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Transcript of statement by Margaret Chan, Director-General of the World Health Organization
Transcript of statement by Margaret Chan, Director-General of the World Health Organization (WHO, June 11, 2009, edited)
Transcript of statement by Margaret Chan, Director-General of the World Health Organization
11 June 2009
[Original Document: LINK. EDITED.]
Mr Gregory Hartl:
Good evening and welcome to this Press Conference being given by Dr Margaret Chan. Dr Chan will read a statement and then we will open the floor to questions. Dr Chan, thank you very much.
Director-General:
Ladies and gentlemen,
In late April, WHO announced the emergence of a novel influenza A virus. This particular H1N1 strain has not circulated previously in humans. The virus is entirely new, the virus is contagious, spreading easily from one person to another, and from one country to another. As of today, nearly 30 000 confirmed cases have been reported from 74 countries. This is only part of the picture with few exceptions countries with large numbers of cases are those with good surveillance and testing procedures in place.
Spread in several countries can no longer be traced to clearly-defined chains of human-to human transmission. Further spread is considered inevitable. I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose.
On the basis of available evidence and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met. I have therefore decided to raise the level of influenza pandemic alert from Phase 5 to Phase 6.
The world is now at the start of the 2009 influenza pandemic.
We are in the earliest days of the pandemic. The virus is spreading under a close and careful watch. No previous pandemic has been detected so early or watched so closely, in real-time, right at the very beginning. The world can now reap the benefits of investments, over the past five years, in pandemic preparedness. We have a head start. This places us in a strong position. But it also creates a demand for advice and reassurance in the midst of limited data and considerable scientific uncertainty.
Thanks to close monitoring, thorough investigations, and frank reporting from countries, we have some early snapshots depicting spread of the virus and the range of illness it can cause. We know, too, that this early, patchy picture can change very quickly. The virus writes the rules and this one, like all influenza viruses, can change the rules, without rhyme or reason, at any time. Globally, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity as we know from experience severity can vary depending on many factors from one country to another. On present evidence, the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery ? often in the absence of any form of medical treatment.
Worldwide the number of deaths is small, each and everyone of these deaths is tragic. We have to braise ourselves to see more. However, we do not expect to see a sudden and dramatic jump in the number of severe or fatal infections. We know that the novel H1N1 virus preferentially infects younger people. In nearly all areas with large and sustained outbreaks, the majority of cases have occurred in people under the age of 25 years. In some of these countries, around 2% of cases have developed severe illness, often with very rapid progression to life-threatening pneumonia. Most cases of severe and fatal infections have been in adults between the ages of 30 and 50 years.
This pattern is significantly different from that seen during epidemics of seasonal influenza, when most deaths occur in frail elderly people. Many, though not, severe cases have occurred in people with underlying chronic conditions. Based on limited, preliminary data, conditions most frequently seen include: respiratory diseases ? notably asthma ? cardiovascular disease, diabetes, autoimmune disorders, and obesity. At the same time, it is important to note that around one third to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people. Without question, pregnant women are at increased risk of complications. This heightened risk takes on added importance for a virus, like this one, that preferentially infects younger age groups.
Finally, and perhaps of greatest concern, we do not know how this virus will behave under conditions typically found in the developing world. To date, the vast majority of cases have been detected and investigated in comparatively well-off countries. Let me underscore two of many reasons for this concern. First, more than 99% of maternal deaths ? which are a marker of poor quality care during pregnancy and childbirth ? occur in the developing world. Second, around 85% of the burden of chronic diseases is
concentrated in low- and middle-income countries.
Although the pandemic appears to have moderate severity in comparatively well-off countries, it is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems.
A characteristic feature of pandemics is their rapid spread to all parts of the world. In the previous century, this spread has typically taken around 6 to 9 months, even during times when most international travel was by ship or rail. Countries should prepare to see cases, or the further spread of cases, in the near future. Countries where outbreaks appear to have peaked should prepare for a second wave of infection. Guidance on specific protective and precautionary measures has been sent to ministries of Health in all countries. Countries with no or only a few cases should remain vigilant.
