Finland prepares for influenza pandemic

The preparedness plan provides a basis for all administrative sectors and to an extent also to business and economic life to define the threats and increase readiness to face these threats.

The phases of development in a pandemic

Nowadays epidemics in poultry caused by influenza viruses, even rare individual cases of infections in humans are spotted quickly through the international influenza monitoring systems coordinated by the World Health Organization (WHO), the World Organisation for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO). Thus the possible development of the threat of a pandemic into an actual pandemic can be closely monitored, and measures can be planned to prevent a pandemic from occurring or to slow down its progress.

In the WHO's global influenza preparedness plan, pandemic development has been divided into six possible phases. (Table below). It is impossible to predict the length of each phase. The transfer from one phase to another may take place rapidly or it might take years. The WHO has indicated that at the moment we are at phase three.

Scenario as the basis of the preparedness plan

It is impossible to predict the timeframe and severity of the next pandemic. However, certain basic assumptions about a pandemic are required in order to establish a pandemic preparedness plan. The calculations for the Finnish pandemic preparedness plan are based on the assumption that during the first pandemic wave of eight weeks' duration, 35 per cent of the population would fall ill, 11,000 to 36,000 of whom would require hospital treatment and 3,500 to 9,000 would die. As a comparison, 5 to 20 per cent of the population fall ill annually with ordinary seasonal influenza, of whom one or two per thousand over 65-year-olds (800-1,600) die as a result. The first wave of the pandemic might be followed by a second and even a third wave at intervals of a few months. The following waves could be weaker than the first wave but there is no certainty about this. The Working Group stresses that the figures are not predictions, but purely a basis for calculations.

How can the spread of infections be prevented or slowed down?

During the pandemic threat phases, the aim is still to prevent the outbreak of a pandemic or to slow it down as much as possible. Studies show that careful, frequent hand washing using soap prevents respiratory infections caused by viruses. Droplets spread through coughing and sneezing are a significant risk for infections. Hence, coughing and sneezing related hygiene is important in order to prevent transmissions. The Working Group does not recommend the use of face masks in everyday life. Separate recommendations and regulations will be given for the use of face masks for occupational safety and health reasons.

During pandemic threat phases three to five, it is essential that the chain of transmission is broken by targeting measures at individuals who have been exposed to the disease and possibly become infected. The exposed individuals must be defined and traced and a decision must be made on whether a short course of inhibitor drugs or quarantine is required. Drugs are discussed below.

Quarantine would normally be carried out on a voluntary basis at home under the supervision of health care personnel. In some cases, putting airplane passengers under quarantine, for example, could be considered. During the actual pandemic, tracing exposed individuals would no longer be useful, as there are too many infected people.

During the pandemic, it might be justifiable to close down daycare centres and schools and limit public gatherings. This could be considered in pandemic phases four to five if they take place in Finland.

The transmission of infections can also be slowed down by educating the public to recognize the symptoms of the disease as early as possible. This would allow individuals to follow the hygiene guidelines provided and seek treatment and, consequently, to prevent them from infecting others.

During the threat of a pandemic and the pandemic itself, the WHO, the European Union and the European Centre for Disease Prevention and Control (ECDC) give situation-specific recommendations on measures affecting international transport and trade. In the EU, the aim is to execute these measures in different member states in as similar a way as possible. The WHO emphasizes that the key measures for preventing a pandemic are carried out at a national level in each country. Limiting international transport has little effect on preventing a pandemic.

Vaccines

A mock-up vaccine that will be manufactured from the influenza virus H5N1 subtype causing a pandemic threat will probably be available in Finland during 2007. Finland has ordered enough of the mock-up vaccine to immunize the whole population. Guidelines on vaccinating will be given if vaccinating becomes a topical issue.

A targeted vaccine that will be manufactured from the subtype of the influenza virus causing the pandemic can only be manufactured once the pandemic has started. The manufacturing process for the targeted vaccine takes months; hence, it is unlikely that the vaccines will be available during the first wave of the pandemic. They should be available to combat the second wave, however.

Antiviral drugs

The susceptibility of the virus causing the threat of a pandemic to antiviral drugs determines which drugs can be used to prevent the influenza pandemic and treat patients. The virus may also become resistant to one or more drugs.

Influenza antiviral drugs are used, both to treat influenza patients and as short-term inhibitor drugs after exposure to the virus, to complement other means of preventing progress towards a pandemic or in order to delay it during WHO phases three to five. In such cases, the drugs are given to those who have been in contact with infected individuals such as members of their families and others who have been closely exposed to the infection.

Stockpiles

Finland has ordered 5.2 million doses of the mock-up vaccine. The aim is that the vaccines will be in store in Finland by the end of this year.

