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| Journal of the New Zealand Medical Association,
25-July-2008, Vol 121 No 1278
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Border control measures in the influenza pandemic
plans of six South Pacific nations: a critical review
Melissa McLeod, Heath Kelly, Nick Wilson, Michael G
Baker
IntroductionWith the threat of an influenza pandemic, which may be
related to the current H5N1 avian influenza epizootic (http://www.who.int/csr/disease/avian_influenza)
the World Health Organization (WHO) recommends the development of national
pandemic preparedness plans by each member state. WHO has developed a checklist
and identified pandemic phases to assist with this
process.1,2 In addition, the International
Health Regulations (IHR) came into force on 15 June
2007.3
The IHR 2005 includes detailed obligations for member states
covering public health surveillance, response, management of borders and
national public health emergency planning (http://www.who.int/csr/ihr/en/). The
IHR have important implications for pandemic preparedness. They specify
“Human influenza caused by a new subtype” as a condition that member
states are required to notify to the WHO within 24 hours of detection.
Border control may potentially be an important part of a
country’s pandemic response plan, especially for smaller island countries
that are more able to control entry points and may have relatively low traveller
numbers. Previous modelling work has been fairly dismissive of the potential for
border control measures such as entry screening to prevent or delay the entry of
pandemic influenza in settings such as the United
Kingdom.4 Others have suggested that border
control in the form of extreme restrictions on air travel would be needed to
delay pandemic spread between
countries.5–7 However, we have identified
no modelling work that relates specifically to the border control for pandemic
influenza in small island nations.
On the other hand there are historical precedents for the
success of border control in island nations during the 1918–19 pandemic.
Strict maritime quarantine, with facility quarantine on land, appeared to reduce
the impact of the 1918–19 pandemic in some Pacific island
jurisdictions.8 Quarantine or “protective
sequestration” also appears to have protected some remote Canadian
towns,9 parts of
Iceland,10 as well as various communities in
the continental US and Alaska.11–13
There is also historical evidence that social distancing
measures (including isolation and quarantine) were partly effective in reducing
the impact of pandemic influenza during 1918/1919 in the US
cities14–16 and in
Australia.17 More generally, a systematic
review has also reported evidence that interventions that included quarantine (2
studies) and isolation measures (10 studies) provide some evidence for
effectiveness in containing the spread of respiratory virus
epidemics.18
Previous reviews have focused on the availability and
quality of pandemic plans, and also prioritisation strategies for anti-viral and
vaccine rationing.19,20 There has been no
review of pandemic plans that has focussed specifically on border control, or
proposed a framework for evaluating border control strategies. This study aimed
to evaluate the strengths and weaknesses of the border control strategies
included in the publicly available pandemic preparedness plans for the South
Pacific Islands, New Zealand, and Australia, using a checklist developed
specifically for this review.
MethodsTwo authors (MM, HK) independently developed a
checklist of important criteria related to border control based on:
Differences in the initial checklists were
reviewed, with the final checklist based on agreement of all
investigators.
Checklist for border control strategies in the pandemic planEach pandemic plan was evaluated against the following
checklist of 10 items.
Travel warnings—These involve
communication with the public, warning against travel to pandemic-affected
countries. Such warnings are considered likely to reduce the numbers of
returning infected residents by discouraging travel from the home country. The
pandemic plans should identify when and who will issue travel warnings, and
whether warnings will be extended should the pandemic progress.
Travel restrictions—Travel
restrictions include restricting the travel of departing residents as well as
restricting inbound travel. Modelling evidence indicates that restrictions need
to be almost complete to significantly delay the arrival of influenza. However,
travel restrictions of lesser volumes may reduce the burden on entry screening
and any subsequent quarantine. Travel restrictions may still permit the return
of citizens, or specifically focus on restricting or forbidding the entry of
travellers from countries where human-to-human transmission of pandemic
influenza has been established.
Entry screening—Entry screening
measures are important to identify travellers potentially infected with pandemic
influenza. A highly detailed pandemic plan will include the methods and timing
of entry screening, as well as a detailed pathway for investigation of suspected
cases. This pathway should include an arrangement for medical examination at the
airport, the identification of isolation facilities (criterion 5) and a strategy
for laboratory testing (criterion 9). Entry screening of all air and sea craft
also requires a health declaration that no symptomatic individuals are on board,
before passengers on the aircraft or ship are allowed to disembark. Exit
screening is not included here as it is not generally possible for countries to
manage this process within the scope of their domestic pandemic planning.
Quarantine strategy—Historical
and modelling evidence suggests that border quarantine must be implemented
early, prior to the arrival of infected cases in a country. Successful
quarantine must be complemented by clear legislation providing a legal mandate,
and facilities for quarantine, which may be voluntary or involuntary, at home or
in designated facilities.
