Post on 24-Jun-2020
Supporting Health Protection Planning:Supporting Health Protection Planning:The Health Protection Agency
d S i Fland Swine Flu
Professor Anthony KesselDirector of Public Health Strategy and Medical Director, HPA
The King’s Fund Board Leadership Programme for London14 July 201014 July 2010
Seminar outline
• Health Protection AgencyB k d i fl i d• Background: influenza virus and pandemic influenza
• Evolution of the swine flu pandemic• HPA roles/activities in the pandemicHPA roles/activities in the pandemic• Recent developments
Di i hi ki• Discussion: partnership working on infection disease planning and response
Role of the Health Protection Agencyg y
Established in 2004 as an independent government p gagency with responsibility for health protection
• Infections – surveillance andInfections surveillance and diagnosis
• Chemical and radiation threats• Emergency planning andEmergency planning and
preparedness for public health threats
• Local and regional services for gcommunicable disease control
R ibilitiR ibilitiResponsibilitiesResponsibilities• Advice to Government on
health protection• Delivery of services to theDelivery of services to the
NHS and other agencies • Impartial, authoritative
information and advice to the public professionals
• Rapid response to new threats and emergencies
• Improved knowledge base through research and development, education and trainingand training
Organisation: 2010Organisation: 2010Organisation: 2010Organisation: 2010
Centre for Infections (CfI)Centre for Emergency
Preparedness & Response Centre for Infections (CfI)Preparedness & Response (CEPR)
Aims and Roles• Infectious disease surveillance.
Aims and Roles• Specialist scientific and medical
• Specialist microbiology services.• WHO National and Global
Reference Laboratories.
advice on emergency planning and response including CBRN threats.
• Antimicrobial and antiviral drug testing
• Co-ordination of disease outbreaks.• Scientific advisory role to
Government on the risks posed by
testing.• Biopharmaceutical Manufacturing
Capabilities.• Culture collections infectious agents.
• Training courses.
• Culture collections.• Research partnerships – vaccines.• Specialist diagnostic services for
dangerous diseasesdangerous diseases.
Centre for Radiation, Chemical & Environmental
National Institute for Biological StandardsChemical & Environmental
Hazards (CRCE)Biological Standards
& Control (NIBSC)
Aims and Roles• Advance knowledge of protection from
i i i d i i i di ti
Aims and Roles• WHO International Laboratory for
Standardsionising and non-ionising radiations.• Offer laboratory and technical services.• Advisory role to Government and
intergovernmental organisations
Standards - Biological reference materials.
• Bioprocessing.• Batch release testing – safety andintergovernmental organisations.
• Chemical incident surveillance and response systems - natural disasters.
• National Poisons Information Service
Batch release testing safety and efficacy- Official Medicines Control Laboratory
• R&D.• National Poisons Information Service and the Compendium of Chemical Hazards.
• Training - WHO Global Training Network.
Local & Regional Regional Microbiology gServices (LaRS)
Aims and Roles Aims and Roles
Network (RMN)
• Frontline services.• Investigation and management of public
health incidents and outbreaks.L l di ill
• Specialist advice and support- outbreaks and incidents.
• Referred tests.• Local disease surveillance.• Syndromic surveillance.• Port health.• Alert systems
• Molecular diagnostic tests• Emergency response
- outbreaks and incidents.• Alert systems.• Emergency response training courses
and exercises for health care providers.
outbreaks and incidents.• Specialist identification or typing.
