Avian Influenza and the Pandemic Threat

The meeting took place on 27-29 June, 2007 in Rome, Italy

• Agenda

• Introduction by Dr. David Nabarro
• Closing remarks by Dr. David Nabarro
• Presentations, background papers and references

During the International Partnership on Avian and Pandemic Influenza (IPAPI) Meeting held in Bamako on 8 December 2006, the need was discussed for a technical meeting on to be scheduled prior to the Senior Officials Meeting Conference to be held in New Delhi. FAO-OIE-WHO in collaboration with UNICEF and UNSIC are co-organizing the Technical Meeting, which is to be held in Rome, from 27-29 June 2007.

Participants will be presented a summary of the current global epidemiologic situation of HPAI in poultry, and a risk assessment of human infection with the H5N1 virus. An assessment of the current risk of a pandemic of influenza and the state of preparedness of countries will also be presented. There will be an assessment of current strategies and practices as have been applied over the last three years for the control of HPAI in poultry and reduction of the associated risk of human infection.

A report will be prepared which will provide strategic guidance for the prevention and control of HPAI/H5NI in poultry and associated human infections, in the short, mid, and longer-term. The report, which will be circulated among the donor community and the participants of the New Delhi Conference, is expected to inform and drive high-level policy and decision-making.During the International Partnership on Avian and Pandemic Influenza (IPAPI) Meeting held in Bamako on 8 December 2006, the need was discussed for a technical meeting on to be scheduled prior to the Senior Officials Meeting Conference to be held in New Delhi. FAO-OIE-WHO in collaboration with UNICEF and UNSIC are co-organizing the Technical Meeting, which is to be held in Rome, from 27-29 June 2007.

Participants will be presented a summary of the current global epidemiologic situation of HPAI in poultry, and a risk assessment of human infection with the H5N1 virus. An assessment of the current risk of a pandemic of influenza and the state of preparedness of countries will also be presented. There will be an assessment of current strategies and practices as have been applied over the last three years for the control of HPAI in poultry and reduction of the associated risk of human infection.

A report will be prepared which will provide strategic guidance for the prevention and control of HPAI/H5NI in poultry and associated human infections, in the short, mid, and longer-term. The report, which will be circulated among the donor community and the participants of the New Delhi Conference, is expected to inform and drive high-level policy and decision-making.

Background to the Meeting
Introduction by Dr. David Nabarro

1. The meeting offers an opportunity for experts to review the strategies that have been used (a) to control highly pathogenic avian influenza, (b) to prevent and manage human infection with the H5N1 virus and (c) to prepare for containment and mitigation of the next influenza pandemic - all within the context of efforts to detect and respond effectively to outbreaks of diseases that endanger human survival. By strategies I mean "doing the right thing, in the right place, at the right time".
2. The question of the week is "to what extent are the strategies currently being used (a) technically appropriate for a range of different settings, (b) implemented effectively and (c) achieving the desired impact?
3. implement these strategies is being supported - particularly through technical and financial assistance provided via regional and global support mechanisms.
4. This meeting is expected to confirm those elements of strategies that are appropriate both for the current epidemiological situation for avian and human influenza, and for any potential changes in the epidemiology - eg an exacerbation of HPAI incidence or transmission, a change in the pathogenicity of H5N1 resulting in more instances of asymptomatic infection, or the emergence of increased transmissibility of this virus (or another like it) between humans.
5. Any substantial problems with the strategies will be exposed, and recommendations will be developed for finding ways to correct them. There will also be instances where aspects of the strategies that need fine tuning will become apparent and ways will be established to ensure that they are tuned to reflect the needs of different contexts.

   The Importance of the Strategies

6. This is important because many different entities throughout the world plan their actions on the basis of the strategies that have been developed by UN system specialized international agencies in conjunction with specialized entities in their member states. The impact of the strategies stretches into multiple sectors, a range of organizations, the perceptions of those who work in the media, and both national and international policymaking. If they are not right there will be significant consequences - in terms of both direct and opportunity costs - that not only have financial and human resource implications but may also impact on risks of ill health.
7. Different parts of the international system use the strategies when they contribute to tackling HPAI and preparing for a pandemic. The UN Children's Fund supports efforts to mobilize societies around the risks and threats associated with exposure to the H5N1 virus and the response to the next pandemic. Loans and grants to national authorities that are managed by the World Bank and Regional Development Banks support programmes of investment in priority actions for animal and human health. The UN Development Programme assists national authorities with coordination, governance, border actions and compensation issues. The UN World Tourism Organization helps tourism ministries prepare for disease outbreaks and pandemics with the creation of an information dissemination system and pandemic simulations. The International Civil Aviation Organization also helps national air travel authorities to get prepared through training and simulations. The International Labour Organization works with different employer and union groups focusing on the risks to health associated with the two threats. The UN High Commission for Refugees focuses on preparing refugee communities and those who work with them to with stand a pandemic and the International Office of Migration is doing the same with migrants. The International Monetary Fund offers training to national financial regulators, central bank directors and Finance Ministry officials to prepare for the impact of a pandemic. The UN Office for the Coordination of Humanitarian Affairs is bringing together humanitarian organizations so that they can get prepared for pandemic response and mitigation. The World Food Programme is developing common systems and logistic support services that can function effectively were there to be populations (perhaps several millions) with substantial needs for food, water and the like as a result of a disease outbreak or pandemic. All these entities draw on the technical strategies that we will be reviewing over the next three days - technical strategies that drive national and international efforts to ensure animal safety and human security.