Isolation strategy—Successful
isolation strategies require facilities that are operated by a critical mass of
health workers, with high standard infection control practices.
Contact tracing—Quarantine will
also require a contact tracing strategy. This involves the identification of
individuals who may be infected as a result of “close contact” (a
definition of close contact should be provided) with an infected person. As a
border control measure, this strategy relates to the management of passengers on
air and sea craft, where an infected individual has been identified.
Anti-viral strategy—The use of
anti-viral medication is likely to improve existing border control strategies.
Pandemic plans should acknowledge the worldwide shortage of anti-viral
medication, and have developed a protocol to prioritise available doses from the
national stockpile (including to health and other staff involved in border
control).
National stockpile—To prepare
for a pandemic a national stockpile should be arranged which could include
anti-virals, antibiotics, and personal protective equipment such as masks.
Laboratory testing strategy—An
effective laboratory testing strategy
includes consideration of the type of laboratory test to be used
for suspected cases, as well as the identification of national and international
reference laboratory facilities for confirmation. Ideally there should be plans
to stockpile relevant test kits (when available) as the appropriate use of these
could reduce the burden on any quarantine facilities.
Intersectoral
approach—This requires the
identification of key stakeholders for each action identified above. Clear
responsibilities among key agencies should be identified in advance.
Criteria that were not
included—Several other elements that are likely to be important
for the success of border control were not included in these criteria. Most were
not detailed in any of the pandemic plan documentation. These criteria were:
Identification and scoring of publicly available pandemic plansSearches of the Secretariat for the Pacific Community
(SPC) (http://www.spc.int/phs
/pphsn/ Outbreak/Influenza/Pand-Preparedness-plans-Pacific-countries.htm)
and WHO websites (http://www.who.int/csr/
disease/influenza/nationalpandemic/en/) were performed to identify and
obtain all publicly available pandemic plans for the South Pacific Islands
(members of the Secretariat of the Pacific Community), New Zealand, and
Australia.
The WHO website aims to maintain a current list of
published pandemic plans. Further searches of Medline, Google, and Google
Scholar revealed no other published plans and no other published plans were
identified by WHO colleagues in the Pacific Islands Office in Suva, Fiji or
colleagues from SPC in Noumea, New Caledonia.
The plans were then tabulated against the checklist of
border control criteria, and ranked according to the level of detail included in
the plan. The ranking was on a scale between 0 and 3 as listed below:
ResultsPandemic plan identificationSix pandemic plans were identified for the South Pacific
Islands, New Zealand, and Australia. To provide the context within which the
pandemic plans have been prepared, it is important to consider the relative size
of the country’s population, and available resources (GDP per capita). The
country’s level of economic development will impact both the ability to
plan and the ability to implement any plan. Nauru has the smallest population,
for which a pandemic plan was identified, and has the lowest GDP per capita
(Table 1). In contrast, New Zealand and Australia are much larger and more
developed countries.
Table
1. Population size and GDP of the countries in the South Pacific that have
influenza pandemic plans available for review
Source: Data from Wikipedia available at http://en.wikipedia.org
Comparison of level of detail in pandemic plansThe highest level of detail was seen in the New Zealand
Influenza Pandemic Action Plan (29 out of the 30 criteria met). The least
detailed plans were from Tonga and Palau, both with 9/30 (Table 2).
Table 2. Comparison of border control
strategies across pandemic plans (see Methods for the grading system
used)
 The Australian plan for pandemic influenza outlines border
management strategies under section 3.3; Slowing the spread of a pandemic in
Australia.24 The Australian plan contains
a reasonable level of detail on the measures of travel restrictions, travel
warnings, entry screening, and quarantine.
Travel restrictions will be placed
upon affected countries, with priority given to Australian residents returning
home. In phase 6 (pandemic established in many regions of the world), all
non-essential travel to Australia will cease. The Department of Foreign Affairs
and Trade (DFAT) is responsible for issuing travel warnings to affected areas
from phase 3.
The quarantine of travellers from affected areas, and any
close contacts, will be either home-based (with daily reporting) or in a
designated facility for up to 1 week. Contact tracing includes the
identification of household members for those on home quarantine, and others who
have travelled with an infected person. Entry screening will include both health
declaration cards and thermal scanning of arriving passengers. A clear pathway
of assessment includes nurse assessment at the airport, and transportation to
health facilities for suspected cases.
The Australian Government has a stockpile of anti-viral
medication with 3.8 million courses of the anti-viral oseltamivir, at October
2006. Smaller quantities of zanamivir have also been stockpiled. The Australian
plan did not include a prioritisation protocol for the usage of vaccines and
anti-virals.
