Supporting Health Protection Planning:Supporting Health Protection Planning:The Health Protection Agency

d S i Fland Swine Flu

Professor Anthony KesselDirector of Public Health Strategy and Medical Director, HPA

The King’s Fund Board Leadership Programme for London14 July 201014 July 2010

Seminar outline

• Health Protection AgencyB k d i fl i d• Background: influenza virus and pandemic influenza

• Evolution of the swine flu pandemic• HPA roles/activities in the pandemicHPA roles/activities in the pandemic• Recent developments

Di i hi ki• Discussion: partnership working on infection disease planning and response

Role of the Health Protection Agencyg y

Established in 2004 as an independent government p gagency with responsibility for health protection

• Infections – surveillance andInfections surveillance and diagnosis

• Chemical and radiation threats• Emergency planning andEmergency planning and

preparedness for public health threats

• Local and regional services for gcommunicable disease control

R ibilitiR ibilitiResponsibilitiesResponsibilities• Advice to Government on

health protection• Delivery of services to theDelivery of services to the

NHS and other agencies • Impartial, authoritative

information and advice to the public professionals

• Rapid response to new threats and emergencies

• Improved knowledge base through research and development, education and trainingand training

Organisation: 2010Organisation: 2010Organisation: 2010Organisation: 2010

Centre for Infections (CfI)Centre for Emergency

Preparedness & Response Centre for Infections (CfI)Preparedness & Response (CEPR)

Aims and Roles• Infectious disease surveillance.

Aims and Roles• Specialist scientific and medical

• Specialist microbiology services.• WHO National and Global

Reference Laboratories.

advice on emergency planning and response including CBRN threats.

• Antimicrobial and antiviral drug testing

• Co-ordination of disease outbreaks.• Scientific advisory role to

Government on the risks posed by

testing.• Biopharmaceutical Manufacturing

Capabilities.• Culture collections infectious agents.

• Training courses.

• Culture collections.• Research partnerships – vaccines.• Specialist diagnostic services for

dangerous diseasesdangerous diseases.

Centre for Radiation, Chemical & Environmental

National Institute for Biological StandardsChemical & Environmental

Hazards (CRCE)Biological Standards

& Control (NIBSC)

Aims and Roles• Advance knowledge of protection from

i i i d i i i di ti

Aims and Roles• WHO International Laboratory for

Standardsionising and non-ionising radiations.• Offer laboratory and technical services.• Advisory role to Government and

intergovernmental organisations

Standards - Biological reference materials.

• Bioprocessing.• Batch release testing – safety andintergovernmental organisations.

• Chemical incident surveillance and response systems - natural disasters.

• National Poisons Information Service

Batch release testing safety and efficacy- Official Medicines Control Laboratory

• R&D.• National Poisons Information Service and the Compendium of Chemical Hazards.

• Training - WHO Global Training Network.

Local & Regional Regional Microbiology gServices (LaRS)

Aims and Roles Aims and Roles

Network (RMN)

• Frontline services.• Investigation and management of public

health incidents and outbreaks.L l di ill

• Specialist advice and support- outbreaks and incidents.

• Referred tests.• Local disease surveillance.• Syndromic surveillance.• Port health.• Alert systems

• Molecular diagnostic tests• Emergency response

- outbreaks and incidents.• Alert systems.• Emergency response training courses

and exercises for health care providers.

outbreaks and incidents.• Specialist identification or typing.

