March 29, 2006

International Influenza Meetings: Summary Pages

· Meeting of the International Partnership on Avian and Pandemic Influenza Washington, DC, October 6-7, 2005

· Global Pandemic Influenza Readiness - An International Meeting of Health Ministers Ottawa, Canada October 24-25, 2005

· Meeting on Avian Influenza and Human Pandemic Influenza. Geneva, Switzerland. November, 7-9, 2005

· Vietnam Avian Influenza/Pandemic Preparedness Communication Workshop Hanoi, Vietnam, November 29, 2005

· Japan-WHO Joint Meeting on Early Response to Potential Influenza Pandemic Tokyo, Japan, January 12-13, 2006

· The International Pledging Conference on Avian and Pandemic Influenza Beijing, China, January 17-18, 2006

· OIE Meeting on Highly Pathogenic Avian Influenza. Paris, France, February 27-28, 2006

· Upcoming & Recent Meetings

DC Meeting

In September 2005, President Bush announced the International Partnership on Avian and Pandemic Influenza during the UN General Assembly. Since then, the US Department of State hosted the first partnership meeting in Washington DC on October 6-7, 2005. The meeting brought together senior health, agriculture and foreign affairs officials from eighty countries and eight international organizations. While covering general topic areas of surveillance and prevention; preparedness, planning and outreach; and response and containment of avian flu, the international partnership’s purpose is to improve global readiness through the following*:

§ Elevating the issue on national agendas

§ Coordinating efforts among donor and affected nations

§ Mobilizing and leveraging resources

§ Increasing transparency in disease reporting and surveillance

§ Building capacity to identify, contain and respond to a pandemic influenza

*Sources: U.S. Department of State

During the partnership meeting in Washington DC, officials from partner nations convened to establish implementation committees and advance specific actions in support of the Partnership’s core principles so as to address the growing threat of avian influenza becoming a global outbreak affecting animals and humans.

Ottawa Meeting

The Ottawa international meeting for the Health Ministers on the global pandemic readiness was attended by delegates from 30 countries and representatives from nine international organizations to discuss how to work together to plan, prepare, and respond to a possible pandemic influenza. Canada’s Minister of Health believed that this was the perfect opportunity for the delegates to use their political influence to raise the profile of this urgent global health security matter. This could be done by fostering support within each jurisdiction for the various international collaborations that are already in progress.

The representative from the World Health Organization, Dr. Lee Jong-Wook began the meeting by defining the three types of influenza; the common flu that occurs yearly, the avian influenza that affects birds, and the global pandemic influenza that has devastated the world three times in the past. WHO described six phases. We are now in phase three, in which a virus new to humans is causing infections but does not spread easily. Dr. Jong-Wook also outlined several goals that he hoped to achieve at the conference, which included reducing the risk of the pandemic internationally, improving surveillance of animals and humans, keeping open lines of communication between countries, and assembling all the resources necessary for vaccine development should be appropriately. All of these are commendable goals for the international healthcare community.

To reduce the risk of another pandemic occurring, it was suggested that timely and accurate outbreak reporting and minimization of poultry infections by culling infected flocks are crucial. Reducing human exposure was also considered vital and vaccinating the population against the seasonal flu virus is another key factor. This is true because if the avian flu and the seasonal flu were combined it just might create the pandemic strain that everyone fears. A reccurring subject at the conference was the time to devise a plan is now, because it will be too late once the pandemic occurs. WHO has sent guidance to each country on what to do, but so far only about 40 countries have a plan in place or are formulating one.

Another key issue discussed was stockpiling antiviral medication. Every country must have access to antiviral medication. It should be provided to developing countries unable to obtain it on their own, through collaboration with other countries to ensure that the virus is contained once or if it hits a country. To improve surveillance for humans and birds, early warning systems need to be in place in all affected and at-risk countries to allow quick dispatch of the antiviral stockpiles. In each phase, risk communication is vital and the best way to put populations on guard so they will be able to handle the situation at hand with the least amount of fatalities. However, the best protection of all is an effective vaccine. Of course, this can only be made once the pandemic virus has emerged. There is currently no known vaccine that will be effective, nor is there currently sufficient manufacturing capacity once a vaccine does become available. Its has been estimated that the world will need to produce billions of doses of vaccine when the time comes, but the efficacy or side effects for children or immuno-compromised people will not be known. The time between the emergence of the virus and the production of the vaccine must be minimized to significantly decrease the amount of infected people.

