What does a pandemic look like? – Dr Graham Tallis

Pandemic Preparedness:
What does a pandemic look like?
Dr Graham Tallis
WHO Indonesia

Asian Media Summit Pandemic Workshop
Manado Indonesia 28 May 2013
Outline of Presentation
Why influenza pandemics occur
Current pandemic threats
The International Health Regulations and WHO
Pandemic Preparedness Framework
Responding to a pandemic
Communication in a pandemic

Why influenza pandemics occur
A pandemic is a global infectious disease outbreak

The Pandemic ThreatThe Pandemic Threat

Influenza Pandemics Mortality
H1N1
H2N2 H3N2
1918: “Spanish Flu”
1957: “Asian Flu”
1968: “Hong Kong Flu”
40-50 million deaths
1-4 million deaths
1 million deaths
“Pandemic H1N1 (2009)”
>18, 000 deaths*
H1N1
* Only Laboratory Confirmed

What will happen during an influenza pandemic?
 Perhaps 2-3 waves, each lasting about 2-3 months
 Mortality impact greatest in vulnerable populations
– Risk factors: overcrowding, malnutrition, poor access to health
care, HIV
– Can be reduced through known interventions:
 adequate pneumonia case management with antibiotics
 vitamin A supplementation
 antivirals if indicated and available
 Vaccines to prevent infection – takes time to develop

What will happen during a pandemic?
Heavy burden on health care facilities
– Increased febrile respiratory illness (hard to distinguish from
other common illnesses)
– Increased non-severe and severe pneumonia
– Increased consumption of drugs (especially antibiotics) and
supplies
Economic and social disruption
– High workforce absenteeism, affecting critical government
services
Threats to Rule of Law and Security

Influenza A Virus – Some Science
Hemagglutinin (H)–16 subtypes
(attachment, penetration)
Neuraminidase (NA)–9 subtypes
(release)
8 viral genes
(assembly, replication)
M2 protein
(penetration)
Hemagglutinin (H)–16 subtypes
(attachment, penetration)

Types of Influenza A
•Many subtypes (16 H and 9
N)
•3 subtypes have caused
human epidemics
•H1N1
•H2N2
•H3N2
•Subtypes that usually
infect birds but that have
also caused infections in
humans:
H5, H7, and H9

Evolution of Influenza Viruses
Antigenic Shift (Re-assortment)
•A sudden shift in the antigenicity of a virus resulting from
the recombination of the genomes of two viral strains.
Antigenic 'shift' occurs in HA and NA and is associated with
pandemics.
• No vaccine available but can be developped
Antigenic Drift (Mutation):
•Viral genes are constantly mutating, producing new forms
of antigens. Antigenic 'drift' occurs in HA and NA, and is
associated with seasonal epidemics.
• The reason flu vaccination needs to be updated every
year

How Human to Human Transmission Occurs

Current Influenza Pandemic Threats
H5N1 and H7N9

H7N9
Completely new virus appeared in China in 2013
Highly lethal in humans but not birds
Humans: 11 provinces in China and Taiwan
– a total of 131 laboratory-confirmed cases of human infection
virus have been reported.
– 32 have died, and 44 have been discharged from hospital.
– The majority of cases continue to have clinically severe illness.

Affected Provinces in China

The International Health
Regulations and WHO
Pandemic Preparedness
Framework

Emerging Diseases in Asia-Pacific

The world is changing rapidly
 Population expansion
 Urbanization
 Increase in international travel
Social changes - New knowledge – New risks
 Rapid and widespread communication

The International Health Regulations (2005)
 Established by negotiation between States
 Adopted at the World Health Assembly (2005)
& legally binding on WHO’s Member States
 Entry into force on 15 June 2007
– Voluntary early compliance – Avian Flu – 2006 WHA
 Five years to develop country core capacities

PHEIC
Member States need to report any event that may constitute
a “Public Health Emergency of International Concern”
“an extraordinary event which constitutes a public health risk to
other States through the international spread of disease and
potentially require a coordinated international response”
– Relatively infrequent, determined by WHO (in consultation), results
in global action
– State actions under IHR more often based on lower thresholds
– States report ‘potential PHEICs’ - lower threshold than actual PHEIC