Various DepartmentsVarious Departments

8 Regional Laboratories9 Regional Offices28 Health Protection UnitsEmergency Response Department

8 Regional Laboratories9 Food, Water, and Environment testing

Laboratories37 HPA Collaborating Laboratories

The Division of Public Health Strategy coversThe Division of Public Health Strategy covers the following areas of work:

• Public Health Strategy• Clinical & Health Protection GovernanceClinical & Health Protection Governance• Knowledge Management• Professional Development• International Health• Chair of the Influenza and Respiratory Virus Programme Board

B ildi id i l i l it• Building epidemiological capacity• Health Protection Training (oversight of 28 public health

and medical microbiological trainees)g )• CBRN policy lead• Medical Director

FundingFunding62% of funding from the Department of Health (government grant in aid)

38% (£117m) of funding from non-grant in aid sources – contracts and services, products and royalties and research grants

Expenditure by division 2008/09

Distribution of staff between centres and divisions 2009/10

2008/09 Staff Profile

RelationshipsRelationshipspp

Public

Academic &Professional

bodiesCommerce

HPALocal

InternationalNational Health

Service

LocalRegionalNational

Local Authorities& Government&

Government Offices

in the Regions

GovernmentDepartments& Agencies

Influenza A =a zoonotic diseasea zoonotic disease

Naturally present in a range of animalsNaturally present in a range of animals

Cross species reassortmentCross species reassortment

Courtesy of the CDC

Influenza:h t i ihuman transmission

Pandemic InfluenzaPandemic Influenza

PAN (all, παν )PAN (all, παν )

+

DEMOS (people, δήμος )DEMOS (people, δήμος )

= an epidemic that affects all people

Circulating influenza strains in humans d d i i 20th 21st C t iand pandemics in 20th – 21st Centuries

1918: “Spanish Flu”

40-50 million d th

1957: “Asian Flu”

1 million

1968: “Hong Kong Flu”

1 million deaths P d i

H3N2

deaths 1 million

deaths

1 million deaths Pandemic(H1N1) 2009

H1N1 H1N1H2N2

1920 1940 1960 1980 2000 20101976: “Swine flu” (US scare)1977: “Russian Flu”

Shortest interval = 11 yearsLongest interval = 41 years

1918-1919 Pandemic: A(H1N1)influenza deaths, England and Wales

18,000

12 000

14,000

16,000

nd W

ales

8,000

10,000

12,000

Eng

land

a

4,000

6,000

8,000

Dea

ths,

0

2,000

7 9 1 3 5 7 9 41 43 45 47 49 51

2 4 6 8 10 12 14 16 1827 29 3 33 3 3 3 4 4 4 4 4 5 1 1 1 1 1

1918 1919Week number and year

1957-1958 pandemic: A(H2N2)p ( )influenza deaths, England and Wales

1,000

800

d W

ales

400

600

Engl

and

and

200

Dea

ths,

E

0

6 13 20 273 10 17 24 31 7 14 21 28 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25 1 8 15 22

July August September October November December January February

Week number and monthWeek number and month

Courtesy of the Health Protection Agency, UK

1968-1969 pandemic: A(H3N2)p ( )GP consultations, England and Wales

1,400

Seasonal

1,000

1,200

ns p

er w

eek influenza

600

800

cons

ulta

tion

Initialappearance

200

400

GP

'ILI'

c

0

42 48 4 12 20 28 36 44 50 8 16 24 32 40 48 4 12 20 28 36

1967 1968 1969 1970

Week number and year

Courtesy of the Health Protection Agency, UK

Pandemic (H1N1) 2009( )

Pandemic (H1N1) 2009:timeline

( )

• 12 April: outbreak of influenza-like illness in La Gloria, Veracruz Mexico

• 15-17 April: two cases of the new A(H1N1) virus infection identified in two southern California counties, USA

• 23 April: novel influenza A (H1N1) virus infection confirmed in23 April: novel influenza A (H1N1) virus infection confirmed in several patients in Mexico

• 24 April: WHO declares a public health event of international concern• 27 April: WHO declares pandemic phase 4 - sustained community

transmission in Mexico, cases confirmed in UK and Spain

• 29 April: WHO declares pandemic phase 5 (2 countries affected)• 29 April: WHO declares pandemic phase 5 (2 countries affected)• 11 June: WHO declares pandemic phase 6 (spread to more than 2

WHO regions)

• In 9 weeks, all WHO regions report cases of pandemic (H1N1) 2009

Pandemic (H1N1) 2009:what were the early challenges?

