Pandemic Influenza

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Pandemic Influenza Building a platform for global
collaboration 28 30 January 2007 Jeremy
Farrar The Hospital for Tropical Diseases Ho Chi
Minh City Viet Nam
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The Hospital for Tropical Diseases Oxford
University Clinical Research UnitViet Nam
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Some key facts.

• Quite lot of people live in Asia and even more
  chickens, ducks and migrating birds
• 1.3 billion people and 14 billion chickens in
  China (on any given day ..approx)
• 163 deaths (269 cases) from H5N1 since January
  2004
• Ratio of human cases of H5N1 to meetings on H5N1
  approximately 110
• Billions of poultry/birds move between countries
  every day naturally, legally and illegally
• 170,000 200,000 people per day fly from Asia to
  EU/USA/Japan
• So far pledged to H5N1 US10 billion
• In the same time period approximately X,000,000
  deaths from malaria, Y,000,000 from TB, Z,000,000
  deaths from HIV/AIDS,
• In thinking about this how do you balance the
  small (impossible to quantify) potential risk
  against the possibility of a truly catastrophic
  global event.

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Cross-bordercontainment failure

• Policies need to be trans-national to optimise
  chance of success.
• e.g. Containment working in Thailand, but
  infection crosses border and epidemic grows
  there.

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A patient with suspected avian flu in Asia
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Development of Oseltamivir resistance on
treatment leading to clinical deterioration and
death
22 Jan
25 Jan
23 Jan
24 Jan
oseltamivir
oseltamivir
oseltamivir
oseltamivir
No 02
No 02
No 02
H274Y mutation
26 Jan
27 Jan
28 Jan
oseltamivir

CPAP
CPAP
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Viral load in throat during oseltamivir treatment
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From efficacy to community effectivenessCommuni
ty-based attrition rates
From Efficacy to Effectiveness
Efficacy
80
X Access
x 80
Health System Factors / Partnership
X Targeting Accuracy
x 80
X Provider Compliance
x 75
X Consumer Adherence
X 75
Effectiveness
29
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Are we better prepared in 2007 compared with 1918?
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Containing the H5N1 poultry outbreak in
Asiasome of the problems
Farming/market practices
Bird migration
Transport
Urbanisation
Health Systems Implementation
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Collaboration and Fair Engagement in Global
Health A Personal view from a simple
clinician

• World Economic Forum in Davos, Challenges of
  Globalization and Climate Change
• Many of the issues share common ground with
  Global Health and Influenza
• How to utilise the opportunities globalisation
  offers to bring benefits to the maximum number of
  people
• Despite the challenges we currently face we also
  have an unprecedented opportunity in Global
  Health which we should not waste.
• However despite the current challenges we may in
  fact be in a honeymoon phase and bigger
  challenges certainly lie ahead.
• Pandemic Influenza clearly needs an Immediate and
  Urgent response.
• It also needs a Long Term Strategy.
• Diagnostics, Drugs, Vaccines, Health Policy,
  Human Resources and Public Opinion
• Beware of the Boy Who Cried Wolf Syndrome,
  competing issues within affected countries,
  fatigue and the need to retain public support

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Since 1997 when H5N1 first infected a
humanNumber of deaths
Infectious diseases
Malaria 20,000,000 TB
40,000,000 HIV 15,000,000 Diarrhoea
35,000,000 Accidents
10,000,000 Cardiovascular
20,000,000 Typhoid 2,000,000 Tetanus
2,000,000 Etc Struck by lightening
267 Avian Influenza
156 But
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Collaboration and Fair Engagement in Global
Health A Personal view from a simple
clinician...

• Political Framework for Global Health
• Binding commitments, responsibilities,
  partnership, benefits in terms of quick
  mobilization of support if things go wrong (World
  Bank), and a forum to take disputes (World Trade
  Organisation). Is this the New International
  Health Regulations?
• Any political framework must be based on a shared
  sense of decision making not the exclusive club
  of the developed world. But should also not just
  descend to a meaningless compromise.
• WHO review its role?. All things to all men or
  focused? Must provide a lead on openness
• The developed world needs to open up and share
  the benefits not just in AID but in real
  partnership. The Developing world currently
  suspects that if the muck hits the fan they are
  on their own.
• There needs to be Fair Trade
• Non-Governmental Sector
• Gates, Wellcome, Philanthropic Foundations in
  Asia (Li Ka Shing Foundation) have absolutely
  vital role to play
• Stringent scientific review process, strategic
  use of funds, a non political agenda, influence
  on the researchers they fund and advocacy
• Private Sector
• International, Joint Ventures, Partners and
  Opportunities in Asia
• Diagnostics, drugs, vaccines.

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Collaboration and Fair Engagement in Global
Health A Personal view from a simple
clinician...

• Scientific Community
• Researchers need to take a lead, commit to data
  and sample sharing, and open access.
• A role for an advocacy group such as Researchers
  Without Borders ?
• We need to look at Ethics, Regulation, GCP, GLP
  etc (the Ethics of Inaction).
• International Collaboration
• International Reaction is crucial but it will be
  the local response that will determine success
• Not focused on Emerging Diseases but with the
  required infrastructure and people to respond
• Must be based on local capacity, equal
  partnership and an equitable share in any
  benefits.
• Agendas set locally not just when the West
  panics.
• Centre of gravity, Critical Mass and Locally
  based training
• Harness the power of small institutions (Gerry
  Keusch Nature 2003)
• Clinical research hubs around the world, open and
  linked but not just another club.
• Long term international collaborations built up
  over years, embedded in host institutions and
  responsive to locally defined needs
• Greater utilisation of Information Technology and
  Telecommunications
• Question the 19th Century separation of public
  health from clinical service.
• Integrated approach which includes the animal
  sector, social sciences, ensures research is
  close to patients and addresses the resource gap
• Everything comes down to confidence and trust.
  Can take years to develop and can be lost
  overnight.

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Influenza Clinical Research Network in Asia
Indonesia Thailand Viet Nam World Heath
Organisation
Other countries?
National Institutes of Health
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(No Transcript)
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Thank you
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Influenza
clinical
epidemiology
pathogenesis

• pathogen surveillance
• - humans
• - animals
• - environment
• serological surveillance
• - health care workers
• - farmers and cullers
• molecular epidemiology

Dong Thap/An Giang Hospitals
virology - virulence - evolution
immunology - cytokines - T-cells - antibodies
host genetics - disease susceptibility
Paediatric Hospital No. 1, HCMC
diagnostics treatment clinical follow-up
spectrum of disease
Preventive Medicine, HCMC
Animal Health Dept., HCMC
University of Oxford
University of Hong Kong
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10 Cotidianul (Romanian Herald) Joi 23 februarie
2006 Medic in groapa aviarelor
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Thank you