David Nabarro

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RESPONDING TO AVIAN INFLUENZA AND PREPARING FOR
THE NEXT PANDEMIC INTERNATIONAL PERSPECTIVE

• David Nabarro
• March 14th 2007
• New Fields 4th International Bird Flu Summit

UN System Influenza Coordination
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Three Kinds of Influenza
Seasonal Influenza The Flu
Avian Influenza Bird Flu
Pandemic Influenza A Pandemic
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Pandemic of 1918-19
A/H1N1 Spanish influenza

• 3 epidemic waves in close succession
• March 1918, Sept 1918, Feb 1919
• Estimated 40 million deaths world-wide,

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Geographic spread 1918-19
06/18
?
04/18
03/18
06/18
05/18
?
01/19
06/18
C.W. Potter, Textbook of Influenza, 1998
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AVIAN INFLUENZA

• Birds frequently affected by influenza
• Current virus - H5N1 - is highly pathogenic
• 15 countries affected 2003 05
• More than 30 countries reporting H5N1 since
  January 2006
• Viral variability (2 clades and sub-clades)
• Incidence continues
• Settings where H5N1 remains endemic among poultry
  (includes Egypt, Indonesia, Nigeria)
• Settings in which H5N1 has been endemic and is
  reportedly under control (Vietnam, China,
  Thailand)
• Settings recently affected by outbreaks of H5N1
  (UK, Hungary, Japan, Republic of Korea, Sudan,
  Pakistan, Afghanistan, Russia, Laos, Kuwait,
  Turkey)
• Sporadic human cases (277) with over 50 dead

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HIGHLY PATHOGENIC AVIAN INFLUENZA
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HUMAN CASES OF (C) AND DEATHS (D) DUE TO
INFLUENZA TYPE A H5N1 VIRUS (Feb 2007)
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Threat of Human Influenza Pandemic
Inter-pandemic Period
Pandemic Alert Period
Pandemic Period
?
H5N1

• Circulating in wild birds and poultry since 2003
• Highly contagious / deadly among birds
• Spreading from Asia to Europe, Middle East and
  Africa

• Has infected humans in rare instances - resulting
  from close exposure to sick birds and/or their
  droppings

• If H5N1 evolves into a human virus it could cause
  a human influenza pandemic
• Also possibility that H5N1 never evolves into a
  human virus

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DETERMINANTS OF PANDEMIC INFLUENZA
A new influenza virus emerges to which the
general population has little/no immunity
The new virus must be able to replicate in humans
and cause disease
NOT TO DATE
The new virus must be efficiently transmitted
from one human to another
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What is the current threat level?
UN System Influenza Coordination
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THREE SCENARIOS
Scenario 3 - Rapid Onset / Widespread
impact Little time for preparation, rapid
containment vital, movement restrictions, social
distancing, emphasis on mitigation
Scenario 2 - Slow Onset / Localized Impact Slowly
acquires infectivity Containment may be
successful Limited pandemic
Impact
Scenario 1 - Extended Phase 3 / Avian Influenza
outbreaks continue Sporadic human cases Impact on
livelihoods due to culling of birds
Time
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AVIAN PANDEMIC INFLUENZA THREATS
Livelihoods

• Food and income loss from poultry deaths, culling
  decreased economic activity

• High illness potentially higher death rates
• Overstretched health facilities
• Disproportionate impact on vulnerable

Human Health

• Increased demand for governance security
• Higher public anxiety
• Reduced capacity due to illness death

Governance Security

• Deterioration of coping support mechanisms
• Interruption in public services
• Quarantine policies

Social Humanitarian Needs

• Trade commerce disruptions
• Degraded labour force
• Interruption of regular supply systems

Economic Systems
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IMPACT OF NEXT PANDEMIC

• High absenteeism in all sectors
• Significant economic effects
• Compare with SARS - lt1000 dead, 50 billion
  economic loss.
• Markets close, utilities become unreliable,
  telecoms break, cash in short supply
• Travel and leisure travel reduces, demand for
  food changes
• Threats to Rule of Law and Security
• Need for Humanitarian Response

