FULL TRANSCRIPT OF JUNE 9 VITUAL PRESS CONFERENCE

Transcript of virtual press conference with Dick Thompson, Communications office, and Dr Keiji Fukuda, Assistant Director-General ad Interim for Health Security and Environment, World Health Organization9 June 2009

Dick Thompson: Welcome to the WHO 5 o'clock virtual press briefing. Today’s briefing, Tuesday 9 June, is an update of influenza A(H1N1) situation with Dr Keiji Fukuda. We will start with a statement by Dr Fukuda and then we will take your questions. I would now like to hand over to Dr Keiji Fukuda.

Dr Fukuda: As usual with this briefing, I will do a quick update then there are some issues that I will highlight, and then I will throw it open to questions. As of today, which is 9 June 2009, the number of countries reporting laboratory-confirmed cases to WHO is 73 and the number of laboratory-confirmed cases reported to WHO is 26 563. This is a little bit more advanced than the numbers that are posted on the web right now. In these cases, this includes 249 deaths (this was an error and was corrected later). In terms of what we are seeing right now, we continue to see the spread of this virus evolve and we continue to see new countries report the virus, and we continue to see evolution of activity within countries. As we have for the past several weeks, we continue to see ongoing infection occur within community in North America but we also have increasing reports of activity occurring in the Southern Hemisphere, particularly from South America and countries such as Chile, as well as from other countries, such as Australia. We know that Australia, for example, is seeing a great deal of activity in Victoria at the community level. In addition, similar to the activity in previous weeks, we continue to note that there is activity going on in Europe. In terms of the virus, at this point, it is fair to say that the virus that we are seeing is relatively the same as the virus that we saw several weeks ago and there are no major changes to report at this time. The virus continues to be sensitive to oseltamavir and zanamivir, two antivirals drugs usually against this virus. In terms of the epidemiology, we continue to see that the majority of infections are occurring in younger age groups, people younger than 60 and this is not exclusive. There are infections that are occurring in older people. In terms of the clinical picture, what we are seeing in the southern hemisphere is similar to what has been reported from the northern hemisphere. That is, most of the people who have gotten infected have self-limiting illness which can be taken care of at home, or without specialized medical care and these people recover. However, as noted, there have been a number of serious cases – typically these are pneumonia cases or cases of respiratory failure sometimes requiring ventilators, sometimes ending in fatalities. Much of the earlier epidemiology of this situation was characterized by seeing infections occur in travellers, in institutions such as schools, sometimes military institutions and cruise ships. As we see the situation evolved, we know that outbreaks can occur in communities. And again this is the overall pattern that we are seeing. There are some examples, however, that we are paying very close attention to. For example, up in Canada, we know that there are reports of infections occurring in Inuit communities with a disproportionate number of serious cases occurring. These are observations of concern to us. Now, there have been a number of questions which have been posed to WHO over the past weeks since we last had a press briefing, so what I would like to is go for a couple of them. For example, one of the most basic questions that has come up is simply “What is a pandemic?” So here let me review what we are seeing and why we consider this situation which is potentially evolving into a pandemic. What we are seeing right now is the emergence of a new influenza virus that has not been previously known to infect people. What that means is that most people in the world really have very little background immunity to such a virus. We are seeing that this virus is spreading rapidly around the world, again the characteristics of previous pandemic viruses, and we are also seeing that the disease patterns caused by this virus are not what we see for seasonal influenza. For example, in the northern hemisphere we have seen a great deal of activity occurring in the summer months, and we also have seen that most of the infections are occurring in younger people with the serious complications also occurring in the younger people. Again these are patterns which are not what we see with normal seasonal influenza. When you put all of these things together, what it really suggests is that we are in a situation which is really moving towards more or less a pandemic type of situation. The pandemic really refers to the fact that we are seeing the geographical spread of a virus that is causing this disease. The second question that has come up is about the name of the virus. We know that the situation has been confusing. For example, right now, we know that there are H1N1 viruses which have been circulating in people for a number of years. This is a new H1N1 virus. And we also know that there had been H1N1 viruses which had been circulating in swine or in pigs for many years. And this has really led to a complicated situation of what you call a new virus. One of the primary concerns and one of the difficulties of naming such a new virus is to avoid adverse effects, or stigma associated with a virus name, especially if it causes some unwanted effects in either some sector or in some groups of people. For example, we have seen in association with this outbreak concerns about food, concerns about pigs, which for our practical purposes are not warranted. Food has been perfectly safe, pork meat has not posed a danger for people, yet there has been a fair amount of anxiety associated with the virus originating in pigs and so to call this a swine flu virus is something that is really has a lot of potential for causing greater anxiety associated with eating pork or with these animals which is unwarranted. We have also seen that in past pandemics, the naming of viruses associated with geographical locations can often lead to a stigma and erroneous association that somehow the virus is more dangerous in an area, or perhaps