Countries with widespread transmission should focus on the appropriate management of patients. The testing and investigation of patients should be limited, as such measures are resource-intensive and can very quickly strain capacities. WHO has been in close dialogue with influenza vaccine manufacturers. I understand that production of vaccines for seasonal influenza will be completed soon, and that full capacity will be available to ensure the largest possible supply of pandemic vaccine in the months to
come. Pending the availability of vaccines, several non-pharmaceutical interventions can confirm some protection. WHO continues to recommend no restrictions on travel and no border closures.
Influenza pandemics, whether moderate or severe, are remarkable events because of the almost universal susceptibility of the world?s population to infection. We are all in this together, and we will all get through this, together.
Questions
G. Hartl:
Dr Chan will take questions and additionally may re-direct them to her staff if it is more appropriate.
Question :
What do you expect countries to do differently as a result of this change?
Dr Chan:
With the announcement from Phase 5 to Phase 6, clearly, it sends an important message to countries that, irrespective of what state the epidemic is in their country, they must maintain continuous vigilance. As I said, the influenza virus is full of surprises. It is
important, and depending on the state of infection in the country, if, say for instance, in a country that has been reporting cases, they must be on the watch out for the arrival of the infection and start to prepare their people and also the health care system to deal with the arrival of the new disease. For example the United Kingdom, it is a country in transition that has already started very robust measures trying to contain the spread of the disease. You can only do containment for some weeks and if you are seeing continuing spread of infection in the community, it is important that they move to mitigation measures, which is what they are doing. This is a smart way to conserve limited health manpower resources in the health system, medicines so that you can now focus attention on identifying patients, early treatment of patients, and making sure that vulnerable groups as described earlier get proper and timely treatment to prevent death.
Question :
Does this increased spread step up the moral pressure on the developed countries to perhaps donate vaccines to the developing world that does not have such a good secondary health care system?
Dr Chan:
Calling a pandemic is also a signal to the international community. This is a time where the world's countries, rich or poor, big or small, must come together in the name of global solidarity to make sure that no countries because of poor resources, no countries' people should be left behind without help. And that is an excellent question. In that respect, I would like to advise you that the World Health Organization has been in contact with donor communities, development partners, resource-poor countries, and also drug companies as well as vaccine companies. I think this is my duty to get the views from the different groups of countries and see what WHO can do to make this a better world through equity, social justice and solidarity.
Question:
What has changed and what made you take this decision today? In the case of Mexico, a lot of measures have already been taken to contain this virus, what more can be done?
Dr Chan:
First and foremost, you understood that I called a meeting by teleconference yesterday with a group of countries, trying to look at the evidence on the ground. And the evidence I am receiving, formal and informal, and after consultation with a group of
countries, I made the decision to call the Emergency Committee set out under the International Health Regulations to examine the evidence available to us. It is a fact that all Member Countries as well as the experts on the Emergency Committee reviewed the
evidence and there was consensus ? unanimous decision ? that we have indisputable evidence that we are at the beginning days of a global pandemic caused by a new H1N1 virus. Now, your second question. Mexico, actually, in terms of its evolution of the outbreak in the country, it is coming to a steady state. They are only seeing sporadic cases and small outbreaks as reported to us this morning by the country so they have switched their measures. They should go into mitigation. Again as I said this virus is very unpredictable. In the event that Mexico is coming out of its first wave, it doesn't mean that Mexico should let down its guard. Mexico should continue to be prepared and keep up this vigilance because the virus can come back in a second wave. In other words, when you are over with the first wave, start preparing for the future.
Question:
Dr Chan, in the run up to this announcement there was a lot of talk of WHO giving clear information on the severity of this virus. Could you elaborate a little bit on what ?moderate? means and for the normal average person, should they be losing any sleep
over this now that the pandemic has been declared?