   Are the Strategies making a difference?

8. One of the challenges that face us is that we do not have a "control group" to assess the different strategies pursued so far. But comparisons both within and between countries can be helpful, as can studies of changes over time, and I sense that this is the beginning of a period of intense reflection on the costs and benefits both of national and international responses to HPAI and of preparations for the next pandemic. Is the world a safer place as a result of the funds being invested? Has the risk of HPAI among poultry now been reduced? Are countries ready to respond together once there is suspicion that human-to human transmission of a virus with pandemic potential is being sustained?
9. The first requirement for such an analysis is that the strategies are as good as they can be. Secondly, the institutions that support implementation of strategies need to be working effectively. And thirdly, the international political system - working via formal and informal intergovernmental dialogue and action - needs to provide an umbrella within which there is sufficient synergy, solidarity and trust for countries to be able to work together not only in the current environment but also if (or should it be when) the pandemic does emerge. Can the systems of international diplomacy work together well enough to manage these threats to human survival on a global scale? I sense that some of these issues will be examined with care as we move towards December 2007 - when the Government of India expects to host the next major international conference on avian and pandemic influenza.

   The changing context for work on HPAI and Pandemic Preparedness

10. One other issue to be addressed by those concerned with strategies and their implementation is the evolving context within which we are working. Two years ago we were working in a climate of widespread international concern about the potential impact of a pandemic including high level media coverage and strong engagement of political leaders. The level of media coverage influences the ways in which some legislators respond to the threats: one result of the strong and coordinated response to the threats (and, perhaps, the impact of the global effort), the coverage has fallen. This may have led some to perceive that the threat has diminished. It has not. The challenge for us all is to sustain the effort to ensure that the threats receive adequate attention, that there is national and international preparation to respond to them once they materialize, and that the work can be undertaken in ways that catalyze institutional and programme linkages with sustained benefits that go beyond readiness of pandemic influenza.
11. There are several ways in which the context within which we are working has evolved in the last two years. The six that seem most important to me are:
    • We are still uncertain as to how the H5N1 epizootic and pandemic risk will develop in the next 12 to 24 months. Some (eg OiE) have suggested that the H5N1 virus is causing less disease among wild birds. WHO stresses that the pandemic risk is unchanged. Although such uncertainty adds to the complexity of forward planning, it is an inevitable aspect of our work.
    • We do recognize that there are major differences - between countries - in the levels of HPAI infection in poultry, in ways that authorities are responding to HPAI and the intensity with which preparations are being made for the next influenza pandemic. In some countries H5N1 is entrenched in poultry populations despite strenuous efforts to control it. A few governments have had real difficulty with maintaining effective responses. Preparations for the next pandemic vary greatly between countries. This all implies that the strategies are being applied in very different national situations: in all of them, success calls for well-directed implementation and careful monitoring.
    • There is increasing recognition of the way in which HPAI in poultry can affect the livelihoods of people who obtain an income through poultry rearing: a livelihoods approach to the control of HPAI is essential.
    • In some settings there is increasing convergence of veterinary and human health concerns especially with regard to epidemiology, pathology and molecular biology, therapy and immunology related to infectious diseases
    • There is a range of new opportunities posed by the coming into force of the International Health Regulations and the potential for combined action by countries to see how they will work together in response to infectious disease threats including the next pandemic.
    • There is increasing engagement of government departments beyond the health sector in implementing actions that will mitigate the consequences of an influenza pandemic for people's health (health and other essential workers, tourists and travelers, financiers and bankers). Organizations which prepare both local communities and national authorities for crises, disasters and humanitarian action are increasingly involved in preparing for an influenza pandemic

    I anticipate that during the meeting we will identify other context changes and take them into account. We will consider how context changes affect both the strategies to be used and the means of implementation.

