1. Wrap-up Day 2

2. Plenary Four: Pandemic and avian influenza updates Pandemic H1N1 – Origin of pandemic H1N1 virus – Genetically and antigenically homogenous – A few isolates resistant to oseltamivir – Pathogenesis and transmissibility: ferret model Higher virulence? Lower transmissibility – Serosurveys No cross reactivity with seasonal H1N1 33 % elderly have antibody H5N1 – 436 human cases – 2009 human cases in Egypt, Vietnam and China – Antigenic differences among different clades – Unique characteristics of H5N1 epizootic (spread / various species / human cases / mutations) Virology Update: Pandemic H1N1 and H5N1

3. Plenary Four: Pandemic and avian influenza updates H5N1 – More than 20 clinical trials – Different types of vaccines – No standard reagents Pandemic H1N1 – Quality / efficacy / safety – Clinical trial starting – Immunogenecity: Probably OK – Adjuvant required? – Availability – Access Vaccine development: Pandemic H1N1 and H5N1

4. Plenary Four: Pandemic and avian influenza updates Cambodia – 8 cases so far, 7 died – Continue vigilance – Rapid response team ready to respond – Hospital preparedness – Laboratories (PI, NIPH, NAMRU2) China – Surveillance – 38 cases – Lower mortality in children – Two family clusters: one possible h-to-h Viet Nam – 111 cases with 56 deaths – 4 cases in 2009 – Human isolates in different clades – Continuous outbreaks in poultry – Different clades in South and North Updates on AI Situation

5. Plenary Five: Pandemic preparedness and response – Prepare for extensive community transmission – APSED approach – Framework for action – Different stages and required intervention – Gaps identified Framework of action Fukuoka Meeting Summary – Progress with Pandemic preparedness – Areas for improvement – Recommendations

6. Plenary Five: Pandemic preparedness and response – Goals of PH intervention – Many available PH measures – Key considerations Bases on risk assessment, esp severity and potential impact Should be evidence-based Balance benefits against costs Need to be tailored to country and local setting Planning, coordination and communication are a key Options for public health measures Monitoring and Evaluation Joint WPRO/ USCDC – Assess core capabilities – Determine progress – Compatible with APSED framework – Some key findings

7. SURVEILLANCE COMMAND PUBLIC HEALTH INTERVENTION COMMUNICATION HEALTH CARE RESPONSE HEALTH SECTOR SOCIETAL LEVEL How to slow down the transmission Individual LEVEL Laboratory How to minimize preventable deaths Partnership

8. Lessons Learnt (Epidemiology) Countries have been experiencing different stage – Sporadic imported cases – Local transmission / unlinked cases / school outbreaks – Widespread community transmission – Appearance of severe cases / deaths Different responses are required for different stages – Containment to mitigation: difficult to make a decision (political / technical issues) Majority cases self-limiting, but some severe cases / deaths – Occurrence of severe cases / deaths depend on epidemiological situation

9. Lessons Learnt (Command) Responses are based on existing national plan – National plans developed / revised before H1N1 pandemic Needs for adaptations of plan for H1N1 pandemic High level command system in place in most countries – Inter-ministerial coordination – Multi-sectoral coordination Some issues for coordination – e.g. private sectors

10. Lessons Learnt (Surveillance) Improved surveillance capacity in past years – Fully utilized for H1N1 pandemic response – Laboratory capacity – Sentinel surveillance system Counting cases – Important and necessary in early stage – Less important and less informative after widespread community transmission – Changing sampling strategies Changing objectives for surveillance – Early detection / Description and assessment / Monitoring Change in sampling strategy not done in timely manner – Large number of samples sent to NIC – Pressures from hospitals / national authorities / politicians – Testing for PH surveillance vs. Testing for patient management – Labs overwhelmed Limited laboratories with diagnostic capability available – No lab at local level

11. Lessons Learnt (PH Interventions) Different policies for public health interventions, esp. school closures and border control measures – Lack of concrete evidence – Some effect in delaying the spread? – Negative impact / consequences depend on local setting – Public acceptance also depends on local setting

12. Lessons Learnt (Communication) Most countries appreciate importance of communication Governments have been active in disseminating necessary information – Media briefing – 24/ 7 hotlines etc. There are some issues and challenges – Confusing messages from media – Information does not reach to target groups (e.g. physician)

13. Lessons Learnt (Hospital preparedness) Many countries put hospital preparedness as a priority – Isolation facilities identified – Available isolation facilities limited (no surge capacity) Infection control: important, but still not fully addressed – Training – Availability of PPE Case management – Shortage of antiviral stockpiles – Late treatment with antivirals – Many challenges and issues if many severe cases occur (ICU beds, respirator) Coordination: important but not easy – Hospital authorities – Private hospitals

14. Epidemiological Curve in Japan Number of Confirmed Cases

16. 8 Weeks Pandemic Preparedness Pandemic Response Post-Pandemic Preparedness

17. Pandemic Preparedness Pandemic Response 2 years

18. Pandemic Preparedness 2 years Pandemic Response

19. Pandemic Preparedness 2 years Pandemic Response Pandemic Preparedness Fatigue

20. Pandemic Preparedness 2 years Pandemic Response Pandemic Preparedness Fatigue Pandemic Response Fatigue

21. Pandemic Preparedness 2 years Pandemic Preparedness

22. 2 years Pandemic Response H5N1? H9N2? Novel H3N2?

23. Pandemic Preparedness 2 years Pandemic Response H5N1? H9N2? Novel H3N2? Influenza viruses are unpredictable There have been and will be many unexpected There are still many unknowns about H1N1 pandemic We have to be prepare for unexpected We should not forget about other threats