Various DepartmentsVarious Departments
8 Regional Laboratories9 Regional Offices28 Health Protection UnitsEmergency Response Department
8 Regional Laboratories9 Food, Water, and Environment testing
Laboratories37 HPA Collaborating Laboratories
The Division of Public Health Strategy coversThe Division of Public Health Strategy covers the following areas of work:
• Public Health Strategy• Clinical & Health Protection GovernanceClinical & Health Protection Governance• Knowledge Management• Professional Development• International Health• Chair of the Influenza and Respiratory Virus Programme Board
B ildi id i l i l it• Building epidemiological capacity• Health Protection Training (oversight of 28 public health
and medical microbiological trainees)g )• CBRN policy lead• Medical Director
FundingFunding62% of funding from the Department of Health (government grant in aid)
38% (£117m) of funding from non-grant in aid sources – contracts and services, products and royalties and research grants
Expenditure by division 2008/09
Distribution of staff between centres and divisions 2009/10
2008/09 Staff Profile
RelationshipsRelationshipspp
Public
Academic &Professional
bodiesCommerce
HPALocal
InternationalNational Health
Service
LocalRegionalNational
Local Authorities& Government&
Government Offices
in the Regions
GovernmentDepartments& Agencies
Influenza A =a zoonotic diseasea zoonotic disease
Naturally present in a range of animalsNaturally present in a range of animals
Cross species reassortmentCross species reassortment
Courtesy of the CDC
Influenza:h t i ihuman transmission
Pandemic InfluenzaPandemic Influenza
PAN (all, παν )PAN (all, παν )
+
DEMOS (people, δήμος )DEMOS (people, δήμος )
= an epidemic that affects all people
Circulating influenza strains in humans d d i i 20th 21st C t iand pandemics in 20th – 21st Centuries
1918: “Spanish Flu”
40-50 million d th
1957: “Asian Flu”
1 million
1968: “Hong Kong Flu”
1 million deaths P d i
H3N2
deaths 1 million
deaths
1 million deaths Pandemic(H1N1) 2009
H1N1 H1N1H2N2
1920 1940 1960 1980 2000 20101976: “Swine flu” (US scare)1977: “Russian Flu”
Shortest interval = 11 yearsLongest interval = 41 years
1918-1919 Pandemic: A(H1N1)influenza deaths, England and Wales
18,000
12 000
14,000
16,000
nd W
ales
8,000
10,000
12,000
Eng
land
a
4,000
6,000
8,000
Dea
ths,
0
2,000
7 9 1 3 5 7 9 41 43 45 47 49 51
2 4 6 8 10 12 14 16 1827 29 3 33 3 3 3 4 4 4 4 4 5 1 1 1 1 1
1918 1919Week number and year
1957-1958 pandemic: A(H2N2)p ( )influenza deaths, England and Wales
1,000
800
d W
ales
400
600
Engl
and
and
200
Dea
ths,
E
0
6 13 20 273 10 17 24 31 7 14 21 28 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25 1 8 15 22
July August September October November December January February
Week number and monthWeek number and month
Courtesy of the Health Protection Agency, UK
1968-1969 pandemic: A(H3N2)p ( )GP consultations, England and Wales
1,400
Seasonal
1,000
1,200
ns p
er w
eek influenza
600
800
cons
ulta
tion
Initialappearance
200
400
GP
'ILI'
c
0
42 48 4 12 20 28 36 44 50 8 16 24 32 40 48 4 12 20 28 36
1967 1968 1969 1970
Week number and year
Courtesy of the Health Protection Agency, UK
Pandemic (H1N1) 2009( )
Pandemic (H1N1) 2009:timeline
( )
• 12 April: outbreak of influenza-like illness in La Gloria, Veracruz Mexico
• 15-17 April: two cases of the new A(H1N1) virus infection identified in two southern California counties, USA
• 23 April: novel influenza A (H1N1) virus infection confirmed in23 April: novel influenza A (H1N1) virus infection confirmed in several patients in Mexico
• 24 April: WHO declares a public health event of international concern• 27 April: WHO declares pandemic phase 4 - sustained community
transmission in Mexico, cases confirmed in UK and Spain
• 29 April: WHO declares pandemic phase 5 (2 countries affected)• 29 April: WHO declares pandemic phase 5 (2 countries affected)• 11 June: WHO declares pandemic phase 6 (spread to more than 2
WHO regions)
• In 9 weeks, all WHO regions report cases of pandemic (H1N1) 2009
Pandemic (H1N1) 2009:what were the early challenges?
