WHO activities in avian influenza and pandemic influenza preparedness

EPIDEMIC AND PANDEMIC
ALERT AND RESPONSE
WHO activities in avian influenza
and pandemic influenza preparedness
January - December 2006
WHO/CDS/EPR/GIP/2006.6

WHO activities in avian influenza
and pandemic influenza preparedness
January - December 2006
© World Health Organization 2007
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WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Contents
Introduction 3
I. Reduce human exposure to the H5N1 virus 6
II. Strengthen the early warning system 12
III. Intensify rapid containment operations 16
IV. Build capacity to cope with a pandemic 19
V. Coordinate global scientific research and development 26
Conclusion 29
Selected WHO information resources 30
Contributing partners 33
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Introduction
The World Health Organization (WHO), its Member States and its partners have been
monitoring the possibility of a new pandemic of human influenza since 1968 when the
last of the previous century's three pandemics began. Concerns were raised in early 2004
following reports that a new highly pathogenic strain of avian influenza, H5N1, was
spreading across Asia, infecting both poultry and people. Although the virus has not yet
gained the capacity for sustained human-to-human transmission, it continues to undergo
genetic changes and has the potential to develop this capacity. By the end of December
2006, the virus had infected 263 people in ten countries from eastern Asia to Turkey1 and
a total of 158 people had lost their lives, almost half of whom died in the last 12 months.
These events have given the world its first advance warning that a pandemic may be near
and an unprecedented opportunity to undertake appropriate protective actions. Pandemic
influenza is a global threat from which no country is immune and the actions required are
a shared responsibility of the whole international community. The experience of SARS
has demonstrated that in the 21st century a pandemic virus could spread throughout the
world in a matter of months, if not weeks.
The principal tasks facing the international community are twofold: (1) reduce the
opportunities for the H5N1 virus to improve its pandemic potential and (2) be prepared
for a pandemic should these efforts fail.
In November 2005, a meeting was convened by WHO, the Food and Agriculture
Organization (FAO), the World Organisation for Animal Health (OIE) and the World
Bank to review the current status of highly pathogenic H5N1 avian influenza in animals
and to assess the risks it posed to humans including the likelihood of the virus developing
pandemic potential.
The meeting agreed that solutions should be based as far as possible on existing
infrastructures and mechanisms at both the country and regional level. Any additional
emergency measures that would be needed should be combined with longer-term
measures aimed at strengthening institutional capacities that would equip the world to
protect itself in the long term against other emerging and epidemic-prone infectious
diseases.
A 12-point action plan was drawn up. WHO is taking the lead in the five key areas that
concern human health: to reduce human exposure to the H5N1 virus, to strengthen the
early warning system, to put in place measures that might contain an emerging pandemic
influenza at its source, to increase the capacities of countries and the international
community to prepare for and cope with a global pandemic of influenza and to encourage
all possible efforts into research and development of pandemic vaccines and antiviral
medications and into improving global production capacity.
1 Countries in which confirmed human cases of avian influenza H5N1 have been reported to WHO:
Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey, Viet Nam.
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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In early 2006, WHO developed and issued its Strategic Action Plan for Pandemic
Influenza 2006–2007. The plan outlines the rationale and the key interventions needed in
each of the five priority areas. It is accompanied by a budget for the biennium totalling
USD 99.40 million dollars.
Since the Action Plan was issued, WHO headquarters, regional offices and country
offices have been initiating and undertaking activities within the framework of the
strategic objectives. The Global Influenza Programme, housed within the Department for
Epidemic and Pandemic Alert and Response at WHO headquarters has overall
responsibility for providing technical leadership as well as having a central coordinating
function of the activities taking place across the organization. However, a wide range of
departments and teams beyond the Department are bringing a wealth of different expertise
to bear in what is multi-disciplinary endeavour. WHO is working closely with partners in
ministries of health and agriculture of Member States, national and regional laboratory
technicians, colleagues in UN agencies, other international organizations and nongovernmental
organizations as well as the wider scientific and research community.
WHO strategic action plan for pandemic influenza
Strategic action Goal
1 Reduce human exposure to the
H5N1 virus.
Reduce opportunities for human infection and, in
so doing, reduce opportunities for a pandemic
virus to emerge.
2 Strengthen the early warning
system.
Ensure that affected countries, WHO, and the
international community have all data and
clinical specimens needed for an accurate risk
assessment.
3 Intensify rapid containment
operations.
Prevent the H5N1 virus from further increasing
its transmissibility among humans or delay its
international spread.
4 Build capacity to cope with a
pandemic.
Ensure that all countries have formulated and
tested pandemic response plans and that WHO is
fully able to perform its leadership role during a
pandemic.
5 Coordinate global scientific
research and development.
Ensure that pandemic vaccines and antiviral
drugs are rapidly and widely available shortly
after the start of a pandemic and that scientific
understanding of the virus evolves quickly.
WHO has welcomed the generous financial support provided by the donor community as
well as the in-kind contributions and donations that have been received from other
partners, including the private sector. Donors have generously provided funding to WHO
in its efforts to assist Member States totalling USD 68 million as at the end of 2006. Of
the funding received by WHO, at least 77% has been allocated to WHO regional and
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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country offices to support the efforts of Member States. Further financial support and
contributions in kind are being provided on a bilateral basis by donors to Member States.
A list of partners providing financial support is provided at the back of this document.
This report provides an update on progress made by WHO in each of the five strategic
areas of the two year Action Plan.
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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I. Reduce human exposure to the H5N1 virus
H5N1 is an avian influenza virus that has been circulating among bird populations for
over three years. In that time, it has shown itself to be both highly contagious as well as
pathogenic for poultry. Tens of millions of birds have contracted the virus over a large
geographical area stretching from South-East Asia, to Africa and across Europe.
For now, the virus is not easily transmitted to humans. Most infections in humans have
occurred as a result of close contact with birds in environments where families live
alongside their backyard poultry stocks. Nevertheless, H5N1 is a significant threat to
global public health. Firstly, the severity of the symptoms in humans is raising concerns.
Unlike seasonal influenza, most patients who become infected with H5N1 develop life
threatening conditions such as multiple organ failure and pneumonia. Over half of all
laboratory-confirmed cases have died. However, it is the possibility that this virus could
alter its genetic structure to become more easily transmissible among the human
population that has caused the greatest concern. If that were to happen, a global pandemic
of human influenza could be triggered.
It is essential that all efforts are made to reduce the amount of exposure humans have to
the H5N1 virus. Not only will this lessen the risk of infection and mortality among those
who come in contact with infected poultry, but it will also limit the opportunities for the
virus to adapt its genetic structure to suit human transmission either through mutation or
by sharing its genes with another seasonal human influenza virus in circulation.
WHO's strategic approach in this area is focused on several concurrent areas of activity.
Firstly, any outbreak of avian influenza in humans demands an immediate response to
investigate its source and minimize the risk of others also being infected. A greater
understanding is also needed of the factors that increase the risk to humans of contracting
H5N1 from infected birds. Collecting evidence from actual events of the transmission
from birds to humans as well as the environmental and behavioural factors that can
exacerbate the risk can provide valuable information to reduce human exposure.
This information is also critical for the development of policies to bring about behavioural
change, providing the public with advice on the risks to health associated with close
contact with poultry and how to protect themselves. Likewise, countries need to
understand how to protect particular groups that could be most at risk, such as poultry
cullers, laboratory workers or health-care providers. They need to know what measures to
take to limit the amount of exposure these groups may have to the virus as well as the
equipment and supplies that should be provided to protect them.
Investigating outbreaks and assessing risk
WHO's operational activity in this area is focused on responding to and investigating
actual instances of human infection with the H5N1 virus. Multi-disciplinary international
teams are deployed as rapidly as possible to areas in which cases have been reported.
In 2006, over 200 experts took part in field investigation and assessment missions.