The Nauru plan is a 13-page document, which
includes border control strategies.22 The
strengths of this plan include the arrangements for quarantine and travel
restrictions. From phase 6, passengers from affected countries will be denied
access to Nauru. All vessels entering Nauru will be required to undergo a
quarantine of up to 1 week, which will continue until cases are identified
in Nauru. Nauru has a stockpile of 200 doses of anti-viral medication, with a
prioritisation strategy for their distribution.
Less detail is available on laboratory testing and the
implementation of an intersectoral approach. The plan identifies sectors
involved, but fails to delegate tasks to specific agencies and individuals,
although this omission is probably not such an important one given the small
population of this island nation. Nauru does not include border screening in
this pandemic plan and identifies travel warnings as the responsibility of the
WHO.
The New Caledonian plan is only available in the public
domain in the French language.21 For this
review, a translated version of the border control strategy was provided to us
by Dr Martine Noel, New Caledonia Department of Health. The border control
aspects of the New Caledonian plan are likely to be underestimated, as a copy of
the full plan in English was not available. In particular, the border control
strategy that was available for review lacked an intersectoral approach and
details on this and laboratory testing may have been included elsewhere in the
plan.
The border control strategy is presented as a flow diagram,
with a clear pathway through entry screening, testing, isolation, and contact
tracing. Key elements of the pandemic plan for New Caledonia include: entry
screening with health declaration cards, thermal scanning and visual inspection
by staff; advice against travel to affected areas from phase 4; closure of
borders to passengers in phase 6, and the quarantine of close contacts, with
home surveillance. There is a lack of detail on the location of quarantine for
non-residents and the length of quarantine required.
The New Zealand plan was the most detailed of the identified
plans.25 The border control strategies are
included in a 10-page appendix, with separate appendices covering laboratory
testing, anti-viral medication, and isolation facilities and precautions. A real
strength of this plan is the involvement of other sectors.
The Ministry of Health is the lead agency, but specific
tasks have been delegated to the other agencies. Key elements of the border
control strategy for New Zealand include the use of travel advisories and travel
restrictions from affected countries from phase four; the quarantine of all
arriving passengers from affected areas beginning in phase five, either at home
or in designated quarantine facilities; and entry screening with health
declaration cards. This plan also includes a clear laboratory testing strategy.
The pandemic plans for Tonga and Palau contain similar
levels of detail. Both plans are vague about the implementation of border
control strategies. The plan for Palau indicates an
intention to discourage or disallow travel from affected
areas.23 Other strategies mentioned in this
plan include travel advisories, isolation and quarantine, but with little detail
on their implementation. The Palau plan involves the health sector, with some
higher government engagement but little involvement from other sectors. Both the
testing strategy and anti-viral prioritisation plans are yet to be developed.
The Tongan plan identifies areas which require consideration
prior to a pandemic, but contains little detail for most of the border control
strategies.26 The plan identifies the need for
further work on establishing a legal framework, and to develop a prioritisation
strategy for anti-viral medication. Poorly detailed border control strategies
mentioned in the Tongan plan include entry screening, travel warnings, and
quarantine. Although intersectoral agencies have been identified in the Tongan
plan, there remain a number of unallocated action points. WHO is expected to
guide any decisions on travel restrictions.
DiscussionThis review revealed considerable variation in the level of
detail of the border control aspects of the pandemic plans across the South
Pacific Islands, New Zealand, and Australia. The plans ranged from those which
provided a strategic framework against which a pandemic response will be
developed, to those which can be used as an operational guide. The most detailed
plans were from the larger and more developed countries, New Zealand, and
Australia. This finding is consistent with a previous survey of national
pandemic plans from the Asia-Pacific
region.20
The New Zealand Influenza Pandemic Action Plan is of high
quality when compared with the other national pandemic plans. It has been
repeatedly tested with exercises, the most recently being one in early 2007.
Despite this, there are areas in this plan that probably require further
development. For example, the plan does not adequately cover the prioritisation
and ethical issues related to rationing of limited supplies of anti-virals and
antibiotics (similar issues would apply for use of a pandemic strain vaccine).
A document on ethical issues is referred to in the New
Zealand plan—but ideally there needs to be a well understood and explicit
protocol that describes priorities for use of anti-viral medication and other
limited supplies. There is also no evidence that the plan has been externally
peer reviewed or that it has bipartisan political support. This is desirable to
facilitate key decisions around issues such as border control, which may have
large economic impacts on key sectors such as tourism.
