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The French pandemic influenza plan

Country: 
France
Partner Institute: 
Institut de Recherche et Documentation en Economie de la Sant (IRDES), Paris
Survey no: 
(14) 2009
Author(s): 
Chantal Cases, Zeynep Or
Health Policy Issues: 
Public Health, Prevention
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Abstract

Following the WHO alert for a risk of H1N1 pandemic, the French government has developed a national plan to prevent and control an influenza pandemic. The plan is an operational tool, based on standardized measures that the authorities can apply at different levels of the pandemic and has been implemented since the beginning of the A(H1N1)crisis in April 2009.

Purpose of health policy or idea

An influenza pandemic is characterized by the appearance of a new influenza virus against which the population's immunity is low or non-existent. The rapid spread of the new H1N1 influenza virus in many countries triggered fear of the emergence of a pandemic flu in France.

The aim of the national plan for the prevention and control of influenza pandemic is to support the public administrations and local authorities through a detailed strategy of action and organizational arrangements when dealing with a H1N1 pandemic. The plan provides the details of

  • how the pandemic monitoring system should be organised,
  • the way to trigger each level of alert;
  • how the health care system should treat infected persons,
  • measures to prevent the spread of the virus;
  • and tools of information and communication.

Different measures are proposed for implementation at different levels of the pandemic situation.

At the beginning emphasis was placed on understanding the evolution of the virus and developing devices for prevention and control to slow down the spread of the virus in France. Everybody suspected to suffer from A(H1N1) flu was asked to go to  hospital for treatment. Following the epidemic phase (in September), the objective is now to slow viral transmission and outpatient treatment is preferred, except in the case of complications.

Beyond the medical challenges, the plan also attempts to maintain the continuity of social and economic life, in order to minimize the damage that might be caused by the pandemic.

Main points

Main objectives

The plan aims mainly to protect the population in France against the threat of a pandemic influenza and to ensure the functioning of vital economic and social activities.

The plan consists of detailed measures for preventing a major flu pandemic, for detecting the appearance of a new influenza with the inter-human transmission capacity and curbing its spread, for ensuring optimal treatment of patients (during the pandemic alert phase), reducing morbidity and mortality, ensuring that the population has the best possible access to the means of prevention and care, ensuring the essential functions for the continuity of government action, security, and maintenance of economic activity (in the pandemic period). Some of the major measures are summarized below:

Vaccines and drugs orders: In July 2009, France ordered 94 million doses of vaccines from three laboratories: Sanofi Pasteur, GlaxoSmithKline (GSK) and Novartis. At the same date, the Prime Minister announced that 33 million doses of antiviral drugs were in stock, representing a coverage of 25% of the population, as well as more than 700 million individual protective masks for professionals in contact with patients and a billion suppression masks, which will be worn by patients to protect their environment. Health Minister Roselyne Bachelot appeared before the Committee on Social Affairs of the National Assembly in September and stressed "the very significant financial effort" made to fight the H1N1 influenza. The supplementary health expenditure is estimated to be around 1.5 billion euros, (808 million euros for vaccines and 240 million euros for compensating health professionals requisitioned through the vaccination campaign). This cost will mostly be covered by the State and the public health insurance fund; nevertheless in October private complementary health insurance organisations agreed to contribute to purchase of vaccines (they will pay approximately 280 million euros).

Treatment of infected persons: Untill the end of July, all of the suspected cases were supposed to be treated and isolated in dedicated hospital departments; antiviral drugs were systematically prescribed. As most of the cases appeared benign, and as their number was growing, the responsibility was passed to GPs, except for severe and complicated cases. Antiviral drugs are not anymore systematically recommended and GPs are now supposed to propose hygienic measures and isolation at home. It is up to GPs to decide if it is necessary to refer severe cases, in particular children under 1 year old, to the emergency care. The number of hospitals that can ensure an isolated ward for patients has been increased from 112 in the beginning of epidemic to 450 in October. Pharmacies are asked to deliver masks and antiviral drugs on prescription; they are reimbursed by the public health insurance fund.

