Lessons from the European Experience with A(H1N1) 2009Angus Nicoll CBE European Centre for Disease Prevention and Control

3rd meeting of the National Influenza Centres in the Western Pacific and South East Asian Regions, Beijing

Pandemics of influenza

H7

H5

H9*

1980

1997

Recorded new avian influenzas

1996 2002

1999

2003

1955 1965 1975 1985 1995 2005

H1N1

H2N2

1889Russianinfluenz

aH2N2

H2N2

1957Asian

influenzaH2N2

H3N2

1968Hong Konginfluenza

H3N2

H3N8

1900Old Hong

Kong influenza

H3N8

1918Spanishinfluenza

H1N1

1915 1925 1955 1965 1975 1985 1995 20051895 1905 2010 2015

2009Pandemicinfluenza

H1N1

Recorded human pandemic influenza(early sub-types inferred)

Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research, National Institute of Infectious Diseases (NIID), Japan.

Animated slide: Press space bar

H1N1Pandemic

H1N1

The situation could be a lot worse for Europe! (Situation circa summer 2009) A pandemic strain emerging in the

Americas. Immediate virus sharing so rapid

diagnostic and vaccines. Pandemic (H1N1) currently not that

pathogenic. Some seeming residual immunity in a

major large risk group (older people). No known pathogenicity markers. Initially susceptible to oseltamivir. Good data and information coming out of

North America. Arriving in Europe in the summer. Mild presentation in most.

A pandemic emerging in SE Asia

Delayed virus sharing

Based on a more pathogenic strain, e.g. A(H5N1)

No residual immunity

Heightened pathogenicity

Inbuilt antiviral resistance

Minimal data until transmission reached Europe

Arriving in the late autumn or winter

Severe presentation immediately

Contrast with what might have happened — and might still happen!

Some ‘Lessons Learnt ‘ points Five years preparation paid off – for those who did it

But need to operationalise and adapt the plans for this pandemic

The ‘acid tests’ have been crucial e.g. can you distribute antivirals quickly and efficiently ?http://ecdc.europa.eu/en/healthtopics/Pages/Pandemic_Influenza_Assessment_Tools.aspx

Built around a regularly updated risk assessment http://ecdc.europa.eu/en/healthtopics/Documents/0907_Influenza_AH1N1_Risk_Assessment.pdf

Planning projections has to be adjusted http://ecdc.europa.eu/en/healthtopics/Documents/0908_InfluenzaA_H1N1_Planning_Assumptions_for_the_First_Wave_of_Pandemic_A(H1N1)_2009_in_Europe.pdf

Surveillance has had to be adjusted http://ecdc.europa.eu/en/publications/Publications/0908_MER_Surveillance_and_Studies_in_a_Pandemic_Meeting_Report.pdf

Personal interventions - are justified Societal Public Health Interventions – mostly not justified

http://ecdc.europa.eu/en/publications/Publications/0906_TER_Public_Health_Measures_for_Influenza_Pandemics.pdf http://ecdc.europa.eu/en/healthtopics/Documents/0908_InfluenzaA_H1N1_Managing_schools_during_the_current_pandemic_(H1N1)_2009.pdf

Containment vs. Mitigation – beware of policy decisions http://ecdc.europa.eu/en/healthtopics/Documents/0906_Influenza_AH1N1_Mitigation_and_Delaying_Strategies_for_the_Influenza_in_Europe.pdf

Beware of stating numbers – deaths are difficult

The health care sector is a vulnerable point

Idealised national curve for planning, Europe 2009: Reality is never so smooth and simple

Single-wave profile showing proportion of new clinical cases, consultations, hospitalisations or deaths by week. Based on London, second wave 1918.

Source: Department of Health, UK

0%

5%

10%

15%

20%

25%

1 2 3 4 5 6 7 8 9 10 11 12Week

Pro

port

ion

of

tota

l ca

ses,

con

sult

ati

on

s, h

osp

italis

ati

on

s or

de

ath

s

Initiation Acceleration Peak Declining

Animated slide: Please wait

One possible European scenario — summer 2009

In reality, the initiation phase can be prolonged, especially in the summer months. What cannot be determined is when acceleration takes place.

0%

5%

10%

15%

20%

25%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Month

Pro

port

ion

of

tota

l ca

ses,

con

sult

ati

on

s, h

osp

italis

ati

on

s or

death

s

Initiation Acceleration Peak Declining

Animated slide: Press key

Apr

Switch to deaths

Some ‘Lessons Learnt ‘ points Five years preparation paid off – for those who did it

But need to operationalise and adapt the plans for this pandemic

The ‘acid tests’ have been crucial e.g. can you distribute antivirals quickly and efficiently ?http://ecdc.europa.eu/en/healthtopics/Pages/Pandemic_Influenza_Assessment_Tools.aspx

Built around a regularly updated risk assessment http://ecdc.europa.eu/en/healthtopics/Documents/0907_Influenza_AH1N1_Risk_Assessment.pdf

Planning projections has to be adjusted http://ecdc.europa.eu/en/healthtopics/Documents/0908_InfluenzaA_H1N1_Planning_Assumptions_for_the_First_Wave_of_Pandemic_A(H1N1)_2009_in_Europe.pdf

Surveillance has had to be adjusted http://ecdc.europa.eu/en/publications/Publications/0908_MER_Surveillance_and_Studies_in_a_Pandemic_Meeting_Report.pdf

