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Seminar on "Pandemic Preparedness in Southeast Asia”

by Dr. Takeshi Kasai
Regional Advisor for the World Health Organization's Western Pacific Regional

Date: 20th October 2008
RSIS Seminar Room 1 and 2
Time: 10.30am - 12.30pm


The seminar on Pandemic Preparedness began with Dr. Takeshi Kasai of the WHO WPRO emphasizing that pandemics are neither a new security threat nor a phenomenon that belongs to the past. As a representative of the WHO, he pointed out that it was impossible to accurately predict the actual effects and the size of pandemics. What was possible, however, was for the WHO to develop frameworks for preparing for and dealing with pandemics, and to enable the sharing of information. Dr. Kasai divided his presentation into three sections. The first section detailed the phenomenon of Emerging Infectious Diseases (EIDs) and the development of International Health Regulations to deal with the rapid demands of EIDs. His second section explained the current status of Avian Influenza and Pandemic (Bird-to-Human) Influenza and how serious the threat of each was. Finally, he discussed Pandemic Preparedness Initiatives that the WHO was leading and about the challenges and results of the plans so far.

Emerging Infectious Diseases & the new International Health Regulations

The Threat Posed by EIDs

Dr. Kasai outlined the ongoing threat posed by Infectious Diseases, saying that these diseases brought social systems to the breaking point in the past, and could do so again. He particularly emphasized the high lethality of novel pathogens such as SARS, Ebola, Nipah, Marburg and H5N1, which are lethal precisely because they are poorly understood as they emerge, leading to a failure of containment and treatment measures. Even while the death toll from these new pathogens is low when compared to more well-known ones such as Malaria and HIV/AIDS, the appearance of these new diseases has a high impact on health and social infrastructure because of the panic and fear they generate.  In addition, new driving forces shape the spread and lethality of these diseases. Higher levels of urbanisation, the poor state of sanitation infrastructure in most of the world, the lengthening of food chains, the improvements in the population mobility, and increased human-animal contact in unsanitary conditions not only made diseases spread faster, but also evolve quicker.

Containment Measures

The experience of SARS showed the WHO that there was a need for better coordination of information between itself and the various health ministries in the Western Pacific. During the crisis, despite the fact that the WHO had issued critical warnings against travel to Hong Kong and Guangzhou, there was no way to directly inform health ministries of the travel warning. Instead, the WHO had to post this information publicly on its website and let the media broadcast this information.

Given this experience, the WHO instituted new International Health Regulations that were designed to help overcome these shortcomings. These new International Health Regulations (IHRs) define rights, obligations and permissions between the WHO and its member states and have been given binding powers to enforce their provisions. The new framework has also incorporated paradigm shifts that aim to make cooperation on pandemics more effective and more active. The first paradigm shifted containment measures from focusing on the control of borders to containing the pathogen at its source. The second paradigm expanded public attention from a dedicated list of disease threats to a broader list of public health threats. Finally, the third paradigm changed the focus on a preset list of measures to deal with outbreaks to a more flexible one allowing adapted responses. This paradigm shift was accompanied by an implementation plan, (known as the ‘Lighthouse Plan’) that will be active in the following areas: international travel, national surveillance and response, a WHO Global Alert and Response system, and Threat-specific control programmes. The IHR, Dr. Kasai emphasized, aims to provide a public health response to the spread of disease internationally, but without interfering unnecessarily with trade, transport, and the domestic sphere of the state.
The new IHR has combined features that help to operationalise responses to public health threats.  A “National Focal Point” has now been designated by each member country to enable direct and continuous communication between the WHO and the national officials of the state. Guidelines have been established with clear criteria for risk assessment, and a secure website has been established to allow national stakeholders to share information and reports securely and confidentially. However, Dr. Kasai acknowledged that local risk assessment capacity in some countries may be limited by the lack of established communication procedures and manpower.