( )

• Recognition of the first human cases in the UK: di i d fi tidiagnosis and confirmation

• Monitoring the first cases and contacts very closely• Public health interventions: schools planes• Public health interventions: schools, planes• Hygiene and social distancing messages• Antivirals - systems for distribution• Antivirals - systems for distribution• Managing social disruption • Vaccine availabilityVaccine availability• Advising Government …

ill tPandemic (H1N1) 2009:

surveillance systemsGeneric surveillance systems• National laboratory reporting scheme• RCGP Weekly Returns Service• NHS Direct syndromic surveillance• Mortality monitoring• Hospital admissions

S l i fl ill tSeasonal influenza surveillance systems• QFLU (as a component of Q-Surveillance)• HPA spotter practice scheme

HPA A ti i l R i t M it i d Vi l S i f I fl• HPA Antiviral Resistance Monitoring and Viral Sequencing of Influenza • Medical Officers of Schools Association

Pandemic Preparedness SystemsPandemic Preparedness Systems• National Pandemic Flu Service• Enhanced surveillance of pandemic (H1N1) 2009• First Few Hundred (FF100)• First Few Hundred (FF100)• Flu Clinical Information Network (Flu-CIN) • Hospitalisation study

Policy decision making in emergencies

• Civil Contingencies Secretariat (CCC)– CCC (O) and CCC (M)

• Government takes (public) health advice from a variety of sources– Chief Medical Officer (DH)– SAGE– HPA– Other key bodies e.g. JCVI

Pandemic (H1N1) 2009:( )once established, what were the ongoing challenges?

GP swab kitsFlu Response Centres

school closure

Pandemic (H1N1) 2009:UK Strategy

C t i t Ph ( b d ill ) 27 A il

( )

Containment Phase (case based surveillance) 27 April• Meeting aircraft from Mexico, information for travellers• Identification of cases - treatment

Identification of close contacts prophylaxis• Identification of close contacts - prophylaxis• Closing of affected schools for 7 days

Outbreak management (case based surveillance) 19 JuneOutbreak management (case based surveillance) 19 June• No case finding at ports of entry• Flexible approach to schools - local risk assessment• Clinical diagnosis for contacts of confirmed cases• Clinical diagnosis for contacts of confirmed cases• Widespread community transmission areas

Treatment Phase (routine winter surveillance) 2 July• Clinical diagnosis, not laboratory testing• Treatment available for all (especially risk groups)• No contact tracing• No prophylaxis, except for risk groups• Move from daily reporting of laboratory confirmed cases to general

estimates of disease spread

situation could be a lot worsePandemic (H1N1) 2009:situation could be a lot worse

A pandemic emerging in SE Asia Pandemic strain emerging in the Americas emerging in SE Asia Pandemic strain emerging in the Americas

Delayed virus sharing Immediate virus sharing, enabling rapid

diagnostic and vaccine production could begindiagnostic and vaccine production could beginBased on a more pathogenic strain, e.g. A(H5N1)

Based on A(H1N1) currently not very virulent

No residual immunity Residual immunity in a major large risk group

Heightened pathogenicity No known pathogenicity markers

Inbuilt antiviral resistance Susceptible to oseltamivir

l d l Good data and information from North America

Minimal data until transmission reached Europe

Good data and information from North America

Arriving in the late autumn or winter Arriving in spring/summer

Contrast with what might have happened — and might still happen!

Severe presentation immediately

Mild presentation, initially

Discussion: working collaboratively g yon infectious diseases

• Pandemic Flu : planning arrangements: update of national plan: operational responsep p

Q: What could work better?

• Surveillance for infectious diseases e.g. other respiratory viruses, HIV, HCAIs

Q: What could work better?

Response to infectious diseases e g Godstone Farm• Response to infectious diseases e.g. Godstone Farm

Q: What could work better?

Contact: anthony.kessel@hpa.org.uk