Communication: Since April 30, the Ministry of Health and Sports and the National Institute of Prevention and Health Education (INPES) have started an information campaign  to promote hygienic measures to limit the transmission of the virus. Another information campaign began in late August (continues currently) and uses the media to improve hygienic habits of the population (regular hand washing, etc.).  

The Minister of Education has also distributed a four-page leaflet, printed in 12 million copies, providing information on how to minimize contamination of the virus to all primary and secondary school students. In case of an outbreak of influenza, local state authorities will be able to temporarily close the classes or schools. Against the possibility of a national closure of schools, the Ministry of Education has prepared some lessons that may be diffused via the Internet, television and radio. The Health Ministry addressed an information letter to physicians and a national website has been set up to provide information to healthcare professionals and the population.

Vaccination campaign: In October, after having received several advises on the vaccination strategy, among which a proposal by the experts of the high council for public health, the Prime Minister announced that health workers, pregnant women and vulnerable people (babies and people with chronic respiratory diseases) will have priority in a vaccination campaign. Local State authorities ("préfets") will establish departmental plans for vaccination for the general population over a period of 4 months (October-January). One issue to resolve is how to trace immunized individuals and monitor possible side effects. Immunization will be on a voluntary basis, as for seasonal influenza. Special vaccination centers will be set up in public places such as sports centers. Vaccination will be free: the cost will be covered by the State and public health insurance funds which will send vouchers to priority persons.

Emergency measures: In case of an outbreak, several drastic measures are proposed in the pandemic flu plan. Beyond school closures, emergency measures could be taken for food distribution. The concert halls, cinemas and restaurants could be closed by government decisions. The rail traffic could be restricted to give priority to the transport of essential goods (food and energy). Mail distribution could be limited or suspended during the peak of the epidemic. In business, priority missions have been defined and will be maintained. Most employers have already developed an action plan to insure a minimal activity and how to decide a closure to the public; some have distributed masks to their employees.

Type of incentives

Regulatory

 

Groups affected

General public, generalists, hospitals, health administration, health insurance funds

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Characteristics of this policy

Degree of Innovation traditional neutral innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent neutral system-neutral

Political and economic background

In France, the memory of previous sanitary crises, notably the 2003 heat wave and its severe consequences, had a strong impact on the feelings of people, the media and the response of health authorities.

Moreover in 2003, the persistence of a highly pathogenic avian flu virus, H5N1 has created awareness about the possibility and quick emergence of a flu epidemic.

Complies with

WTO/GATS

International Health Regulations , 2005

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes yes no no

Origins of health policy idea

The plan is part of an international strategy against pandemic influenza coordinated by the WHO. The first version of this plan was actually published in October 2004 after the outbreak of avian influenza and bird flu cases in different countries. The International Health Regulations (2005) developed by the WHO and have been in force since 15 June 2007, have been gradually integrated in the national plan.

Moreover, the work carried out under the aegis of a new Interministerial delegate to the fight against avian influenza "Influenza, the White Paper on defense and national security, lessons learned from a national exercise conducted in January 2008" led to update the National Plan for Prevention and Control of Pandemic Influenza. The current plan published in February 2009 is the fourth edition of this initial plan developed for avian flu.

 

 

 

Initiators of idea/main actors

  • Government: The President of the Republic and the Prime Minister lead the political and strategic response and initiated the plan.
  • Providers
  • Payers
  • Patients, Consumers

Approach of idea

The approach of the idea is described as:
renewed:

Stakeholder positions

Health professionals, especially GPs deplore the lack of information on their role and lack of support to deal with this new virus and stress the difficulty of finding an interlocutor when they need to  declare and/ treat grouped cases. They are also quite skeptical about the effectiveness of the new vaccine since there was not enough time for their development; more than half appeared to be reluctant to get vaccinated, fearing adverse effects (Ifop). But this might be a rather a reaction to a public policy asking them to take a major responsibility to fight against this new epidemic without any return.

