S
HEALTH in
uth-East Asia A SEARO Newsletter | November 2009 Vol. 2 No. 2
This Issue: Pandemic (H1N1) 2009
Message from the Regional Director On 12 April 2009, Mexico reported to WHO an outbreak of influenza-like illness in a small community in La Gloria, Veracruz. The following week the Mexico Ministry of Health received notification of clusters of rapidly progressive severe pneumonia occurring in Distrito Federal (metropolitan Mexico City) and San Luis Potosi. In the same week (1517 April) the first two cases of a novel influenza virus infection were identified in two southern California counties in the United States. On 23 April, Mexico confirmed cases of infection with the same virus and reported sustained human-to-human transmission of the novel H1N1 influenza A virus to the World Health Organization. Given the risk of a pandemic and the unique genetic and antigenic characteristics of this influenza A (H1N1) variant of animal origin, WHO, in accordance with established procedures as defined by the revised International Health Regulations (IHR 2005), convened a meeting of the Emergency Committee comprising international experts to assess the situation and recommend actions to be taken. On 27 April, the WHO Director-General announced the first public health emergency of international concern (PHEIC) based on the Emergency committee’s recommendation and raised the pandemic alert level from phase 3 to phase 4. Two days later, the alert level was further raised to phase 5 after it became clear that a pandemic was imminent. The declaration of a PHEIC would test the applicability of the revised International Health Regulations, as well as the ability of WHO to coordinate a worldwide response to the pandemic to balance the interests of travel and trade with those of public health. The virus spread much faster than expected; within a week, 10 countries had reported infections with the novel virus, and after two weeks 24 countries had reported confirmed cases. By the time pandemic phase 6 was declared on 11 June 2009, 74 countries had reported cases of infection. At the end of August the virus had spread to over 180 countries worldwide. No previous pandemic had been detected so early or monitored so closely in real time. As soon as the first reports of a novel virus reached the South-East Asia (SEA) Region, WHO started working with its country offices as well as ministries of health to disseminate key messages aimed at limiting the spread of the virus and protecting the health of the public. Pandemic response involves a multifaceted set of actions that encompasses not only surveillance and characterization of epidemiological features of the pandemic, but also includes enhancing laboratory capacity, ensuring adequate and accessible supplies of essential medicines and protective gear, and getting the right messages out directly to people. Pandemic control takes place not only in laboratories and hospitals, but also at homes, in crowded streets, and in airplanes. Simple preventive measures such as frequent hand-washing and “social distancing” can limit transmission if people know these. Messages should be communicated to the public through multiple channels of media. One of the most powerful means of communication is word–of-mouth. While some health-care professionals may be focused on caring for the sick, and others on developing vaccines, all healthcare workers have a role to play in dispelling fear and promoting public health measures, which will help people protect themselves effectively. A pandemic calls for action at all levels, including that of the individual. This issue of Health in South-East Asia contains articles on the pandemic and documents actions that were taken and how the revised International Health Regulations (IHRs) were used in the pandemic. Evidence suggests that this pandemic will probably continue to evolve over the next couple of years. Present experience has shown that the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery. But severity may vary from country to country and it may change over time. It is said that the only thing predictable about influenza viruses is that they are unpredictable. That means we will need to continuously monitor the pandemic, and our actions and interventions will need to be modified based on experience to minimize loss of lives. Like the rest of the world, the population in the SEA Region is highly vulnerable. Its density is high and many people live in remote and underserved areas. Thus it is our job to reach the unreached before the virus does and to empower our Member States and the people through sharing of information and knowledge about key interventions that can save lives.
Dr Samlee Plianbangchang Regional Director
2 | HEALTH in South-East Asia || November June 2009 2009
Pandemic Influenza: Are you prepared? 10 essentials for national pandemic preparedness and response: 1. 2. 3. 4. 5. 6. 7. 8. 9. Activate command, control and coordination mechanisms Intensify surveillance and monitoring Build and strengthen laboratory capacity Institute case management and infection control procedures Wash hands frequently and practise cough and sneeze etiquette Practise social distancing Establish and manage stockpiles of essential medicines and supplies Disseminate health education and risk reduction messages Reduce fear and panic in the community
10. Adhere to global policies on vaccine usage
Inside: © World Health Organization 2009 All rights reserved. Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be addressed to Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors/interviewees alone are responsible for the views expressed.
