Avian Influenza A(H7N9):

An Ongoing Emerging Disease Threat

Division of Health Security and Emergencies WHO/WPRO, 19 Feb 2014

Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Outline
About influenza virus
Seasonal influenza Avian influenza Pandemic influenza

Avian influenza A(H7N9)

Situation update Risk assessment WHO response Why concern? And what to do?

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Influenza A:
A zoonotic disease with many possible hosts

H: hemagglutinin N: neuraminidase
Central host are Water fowl eg. ducks, 16 Influenza A HA subtypes; most infections occur in GI tract and do not affect birds health
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Source: Dr. Ian Barr , WHO Collaborating Centre for Reference and Research on Influenza, Melbourne

H5N1 outbreaks in poultry and human infections in China and the Mekong area 2013-14

Poultry outbreaks

Human cases

Source: EMPRES-I, FAO

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Source: EMPRES-I, Global Animal Disease Information System

Human cases of H5N1 reported to WHO

(As of 10 Feb 2014)
Human H5N1 Cases by Onset Date and Country

Cambodia 2013: a big A/H5N1 year for Cambodia 2014: human cases reported in Cambodia, China and Viet Nam

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Pandemic Influenza Prerequisites

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Influenza pandemics: 20th century

Credit: US National Museum of Health & Medicine

1918: Spanish Flu

20-40 million deaths A(H1N1)

1957: Asian Flu

1-4 million deaths A(H2N2)

1968: Hong Kong Flu

1-4 million deaths A(H3N2)

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Pandemic (H1N1) 2009: Global Spread

April 2009 - February 2010

April 2009

May 2009 (1 month)

July 2009 (3 months)

September 2009 (5 months) December 2009 (8 months) February 2010 (10 months)
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Big questions for all of us

Is the world still facing the pandemic risk? Why the Asia Pacific Region is seen as a very vulnerable region? What are we currently managing - Recent avian influenza events affecting humans in the Region
H5N1 H10N8 H9N2 ...?

Should we worry more about H7N9? Will the H7N9 become the next pandemic flu virus? Are we well prepared for the next shock?
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Avian Influenza A(H7N9) virus

Avian influenza viruses normally circulate among birds Avian H7 viruses (H7N2, H7N3 and H7N7) occasionally found to infect humans No human infections with A(H7N9) viruses reported until March 2013

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Situation Update: H7N9

On 31 Mar 2013, China notified WHO of 3 human cases of avian influenza A (H7N9) virus as an event that may constitute a public health emergency of international concern under IHR (2005) As of 18 February 2014, there have been 355 cases and 67 deaths Since 2013, human cases have occurred in mainland China, Hong Kong SAR and Taiwan, China. 1 case with travel history detected in Malaysia Majority of cases continue to have exposure to poultry
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Human infection with Avian Influenza A(H7N9) Virus, by day of onset ( n= 330, as of 11 Feb 2014)
1st wave Feb- Sep 2013 2nd wave Oct 2013 -

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Provinces reported H7N9: 1st wave

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Provinces reported H7N9: 2nd wave

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Age distribution of human cases in 1st and 2nd wave (as of 17 Feb 2014)

Number of cases

Age-groups of cases

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Sex distribution of human cases in 1st and 2nd wave (as of 17 Feb 2014)

Number of cases

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Transmission
Most cases continue to have exposure to poultry (e.g. live birds markets) History of known exposure to poultry at notification 1st wave: 77%*1 2nd wave: ~80%*2
1. Li et al (2013) NEJM 2. Based on current cases information reported

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Surveillance of H7N9 in China- animals

Virus does not cause disease in poultry so it is difficult to detect and eradicate
In 2013, >150 million samples from poultry and the environment
88 positive samples were found

In 2014, >33,000 samples were collected from >2,400 locations

6 positive samples found

To date, H7N9 virus has not been identified in poultry farms

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WHOs Response to H7N9

Globally, guided by the International Health Regulations or IHR (2005) Regionally, implementation of the Asia Pacific Strategy for Emerging Diseases or APSED (2010) Operationally, managed according to the new WHO Emergency Response Framework (ERF)

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Asia Pacific Strategy for Emerging Diseases (APSED)

Provides a common framework for countries to strengthen national and local capacities required for managing all public health emergencies, including influenza pandemic A road map for Member States in the Asia Pacific Region to build up the IHR core capacity requirements

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Essential IHR Reporting

Trigger WHOs system for rapid sharing of information
Event management system(EMS), Event Information Site (EIS), Disease Outbreak News (DON), talking points, Q&A

Contribute to joint risk assessment and decision-making Advise public health actions
Public health intervention (e.g. travel measures) Informing pandemic preparedness actions
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WHO Activated EOCs

Within 24 hours
after the first IHR notification, One WHO Event Management System activated WPRO activated its newly upgraded Emergency Operations Center (EOC) served as a common operational platform
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WHOs new way of working: ERF

The new WHO Emergency Response Framework (ERF) provides a useful guide to facilitate WHO response WHO 3 policies ( e.g. no regret) and 4 core functions
Leadership Information Technical expertise Core services

H7N9 as the first Grade 2 emergency, announced by WPRO Regional Director on 18 April 2013
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WHO System:
Situation Monitoring & Sharing of Information

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WHO Global Influenza Surveillance and Response System (GISRS)

- 6 (3 in WPR)

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H7N9: why are we still concerned?

High number of human infections with severe illness and further human cases are expected Difficulty to detect in animal population (low pathogenic in animals) Critical information gaps (unknowns) e.g. scope of spread in animal population Potential for Pandemic? no evidence of human to human transmission so far, but need for vigilance due to the unpredictable behaviour Regional capacities improved but not well-prepared for rapid response
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IHR core capacities in WPR

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IHR Extension to June 2012 deadline

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H7N9: WHO Framework for action

In line with IHR and APSED, WPROs preparedness and response focusing on the following core areas:

Surveillance, risk assessment and response

Event-based surveillance Indicator-based surveillance Risk assessment and decision for response (LBM closure?)

Laboratories Collaboration between human & animal health sector Clinical management, infection prevention and control Risk communication An effective regional alert and response system
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Possible Rapid Containment

Shift the peak Gain the time for preparing to sustain the essential social function Implementing Rapid Containment measures

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