Transcript Slide 1

Keeping Europe healthy
Influenza pandemic in the EU: the threat
is real!
Zsuzsanna Jakab Director
European Centre for Disease Prevention and Control
November 12th 2009
Overview
 Context
 Vaccination as key tool for public health
 Pandemic influenza
 How serious a threat to health in Europe?
 Pandemic preparedness
 Evolution of the pandemic in the EU
 Vaccination against pandemic influenza
 Use of vaccination against seasonal influenza
 Conclusions
2
Vaccination: a key tool for
disease prevention
1980: Smallpox Eradication
the last naturally
occurring case in the
world was in Somalia in
1977
2002: Polio elimination in Europe
1998. Melik Minas: the
last case of naturally
occurring polio in
Europe.
Disease burden reduction after vaccination
in Europe
 Diphtheria: nearly eliminated. Few cases reported in the EU
during the last years (mainly in the Baltic States)
 Tetanus: between 100 and 200 cases yearly reported in the
EU, mainly in elderly people not vaccinated
 Pertussis: sharp decline during last ten years from 11 to 4.4
cases per 100,000 population
 Haemophilus influenza type b: only sporadic cases reported.
Source: ECDC Annual Epidemiological Report 2009
Measles situation in the European
Region: elimination goal 2010
Source: WHO
Measles, 2008
cases x 100.000
Data source: EUVAC.NET
Measles mortality and morbidity,
2005-2008
Countries reporting deaths, (n=20)
2005
2006
2007
Germany
1
2
-
Italy
-
-
1
11
3
-
Turkey
1
-
-
UK
-
1
-
Romania
2008
1
1
Countries
reporting measles-related encephalitis, (n=29)
2005
7
2006
2007
2008
7
1
4
1
-
Germany
1
Greece
-
Italy
-
-
-
Romania
3
-
-
Switzerland
-
1
5
UK
-
1
1
1
Data source: EUVAC.NET
1
1
2
1
Data as of 5 November 2008: Provisional data
Perception about infectious diseases
is changing
New York,
1939
People in line
for getting the
smallpox
vaccine
Pandemic influenza – the threat
is real
Number of confirmed deaths among
pandemic (H1N1) 2009 influenza cases by
week of notification
EU and EFTA countries, week 25 to week 43, 2009.
calendar week 2009
Source ECDC Daily Update, 29 October 2009. Available from:
http://www.ecdc.europa.eu/en/healthtopics/Documents/091029_Influenza_AH1N1_Situation_Report_0900hrs.pdf
Weekly influenza surveillance output
Week 43. October 30, 2009: Intensity
No report
Low
No influenza activity
or influenza at
baseline levels.
Medium
Usual levels of
influenza activity.
High
Higher than usual
levels of influenza
activity.
Very high Particularly severe
levels of influenza
activity.
=
A(H1N1)v
A(H1N1)v
A(H1N1)v
A(H1)v
=
A(H1)v
A(H1N1)v
=
A(H1)v
A(H1N1)v
A(H1)v
=
A(H1N1)v
A(H1n1)v
A(H1)v
=
A(H1)v
=
A(H1)v
A(H1N1)v
*
Decreasing clinical activity.
Stable clinical activity.
Increasing clinical activity.
Type A, subtype H1v.
Type A, subtype H1N1v.*
A(H1N1)v
=
A(H1)v
A(H1N1)v
A(H1N1)v
A type/subtype is reported as dominant
when > 40 % of all samples are positive for
the type/subtype.
Source ECDC Weekly Influenza Surveillance Output – Week 43 October 30th 2009
http://www.ecdc.europa.eu/en/publications/Publications/091030_EISN_Weekly_Influenza_Surveillance_Overview.pdf
Chief Medical Officer England’s Officer Investigation of A(H1N1)
2009 Deaths (Version 22/10/2009, n=93)
Underlying conditions information
for fully investigated deaths
These are not ordinary pneumonias –
they are hard to manage.
