Communicating about influenza is one of the most difficult things I, and my scientific colleagues in the ECDC, have to do.
Because when we talk about “influenza” we need to be very clear about what kind of flu we mean.
Do we mean:
- Ordinary human influenza, of which we see an outbreak in Europe every winter;
- Avian influenza – “bird flu” as it has come to be known, which is an animal virus that can occasionally infect humans;
- Or pandemic influenza – a highly aggressive form of human influenza last seen in 1968, but which we have reason to fear could re-appear in the coming years.
These are three different health threats.
But, to make my life - and your life – more complicated, there are important linkages between them.
Let me start by saying a few words about ordinary seasonal influenza.
I often hear people talking about “normal” human flu as if its not a serious disease.
Let me dispel that myth. Ordinary human flu is a killer.
We do not know how many people in Europe are killed by influenza each year, because its victims tend to be the elderly and people suffering from chronic disease. Influenza does not usually appear on their death certificate as the cause of death – it will be attributed to pneumonia or heart failure.
However, I am convinced that EU countries could save thousands of lives each year by stepping up their efforts to present seasonal influenza.
And indeed the need to step up our efforts against seasonal influenza was one of the key conclusions of the joint EU / WHO Workshop on Pandemic Influenza Preparedness, which was hosted by ECDC in Uppsala, Sweden in May.
To give just one example, most European countries are a long way from meeting the target – agreed to by them all at the World Health Assembly in 2003 – for increasing uptake of the seasonal influenza vaccination amongst the elderly.
By 2008 all countries are meant to be vaccinating at least 50% of people aged 65 and over. ECDC approached 28 European countries earlier this year to see what progress they were making towards meeting this target. Half of the countries could not even provide figures for vaccine coverage amongst this section of the population.
I say immediately – before you ask – this was done as an anonymous survey, so I cannot “name and shame”, even if I wanted to. Getting a clearer picture on seasonal influenza vaccination among the elderly is now a priority.
By stepping up prevention against seasonal influenza we can save lives immediately. Just as importantly, by improving our understanding of how normal human influenza spreads we can improve our preparedness against a pandemic.
For most of the measures governments are contemplating to control a pandemic – distribution of face masks, closure of schools, closure of borders – we have little or no evidence as to whether they will actually work.
Every flu season, then, is an opportunity to find out what sort of measures are effective in controlling an influenza outbreaks.
We do not know how many more of these “normal” flu outbreaks we have before the next pandemic. Public health research on seasonal flu should therefore be an urgent priority for the EU and Member States
H5N1 avian influenza
On ‘bird flu’, Let me first of all start with the good news about H5N1
Firstly, the early wave of H5N1 Infection from the East amongst the wild bird population in Europe peaked in February and March and has not been replaced by infections from Africa:
Secondly, the epidemiology of the virus among humans seems to have changed little since it first appeared in Hong Kong in 1997:
H5N1 as yet is an animal virus, poorly adapted to humans. It’s a very dangerous pathogen for humans but its not very infectious.
The main risk factor is close contact with sick birds
Thirdly, so far, EU veterinary policies have been effective in preventing and major outbreak of H5N1 in domestic poultry flocks here.
Therefore, at the present time, H5N1 is a very low level risk to public health in the EU.
Even if we were to have a major outbreak of H5N1 amongst poultry in the EU, the risk to most EU citizens would still be low. Very few of us keep birds or have close contact with them – you rarely see chickens walking down the boulevards in Brussels.
What is the bad news then?
Human cases of H5N1 are rare, but they are often fatal. More than 50% of the known human cases to date have died. It may be a low level threat, but it is one we must take very seriously.
H5N1 infection amongst wild birds in Europe has peaked for now, but we are likely to see further waves of infection. As long as the virus in endemic in parts of Asia and Africa it is likely to keep reappearing in Europe. Most recently we have seen this in Hungary and Romania.
