Humanitarian Initiative to Prepare for a Pandemic Influenza Emergency (HIPPIE) Ron Waldman, MD Avian and Pandemic Influenza Unit USAID/Washington
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1 Humanitarian Initiative to Prepare for a Pandemic Influenza Emergency (HIPPIE) Ron Waldman, MD Avian and Pandemic Influenza Unit USAID/Washington
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4 Objectives of Presentation Review current status of avian influenza (very briefly) Discuss why USAID should care What USAID proposes to do about it
5 What is the difference between an epidemic and a pandemic? Epidemics occur every year due to minor changes in influenza A viruses that circulate Pandemics happen only occasionally when a completely new influenza A virus circulates A really large worldwide epidemic Results in more severe illnesses and more deaths
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7 How do yearly epidemics occur? Antigenic Drift Imperfect manufacturing of virus Small changes in H and N components due to random genetic mutations Can prevent the body s immune system from fully protecting against the virus, and re-infection can occur Reason for yearly flu vaccination Reason that 1 or 2 of the three virus strains in the vaccine are updated every year
8 Why does a pandemic occur? Antigenic shift Sudden change in the antigenic structure of microorganisms, especially viruses, which produces new strains new strains of the microorganism Hosts previously exposed to other strains have little or no acquired immunity to the new strain Antigenic shift is believed to be the explanation for the occurrence of strains of microorganisms, such as the influenza virus, associated with large scale epidemics. SHIFT HAPPENS
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10 WHO Classification of Pandemic Phases WHO Pandemic Classification
11 Current Status of Avian and Human H5N1 Influenza
12 Source: OIE (and WHO) reports. * Bangladesh has not officially reported since May. ** No official data on Nigeria, except Jan 07 human case; assumed to be all months of 2007 since AI is endemic. *** Vietnam s outbreaks have run from Aug 06-Nov 07.? indicates that virus may still be circulating in these countries throughout 2007, despite the absence of official reports. Afghanistan15 Bangladesh14 Burma13 Cambodia12 China@ 11 Egypt@ 10 9 Indonesia@ 8 Kuwait 7 Nigeria@ 6 Pakistan 5 Russia 4 S. Korea 3 Thailand 2 Turkey 1 Vietnam 16 Four Countries with Nearly Continuous H5N1 Transmission from Aug 06-Oct 07 Only shown are countries with 20 or more poultry outbreaks since Dec 2003????? 0 J F M A M J J A S O N D J F M A M J J A S O N
13 Most Human Cases and Deaths Occur in Young People Cases (n=290) 7% Age 40+ Deaths (n=193) 7% Age % Age Age % 40% Age Age % Lab-confirmed H5N1 cases in humans reported to WHO between November 2003 and November 12, 2007 for which there is age data.
14 Most Human Cases Not Hospitalized In Time to Get Maximal Benefit from Tamiflu maximum Tamiflu efficacy mean = 4.6 days # human H5N1 cases and deaths % CFR 22% CFR 76% case fatality rate (CFR) Days between symptom onset and hospitalization = cases = deaths Lab-confirmed H5N1 cases in humans reported to WHO between November 2003 and November 12, 2007 for which there is symptom onset and health status data.
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17 Total number of cases includes number of deaths. WHO reports only laboratory-confirmed cases. All dates refer to onset of illness. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO 23 January 2008 Country Total cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths Azerbaijan Cambodia China Djibouti Egypt Indonesia Iraq Lao People's Dem Repc Myanmar Nigeria Pakistan Thailand Turkey Viet Nam Total
18 Top Three Reasons Why You Should Care Reason #3: It has happened before; there is no reason why it will not happen again. There is virtual unanimity in the scientific community that it is a pandemic is a question of when, not if: at a recent meeting, 90% of experts polled said there would be a pandemic within one generation, 15% within 3 years
19 What about past flu pandemics? Credi: US National Museum of Health and Medicine 1918: Spanish Flu 1957: Asian Flu 1968: Hong Kong Flu million deaths 575,000 US deaths 1-4 million deaths 70,000 US deaths 1-4 million deaths 34,000 US deaths Barbara Wallace, New York State Department of Health 2005
20 Cholera in Peru 7 th pandemic began in Indonesia in 1961 and spread to Asia, Europe, and Africa before arriving in LAC (for the first time in one hundred years) in 1991 In 1991, there were 400,000 cases, and 4,000 deaths in 16 countries in this Region In Peru alone, the macro-economic loss was $770 million from trade embargoes and the decline in tourism What was the economic impact at the household level?