National staff from ministries of health, agriculture and environment were accompanied
by staff from WHO headquarters, regional and country offices as well as members of the
WHO activities in avian influenza and pandemic influenza preparedness
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Global Outbreak Alert and Response Network (GOARN), the Global Influenza
Surveillance Network, FAO and OIE. The teams include experts in epidemiology,
infection control, logistics, social mobilization and communication. GOARN has played a
central role in mobilizing these experts needed to participate in the missions.
In 2006 WHO mobilized a total of nine rapid response missions to investigate actual
confirmed cases of avian influenza in human populations. These missions took place in
Azerbaijan, Djibouti, Egypt, India, Indonesia, Iraq, Romania, Turkey and the West Bank
and Gaza. A further 30 missions were conducted by teams from WHO headquarters,
regional and country offices with the support of experts from GOARN and other
international agencies to countries across all five regions of WHO. These missions
assessed the capacity of national and local authorities and facilities to detect and respond
to potential cases of human avian influenza.1 They provided a better understanding of the
alert and response mechanisms in place including the capacities for national early warning
and verification. The missions assessed the local health infrastructure, availability of
resources, clinical management and containment measures in place and the capacity of
local laboratories to sample, handle and diagnose the H5N1 virus.
In September 2006, WHO and GOARN partners met for an operational workshop to
review the avian influenza response operations that had taken place in 2006. Participants
included 12 GOARN institutions, 3 WHO regional offices, the WHO Mediterranean
Centre for Vulnerability Reduction (WMC) and the departments at WHO headquarters
concerned with avian influenza risk reduction. The workshop reviewed the operational
and technical aspects of the missions, identified strengths and weaknesses in planning and
deployment as well as post-mission follow-up. The workshop provided an opportunity to
strengthen the participation of GOARN partners and regional networks in future
international response operations and identified issues concerning the safety and security
of team members that needed further attention.
Coordinating the response teams
For each major outbreak of human avian influenza, an avian influenza response group
was established at WHO Headquarters to coordinate all outbreak response activities
across the world. In 2006, the response group conducted 360 teleconferences and 55
videoconferences from its base within the JW Lee Centre for Strategic Health Operations
with over 30 country offices in response to the increasing number of reports of cases in
humans and animals of avian influenza. The response group mobilized members of the
investigation teams and coordinated and supported their activities in the field.
Investigation kits
To enable WHO country offices to conduct investigations of avian influenza at the
national level, Avian Influenza Investigation Kits have been assembled and are being
dispatched to 116 country offices, as well as regional offices and partner organizations.
Each kit contains Personal Protective Equipment, face masks, material to collect and
transport virus samples safely and quickly, courses of antiviral drugs to be used in the
event of exposure or infection with the virus and guidelines to help the national teams
1 Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Burkina Faso, Cambodia, Cameroon,
Côte d'Ivoire, Cyprus, Egypt, France, Georgia, Iran, Italy, Jordan, Lao People's Democratic Republic,
Lebanon, Moldova, Myanmar, Niger, Nigeria, Pakistan, Romania, Russian Federation, Sudan, Syria,
Tajikistan, Turkmenistan, Ukraine.
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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conduct the investigation. A total of 14 000 sets of Personal Protective Equipment and 30
000 courses of the antiviral oseltamivir have been sent to countries at the frontline of
avian influenza outbreaks. In the anticipation of possible larger-scale field investigations
and outbreak response, strategic stockpiles of additional investigation kits are prepositioned
with the alert and response logistics mobility platform at Geneva and Dubai,
United Arab Emirates.
Alert and response to animal outbreaks
Experts in animal health from FAO and OIE have joined the WHO investigation teams in
helping to assess the risk to people from the outbreaks in animals. Every animal outbreak
presents an increased risk of infection to humans who come into contact with the infected
animals. WHO is continuing to work very closely with FAO/OIE operations and
procedures are now in place to ensure close inter-agency collaboration and cooperation
between the animal and human health sectors.
Training and guidelines
Training modules have been developed for ministries of health, health professionals and
national laboratories in preparing for and managing investigations into possible cases of
human avian influenza. In June 2006, a sub-regional training course on avian influenza
was held in Harare, Zimbabwe organized jointly by WHO headquarters and the WHO
Regional Office for Africa. The course was provided for epidemiologists, laboratory
experts and clinicians from six southern African countries. Additional sessions were also
held for West African countries in French.
Two sessions of the WHO/GOARN Outbreak Response Training were organized in
Geneva in 2006, in February and in October. Overall, 51 participants from GOARN
institutions and WHO headquarters, regional offices and country offices received training
on the various components of international outbreak response, including that of avian
influenza.
Infection control
While reducing the chance of close contact with infected poultry is an important aspect of
public health measures, there are certain occupational groups whose work will inevitably
involve direct and close contact with the H5N1 virus. These include outbreak
investigators, health-care providers who are caring for sick patients, veterinarians
responding to animal outbreaks and laboratory technicians who handle the live virus
strains. Adhering to rigorous biosafety procedures is critical to control the spread of
infection and reduce the risks to which these workers are exposed.
WHO experts on infection control and case management have accompanied field outbreak
and assessment missions to provide advice to the teams in the use of Personal Protection
Equipment and other procedures that should be followed when operating in affected areas.
As part of the missions, on-site visits were carried out to hospitals, provincial and district
health authorities, laboratories and to ministries of health. Health-care workers and other
hospital staff were provided with advice and training on infection control when caring for
patients infected with avian influenza and in following the appropriate biosafety
procedures when handling samples.
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Additional technical guidelines and information notes have been developed for healthcare
staff on measures they should be taking to protect themselves when working with
patients infected with H5N1 and in controlling the spread of the virus within the hospital
facilities. Guidelines have also been produced for laboratory technicians in gathering,
sampling, analysing and transporting live avian influenza viruses to ensure their
procedures comply with all biosafety requirements. In April 2006, the WHO Regional
Office for the Western Pacific updated comprehensive guidelines on infection control
within health-care facilities. A series of posters in Bahasa Indonesia is also under
preparation for distribution to hospitals and health departments across Indonesia. A threeday
course in infection control and basic hygiene principles was piloted in Azerbaijan and
has now taken place in Bulgaria, Armenia and the Russian Federation. The course is
available on request to other countries.
Managing human cases of avian influenza
Although human cases of avian influenza remain sporadic, the disease is severe and the
case fatality rate is high. In March 2006, WHO assembled an international panel of
experts to develop measures to be taken by health-care workers to alleviate patients'
symptoms and improve their chances of survival.
In May 2006, WHO published guidelines on the pharmacological management of humans
infected with H5N1. The guidelines include recommendations on the use of currently
available formulations of antiviral medications and other appropriate treatments for
patients with suspected avian influenza infection. It also has recommendations on the use
of antivirals for prophylaxis according to the level risk to which members of the
community may have been exposed.
Averting high-risk behaviour
In many countries in which H5N1 is thriving, poultry is a prime source of food. Many
rural and periurban households have backyard flocks of chickens and ducks and slaughter
their birds at home. Live poultry is sold in local markets close to where food is being
prepared and consumed. Understanding how the virus spreads from animals to humans
can help to identify what measures people should take on their own to reduce the risk of
exposure to the virus before and during an outbreak. Well planned public awareness and
social mobilization initiatives are effective in reaching a wide number of people.
In March 2006, the WHO Mediterranean Centre for Vulnerability Reduction (WMC),
FAO and the United Nations Children's Fund (UNICEF) came together in an ad hoc
meeting on behavioural interventions for avian influenza risk reduction. The meeting
identified the four highest priority behaviours that would have most impact and feasibility
i. reporting unusual sickness or death among birds or animals in the vicinity and seeking
treatment immediately should fever develop after contact with a sick bird ii. separating
poultry stocks from other species, from wild birds and from children iii. washing hands
after contact with birds and disinfecting cages, clothes and vehicles regularly, and iv.
handling, preparing and consuming poultry meat safely.