Dr Chan:
This is one question that has been on the minds of many people. WHO now, based on available evidence, will look at of course a group of indicators, and some people call it a ?basket of indicators?. For example, the number of deaths, the number of people
getting seriously ill, look at the high-risk groups, and then also look at what is the impact of this new disease on countries. I would like perhaps later ask Dr Keiji Fukuda to provide you with more details but I just want to make an important point on severity.
Severity can be taken in two dimensions: at the global level, that is what WHO is doing, we are reviewing the situation in different countries within the World Health Organization, and we give a global assessment. But we would encourage each country to look at their own situation to make a national assessment on severity; and in continental countries ? big countries - they may even consider look at what would be the severity at sub-national level.
Dr Fukuda:
Just to amplify a little bit. Some of the things we looked at are the clinical features of the infection ? how many people do develop serious illness and death and so on ? and when we look at it that way, one of the things that we see clearly from most places is
that most of the people develop illness that is self-limited. They do not need specialized medical care, they get better. And this is really what happens to the vast majority of people. However, we also know that there have been a number of people who have developed serious illnesses ending up on respirators, having respiratory failure, and we also know a number of these serious cases have ended in death. And so, when we looked at that, we saw that while some of these are occurring in different age groups, really the predominant number of serious illnesses are taking place in younger people. So this is different from what we see with regular seasonal influenza. Moreover, we saw that about half of these take place in people who were previously healthy and do not have any pre-existing conditions. Another thing we looked at when we spoke with the countries was really to ask them questions about how are the health systems coping, how are they able to take care of people and in general, there are places where the health systems clearly have been stressed, but in general the health systems have been able to cope. So by looking at a group of considerations like this, we felt that the level of assessment at this time appropriately is ?moderate? but as the DG mentioned there are a couple of things that we want everybody to understand. One is that severity can change over time. What we see now is not necessarily what we will see in a few months or later in the year. This is one important point. The second important point is that severity can reflect a number of different things: it is partly what the virus does, but it is partly the populations. So as the DG mentioned, we know that in the Southern Hemisphere there are populations which are younger, which have high levels of poverty in some areas, which have high levels of chronic diseases, and we know that if a virus that has a mild effect in a well-off populations goes to such populations, sometimes it can be more severe than what we are seeing. We know that there can be variations from place to place and these are things that we are aware of now and that we are concerned about. What we are going to do is monitor this closely, we need to monitor it on a global level, we also know that local and national authorities need to monitor it at their level because what they see in one location may be different than in another location.
Question:
You have mentioned that an important message you want to convey that we should help developing countries which are not prepared. So in what way can we help them and another question is in this pandemic situation, what are you going to recommend about the vaccine ? the balance between the seasonal vaccine and the pandemic vaccine?
DG:
Thank you very much and yes, for countries, actually since day one of the emergence of this new virus, WHO has been working with our Collaborating Centres and with our development partners to provide technical support to our countries and that includes
investigation on the ground, as in the case of Mexico for example, and we also sent laboratory diagnostic kits to the laboratories around the world to enhance their ability to make prompt and quick diagnoses, and we of course help to train their people and we will continue to do that. We also have ? within the donation of antivirals ? we have despatched to 121 countries in WHO so that resource-poor countries have a stock pile of antivirals for use, should the virus arrive at their doorsteps. On the subject of vaccine, we have been in regular discussion with the vaccine manufacturers of the world, both in developed as well as developing countries. We were given to understand that they are close to the end of finishing their seasonal influenza vaccine production. So, they are prepared to start full-scale production of the H1N1 pandemic vaccine. Now, clearly, making the vaccine is a business decision and that is why some of them actually started earlier. There are vaccine companies that do not make seasonal influenza vaccine, so they have already started production, and there are also vaccine companies who have several plants, so some plants are making the seasonal vaccine and the other is moving getting ready to make the pandemic vaccine. So, it is a patchwork of different approaches, but at the end of the day, it is very clear now that WHO has made the announcement of Phase 6, we will get in touch with them urgently and assist them in any way we could, because we need to also bring together the regulatory authorities to look at what are some of the road blocks, so that we can help to fast track the registration so that vaccines that are safe, effective can be made available as soon as possible.