• Global response to Pandemic (H1N1) 2009 ...............................4 • Pandemic (H1N1) 2009 and vaccination.......7 • From information to intervention: the IHR in action ..........................................9 • Do’s & Don’ts in local languages ...................12 • Pandemics, medicines, and society.................15 • Flu: Spread the message, save lives.................18 • How to wash your hands well ......................20
HEALTH HEALTH in South-East in South-East Asia ||Asia November || June 2009 | 3
Global response to Pandemic (H1N1) 2009 Influenza viruses have an unstable genetic makeup caused 433 cases and 262 deaths in 15 countries. which permits “reassortment” in their genetic While the world was grappling with H5N1 avian structure, leading to periodic evolution of new flu and preparing for a pandemic that could subtypes. At times the virus acquires the unusual emerge, a novel H1N1 subtype appeared suddenly capability to cause widespread disease in an in Mexico in March 2009. immunologically naïve, vulnerable population, The Pandemic and swiftly moves across geographical borders to cause pandemics, possibly on a global scale. The The novel influenza virus has a genetic structure previous century saw three such pandemics; the first resulting from reassortment of genes from four (Spanish flu), caused by influenza influenza viruses. Two of these, A (H1N1), killed around 20-50 North American swine influenza While the world was million people. The other two and Asia/Europe swine influenza, grappling with H5N1 pandemics, in 1957 and 1968, led to the initial designation of this avian flu and preparing were relatively milder but still strain as “swine flu”. It also contains for a pandemic that could killed nearly one million people. human influenza and avian emerge, a novel H1N1 The current millennium saw the influenza (non-H5) genes. The subtype appeared suddenly appearance of a novel subtype of virus has a unique genetic genes in Mexico in March 2009. influenza A (H5N1) in 2003. composition that has never been Till 22 July 2009 this virus had seen before. As a result of this, 4 | HEALTH in South-East Asia || November 2009
within a period of months (up to 13 August 2009) However, it would be naïve to extrapolate the virus had spread to 175 countries, caused more from the impact of the 1918 pandemic to the than 182 166 cases and 1799 deaths. The 2009 current event because of the more effective influenza pandemic has spread internationally tools that are available today including drugs, with unprecedented speed. With rapid spread of diagnostics and the level of preparedness infection from Mexico to other in place in the countries. countries, WHO, as a part of the Advances in technology are International Health Regulations The 2009 influenza pandemic now swiftly translatable into (2005), declared the event a has spread internationally with tools. This is demonstrated Public Health Emergency of f unprecedented speed. WHO, as by the determination of International Concern (PHEIC) a part of International Health the genetic sequence of on 25 April 2009. The risk Regulations (2005), declared the Pandemic (H1N1) 2009 level was raised to the highest event a Public Health Emergency and the development of level, phase 6, when sustained of International Concern diagnostic reagents within a community-based transmission (PHEIC) on 25 April 2009. few days of isolation of the was verified in several countries. causative agents, as well as This triggered a multisectoral determination of the virus’s response by national authorities to not only mitigate susceptibility to currently available influenza the impact on the health of the people but also drugs. The virus continues to remain susceptible minimize the social and economic consequences. to oseltamivir and zanamivir. The access to these drugs and their rational use are critical In past pandemics, influenza viruses have needed in mitigating disease as well as prolonging the more than six months to spread as widely as the new utility of the drugs by obviating the emergence virus spread in less than six weeks. of resistance. A vigorous process is underway to rapidly develop a vaccine and ensure mass Preparedness production.However, the supply of vaccine, The H1N1 virus was responsible for Spanish at least during the first year of the pandemic, Influenza Pandemic of 1918. The causative will be finite and not easily accessible to the agent of the current event seems to have vast majority of people living in developing evolved from the H1N1 of the 1918 pandemic. countries.
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P PANDEMIC INFLUENZA PHASES
PHASES 5-6/ P PANDEMIC PHASES 4 PHASES 1-3
POST PEAK POST PANDEMIC P
TIME PREDOMINANTLY L ANIMAL ANI MAL INFECTIONS; ; FEW HUMAN INFECTIONS SUSTAINED T HUMAN HUM AN TO HUMAN HUM AN TRANSM TRA NSMISS ISSION ION WIDESPREA WIDESP READ D HUMAN INFECT INF ECTION ION POSSIBILITY OF REC RECURR URRENT URR ENT EVENTS EVE NTS DISEASE ACTIVITY ACTIVI TY AT SEASONAL LEVELS LEV ELS
Intensive public education for adopting costeffective non-pharmaceutical interventions can yield substantial results. Non-pharmaceutical prevention — repeated hand-washing and following cough/ sneeze etiquettes — can be easily employed at all levels in communities and prevent spread of disease. Isolation of cases and proper case management, including infection control, are equally important to cut down on the transmission of the disease.
