Humanitarian Pandemic Preparedness and Response Phnom Penh 12 October, 2009 Ron Waldman, MD

What does an influenza virus look like? Hemagglutinin protein –Allows virus to stick to cells –Determines cell and species specificity Neuraminidase protein –Releases new virus particles from cells Genetic material divided into 8 separate segments Fig.1 Electron micrograph Fig.2 Schematic of influenza virus

Three Different Kinds of Influenza Seasonal Influenza “The Flu” Seasonal Influenza “The Flu” Avian Influenza “Bird Flu” Avian Influenza “Bird Flu” Pandemic Influenza “A Pandemic” Pandemic Influenza “A Pandemic”

Why does a pandemic occur? Antigenic shift Sudden change in antigenic structure of microorganisms, especially viruses, which produces new strains of the microorganism; hosts previously exposed to other strains have little or no acquired immunity to the new strain. “Novel Influenza A (H1N1)”

What is required for a pandemic of influenza to occur? Novel virus to which population has little or no immunity Virus that is pathogenic and virulent in humans Virus must be capable of sustained person-to-person transmission

A pandemic will result in larger numbers of all types of cases than in seasonal flu. The proportions of types of cases in a pandemic will depend on the severity of the pandemic.

How does the virus spread? Pigs? (why is it called “swine flu”) Airplanes? (yes, but…)

Rapid transition from Phases 3 to 6, followed by quick spread around the world, may leave us little time to prepare.

New WHO Phases of Pandemic Alert Phase 6 = Sustained community transmission of a new flu virus in 2 or more WHO regions. “Designation of this phase will indicate that a global pandemic is under way.” ( - See notes below)

First H1N1 Death in Cambodia 28 September 2009

Why We Should Care

Reason #3: Pandemics have happened before; one is happening now. They can be severe. They are always important.

What were past flu pandemics like? 1918: “Spanish Flu” 1957: “Asian Flu”1968: “Hong Kong Flu” million deaths 675,000 US deaths 1-4 million deaths 70,000 US deaths 1-4 million deaths 34,000 US deaths Credi: US National Museum of Health and Medicine

Reason #2: The humanitarian consequences of a pandemic could be devastating in terms of lives lost, economic disaster, and societal upheaval.

Reason #1: More than ever before, we can save lives during a pandemic!

H2P – Humanitarian Pandemic Preparedness and Response To limit excess mortality during a pandemic

New Tools for Intervention during a Pandemic Non-pharmaceutical (community mitigation) measures Strain-specific influenza vaccine Antiviral drugs (Tamiflu, Relenza) Antibiotics Infection control measures

Community Mitigation Isolation of those ill Voluntary quarantine of household members Social distancing of children (close schools?) Social distancing of adults (stagger working hours, close places of employment, places of worship, places of amusement) – those ill should stay home

Days Since First Case Daily Cases Pandemic Outbreak: No Intervention Pandemic Outbreak: With Intervention Delay outbreak peak Decompress peak burden on hospitals/infrastructure Diminish overall cases and health impacts 2 1 3

WHO/IFRC/UNOCHA/UNICEF “Call to Action” 1.Identify populations at increased risk of disease and death -- health care workers and other critical personnel -- pregnant women -- children -- underlying illness -- poor access to health care

WHO/IFRC/UNOCHA/UNICEF “Call to Action” 2.Reduce death by treating acute respiratory illness and pneumonia -- train, supervise and ensure health care workers, including CHWs, can identify, classify and treat acute lower respiratory illnesses -- plan for a 30% buffer stock of antibiotics, O 2, etc. -- educate communities about home-care, when to seek care outside the home, and when anti-virals are appropriate

WHO/IFRC/UNOCHA/UNICEF “Call to Action” 3.Reduce spread of disease -- prepare and disseminate risk communication messages -- map and train social mobilization networks to promote prevention -- identify target groups to receive first doses of vaccination and advocate for their access -- develop operational plans for mass vaccination

Current Knowledge Regarding H1N1 Vaccine A single dose of non-adjuvanted vaccine induces an immunogenic response in healthy young and middle-aged adults More people can be vaccinated with a fixed amount of vaccine Antibody responses will develop more rapidly than with two doses Vaccination campaigns will be easier to conduct

Current Knowledge Regarding H1N1 Vaccine Many countries have not developed plans for use of H1N1 vaccines: -- high-priority groups -- cold chain requirements -- points of distribution and delivery -- post-vaccination surveillance

WHO/IFRC/UNOCHA/UNICEF “Call to Action” 4.Continue critical services and plan for the worst -- review or create business continuity plans -- prioritize continuation of critical health and other essential services as part of a whole of society approach; build on existing multi-hazard, multi-sector plans -- ensure 8-12 weeks of buffer stocks of essential medicines to continue treating priority conditions

WHO/IFRC/UNOCHA/UNICEF “Call to Action” 5.Plan and coordinate efforts -- incorporate pandemic activities into existing coordination mechanisms -- recognize that no one agency can provide all of the priority interventions. Build on capacities and comparative advantages of each partner -- do not allow “lack of coordination” to become a cause of death

Aceh, Indonesia, December 2004

Recommendation (2005) “An improved seismic detection system should be developed and implemented in the region as quickly as possible.”

The only thing more difficult than planning for a pandemic would be explaining why you did not do it.