( )
• Recognition of the first human cases in the UK: di i d fi tidiagnosis and confirmation
• Monitoring the first cases and contacts very closely• Public health interventions: schools planes• Public health interventions: schools, planes• Hygiene and social distancing messages• Antivirals - systems for distribution• Antivirals - systems for distribution• Managing social disruption • Vaccine availabilityVaccine availability• Advising Government …
ill tPandemic (H1N1) 2009:
surveillance systemsGeneric surveillance systems• National laboratory reporting scheme• RCGP Weekly Returns Service• NHS Direct syndromic surveillance• Mortality monitoring• Hospital admissions
S l i fl ill tSeasonal influenza surveillance systems• QFLU (as a component of Q-Surveillance)• HPA spotter practice scheme
HPA A ti i l R i t M it i d Vi l S i f I fl• HPA Antiviral Resistance Monitoring and Viral Sequencing of Influenza • Medical Officers of Schools Association
Pandemic Preparedness SystemsPandemic Preparedness Systems• National Pandemic Flu Service• Enhanced surveillance of pandemic (H1N1) 2009• First Few Hundred (FF100)• First Few Hundred (FF100)• Flu Clinical Information Network (Flu-CIN) • Hospitalisation study
Policy decision making in emergencies
• Civil Contingencies Secretariat (CCC)– CCC (O) and CCC (M)
• Government takes (public) health advice from a variety of sources– Chief Medical Officer (DH)– SAGE– HPA– Other key bodies e.g. JCVI
Pandemic (H1N1) 2009:( )once established, what were the ongoing challenges?
GP swab kitsFlu Response Centres
school closure
Pandemic (H1N1) 2009:UK Strategy
C t i t Ph ( b d ill ) 27 A il
( )
Containment Phase (case based surveillance) 27 April• Meeting aircraft from Mexico, information for travellers• Identification of cases - treatment
Identification of close contacts prophylaxis• Identification of close contacts - prophylaxis• Closing of affected schools for 7 days
Outbreak management (case based surveillance) 19 JuneOutbreak management (case based surveillance) 19 June• No case finding at ports of entry• Flexible approach to schools - local risk assessment• Clinical diagnosis for contacts of confirmed cases• Clinical diagnosis for contacts of confirmed cases• Widespread community transmission areas
Treatment Phase (routine winter surveillance) 2 July• Clinical diagnosis, not laboratory testing• Treatment available for all (especially risk groups)• No contact tracing• No prophylaxis, except for risk groups• Move from daily reporting of laboratory confirmed cases to general
estimates of disease spread
situation could be a lot worsePandemic (H1N1) 2009:situation could be a lot worse
A pandemic emerging in SE Asia Pandemic strain emerging in the Americas emerging in SE Asia Pandemic strain emerging in the Americas
Delayed virus sharing Immediate virus sharing, enabling rapid
diagnostic and vaccine production could begindiagnostic and vaccine production could beginBased on a more pathogenic strain, e.g. A(H5N1)
Based on A(H1N1) currently not very virulent
No residual immunity Residual immunity in a major large risk group
Heightened pathogenicity No known pathogenicity markers
Inbuilt antiviral resistance Susceptible to oseltamivir
l d l Good data and information from North America
Minimal data until transmission reached Europe
Good data and information from North America
Arriving in the late autumn or winter Arriving in spring/summer
Contrast with what might have happened — and might still happen!
Severe presentation immediately
Mild presentation, initially
Discussion: working collaboratively g yon infectious diseases
• Pandemic Flu : planning arrangements: update of national plan: operational responsep p
Q: What could work better?
• Surveillance for infectious diseases e.g. other respiratory viruses, HIV, HCAIs
Q: What could work better?
Response to infectious diseases e g Godstone Farm• Response to infectious diseases e.g. Godstone Farm
Q: What could work better?
Contact: anthony.kessel@hpa.org.uk