UN agency with a mandate for health sector response, WHO is coordinating global response through information sharing, provision of critical supplies (especially diagnostics and drugs), technical support in strengthening national response, and dissemination of technical guidelines to assist national authorities in mounting an effective response.
The global response to the spread of avian influenza A (H5N1) that began in 2003 has helped shaped a number of significant public health advances. Global response However, experience with previous influenza Preparedness and surge capacity are the key to pandemics shows the occurrence of pandemics combating this pandemic. Fortunately, the global in several waves, with an increase in the severity of community is in a better state of preparedness than at disease. This pandemic has been characterized, to date, any time in the past. Since 2003, when influenza A by the mildness of symptoms in the overwhelming (H5N1) emerged as a potential influenza pandemic, majority of patients, who usually recover, even the global community and national authorities have without medical treatment, within a week of the been engaged in strengthening their response efforts onset of symptoms. However, there is with assistance from WHO and other still an ongoing need in all countries development partners. In the SouthFortunately, the global to closely monitor unusual events, East Asia (SEA) Region, all countries community is in a better such as clusters of cases of severe or have prepared National Influenza state of preparedness than fatal Pandemic (H1N1) 2009 virus Pandemic Preparedness Plans, which at any time in the past. infection, clusters of respiratory have provided a valuable framework illness requiring hospitalization, of action. These plans, with minor or unexplained or unusual clinical modifications, are being activated to launch effective patterns associated with serious or fatal cases. There is response to the current event. The need of the hour is an urgent need to keep vigilant for subsequent waves to maintain swift action on all fronts by triggering the of the pandemic, along with monitoring of severity surge capacity at all levels both within the countries of the disease and the genetic structure of the virus. and at the global level. WHO is closely monitoring the influenza situation, which is evolving rapidly. As an intergovernmental 6 | HEALTH in South-East Asia || November 2009
Jai P Narain Director Communicable Diseases
Pandemic (H1N1) 2009 and vaccination The influenza virus is a “smart” virus because it keeps on changing its makeup. Every year, a different influenza virus causes seasonal influenza. So if you want to control seasonal influenza, you need a vaccine that is well-matched with the influenza virus in circulation during that influenza season. This is how the world has attempted to control seasonal influenza. world’s population of 6.7 billion would be susceptible to the virus by the time a pandemic vaccine becomes available for use. Meanwhile, in the absence of a vaccine, other control measures, such as antiviral drugs, antibiotics, and public health disease control measures are being used to contain and delay spread of the virus to allow time for vaccine development.
The World Health Organization is coordinating Similarly, a well-matched vaccine (when available) global efforts to rapidly develop and deploy a could also help in controlling the current Pandemic pandemic vaccine to combat the current epidemic. (H1N1) 2009 influenza pandemic, The expectations are that a pandemic but would be most effective only vaccine could be developed within v It is unclear what proportion if used in populations that have of the world’s population of 6.7 the next six months. Ideally, once been minimally exposed to the developed, the vaccine should also billion would be susceptible to pandemic virus. Given the rapid the virus by the time a pandemic be made available to the 2.7 billion spread of the virus worldwide, it vaccine becomes available for use. people of the 11 Member States of is unclear what proportion of the the South-East Asia Region. The
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reality is that very little of the vaccine would be available for the people of the Region. To put it into perspective, by the end of 2009, the world’s vaccine manufacturers may be able to produce only about 850 million doses of the pandemic vaccine, most of which has already been booked by the developed countries, thus leaving very little for use elsewhere.
It will be critically important for Member States in the Region to be very strategic in the allocation of pandemic vaccine and in targeting of the population to be vaccinated.
Within the South-East Region, WHO has provided some financial support and overseen technology transfer for seasonal influenza vaccine production to the Serum Institute of India, BioFarma Indonesia and the Government Pharmaceutical Organization Thailand. Other manufacturers in India have also been involved.
Under WHO’s overall coordination, scientists and vaccine manufacturers are exploring ways to boost production capacity. These measures include new vaccines that use fewer viral particles per dose, thus enabling more people to be vaccinated; building surplus capacity in existing manufacturing plants; and building new facilities in developing countries. Additionally, WHO is negotiating with manufacturers for a contribution of 10% of their production to build a global stockpile of vaccine.
Through these efforts, enough vaccine could be produced for the 6.7 billion people of this world. However, until such time, there would be limited access to and uneven distribution of the vaccine supply worldwide and in this Region. Therefore, it will be critically important for Member States in the Region to be very strategic in the allocation of pandemic vaccine and in targeting of the population to be vaccinated.