Status of Avian & Pandemic Influenza

Avian Influenza

Dr. Kasai gave a brief history of avian influenza in the region and explained where outbreaks were likely to break out in the future. Avian influenza first appeared in South Korea in 2003, and spread throughout Asia by 2004. Thailand, Vietnam and Indonesia have reported the most cases in the region. A worrisome development is that wild birds have begun to die of avian influenza, even if these birds are normally more resistant to disease than domesticated birds. It also indicated that the virus could now travel outside Asia, by vectors that were largely uncontrollable (the migration of wild birds). Good husbandry practices could contain the virus on sight if detected early enough, but once the virus became entrenched, such as the case with Indonesia and Thailand, it becomes difficult to eradicate. Outbreaks of avian flu have recurred in these countries.

Pandemic Influenza

Since 2003, there have been over 15 countries globally that reported cases of H5N1 in humans, with a total of 387 cases as of the fifteenth of October, 2008.  Over 80% of the cases were in the region, with over 8 countries reporting cases of Pandemic Influenza. However the species barrier between birds and humans is still high, as most cases of human transmission of H5N1 occurred as a result of extensive exposure, usually between members of the same family or community. The pattern of cases so far has shown that the primary source of outbreaks has moved from Vietnam to Indonesia. The mortality rate has also increased from 60% in Vietnam to 80% in Indonesia.

However, the virus has a limited capacity to spread broadly as a result of the high mortality rate of its vectors. Most people infected by the virus die too quickly before they are able to spread the disease. The average time between onset and death is only 9 days, and most cases of H5N1 affect those between 0-29 years old, affecting men and women equally. The predominant cause of death listed is bacterial pneumonia. Dr. Kasai mentioned an interesting development in the way cluster cases were reported as well. Whereas before cluster cases were defined as human-to-human direct transmissions, they are now defined as cases of limited non-sustained person-to-person transmission. Essentially, the virus does not readily spread by human to human contact unless the vectors in question maintain constant contact and/or are genetically related.  However, these kinds of infections are still rare. The primary cause of infections is still exposure to dead birds.

H5N1 has already begun to evolve rapidly, with over 4 variations, called “clades” already detected. Clade 1 is specific to Korea, Japan and Vietnam. Clade 2.1 is endemic to Indonesia. Clades 2, 3 and 4 have spread widely throughout Central Asia and Europe. The effectiveness of antivirals is now in question as the virus evolves, along with the question of whether an antiviral will be effective across all clades. At present, H5N1 still has limited capacity for human to human transmission. It is entrenched in Asia, however, and cases of animal-to-human transmission do exist. A pandemic risk, therefore, remains. The estimated damage from an Influenza Pandemic has estimates going as high as US$800 billion within a year, in contrast to SARS, which cost only US$40 billion. The fact that over 96% of pandemic influenza cases are projected to occur in the developing world, which has inadequate resources to meet this kind of crisis, is also worrisome.

Current situation of Pandemic Preparedness Initiatives

Stages of Interventions

Dr. Kasai introduced a formal model of modelling pandemic interventions, called “Stage-wise Intervention”. This model contains three stages. The first, Averting Avian influenza, is concerned with preventing animal outbreaks of influenza and the culling of infected stock. The second, Rapid Containment, involves the release of antiviral drugs and the implementation of quarantines and other social restrictions to prevent the spread of the disease. The last, Pandemic Response, requires multi-sectoral cooperation between national governments, local government units, NGOs and business in order to conduct pandemic response exercises. These exercises, in turn, help ensure that a country is prepared to deal with an influenza pandemic. Dr. Kasai noted that most governments prepare for the first 2 stages, but do little for the last stage, where local government units assume most the burden. He decided to focus the rest of his discussion on the latter 2 stages.

With regards to rapid containment, Dr. Kasai explained that the ASEAN regional stockpile of antivirals (Oseltamivir) has already been established in Singapore. The antivirals can be delivered to neighbouring countries within 1-4 days. However, he pointed out that there were cases where rapid containment would either be infeasible or impossible. These included situations where the virus was highly transmissible so that a large population would already have been infected by the time the plan was put into effect, or when a large segment of the population was already affected by the time an outbreak was detected. (For example: cases of viral outbreaks in urban areas) In these cases, rings of vaccinations around a large infected area were recommended to provide a ‘barrier’ to prevent the disease from spreading further. Some good news was reported in the field of detection. While it took an average of 17 days from the case’s occurrence to when it was reported to the WHO, it now takes 11.3 days. This was credited to massive training programmes conducted for rapid response teams.

