|This is a synposis from the notes I took of his presentation, which I thought was one of the best analysis of pandemic risk from the global perspective, as befits his work, I guess.
The major theme is the same as what he reiterated before, at the Katrina meeting, that pandemics are wicked problems with no easy answers, only uncomfortable knowledge and clumsy solutions. He also spoke of pandemics as an example of large scale or 'megadisasters' which another speaker Irwin Redlener from Columbia University, defined as a disaster that overwhelms the ability of local and regional government to respond. As with other such similar disasters including HIV/AIDS, it is the poor who will suffer the most.
The 1918 pandemic swept through the world inexorably from continent to continent, with very bad consequences for some island states in the Pacific and some parts of New Zealand and Australia (NB. Note this reference to very high mortality among some island states and Alaska, in this commentary on EU public health measures ) but there is good evidence now that those countries and communities that practiced "proper and adequate PH" were able to reduce consequences, both in human loss, as well as sociao-economic losses. He referred again later in the speech to social distancing measures as the first and most important strategy for mitigation, when compared to antivirals and vaccines.
On H5N1 specifically, Nabarro calls it "the nastiest flu virus we've ever known, and I'm going to keep repeating that". The virus is now in > 60 countries, and is being transmitted continuously among poultry in many of these countries, ie the virus is now enzootic. In West Java, for example, the virus is entering the environment in large amounts, and has been isolated not just from poultry, but in the water, in fish, as well as in some mammals. The presence of such large amounts of virus in the environment means the risk of human infection continues and is not going away, despite efforts at eradication in the past few years.
H5N1 is a strong candidate for a pandemic because it replicates within humans, producing severe pneumonias and cytokine reactions (in comparison to other avian viruses causing only mild and localized human infections eg conjunctivitis rather than systemic disease). Despite the use of tamifu, the CFR in Indonesia is still >80%, although later in the speech he did say there seems to be some reduction in mortality in Egypt with the use of tamiflu. Although 2007 was a relatively good year in terms of human cases, 2008 is getting off on a bad start.
Indonesia is the major epicenter, but a new epicenter is opening in West Bangal, where culling has been extremely difficult because of poverty and the reluctance of people to give up on their livelihood. What's more, since we do not know for sure that H5n1 is going to cause a pandemic, it becomes very difficult to justify asking people to give up their livelihood.
This combination of the possibility of a global megadisaster with huge uncertainties bumping up against people's livelihood is an example of what he said earlier, about wicked problems.
Some people see the main impact of a pandemic as on people's health, with maybe 30% people sick and 2-3% of them dying, healthcare overwhelmed etc. but pandemics cause a lot more problems beyond health, including problems in systems of government, security systems, prison systems, police service, military. Also in social and humanitarian needs, to satisfy populations' demands for food and other essential services. There will be severe economic disruptions due to disturbance in trade and commerce, and breakdown in banking and other systems.
Taken together, social, economic, governance and humanitarian consequences need to be treated with greater urgency than public health and clinical health problems.
SARS gave us a foretaste of things to come. Although it only resulted in 8000+ cases and 774 deaths, ie the human suffering was relatively small, and by all accounts it was a major public health success, it caused huge economic losses of 50 billion. The World Bank estimates that even with mild pandemics such as 1957 or 68, the economic losses will be in the order of 2 trillion dollars with 5% reduction in global GDP, not just from absenteeism but from the extraordinary efforts people will take to "insulate themselves from infection". Interestingly, on this, Nabarrro said "as long as they do the right thing at the right time, much rather they do that than expose themselves to risk", but the consequences are huge - markets will close, utilities will become unreliable, telecommunications will break because of heavy load, cash will be in short supply.
He summarized the consequences of a pandemic into these areas:
- Human health
- Governance and security
- Social and humanitarian needs
- Economic systems
He also says pandemic is a threat to global security, that those involved in peacekeeping, for example, views this threat very seriously.
What is needed is multi-sectoral pandemic preparedness, globally. Since there really is no global 'government' then consensus needs to be built every step. They started in 2005 with the first agreements, to start work on the bird problems first, because it was the only way to get the attention of heads of governments. Now they are moving towards human disease, but every thing needs consensus from 192 countries. His office deals with 500-1000 different parties, such are the complexities in developing a global strategy.
The first part of the global strategy involves dealing with the initial outbreak. The key is to get there quickly. Nabarro says they have about 20 days to get there and work with local authorities, to try and contain it, otherwise containment will fail. But if the initial outbreak is near an international airport, if people start traveling, etc then we won't have those 20 days.
There are 3 strategies for containment, one of which he said will not work. The first and most important is social distancing, personal protection, restriction of movement from the affected area, and maintenance of infrastructure to satisfy the needs of the communities isolated. The second is the careful use of antivirals, potentially only to those exposed to the virus so that it will not be wasted. We don't know if it will work, but it's only the best we have. The third is rapid deployment of vaccines, but that is unlikely to happen since we simply do not have them.
He commended the US government for having done the most work on the use of NPI, and that these measures should be at the center of control measures.
If containment fails, the next we will have to depend on mitigation. We need to build resilience. Governments have to reach out and work with private entities and voluntary bodies, something that governments are not used to nor good at. Also, government and voluntary bodies have to get ready for large scale humanitarian relief.
Next, what we need by way of procedures:
- Robust information systems - so we don't have blockage of data
- Protocols for use of stockpiles of antivirals and vaccines
- Synchronize civil society, ngo, govt - right now different sectors are preparing separately, must get them to synchronize. Nabarro's office is working with 500-1000 stakeholders
- System for dissemination of information to public - via media developed and tested
- Continuity plans for different entities - simulated and lessons applied
- Concept for putting multiple plans into practice, together, developed and put to the test(CON-OPS) - not good enough to have separate plans
Finally, some enabling factors for global success:
- Good info
- Effective interventions (requires political direction)
- Rapid scale up
- Social mobilization
- Incentives for prompt reporting
- Alliances - of all goverments and different partners
UPDATE Dr Nabarro's slides are available here