1. ASEM Workshop on Avian Influenza Control
Global Update and Future Direction of Avian Influenza Control (in context of influenza pandemic preparations)
ASEM Workshop on Avian Influenza Control
Presentation by David Nabarro
UN System Influenza Coordinator
Tuesday November 12th 2007

2. Outline of Content
Influenza Pandemic Prevention: Responses to the threat of Highly Pathogenic Avian Influenza H5N1
Pandemic Preparedness: The importance of multi-sectoral approaches to human health security
Pandemic Readiness: Testing preparedness to assess state of readiness
Inter-Governmental Approaches: Encouraging joint action by countries
Future Directions: Preventing and being ready to respond to animal diseases that affected humans

3. Past Influenza Pandemics
1900
1850
1950
2000
1847
1889
1918
1957
1968
42 yrs
29 yrs
39 yrs
11 yrs

4. 1918-19: a two year global crisis caused by an Influenza Virus
06/18 ?
04/18
03/18
06/18
05/18 ?
01/19
06/18
C.W. Potter, Textbook of Influenza, 1998

5. 1 Influenza Pandemic Prevention
The threat from Highly Pathogenic Avian Influenza H5N1

7. GLOBAL AVIAN INFLUENZA SITUATION
15 countries have been affected by end 2005, 55 by end 2006, and 60 by November 2007
Powerful efforts to respond to outbreaks successful in most cases.
Continued, often silent, transmission of H5N1 in bird population in parts of Indonesia, Egypt, Nigeria, Bangladesh, Vietnam and China
Potential for a marked increase in outbreaks during next few months
Uncertain epidemiology
Contribution of migrating birds?
Contribution of in-country and cross-border trade?

8. SPORADIC HUMAN CASES OF AVIAN INFLUENZA
Human infection with H5N1 is rare, and usually the result of virus transmission from birds to humans
H5N1 infected over 300 people since 2003
Over 200 have died, mostly children and young adults
Genetic make-up of virus evolves but there is no evidence of sustained human to human transmissibility

9. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO
5 November 2007
Country
2003
2004
2005
2006
2007
Total
cases
deaths
Azerbaijan 8 5
Cambodia 4 2 1 7
China 13 3 25 16
Djibouti
Egypt 18 10 20 38 15
Indonesia  55 45 37 32
112 90
Iraq
Laos
Nigeria
Thailand 17 12
Turkey
Viet Nam 29 61 19
100 46 98 43
115 79 71 47
334
205

10. TECHNICAL AND FINANCIAL ASSISTANCE: PROGRESS SINCE 2006
Of the $ 2323 million pledged in 2006, $1678 million (72%) has been committed and $1018 (43%) has been spent
The figures suggest that considerable funds are available for spending, but this is not the case. The original pledge included $1340 million of grant funds and $983 million of loan funds
Of the $1340 million grant funds that were pledged reveals that $1287 million (96%) has already been committed. $ 955 million (74%) of the committed grant funds have already been disbursed.
Over time countries have become more dependant on loans as the availability of grants has declined.
Of the $983 million loan funds that were pledged, approximately $592 million remained uncommitted as of end-June 2007.
Loans are used to finance medium-term integrated country programs, which take time to prepare, and developing countries prefer to use grants, rather than loans, to finance their integrated programs

11. Funding status
Commitments and Disbursements Received by International Organizations, $ million
Commitments
Disbursements
WHO
178.5
126.8
FAO
89.9
65.8
OIE
28.5
20.4
UNICEF
68.5
66.9
Other a/
67.6
36.8
Total
433.0
316.7
Source: Donor reports to the World Bank polling exercise as of June 30, 2007.

12. Countries Receiving $10 million or More in Commitments
Recipients
Countries Receiving $10 million or More in Commitments
($ million)
Country
Commitments
Disbursements
Vietnam
107 39
Indonesia 97 53
Nigeria 54 25
Turkey 47 12
Romania 42 4
India 35 3
Cambodia 28 13
Lao PDR
Nepal 19 1
Bangladesh 18 2
Egypt 15 7
Afghanistan 14
West Bank & Gaza
Armenia 5
Georgia 11
Moldova
China 8

13. Human Cases, Deaths from H5N1 and Countries Affected

14. H5N1 still a global issue end 2007….

15. CONTRIBUTION OF ASIAN AND EUROPEAN COUNTRIES
Improvements in Animal Health Surveillance Systems
Capacity for Disease Detection and Response
Improvements in Bio-Security – in both family and commercial poultry production and in markets
Mass Information to the General Public
Widespread Vaccination Programmes
Capacity to Monitor and Adjust for better performance
Development of new vaccines and diagnostics
Improvement in Public Health Capacity
Pandemic Preparedness Planning

16. NEXT STEPS IN AVIAN INFLUENZA CONTROL 2008 ONWARDS
Using a livelihoods perspective, regularly analyze the epidemiological determinants of outbreaks in poultry and of human cases
Using epidemiological and economic data, encourage long-term reduction in risk of HPAI and other diseases through improving biosecurity in (a) family poultry and (b) commercial poultry production and marketing systems
Intensify an monitor efforts to control HPAI in settings of continuous transmission (including with vaccination), maintaining an overview of implementation and impact of poultry vaccination

17. 2: Multi-sectoral Pandemic Preparedness
Getting ready to detect and act decisively