Challenges for Pandemic Response

The area of Pandemic Response was also examined under the frame of health infrastructure capacity-building. This field includes Risk Communication, Infection Control, Zoonoses, Surveillance and Response and Laboratory capabilities. Risk Communication is a crucial element in Pandemic Response, as a small window of opportunity of two to three weeks is all that is available for a government to detect and take action if it wants to contain an outbreak. Responsiveness and information dissemination to stakeholders is therefore crucial. Pandemic Responses, especially in the form of coordination between local and national health officials, the capacity of health professionals to efficiently diagnose and report pandemic cases, and the surge capacity of the local health care infrastructure were all listed as crucial by Dr. Kasai to ensuring that pandemic plans were implemented successfully.  Another problem is the cost of pandemic response itself. The cost of antivirals alone for a lower middle-income country is estimated to take up 4.87% of its annual health expenditure. Better exercises that examine the coordination between local and national governments and other actors also need to be undertaken.
Dr. Kasai closed his lecture by pointing out what needed to be done in terms of research, exercises, planning, and core capacity development. More research in terms of the modelling of the spread and severity of a pandemic in developing countries is necessary and urgent. The patterns of seasonal influenza burdens should also be given attention, as they may be a litmus test of public health infrastructure. Improvements of existing pandemic preparedness plans should also be undertaken in the region, in accordance with WHO guidelines and their new emphasis on a holistic pandemic response and mitigation strategy. Standard operating procedures should also be created and tested using exercises, to ensure than the plans are operationalised even at the ground level. Finally, he reminded the audience that readiness was a direct result of building core capacity in public health infrastructure.

Question & Answer Portion

In the Q&A session, Rodney Hoff from the REDI Centre inquired about how pandemic preparedness was being coordinated between different UN agencies, APEC, and ASEAN. Dr. Kasai replied that the UN system coordinates between member countries and other partners. He however noted that it is at the country-to-country level where coordination is most vital. Tay Joc Cing from Ross Scientific asked what risk assessment required at the local level. Dr. Kasai explained that this was different from infection control done at major hospitals, and required the stakeholder to assess the severity of the threat and what to do about it, including reporting a case to national authorities. Dr. Hoff again enquired about the status of antiviral vaccines in the region, and if a ‘ring strategy’ employing 200-300 million doses was possible. Dr. Kasai confirmed that the antivirals were available, but logistical problems, especially regarding transport, and licensing concerns were still present. Finally, Prof. Mely Caballero-Anthony closed the seminar by asking: how do you balance between building awareness of an imminent pandemic and creating widespread panic? She answered that public officials needed to be clear about what is known about the pandemic, and what is not, and to be transparent on what we don’t know to avoid fearful speculation.

About The Speaker:

Dr Kasai serves as a Regional Advisor for the World Health Organization's Western Pacific Regional Office. Dr Kasai has extensive experience in public health and infectious disease, with responsibilities spanning programme planning, monitoring and evaluation, international collaboration, immunization policy and outbreak management.

As a Regional Advisor for the Communicable Disease Surveillance and Response Unit at the WHO's Western Pacific Regional Office, Dr Kasai leads the efforts to implement the International Health Regulations (2005). Dr Kasai guides the development of strategic priorities, preparing the 37 countries of the Western Pacific Region to avert or respond to an influenza pandemic. Dr Kasai directs a team of public health professionals who provide technical support, disease surveillance and outbreak management to the region. Dedicated to global public health, Dr Kasai has also served as Medical Officer for tuberculosis for the World Health Organization.

As the previous Deputy Director General of the Welfare and Health Bureau of the Miyazaki Prefectural Government, he was responsible for the development and implementation of Japan's very first regional influenza pandemic plan, which was distributed as a model to other regions through the Ministry of Health Labour and Welfare.

Dr Kasai is noted for his contributions to the revision of the National Infectious Diseases Control Law, the National Immunization Law and the Development of the National Infectious Surveillance including influenza, during his tenure as Chief Medical Advisor of the International Affairs Division in Tokyo.

Dr Kasai graduated from the Keio University School of Medicine with a medical degree. His further studies include Public Health, Health Policy and Economics, and Infectious Diseases at the London School of Hygiene and Tropical Medicine.