Summary report of a High-Level Consultation: new influenza A (H1N1) - Geneva, 18 May 2009

INFORMATION NOTE/2009/2
20 May 2009

[Original Document: LINK. EDITED.]


INTRODUCTION

1. In view of the threat posed by the current outbreak of new influenza A (H1N1), the Director-General of the World Health Organization convened a High-Level Consultation for all Member States at the start of the Sixty-second World Health Assembly.
2. The consultation provided an opportunity for Member States to share experiences, to discuss lessons learnt, and to highlight the challenges that now confront the world community. The list of main speakers and programme is given in the Annex.

CURRENT EPIDEMIOLOGICAL SITUATION

• 3. As at 18 May 2009, 40 countries have officially reported 8829 laboratory-confirmed cases of new influenza A (H1N1) infection.
• 4. Countries reporting the largest number of confirmed cases include: the United States of America (4714), Mexico (3103), Canada (496), Japan (125), Spain (103) and the United Kingdom of Great Britain and Northern Ireland (101). Together these six countries account for 97.9% of the total number of confirmed cases.
• 5. A total of 74 new influenza A (H1N1) infection-related deaths have been reported from four countries: Mexico (68), United States of America (4), Canada (1) and Costa Rica (1). The majority of deaths have occurred in persons below 60 years of age.
• 6. The virus is transmitted sufficiently easily from person-to-person to sustain institutional and community outbreaks and to spread regionally.
• 7. Most cases of new influenza A (H1N1) infection seem to be mild and self-limited and do not require admission to hospital. However, severe illness and death have been reported in a small proportion of cases.
• 8. In seasonal influenza, the overwhelming majority of severe morbidity and mortality occur in persons of 65 years of age or more. However, with new influenza A (H1N1), a substantial proportion of the cases of severe illness and death has occurred among young and previously healthy adults.
• 9. In addition, severe illness and deaths have also been reported in adults with underlying medical conditions including: chronic lung or cardiovascular disease, diabetes, immunodeficiencies and obesity. Moreover, pregnant women may be at increased risk of complications from new influenza A(H1N1).

KEY UNCERTAINTIES

• 10. The only thing certain about influenza viruses is that nothing is certain.
• 11. It remains uncertain how fast the new influenza A (H1N1) virus will spread throughout the world and whether it will become widely established.
• 12. It remains uncertain whether the infectivity and virulence of the new influenza A (H1N1) virus will change over time.
• 13. To date, most infections of new influenza A (H1N1) have occurred in the northern hemisphere. There is concern that the spread of the virus to the southern hemisphere could have different and perhaps more severe effects than seen in the northern hemisphere, particularly since the populations in the southern hemisphere are generally more vulnerable. These groups are younger and often live in crowded urban settings.

LESSONS LEARNT

• 14. Being prepared has made a vital difference: Investment in developing national and regional pandemic preparedness plans over the past five years has paid major dividends. People and institutions know what to do and have been ready to work with each other. Even where the recent outbreak has revealed weaknesses in planning, there is now an opportunity for these to be remedied.
• 15. The International Health Regulations (2005) have been tested for the first time in a public health emergency affecting multiple countries and the experience has shown that Member States are prepared to meet their 2005 commitments. The importance of transparency, rapid information sharing, collaboration between and within countries were key themes in many presentations.
• 16. Success depends on a multi-stakeholder approach: Many preparedness plans emphasize a whole of government approach. Recent experience from the countries currently most affected shows the value of including others (for instance international agencies and neighbouring countries) in what are otherwise exclusively national discussions. Communication with the pharmaceutical and vaccine industry and with experts from other relevant fields started immediately and continues. No one organization can succeed alone – harnessing the energies of the private and voluntary sector is essential. A successful response is one that engages a well-informed public as active partners in the ongoing response.
• 17. Effective communication is paramount. Real-time exchange of information has been a key feature of the response so far. The short time that elapsed between first reports of the outbreak, diagnosis and international action illustrates this. Communication with the general public is equally important, balancing the need to make people aware of risk without causing panic, and, on the other hand, avoiding complacency. This is a particular concern given the uncertainty inherent in how the new influenza A (H1N1) virus will evolve. Evaluating the effectiveness of communications (levels of public awareness, degree of concern) is a key element of the strategy.
• 18. Science-based approaches remain the bedrock of the response: The outbreak is at different stages in different countries and continents. In some circumstances a policy of aggressive containment appears to have limited the spread of infection, and has bought time for more extensive preparation. In others, containment is no longer feasible and mitigation of impact is the logical approach. In either case, and in deciding on how and when to move from a policy of containment to mitigation, the vital factor is having good data for decision-making. Participants strongly reaffirmed the need for policy – in relation to the disease itself and to any restrictions imposed on the movement of people or consumption of goods – to be based on scientific evidence.
• 19. Health systems matter: Many of the countries that have been affected to date stressed the importance of universal access to health care, and the need for strong primary health care. The health system is vital at all stages in the response to the pandemic: from detection and confirmation of cases to providing care, treatment and advice to those affected. Ensuring continuity of health care services is a key part of preparedness planning. This may include plans for how those affected can access treatment – by phone, Internet, or through community health care workers – without having to attend health-care facilities themselves.

