The A(H1N1)v influenza pandemic is an issue of global concern and constitutes the largest threat to public health seen in recent years. Here, EPHA presents here a few Frequently Asked Questions (FAQ).
The current figures from the European Centre for Disease Prevention and Control (ECDC) as of August 25, 2009:
In the EU and EFTA Countries: 43 245 cases including 93 deaths
Outside EU and EFTA countries: 211 702 cases including 2501 deaths
Bringing the Global number to: 254 947 cases including 2594 deaths
All 31 EU/EFTA countries have confirmed cases.
A full break down and daily updated situational report can be found at the ECDC website
Of the 31 EU/EFTA countries, the UK has reported the largest number of cases 12 470 with 40 deaths. The Chief Medical Officer of England, Sir Liam Donaldson, claimed in the UK press that this is due to the large amount of travel between to the United States (which has been the worst affected globally: 43 771 cases and 436 deaths (a/o 10 August 2009)). He stated that the UK’s surveillance systems are very well developed, so that cases are more easily identified in the UK than many other countries. In EU/EFTA countries, aside from Lichtenstein that has 5 cases, Latvia and Lithuania are fairing the best with reports of only 23 and 47 cases respectively.
The presentation of type A(H1N1)v has, so far, been fairly mild. In the majority of cases the patients recover quickly after a mild illness. The deaths attributed to A(H1N1)v influenza have been restricted, for the most part, to at-risk-groups (defined as older people, young children, pregnant women and people with underlying health conditions). However this must not be cause for complacency. Epidemiological data from the 1918 and 1958 influenza pandemics show that the viruses, while initially having a mild presentation ’turned nasty,’ as they headed into winter. It can also be seen from previous pandemics that there is often an initial spike in case numbers and then a lag period for a few months before the peak onset of the pandemic.
So far Europe has been ’lucky’ in that this pandemic struck as we were heading into summer, a period when, in temperate climates (such as northern Europe) influenza is typically less virile and transmission less frequent. However as we head towards winter, epidemiological data from previous pandemics has shown us that the influenza virus can become more virile. The additional problem presented by colder seasons in a pandemic year is seasonal flu, the disease burden of which remains significant. In a moderate year in the EU, seasonal influenza, contributes to around 40 000 excess deaths and 220 000 in a bad year. It can also be observed that during pandemic years, the seasonal flu virus is invigorated with new genetic material and can become more vigorous. So we can be reasonably clear that heading into winter, the situation will get worse.
In cases of Pandemic or the build up to a pandemic, decision makers have two options, containment or mitigation. The two are not mutually exclusive but in both cases it is a question of timing and location. In the case of A(H1N1)v influenza, containment (the quarantine or isolation of an area or population to prevent transmission) is for the most part no longer a viable option. There are some situations where containment remains plausible, with already isolated communities or personal quarantine (such as staying at home or avoiding crowded areas). However, generally speaking, it is too late for containment and it is not recommended in stage 5 & 6 of the World Health Organisation (WHO) Pandemic response. Mitigation of the effects of the pandemic through surveillance, vaccination and where possible, treatment is the sole remaining option for the vast majority of the population. Mitigation strategies have in past situations been seen to blunt, delay or flatten epidemic peaks and buy time. This is not a perfect strategy but is the most effective at this stage.
Various systems exist presently to monitor influenza strains in preparation of an outbreak. The WHO Global Influenza Surveillance Network was established in 1952 and consists of over 120 National Influenza Centres in over 90 countries that monitor influenza activity and isolate influenza viruses in every region of the world. This network feeds into the Global Outbreak Alert & Response Network (GOARN) which is a WHO-led technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance.
In Europe, the ECDC runs a project called the European Influenza Surveillance Scheme (EISS) that has been providing weekly updates on the Influenza situation in Europe since 1996. The WHO Europe regional office also feeds into the EISS. The ECDC is an executive agency of the European Commission, works to identify emerging health threats and to neutralise them early on. DG SANCO is constantly monitoring and feeding into the WHO surveillance systems, as are all the EU Member States.
The WHO identified the virus and provided vaccine manufacturers with the seed virus in the spring. Vaccines are made from generating an immune reaction to a piece of material biologically similar to the virus or from an attenuated form of the virus itself. The seed virus is the material that the vaccine must be based on to illicit the necessary immune response and begin manufacture of the virus. Information from the European Vaccine Manufacturers (EVM) states that batch production for initial test phase (required by EMEA and other medicines authorities) has begun by several producers.
"Manufacturers stand ready to move into full-scale production as soon as requested by national authorities and the WHO. Some manufacturers who are not producing seasonal influenza vaccines have initiated full-scale production already" says EVM. Seasonal flu vaccine production is nearing completion for most manufacturers and so it will be possible for them to switch to preparation of pandemic flu vaccines. The WHO has stated that if vaccine manufacturers can reach the same volume of production as they do for seasonal flu, it will be possible, worldwide, produce 4.9 Billion doses of vaccine for A(H1N1)v influenza, however a more conservative estimate put this at 1-2 billion doses.
Early September is the best estimate for the production of the first usable quantity of vaccine. According to the European Commissioner for Health, Androula Vassiliou, the first 60 million of these doses will be earmarked for health professionals and at-risk-groups. Worldwide, the decision on which groups will be prioritised to receive the vaccine will be taken by the Strategic Advisory Group of Experts on Immunisation (SAGE) at the WHO.
The swine flu virus has spread to almost every country in the world. In addition, the Southern hemisphere winter influenza season is now under-way - making the population inhabiting the region, the majority of them developing countries, particularly vulnerable to the pandemic.
The swine flu vaccine is expected to enter the market in September at the very earliest. While governments of rich countries are already placing orders for hundreds of millions of vaccine doses to meet the needs of their citizens (i.e. France, the UK, the US and Australia), poor countries may have to fall in line at the back of this queue for limited supplies. Almost all of the global vaccine production capacity is located in only 9 developed countries. It is highly likely that commitments will be made to meet the needs of the populations within the countries that can afford the vaccines. "The lion’s share of these limited supplies will go to wealthy countries. Again we see the advantage of affluence. Again we see access denied by an inability to pay" - said Margaret Chan, Director General of WHO. The threat of the world’s potential stock of the vaccine running out and prices massively increasing could become a reality.
The WHO is negotiating with vaccine producers to increase global access to vaccines, to place a portion of the vaccine manufacturers’ profits into a fund for developing countries, to secure donations or tiered pricing for developing countries, while wealthy countries are asked to donate some of their vaccine stocks and to conserve global stocks.
Until a mechanism of delivery of sufficient vaccine has been established, developing countries will be endangered by inadequate or unaffordable supplies of the swine flu vaccine.
DG SANCO is maintaining a continuous presence in Luxembourg throughout the crisis and will continue to monitor developments and coordinate best practice examples of pandemic response. THE ECDC is providing daily updates and coordinating joint actions between EU Member States. The Commissions role comes down to attempting to boost solidarity between Member States, the sharing of stockpiled antivirals and eventually coordinating the distribution of vaccines. The Commission recently released a Communication on seasonal influenza vaccination in which it stresses, while not making any specific recommendations on, the importance of solidarity in the face of pandemic influenza.
For More Information
Please visit the US Centres for Disease Control for more information on the US response to the pandemic.
Please visit the WHO website for more on the global response to the pandemic.
Please visit the DG SANCO Influenza webpage for more information
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