The WMC is providing technical input into a research project being conducted by the
West Africa Regional Office of UNICEF. The project aims to study and document the
impact of H5N1 on livelihoods and explore community coping mechanisms in Burkina
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Faso and Nigeria. It is hoped that the results will help agencies develop more targeted and
appropriate communication strategies for the region. The WMC is also working with
UNICEF to produce chapters on avian influenza and pandemic influenza for the UNICEF
publication series Facts for Life. The chapters are designed to deliver technical
information through simple key messages that will inform households and communities
on how best to protect themselves from the risk of infection of H5N1.
The WMC has also been working closely with food safety experts at WHO headquarters,
country offices and ministries of health to develop a series of easily accessible food safety
messages in print and in DVD format for schools and communities. Technical support has
been provided to Cambodia, Egypt, Iraq, Niger, Nigeria and Turkey.
An assessment of the day-to-day activities in Indonesia's live markets was undertaken in
January 2006 by experts in food safety from WHO headquarters and from the WHO
Regional Offices of South East Asia and the Western Pacific. The assessment has
provided valuable information on the potential risks of exposure to the virus. Guidelines
and information notes have now been developed for workers in the poultry production
industry, including those working in live markets, to help reduce those risks of contracting
the virus should they come into contact with infected bird stocks. The material has now
been compiled into an information kit and distributed to 51 countries directly affected by
avian influenza.
Training modules in social mobilization and food safety have been developed to be
included in standardized WHO training packages for ministries of health in H5N1 control
and preparedness. The modules have been field tested in countries in the Region of
Africa and in the Russian Federation.
The role of communications in reducing risk
Communications can play a significant role in reducing the risk to human beings of
contracting H5N1 during an outbreak as well as informing the population of investigation
and containment measures that may be necessary in their communities. It is also essential
for developing a relationship of trust between government authorities and communities
who may be fearful for their safety and livelihoods.
WHO has developed training modules and guidance material for media professionals and
communications staff working within national authorities. A comprehensive toolkit is
being developed in collaboration with UNICEF that addresses all aspects of the
development of a communications strategy in the event of widespread outbreaks of avian
influenza in humans. Communications experts supported outbreak investigations teams in
Azerbaijan, Egypt, Indonesia, Iraq, Romania and Turkey.
Dissemination of technical information
WHO has a central role to play in making technical information and guidance widely and
promptly available that reflect the rapidly evolving level of understanding of the nature of
the H5N1 avian influenza and the risk it poses to human beings.
Information concerning the number of human cases of H5N1 around the world is posted
on the WHO web site and is updated whenever a new case is confirmed. Maps that reflect
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January–December 2006
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the spread of the virus within bird populations are available. Reports on the results of
investigation and assessment missions to countries are published in all six of the official
WHO languages and new guidelines, recommendations and other technical resources are
published on the web site as soon as they become available. New findings into the
epidemiology of H5N1 are published when available in the Weekly Epidemiological
Record www.who.int/wer
Advice for persons who may be considering travel to regions and countries affected by
avian influenza is available on the WHO web site and is reflected will be reflected in the
updated 2007 edition of International Travel and Health.
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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II. Strengthen the early warning system
Early warning of the emergence of a pandemic influenza virus is essential if the
international community is to be able to mobilize all necessary efforts to contain its
spread. Countries affected by outbreaks need to be able to detect and manage cases
quickly while WHO and the international community must obtain the epidemiological
data and clinical specimens needed for accurate risk assessment, to determine the level of
pandemic alert and to develop pandemic influenza vaccines. This requires strong and
effective surveillance and reporting systems at the national and international level.
Existing surveillance systems in many of the countries on the frontline of avian influenza
remain inadequate, particularly in rural areas where many cases have occurred. This
limitation undermines the accuracy of risk assessment and leads to gaps in our
epidemiological understanding of the evolution of the virus.
The newly revised International Health Regulations ("IHR(2005)") are designed to
provide a standardized way for the international community to detect, report and respond
to signs that a public health emergency of international importance may be developing.
Once the IHR(2005) come into force in June 2007 and countries work towards improving
their own national capacities that will be needed under the revised Regulations, the
international health community will have a clearer early warning should pandemic
influenza appear.
In 2006, the World Health Assembly (WHA) called upon Member States to comply
immediately on a voluntary basis with some of the general provisions of the IHR(2005)
that are considered particularly relevant to the current risks posed by avian and pandemic
influenza. The WHA also instructed WHO to upgrade its own capacity in line with
IHR(2005) to meet the demands of avian and pandemic influenza alert and response.
Over half of Member States have already nominated a National IHR Focal Point. WHO
has established a database to register all relevant information concerning the Focal Points
and has published guidance on their roles and responsibilities. WHO has designated IHR
Contact Points in all six of the WHO regional offices and at WHO headquarters and they
are available on a round-the-clock basis, seven days a week.
Improving influenza surveillance
Samples of the virus need to be collected and analysed rapidly and accurately to ascertain
the presence of H5N1 as well as to detect any significant shifts in its genetic structure.
The WHO Global Influenza Surveillance System is founded on the participation of local
laboratories across the world. It has served the international community for well over 50
years in the detection and analysis of seasonal influenza virus strains. However the
emergence of the highly pathogenic influenza virus H5N1 with pandemic potential is
presenting the system with significant technical challenges which will be amplified during
the demanding conditions of a large scale outbreak. National laboratories need to be
provided with up-to-date information and material for the safe collection and shipment of
virus specimens. Other laboratories that have the expertise and facilities to work with the
H5 virus strain may require further training and support to reliably diagnose H5N1 and
any other novel virus subtypes that may emerge.
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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At the national level
The capacities of the existing surveillance systems have been assessed in over 30
countries across all WHO regions.1 National surveillance systems are being strengthened
and improved to enable the rapid detection, confirmation, investigation and reporting of
suspected human cases of H5N1. Field epidemiology capacity in all regions is being
improved through training programmes and workshops. Training workshops were held in
the South-East Asia region and in south-eastern Europe and support was provided to the
ministries of health of Viet Nam, Cambodia, China and Lao PDR to develop their national
field and hospital surveillance capacities. WHO is also providing technical support for
rapid mapping assessments in high risk areas as well as guidance, training and tools to
enable the integration of Geographic Information System (GIS) into national surveillance
systems.
New early warning systems have been established and existing surveillance mechanisms
have been enhanced in several countries in Asia and Africa.2 In the Region of the
Americas, the Regional Office has been working to expand surveillance targets and
strengthen the existing surveillance network. A new generic protocol for influenza
surveillance is being developed in collaboration with the US Centers for Disease Control
and Prevention (CDC) to ensure that influenza surveillance is harmonized and
comprehensive throughout the region.
The National Influenza Centres (NIC) at the country level are frequently the first stage in
the global process of collection and sampling of influenza viruses. They play a crucial
role in ensuring that influenza virus strains collected from patients together with
analytical information on their genetic structure are provided to vaccine producers. The
WHO diagnostic kits for seasonal influenza have been updated and distributed to all
National Influenza Centres. Recent advancements in diagnostic and surveillance systems
have been reviewed and recommendations on introducing new systems and procedures
have been provided to countries. The WHO manual of laboratory diagnosis of influenza
infections is currently under review and will be updated in 2007.
Not all countries however, have a recognized National Influenza Centre able to participate
in global influenza surveillance, particularly the low income countries at the frontline of
avian influenza. WHO has been working with many of these countries to help establish
NICs. New centres are now planned for Georgia, Ukraine, Azerbaijan, Estonia, Lithuania
and Kyrgyzstan.
Even in countries that have an established NIC, few are equipped with the necessary
expertise and facilities to work with H5N1. These laboratories must be provided with all
the necessary information, guidance and materials to allow them to recognize, store and
safely transport samples of deadly H5N1 to more specialized laboratories. WHO is
providing equipment and training to staff working within national laboratories as well as
deploying experts to provide hands-on support.