Dr Arun Thapa
8 | HEALTH in South-East Asia || November 2009
From information to intervention: the IHR in action Any public health interthe environment in which vention is, in essence, to act on a Public Health Any public health information transformed Emergency of International intervention is, in essence, into action. It could be an Concern (PHEIC) and information transformed immunization campaign for prevent its spread and protect into action. Actions have measles among displaced people’s health. However, an information base people in a conflict area; such a framework seems which is dynamic and to handwashing promotion so large in scope and reach a certain extent specific to in schools; or the use of context, time and place. that it is difficult to imagine bednets in households. Such how it instigates a cascade of actions have an information actions. This article will try base which is dynamic and to explain that. to a certain extent specific to context, time and Once a PHEIC is declared, then a set of actions place. need to be in place. Mostly these will relate to The International Health Regulations is issues like the following: no exception. It is an international policy What is the nature of the event? framework which brings to the fore the need to get information, declare it and in the end act on If it is an outbreak, then what are the it. It is a global legal framework that provides characteristics of the agent? The cases?
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What about the virulence of the causative agent, and the communicability of the disease? How do you test for this? What are the medicines cases can be treated with? Is there a vaccine?
What kind of demands will this have on the information system? What do we say to the public? What do we ask people to do, and how? The answer to each question in turn relates to a set of actions summarized in the table below: Subject area of questions Surveillance systems Laboratory tests Action Need to be strengthened for identification of cases, which leads to early notification for timely action. Capacities of laboratories need to be increased to provide definitive diagnosis, to improve the quantity and quality of tests and the technology for certain tests (if they are new) Need to prepare them with proper plans to accommodate the surge of patients–increasing in the compliment of staff, supplies and support equipment needs to be addressed. Proper case management and infection control measures need to be well prepared. Specific messages for certain audiences related to the nature of the disease need to be crafted and released through proper channels and at the right time. Message, medium and audience have to be aligned. Points of entry Supplies and logistics Quarantine officers need to be trained to be well aware of IHR obligations and implement proper preventive measures at ports. A system of provision of supplies, people and equipment needs to be systematic and focused on addressing areas where there is high risk of catching the disease.
Hospitals
Communications
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The above are just a few examples of the main areas that need focus and monitoring. Looking back at how the Pandemic (H1N1) 2009 flu has evolved, all the above were areas that were looked at, and answers to all the questions emerged as time went by. However, a few points are clear: 1.
5.
Having sound information analysed and interpreted provides a basis for further action. Details such as the amount of antivirals stocked, or personal protective equipement (PPEs) in place in hospitals, should be based on certain assumptions. The health sector cannot do everything—the spread of a disease is determined sometimes by factors aside from those in the health sector. It is important to be cognizant of this and involve as many partners as rationally as possible so that there are both a logical division of tasks and greater reach of interventions. This novel influenza virus continues to evolve, but taking stock of this recent event can help everyone involved in the response better implement IHR (2005) in the future. IHR (2005) is a powerful tool if the information it provides is transformed into action. Dr Kanchit Limpakarnjanarat Dr Roderico Ofrin
The actions required are focused in a certain locality, and these vary accordingly. Although globally a Phase 6 may be declared, some countries will have no cases while others are experiencing wider community spread.
6.
2.
Certain public health events evolve fast, and thus addressing current The health sector cannot needs with speed is do everything—the spread essential. of a disease is determined Telling the public what to do and providing them timely information decreases panic.
3.
sometimes by factors aside from those in the health sector. It is important to involve as many partners as rationally as possible.
4.
A health system/ health facility that is prepared for all hazards can adapt better to evolving situations.