Question:
I just wanted to clarify, where do we stand on the creation of a vaccine? How do we go down from here? In the sense that we are now at 6, we cannot go higher, how can we go lower?
DG:
Well, let me answer a couple of comments and then I invite my vaccine expert, Dr Marie-Paule Kieny, she would be able to give you more details on the vaccine question. You are absolutely correct, I mean at least there is equity now: no country has pandemic
vaccine for the next few months because normally it takes about 4 to 6 months to make vaccine. For the next 3 months or so, definitely before September, no country would have vaccine . Even when we get into September and beyond, there will be limited supply of vaccine, and the challenge for the world is to look at who should get the vaccine and within a country, again which groups get the vaccine, so on that I turn over to Marie-Paule Kieny, to give more details on the vaccine.
Dr Marie-Paule Kieny:
Yes, the vaccine manufacturers are standing ready to start producing since quite a number of weeks now. They have all of them have received the vaccine virus, which is the starting material, which allows them to go into large scale preparation. A very small number has been able to start, the other ones ? we have discussed ? will be starting next week or the week after that, so it is really the quick scaling up of production and we expect, as the Director-General said, to have the first doses of vaccine available somewhere in September. I cannot give you exact dates because it is a question of seeing how the preparation goes and how the regulatory authorities review the dossier. We must say also that at that period of time the number of doses of course will be very small and only by coming weeks and months there will be an accumulation of vaccine. In terms of recommendation for user vaccine, WHO is following the situation that is developing now in the Southern Hemisphere and also the situation of the Northern Hemisphere. When enough evidence is available in the coming weeks we will make policy recommendations on which group, which population should be prioritized for the use of the first doses of vaccine.
Question:
As a follow-up question: how do we go down?
Dr Keiji Fukuda:
In terms of how we go down, I think that there are a couple of parts to this. If we take a look at what is happening right now, we are in a period in which this new virus appeared and it is spreading around the world, and we expect this period in which the virus spreads to go on for some number of months. But at some point, it will become established in most of the countries around the world, which means that there will be a lot of people who will have got infected over the next one or two years, and then we will begin to see immunity build up in the population. We will see that this virus circulates and that it will really become much more like a regular seasonal influenza virus. At that point, all things which go up come down at some point, and so I think a lot of the heightened alert really switches over and makes a transition over to dealing with this as a long-term seasonal influenza virus. The really important point here is that, as we have tried to stress at the outset, when you are talking about pandemic influenza you are talking about a marathon, you are not talking about a sprint. We know that the virus is spreading, we know that we have to deal with this for a while and then we will adjust to it and countries ? everybody will adjust to it.
Question :
Dr Chan, are there any indications so far that the virus may be changing?
Dr Chan:
Based on the evidence that we have discussed, as late as yesterday, from all the countries with the highest number of cases, the virus is pretty ?stable?, shall I put it in quotations, and the virus being analysed and looked at carefully in different countries, they
look very, very similar, but you know you bring up an important point. We need to continue to track this virus and monitor it, and as and at the earliest sign of any change, we need to inform the world and we should never forget ?as we are talking about H1N1 in Phase 6 ? we still have H5N1 in Phase 3 and this is the first time we have two new viruses co-existing at different levels of the pandemic alert. This is an extremely unusual situation and that is why it is incumbent upon WHO working with all my Member States to stay vigilant and alert for the next year or two, or even beyond.