Canada has recently invested $15 million in the WHO Canada-Asia Regional Emerging Infectious Diseases project. Canada’s National Microbiology Lab in Winnipeg is working in conjunction with Vietnam's National Institute of Hygiene and Epidemiology to improve their testing capability for avian influenza. Canadian Prime Minister Martin recently joined his APEC colleagues in calling for concerted efforts to build and share knowledge, develop networks, systems and protocols, improve the transfer of information, and strengthen supply lines and infrastructure.

In addition, Dr. Jacques Diouf, Director-General of the Food and Agriculture Organization of the United Nations, stressed the importance of combating the spread of the avian flu by targeting poultry. The FAO is working with countries to strengthen their veterinary programs. This will allow for much improved measures in prevention, surveillance and control. The FAO is also providing advice on the isolation of poultry, hygiene at the farm level, vaccines, monitoring and quick culling if necessary. Another issue the FAO wants to improve is information sharing and networking. This would allow for a more accurate account on the progression of the virus and will assist in more timely control techniques. Dr. Diouf’s last point was to advocate the importance of this campaign against the disease. Twenty-five million has been pledged, but it would take $125-150 million over three years to run this “Global Strategy.” FAO has been able to devote US$5.5 million toward the avian influenza crisis in Asia, and is currently freeing up another US$2 million to address the spread of the disease outside Asia.

Geneva Meeting

A meeting concerning Avian Influenza and Human Pandemic influenza took place in Geneva, Switzerland on November 7-9^th, 2005. The meeting was co-organized by WHO, the Food and Agriculture Organization (FAO), the World Organization for Animal Health (OIE), and the World Bank. Over 600 animal and human health experts, senior policy makers, economists and industry representatives from over 100 countries were in attendance. The goal of the meeting was to formulate a global consensus for controlling the disease in animals, and further prepare for the possibility of a human pandemic. A summary of the ten conclusions and twelve recommendations for integrated action as outlined by the meeting’s participants is given below.

Conclusions

Concurrently with the development of preparedness and response plans, a rapid reduction of the H5N1 avian viral burden needs to be initiated. To minimize the threat of spreading H5N1, actions such as poultry culling and mass vaccination of avian populations are useful. Timely reporting of such outbreaks is emphasized, as countries with previous experience in avian flu outbreaks are available to offer expertise, resources, and support. Additionally, strengthened veterinary services and early warning and surveillance systems may help in monitoring the emergence of new strains, as well as emergence of strains into previously uninfected areas.

Preparedness efforts in every country and region are vital. Country plans should be aimed at integrating and strengthening existing systems in place, running simulations to test response mechanisms, and further developing community involvement. The recent high-level meetings regarding avian flu have unified the participating countries on what needs to be done, and as a result the public can be presented with accurate information. Including civil society, nongovernmental organizations and other community groups in this unified agenda is of utmost importance.

Resources have a huge impact on preparedness and response plans. The current resources available to contain an outbreak are insufficient, as evident from the low quantity of stockpiled antiviral drugs. Confusion still remains about access and distribution of these drugs. Also of concern is the need for a universal non-specific pandemic vaccine, as the best protective solution for human influenza. Continued discussions of relevant issues such as technology transfer, resolution of licensing and regulatory obstacles, sustained use of good manufacturing practices and pre-qualification are important in the development of such a vaccine.

Directly related to the issue of resources is finances. An international financial support system has been put in place to minimize transaction costs for donor countries, with emphasis on assistance for resource-poor countries. It is estimated that about 1 billion dollars will be needed over the next three years to support the recommendations of this meeting. An additional 35 million dollars is needed within the next six months to support the high priority actions at the global level.

Recommended Actions

For the most part, the actions recommended at the conference were a direct result of the conclusions that were made. They addressed the need to integrate regional, national and international plans for avian flu control, preparedness and response. Furthermore, it was expressed that at each level, the networks should be in compliance with international best practices.