1 Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria, Burkina Faso, Cambodia, Cameroon,
Côte d'Ivoire, Cyprus, Egypt, France, Georgia, Iran, Italy, Jordan, Lao People's Democratic Republic,
Lebanon, Moldova, Myanmar, Niger, Nigeria, Pakistan, Romania, Russian Federation, Sudan, Syria,
Tajikistan, Turkmenistan, Ukraine.
2 Burkina Faso, Cambodia, Cameroon, China, Côte d'Ivoire, Lao PDR, Niger, Nigeria, Viet Nam
WHO activities in avian influenza and pandemic influenza preparedness
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At the regional level
The network of specialized laboratories with the particular expertise and facilities
required to analyse H5 virus strains is also being enhanced to ensure every country has
access to a regional H5 laboratory facility. The Terms of Reference for these specialized
centres are under review and other laboratories in areas without this capacity are being
upgraded to meet the requirements of H5 designation. The H5 Reference Laboratory
network provided support to several countries in shipping specimens and providing rapid
confirmation of suspected cases of human infection with avian influenza.1 In December
2006 WHO published the criteria by which the diagnostic results of H5N1 submitted by a
laboratory to WHO will be accepted.
In Africa, two national reference laboratories in Nigeria, one in Cameroon and one in
Côte d'Ivoire have been upgraded with the support of Institut Pasteur to enable them to
conduct H5 diagnosis and another reference laboratory in the Russian Federation is
currently being considered for H5 diagnostic capacities.
WHO is developing a training programme in partnership with the WHO Collaborating
Centres to improve regional influenza diagnostic capacity and the coverage of influenza
surveillance.
A series of Best Practices for Sharing Influenza Viruses and Sequence Data has been
developed that will provide guidance and will outline the responsibilities of members of
the global influenza surveillance community. The Best Practices cover the process by
which viruses and their genetic structure are shared as soon as they are obtained, the
importance of making critical findings publicly available as soon as possible and the
principles of ensuring that countries from which the viruses originate are able to share in
the benefits and are recognized for their contribution to the system.
Tracing contacts
Anyone who has had contact with a patient exhibiting symptoms of avian influenza must
be traced as quickly as possible. Not only may they also have contracted the virus from
the same source, but any indication of human-to-human transmission would raise
significant alarms that a pandemic could be imminent. Mounting a contact tracing
operation in the densely populated and impoverished areas in which many avian influenza
cases are occurring presents significant challenges for under resourced health authorities.
WHO has developed a Field Information Management System (FIMS) to manage the
information generated at the field level during an outbreak investigation, including
information on contacts. Data concerning case contacts can be stored easily and analysis
generated to facilitate further investigation. The FIMS model is now being introduced in
several WHO country offices and is currently being used by the WHO Country Office in
Jakarta as well as by the Ministry of Health in Indonesia to manage the ongoing cases in
the country. Other countries are field testing the system and adapting the modules to their
national needs.
1 Azerbaijan, Egypt, Indonesia, Iraq, Nigeria, Turkey.
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Animal outbreak surveillance
The geographical spread of H5N1 in animals in 2006 has been the fastest and most
extensive of any pathogenic avian influenza virus recorded since the disease was first
detected. The animal health and agricultural authorities are actively tracking and verifying
animal outbreaks. Collaboration between these authorities and the human health sector is
essential.
In July 2006, the Global Early Warning and Response System (GLEWS) for animal
diseases that are transmissible to humans was launched by FAO, OIE and WHO.
GLEWS is the first joint early warning and response system conceived with the aim of
tracking and responding to animal diseases including avian influenza. Up-to-date and
detailed maps that show the spread of the disease in animals are available on the WHO
web site. In September 2006 WHO convened a working group of senior scientists and
laboratory directors involved in research on the animal and human interface. The
discussions focused on improving diagnosis of the disease in humans and the genetic and
environmental factors that may increase human vulnerability to the virus. Control
strategies including culling and the use and quality of existing animal vaccines, virus
activity in areas of dense human population such as live urban markets and backyards
flocks and the role of migratory birds and other animal species in the generation of
pandemic viruses were also discussed.
Enhancing connectivity
In addition to strong surveillance systems, reliable global telecommunications
connectivity is needed to ensure rapid reporting and exchange of information. This will be
particularly important in the early stages of a pandemic when existing information
channels are likely to become rapidly overloaded. WHO is establishing connections for its
country offices that are based on a Global Private Network that will be able to continue to
operate when external communication systems may be compromised.1 Upgrades in
equipment are ongoing for some country offices and satellite communications hubs are
being improved to absorb the network overload during pandemic situations.2
1 Cambodia, East Timor, Fiji, Kiribati, Lao PDR, Malaysia, Samoa, Solomon Islands, Tonga, Turkmenistan,
Uzbekistan, Vanuatu, Viet Nam
2 Bangladesh, Bhutan, East Timor, Indonesia, Mongolia, Thailand.
WHO activities in avian influenza and pandemic influenza preparedness
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III. Intensify rapid containment operations
In 2005, two research groups published studies1 based on mathematical modelling
indicating that rapid intervention at the earliest sign of the emergence of pandemic
influenza could be effective in containing the outbreak and stopping it from spreading
beyond the immediate area. The studies also suggest that even if the strategy ultimately
failed to contain the virus at its source, valuable time would be gained before the outbreak
could spread internationally providing countries and the international community with a
window of opportunity to intensify preparedness activities and minimize the scale of
mortality and illness.
No attempt has ever been made to alter the natural course of a pandemic at its start and
the behaviour of influenza viruses is hard to predict. Nevertheless, the rapid containment
approach is considered one of the key elements of pandemic influenza preparedness. The
strategy is based on rapid detection and reliable reporting of outbreaks, immediate
availability of the necessary antiviral medications for large numbers of people and the
restriction of movement of people in and out of the area affected. It will require excellent
surveillance and logistics mechanisms as well as an ability to ensure compliance with
policy directives.
Activities towards strengthening the national and international surveillance mechanisms
to ensure the rapid detection and verification of an outbreak are a central part of WHO’s
efforts to improve early warning systems. What is needed in addition, however, is an
agreement and common understanding on how a rapid containment operation should be
launched and conducted in the event of a significant outbreak and what the key roles and
responsibilities would be of all actors, including international agencies and national
governments throughout. In parallel, there is also a need to establish a stockpile of the
necessary drugs and equipment that would be required.
Rapid response and containment strategy
In January 2006, a meeting was convened jointly by WHO and the Government of Japan
in Tokyo at which more than 130 participants from more than 14 Asian countries, donor
governments and international organizations discussed the elements of a draft protocol
that would guide a rapid response and containment operation.
Two months later, in March 2006, WHO brought together 70 international experts in
epidemiology, virology, logistics, outbreak response, health legislation, social
1 Ferguson NM et al. Strategies for containing an emerging influenza pandemic in Southeast Asia.
Nature, 2005, 437: 209–214
Longini IM et al. Containing pandemic influenza at the source.
Sciencexpress/www.sciencexpress.org/ 3 August 2005: 1–5
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January–December 2006
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mobilization, communications, laboratory and public health issues in a three day
consultation to discuss the operational details of such a rapid response and containment
operation. The meeting focused on three areas: the operations and logistics required to
mount such an effort, surveillance and epidemiology issues and the public health
measures that would be needed including quarantine, social distancing and the
distribution of antiviral medication.
A draft protocol was published on 30 May 2006. Since then WHO has been planning a
series of workshops to raise awareness and understanding of the containment strategy and
to develop further the operational aspects of the draft protocol.
The protocol covers all stages of a rapid response and containment operation. At the
outset, detecting, investigating and reporting early signals that human-to-human
transmission has taken place is central if the strategy is to have any chance of success.
That will be dependent upon efficient and effective surveillance and early warning
mechanisms as foreseen under the revised IHR (2005).
