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Overview of Influenza

Global H5N1 Epidemiology Status of Pandemic Preparedness 29 January 2007 Beijing Keiji Fukuda Global Influenza Programme. Overview of Influenza. Currently , people affected by 2 forms of influenza Seasonal human Occurs every year in the world Avian (H5N1) influenza

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Overview of Influenza

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  1. Global H5N1 EpidemiologyStatus of Pandemic Preparedness29 January 2007BeijingKeiji FukudaGlobal Influenza Programme

  2. Overview of Influenza • Currently, people affected by 2 forms of influenza • Seasonal human • Occurs every year in the world • Avian (H5N1) influenza • Primarily infection of birds • Occasionally infects people as zoonotic infection • Anticipated for future - pandemic influenza • 3 in 20th century • Timing of next uncertain • Could result from H5N1 or another animal influenza virus

  3. Spread of Avian H5N1 Influenza Among Birds

  4. H5N1 in Poultry or Wildbirds Since 2003

  5. H5N1 in Poultry or Wildbirds 1-23 Jan. 2007

  6. Since late 2006 • Continued disease in poultry in Asia and Africa • Asia • China, Indonesia, Japan, Republic of Korea, Thailand & Vietnam • Africa • Egypt, Nigeria • Infected wild birds in Hong Kong SAR

  7. Epidemiology of human H5N1 cases as of 23 Jan 2006

  8. WHO Lab-confirmed H5N1 Human Cases As of 28 Jan 2007

  9. WHO Lab-confirmed H5N1 Human Cases As of 28 Jan 2007

  10. Confirmed Human H5N1 Cases2003 – 28 Jan 2007 Latest maps: http://gamapserver.who.int/maplibrary/pgrms/avian_influenza.aspx

  11. Confirmed Human H5N1 Cases1- 28 Jan 2007

  12. Human H5N1 Cases by Month 2003 – 28 Jan 2007

  13. H5N1 Cases by Age Group (N=269)

  14. H5N1 Incidence Rates by Age Group Viet Nam & Indonesia Age specific human H5N1 incidence rates in Viet Nam (25 Nov 03 - 24 Nov 06), (n=91) Age specific human H5N1 incidence rates in Indonesia (25 Nov 03 - 24 Nov 06), (n=74) Paper to be published in the WHO Weekly Epidemiological Record on 9 Jan 2007: Update: Epidemiology of WHO-confirmed human cases of avian influenza A (H5N1) infection from 25 November 2003 to 24 November 2006

  15. H5N1 Case Characteristics • Male / Female : 1.0 (134/135) • Illness onset to hospitalisation: Median 4 days (n=201) • 2004: 5 days • 2005: 4 days • 2006: 5 days • Illness onset todeath : Median 9 days (n=159) • 2004: 11 days • 2005: 9 days • 2006: 9 days

  16. H5N1 Case Fatality • Case fatality: 61 % (n=269) • 2004: 74% (n=46) • 2005: 42% (n=104) • 2006: 70% (n=109) • Sex-specific Case Fatality • Higher in females (67%) than males (54%) [P=0.04] • 30 - 39 years: 81% vs 52% [P=0.02).

  17. Avian Influenza A/H5N1: Transmission • Exposure to poultry • Implicated ~80% of patients • Handling, butchering, plucking feathers, preparing • Ingestion of undercooked poultry (duck blood) • Environment • ? Contaminated surfaces, water (swimming), fertilizer • ? Aerosols of bird droppings; • Human to human • Observed associated with conditions of close, intimate contact • Inefficient • No sustained chains of transmission • Global • Combinations of movement of poultry, wild birds, other vehicles Ungchusack et al. NEJM 352:333, 2005; Liem et al. Emerg Infect Dis 11:210, 2005

  18. Ongoing Evolution of H5N1 Viruses • Sub-lineages continue to develop • Gentically & antigenically distinct • Sub-lineages in China • Strains isolated from humans • Continue to reflect strains in local poultry populations • Confusion over nomenclature • WHO International work group to clarify & standardize

  19. Global Challenges and Response

  20. Common Challenge for All Countries • Scientific & other inherent uncertainties • Political sustainability • Practicalities • Requirements • Time • Strengthening of existing capacities, capabilities & practices • Adoption of new concepts, capacities, practices, attitudes, relationships, technologies • Adequate financial resources

  21. Response Needs to Meet the Challenge • Acknowledgement of Problem • Global threats differ from local or regional ones • Global vision & strategy • National capacities • Public health oriented tools, relationships & practices • Technologies

  22. Engagement of Multiple Levels & Programmes At WHO

  23. WHO Strategic Action Plan Pandemic Influenza 1 Reduce Human Exposure to H5N1 virus Intensify Rapid Containment operations 2 Strengthen Early Warning system 3 4 Build Capacity to cope with pandemic Coordinate Global Scientific Research and Vaccine Development 5

  24. Strengthening Current Capabilities

  25. Enhancement of Global Influenza Surveillance Network (GISN) • One of the oldest WHO surveillance networks (estab. 1952) • Current Network: • Contributing local laboratories, hospitals • 116 National Influenza Centres in 87 countries • 4 WHO CC on Reference and Research on Influenza • 1 WHOCC on Influenza Ecology in Animals • Coordinated by Global Influenza Programme • Central, essential role in defence against influenza • For biannual selection of influenza vaccine strains • For global alert for viruses posing pandemic threat