Personal interventions - are justified Societal Public Health Interventions – mostly not justified

http://ecdc.europa.eu/en/publications/Publications/0906_TER_Public_Health_Measures_for_Influenza_Pandemics.pdf http://ecdc.europa.eu/en/healthtopics/Documents/0908_InfluenzaA_H1N1_Managing_schools_during_the_current_pandemic_(H1N1)_2009.pdf

Containment vs. Mitigation – beware of policy decisions http://ecdc.europa.eu/en/healthtopics/Documents/0906_Influenza_AH1N1_Mitigation_and_Delaying_Strategies_for_the_Influenza_in_Europe.pdf

Beware of stating numbers – deaths are difficult

The health care sector is a vulnerable point

RCGP (England and Wales) ILI consultation rate per 100,000 2008/09

and recent seasons.

0

50

100

150

200

250

40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38

Week

Rat

e p

er 1

00 0

00 p

op

ula

tio

n

2008/09

2007/08

1999/00

Baseline Activity (<30 per 100,000)

Normal seasonal activity

(30-200 per 100,000)

Epidemic activity (>200 per 100,000)

First UK cases

detected

Treatment only phase

NPFS launched and schools closed for summer holidays

Some revised planning assumptions for the pandemic – first wave A(H1N1) 2009These represent a reasonable worst case applying to one European country (the

United Kingdom) with data available as of July 2009 They should not be used for

predictions Source: UK

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102892

Clinical attack rate 30%

Peak clinical attack rate 6.5% (local planning assumptions 4.5% to 8%) per

weekComplication rate 15% of clinical cases

Hospitalisation rate 2% of clinical cases

Case fatality rate 0.1% to 0.2% (cannot exclude up to 0.35%) of clinical cases

Peak Absence Rate 12% of workforce

Some ‘Lessons Learnt ‘ points Five years preparation paid off – for those who did it

But need to operationalise and adapt the plans for this pandemic

The ‘acid tests’ have been crucial e.g. can you distribute antivirals quickly and efficiently ?http://ecdc.europa.eu/en/healthtopics/Pages/Pandemic_Influenza_Assessment_Tools.aspx

Built around a regularly updated risk assessment http://ecdc.europa.eu/en/healthtopics/Documents/0907_Influenza_AH1N1_Risk_Assessment.pdf

Planning projections has to be adjusted http://ecdc.europa.eu/en/healthtopics/Documents/0908_InfluenzaA_H1N1_Planning_Assumptions_for_the_First_Wave_of_Pandemic_A(H1N1)_2009_in_Europe.pdf

Surveillance has had to be adjusted http://ecdc.europa.eu/en/publications/Publications/0908_MER_Surveillance_and_Studies_in_a_Pandemic_Meeting_Report.pdf

Personal interventions - are justified Societal Public Health Interventions – mostly not justified

http://ecdc.europa.eu/en/publications/Publications/0906_TER_Public_Health_Measures_for_Influenza_Pandemics.pdf http://ecdc.europa.eu/en/healthtopics/Documents/0908_InfluenzaA_H1N1_Managing_schools_during_the_current_pandemic_(H1N1)_2009.pdf

Containment vs. Mitigation – beware of policy decisions http://ecdc.europa.eu/en/healthtopics/Documents/0906_Influenza_AH1N1_Mitigation_and_Delaying_Strategies_for_the_Influenza_in_Europe.pdf

Beware of stating numbers – deaths are difficult

The health care sector is a vulnerable point

Daily and Weekly hospitalisations with suspected pandemic influenza

in England, by age group.

0

1

2

3

4

5

6

Thu 16 Jul Thu 23 Jul Thu Jul Thu 06 Aug Thu 13 Aug

Day

Rat

e p

er 1

00,0

00

<5 5-15

16-64 65+

Total

Age Group 30 31 32

<5 442 (15.0) 312 (10.6) 184 (6.2)

5-15 195 (2.9) 112 (1.7) 72 (1.1)

16-64 799 (2.4) 667 (2.0) 505 (1.5)

65+ 229 (2.8) 208 (2.6) 147 (1.8)

Total 1665 (3.3) 1299 (2.6) 908 (1.8)

Weekly number (rate per 100,000 population) of new hospitalisations

Daily rate per 100,000 population of new hospitalisations.

Hospitalised patientsEngland

Age group (years)

< 5 5-15 16-64 65+ Total

Total number of patients

in hospital

46 25 227 73 371

Number of

patients in critical

care

2 0 31 6 39

At 12 August 0800

At 12 August 0800

0

1

2

3

4

5

6

<5 5 to 15 16 to 64 65+

Age group (years)

Num

ber

of p

eopl

e in

hos

pita

l per

100

,000

pop

ulat

ion

of t

hat

age

15th July

22nd July

29th July

5th August

12th August

Hospitalisation ratiosper 100,000 population of that age

Some ‘Lessons Learnt ‘ points Five years preparation paid off – for those who did it

But need to operationalise and adapt the plans for this pandemic

The ‘acid tests’ have been crucial e.g. can you distribute antivirals quickly and efficiently

Built around a regularly updated risk assessment

Planning projections has to be adjusted

Surveillance has had to be adjusted Personal interventions - are justified

Societal Public Health Interventions – mostly not justified

Containment vs. Mitigation – beware of policy decisions

Beware of stating numbers – deaths are difficult

The health care sector is a vulnerable point