The National Public Health Institute has concluded a five-year advance reservation contract for targeted vaccine with a Dutch vaccine manufacturer. The vaccine will arrive in Finland in one or more batches approximately six months after the start of the pandemic. The manufacturing of the vaccine will not be started until after the WHO has declared that the pandemic has started. The National Emergency Supply Agency has stored 1.3 million treatment courses of Tamiflu and its powder version, oseltamivir. The drug works only if it is taken within 48 hours of becoming infected, so it is very important that the distribution of the drug works well. The Pandemic Working Group has discussed drug logistics and given its recommendations. Importers and manufacturers of pharmaceuticals as well as hospitals and health centres have statutory obligatory stores.

The Pandemic Working Group has also discussed the stockpiles and obligatory stores of drugs and equipment required to treat patients and protect personnel and made proposals on how to implement the storage.

Ethical discussion on possible prioritisation

The Pandemic Working Group has asked for a statement from the National Advisory Board on Health Care Ethics (ETENE) on issues related to the preventive and treatment use of vaccines and antiviral drugs in a pandemic. The basis for preparations in Finland is that everyone will be vaccinated and everyone requiring drugs will receive them. This is the basis for setting aside the resources. However, there could be problems in getting the entire batch of vaccine into the country in one go. That would mean prioritising those who should be vaccinated first. Prioritisation in health care must be based on thorough ethical discussion. The Pandemic Working Group does not know of any other country whose preparedness plan includes discussing the ethical question as extensively as the Finnish plan.

Health care services during the threat of a pandemic and the pandemic

During the pandemic threat phases (phases 3-5) the aim is to prevent the pandemic entirely or to delay it considerably. At this stage there will be a maximum of a couple of dozen patients in Finland, and they can be treated normally. There would be enough special premises, drugs and equipment; health care would work as normal.

During the pandemic, due to the major strain on hospital care, it will probably be necessary to make emergency arrangements for organizing health care and health care premises. It may not be possible to implement the same level of protection and isolation of the infected individuals as during the pandemic threat phases.

The Working Group proposes that the aim should be that everyone who falls ill receives medication within 48 hours of infection. Medication started later than that is unlikely to be beneficial. The majority of the influenza patients will be treated at home. It will probably be necessary to set up separate influenza clinics within primary health care, particularly if drug treatment of everyone who has been infected is initiated. It might be necessary to take reserve hospitals into use to accommodate patients needing hospital care.

The Pandemic Working Group has drafted guidelines on patient advice, reception, examination and treatment for both primary health care and specialized medical care. It has also discussed private health care in relation to pandemic preparedness and during a pandemic. The plan also includes guidelines for health care professionals on how to protect themselves from infection through health care.

The plan also considers the sufficiency of health care personnel. Regional and local level health care organizations are responsible for practical ways of ensuring adequate personnel resources.

The hygiene and treatment guidelines given to influenza patients as well as telephone advice and guiding patients to the right place for treatment require efficient communication through e.g. an Internet service and the media. Telephone advice must also work properly. The importance of communication is stressed in health centres' and hospitals' pandemic preparedness plans, and sufficient resources must be allocated to implement it.

Social welfare services in a pandemic

In a pandemic, much expectation and a lot of work and reorganization of functions are focused on the social welfare services. In the social welfare services' current preparedness guidelines, a communicable disease epidemic isnot discussed as a threat; hence, preparing for one now has to be planned and coordinated together with the health care services.

The municipal social administration must make plans on how to organize children's daycare, child welfare, increased home service needs, care for older people and people with disabilities, income security issues and other general social work. It must organize temporary accommodation, provisioning, clothing and transport for those who for one reason or another cannot live at home during the pandemic. The clientele might increase, at the same time as many social workers are ill, as are also many of the clients' family members who could otherwise help in an emergency.

Economic and social impact

In addition to its harmful effects on health, an influenza pandemic will have extensive economic, social and political impact all over the world. During the SARS epidemic, Hong Kong estimated that financial losses in South-East Asia were approximately USD 60 billion. In Toronto, the losses are estimated to have reached approximately CAD 2 billion despite the fact that during the entire epidemic 8000 people fell ill in South-East Asia and 250 people in Toronto.

So far, avian influenza has not had much effect on tourism or international business in South-East Asia, but if avian influenza becomes more adapted to humans or if human-to-human transmissions occur, tourism and other businesses would immediately be affected. In a pandemic threat individual countries might set restrictions on tourism and trade, which the WHO does not recommend and other countries do not support. This would also cause increased political tension between countries.

In Finland as well, the major challenges of a pandemic are connected with maintaining the vital functions of society when the majority of employees are ill or caring for others who are ill, or at home looking after their children because daycare centres and schools are closed. The different sectors of society will define their own vital functions, but these will include at least the energy supply, securing the food supply, maintaining functional transport and communications, and ensuring people's safety.