15
Pandemic preparedness in
the EU
Pandemic preparedness in the EU
 EC / ECDC / WHO Euro
workshops
 Joint assessments of
preparedness of all EU and
EEA/EFTA national plans
 ECDC guidance and self
assessment tools
 Active contribution to new
WHO guidance (issued 2009)
EC/ECDC/WHO Euro
pandemic preparedness
workshop, Uppsala May 2006
17
ECDC working hand in hand with Member
States, WHO and the European Commission
on pandemic preparedness since 2005
18
“ No battle plan
ever survives
contact with the
enemy…”
Field Marshall
Helmuth Carl Bernard
von Moltke
1800 – 1891
I.e. you have plans
but then you have to
adapt
19
Pandemics of influenza
Recorded human pandemic influenza
(early sub-types inferred)
H2N2
H2N2
H1N1
H1N1
H3N8
1895 1905
1889
Russian
influenza
H2N2
1915
Pandemic
H1N1
H3N2
1925
1900
Old Hong Kong
influenza
H3N8
1955
1918
Spanish
influenza
H1N1
1965
1957
Asian
influenza
H2N2
1975
1985
2010
2015
H9* 1999
H5 1997 2003
H7 1980
Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research,
National Institute of Infectious Diseases (NIID), Japan.
2005
2009
Pandemic
influenza
H1N1
1968
Hong Kong
influenza
H3N2
Recorded new avian influenzas
1955
1995
1965
1975
1985
1996
1995
2002
2005
Animated slide: Press space bar 20
The situation could be worse
for Europe! (Situation circa autumn 2009)
A pandemic
 A pandemic strain emerging in the Americas.
emerging in SE Asia
 Immediate virus sharing so rapid diagnostic
Delayed virus
sharing
and vaccines.
Based on a more
 Based on A(H1N1) currently not that
pathogenic strain, e.g.
pathogenic and without pathogenicity markers.
A(H5N1)
 Some seeming residual immunity in a major
No residual
large risk group (older people).
immunity
 Initially susceptible to oseltamivir.
Inbuilt antiviral
resistance
 Good data and information coming out of
Minimal data until
North America and the southern hemisphere.
transmission reached
Europe
 Arriving in Europe in the summer.
Arriving in the late
 Mild presentation in most
autumn or winter
people infected.
Contrast with what might have
Severe presentation
happened
 So far an unchanging genotype. immediately
— and what might still happen!
A changing virus
escaping the vaccine
envelope
21
We have learnt a lot from the Southern Hemisphere
– They are the first to have gone through a winter
with this virus – But is it right for Europe?.
The experience in Argentina,
Australia, Chile and New Zealand
22
Pressures on emergency room services:
Attendances in Western Australia 2007-09
 Emergency
Departments can
be especially
stressed if primary
care or help lines
do not take the
strain.
 What will happen at
Christmas and the
New Year in Europe
when primary care
may shut down?
Source: Australian Government, Department of Health and Ageing, Australian Influenza Surveillance Summary Report No. 19 2009,
reporting period: 12 Sept – 18 Sept 2009.
23
Good news: Absenteeism during the
pandemic and preceding winters in a
National employer in Australia
 Little greater effect
on absenteeism.
 Adequately prepared
essential services
should be able to
cope.
Source: Australian Government, Department of Health and Ageing, Australian Influenza Surveillance Summary Report No. 19 2009,
reporting period: 12 Sept – 18 Sept 2009.
24
Chile’s experience: other respiratory
infections
 In Chile, the virological
surveillance system held
up well.
 Found that other viruses
(notably respiratory
syncytial virus – RSV)
was an important
burden also in children.
 What other winter
pressure can we expect
this season in Europe?
Co-circulation, including RSV and adenovirus.
For week 30, RSV is the
main virus in circulation.