For lesser resourced islands, a small number of carefully
planned strategies at the border are likely to be more effective than a poorly
planned but broad approach. This point was dramatically illustrated during the
1918–19 pandemic. American Samoa implemented strict maritime quarantine
and had no deaths attributable to pandemic influenza. In contrast, neighbouring
Samoa (then Western Samoa) had no border control measures implemented by the
governing New Zealand authorities and suffered the loss of around 22% of the
population.31
The timing and responsibility for releasing travel alerts
and travel restrictions varied between the pandemic plans. The New Zealand plan
covered the issues of travel warnings to affected areas from phase 4 and
Australia planned to issue the same warnings from phase 3. Nauru identified the
issuing of travel advisories as a responsibility of the WHO. Tonga plans to
issue its own travel advisories, but believed the WHO will issue the necessary
travel restrictions. A limitation of all of the pandemic plans included in this
study was the dependence upon the earlier phases to develop and implement a
systematic response. This approach does not account for a pandemic which may
develop rapidly or unpredictably.
The prioritisation of pharmaceutical interventions for
pandemic influenza is an important part of any border control plan. Rationing of
anti-viral medication and vaccines is likely to be required due to manufacturing
limitations and cost.19 From the six pandemic
plans included in this study, only Nauru included a prioritisation plan for the
distribution of anti-viral medication. This sub-optimal situation was also
identified in a review of 45 national pandemic plans, where only 49% included a
prioritisation strategy for anti-virals and 62% a strategy for vaccine
rationing.19
Quarantine was included as a strategy in all of the pandemic
plans, with considerable variation in the proposed implementation. The timing of
quarantine measures is vitally important in the success of this strategy, yet
despite this implementation varied from phase 4 to phase 6 in these plans. The
length of quarantine also influences the effectiveness of this measure, the
range of quarantine lengths in the pandemic plans varied from 3 to 8 days.
Home-based quarantine was identified in all of the detailed plans, however the
definition of a “close contact” varied in its inclusion of
subsequent household contacts. The New Caledonian plan failed to indicate where
non-residents requiring quarantine would be placed.
The checklist of important border control elements in this
review was limited to those identified in pandemic plans, and therefore did not
consider other important elements that are necessary for the practical
implementation of the plan. As noted in the Methods above, these
elements include adequately trained staff, facilities, a process of regularly
testing and refining the plan, a communications strategy, and consideration of
wider governance issues. There was also no consideration of the quality of other
components of the pandemic plan.
The six plans included in this study were those available in
the public domain. Although pandemic plans have been developed for most of the
South Pacific Islands, these have not yet been included on the SPC website (T
Kiedrzynski, SPC, personal communication, 20 April 2007).
There are several limitations associated with using the
level of detail in the pandemic plans as a proxy for the quality of the border
control plan. Pandemic plans with high levels of detail scored well regardless
of the effectiveness of the proposed strategies. For example, four of the six
islands included entry screening in their pandemic plans despite evidence that
the use of entry for the control of influenza is limited by the poor sensitivity
of available screening tools, and the inability to detect asymptomatic
individuals.4
In the larger countries (Australia and New Zealand),
regional and state adaptations of the national pandemic plans may provide more
operational detail. Therefore a broad and less detailed national plan may not
necessarily reflect the quality of the nation’s overall strategy.
The subjective scoring system used in this review required
some thought in interpretation. In particular, pandemic plans which mentioned a
border control strategy but provided no detail scored more than a plan which did
not mention the strategy at all. However, the intentional decision to not
mention a particular border control strategy may in fact be more appropriate
than mentioning a strategy that is poorly resourced and with no preparations
made for its implementation.
The opportunity remains for South Pacific Islands to
increase the detail of their influenza pandemic plans, and to revise and test
these plans periodically. Specific recommendations to the
Regional Health Agencies and donor nations with links to the South Pacific are
outlined below:
The analysis contained
in this paper should be repeated in the future. Potential refinements would
include: expanding the criteria to include additional important features;
collecting information on important criteria that are not necessarily recorded
in the plan itself; applying the criteria to a wider set of plans (when these
become publicly available); and carrying out this process in a more interactive
manner with the countries involved as a way of improving the quality of their
pandemic planning.
Competing interests: None known.
Author information: Melissa McLeod, Public
Health Medicine Registrar, Department of Public Health, University of Otago,
Wellington; Heath Kelly, Head of Epidemiology Division, Victorian Infectious
Diseases Reference Laboratory, Melbourne, Australia; Nick Wilson, Senior
Lecturer, Department of Public Health, University of Otago, Wellington; Michael
G Baker, Associate Professor, Department of Public Health, University of Otago,
Wellington
Acknowledgements: We thank the
Centers for Disease Control and Prevention (USA) for contributing to funding our
research work on pandemic influenza control, of which this work is a related
component (via grant: 1 U01 CI000445-01).
Correspondence: Dr Melissa McLeod,
Department of Public Health, Wellington School of Medicine & Health
Sciences, PO Box 7343 Wellington South, New Zealand. Email: Melissa.McLeod@otago.ac.nz
References:
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