associated with an area. This can manifest itself by travel restrictions or travel concerns that may not be warranted. And so again, in approaching the whole issue of naming the virus, these are some of the issues with which many people – not just WHO – but many people in scientific societies and different groups have been wrestling with. We hope to come up with names that are easy enough to remember, easy enough to use but really do not cause harm for either people or for sectors. This is one of the issues that has been wrestled with right now. Another question that has come up is that “Are we in Phase 6 now, or why haven't we declare Phase 6 now?" In here I think I simply want to say that we know that the virus is spreading and we are now seeing that activity is picking up in a number of countries and this is, as I had mentioned before last week, we know that we are getting closer to probably a pandemic situation. But in the period of time since we last discussed this, I want you to know that WHO has been working extremely hard in terms of preparing countries, in terms of preparing populations for what a potential move to Phase 6 or pandemic would entail. For example, there is work that is being undertaken right now so people understand really what does a pandemic mean, what does going to Phase 6 mean? Does this mean that we are seeing something really severe change? Does this mean that there is a need for drastic actions to be taken? And here I want to point out that by going to Phase 6, what this would mean is that spread of the virus has continued and that activity has become established in at least two regions of the world. It does not mean that the severity of the situation has increased and that people are getting seriously sick at higher numbers or higher rates than they are right now. This is a very important point for countries to understand, for the media to understand, even if it is a little bit paradoxical. You would think that by going up scale would mean that the level of concern should go up, but really what the going up a scale would mean is that we are seeing greater spread of the virus. We are working with different groups to make sure these kinds of messages are understood and the difference between severity and geographical spread is understood. As I discussed last week, right at this time, we considered the situation and the impact on countries to be relatively moderate, and this is again a critical point. If there are some uncertainties, I hope you come back with questions on this. One of the other things that is very important to understand and there has been a number questions about this, are changes over time. We are, as we have pointed out, I think a number of times in the past, at the beginning of the spread of this virus. Unless this virus suddenly disappears overnight, it is likely that the spread of this virus will continue and that activity will increase in some countries and go up and down in other countries. Now we know from past pandemics that in these kinds of situations, we can expect potential changes as we go through different populations and overtime. What does this mean? Well, it means that if we see spread of this virus into populations which are especially vulnerable, it means we may see more severe disease than we would see in populations which are relatively well off. I think the current reports coming from Canada about what has been seen in some of the Inuit villages is a good example of this. These are some of the potential changes that we know we could see as the virus moves through the southern hemisphere, different kinds of changes may happen overtime. If we look to the past, we see that how the outbreaks have behaved early on in a pandemic can be different than how the outbreaks occur later in the year, and months later. Again this whole concept that situation can change is important for everybody to understand because things may need to change, may need to be adapted, actions to be taken by countries and by people, and so on if situations change. The last point that I will cover before we throw it open for questions is really another difficult issue. This simply has to do with uncertainties. Whenever we see a new disease, whenever we see any kind of large series of outbreaks caused by viruses that are new to the scene, we are in a period of great uncertainty. This is true of the current period right now. One of the difficulties for decision-makers and countries and public health institutions is that they need to make decisions, they need to move ahead even though many things are not so clear or are not known. To give you an example, right now, we know what the impact of the virus has been up to now in countries that are relatively developed, or in a number of other countries in which the number of infections has been relatively small. But we do not know what the impact on the population would be as the numbers of infected people grow in populations, for example, in Africa or other continents where they may be large numbers of vulnerable people. We also do not know how this virus is going to evolve. It could become more mild over time, or it could become more severe over time, or it could stay pretty much as it is now. These are uncertainties that we have to take into account but we really do not know how that is going to go forward. Finally, we also do not know how in this global era in which there is so much media coverage, how populations will respond if we move to a pandemic situation, or a pandemic declaration. For example, will the kinds of information being provided by countries and by media really be enough to address the anxieties of people or will people feel more anxious in this situation, and then how would they behave? These are really important considerations for public health authorities and for people who are working to make sure we have balanced an approach and a balanced response to handling the situation as possible. So at this current period right now, as we see the situation evolve, I can just summarize that WHO and its many partners, the Member States, the many public health institutions we are working with are really working to make sure that as the situation evolves we take all possible steps to reduce any adverse effects, any unwanted actions associated with uncertainties of a pandemic situation. With that let me stop and then let us throw it open for questions.