25
ECDC’s new pandemic planning
assumptions - issued 6 November 2009
http://www.ecdc.europa.eu/en/healthtopics/Pages/Influenza_A(H1N1)_Risk_Asse
ssment.aspx
Clinical Attack Rates:
up to 20 %
Mortality rates:
up to 3 per 100,000
of population
Hospitalisation rates:
up to 100 per 100,000
of population
15% of those hospitalised to be in intensive care
(25% on any given day)
26
The biggest pressure will be on
the hospitals and especially
intensive care
27
What is happening now in
Europe?
28
Weekly influenza surveillance output
Week 43. October 30, 2009: Intensity
No report
Low
No influenza activity
or influenza at
baseline levels.
Medium
Usual levels of
influenza activity.
High
Higher than usual
levels of influenza
activity.
Very high Particularly severe
levels of influenza
activity.
=
A(H1N1)v
A(H1N1)v
A(H1N1)v
A(H1)v
=
A(H1)v
A(H1N1)v
=
A(H1)v
A(H1N1)v
A(H1)v
=
A(H1N1)v
A(H1n1)v
A(H1)v
=
A(H1)v
=
A(H1)v
A(H1N1)v
*
Decreasing clinical activity.
Stable clinical activity.
Increasing clinical activity.
Type A, subtype H1v.
Type A, subtype H1N1v.*
A(H1N1)v
=
A(H1)v
A(H1N1)v
A(H1N1)v
A type/subtype is reported as dominant
when > 40 % of all samples are positive for
the type/subtype.
Source ECDC Weekly Influenza Surveillance Output – Week 43 October 30th 2009
http://www.ecdc.europa.eu/en/publications/Publications/091030_EISN_Weekly_Influenza_Surveillance_Overview.pdf
Weekly influenza surveillance output
Week 43. October 30, 2009: Geographic spread
No report
No activity
No evidence of influenza virus
activity; clinical activity remains
at baseline levels.
Sporadic
Isolated cases of laboratoryconfirmed influenza infection.
Local
outbreak
Regional
activity
=
A(H1N1)v
Increased influenza activity in
local areas (e.g. a city) within a
region, or outbreaks in two or
more institutions (e.g. schools)
within a region (laboratory
confirmed).
Influenza activity above baseline
levels in one or more regions
with a population comprising
less than 50% or more of the
country's population (laboratory
confirmed).
A(H1N1)v
A(H1N1)v
=
A(H1)v
A(H1N1)v
*
Decreasing clinical activity.
Stable clinical activity.
Increasing clinical activity.
Type A, subtype H1v.
Type A, subtype H1N1v.*
=
A(H1)v
A(H1N1)v
=
A(H1)v
A(H1N1)v
A(H1)v
Widespread Influenza activity above baseline
levels in one or more regions
with a population comprising
50% or more of the country's
population (laboratory
confirmed).
A(H1)v
=
A(H1N1)v
=
A(H1)v
A(H1)v
A(H1N1)v
=
A(H1)v
A(H1N1)v
A(H1N1)v
A type/subtype is reported as dominant
when > 40 % of all samples are positive for
the type/subtype.
Source ECDC Weekly Influenza Surveillance Output – Week 43 October 30th 2009
http://www.ecdc.europa.eu/en/publications/Publications/091030_EISN_Weekly_Influenza_Surveillance_Overview.pdf
Surveillance in Primary Health Care
Increasing Trends in the WISO – Week 43
Belgium
Bulgaria
Germany
Ireland
Italy
Malta
Netherlands
Norway
Poland
Slovakia
Spain
Sweden
United Kingdom
31
31
INVS – France - Weekly number of Emergency Department (ED)
visits for influenza and proportion of hospital
admissions in the 85 ED participating to the
Oscour® network since October 2007 in France
Daily number of Emergency Department (ED) visits
for influenza in children < 15 years (ED participating
to the Oscour® network in Paris area)
• Netherlands Wekelijks aantal consulten bij de NIVEL peilstation huisartsen
voor IAZ of pneumonie, per 10.000 inwoners t/m 18 oktober 2009 / week 42
IAZ consultatie-ratio 2008
IAZ consultatie-ratio 2009
Pneumonie consultatie-ratio 2009
25
Wekelijkse aantal consulten
per 10.000 inwoners
Baseline IAZ 'milde epidemie'
Baseline IAZ 'matige epidemie'
20
15
10
5
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Week
23-10-2009
Conclusion and forward look
 ECDC has been regularly monitoring the pandemic and
updating the risk assessment.