At the regional and national level, the recommendations focused on the networks within the country. It was suggested that each country strengthen their surveillance, diagnosis, alert and response systems. It was also advised that they expand their influenza laboratory networks so that joint work can be reported and shared.

Internationally, the recommendations focused on countries assisting and participating with others on an international level, as well as the importance of vaccine production. It was proposed that each country help other countries understand the role of birds in transmission and assist in controlling this transmission. This included working towards multi-country networks of control and prevention of animal trans-boundary diseases, as previously established by the Global Framework for the Progressive Control of Trans-boundary Animal Diseases. Other important recommendations included pre-assembling a ready team of trained epidemiologists to respond and investigate outbreaks, as well as assessing veterinary infrastructures to ensure compliance with OIE standards.

One of the major speaking points of the conference was pandemic vaccines and antiviral drugs. It was agreed by many of the participants that the vaccines would act as the first line of defense, while antiviral drugs would take a supporting role during a pandemic. It was suggested that participants coordinate vaccine research, development, mass production, access and distribution. Also, the expansion of the global antiviral stockpile and means of access and distribution was advised.

Finally, it was recommend that participants bring proposals to the WHO Executive Board at its 117^th meeting, urging for immediate and voluntary compliance, as outlined by articles in the International Health Regulations (2005). Financial issues and budget allocution will be further addressed in an upcoming pledging meeting to take place in January 2006, graciously hosted by the Chinese Government.

For more information, see: http://www.who.int/mediacentre/events/2005/avian_influenza/en/index.html.

Hanoi Meeting

The Avian Influenza IEC (Information, Education, and Communication) Working Group held a one-day workshop to support the Joint United Nations Programme to Fight Highly Pathogenic Avian Influenza (HPAI). Given the cultural practices of poultry movement, slaughter and consumption during the annual lunar festival of Tet and the high potential for avian influenza transmission during this event, authorities felt it was a critical time to convene such a Working Group. Participants of the workshop included the Vietnam’s Ministry of Agriculture and Rural Development (MARD), Ministry of Economy & Trade (MOET), Ministry of Health (MOH), and the Ministry of Commerce and Industry (MOCI). In addition, technical experts from the World Health Organization (WHO), Food and Agricultural Organization (FAO), United Nations Development Programme (UNDP), UNICEF and other key organizations were in attendance. The objectives of the workshop included: 1) identifying critical elements for a comprehensive Avian Influenza IEC and Behavior Change Framework and 2) prioritizing actions and messages for an intensive Pre-Tet campaign.

As a result, the Working Group concluded that communication is essential for preventing, preparing, and responding to a potential human influenza pandemic. The MOH has been designated the lead Ministry in response to human health issues, and the MARD has been designated the lead in response to animal health issues. It is essential both the MOH and MARD agree on action items for a potential avian influenza pandemic. The recommended action items for the Pre-Tet campaign include avoiding contact with sick or dead poultry, using safe methods when handling and slaughtering poultry, cooking poultry thoroughly, and practicing hand-washing after contact with live poultry or poultry products. In addition, the Working Group developed “four essential facts” about avian influenza and creative ideas to educate the public about the emerging threat.

There were five sessions held throughout the day that dealt with avian flu issues surrounding the Tet festival. The first session addressed the current situation in birds and humans in regards to Avian Influenza. It was reported that Vietnam is currently in Phase 3 of the WHO pandemic phases (Pandemic alert). From December of 2003 thru November 24, 2005, there have been 93 confirmed human H5N1 cases in Viet Nam and 42 dead. The second session was a group discussion on actions needed to accomplish four main objectives: 1) Prevent animal to animal transmission, 2) Prevent animal to human transmission, 3) Prevent transmission of normal human flu and other diseases, and 4) Prevent human to human transmission in a pandemic. The results of the discussion were developed into a table of prevention strategies, organized accordingly by each objective. The third session regarded prioritizing actions for Tet. Participants were asked to vote for actions that they saw as improving the H5N1 situation before and during the Tet festival. The action that had the most votes was, “Avoidance of all contact with sick or dying poultry! Report immediately to the authorities.” It was also mentioned that the messages to the public should be clear, correct and quickly delivered to every person, with a special emphasis on poultry care givers, and poultry handlers at households and food production companies. Session four dealt with charting a way forward—introducing a strategic matrix for change. A matrix tool was introduced to assist in the strategic planning of numerous behavioral adaptation activities. Session five dealt with preparing an action plan for Tet and immediate action steps to be taken in the following weeks. The consensus was that agreement was needed on the actual, specific responsibilities of the participants, a universal coordination mechanism, and finally, the IEC group’s composition and representation. In closing, they agreed on a number of follow up actions which included: finalization of documents from the meeting in both languages (English and Vietnamese); a follow up meeting of the IEC working group; IEC working group clarification of modalities; and drafting AI IEC/BCC Framework based on the outcomes of the workshop. Upon completion of the meeting, all participants agreed that it had been a useful and important tool for networking and coordinating, and branded the meeting largely successful.