David Brown, The Washington Post: I am wondering if you can talk a little bit about the deaths and hospitalizations among people who do not have underlying medical risk situations or states that put them at higher risk? And I am wondering if there is any entity that is trying to sort of aggregate those serious cases that do not have underlying complications to try to see what might be going on, what obvious, or if there are any risk factors that can be elucidated that are not obvious ones?

Dr Fukuda: Even though the proportion of people dying who were previously healthy with those who are dying with some kinds of pre-existing medical conditions vary somewhat from location to location. It is probably fair to say that approximately half the people who have died from this H1N1 infection have been previously healthy people. This is one of the observations that has given us the most concern. I think that some weeks ago there was a lot of push by different groups to say that the pandemic was mild, that the disease was mild, but from the outset and from the reports coming from Mexico, we knew that a number of the deaths had taken place among younger people who were previously healthy. This is a kind of pattern that we have seen with the H5N1 virus, this is a pattern and a consequence that we have seen in earlier pandemics and so it did and it continues to give us a great deal of concern. Among those people who have died – or previously healthy people who have died – from this viral infection, we know that some of them have died with clinical pictures consistent with respiratory failure, probably consistent with viral pneumonia. That is when the virus itself directly infects the lungs and causes infection, as opposed to secondary bacterial infections. But I do not think we know really why did those people die as opposed to the many other people who recovered, what kinds of underlying factors led to fatal illnesses. There are a number of institutions, a number of physicians who are looking at these cases and trying to understand if there anything that can be uncovered which provides some clues as to why some previously healthy people end up having fatal infections. Right now it is not possible to point out what may distinguish that group from other healthy people.

Helen Branswell, the Canadian Press: Dr Fukuda, at the beginning of your remarks you said that in Australia a great deal of activity is being seen in Victoria at the community level. Why then has the WHO not declared a pandemic, is there any doubt in your mind that this is a pandemic at this point?

Dr Fukuda: I think that we are really getting very close to that and I think that we again, as I elaborated in one of my points, one of the things that we are really focussing on right now, is to help countries, help institutions, help the media really understand what are pandemics, and really to provide as much information as possible so we reduce the chances for any adverse effects. Adverse effects would be panic, adverse effects would be misunderstandings that may lead to actions which in the end really just cause more anxiety among people and so on. Right now we are really working pretty hard to try to get these kinds of messages, this kind of information, out to people. Again I think that we are very mindful of what is going on in Australia and a number of other countries, and I will simply say that we are getting closer.