 After transmitting at variable rates over the Summer, the
pandemic is accelerating now in most European countries
and all the indications are that this pandemic will be a highly
significant event in Europe.
 We know that risk groups: people with significant underlying
conditions, pregnant women and young children are
especially affected by the virus but the risk extends to other
entirely healthy people.
 While many people will experience only a mild illness, there
are many, including young, healthy individuals, who will
develop severe disease and may die.
35
Conclusion and forward look
 EU citizens should continue to take appropriate preventive
measures, e.g. personal hygiene measures.
 Vaccines are becoming available across the EU and national
vaccination programmes are starting.
 Given the significant risks to health from the pandemic ECDC
would strongly advise all those Europeans who are offered
the vaccine to get vaccinated!!! By being vaccinated you will
not just protect your own health but that of people around
you.
 Vaccination is always an emotive issue and EU citizens
rightly require assurance that vaccines are both safe and
effective. Influenza vaccines have been used for more than
60 years and have one of the best record of safety in all age
groups.
36
Conclusion and forward look
 ECDC expects the influenza ( H1N1 ) 2009 vaccine to have a
similar safety profile as seasonal flu and we will
continuously monitor their application across the EU to
ensure that the most up-to-date information is available to
all.
 This above statement goes for all pandemic vaccines
produced in Europe, no matter which methodology was
used for its production and whether it was licensed at
European Medicines Agency (EMEA) or nationally.
37
Vaccination against pandemic
influenza
Vaccination against pandemic influenza
 Influenza vaccine has been produced for over 60 years –
long track record as a safe vaccine
 Tough regulation at EU and national level to ensure vaccine
safety
 Systems in place to investigate adverse events
 Take home messages:
 The pandemic virus is the real risk
 If you are offered the vaccine take it !!
 You are very lucky in Hungary to have the vaccine
available – use this opportunity to prevent
complications, hospitalization, stay at intensive
care unit and death!
39
Vaccination against seasonal
influenza
Vaccination coverage for seasonal
influenza vaccine in older people
(65 years +) in EU and EEA countries
Latest seasonal data available in spring 2008, VENICE-ECDC routine survey
Important to increase use of seasonal vaccine in Europe in the long term
90
80
Recommended WHO 75% target for 2010
Vaccination uptake %
70
From pandemic preparedness report (2007)
60
Vaccination coverage estimated
50
through telephone surveys
40
(University of Zurich)
30
20
10
Spain
Italy
Germany
France
United
Kingdom
Netherlands
Data not available for: Bulgaria,Cyprus, Estonia, Greece, Iceland, Latvia, Malta
Belgium
Ireland
Sweden
Denmark
Luxemburg
Norway
Portugal
Finland
Hungary
Austria
Slovakia
Romania
Czech
Republic
Slovenia
Poland
Lithuania
0
Source: Data from VENICE Survey and other sources 2008, Version 18 March 2008. Available from: http://venice.cineca.org/Influenza_Study_Report_v1.0.pdf
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19017
41
Conclusion
 Vaccination is one of the most effective means of preventing
infectious diseases
 We are lucky to have a vaccine available against pandemic
influenza
 The threat to Europeans from pandemic influenza is real and
significant
 Healthy young people can die of pandemic influenza, as
well as people in risk groups (persons with pre-existing
medical conditions)
 Pandemic influenza presents a particular risk to pregnant
women
 ECDC advises all Europeans who are offered the pandemic
vaccine to get vaccinated
42