A series of investigations would then be needed to characterize the disease and to
understand its transmissibility. International teams would be deployed to scene of the
outbreak to assess the circumstances of the outbreak, the risk to the population and the
feasibility of immediate control measures such as isolation and infection control as well as
the use of antivirals from the stockpile. At the same time, the country concerned would
work with WHO to agree a communication plan to ensure all relevant information is
made available to the public and the international community in the most expedient way
possible.
The protocol also covers the decision-making process needed to launch a rapid
containment operation and to release supplies from the antiviral stockpile, particularly
given the finite supplies of material and human resources available. It also looks at the
different phases that would be likely to occur during the early days of a pandemic and the
implications for containment interventions at each phase.
Rapid response and containment training
The first International Workshop for Rapid Response and Containment of Potential
Pandemic Influenza took place in Jakarta, Indonesia from 27 November to 1 December
2006. A total of 58 participants attended from 12 countries as well as WHO staff
members from headquarters and regional offices. This first workshop aimed to establish a
cadre of people based in Asia and to train them to be ready to implement a rapid response
and containment operation. It also aimed to refine some of the concepts in the draft
protocol and to identify any gaps in countries’ national strategies.
A second workshop is now under preparation and is scheduled for March 2007. Training
modules on containment and pharmaceutical and non-pharmaceutical interventions are
also being developed in collaboration with the regional offices.
WHO activities in avian influenza and pandemic influenza preparedness
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Antiviral stockpiles for rapid response and containment
In parallel to the development of the draft protocol on rapid response and containment,
WHO has been discussing the establishment of an antiviral stockpile with Hoffman
LaRoche, producers of the antiviral drug oseltamivir which is marketed under the name
Tamiflu®.
Hoffman LaRoche has donated 3 million courses of oseltamivir specifically for the use of
WHO in the event of a launch of a rapid containment operation. Stockpiles are now held
in WHO facilities at Geneva, Dubai and in regional offices.
In addition, Hoffman LaRoche has donated a further 2 million courses of oseltamivir for
stockpiling at the national level to assist countries in their efforts to respond to local
outbreaks of avian influenza as they occur. A total of 116 countries have been identified
as needing stockpiles and treatment courses from these supplies have already been used to
treat patients infected with avian influenza.
A series of Standard Operating Procedures (SOP) is being finalized to guide the use of
antivirals for outbreak investigations at the national level as well as the circumstances
under which stocks from locally held stockpiles can be deployed.
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IV. Build capacity to cope with a pandemic
In the event of an outbreak of pandemic influenza spreading outside of the immediate
vicinity and across international borders, countries will face unprecedented strains on
their health services and are likely to experience high levels of mortality, morbidity and
social and economic disruption. The ability of countries and the international agencies
that support them to cope with the arrival of a pandemic and mitigate its impact will
depend greatly on the accuracy and comprehensiveness of their preparedness plans.
Experience and knowledge from past experience has provided WHO with an
understanding of the likely impact of a pandemic and is working with all countries in
helping them to formulate and test their national pandemic preparedness plans and to
identify gaps in their core capacities. Furthermore, as the leading international agency for
human health, WHO will need to assume a global leadership role should the pandemic
develop and spread across the world.
National pandemic preparedness plans need to address how best health authorities can
protect their citizens from becoming infected with the virus and how best to treat patients
who do fall ill with pandemic influenza. It is unlikely that sufficient quantities of
vaccines and antivirals will be available in any country at the outset of a pandemic.
Authorities will therefore need to make the most of non-pharmaceutical measures to
reduce morbidity, mortality and social economic disruption.
The planning process must also take into account the fact that health and social services
will quickly become overwhelmed by the sudden surge in demand. Absenteeism in all
sectors due to illness will exacerbate the situation. Plans therefore need to foresee ways
to ensure the continuity of essential services and availability of basic needs such as food,
water and sanitation.
National pandemic preparedness plans
WHO is providing technical support to countries as they develop their national
preparedness plans and has prepared generic guidance on their content and structure.
Tools and exercises have also been developed to enable countries to evaluate and test
their plans in advance. Over 178 countries across all WHO regions have now drafted or
finalized a national preparedness plan. A training package is also being developed in
collaboration with technical partners that will comprise a core curriculum and materials
that can be used by all regions and adapted locally as needed. The package will include
basic information about influenza, preparation, surveillance, detection, alert and reporting,
investigation and verification, response and control and clinical management.
Guidelines are also under way for national health services to help plan their response to
the clinical impact of pandemic influenza both in terms of treatment and infection control.
An international training workshop on emergency preparedness and response for healthcare
facilities was launched by WHO in collaboration with the Asian Disaster
Preparedness Center. The course covers hospital infection control procedures, hospital
infrastructure and the organization of teams and community services during a pandemic
situation. The first session of the workshop was held in Bangkok, Thailand in September
WHO activities in avian influenza and pandemic influenza preparedness
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2006 and included the participation of health-care professionals from countries across the
South-East Asia region.
Regional pandemic preparedness plans
WHO Regional Offices are also engaged in regional preparedness and response plans and
are initiating regional and sub-regional training sessions.
In the WHO Region for Africa, a region-wide preparedness and response plan has been
developed and endorsed by 42 Member States and partners. The plan is serving as a
reference for the health sector component of countries’ own national multi-sector plans.
The WHO Regional Office has also developed a package of training material designed for
national health officers and two workshops were held in June and July 2006.
In the WHO Region of the Americas, a multidisciplinary Task Force on Epidemic Alert
and Response has been established to advise, coordinate and monitor all activities of the
organization related to the planning and implementation of influenza pandemic
preparedness and response. All its activities are framed within the requirements of the
IHR (2005). The Task Force has developed a strategic and operational plan to guide the
organization's technical cooperation activities in preparing the region for a pandemic and
in supporting countries to develop their own national capacities.
Sub-regional workshops have been held in the use of modelling software to develop
estimates of the country-level impact of a pandemic in terms of morbidity, mortality and
in direct economic costs. The software also provides estimates of surge capacity
requirements for health services. The Regional Office is also helping countries to assess
their core capacities needed to implement national plans and is developing an influenza
surveillance protocol for the Region of the Americas. National rapid response teams are
being provided with training and are working with staff from the WHO Regional Office
on simulation drills and table top exercises.
In December 2006, WHO held a rapid response training workshop in Cairo, Egypt. The
workshop aimed to develop qualified teams of professionals responsible for the
investigation of outbreaks of human avian influenza and prepare them to conduct further
training of rapid response teams in their own countries. Thirty-one epidemiologists,
clinicians, virologists, laboratory staff, veterinarians, nurses and health administrators
from ministries of health and agriculture from 8 countries in the Eastern Mediterranean
Region participated in the 4-day workshop. The training was facilitated by WHO
headquarters and the Regional Office for the Eastern Mediterranean, the Centers for
Disease Control and Prevention, Atlanta USA and Kenya and the US Naval Medical
Research Unit No. 3.
The WHO Regional Office for Europe has been working closely with the European
Commission and the European Centre for Disease Prevention and Control to update the
current level of understanding of avian influenza and to review lessons learned from joint
missions in the Region. A workshop was held that brought together 52 Member States of
the European Region which assessed the state of preparedness in the Region and
identified areas that required further strengthening. Further sub-regional training
workshops are also taking place and the Regional Office is providing assistance directly
to individual countries upon request.
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A regional preparedness plan has been developed for the South-East Asia Region and
table top exercises are being organized by the Regional Office for countries to assess their
national plans. The table top exercises will be packaged with a compilation of material
from other pandemic influenza exercises executed at the international, national, provincial
and local levels including a lessons learned session. In November 2006, WHO staff
observed table top exercises carried out in Seoul, Republic of Korea and in Brisbane,
Australia. The Korean exercise testing inter-ministerial coordination and effectiveness of
measures in their pandemic preparedness plan revealed that local health authorities would
play an increasingly critical role in managing the pandemic as it progressed. The
Australian exercise, including simulated quarantine procedures, also tested coordination
and communications at all levels. Modelling scenarios in the exercise showed that while
containment measures could have an impact on delaying the virus spread in Australia,
they may not be able to contain the virus.