Fergus Walsh, BBC London: It is a follow up really on Helen's question which is, I've been speaking to infectious disease experts in Australia and they have said that given that there are now over 1000 cases in Victoria, that really the pandemic has started and they pointed out to me that they are actually stopping doing community level testing in Victoria because there are so many cases, they will now just be testing people to go into hospital and a couple of people out there rather wondering why you haven't declared a pandemic when this virus is really well established in the community and it sounded from your answer that in effect – and I don't mean this as a criticism at all – but it's a question of managing the media and managing the effects of when you go to Phase VI rather than the reality of the fact that we do have widespread outbreaks in at least two WHO Regions.

Dr Fukuda: I think that the declaration of Phase changes, the movement from one Phase to another, is not simply getting up in front of press cameras or making an announcement. It is again a way to prepare the world to deal with the situation, and so what is the situation? Well, it is the spread of this virus, the disease that it is causing. In doing so, there really is a great deal of work that has to be done. This is to prepare countries so that they have the kinds of information, the knowledge, the tools to handle increased numbers of people who may be sick, to handle the kinds of enquiries coming from their population about what to do, what does this mean. And it also means trying to make sure that all the steps that can be taken, are being taken. So right now we feel that the essential steps that should be taken are underway. A lot of work is being done on communications, a lot of work is being done for example on vaccine development, a lot of work is being done on improving the antiviral supply, a lot of work is being done on developing clinical guidelines and providing updates on the science and so on, developing networks of calls where we get the clinical information and so on. All of this work is really what is needed in order for the world to deal with these kinds of situations. For WHO, the most important principle of all of this, is that the actions that we take, the announcements that we make, really are there to help people, to help countries, to make sure that we have as positive an effect as possible in making basically countries and populations as resilient as possible. This is not managing the media, this is not nuancing messages, this is really getting countries and organizations and populations ready so that they can handle and deal with this virus as well as possible. This requires a lot of effort and a lot of time and this is what is being done right now.

Jonathan Lynn, Reuters, Geneva: Dr Fukuda, I just wanted to check what you said at the very outset where you referred to 249 deaths and the figures of yesterday was only 139, that seems a very big jump, and I wanted to know if I had heard that correctly, and if so, what is the explanation for that. I had a second question as well but would you like to take that one first.

Dr Fukuda: Jonathan, let me actually ask for a verification on that and let me come back to you. Can you give me your second question.

Jonathan Lynn, Reuters: Is what you were saying about the reasons for going to level 6 and how it has to do with geographical spread and not severity, and I had the impression from what you were telling us last week and in other recent statements that the WHO is looking very much at severity and wants to incorporate that into the final declaration of a
pandemic. Have I just misunderstood that, or has there been a change in your thinking in recent days.

Dr Fukuda: Let me again try to clarify this. When we talk about the declaration of the pandemic, if we go back a few weeks ago, we were talking about how WHO had been approached by a number of countries, again through meetings such as ASEAN and at the World Health Assembly, to look at all of the information that would be needed to move from Phase 5 up to Phase 6 – a declaration of a pandemic. What we consistently heard from those meetings and the countries, as well as from a round of consultations that were held with experts from many countries, from 23 countries, as well as public health experts, was that it was important for WHO to also explain the level of severity of the current situation with any announcement about a pandemic. And the way to look at it is that we consider going out and explaining to people about the severity of the situation as an essential part of the announcement of a pandemic. However, the pandemic itself really does reflect the spread of the virus and the establishment of community level infections and activity in multiple regions. I hope that is clear. One part has to do with what does it actually mean that we have a pandemic but the severity is really critical information requested by everybody so that they can basically know how to take the news and what kinds of actions are appropriate to initiate in the countries. I hope that is clear.

