1. Progress Made on Preparedness for an Influenza Pandemic in Nepal

1.1 Country Preparedness

In February 2006 the Government of Nepal endorsed a joint Health and Agriculture National Avian Influenza and Influenza Pandemic Preparedness and Response Plan (NAIIPPRP). The plan created a joint health and agriculture Technical Subcommitte on Avian Influenza (TSCAI) under the National Disaster Relief Central Coordination Committee.
As the NAIIPRP is strategic in nature, a detailed Operational Plan for the period 2006-2010 was developed and endorsed by the TSCAI in August 2006. This USD18.2 million plan has a human health and an animal health component, as actual implementation will fall mainly under the two responsible line ministries: Ministry of Health and Population and Ministry of Agriculture and Cooperatives. Conversations for funding of the Plan are ongoing with the World Bank and a final appraisal mission is planned for October. This mission will lead to negotiations between GoN and WB. It is expected that the WB will provide full funding of the plan including resources for a compensation fund for indemnification to farmers if culling were necessary to control avian flu. The UN team, (WHO, FAO, UNICEF, UNDP and OCHA) and the WB played a pivotal role in ensuring the technical soundness of the different components of the Plan.
The Plan, that is expected to initiate in December 2006, beyond preparing the country for the advent of avian influenza or an influenza pandemic, will therefore have a significant effect on improving the performance of disease surveillance and control and improvement of both human health and animal health irrespective of the evolution of the avian influenza situation.
In August, the MOHP, Department of Health Services, with support from WHO, trained 50 Regional staff, belonging to the  Rapid Response Teams of the Public Health Network on Human Avian Influenza Outbreak Investigation. Trainers were WHO experts from Thailand and Delhi. WHO has also provided the MOHP with sufficient sets of Personal Protective Equipment and antivirals to respond to 30 outbreaks in each development region. Antivirals and PPE for the hospital management of suspected cases and if necessary for containment activities, have also been procured for the MOHP.  
USAID has provided funding to the MOAC through FAO for training of Animal Health workers on Avian Influenza Surveillance and Response. The training is due to start before the end of the year.  
Since January 2006 a WHO-supported project coordinated among National Public Health Laboratory, Epidemiology and Disease Control Division (MOHP)  and  the Army Forces Research Institute in Thailand, has made a generic influenza A/B rapid diagnosis test (RDT) available for hospitals in Kathmandu and Bharatpur. The latter is where the bulk of the poultry industry is located. Samples of cases are also referred for further influenza type-specific testing in Bangkok.
WHO in coordination with the MOHP and with support from USAID is initiating a pilot of severe pneumonia surveillance based on the Polio surveillance network and is expecting to have initiated the process in the whole network by the end of 2006.

UN System in Nepal Preparedness

Planning and Coordination

The SMT and UNCT have been the higher instance of coordination and Influenza Pandemic Preparedness has been discussed on several meetings. The following coordination groups have been established: Communications, Core Technical Group (EDP flu) , Health and Medical Task Force. Still pending is the Emergency Assistance and Preparedness group. The IAAG has met twice to discuss the administrative guidelines. The crisis management team for an Influenza Pandemic is still pending to be defined along with its roles and responsibilities. This should be a priority in the coming weeks. The UN System Contingency Plan as per the new guidelines is yet to be finalized and endorsed by the UNCT. An extraordinary UNCT meeting is  necessary for this purpose. Desk top exercises and mock drills should be performed in November-December.

Communications

A Comprehensive orientation training package for staff and dependents has been developed with introductory video, hands-on demonstrations and group discussion. 4 Training of Trainers sessions were held and 45 staff from all agencies were trained. This package has been reviewed and revised through  a pilot with UNFPA and UNICEF ROSA.  The revised training package will be used in planned sessions during September and October for UNDP, OCHA, DSS, UNICEF CO. Other agencies should plan training for the coming months. Six staff bulletins have been distributed in past year, bulletin number 7 is in process and will be distributed early next week.