For more information, see: http://www.un.org.vn/who/avian/info/29Nov05_WorkshopReport.PDF.

Tokyo Meeting

A joint meeting on the potential influenza pandemic was convened by the Government of Japan and the World Health Organization (WHO) on January 12-13, 2006, in Tokyo, Japan. One hundred and thirty participants attended the meeting in Tokyo, including representatives from 14 Asian countries, donor countries, regional and international organizations. The participants expressed the need to develop mechanisms to facilitate rapid response and containment of Avian Influenza. The participants identified that avian influenza is already entrenched in many countries in Asia and that it has the potential to cause a serious global pandemic. Participants also realized that a crisis of this proportion could create serious social, economic, and health devastation in Asia and across the globe. The meeting in Japan identified specific “action areas” for decreasing the threat of an influenza pandemic, and made recommendations to both the participating countries and also to the WHO.

The meeting recommendations for countries included strengthening of national and local capacities for early detection and rapid response to a potential outbreak by using surveillance methods, increasing community awareness, and providing health officials with appropriate knowledge about early detection and reporting. Countries were urged to comply with the provisions of the International Health Regulations (2005), which facilitate early reporting and recognition of warning signals that are of international interest. Countries are additionally urged to report any early signs of a pandemic to the WHO, and promptly send laboratory samples for testing. Countries should review preparation and procedures prior to a potential pandemic, so any modifications can be made in a timely manner, especially any necessary modifications to a rapid-containment procedure. Country plans are also suggested to correspond appropriately with national, regional and international partners.

In addition to country recommendations, experts also developed urgent recommendations for both the WHO and other partners regarding early detection, rapid response, and containment. Recommendations for the WHO include developing and strengthening national capacities for early detection and helping countries strengthen their laboratory facilities, in addition to strengthening their own global laboratory networks. It has been recommended that WHO immediately develop or further develop the following: rapid response and containment strategies; an action plan composed of protocols, timeframe, coordination, and partner participation; training modules and education program regarding detection, response and containment; and a risk communication strategy for such an outbreak. Also, WHO should establish a response and containment decision-making process and an external advisory Influenza Pandemic Task Force to provide assessments on critical events related to an avian influenza pandemic. Lastly, WHO should use its Global Outbreak Alert and Response Network (GOARN) and other resources to mobilize staff and experts for rapid response and containment.

Recommendations for other partners in collaboration with the WHO include development and strengthening of regional, national, and international capacities, development of communication strategies, and development of operational plan on stockpiles. All partners should coordinate the supply contents and use of their stockpiles with one another for rapid response.

Given the potential threat of a human influenza pandemic as declared by the WHO, it is critical that governments, public health and medical communities, and international experts are prepared for early detection, response, and containment of what could potentially be a catastrophic event.

Beijing Meeting

The International Pledging Conference on Avian and Pandemic Influenza took place on January 17-18, 2006, in Beijing, China. The meeting was co-sponsored by the Government of the People’s Republic of China, the European Commission, and the World Bank. Representatives from over 100 countries, regions, and organizations were present, including the director of the World Health Organization (WHO) and the General Deputy Director of the Food and Agriculture Organization (FAO). Serving as a follow-up to the November 2005 Geneva meeting, the Pledging Conference allowed nations and other invited parties to coordinate funds for combating the current avian influenza outbreak, and for further preparation for the possible pandemic. In addition to the countries currently experiencing avian influenza outbreaks, the threat of a looming pandemic and its potential to affect all countries and regions has demanded international attention. This has resulted in a common, shared responsibility in aiding in disease control measures on a global scale. The resources needed to make such an effort successful have been estimated to be roughly $1.2 billion. At the conclusion of this meeting, however, pledges of donations exceeded expectations, totaling to approximately $1.9 billion. The contributions from a few sources are displayed in the chart below.