Bryan Walsh, Time Magazine: Since it really seems as if the community level spread you are seeing in Australia, it does meet that definition for Phase 6, is there some threshold you are looking for in terms of this behind the scenes understanding or preparation. Are you looking for that once met you would feel more comfortable moving the definition up to Phase 6 What is it you are looking for when you are making these preparations because it seems as if your case numbers are not really the case here?

Dr Fukuda: Yes, it is not really strictly a matter of numbers. Of course, what we have stressed in the past that more important than the numbers themselves, is the establishment of spread in communities. And again, like you, we very clearly see what is going on in Australia and what we are doing is working very hard to make sure that the countries or partners, that everybody is in the best position as we get closer to a Phase declaration. As I responded to some of the earlier enquiries, I think it is fair to see that we are really getting close to this situation, but we are working very hard to make sure that everybody is as prepared as possible.

Richard Knox, National Public Radio: My connection got interrupted so I may be repeating what other people have asked and what you have already answered. I apologize. First, could you just characterize in somewhat more details what WHO is seeing in Australia and how it relates to your previous statements on the type of spread. You have for instance made a distinction before about spread that is within institutions, or expected kinds of exposures such as people in events versus wider community spread. I would just like to know how you see things in Australia. And then secondly – and other people have touched on this – but I'd just like to be as clear as we can. You know people do expect WHO to be clear and timely and they expect us to be able to explain what you are saying and I think we are all in an awkward situation at the moment. I wonder if you could give us a little bit more guidance on when you do expect to be ready to state what seems to be increasingly obvious.

Dr Fukuda: This is similar to some of the earlier questions. We were actually discussing the situation with Australia today and in Victoria, it is clear that they have been seeing outbreaks occur in both institutions such as schools, but they have also seen infections occurring in other people who are not students in these schools, and the situation has really evolved a lot over the past several days. In response to your question, we are getting really very close to knowing that we are in a pandemic situation or I think declaring that we are in a pandemic situation. Over the past week or so, when we had a discussion at the last press briefing, again I noted that we were getting closer and I think we are again much closer to that, but what we have been doing, what we have been focussing on, in the past week is really all of the preparations that we think are important for going to that kind of announcement by WHO. It is not simply a matter of just going out and saying that we are in pandemic Phase 6, it is really a matter of making sure that countries are as prepared as possible, that they have the right tools to handle the situation, the right kinds of guidance, are able to address the concerns of the populations as well as possible, with the overall goal of WHO being that everybody – countries, their populations – are really as prepared as possible for knowing that we are in a pandemic situation. For example, one of the critical issues, is that we do not want people to over-panic if they hear that we are in a pandemic situation and that they understand that the current assessment of the situation is that this is a moderate level and that, for example, countries may have a variety of options to take in terms of responding to a pandemic in a moderate situation. Again, these are some of the things that we want to make sure, get out there that people are hearing them so that there is not really a blossoming of anxiety. This is one of our concerns, that countries are not adversely affected and their people are not adversely affected by going up to Phase 6.

Jan Gold, DPA, Geneva: I just wanted to understand if you can just specify what exactly would be an adverse reaction. You keep mentioning this word “handle”, that governments have to handle. What exactly do you expect governments to do if and when apparently you declare Phase VI and what do you expect governments to do and what type of adverse reactions could possibly occur?

Dr Fukuda: First let me clarify the number that came up earlier. The number I gave you on the number of deaths was erroneous. The number of deaths is 140 so rather than the 249 – if you can make that correction – that is the number of reported deaths from this virus to WHO is 140. In terms of examples of adverse reaction that we would like to either see not occur or have them be reduced. When we first announced about this virus and the situation, there were certain actions that were taken such as questioning the safety of pork, there was culling of pigs that went on, there were trade embargoes which were issued, there were concerns about travellers coming from certain areas, and there was concern over border closures or travel restrictions... a lot of those kinds of questions came up. These are the kinds of potential adverse facts that you can have if you go out without making sure that people understand the situation as well as possible. In earlier outbreaks, in earlier pandemics, we have often seen that people who are in the category of being worried, but who were not particularly sick, have overrun hospitals, that sometimes the number of patients can lead to a dysfunction in the health system, simply because there are so many people going to emergency rooms and this can adversely affect people who in fact requires those emergency facilities. There is a potential number of
consequences like that, that we would like to really make sure that the chances are minimized. These are some of the potential consequences that we are trying to reduce the chances for.