Staff Safety and Security

The Pandemic Influenza contingency plan has been incorporated into the Nepal Security Plan. Security officers of some agencies under coordination by DSS have performed a Security Risk Assessment in case of an influenza pandemic and developed a matrix to guide security phases and actions. It needs to be reviewed to the light of pandemic scenarios and epidemiological assumptions.

Staff Health and Medical Services

The Action Plan has been developed with Budget and Timeline in line with H&MS Contingency Plan. Costed Drugs and Supplies Procurement, Storage & Distribution Plan has been developed (attached). How will the operational plan for the UN System in Nepal be funded is a matter to be discussed at the UNCT. Recruitment and Training of UN Staff Health Care Volunteers who will be the front line workers in response to medical care for the staff during a pandemic is ongoing. As recommended all staff and dependants should be vaccinated against  Seasonal Influenza again this winter. Vaccination days are being organized for  October, early November.

Ensuring Operational Continuity

All agencies have performed program criticality analysis and identified critical staff for operational continuity. Still pending is the consolidated analysis vis-à-vis the security plan. From the overall analysis each agency should have in writing their individual operational continuity plan.

Support to National Response

Most of the support provided to country is reflected in the country response described above. A matrix to identify potential individual agencies’ support to the country in a pandemic situation was circulated. Response was high and consolidated analysis will be incorporated in the contingency plan.

2. Avian Influenza Situation

2.1 World Status of Human Avian Influenza (HAI)

As of 8 September 2006, WHO has received reports of 244 confirmed human cases of Avian Influenza A (HAI-H5N1) occurring in eleven countries since November 2003, when the first case was reported in China. Of the 244 cases, 59% have died, ranging from 33% in Turkey to a 100% in Cambodia. In the course of 2006, 97 cases have been reported, equivalent to the total number of cases in 2005. In 2006 HAI emerged in Azerbaijan, Djibouti, Egypt, Iraq and Turkey and the epidemic continued in Cambodia, China, Indonesia and Thailand. Viet Nam is the sole country where the disease seems to have receded in 2006. In Indonesia and China the number of cases in 2006 as compared to 2005 has increased by 50% and 131% respectively. HAI is a disease in geographical expansion encompassed with outbreaks in poultry and other domestic birds.

The H5N1 virus has so far not suffered changes in its genetic characteristics that suggest it could become easily transmissible between humans, and human-to-human transmission has been established only in a limited number of instances where very close and sustained contact has taken place. The major source of infection continues to be infected poultry and the transmission rate from animals to humans remains low.    

2.2 Regional and Country Status of Avian Influenza

India reported poultry outbreaks from early February 2006 that continued to April when they were finally contained. In August, India declared itself “Avian Influenza Free” as it had met the conditions set by the OIE to regain this status. Also in September Myanmar declared itself free of the disease after a few outbreaks between March and April 2006. In spite of active case finding no HAI cases were detected in India or Myanmar.
Thailand reported a HAI case having occurred on 15 July, four months after having met conditions to be declared avian influenza free in March 2006. Investigations in the area confirmed that the disease was present in poultry and officially reported it to OIE on the 26 of July. Containment operations are still ongoing.
The most affected country in the region so far is Indonesia, having had 44 human cases and 36 deaths in 2006 and ongoing poultry outbreaks. The most recent cases reported, occurred during the first and second week of August. Containment operations are ongoing in backyard poultry in the West Java province. The situation in Indonesia has been further complicated by an outbreak of dengue affecting most of the country, misleading clinical diagnosis.     
In Nepal so far H5N1 has not been detected in poultry or humans. During 2006 incidents reported of poultry deaths in Kapilvastu, Sarlahi and Nwakot have been investigated by the Animal Health Directorate of Ministry of Agriculture and Cooperatives (MoAC) and Avian Influenza has been discarded.
Influenza A has been circulating in humans in Nepal throughout the year and outbreaks have been detected in the Eastern Region (Bhutanese Refugee Camps), the Central Region and in Bharatpur.