CHALLENGES

• 20. Participants stressed that the response had shown many of the most positive aspects of collaboration, for example citing it as “living proof of the value of international cooperation”. They also pointed to the benefits that had accrued from unequivocal leadership. At the same time, they pointed to many challenges that will have to be faced in the future, most particularly if a second wave of transmission causes more serious illness. Some of the challenges are technical, others more of a political and institutional nature.
• 21. Seasonal and new influenza A (H1N1) vaccines: Given the number of deaths still caused by seasonal influenza; the time and uncertainty involved in developing new vaccines specific to the new influenza A (H1N1) virus; and the manufacturing capacity required to meet new demands; there will be a series of difficult decisions that have to be taken in coming weeks and months. WHO is already engaged with the vaccine manufacturers and these issues will be further debated at the Sixty-second World Health Assembly.
• 22. From containment to mitigation: Several countries appear to have limited the spread of the virus. They recognize, however, that the sustainability of containment strategies may be limited. They will seek advice and guidance on the point at which it is most appropriate to modify their approach.
• 23. Guarding against complacency: In current circumstances dropping the world’s collective guard is a major risk. To date, most of the new influenza A (H1N1) cases have been mild, but this situation might change, possibly rapidly. Expecting the unexpected will be essential; keeping the public appropriately engaged will be a considerable challenge in many countries.
• 24. Maintaining surge capacity and institutional coordination: Particularly for small countries, ensuring an adequate response in terms of the human resources needed to manage the surge capacity and institutional coordination will be also a challenge. In addition, while the immediate response has shown the power of intra- and intergovernmental coordination, sustaining that effort over the long term will not be easy, in both countries and international organizations.
• 25. Sustaining solidarity: Several participants pointed to the fact that this disease has first affected countries best able to cope with its consequences. In addition, some of these countries have not only devoted significant resources to dealing with the outbreak within their own borders, but have also provided material and financial support to others. Many countries are not in such a good position to confront a potential pandemic, either in terms of their preparedness plans, their capacity to access medicines and vaccines, or the strength of their health systems. The fact that some countries are better able to cope than others poses an immediate challenge to global solidarity. Should a more virulent second wave of the disease occur, the challenge of sustaining solidarity will inevitably become more acute.
• 26. Protecting lives, restoring livelihoods: Recent outbreaks have amply demonstrated that epidemics have both human and economic costs. This is due both to the impact of the disease itself, and also due to measures taken to control its spread. The response to the new influenza A (H1N1) virus needs to acknowledge the potential economic impact on individuals, communities and countries from the outset.

CONCLUDING THEMES

The overriding objective is to mitigate the adverse impact of the new influenza A (H1N1) on the health of people and populations.

Facilitating a global response

• 27. Member States agree to work with the Secretariat to assure ongoing, rapid dissemination of epidemiological information and technical guidance based on scientific evidence concerning the current situation. Monitoring and tracking the global spread and impact of the new influenza A (H1N1) virus is being strengthened. This will support better understanding of the virus’s epidemiology, its virological characteristics, diagnosis, clinical management, outbreak control and strategies, etc.
• 28. Through its convening power, the Secretariat will continue to facilitate a multilateral and multisectoral response and maximize collaboration between partners.
• 29. In addition it is providing ongoing technical assistance to countries for epidemic preparedness and response, with a focus on the most vulnerable countries.

Ensuring equity in access to medicines and vaccines

• 30. Given the potential impact of pandemic influenza on populations in low-income countries, where other medical conditions are widespread, concern remains about access to antiviral medicines and vaccines.
• 31. The Secretariat has dispatched antiviral medicines from its emergency stockpile to 72 countries so as to accelerate their availability where they are most needed.
• 32. WHO collaborating centres are developing seed stocks of virus for vaccine production. Close links are being maintained with the pharmaceutical industry and potential financiers to ensure an adequate global manufacturing capacity, and funding for production and distribution of new influenza A (H1N1) vaccine and other relevant medicines.

Building public health capacity

• 33. Building institutional and technical capacity in low-income countries, especially in laboratory services, is needed if the world is to mount an effective response. Securing finance for building this capacity – as a key element of health systems strengthening – will be essential.

Moving from Phase 5 to Phase 6

• 34. The current process is based purely on geographical spread and not on severity of disease. Several Member States spoke in favour of giving the Director-General greater flexibility in the progression between different phases.

ANNEX

HIGH-LEVEL CONSULTATION ON NEW INFLUENZA A (H1N1) - 12:00–14:00 18 MAY 2009 - SALLE 17, PALAIS DES NATIONS, GENEVA

• Introduction
  • Margaret Chan, Director-General, WHO
• Overview of the current epidemiological situation
  • Keiji Fukuda, Assistant Director-General ad interim, Health Security and Environment
• Report from the Emergency Committee
  • John S Mackenzie, Chair
• Country reports
  • Mexico:
    • Jose Angel Cordova Villalobos, Secretary of Health
    • Arturo Cervantes, Director General of Prevention of Accidents Programme
  • United States of America:
    • Kathleen Sebelius, Secretary of Health and Human Services
    • Richard Besser, acting Director, Centers for Disease Control and Prevention
  • Canada:
    • Leona Aglukkaq, Minister of Health
    • John Spika, Senior Medical Adviser, Public Health Agency of Canada
• General discussion
  • Country experience and questions from Member States
• Closing comments from the Panel
• Conclusions
  • Margaret Chan, Director-General, WHO

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