18. THE CURRENT THREAT LEVEL?
Inter-pandemic period
Phase 1
No new influenza virus detected in humans. If a new influenza virus presents in animals, the risk of human infection is considered to be low.
Phase 2
No human infections, but a circulating animal influenza virus poses a risk to humans.
Pandemic alert period
Phase 3
Human infection(s) with a new virus, but no (or very infrequent) human-to-human spread.
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized.
Phase 5
Larger cluster(s) but human-to-human spread still localized
Pandemic period
Phase 6
Increased and sustained transmission in general population.
WHO has outlined 6 phases to help us understand where we are in relation to the threat of a severe global pandemic
Currently we are in Phase 3 where human infections with a new virus are present, but no (or very infrequent) human to human spread has occurred
Progression to Phase 4 would require small clusters of human to human transmission in localized areas to present
If the threat is elevated beyond Phase 4 a very quick progression from Phase 5 to Phase 6 (full pandemic) is likely to occur
It is important to note that:
Further progression of the threat will depend not just on the nature of the virus, but also on the success of containment and other response actions
The ability of WHO to accurately assess and call/announce an elevated threat is dependent on accuracy of analysis and reporting in country.
Technical Note: WHO updated their pandemic phase definitions Feb/March and it was at this time that Phase ‘3’ was declared in the new system. The first human case of H5N1, however, was in 1997 in Hong Kong, and so technically we have been in phase 3 since that time.
UN System Influenza Coordination

19. POTENTIAL IMPACTS OF AVIAN & PANDEMIC INFLUENZA
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
Economic Systems
Trade & commerce disruptions
Degraded labour force
Interruption of regular supply systems

20. PANDEMIC IMPACT RELATED TO CONTINUITY OF…
1 Health Services
Medicines, Commodities, Equipment, R and D, Patient Care, Lab services
2 Financial Services
Banking (cash and settlements), financial regulation, risk management and insurance
3 Food and its distribution
Agriculture and livestock, Distribution and retailing
4 Utilities, Logistics, Personal Services
Electricity, Water, Telecoms, Transport and Logistics, Postal services,
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 Environment and hygiene
Wildlife conservation, Cleaning, Maintenance, Refuse management.

21. 3: Getting Ready: The importance of checking preparedness to decide State of Readiness

22. PANDEMIC READINESS IS THERE A RISK-BASED APPROACH TO PLANNING?
Use of epidemiology, modeling, risk-based planning
Engage professionals from different levels
Ensure high level of popular awareness and understanding
IS THE STRATEGY WIDELY UNDERSTOOD?
Early Detection, Investigation and Confirmation, Containment
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 (Major controversy: will poor countries have access)
HAVE PROCEDURES BEED TESTED AND MODIFIED?
Crisis plan to mitigate effects of pandemic on Economies, Governance, Basic Needs, Border Movements
Protocols developed for use of stockpiles, emergency operations
Humanitarian NGOs, local government, Private Sector synchronized
Communications system
Plans Simulated and Lessons Applied

23. GLOBAL READINESS - SEPT 2007
Preparedness Plans not always fully tested
Containment protocols still to be taken forward by groups of countries
Civil Society and Private Enterprise NOT always involved
Importance of identifying and working with vulnerable populations
Value of clear communications protocols
Readiness being tracked by UN (PIC) and by regional bodies (eg ECDC and APEC)

24. 5: Inter-Governmental Approaches:
Encouraging joint action by countries

25. Governments Working Together
GLOBAL STRATEGY
FAO/OiE/WHO/World Bank and Partners’ strategy meeting (Geneva November 2005) and review meeting Rome June 2006)
INTERGOVERNMENTAL SOLIDARITY
Financial and political (Beijing and Bamako pledging Conference, Washington, Ottawa and Vienna High Level meetings)
EXTERNAL ASSISTANCE
Technical and financial support by specialized and donor agencies

26. Support to Integrated
National Programmes

27. PREREQUISITES FOR SUCCESS
Political Commitment - to joint and effective action based on agreed strategies
Resources – sufficient for incident response
Functioning Alliances – government, public, private, media
Combined operations – people’s health, livestock health, informed population, regulations properly enforced, data and samples shared
Adequate incentives – to report, to cull, to improve safety
Mobilized populations – informed and ready to act for safe food, healthy animals and health

28. 6: A Way Forward: Popular Movements and Networks for Human Health Security: Case study from Indonesia

29. Engaging community members

30. Understand perspectives of
Care-givers and children
I want you to look at this picture for a few minutes. wonder what you feel when you look at this picture:
Discomfort, concern, fear? Im sure many of you will be seeing H5N1
But H5N1 will probably not be top of their mind. Many tell us “Birds die all the time”.
She is probably seeing the loss of a good egg layer, the family food source, and perhaps even a modest income
Her son might well be grieving for a favourite pet – perhaps even a member of his family.

31. Understand concerns of Householders

32. Appreciate the position of market workers

33. Use Clear Messages

34. Explain Messages Repeatedly: Public Service Announcements viewed by more than 120 million people

35. Involve Leaders: Politicians, Imams, Government Officers, Professionals

36. Our societies are threatened by microscopic adversaries that are well-equipped to invade, evade, and surprise
70% of them come from the animal kingdom
They pose a threat to the economic, social and human security of people throughout the world
Countries are responding together, within the framework of the International Health Regulations.
Collective response calls for shared responsibility, systems and costs

37. HUMAN SECURITY - ONE WORLD, ONE HEALTH
Diseases do not respect borders and can emerge without warning
70% of emerging diseases will come from Animals
Importance of convergence: animal health, environmental health, food safety, human health
Importance of governments, voluntary sector, business and community responding together

38. Recap of Content
Influenza Pandemic Prevention: Responses to the threat of Highly Pathogenic Avian Influenza H5N1
Pandemic Preparedness: The importance of multi-sectoral approaches to human health security
Pandemic Readiness: Testing preparedness to assess state of readiness
Inter-Governmental Approaches: Encouraging joint action by countries
Future Directions: Preventing and being ready to respond to animal diseases that affected humans