 Some of the specialists argue that the measures proposed are excessive given the low risk of mortality from this virus. They point to the high cost of this plan.  

The population seems concerned but confident. However the results of the opinion polls on their intention to get vaccinated are far from being unanimous.

 The Media was very active at the beginning in diffusing information and calling attention to the risk presented by the epidemic. But they also denounce what they perceive as "excess" in governmental communication. Medias also echoed some fear for civil liberties as soon as the extreme emergency measures were known.

Actors and positions

Description of actors and their positions
Government
Prime Ministervery supportive strongly opposed
Providers
general practitionersvery supportiveopposed strongly opposed
Payers
Health insurence fundvery supportiveneutral strongly opposed
Patients, Consumers
Patient associationsvery supportiveneutral strongly opposed

Influences in policy making and legislation

There was practically no discussion at the Parlement.

Actors and influence

Description of actors and their influence

Government
Prime Ministervery strong none
Providers
general practitionersvery strongneutral none
Payers
Health insurence fundvery strongstrong none
Patients, Consumers
Patient associationsvery strongweak none
Patient associationsHealth insurence fundgeneral practitioners

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

See above.

Monitoring and evaluation

The French Institute for Public Health Surveillance (InVS) coordinates the monitoring of influenza in France, including A (H1N1). Data for outpatient care is provided by physicians' networks. For inpatient care, a network of emergency services is used. Virological surveillance is coordinated by two national reference centers of influenza virus. Until July 2009, individual cases of influenza were tested under the control of the reference centers. Since July, only patients presenting severe clinical conditions are tested, as well as a sample of patients consulting the physicians of one of the networks participating in monitoring. All of the hospitalized cases of H1N1 in 2009 are reported to InVS and monitored until recovery or death. InVS publishes weekly a newsletter summarizing the data from these surveillance systems and available on its website.

The epidemic threshold has been overrun in mid-September in metropolitan France (over 108 flu cases per 100 000 habitants).

The influenza A (H1N1) continues to spread, but the use of outpatient care for flu and acute respiratory infections is stable. At the beginning of October, the rate of consultations for flu was 156 case for 100 000 habitants. The impact of influenza A (H1N1) in 2009 on care utilization remains low. LnVS estimated about 40 000 consultations for influenza A (H1N1) in 2009.

By mid October, 244 cases and 8 deaths from influenza A (H1N1) had been confirmed in metropolitan France (another 25 deaths were recorded in overseas departments, in particular in Nouvelle Calédonie and Martinique).

Expected outcome

It is too early to assess the effectiveness of this plan for preventing and controlling the flu pandemic. For the moment, the plan appears somewhat excessive for a relatively benign virus, quite different from the avian flu against which the plan was conceived. Moreover the plan appears to be rather technocratic; without much consultation having taken place with the key stakeholders.

Nevertheless, it is important to be prepared and to have an action plan in case of a rapid expansion of the virus. There is no doubt that the Government would be in serious trouble if the situation would get worse and the country was not prepared.

Impact of this policy

Quality of Health Care Services marginal marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low low very high

The government has already spent more than 1.5 billion Euros on the vaccines and other medical materials (masks, etc.) and on the information campaign.

References

Sources of Information

www.pandemie-grippale.gouv.fr

www.invs.sante.fr/display/?doc=surveillance/grippe_dossier/index_h1n1.htm

www.invs.sante.fr/beh/actualite_epidemiologique/r-9.html: BEH web, N° 1 • 29 juin 2009"Influenza A(H1N1)v : Birth of a pandemic".

Author/s and/or contributors to this survey

Chantal Cases, Zeynep Or

Suggested citation for this online article

Cases, Chantal, and Zeynep Or. "The French pandemic influenza plan". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/fr/a14/1