Rich industrialized countries, such as Finland, can buy vaccines, drugs and equipment. Worldwide and even within the EU there are significant differences in the potential for material preparedness for the threat of a pandemic. This brings up questions of international solidarity, and to manage such issues national and international procedures should be in place. A pandemic might also cause strains between employees and employers, for example in cases were work poses a major danger of exposure to the infection. Issues such as these regarding work ethics are particularly apparent in health care but also in other professions such as customer service work. Occupational safety and health aspects are emphasized in these issues.

Legislation

Of key importance to the prevention and treatment of an influenza pandemic is that powers and obligations are dealt with in accordance with the Communicable Diseases Act. Obligations have been laid down for all administrative levels: the Ministry of Social Affairs and Health, State Provincial Offices and local authorities. Private health care does not have a statutory preparedness obligation.

During a pandemic, situations will arise which require examination from the point of view of other legislation in addition to the Communicable Diseases Act: for example, employment legislation will play a significant role in workplaces when the risk of infection and absence from work due to one's own or a family member's illness or children's daycare arrangements are dealt with.

Amendments to legislation

The Ministry of Social Affairs and Health has started drafting an amendment to the Communicable Diseases Decree according to which influenza caused by the H5N1 virus is defined as an infectious disease endangering the public. Further consideration is required on whether an influenza pandemic caused by some other influenza virus would be classified as a disease endangering the public.

The starting point for assessing the need to amend legislation is that the prevention of communicable diseases could be efficiently carried out in accordance with normal legislation. The Working Group finds that an amendment to the Communicable Diseases Act should be drafted giving the Ministry of Social Affairs and Health and State Provincial Offices the possibility to order temporary changes to social and health services under normal legislation. Drafting amendments to the Communicable Diseases Act on authorising quarantine has already been initiated. The main aim is to speed up the decision-making process on ordering individuals into quarantine in urgent cases and also to enable ordering individuals with no symptoms into quarantine if they have been exposed to the infection. Quarantine will not necessarily take place in a hospital; it could also be at home, in a hotel or reception centre. It might be that during the epidemic there is no time to examine and treat patients requiring non-urgent treatment within the fixed time. The Working Group proposes amendments to the Primary Health Care Act and the Act on Specialized Medical Care allowing the local authority and hospital district to give new, temporary instructions regarding the referral to treatment of non-urgent cases.

The Emergency Powers Act is currently being amended so that a widespread communicable disease is comparable to a disaster allowing emergency conditions to be declared. During emergency conditions the Government may, in accordance with the current act and the amendment, order a Finnish resident trained in the field of health care or otherwise suitable for duties in the field to perform tasks within the limits of their training and experience. This provision applies according to the old act to 17-64-year-olds and the amendment to 18-68-year-olds.

Organizations developing and maintaining preparedness

The Government is responsible for preparing for an influenza pandemic and the actions required to manage a pandemic. Preparing for a pandemic requires actions within all administrative sectors. The highest civil servant in each ministry responsible for preparedness is the Permanent Secretary. The Pandemic Working Group proposes that the responsibility for implementing the preparedness plan lies with the council of Permanent Secretaries or preparedness directors.

National pandemic preparedness is directed by the Ministry of Social Affairs and Health using the National Public Health Institute as its expert institution.

Regional preparedness is led and coordinated by the State Provincial Offices which utilize hospital districts' expert knowledge in health care preparedness. The State Provincial Offices update their own plans in accordance with the national preparedness plan and ensure that the plans of hospital districts, health centres and other administrative sectors and local authorities in their own districts are compatible with them.

Health centres prepare plans for a pandemic which cover referral to treatment, diagnosing and treating the disease and organizing possible vaccinations. The plan must also include a pandemic plan for occupational health care organized by the local authority. The plans must include the private health care resources available and the cooperation with private occupational health care. Health centres prepare their plans in cooperation with the State Provincial Office and the hospital district's regional Pandemic Working Group.

Working Group

In May 2005, the Ministry of Social Affairs and Health appointed a Working Group to draw up a preparedness plan in case of an influenza pandemic. Merja Saarinen, Ministerial Counsellor, Health Affairs at the Ministry of Social Affairs and Health has chaired the Working Group.

Further information:
Merja Saarinen, Ministerial Counsellor, Health Affairs, Ministry of Social Affairs and Health, tel: +358 9 160 74030
Juhani Eskola, Deputy Director General, National Public Health Institute: tel: +358 9 4744 8670
Petri Ruutu, Research Professor, National Public Health Institute, tel: +358 9 4744 8670
Tapani Hovi, Research Professor, National Public Health Institute, tel: +358 9 4744 8321
Heli Siikamäki, Specialist Doctor, Hospital District of Helsinki and Uusimaa, tel: +358 50 427 1511