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Do’s and Don’ts in local languages
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Pandemics, medicines, and society Medicines are a part of the routine of illness, there is no “pill for every ill”. There is also the treatment and health; we buy and use them issue of benefit to the individual versus that of when there is a need, and when we don’t need society. If oseltamivir is made easily available to them, they disappear from our thoughts. the population, there could be the benefit of But on rare occasions, when there is an issue early treatment. However, this would be at the serious risk of the development beyond this “simple” use, we of resistance to oseltamivir, as individuals and as a society We are reminded which is an unacceptable think beyond this context. that there is no “pill long-term consequence of such The case of thalidomide in the for every ill”. widespread use. The individual’s 1960s was one example; before desire for immediate treatment that, pharmaceutical companies (even for mild illness, as in the developed and promoted medicines with medical professionals, and majority of Pandemic (H1N1) 2009 cases) patients took them. The highly visible congenital has to be balanced against the needs of society birth defects due to thalidomide forced society to protect and preserve the most effective to regulate the safety (and later the efficacy) of treatments for severe illness. medicines, which is now a major function of This conflict is also reflected in the implicit Ministries of Health. “pact” between pharmaceutical companies and The Pandemic (H1NI) 2009 influenza brings society. In exchange for financing and developing us to another point in the history of medicines medicines, pharmaceutical companies (which in society. Oseltamivir is useful in patients are mainly business institutions) are allowed to with severe infections but of lesser use in mild make their profits in the area of health. And infections; in neither situation is it a “sure that is the issue–profit is the motive, but society thing”. Thus, we are reminded of the fact that expects better health to be the outcome. HEALTH in South-East Asia || November 2009 | 15
However, in many cases there is little potential that “systems and rules, such as those for for profit, and hence there is a danger that intellectual property and patent protection, there will be no improvement in health, at that make perfect sense in many sectors raise least as far as new medicines are concerned. some questions when applied to human In fact, treatment of malaria, tuberculosis and health. . . In the field of health, public policy will many other diseases in the developing world remain imperfect as long as access to life-saving is hampered by a lack of effective medicines. interventions is biased in favour of affluence.” When health and economics are “in step”, Certainly in a pandemic, we are reminded that there is no problem, but “fairness matters in life-andwhen they are not, seeking death ways.” the balance is difficult. A pandemic by definition A pandemic by definition is a vast event that effects Until now society has not is a vast event that effects everybody—all people, and found an effective means everybody—all people, and all institutions of society. to achieve that balance. In all institutions of society. 2001, the WHO DirectorIt therefore raises questions General said that “Drugs that might not otherwise are not a commodity like arise, or that lie below the surface—for example, any other. Access to health care is a human whether an industry exists in society to serve the right”. The call for “reliable access to medicines latter’s needs, and whether it is permissible for on the basis of need rather than on the ability society to allow an industry to focus entirely on to pay” is all the more poignant in the context what is most profitable at the cost of neglecting of the current pandemic. other social needs. In order to achieve a balance, WHO Director-General Margaret Chan society may stipulate that industry produce reiterated these ideas in July 2009, stating what is required (achieving a modest return)
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for the opportunity it has been given to make greater profits in other areas. Vaccines are one of the medicines vital for public health but which have suffered from underproduction because there is often no assured market, which is understandable by commercial logic, but is an impediment to public health. Some believe that society should stipulate that these vaccines and medicines be produced and give some guarantee that they will be purchased at a price that would be reasonable to the seller as well as the buyer. In fact, the Global Alliance for Vaccine and Immunization, through the Advance Market Commitment, will purchase vaccines (developed to the required specifications) for the developing world. However, there have been some criticisms of the implementation of this measure as a subsidy or guaranteed market. Until now, the public health focus of society in the regulation of medicines has been mainly technical, such as ensuring safety and quality. In the few cases where citizens were asked (for example in Australia) about policy issues, they placed a much higher priority on vaccines
for preventable childhood disease than on anticancer medicines, especially for ones such as lung cancer that are brought on by smoking. The current pipeline of pharmaceutical products shows an opposite trend, with many more anticancer medicines than vaccines. The policy issue of what the pharmaceutical industry should be incentivised to produce goes beyond health and the industry itself. Health, the technical expertise in the industry, resource allocation, industrial policy, universities and the research they do—and last but not least, the patients/consumers themselves—should be consulted and involved. The thalidomide disaster brought technical issues to center stage and led to advances in drug regulation. The current pandemic may also produce new thinking and new initiatives, though one would hope that society might reach a stage where these critical issues could be decided without the occurrence of crises. Dr Krisantha Weerasuriya
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DO... $ $ wash your hands
stay more than one arm's length distance from persons sick with flu
$ $ $
avoid crowded places
eat nutritious food and drink plenty of water
get plenty of sleep and rest
World Health Organization, Regional Offic
DO NOT... $ $ $ shake hands or hug spit in public take medicines without consulting a physician
If you are sick, PLEASE $ $ $ $ cover your cough or sneeze stay home and limit contact with others as much as possible rest and take plenty of liquids seek medical advice
ce for South-East Asia. 2009. www.searo.who.int
How to wash your hands well
Use soap all over your hands
Rub hands palm to palm
Clean the backs of your hands too
Clean between all fingers including thumb
Clean under the nails
Rinse hands
Dry hands with something clean or air dry
Clean hands protect against disease For more information visit the website at: www.searo.who.int
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Editorial Board : Dr Poonam Khetrapal Singh, Dr A Sattar Yoosuf, Dr Roderico Ofrin, Mr Bruce Murphy, Ms Vismita Gupta-Smith Produced by : Reports and Documents Unit and Public Information and Adovacy unit, WHO SEARO