Question:
I have a brief question but ahead of that, Dr Chan, as President of the UN correspondents, many of our members were dismayed at the selective briefing given by your agency earlier this afternoon, which created chaos in many newsrooms around the world. My question following this little protest, is that are Member States under the International Health Regulations (IHR) free to impose voluntarily if they feel like, travel bans and other quarantine measures, or do the International Health Regulations preclude that without notifying other Member States.
Dr Chan:
John, we apologize for that. The buck stops with me. Thank you. I take responsibility, do not give my staff a hard time. You ask an extremely important question. At the early stage when we met with the Emergency Committee, based on the evidence, we made some recommendations. Clearly, no closure of border, no restrictions of travel, and also no trade ban and we make those recommendations. Recommendations are recommendations, and we did see that some countries are not following the recommendations coming from WHO under the IHR. But under the IHR, I have a duty: require them to provide me with the public health justification on taking those actions. And we have done so. We keep chasing after all the countries and ask them to explain why they were doing what they were doing. And I am happy to say that things are getting better, but we must recognize that with a new disease, with a new threat, with a lot of uncertainty, it is not unusual to have a degree of overreaction and in some quarters they described it as panic. I think this is understandable, it is acceptable and we do need to give people the right kind of information to allow them to make that adjustment reaction. And we assume that this is being done very well and the countries are lifting all these bans that they have imposed in early phase. Of course we will continue to work with FAO, OIE and also WTO to impress upon the Member States of the countries that they should really follow our recommendations.
Question :
I have two questions, first since this is the highest level we can get, can we assume that countries are free to break patents, for example for antivirals such as Tamiflu?. And secondly, what is your perception of what can be the impact of this declaration? For
example, in the markets, or in the situation of the world economy that is already in recession. Do you predict that it can even make things worse, or what are your basic recommendations to the market itself?
Dr Chan:
Let me take the second question first. I do not have the crystal ball and I am not an economist. I would not delve into areas in which I have no core competencies. I hope you would accept that. The first question, again I am not exactly an expert on international Property but I can share with you what we have been seeing ? since you mention Tamiflu?. Roche has offered sub-licence to many countries and to many drug companies in some countries. In fact WHO has been inviting generic companies to come forward so that we could assist them with pre-qualification, so that generic medicine, generic oseltamivir, would be available as soon as possible. We are happy to say that we have done one prequalification for a company in India. At this point in time, they are available, both patented medicine as well as generic. I wish to say that Roche has made a donation to us ? 5 million courses ? and I have dispersed all of them to the countries, to 221 countries as I mentioned earlier. I am receiving a second donation in the quantity of 5.6 million doses, part of that is paediatric formulation and on receipt of that donation, over time, we will send them to other countries to make sure they have something in hand to deal with the situation.
Question :
Basically my question was, if we leave aside the rather technical and scientific explanation for what the severity of this outbreak is, can you just explain for the average person how they should be thinking about this. Should they be really concerned, is this
something that they can forget about for now, just some explanation that the average person can understand.
Dr Fukuda:
Let me put it in perspective. This is one of those things that is good for people to know about. For example, it is good to know that there are different diseases and so on. But it is also really good for the average person to put it in perspective. If they develop a
fever and cough, the vast chances is that they are going to do well. What is really important for them to know, if you are a mother, or if you are a family, that if you develop something like this, and then you develop something which indicates that there is something more serious going on, you know you have trouble breathing, or you have those kinds of difficulties, then to go seek medical care. I think that the average person should know about these things, their Government and information services may be providing important information, they are certainly going to read about it in the media, and to have a perspective on it, but definitely not to get overly anxious about it. It is like most things in life, understand it, put it in context, and then you go on with things.
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Transcript of statement by Margaret Chan, Director-General of the World Health Organization
11 June 2009
[Original Document: LINK. EDITED.]
Mr Gregory Hartl:
Good evening and welcome to this Press Conference being given by Dr Margaret Chan. Dr Chan will read a statement and then we will open the floor to questions. Dr Chan, thank you very much.