The WHO Regional Office for the Western Pacific has produced guidelines on creating
and validating pandemic preparedness plans. Direct technical assistance has been
provided to over 8 countries in the Region and to the secretariat of the Pacific Community
in the development of the Pacific Regional Influenza Pandemic Preparedness Project.
Ethical concerns in pandemic planning
In the early stages of an influenza pandemic it is likely that the demand for vaccines,
prophylaxis and therapeutic care will be far higher than the supply available at the
national as well as the international level. Governments and authorities will therefore be
forced to take difficult and sometimes politically uncomfortable decisions over access. In
addition, some of the control measures that may be needed could come into conflict with
the rights and freedoms of individuals and communities. At the heart of many of these
choices lie ethical concerns which when identified, discussed and agreed by key
stakeholders can not only help to guide decision-making, but equally importantly can help
to make difficult choices more understandable and palatable.
WHO is working with ethical experts and human rights specialists to help Member States
identify those areas in pandemic planning and response in which ethical issues may arise
and to begin the process of rooting their decisions within their own national ethical
framework. In May 2006, WHO convened a global consultation and four technical
working groups comprising experts within and outside of WHO were established to
consider four distinct focus areas; equitable access to therapeutic and prophylactic
measures, the ethics of public health measures such as quarantine and social distancing
initiatives, the responsibilities and obligations of public health authorities and health-care
workers and the issues that may arise between governments in a multilateral response.
The working groups presented their findings to a second global consultation held in
Geneva in October 2006 at which a series of recommendations for Member States were
developed. The full report of the meeting together with the recommendations is
scheduled to be published in early 2007.
WHO activities in avian influenza and pandemic influenza preparedness
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Developing communications strategies
The development of a comprehensive communications strategy is an integral part of
pandemic preparedness. Effective communications, both prior to the start of a pandemic
and during the different phases of its spread can play a significant role in reducing human
exposure and mitigating the impact of the pandemic.
WHO has developed tools to assess the current communications situations in the regions
and the preparedness actions that should be taken. These include table top exercises for
health workers, ministries of health and journalists, attitude surveys on the current level of
knowledge of pandemic influenza among health-care workers and the public. A tool to
conduct rapid assessment of public trust as the pandemic evolves has also been
developed.
Outbreak communication workshops, including journalist-specific workshops are being
planned in regional and country offices and Standard Operating Procedures for
communications during a pandemic have now been produced. A training-of-trainers
workshop took place in July 2006 in Washington DC for 80 participants from 37
countries in the Region of the Americas. Several workshops have been held in the
Caribbean with a special emphasis on outbreak and crisis communication. In Argentina, a
training workshop brought together communication specialists from ministries of health,
agriculture and education of seven countries in the Region. Training sessions in outbreak
communications have also been provided to officials within the Ministry of Health in the
Russian Federation and to members of GOARN on two occasions.
A journalist's handbook on pandemic influenza has been developed and is available on the
WHO web site. It has now been translated into the six official UN languages plus Bahasa
Indonesia, Dutch, German, Hebrew, Hindi, Khmer, Turkish and Vietnamese. A training
workshop in outbreak communications took place in November 2006 in Bangkok and
included the participation of FAO, UNICEF and ministries of health and agriculture from
16 countries in the WHO Region of South East Asia.
WHO is contributing to the development of the common UN communication strategy for
avian and pandemic influenza. Work is under way in collaboration with UNICEF, FAO
and the Centers for Disease Control and Prevention (CDC) to develop an interagency
communication toolkit. The toolkit will be a simple, succinct and easy-to-use,
standardized approach that helps programme managers responsible for communication
plan strategic communication interventions for highly pathogenic avian influenza and
pandemic influenza.
In July 2006, a meeting was convened by the WHO Regional Office for the Americas that
brought together United Nations agencies, including UN Information Centres, and
officials of the Government of the United States of America to develop an Inter-Agency
Communication Framework for Avian and Pandemic Influenza in the Americas.
Enhancing WHO's capacity to lead
When the next human influenza pandemic occurs, the international community will look
to WHO to lead countries under the IHR (2005) through the crisis from its emergence
through each subsequent wave. WHO headquarters, regional offices and country offices
WHO activities in avian influenza and pandemic influenza preparedness
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will need to carry out greatly expanded functions, around the clock, in coordinating the
global response to the pandemic. The recent experience with SARS provided WHO with
valuable lessons in how its operations, its structure and its expertise should be improved
and scaled-up to meet the demands of a pandemic of influenza.
As part of the implementation of the IHR (2005) WHO has established Contact Points
that are available on a 24 hour basis at headquarters and in the regional offices to receive
reports of any indication of possible cases of pandemic influenza. An Influenza Pandemic
Task Force has been established and met for the first time in September 2006. The Task
Force is a temporary measure until the IHR (2005) come into force in June 2007 and is
designed to provide the Director-General of WHO with advice on the current state of
pandemic alert as well as on areas in which further WHO technical guidance and
leadership is needed.
WHO is also strengthening its own internal systems of alert and response. A new Event
Management System (EMS) is being established that will function as the official
repository of all information relevant to any event that may constitute a public health
emergency of international concern, including an outbreak of pandemic influenza. The
EMS will facilitate global communications and updates on the outbreak and the evolving
pandemic within WHO and with all key partners and Member States. It will greatly
increase the efficiency, timeliness and inclusiveness of WHO's decision making process
and maintain an historic record of operational activities and decisions.
WHO is addressing the likely increases in human resource requirements during a
pandemic. A human resources plan for avian influenza and pandemic influenza
preparedness has been developed. Additional staff members have been seconded to WHO
programmes tasked with avian influenza and pandemic influenza preparedness and the
process of recruitment and selection of additional required staff has been intensified.
Surge capacity plans are under way for key areas of the avian influenza response in
headquarters and in the regions.
Preparedness planning with non-state actors
While the principal responsibility for pandemic planning lies with governments and health
authorities, there is a wide range of non-state actors who either hold responsibility for the
health and well-being of groups of people within their care, or who could potentially have
a significant role to play in preventing the spread of the virus during a pandemic. The
global nature of an influenza pandemic demands that all stakeholders, some of which may
be beyond the scope of WHO's traditional partners are identified and brought into
preparedness planning at an early stage.
The international and regional development banks will have essential roles to play in
helping resource stretched countries finance their pandemic response activities. The Asian
Development Bank has become a major partner of WHO in providing significant financial
assistance to support its activities. WHO has also been holding a series of discussions
with the African Development Bank. A briefing was provided to the IMF at a seminar
held for European countries.
WHO has also been working closely with the humanitarian community to address
pandemic influenza control issues in refugee and displaced populations. NonWHO
activities in avian influenza and pandemic influenza preparedness
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governmental organizations (NGOs) are frequently the principal health-care providers in
humanitarian emergencies and in March WHO was requested by the NGO community to
hold an interagency technical meeting to address pandemic influenza preparedness and
mitigation specifically for refugee and displaced populations. Overcrowding, poor access
to basic health-care services, malnutrition, and a high prevalence of diseases such as HIV
are only a few of the risk factors for increased morbidity and mortality from influenza in
these populations.
Participants included UN agencies, such as the Office of the United Nations High
Commissioner for Refugees (UNHCR) and UNICEF as well as leading humanitarian
NGOs and other international organizations such as the International Organization for
Migration and the International Committee of the Red Cross who work on a regular basis
with refugee and displaced populations. The European Commission's Humanitarian Aid
Office, the Centers for Disease Control and Prevention and Epicentre also participated.