21 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
22 Top Three Reasons Why You Should Care Reason #2: The humanitarian consequences of a pandemic could be devastating in terms of lives lost, economic disaster, and societal upheaval.
23 Which is more important, preventing the next war or preventing the next influenza pandemic? Deaths (100,000s) Civil War WWI Spanish Flu WWII Korea Vietnam
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25 Can pandemic influenza have the kind of impact that AIDS has had at its worst? Life expectancy-usa,
26 Top Three Reasons Why You Should Care Reason #1: You can do something about it!!
27 Can a pandemic be prevented?
28 Many epidemiologists feel that early detection, early response, or surveillance and containment, à la smallpox eradication, can work Computer models suggest that it might be possible with aggressive antiviral use (where the pandemic strain emerges, assuming that the strain is sensitive). Conditions include: Non-urban area Rapid detection Rapid intervention (1 to 3 weeks) Secondary cases < 1.8 Prophylaxis 80-90% in region (1-3 million courses) Movement restriction and social distancing
29 Phase IV Preparedness
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32 Q: Which is more important, early detection or early response, or, put differently How is an ineffective surveillance system like a clinical case of polio?
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34 Phase VI Preparedness
35 Come one, come all to the Humanitarian Circus
36 The Singular Goal To limit excess mortality during a pandemic
37 Assumptions Country capacity will be exceeded Vaccines and anti-virals will not be available in adequate quantity Substantial mortality will be due to illnesses other than influenza Time required for action will be limited Funding will be available for response Limiting impact will be dependent on community-level actions
38 I -- Limit Direct Impact Care for those ill with influenza Vaccine? Antivirals? Limit transmission of influenza but how? Community mitigation (non-pharmaceutical interventions)
39 Martin Cetron, MD Director, Division of Global Migration and Quarantine Centers for Disease Control and Prevention 1 Delay outbreak peak Daily Cases Pandemic Outbreak: No Intervention 2 3 Decompress peak burden on hospitals/infrastructure Diminish overall cases and health impacts Pandemic Outbreak: With Intervention Days Since First Case
40 Isolation of those ill Community Mitigation 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)
41 SOCIAL DISTANCING If the birds can do it.
42 II -- Reduce Indirect Impact Treat potentially fatal diseases when health services are disrupted Bacterial pneumonia Malaria Diarrhea AIDS Tuberculosis Diabetes Hypertension and other CVDs Mental disorders and other NCDs Ensure food security Accelerate resumption of livelihoods
43 Proposed Activities Identify human resources Develop detailed plans Adapt normative guidance to local needs Conduct simulations at district/municipal level Train first responders Deploy pandemic flu kits Ascertain material needs Off the shelf response capacity
44 Specifics of USAID Program IFRC United Nations agencies CORE Group Save, World Vision, CARE AI.COMM, STOP AI Interaction Schools of Public Health US Government agencies
45 Foundation for Recent Estimates
46 Illustrative Estimated Mortality
47 Illustrative Estimated Total Deaths
48 Stage I First visit Dec 07 May 08 Proposed Country Selection Stage II First visit June 08 Nov 08 Stage III First visit Dec 08 May 09 Stage IV First visit June 09 Oct 09 Egypt Mali TBD TBD TBD Ethiopia Uganda TBD TBD TBD Rwanda Angola TBD TBD TBD Nepal Bangladesh TBD TBD TBD Cambodia Malawi TBD TBD TBD Stage V First visit Nov 09 Mar 09 Laos Azerbaijan Ukraine Tanzania DRC Madagascar India Other countries being considered Benin Nigeria Kenya Senegal Haiti Bolivia Indonesia Philippines Pakistan Liberia Sudan Peru South Africa Zambia Afghanistan Ghana Nicaragua Mozambique Burundi
49 The Three P s of Pandemic Preparedness Plan Practice Pray (not necessarily in that order)
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54 Recommendation (2005) An improved seismic detection system should be developed and implemented in the region as quickly as possible.
55 The only thing more difficult than planning for a pandemic would be explaining why you did not do it
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