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GLOBAL STRATEGY

• Promoting Bio-secure Livestock Systems (public
  and private action compensation for culled
  birds incentives for change
• Safeguarding human health (70 of new infectious
  disease outbreaks will be zoonoses)
  surveillance, outbreak detection, confirmation,
  containment, communication
• Mobilizing societies to act act for good
  hygiene and health . effective transmission of
  clear messages
• Limiting the social, economic, governance
  consequences of disease outbreaks planning,
  preparations, procedures and exercises

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National Responses to the Avian and Pandemic
Influenza Threat

• Sustained improvement in Animal Health through
  livestock bio-safety, detection of disease, and
  rapid response
• Stronger Human Public Health Systems for
  detection and limitation of human infections with
  a Highly Pathogenic Influenza Virus
• Mass Mobilization by Peoples Organizations based
  on effective risk communication
• Nationwide preparation for the next Influenza
  Pandemic
• One Government Response - synergy across
  government and with civil society, private sector
  and media partners
• Procedures that ensure continuity of access to
  basic services, of rule of law, of financial
  services and of societies
• Increased reserve capacity for large-scale Relief

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Reducing H5N1 incidence in Poultry

• Key role played by Poultry meat in human diet
  (consumption doubled in 10 years)
• Importance of poultry for poor peoples
  livelihoods
• Complexity of global and local poultry trade
• H5N1 carriage by wild birds and waterfowl, often
  asymptomatic
• Different sectors 1 (large commercial) to 4
  (backyards)
• Controversy about poultry vaccination against
  H5N1
• Insufficient investment in veterinary services
• Importance of community-based animal health
  programmes
• Challenge of responding to incidents movement
  restrictions, culling and compensation
• Restocking and Recovery

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Specific challenges for disadvantaged groups

• Community-level research reveals that
• women and children are most likely to be exposed
  to Avian Influenza risk
• disadvantaged people face particular risks from
  avian influenza control measures
• A task force of Government Representatives,
  International Organizations, NGOs and researchers
  has developed a checklist for attending to
  specific needs of disadvantaged groups
• August 2006

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The International Partnership on Avian and
Pandemic Influenza

• Global Political Process
• More than 80 countries including US, Australia,
  Japan, Canada, China, European Union, APEC
• A series of meetings at intervals (Washington Oct
  05, Beijing Jan 06, Vienna June 06, Mali Dec 06)
  
• Next New Delhi December 2007
• Global Stock-take Risks, Progress, Constraints
• Use of Funds, Funding Needs, Gaps monitored by
  UN and World Bank
• Long tem challenges of improving human security
  for livestock sector, public health sector,
  disaster preparedness
• International support needed up to 1
  billion/year

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EXTERNAL ASSISTANCE

• Supports national AHI programme and plan
• International Financing (Donors and World Bank)
• 1.9 billion pledged Beijing January 2006,
• 0.5 billion pledged December 2006
• Next review November 2007
• Need 0.5 - 1 billion per year
• Technical help from WHO, FAO, UNICEF, OiE
• Careful monitoring of spending and progress
• Private and voluntary sectors engaged

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Key International Bodies

• United Nations Security Council
• UN General Assembly
• UN Economic and Social Council
• International Partnership on Avian and Pandemic
  Influenza (launched by US Government Sept 05)
• Food and Agriculture Organization
• Crisis Management Centre
• Regional Centres (Bangkok, New Delhi, Bamako,
  Gaborone, Nairobi, Budapest, Buenos Aries)
• Monitoring and Risk Assessment
• World Organization for Animal Health (OiE)
• Standards for animal health
• Reporting systems
• Response strategies

UN System Influenza Coordination
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Specialized Agencies and Partners

• World Health Organization
• Pandemic Alert Phase
• Coordinating global response to Human cases of
  H5N1
• Protocols for rapid response and containment
• International Health Regulations
• Disease Surveillance
• Diagnosis and Treatment
• Vaccines and antivirals
• Regional Offices (New Delhi, Manila, Brazzaville,
  Copenhagen, Washington, Cairo)
• United Nations Funds and Programmes
• UNICEF Children and Communications,
• UNDP Coordination
• WFP Common Humanitarian Support Services
• OCHA Crisis Preparedness
• UNHCR Refugees
• International Labour Organization Workforce
• NGOs via Inter-agency Humanitarian Committee
  (IASC)

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DETERMINANTS OF SUCCESS

• Political leadership and functioning alliances
  with civil society and private sector,
• Resources and capacity to scale up, with
  effective systems for direction, management and
  coordination.
• Support for long term reduction in risks of
  animal and human disease
• Sharing of information and viral samples,
  effective communication of risks and responses,
  full community engagement.