Director-General:
Ladies and gentlemen,
In late April, WHO announced the emergence of a novel influenza A virus. This particular H1N1 strain has not circulated previously in humans. The virus is entirely new, the virus is contagious, spreading easily from one person to another, and from one country to another. As of today, nearly 30 000 confirmed cases have been reported from 74 countries. This is only part of the picture with few exceptions countries with large numbers of cases are those with good surveillance and testing procedures in place.
Spread in several countries can no longer be traced to clearly-defined chains of human-to human transmission. Further spread is considered inevitable. I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose.
On the basis of available evidence and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met. I have therefore decided to raise the level of influenza pandemic alert from Phase 5 to Phase 6.
The world is now at the start of the 2009 influenza pandemic.
We are in the earliest days of the pandemic. The virus is spreading under a close and careful watch. No previous pandemic has been detected so early or watched so closely, in real-time, right at the very beginning. The world can now reap the benefits of investments, over the past five years, in pandemic preparedness. We have a head start. This places us in a strong position. But it also creates a demand for advice and reassurance in the midst of limited data and considerable scientific uncertainty.
Thanks to close monitoring, thorough investigations, and frank reporting from countries, we have some early snapshots depicting spread of the virus and the range of illness it can cause. We know, too, that this early, patchy picture can change very quickly. The virus writes the rules and this one, like all influenza viruses, can change the rules, without rhyme or reason, at any time. Globally, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity as we know from experience severity can vary depending on many factors from one country to another. On present evidence, the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery ? often in the absence of any form of medical treatment.
Worldwide the number of deaths is small, each and everyone of these deaths is tragic. We have to braise ourselves to see more. However, we do not expect to see a sudden and dramatic jump in the number of severe or fatal infections. We know that the novel H1N1 virus preferentially infects younger people. In nearly all areas with large and sustained outbreaks, the majority of cases have occurred in people under the age of 25 years. In some of these countries, around 2% of cases have developed severe illness, often with very rapid progression to life-threatening pneumonia. Most cases of severe and fatal infections have been in adults between the ages of 30 and 50 years.
This pattern is significantly different from that seen during epidemics of seasonal influenza, when most deaths occur in frail elderly people. Many, though not, severe cases have occurred in people with underlying chronic conditions. Based on limited, preliminary data, conditions most frequently seen include: respiratory diseases ? notably asthma ? cardiovascular disease, diabetes, autoimmune disorders, and obesity. At the same time, it is important to note that around one third to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people. Without question, pregnant women are at increased risk of complications. This heightened risk takes on added importance for a virus, like this one, that preferentially infects younger age groups.
Finally, and perhaps of greatest concern, we do not know how this virus will behave under conditions typically found in the developing world. To date, the vast majority of cases have been detected and investigated in comparatively well-off countries. Let me underscore two of many reasons for this concern. First, more than 99% of maternal deaths ? which are a marker of poor quality care during pregnancy and childbirth ? occur in the developing world. Second, around 85% of the burden of chronic diseases is
concentrated in low- and middle-income countries.
Although the pandemic appears to have moderate severity in comparatively well-off countries, it is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems.
A characteristic feature of pandemics is their rapid spread to all parts of the world. In the previous century, this spread has typically taken around 6 to 9 months, even during times when most international travel was by ship or rail. Countries should prepare to see cases, or the further spread of cases, in the near future. Countries where outbreaks appear to have peaked should prepare for a second wave of infection. Guidance on specific protective and precautionary measures has been sent to ministries of Health in all countries. Countries with no or only a few cases should remain vigilant.
Countries with widespread transmission should focus on the appropriate management of patients. The testing and investigation of patients should be limited, as such measures are resource-intensive and can very quickly strain capacities. WHO has been in close dialogue with influenza vaccine manufacturers. I understand that production of vaccines for seasonal influenza will be completed soon, and that full capacity will be available to ensure the largest possible supply of pandemic vaccine in the months to
come. Pending the availability of vaccines, several non-pharmaceutical interventions can confirm some protection. WHO continues to recommend no restrictions on travel and no border closures.