  26. Global Influenza Surveillance NetworkOngoing Functions & New Developments • Additional critical activities • Updated protocols for laboratory methods • Production and provision of WHO diagnostic reagents • Training for laboratory scientists & technicians worldwide • Global pool of experts responding to urgent situations • Testing of viruses for antiviral resistance • Enhancements underway • Creation of complementary H5 Reference Network • Increase in Collaborating Centres • Newer approaches to handling of information

  27. Examples of New Public Health Tools New International Health Regulations

  28. EIDs continue to threaten mankind.. …and place sudden intense demands on national and international health systems ….on some occasions have brought systems to the point of collapse > 1100 events followed by WHO between January 2001 and May 2006

  29. … toward a Global Legal Framework, 1995 - 2005 Creation of EMC 1995 WHA 1995 Outbreak Verification List 1997 GOARN 2000 "Bureau des rumeurs" Kikwit, Zaïre International Coordination Group 1996 WHA 2001 Global Health Security GPHIN 1997-98 Anthrax BSE Ebola Meningitis EMS 2002 Yellow fever Smallpox Nipah Plague SARS IHR Regional Consultations 2004-05 Avian InfluenzaH5N1 Chikungunya Pandemic threat Marburg (Angola) XDR-TB IHR Inter-governmental Working Group2004-05 WHA 2006 Immediate voluntary implementation WHA 2005 Adoption of IHR(2005)

  30. The International Health Regulations • Public health concept & tool • To improve the identification & rapid reporting of globally important disease threats • Existing IHR revised at member state's request • Legally-binding global agreement • Adopted at 2005 World Health Assembly • Binding on WHO’s Member States & WHO • Full entry into force in June 2007 • Voluntarily adopted in 2006 for pandemic influenza • Implementation of infrastructure, procedures, education underway

  31. Example of New Strategies Global Pandemic Influenza Vaccine Action Plan

  32. Why a Global Plan? • In order to strengthen pandemic-influenza preparedness and response • Anticipated gap between vaccine demand and supply during an influenza pandemic • Request from WHA 58.5 to WHO secretariat to • seek solutions with international and national partners, including the private sector, • to reduce the potential global shortage of influenza vaccines for both epidemics and pandemics …..

  33. Essential Partnerships • Governments • Research community • Foundations • Pharmaceutical industry • WHO

  34. Major Approaches • Increase use of seasonal influenza vaccine • Increase production capacity for pandemic vaccines, independent of seasonal vaccine use • Research and develop new technologies

  35. Activities Underway • Mapping demand and supply of influenza vaccines • Consortium to improve H5N1 vaccines production yields • Review of technologies amenable to transfer to developing country manufacturers • Establishment of new capacity in developing countries • Development of adjuvanted vaccines, whole virus vaccines, intradermal administration etc

  36. Example of New Practices Adoption of Executive Board Resolution 26 January 2007 "Avian and pandemic influenza: developments, response and follow up, applications of the International Health Regulations (2005) and best practices for sharing influenza viruses and sequence data"

  37. Issues and Context • Modern emerging infectious disease threats cannot be handled by any single country • Protection requires effective action by others • Mutual global health security is the unifying concept • Key information essential for • Disease risk assessment & monitoring • Mobilizing adequate response • Diagnostics, Vaccines, antivirals • Clinical education ….

  38. Issues and Context • But very real balancing concerns • Inappropriate release & use of information • National sovereignty • Balancing urgent public health response & research practices • Inequity • One way flow of information & viruses from affected – often under resourced countries – is not acceptable

  39. EB Resolution 120/R.7 • Adopted by WHO Executive Board on 26 January 2007 • 34 countries • Addresses • Support global influenza surveillance • Establishment of mechanisms to ensure routine and timely sharing of biological materials related to novel influenza viruses ….. From both humans and animals ……… and routine placement of data on genetic sequences in publicly available data bases • Support WHO global pandemic influenza vaccine action plan

  40. EB Resolution • Addresses • Promotion of access to practical products, including pandemic influenza vaccines, resulting from research on influenza viruses …. • Appropriate action if WHO is notified by a Member State that the viruses provided by that Member States were misused for research or commercial purposes in a manner that violates best practice • Facilitation of broader and more equitable regional distribution of the production capacity for influenza vaccine …………

  41. EB Resolution • Addresses • Support to developing countries, including those sharing their viruses, for building capacity for surveillance, case-detection and reporting ……… • Cooperation with Member States to establish feasible and sustainable incentives ……… for sharing their viruses and genetic sequence information • Mobilization of additional support for Member States with vulnerable health systems …..

  42. EB Resolution • Addresses • Identification, recommendations and support for the appropriate implementation of possible options aimed at promoting the accessibility of pandemic-influenza vaccine and antiviral medicines to all, for example by …………….

  43. Conclusions • Balancing complementary generic approaches needed for all disease threats with disease specific actions • Use of reality of new global emerging infectious diseases to forge the new practices, relationships needed • Strengthen what exists while moving in new directions • Accepting ethical dimensions as a practical consideration

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