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					        Pandemic H1N1 (2009)

        Brief History and Current Status

                                European Forum of Medical Associations
                                St. Petersburg, Russia 21 Sept 2010

David Mercer, PhD
Division of Communicable Diseases, Health Security & Environment
WHO Regional Office for Europe
     Content of Presentation

 Introduction
 Brief history of Pandemic H1N1 2009
 Epidemiology of the pandemic in the
  European Region
 Current Status
 Monitoring and Evaluation
 Lessons learned
 Pandemic H1N1 2009 Timeline
• April 12 2009: an outbreak of influenza-like illness
  in Veracruz, Mexico reported to WHO
• April 24: WHO declares a public health emergency
  of international concern (PHEIC)
• April 27: WHO declares pandemic phase 4 -
  sustained community transmission in Mexico
• April 29: WHO declares pandemic phase 5 (2
  countries affected)
• June 11: WHO declares pandemic phase 6
  (spread to more than 2 WHO regions)
   – In 9 weeks, all WHO regions reporting cases of pandemic
     (H1N1) 2009
• August 10 2010: WHO terminates PHEIC
   – Although some countries will continue to experience
     epidemic level of influenza caused by pandemic H1N1
         Age distribution of deaths from severe pneumonia,
                    influenza seasons 2006-2008
                and 24 March- 29 April 2009, Mexico

Chowell G et al, NEJM 2009
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
Intensity of influenza activity
    Overview of influenza activity in the European region

• Currently Influenza activity is at low out-of-season levels in the

• Laboratory confirmed cases of pandemic influenza reported by 49
  out of 53 Member States

    – Majority occurred without complications
 Overview of influenza activity in the
         European region
• 4879 deaths associated with laboratory-
  confirmed pandemic (H1N1) since April 2009
  – An underestimate
• The vast majority (98.8%) of detected
  influenza viruses were pandemic (H1N1)
  – Few B detections compared with previous
• All pandemic viruses characterized were
  similar to vaccine strain
• Majority were sensitive to oseltamivir and
    Detections reported
 week 40/2009-week 21/2010
Country   A-unsubtyped   Pandemic   A         A         B
                         A (H1N1)   (H1N1)    (H3N2)

          12040          99308      101       53        538
          (85.7%)        (65.6%)    (0.6%)    (7.9%)    (23.3%)
EU/EEA    2014           52108      946       621       1774
          (14.3%)        (34.4%)    (90.4%)   (92.1%)   (76.7%)
Total      14054          151 416    1 047     674       2312
      Detections reported
   week 40/2009-week 21/2010


           A unsubtyped   A H1   A pH1   AH3   B
                                         Age distribution of pandemic H1N1 (2009)
                                        deaths and hospitalizations in four countries
                                                                           (Georgia, Ireland, Montenegro, the Netherlands)

Percentage of cases





                              0-4 yrs               5-14 yrs   15-29 yrs            30-64 yrs              65+ yrs
•   Hospitalization rates for children aged <5 years were consistently reported to be higher
    than those of other age groups.
•   However, most deaths have occurred in the 30‐64 year age group in these countries (this
    age group also had the highest mortality rates)
  Were clinical consultation rates and
influenza transmission intensity higher
     than during previous seasons?
       Twenty-two countries observed higher
clinical consultation rates during previous influenza
Three countries observed higher clinical consultation
     rates during the current influenza season
 Impact on health care systems
• However in many countries, clinical consultation rates
  exceeded recent historical peaks within specific age groups.
• This was observed in the 0‐4 age group (three countries), the
  5‐14 age group (ten countries), and in the 15‐64 age group
  (two countries).
• This reflects the particular influence of the current pandemic
  on clinical consultation rates in younger age groups.

• In several locations, intensive care units also were over
  capacity for limited periods of time.
Impact on health care systems
Were indicators of severity and risk
  factors for severe outcomes
       different in Europe?
               Fatality Rates
• Overall crude mortality rate (CMR) for the
  European Region currently stands at 6.0 deaths
  per 1 000 000 population.
• Of 30 countries reporting 20 or more
  laboratory‐confirmed pandemic H1N1 (2009)
  deaths, the CMR ranges from 2.6 to 13.8 deaths
  per 1 000 000 population.
• Differences between countries likely reflect
  variation in
  – the percent of populations exposed to the pandemic
  – the sensitivity of case detection and reporting,
  – Possible differences in case fatality rates
Southern hemisphere indicators

                              Hosp                  Med. age       ICU     Deaths
         % of hosp % of hosp   per                     of      admission    per
          with no     cases  100 000               hospitalize   : hosp    million
Country comorbidity pregnant   pop                  d (years)     case      pop
              Southern hemisphere temperate zone

Argentina     47                         24.5            20      0.013        14.6
 Australia    51              6          22.5            31       0.13         8.6
    Brazil    79            8.3           8.8            26                      7
    Chile     47            2.4          10.8            32       0.39         8.1
     New                    6.5          23.3         20-29       0.12         4.4
  Epidemiologic Conclusions