Donor funds were either channeled directly to specific countries or agencies, or through a trust fund facility created by the World Bank. Donors were also offered a variety of options in determining how and where their pledged funds are to be distributed. To meet country needs, four options were available. The first, broadest option is “Multi-Country Unrestricted Funds,” in which funds may be applied to any developing country, towards any aspect of the Animal-Human Influenza (AHI) integrated strategy for containment. Some of the aspects of the integrated strategy include coordinating the activities of different public health sectors, such as human and animal veterinary agencies, strengthening diagnostic and early warning capabilities, developing national plans, as well as addressing issues of budget support, compensation, and risk communication. The next category that was available is “Regional Multi-Country Unrestricted Funds,” in which funds may be applied for support of a general region, and towards any aspect of the AHI integrated strategy. The third category is “Specific Country Program Funds,” and can be either unrestricted or restricted towards specific aspects of the AHI integrated strategy. The restricted funds are to be applied to one of three sectors, “Animal, Human, or Other,” and support the specific needs of these different aspects of the AHI integrated strategy. Finally, donors could choose to pledge “Special Purpose Funds,” which are distributed directly by the donor for specific support measures as defined by that donor. Additionally, to meet regional and global needs, funds could be donated to support global networking efforts initiated by international and technical agencies, such as WHO, FAO, and OIE. For more information on donor options and the financing framework, please see Avian and Human Influenza: Financing Needs and Gaps, and Avian and Human Influenza: Multidonor Financing Framework, both available via the World Bank’s Avian and Human Influenza website (www.worldbank.org/avianflu)

OIE Paris Meeting

The meeting was organized by the Regional Commission for Europe of the OIE. Approximately 50 countries in the European Region and neighboring countries sent Chief Veterinary Officers to the meeting. The purpose of the meeting was to identify possible approaches to control the spread of the avian flu in the European region. The meeting identified that migratory birds are a main transmission route of the avian flu, and participants recognized that returning migratory birds from the Middle East and Africa this spring pose a serious threat in the further spread of the virus in Europe. The participants recognized that one “defaulting” country could endanger the rest of the world with respect to prevention, identifying and controlling the avian flu.

The meeting urged all Member Countries of the OIE Regional Commission for Europe to endorse the declaration of the Beijing conference with respect to veterinary measures to be taken for the control of avian influenza. These measures include preparing emergency plans in-line with international standards, guidelines and recommendations. Additionally, the meeting identified that veterinary services are on the “front lines” for prevention, detection and control.

The meeting insisted that all countries follow a sanitary policy implemented by the veterinary infrastructure in that country, ensuring compliance with OIE standards, and meanwhile providing a sufficient budget necessary for veterinary officials.

Vaccinations for the control of the disease have been discussed and considered as an option for specific cases. The OIE recommends that only vaccinations carried out with effective monitoring, as to assure the eradication of the disease. Furthermore, the meeting identified the need to have a stockpile of quality assured vaccination materials.

The meeting concluded with an appeal to the European Commission and international donors to support Eastern European laboratories to assist in accelerating testing procedures needed to identify avian influenza infection in animals.

For more information, see: http://www.oie.int/eng/press/en_060228.htm

Upcoming & Recent Meetings

International Meeting on Influenza Containment Strategy, on March 6-8, 2006, to be held at WHO headquarters in Geneva, Switzerland.

Summaries written by: Cari Beesley, Javita Everhart, Joel Guerrero, Yang Li, Kristina Meko, Daneille Meyer, Sarah Nordstrom.

Graduate students in the Master of Science Program (M.S.) in Biohazardous Threat Agents and Emerging Infectious Diseases MICB-524 Course: Emerging Infectious Diseases: The Past as Prologue”, taught by Daniel R. Lucey, MD, MPH. Georgetown University School of Medicine, Washington, DC.