IHR - Event notification and determination
WHO DG
Various disease and event surveillance
systems within a country
National IHR
Focal Points
National IHR
Focal Points
WHO IHR
Contact Points
WHO IHR
Contact Points
Emergency
Committee
Other competent
Organizations
(IAEA etc.)
Detect, verify,
notify, respond to
unexpected events
Communication channel:
Notify WHO of potential
PHEICs, consult other
Ministries, feedback
information from WHO
Receive, assess and
respond to events
notified
Ministries/
Sectors
Concerned
Determine whether an
event constitutes a
PHEIC and
recommend measures
External
advice
Coordinate
Communicate
Report
Review
Committee
WHO’s
Expert
Roster

WHO Pandemic Phases

The 2009 pandemic as a case study
 April 2009 outbreak of severe pneumonia in Mexico
 In USA, scientists identified North American and Eurasian swine
lineages in this new influenza A(H1N1) virus
 This virus has never before circulated among humans and hence
its pandemic potential
 While clinical presentations may be similar, this virus was not
related to previous or current human seasonal influenza viruses
which cause annual epidemics that peak during winter in
temperate regions

Time Lines of Evolving Situation
 The first meeting of the WHO Emergency Committee was held on Saturday 25 April
2009, involving 15 international experts.
 WHO Director-General determined that event constituted a public health
emergency of international concern (PHEIC), under the IHR.
 The Emergency Committee reconvened 27 April and raised the pandemic phase to
FOUR
 DG WHO raised the pandemic phase to FIVE on 29 April
 Emergency Committee met on 5 June, and recommended no change in phase
 Following consultation with eight most affected Member States, further EC meeting
held on 11 June, and recommended conditions for a pandemic met
 DG WHO raised the pandemic phase to SIX the same day
 At an early stage, the pandemic was characterized globally as being moderate in
severity

Role of IHR in Pandemic (H1N1) 2009
 Verification, reporting and notification of a
potential pandemic event in April 2009
 Joint pandemic risk assessment
 Determination of a Public Health Emergency of
International Concern (PHEIC) under the IHR(2005)
 Issuance of WHO recommended temporary
measures
 Ongoing pandemic monitoring and information
sharing under the IHR framework

IHR Temporary Recommendations
WHO recommended that all countries
intensify surveillancesurveillance for unusual outbreaks
of influenza-like illness and severe
pneumonia
WHO also recommended
– not to close borders AND restrict international travel
– It was considered prudent for people who are ill to delay
international travel and for people developing symptoms
following international travel to seek medical attention

Benefit and Value of New IHR
 IHR (2005) has been widely and well applied to the 2009
pandemic response in a coordinated and collective way
 Proving to be a key framework for sharing information among
countries and partners
 Timely notifications and reporting from countries have allowed
– global and regional pandemic situation to be assessed and monitored
– technical guidance to be developed in a timely manner

Report of the Review Committee on the
Functioning of the IHR on Pandemic Influenza
Summary conclusion 1
 The IHR helped make the world better prepared to cope with public health
emergencies. The core national and local capacities called for in the IHR are not
yet fully operational and are not now on a path to timely implementation worldwide.
 WHO performed well in many ways during the pandemic, confronted systemic
difficulties and demonstrated some shortcomings. The Committee found no
evidence of malfeasance.
 The world is ill-prepared to respond to a severe influenza pandemic or to any
similarly global, sustained and threatening public health emergency. Beyond
implementation of core public health capacities called for in the IHR, global
preparedness can be advanced through research, strengthened health-care
delivery systems, economic development in low- and middle-income countries and
improved health status.

Responding to a pandemic

Strategic actions
Health sector strengthening
Public health measures
Pharmaceutical interventions
Surveillance
Whole of Society Approach for Pandemic Preparedness
Risk Communication

Surge capacity in health care settings
 Protocols for the patients triaging (worried well)
 Protocols for patient testing and laboratory confirmation
 Infection control protocols
– Protection of the health care workers
– Protection of the other patients
 Training package for new staff
 Supply (PPE, soap, laboratory reagents, antiviral, antibiotics,
antipyretic…)
 Reduction of excess mortality due to other causes

Public health measures
Eg School closure
 Various measures: school closure, class dismissal, school entry screening
 Decision based on local assessment bearing in mind :
– Timing
; Before the spread of the disease, to reduce speed of transmission (7-14 days)
; When widespread community outbreak : because no teacher or no pupils/students
– Consequences :
; Work absenteeism of the parents
; Less useful if kids gather somewhere else
; Nutrition - Education loss
 Other examples: cancellation of public gatherings, isolation of
cases, quarantine of their contacts, social distancing