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Elements of Pandemic Readiness

• High level of popular awareness and understanding
• All-of-Government approach
• Capacity for Early Detection, Investigation and
  Confirmation
• Containment Strategy based on pandemic severity
• Social distancing, personal protection, movement
  restriction, maintenance of essential
  infrastructure
• Systematic use of anti-viral therapy
  (oseltamivir)
• Rapid development and equitable distribution of
  effective vaccines
• Protocols developed to prioritize access and use
  stockpiles
• Civil soc, NGOs, local government, Private Sector
  synchronized
• Communications system
• Crisis plan to mitigate effects of pandemic on
  Economies, Governance, Basic Needs, Border
  Movements
• Humanitarian Relief Systems prepared
• Contingency Plan developed and Simulated

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Key issues for pandemic management

• Strategies for epidemiology, for surveillance?
• Modelling optimal containment strategies?
• Use of antiviral medicines in containment?
• Research into pre-pandemic vaccines?
• Prospect of developing rapid diagnostics?
• What kinds of mask, for whom?
• What are the consequences of closing schools?
• How to manage communications with the public?

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Coordination in Practice

• Meeting together
• Sharing Information with each other
• Agreeing to work together with one strategy
• Achieving Harmony (No discord)
• Working in Synergy (Better than the sum of the
  parts)
• Establishing Trust and Unity (working as one)

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Business Sectors involved in Pandemic Readiness

• 1 Livestock Production
• Growing, Processing, Marketing and Distribution
  of animal meat for human consumption
• 2 Human Health
• Medicines, Commodities, Equipment, R and D,
  Patient Care, Lab services
• 3 Financial Services
• Banking (cash and settlements), financial
  regulation, risk management and insurance
• 4 Utilities, Logistics, Personal Services
• Electricity, Water, Food, Telecoms, Logistics,
  Postal services, Transport, Retailing (Catering
  for the needs of the most vulnerable)
• 5 Leisure and Recreation
• Tourism and Travel, Airports, Sports
• 6 Government, Security, Military
• Public Services, Law and Order, Judiciary and
  Correction, Private Security, Human Rights
• 7 Media
• Broadcast, Print Podcast and Blog
• 8 Environmental hygiene
• Cleaning, Maintenance, Refuse management,
  wildlife conservation

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Questionnaire for care-givers
and children
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Questionnaire for poultry farmers
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Questionnaire for market workers
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Public Service Announcementsviewed by more than
120 million people
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billboard
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religious leaders support the campaign
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Engaging community members fully in the response
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The Links

• Diseases threaten our future (HIV, SARS, Ebola)
• Diseases do not respect borders
• Diseases appear without warning
• Animals are a key source
• Governments, voluntary sector and business
  community must be engaged

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Focus

• Personal Safety and Security
• Corporate Continuity
• Continued functioning of Government, Economy and
  Rule of Law
• Local, national and international levels

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Action

• Plan identify critical functions that must be
  maintained
• Prepare put in place key steps to ensure that
  they can be maintained
• Put to test simulate a major catastrophe (such
  as pandemic) to see if the preparation works
• Promote make sure that people know what they
  have to do (match message to audience)
• Proceed Make it happen

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Benefits All Round

• Continuity in the event of an influenza pandemic,
  a disease outbreak, a major catastrophe
• Anticipation of risks and threats faced
• Excellence in Management and Governance
• Good Human Resource practice

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"Unless we change direction, we are likely to end
up where we are headed."
But we do need to know which direction is likely
to be better !