Global H5N1 EpidemiologyStatus of Pandemic

Preparedness

29 January 2007Beijing

Keiji FukudaGlobal Influenza Programme

Global H5N1 EpidemiologyStatus of Pandemic

Preparedness

29 January 2007Beijing

Keiji FukudaGlobal Influenza Programme

Overview of InfluenzaOverview 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

Spread of Avian H5N1 Influenza Among Birds

H5N1 in Poultry or Wildbirds Since 2003 H5N1 in Poultry or Wildbirds Since 2003

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

Since late 2006Since 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

Epidemiology of human H5N1 cases

as of 23 Jan 2006

Epidemiology of human H5N1 cases

as of 23 Jan 2006

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

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

YearCases

20034

200446

200597

2006116

20077

Total269

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

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

CountryCasesDeaths

Azerbaijan85

Cambodia66

China2214

Djibouti10

Egypt1911

Indonesia8062

Iraq32

Thailand2517

Turkey124

Viet Nam9342

Total269163

Confirmed Human H5N1 Cases2003 – 28 Jan 2007

Confirmed Human H5N1 Cases2003 – 28 Jan 2007

Latest maps: http://gamapserver.who.int/maplibrary/pgrms/avian_influenza.aspx

Confirmed Human H5N1 Cases1- 28 Jan 2007

Confirmed Human H5N1 Cases1- 28 Jan 2007

Human H5N1 Cases by Month 2003 – 28 Jan 2007

Human H5N1 Cases by Month 2003 – 28 Jan 2007

H5N1 Cases by Age Group (N=269)

H5N1 Incidence Rates by Age Group Viet Nam & Indonesia

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

H5N1 Case CharacteristicsH5N1 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 to death : Median 9 days (n=159)– 2004: 11 days– 2005: 9 days – 2006: 9 days

H5N1 Case FatalityH5N1 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).

Avian Influenza A/H5N1: Transmission 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

Ongoing Evolution of H5N1 VirusesOngoing 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

Global Challenges and Response

Common Challenge for All CountriesCommon 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

Response Needs to Meet the ChallengeResponse 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

Engagement of Multiple Levels & Programmes At WHO

Engagement of Multiple Levels & Programmes At WHO

GIP

Global Influenza Programme

Alert and Response Operations

WHO Mediterranean Centre for Vulnerability Reduction

General ManagementImmunization, Vaccines and Biologicals

Information Technology & Telecommunications

Food Safety, Zoonoses and Foodborne Diseases

International Health Regulations

Country & Regional OfficesCommunications

Dangerous Pathogens

Ethics

Director-General's Office

WHO Strategic Action Plan Pandemic Influenza

WHO Strategic Action Plan Pandemic Influenza

Strengthen Early Warning system

Reduce Human Exposure to H5N1 virus

Intensify Rapid Containment operations

Build Capacity to cope with pandemic

Coordinate Global Scientific Research and Vaccine Development5

4

3

2

1

Strengthening Current Capabilities

Enhancement of Global Influenza Surveillance Network (GISN)

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

Global Influenza Surveillance NetworkOngoing Functions & New Developments

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

Examples of New Public Health Tools

New International Health Regulations

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

> 1100 events followed by WHO between

January 2001 and May 2006

… toward a Global Legal Framework, 1995 - 2005… toward a Global Legal Framework, 1995 - 2005

WHA 1995WHA 1995Creation of EMC 1995

WHA 2001 Global Health

Security

WHA 2001 Global Health

Security

GOARN 2000

WHA 2005

Adoption of IHR(2005)

WHA 2005

Adoption of IHR(2005)

Outbreak Verification List 1997

IHR Inter-governmental

Working Group2004-05

WHA 2006

Immediate voluntary

implementation

WHA 2006

Immediate voluntary

implementation

IHR Regional

Consultations 2004-05

EbolaAnthraxSmallpox

Meningitis

SARS

Marburg (Angola)

Avian Influenza

H5N1

International Coordination Group 1996

Yellow feverNipah

ChikungunyaPandemic threat

"Bureau des rumeurs"

Kikwit, ZaïreGPHIN 1997-98

PlagueBSE

XDR-TB

EMS 2002

The International Health Regulations 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

Example of New Strategies

Global Pandemic Influenza Vaccine Action Plan

Why a Global Plan?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 …..

Essential PartnershipsEssential Partnerships

Governments

Research community

Foundations

Pharmaceutical industry

WHO

Major ApproachesMajor Approaches

I. Increase use of seasonal influenza vaccine

II. Increase production capacity for pandemic vaccines, independent of seasonal vaccine use

III. Research and develop new technologies

Activities UnderwayActivities 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

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"

Issues and ContextIssues 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 ….

Issues and ContextIssues 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

EB Resolution 120/R.7EB 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

EB Resolution 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 …………

EB Resolution 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 …..

EB Resolution 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 …………….

ConclusionsConclusions

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