    The specific challenge of Poultry Production Systems

12. HPAI forces us all to consider the future shape of poultry production in general, and the livelihoods of poorer people who depend on the poultry they keep, grow, and sell, there is one over-riding issue. They want to be sure that investments made now will prevent crises due to HPAI or other similar pathogens recurring again... and again..and again? One approach is to gain a better understanding of the structure and operation of the poultry sector and its market chains within different locations. Then, analyze what can be done to make them safer. For some people this would be called "promoting biosecurity". Others would call it "restructuring". Both of these will be discussed during the meeting. During the last year I have seen colleagues from NGOs, Government and Private Sector getting serious about analyzing disease risk in the global poultry sector - trying to assess why it has grown, and looking for ways to reduce it again. This is urgent in the countries that are currently dealing with endemic disease, where simple control measures will not work and strategies are needed that combine a package of measures. It is important that we identify the parts of the sector that are at greatest risk of disease introduction and spread - and at the same time, the people who will be most vulnerable to changes and have no safety nets. We can then set in motion the long term changes needed to reduce risk where it exists and monitor it, identifying who will be responsible. At the same time we must have clear plans and funding to provide assistance for those who need it to improve their systems or find other ways to earn a living - and we can make sure to avoid upsetting the livelihoods of those who are not a high risk. This is an investment in the future that will reap long term benefits.
13. More and more private entities are partners in this work - they recognize that they have a major role both in reducing the circulation of HPAI and in contributing to pandemic readiness within their own concerns and in the communities where they work.

    Making sure that the UN is 'Pandemic Ready"

14. The UN System has more than 200 k employees, has key roles to play now, in phase 3, and as the pandemic evolves (when it comes). We have a single strategy for 12 UN agencies, funds and programmes, and their partners, a consolidated action plan, a set of principles for how we will work under pandemic conditions, pandemic plans for all UN country teams, peacekeeping missions and headquarter offices, and an online tracking system for monitoring preparedness run by the UN Pandemic Influenza Contingency team based in Geneva. Simulations of work under pandemic conditions have been used to test the extent to which we will be able to maintain operational continuity under pandemic conditions, and this work will evolve as the core of a novel system for Business Continuity Management in the UN.

    Conclusion

15. The last two years have seen an extraordinary effort to tackle HPAI and prepare for a pandemic. This has been reflected in synergy between many different nations and organizations. The benefits will go far beyond influenza preparedness. Strengthening surveillance and laboratory capacities, health infrastructures, public understanding and bio-safety will impact positively on the level of preparedness for, and response to, any kind of zoonotic diseases. The human capital, finance and energy invested will yield a substantially greater return than on the threats associated with influenza. There are also challenges and gaps that must be assessed and understood, and tough questions to be asked about what is being done with resources being made available both nationally and internationally. We are at the start of a period of reflection - and repositioning - that must help to shape the way in which communities, nations and the world as a whole responds to the twin threats posed by infectious diseases that affect animals and humans. Our work now will not only bring benefit to today's world but will also leave improve security for future generations - of humans and animals.

Closing Remarks of Technical Meeting
by Dr. David Nabarro

What we set out to do

We set out to review strategies

• to control highly pathogenic avian influenza,

• to prevent and manage human infection with the H5N1 virus and
• to prepare for containment and mitigation of the next influenza pandemic - all within the context of efforts to detect and respond effectively to outbreaks of diseases that endanger human survival.

By strategies we meant "doing the right thing, in the right place, at the right time."

We asked some questions

1. To what extent are the strategies currently being used
   technically appropriate for a range of different settings,
   • implemented effectively and
   • achieving the desired impact?
2. How well are the strategies being implemented in different contexts?
3. We examined ways in which national implementation of strategies is supported with technical and financial assistance from regional and global mechanisms.

What we did

There was consensus around the need for the following:

1. A technical report on the state of the strategies that draws on the conclusions of the meeting

2. An articulated long-term vision and plan on HPAI control (HPAIc) and Pandemic Preparedness (PanPrep)
3. A HPAIc and PanPrep Communications Strategy
4. The Progress Report on HPAIc and PanPrep (end-August 2007) with
   • an assessment of achievements, outcomes and impact,

   • examination of gaps and identification of priority needs
   • suggestions of priority actions and indicators for the future at country and inter-country levels
5. Assess of Achievements, Outcomes and Impact
6. Livelihood-based approaches to transforming the poultry sector to reduce risks of ill health
7. Advocacy for OneHealth (An,Hum,Env)
8. Preparati0on for the Ministerial Conference on Avian and Pandemic Influenza in New Delhi