Aline Gobert, CBC: What is happening in the Indian community in Canada, in the First Nation community? Is it just a question of maybe means, the fact that those populations are very poor, or could it be some racial or some genes among First Nations in Canada that could be of the same far away family than the Mexican people who were sick also?

Dr Fukuda: What we can say is that when we look at past pandemics, we know that some groups of people, some populations have been particularly hit hard. For example, in some of the earlier pandemics, pregnant women have been a population that was hit very hard, much harder than most people, than most groups of people. We also know that outbreaks of regular influenza, in some communities, the effects can very severe. We have seen outbreaks of seasonal influenza take place in some African communities with the effect that significant numbers of children died, and significant numbers of older people died and in those instances, it is not really so clear what specific factors increase the disease and the severity in the populations: what is poverty, what is some other underlying disease, it is often not very clear. In terms of the Inuit population, we know for example that some of the background level of chronic diseases can be higher in this population. These have occurred in villages that are relatively isolated although there are good health care services available. At this time we can say that we know a larger number than expected of young Inuit people did developed serious illnesses and had to get hospitalized. I do not think we know whether this reflects one characteristic, whether it reflects socio-economic factors, whether it reflects genetic factors, whether it reflects chronic underlying diseases. This is not possible to say at this time. We do know that in past pandemics, Inuit populations were very severely hit, and this is why these reports raise such concern to us. That is about the level of information that we have right now.

Maria Chang, Associated Press: I was wondering if you could clarify where WHO is in terms of redefining the criteria for Phase 6? You mentioned a couple of weeks ago that you were going to re-examine if there should be other things like severity, and now you sort of partly address that and I wonder where we stand with that and if there is going to be a new definition? And secondly am wondering if there is any concern at WHO that there may be community spread happening in certain countries in Europe, like say Britain, that are not reporting, are not testing for it. Do you think you are getting accurate information from these countries?

Dr Fukuda: In terms of redefining Phase 6, what we have decided to do is not so much “redefine” Phase 6, but to stay with the current criteria, really to augment the information provided when an announcement is made to Phase 6. Augmenting it really means coming out and explaining what we consider to be the severity of the pandemic, and also to come out with information for countries in terms of how to tailor them some of responses to the pandemic situation, which may differ from the pre-existing national plans. One of the issues that countries have been struggling with right now is that many of their existing pandemic plans where really based on a more severe scenario – the spread of the H5N1 virus – and some of the actions which their plans call for may be inappropriate. One of the things that we would like to do is, in addition to making any announcement about going to Phase 6, also discuss the severity of the situation, and also provide guidance to countries about how to modify and tailor the response actions to meet the current situation, and not to be so locked into by the pre-existing plans. In terms of Europe, we know that the situation has been ongoing and continuing in some of the key countries. There has been a lot of attention being paid to the UK and to Spain over the past several weeks, both by the media as well as by the countries themselves, but in fact there is infection in a number of countries and reported by a number of countries in Europe. Our primary concern is not so much the numbers that are being reported. All of the countries without exception are working really quite hard to get a sense of what the situation in a country is and to report that information to WHO. It is really quite a different situation that we have seen in some of the other global and big outbreaks in the past. Countries are really working very hard to provide whatever information they can. Our biggest concern is whether the recommendations, whether the actions being taken by countries should be underway to handle the situation right now, and so whether the information that is being provided by countries, whether the actions being taken to develop important tools such as vaccines are underway. That is really where at WHO our primary focus is on. Are the critical public health actions being undertaken? In here we feel pretty comfortable that what can be done is really being pushed forward right now.