• Season was early, similar timing to 2003/2004
• Evidence of an overall W-E pattern of progression
  in western part of European Region but not in
• In most countries, consultation rates and positivity
  rates have been within historical range
• Severity and risk factors appear similar to what
  was observed in Southern Hemisphere winter
• Standard monitoring for severe cases and
  reporting risk factors is needed (SARI) is needed!
Regional Response and
  Pandemic Vaccine
      Pandemic vaccine implementation
           globally by week, 2009

Timeline - 2009
      China, Oman                                   Denmark, Ireland, Israel, Qatar,
                                                    Saudi Arabia, Singapore, Turkey
             Australia, Hungary
                                                    Netherlands, Russian Federation,
                       USA                                  Switzerland, UAE

                      Belgium, Italy, Sweden                   Greece, Jordan, Spain
                                                                      Croatia, Cyprus,
                             Finland, France, Japan, Monaco,             Romania
                                 Norway, United Kingdom
                                   Austria, Canada, Germany,                  FYROM,
                                  Kuwait, Luxemburg, Portugal,                  Iran,
                                   Republic of Korea, Slovenia                 Monte-

 39   40    41   42    43    44    45   46     47    48   49     50    51    52   53
September        October                November                  December
  Pandemic vaccine implementation in
 European Region as of September 2010
• 43/53 Member State vaccination against pandemic
• ~75 million doses administered in Region
   – 50 million doses administered (22 MS reported to
     • 394 000 pregnant women vaccinated (reported to
   – 25 million doses administered (+21 MS)
• Great variations by countries in coverage rates (6%-
Monitoring & Evaluation
    Adverse Events Following
 Immunization (AEFI) Surveillance
• Existing national systems in countries


• Paniflow (UMC - WHO)

• Need for large numbers to detect some signals,
  therefore, need to combine data across
    Pandemic A/H1N1 influenza vaccines – reports of AEFI
                from EEA (week 10 2010) for 3 vaccines*

 Similar to vaccination patterns, leveling off in last few weeks






         3     9   16    23    6     13    20    27    3   10    17  24   10
        Dec   Dec Dec   Dec   Jan   Jan   Jan   Jan   Feb Feb   Feb Feb   Mar

*Arepanrix, Focetria, Celvapan
    Adverse events following immunization

• Common side effects (seen with more than 1 in 10 doses of
  the vaccine):
   – headache, arthralgia (joint pain), myalgia (muscle
     pain), reactions at the site of the injection (hardening,
     swelling, pain and redness), fever and fatigue

• Studies do not show harmful effects from the pandemic
  influenza vaccine with respect to pregnancy, fertility, or a
  developing embryo or fetus, birthing or post-natal
     Ongoing or planned pandemic vaccine
      evaluations in the European Region
         Title              Partners                Comments
Pandemic vaccine     EU-EEA (HPA)             Country tool-kit
AEFI monitoring      EU-EMA
                     ECDC                     VAESCO
                     WHO                      Paniflow (UMC)

Pandemic vaccine     EU-EMA
administration       WHO
Pandemic vaccine     ECDC                     VENICE
coverage             WHO                      Selected MS-

Pandemic vaccine     ECDC                     I-MOVE
effectiveness        National authorities-7
Seasonal influenza   ECDC                     VENICE
                     WHO                      Global
Lessons Learned and
    Next Steps
         Planning and coordination for
                      Member States
• Maintain trust across all agencies and
  organizations and with the public
• Designate special status as needed, such as
  declaring a state of emergency
• Provide leadership and coordination to
  multisectoral resources to mitigate the societal
  and economic impact of a pandemic
• Work for rational, ethical, and transparent access
  to resources
• Assess if external assistance is required to meet
  humanitarian needs
• Update preparedness plan as needed
                  Lessons learned - 1
• Investments in pandemic planning paid off BUT
  response plans must be adaptable and science-
• Best practices on strategies to deploy/monitor
  vaccines should be shared with all Member
• Pre-planning by international agencies should
  include negotiations with major manufacturers on
  access to vaccines for countries most in need,
  creating equity
• Procurement option must be developed to allow
  access for middle income countries – pooled
  procurement, other mechanisms?
                   Lessons learned - 2
• Need for international collaboration in
  monitoring and evaluation for maximum
  effectiveness and reducing burden on
   – Vaccine coverage

   – Pharmacovigilance

• Clear, straightforward public information is
  essential for allaying fears and building trust –
  need for risk and crisis communication
   – Media, general population, health care
     professionals, targeted populations
A look forward to this flu
      Seasonal influenza advisory group
   recommended viruses for Southern and
           Northern Hemispheres

• Southern Hemisphere 2010
   – A/Perth/16/2009 (H3N2) –like virus
   – B/Brisbane/60/2008 –like virus
   – A/California/7/2009 (H1N1) –like virus
   – SAGE considered availability of trivalent, bivalent +
     monovalent vaccine options available for MS
     decision for Northern Hemisphere 2010-2011

• Same viruses recommended for Northern Hemisphere
  2010/2011 with close monitoring of southern
  hemisphere experience (ongoing)
Thank You

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