Every outbreak of H5N1 amongst birds carries a risk of humans becoming infected.
Every human case of H5N1 carries the risk of the virus adapting, mutating or combining with a seasonal virus to change into a human pandemic virus.
The more human exposure there is to H5N1 around the world the more the opportunity the virus has to evolve into a human virus. That is why ECDC in our recent risk assessment was so concerned about the continued spread of H5N1 in Asia and Africa.
Our aim in Europe must be zero human cases, and zero deaths from H5N1, on our continent.
So when will the pandemic happen?
We do not know. No one knows. Nor can we say for sure that it will be caused by H5N1. Our working assumption is that H5N1 has pandemic potential, but we cannot even say that for sure.
What we do know, is that there were three pandemics during the 20th century. The centuries before them also had pandemics. So a 21st century pandemic would seem to be inevitable. Even a “mild” pandemic – one like the pandemics of 1957 and 1968 – will cause disruption to our societies and result in a significant number of deaths.
By preparing now we can save lives.
So what has ECDC been doing to strengthen pandemic preparedness?
We have devoted a lot of time and energy to monitoring developments on H5N1 avian influenza and advising on the risks. I think you have all been given a compendium of our scientific work on this.
ECDC has also had experts out in the field, assisting countries affected by the virus in investigating and responding to outbreaks.
Often working with WHO, ECDC has provided either staff or expertise for missions to:
- The part of Cyprus not under the effective control of the Cypriot government
Being part of the team helping affected countries investigate human cases of H5N1 means we have access to the most up to date information. ECDC is getting first hand information on whether and how the virus is evolving. And we are sharing this on a day to day basis with public health institutes across the EU.
In parallel to this we have been assisting Member States with their preparedness planning. In 2005 a joint team of officials from ECDC, the Commission and WHO visited six European countries to help them review their preparedness.
- Ukraine and
the United Kingdom
…using an ECDC developed assessment tool and a methodology jointly drawn up with other partners.
In the first half of 2006 ECDC teams visited a further six countries:
- Portugal and
We will conduct more country visits in the second half of this year, along with holding joints meetings with groups of Member States not yet visited.
ECDC has already seen a good cross section of Member States and helped them review their preparedness. By the end of this year we will have an even better picture of preparedness across the 25 Member States.
In May this year in Uppsala senior public health officials from nearly 50 European countries, the EU, WHO and the UN met to review progress on pandemic preparedness and agree priorities for the coming year.
It was clear at that meeting that the level of preparedness in EU Member States is way ahead of preparedness in other parts of Europe, and indeed most of the world.
The Uppsala workshop produced an excellent road map for strengthening pandemic preparedness in Europe, which I am determined to make use of.
The bad news on pandemic preparedness
There are still gaps in our knowledge about influenza and in our preparedness against a pandemic. I have already spoken of the need for more public health research on seasonal influenza.
If we can improve our understanding of how normal human influenza viruses spread, and how we can protect people against them, then we will be much better prepared for pandemic influenza when it arrives.
Even more difficult, but equally important are the political and organisational questions:
Pandemic preparedness is not just a health issue. A pandemic, especially a bad one will impact areas of public policy ranging from transport, education and utilities to law and order and foreign policy. Planning needs to be across government and truly multi-sectoral at national, regional and local levels
More work is needed to achieve local preparedness. You may have a great national plan, but are local hospitals and local officials aware of it. These will be the people on the frontline in a pandemic
Even if you have antivirals how will you deliver them to people as quickly as you need
These are not easy questions. But they are ones to which we can find answers.
However, it will not be easy. Indeed, we should be suspicious of easy answers.
Preparedness is a process, not a final destination. European countries need to keep their plans and systems under constant review, updating them as our knowledge of influenza – and how to protect against it – evolves.
Above all, it means continuing to ask how we can do things better.
Visit in the second half of 2006 are likely to be to: Austria, Belgium, Czech Republic, Hungary, Latvia, Spain.