Discussions focused on practical preparedness steps field staff can take to reduce impact
of pandemic influenza on refugees and displaced populations and to protect agency staff.
The meeting reached agreement on a list of supplies to be pre-positioned, the importance
of public health measures and the necessary interventions that would apply in a camp
setting. WHO has now published the guidelines on its web site.
Training material for first-line health and essential services staff working with refugee
and displaced populations has been field tested in two refugee camps in Kenya and is
currently being finalized before broad distribution to partners in the field. Technical
information and updates are being provided to NGO partners, UN agencies and donors.
Continuity planning
International organizations, based in Geneva, have been developing plans dealing with
business continuity and health and safety of staff. A pandemic preparedness plan for
"International Geneva" is currently being elaborated, with UN agencies meeting regularly
to exchange information regarding their own internal preparedness plans. The overall plan
aims to support the harmonization of pandemic preparedness activities by UN agencies
and other international organizations, serving as a model for other international capitals.
Issues being addressed for each phase of a pandemic include travel policies, international
meetings, preventive measures, the scaling-down of non-essential functions, increases in
teleworking and possible in-office quarantine measures for essential staff during a phase 6
pandemic situation. A contingency plan has been developed for the UN Medical Services
to respond to the needs of UN staff members during a pandemic. A set of
recommendations on measures to protect staff and their dependants will be included.
WHO has also been liaising with the New York based United Nations System Influenza
Coordinator on preparedness planning for the global UN system as a whole.
Briefings were provided to the Financial Stability Forum, a high level global committee
of finance ministry officials, central bankers and financial regulators on pandemic risk
and public health response measures. WHO participated in seminars organized by the
International Monetary Fund for central banks and financial sector supervisors on
preparedness planning for the financial sector in the event of an influenza pandemic.
WHO has also met with the International Civil Aviation Organization (ICAO) to discuss
preparations for a possible influenza pandemic from the perspective of airlines, airports
WHO activities in avian influenza and pandemic influenza preparedness
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and aviation authorities. Technical guidance from WHO has contributed to the plans
under preparation by ICAO as well as the World Tourism Organization, the International
Air Transport Association and the Airport Council International.
WHO activities in avian influenza and pandemic influenza preparedness
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V. Coordinate global scientific research and
development
Vaccines are potentially the most effective intervention for reducing morbidity and
mortality during a pandemic. If available early enough and in sufficient quantities, they
can provide population-wide protection against infection. However, existing global
manufacturing capacity for influenza vaccines falls far below expected demand during a
pandemic and supply and access is inequitably distributed.
At present 90% of the global manufacturing capacity for all influenza vaccines is
concentrated in Europe and North America in countries that account for only 10% of the
world's population. The present maximum manufacturing capacity - at around 420 million
doses of trivalent vaccine per year - falls far below the expected demand during a
pandemic. Moreover, the manufacturing process is relatively fragile and technical
problems can significantly disrupt supply.
Greater research efforts are needed to accelerate the development of new vaccines and
technology that could radically increase vaccine supplies and facilitate the delivery of the
vaccines to all countries that need them. The time delay between the assessment of a new
candidate vaccine and the granting of a marketing license needs to be reduced. This could
be achieved through greater coordination of research initiatives and standardized
assessment protocols.
Antiviral drugs are the only interventions available at present for the direct treatment of
infection. However, only a small number of antiviral drugs are currently available and
supplies remain limited.
At the start of a pandemic there will be an urgent need for epidemiological data to
characterize the virus and to understand the principal age groups affected, the modes of
transmission and its pathogenicity. Rapid gathering of clinical data will be needed to
establish management protocols and to track possible changes in the virulence and
severity of the illness during the second or possibly third wave of international spread. To
ensure this research can take place in a timely and coordinated manner, networks of
experts need to be established in advance.
In May 2006 WHO convened a consultation in Geneva and invited over 120 scientific
experts from national immunization programmes, national regulatory authorities, vaccine
manufacturers and the research community. The objective of the consultation was to
identify and prioritize practical solutions to reduce the anticipated gap in vaccine supply.
Participants drew up an Action Plan which outlined strategies for the short, mid and long
term based on three main approaches: to increase the uptake of seasonal influenza
vaccine; to increase production capacity and; to stimulate further research and
development.
WHO activities in avian influenza and pandemic influenza preparedness
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Global pandemic influenza action plan to increase vaccine supply
The Global Pandemic Influenza Action Plan to Increase Vaccine Supply was published by
WHO in September 2006. It describes the current situation of vaccine production, the
estimated demand during a pandemic and the key challenges the scientific community is
facing to close the gap. The plan presents the three main approaches to increasing vaccine
availability and outlines the key activities needed within each.
Increasing the use of seasonal vaccines
Increasing the uptake of the seasonal influenza vaccine would provide the vaccine
industry with a solid demand forecast and stimulate it to increase production capacities.
The most effective way to achieve this is to encourage countries that could afford to do so
to introduce a standard seasonal influenza vaccination programme into their national
health policies. WHO regional offices will develop plans for influenza vaccination
programmes in consultation with their Member States and will provide technical
assistance wherever needed in addressing the impediments countries may be facing in
implementing such a strategy.
Increasing the global influenza vaccine production capacity
The second approach concentrates on increasing production capacity for pandemic
vaccines. If a pandemic were to emerge that appeared to cause high mortality, there would
be calls to vaccinate the entire global population, currently estimated to be 6.7 billion. The
Action Plan outlines a number of ways in which improved vaccine preparedness could be
achieved; i. improving the production yields and immunogenicity of vaccines based on
H5N1 influenza strains, ii. building new production plants in both developing and
industrialized countries, iii. exploring other formulations of influenza vaccine than those
commonly used for seasonal vaccination and iv. exploring alternative ways of
administering the vaccine to lower the dosage required.
Promoting further research and development
The third approach builds on the research and development efforts currently being
undertaken by the research community including the vaccine industry to design more
potent and effective vaccines. Efforts are focusing on developing vaccines that could
provide sufficient protection after just one dose and, in parallel, on developing vaccines
that would provide long-lasting immunity against a wide range of influenza virus strains,
including pandemic strains.
WHO is working with the wider research community to explore all the options laid out in
the Action Plan and to encourage the levels of financial investment that will be needed
from all sources. Although none of these initiatives would be able to close the gap
immediately, it is hoped that action taken now will bear fruit within three to five years.
Reducing the licensing time delay
Finding ways to reduce the time delay between the emergence of a pandemic influenza
virus and the availability of a safe and effective vaccine is a priority. Regulatory
procedures and expectations concerning quality, safety and efficacy of vaccines vary
between different national authorities. In 2006, WHO convened two workshops for
WHO activities in avian influenza and pandemic influenza preparedness
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regulators and has issued a draft guidance note on regulatory preparedness for pandemic
influenza vaccines which covers a range of issues from production and quality control
through to post-marketing surveillance. The document is currently being finalized and
further efforts are planned to bring the global vaccine regulatory community towards
internationally agreed specifications that will accelerate the licensing of human pandemic
influenza vaccines.
Assessing current vaccine clinical trials
At present more than 30 vaccine clinical trials are in progress based on viruses collected
by the National Influenza Centres in the countries experiencing human infections of
H5N1. WHO has been holding information discussions with experts engaged in these
trials and reviewing the progress. WHO Collaborating Centres and H5 Reference
Laboratories have also been selecting, reviewing and developing several new recombinant
H5N1 prototype vaccine strains. Five of the most promising strains have now been made
available to interested manufacturers and institutions. In August 2006, WHO published a
guidance document for national authorities and vaccine companies on the selection of
candidate viruses for use in vaccine development.
Discussions have also been held in collaboration with FAO and OIE on the technical
feasibility of producing human influenza vaccines during a pandemic in facilities
normally used to produce animal vaccines.
Broadening research and development efforts
While efforts to develop and produce an effective vaccine remain a high priority for
WHO and the international research community, increased research efforts are also
needed into improving risk assessment, prophylaxis, diagnosis and clinical management.
