtain feedback from existing international databases, such as WHO?s FluNet4 and FluID.(5)
4. Each country should strengthen coordination within its own borders to make better use of data from surveillance systems and other sources, such as government ministries and academia.
Establish and adapt surveillance for influenza
Most countries in Africa do not have an influenza surveillance system that incorporates both disease surveillance and laboratory testing. Some countries have only a partial system. Due to competing public health needs, establishing a new, vertically integrated surveillance system focused on a single disease, such as that needed for influenza, will be difficult for many resource-limited countries. Countries need to establish, adapt and integrate influenza surveillance into the African context;(5) strategic areas in which work should be conducted include:
1. standardizing surveillance approaches ? that is, countries should adapt and use WHO influenza protocols and standardized case definitions, tools and reporting forms;
2. improving influenza surveillance by evaluating existing systems and considering the lessons learnt from evaluations;
3. linking influenza surveillance with surveillance for other diseases (for example, for polio); finding ways to motivate health-care workers to collate information and use appropriate tools to collect information on influenza;
4. promoting collaboration among different laboratories to increase capacity ? for example, among veterinary laboratories and public health laboratories; supporting the development of national laboratory capacity; supporting the development of regional confirmatory or reference laboratories; promoting the twinning of laboratories that have more capacity with those that have less so they can learn from each other; and promoting collaboration among epidemiological units and technical laboratory units;
5. promoting reporting to FluNet(4) and FluID(5) by Member States in order to improve information sharing; promoting equity and transparency in data-sharing for mutual benefit; safeguarding data ownership; considering jointly publishing data from WHO and the Africa Flu Alliance to acknowledge contributions made by different countries; and providing feedback to those that report data.
Improve patient care
Collecting data alone will not engage people in Africa where the disease has not been recognized as a major health threat, thus benefits to the population need to be explicit and immediate. As common approaches are used to care for pneumonia patients, access to antiviral medicines, antibiotics and other therapies (such as the use of oxygen) will facilitate the treatment of patients with influenza and its complications, as well as other pneumonias, and will prevent severe consequences.
Many countries on the African continent, however, either have no access or only limited access to these resources. Strengthening the capacity of health-care systems to respond to influenza outbreaks and epidemics will eventually benefit the management of all respiratory infections. Improving access to health care, increasing the knowledge and skills of health-care staff, and improving resources for health-care workers are technical areas that should be targeted for improvement. A focused approach was emphasized aiming at:
1. further developing nurse-led primary care in communities by providing training in diagnosing and treating acute respiratory infections;
2. increasing the knowledge of the population about the disease ? for example, through the mass media, community health workers and social mobilization campaigns; and
3. strengthening pneumonia care in hospitals by providing in-service training, delivering equipment as a package (for example, oxygen, masks, pulse oximeters) and emphasizing strategic planning for funding and maintaining human resources.
Resource constraints will need to be considered when trying to make improvements to the care of patients, and distinct approaches will need to be adopted in countries with weak health-care systems, in those with functioning systems but insufficient resources, and in countries with functioning systems and resources.
Ensuring access to care encompasses ensuring access to both technologies and treatments.
Introduce and adapt prevention and control policies
Policies for prevention and control should reflect African needs and realities, and must be tailored to reflect the heterogeneity of countries in Africa (for example, in terms of climate, culture and language); they should also be adaptable so that they can be modified as conditions change. Four areas to be targeted for improvement were identified.
1. Countries should establish systems for regional collaboration during emergencies ? for example, by establishing a regional stockpile of antiviral medicines and vaccines, and ensuring the availability of emergency funds.
2. Countries should work to ensure that communication, advocacy and the management of behavioural change are integral parts of implementing evidence-based policies. For example, the uptake of vaccines and immunization programmes are sometimes hampered by inadequate or inaccurate information circulating among the public, and communication needs to target all levels of society, including the general public, community leaders, politicians and academic centres.
3. Countries should evaluate their experience with the recent pandemic A(H1N1) 2009 virus and adapt their pandemic preparedness plans accordingly. The evaluation should measure the impact of interventions.
4. Countries should integrate and create links among influenza prevention and control strategies and other health programmes and intervention strategies ? for example, with the Integrated Disease Surveillance and Response strategy for surveillance and with the WHO global immunization vision and strategy(6) for vaccination.
They should also consider including the private health-care sector and other public sectors in such efforts.
Next steps for the Africa Flu Alliance
Participants at the meeting(7) requested that WHO coordinate and promote the objectives and future activities of the alliance. Future activities will include mapping existing capacities, and projects in the Africa Flu Alliance?s road map. WHO and members of the alliance will emphasize the implementation of strategic actions ? for example, by organizing a meeting on the clinical management of influenza patients in resource-limited settings and workshops to provide opportunities to exchange information and knowledge. The road map will be used as a monitoring tool for the implementation of actions defined by the alliance.
-
1 See No. 46, 2002, pp. 381?386.
2 See No. 1/2, 2003, p. 1.
3 Report of the 1st Africa Flu Alliance Meeting: 3?4 June 2010, Marrakesh, Morocco. Geneva, World Health Organization, 2010 (WHO/HSE/GIP/DAC/2011.1). (Also available from (LINK).)
4 FluNet. Geneva, World Health Organization, 2011 ((LINK), accessed May 2011).
5 FluID. Geneva, World Health Organization, 2010 ((LINK), accessed May 2011).
6 Global immunization vision and strategy. Geneva, World Health Organization, 2010 ((LINK), accessed February 2011).
7 See Annex III, in reference 3 for a full list of participants.
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