Pharmaceutical interventions
Antiviral medication (like tamiflu)
Limits spread in population and shortens illness in
individuals
Vaccine
Takes 4 – 6 months to be ready
Prevents infection in most people

Surveillance
1. Important for measuring progress of pandemic
2. Identifying high risk groups to target control measures
– Eg pregnant women in 2009 pandemic
1. Measure impact of pandemic
2. Develop laboratory diagnostic strategy to monitor viral changes

Potential impacts on Non Health SectorsPotential impacts on Non Health Sectors
Pandemic could infect 25 - 35% of World’s PopulationPandemic could infect 25 - 35% of World’s Population

The Readiness Framework for
Whole 0f Society Approach
1. WHOLE-OF-SOCIETY
APPROACH
3. CRITICAL
INTERDEPENDENCIES
2.
PREPAREDNESS
AT ALL
LEVELS
4. SEVERITY-BASED
RESPONSE
5. RESPECT FOR ETHICAL NORMS

Business Continuity PlanningBusiness Continuity Planning
(Organizations, facilities, departments)(Organizations, facilities, departments)
Step 2
Identify your business’
core services, essential
staff and skills
Step 1
Establish a
pandemic/contingency
planning team
Step 3
Plan for staff absences
Consider effects of supply
shortages, lack or excess
demand on operations
Step 4
Step 5
Identify &
communicate critical
interdependencies
with other sectors
Step 6
Test your plan, revise it
and know when to
activate and when to
de-activate it
MaintainMaintain
essentialessential
servicesservices
BusinessBusiness
ContinuityContinuity
Develop measures for
maintaining services
(HR, IT, relocation, etc.)

Communication in a
pandemic

What does risk communication do?
Three paradigms:
1. Low concern → increase concern, motivate them to
appropriate action.
2. Excessive alarm → diminish concern, deter them
from unnecessary and harmful action.
3. Justifiable concern→ harness and guide into
appropriate action

People see things differently
Public
Public health
officials
Bacteria, virus, fungi,
other microbes
Disease
Symptoms
Fever
Cough
Sore throat
Body ache
Diarrhea
Hard work,
Stress,
Getting wet in
the rain,
Mosquitoes,
Evil eye/
Superstition

Risk Communication
1. Trust – without trust, audience will not believe in,
or act on, health information
2. Announcing early – forms important first
impression.
3. Transparency – maintaining trust requires
transparency,
4. Listening – to understand audience perception
of risk
5. Planning

…All in a High-Pressure Situation
Limitedtreatmentoptions
Uncertain,
rapidly
evolving
situation
Probably no vaccine
May not directlyreach all people withintervention
Political sensitivity
Economic
impact
Multiple players
involved, each with
own goals

Emergency Communication Demand
 Analysis further suggests it is not only workload that increases
 Emergency communication typically has unique characteristics:
– Shift from national to international interest
– Non-health media involvement
– Economic consequences
– Direct involvement of senior political actors

Bridging the gap between the media
and public health experts:
 Regular health sector/WHO meetings with media helps both sides to
understand the needs and constraints faced.
 During health emergencies, the health sector should have a spokesperson and
ensure regular briefings for the media and provide key technical points in
writing to ensure accuracy in reporting.
 The health sector should adopt the use the internet technologies to bridge the
information gap in a fast-moving situation, (virtual press conferences, upload
latest information on home pages, SMS alerts).
 Health sector should use social media proactively to disseminate health
messages to the media, to local doctors and the public, particularly to counter
misinformation.
 Media briefings should be in simple language to ensure their correct
understanding.

Bridging the gap between the media
and public health experts:
 Field visits set up by the health experts are extremely useful in demonstrating
key health issues and serve to enthuse journalists and also in providing them
with new and surprising angles for their stories.
 Where the health sector can provide video clips/video news release, it helps
electronic media to carry a story with ready visuals.
 Health organizations should add to the technical information with examples
and “human interest” stories to help the media and public relate to the
messages emotionally as well as intellectually.
 There should be more training/public health courses for health journalists to
provide them with a greater understanding of public health issues.

Conclusions
Pandemics will occur, threats exist
Preparedness still needed
Responding to a pandemic is multi sectoral
Communications is a vital component of a pandemic
response

Thank You

What does a pandemic look like? – Dr Graham Tallis

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