WHO is participating in the development of a South-East Asian Clinical Influenza
Network. The full implementation of the oseltamivir treatment protocol is under way with
an anticipated enrolment period of 2 years.
The Regional Office for South-East Asia has compiled a bibliography of research
undertaken into avian influenza to help identify research priorities and has participated in
the Asian Research Partnership in Beijing.
WHO activities in avian influenza and pandemic influenza preparedness
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Conclusion
The first six months of 2006 saw an unprecedented rise in the number of human infected
with H5N1 avian influenza as well as a dramatic spread of the disease in bird populations.
This was inevitably accompanied by a rapid demand from all sources for information,
guidance and support in dealing with the outbreaks.
While sporadic cases of human infection with avian influenza and outbreaks in animals
continued to occur in the second half of the year, WHO was also presented with a
valuable opportunity to consolidate and review its operations and policies and to identify
gaps and plan new initiatives.
As countries prepare for the revised IHR(2005) to come into force in June 2007, great
challenges still remain at all levels. WHO will continue to assist countries and to
strengthen the international mechanisms to support global health security.
WHO activities in avian influenza and pandemic influenza preparedness
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Selected WHO information resources
General
− WHO Strategic Action Plan for Pandemic Influenza 2006–2007
www.who.int/csr/resources/publications/influenza/WHO_CDS_EPR_GIP_2006_2c.pdf
− Avian Influenza (Bird Flu): What people need to know, AFRO, March 2006
www.afro.who.int/csr/epr/avian_flu/bird_flu_information.pdf
− Influenza Pandemic Risk Assessment and Preparedness in Africa, AFRO, 2005
www.afro.who.int/csr/epr/avian_flu/afr_avian_flu_31_10_05.pdf
Outbreak investigations
− Collecting, preserving and shipping specimens for the diagnosis of avian influenza
A(H5N1) virus infection: Guide for field operations, October 2006
www.who.int/csr/resources/publications/surveillance/WHO_CDS_EPR_ARO_2006_1.pdf
− Guidelines for case definitions for human infections with influenza A(H5N1) virus,
August 2006
www.who.int/csr/disease/avian_influenza/guidelines/case_definition2006_8_29/en/index
Averting high risk behaviour
− Avian influenza: protecting human health from farm to fork- public information film
− Questions and answers: A selection of frequently asked questions on animals, food and
water
− Successful strategies in controlling avian influenza, August 2006
− Highly pathogenic H5N1 avian influenza outbreaks in poultry and in humans: food safety
implications, November 2005
− Healthy food markets, April 2006
− Stop the spread: measures to stop the spread of highly pathogenic bird flu at its source,
March 2006
− Public health interventions for prevention and control of avian influenza: a manual for
improving biosecurity in the food supply chain, March 2006
− WHO/FAO/UNICEF ad hoc meeting on behavioural interventions for avian influenza
risk reduction, Summary Report and Recommendations, March 2006
All available at:
www.who.int/foodsafety/micro/avian/en/index.html
− Advice for People Living in Areas Affected by Bird Flu or Avian Influenza, WPRO,
www.wpro.who.int/NR/rdonlyres/04FA6993-8CD1-4B72-ACB9-
EB0EBD3D0CB1/0/Advice10022004rev08112004.pdf
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Infection control
− Avian influenza, including influenza A(H5N1), in humans: WHO interim control
guideline for health care facilities
www.who.int/csr/disease/avian_influenza/guidelines/infectioncontrol1/en/index.html
− Aide-Memoire -Infection control recommendations for avian influenza
www.who.int/csr/disease/avian_influenza/guidelines/EPR_AM_final1.pdf
− Avian Influenza, Including Influenza A(H5N1), in Humans: WHO Interim Infection
Control Guideline for Health Care Facilities, WPRO, April 2006
www.wpro.who.int/NR/rdonlyres/04FA6993-8CD1-4B72-ACB9-
EB0EBD3D0CB1/0/Advice10022004rev08112004.pdf
Case management
− WHO Rapid Advice Guidelines on pharmacological management of humans infected with
avian influenza A (H5N1) virus, May 2006
www.who.int/medicines/publications/WHO_PSM_PAR_2006.6.pdf
Epidemiological information
− The WHO Weekly Epidemiological Record,
Human avian influenza in Azerbaijan, February–March 2006
No. 18, 2006, 81, 5 May 2006
www.who.int/wer/2006/wer8118.pdf
Epidemiology of WHO-confirmed human cases of avian A(H5N1) infection
No. 26, 81, 249–260, 30 June 2006
www.who.int/wer/wer8126.pdf
Human cases of influenza A(H5N1) infection, in eastern Turkey, December 2005–January 2006
No. 43, 2006, 81, 27 October 2006
www.who.int/wer/2006/wer8143.pdf
International Health Regulations (2005)
The designation or establishment of National IHR Focal Points
www.who.int/csr/ihr/nfp
Global influenza surveillance
− WHO criteria for accepting positive results of H5N1 infection in humans from national
reference laboratories, November 2006
www.who.int/csr/disease/avian_influenza/whoacceptancecriteria.pdf
Rapid response and containment
− WHO pandemic influenza draft protocol for rapid response and containment, May 2006
www.who.int/csr/disease/avian_influenza/guidelines/protocolfinal30_05_06a.pdf
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Pandemic preparedness
− WHO global influenza preparedness plan, November 2005
www.who.int/csr/resources/publications/influenza/GIP_2005_5Eweb.pdf
− Maintaining a Safe and Adequate Blood Supply in the Event of Pandemic Influenza
www.who.int/bloodproducts/quality_safety/WHO_Guidelines_on_Pandemic_Influenza_and_Bloo
d_Supply.pdf
− Pandemic influenza preparedness and mitigation in refugee and displaced populations,
WHO guidelines for humanitarian agencies
www.who.int/csr/disease/avian_influenza/guidelines/humanitariandoc2006_04_07/en/print.html
Research and development
− Global pandemic influenza action plan to increase vaccine supply, September 2006
www.who.int/csr/resources/publications/influenza/CDS_EPR_GIP_2006_1.pdf
− Influenza research at the human and animal interface: Report of a WHO working group,
September 2006
www.who.int/csr/resources/publications/influenza/WHO_CDS_EPR_GIP_2006_3C.pdf
− Antigenic and genetic characteristics of H5N1 viruses and candidate H5N1 vaccine
viruses developed for potential use as pre-pandemic vaccines , August 2006
www.who.int/csr/disease/avian_influenza/guidelines/recommendationvaccine.pdf
− Availability of new H5N1 prototype strain for influenza pandemic vaccine development
March 2006
www.who.int/csr/disease/avian_influenza/guidelines/avianinfluenzastrains2006/en/print.html
− Availability of new H5N1 prototype strain for influenza pandemic vaccine development
May 2006
www.who.int/csr/disease/avian_influenza/guidelines/2strains2006/en/print.html
− Availability of new H5N1 prototype strain for influenza pandemic vaccine development
June 2006
www.who.int/csr/disease/avian_influenza/guidelines/2strainsJune2006/en/print.html
− Availability of new recombinant H5N1 vaccine virus
December 2006
www.who.int/csr/disease/avian_influenza/guidelines/h5n1vaccinevirus/en/print.html
− Avian influenza: significance of mutations in the H5N1 virus, February 2006
www.who.int/csr/2006_02_20/en/index.html
Further information resources are available at:
www.who.int/csr/disease/avian_influenza/en/index.html
WHO activities in avian influenza and pandemic influenza preparedness
January–December 2006
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Contributing partners
WHO gratefully acknowledges the financial support of our partners:
African Development Bank
Asian Development Bank
Australia
China
Canada
European Union
Finland
France
Greece
Iceland
Ireland
Japan
Norway
Poland
Spain
Sweden
Switzerland
United States of America