Influenza pandemics, whether moderate or severe, are remarkable events because of the almost universal susceptibility of the world?s population to infection. We are all in this together, and we will all get through this, together.
Questions
G. Hartl:
Dr Chan will take questions and additionally may re-direct them to her staff if it is more appropriate.
Question :
What do you expect countries to do differently as a result of this change?
Dr Chan:
With the announcement from Phase 5 to Phase 6, clearly, it sends an important message to countries that, irrespective of what state the epidemic is in their country, they must maintain continuous vigilance. As I said, the influenza virus is full of surprises. It is
important, and depending on the state of infection in the country, if, say for instance, in a country that has been reporting cases, they must be on the watch out for the arrival of the infection and start to prepare their people and also the health care system to deal with the arrival of the new disease. For example the United Kingdom, it is a country in transition that has already started very robust measures trying to contain the spread of the disease. You can only do containment for some weeks and if you are seeing continuing spread of infection in the community, it is important that they move to mitigation measures, which is what they are doing. This is a smart way to conserve limited health manpower resources in the health system, medicines so that you can now focus attention on identifying patients, early treatment of patients, and making sure that vulnerable groups as described earlier get proper and timely treatment to prevent death.
Question :
Does this increased spread step up the moral pressure on the developed countries to perhaps donate vaccines to the developing world that does not have such a good secondary health care system?
Dr Chan:
Calling a pandemic is also a signal to the international community. This is a time where the world's countries, rich or poor, big or small, must come together in the name of global solidarity to make sure that no countries because of poor resources, no countries' people should be left behind without help. And that is an excellent question. In that respect, I would like to advise you that the World Health Organization has been in contact with donor communities, development partners, resource-poor countries, and also drug companies as well as vaccine companies. I think this is my duty to get the views from the different groups of countries and see what WHO can do to make this a better world through equity, social justice and solidarity.
Question:
What has changed and what made you take this decision today? In the case of Mexico, a lot of measures have already been taken to contain this virus, what more can be done?
Dr Chan:
First and foremost, you understood that I called a meeting by teleconference yesterday with a group of countries, trying to look at the evidence on the ground. And the evidence I am receiving, formal and informal, and after consultation with a group of
countries, I made the decision to call the Emergency Committee set out under the International Health Regulations to examine the evidence available to us. It is a fact that all Member Countries as well as the experts on the Emergency Committee reviewed the
evidence and there was consensus ? unanimous decision ? that we have indisputable evidence that we are at the beginning days of a global pandemic caused by a new H1N1 virus. Now, your second question. Mexico, actually, in terms of its evolution of the outbreak in the country, it is coming to a steady state. They are only seeing sporadic cases and small outbreaks as reported to us this morning by the country so they have switched their measures. They should go into mitigation. Again as I said this virus is very unpredictable. In the event that Mexico is coming out of its first wave, it doesn't mean that Mexico should let down its guard. Mexico should continue to be prepared and keep up this vigilance because the virus can come back in a second wave. In other words, when you are over with the first wave, start preparing for the future.
Question:
Dr Chan, in the run up to this announcement there was a lot of talk of WHO giving clear information on the severity of this virus. Could you elaborate a little bit on what ?moderate? means and for the normal average person, should they be losing any sleep
over this now that the pandemic has been declared?
Dr Chan:
This is one question that has been on the minds of many people. WHO now, based on available evidence, will look at of course a group of indicators, and some people call it a ?basket of indicators?. For example, the number of deaths, the number of people
getting seriously ill, look at the high-risk groups, and then also look at what is the impact of this new disease on countries. I would like perhaps later ask Dr Keiji Fukuda to provide you with more details but I just want to make an important point on severity.
Severity can be taken in two dimensions: at the global level, that is what WHO is doing, we are reviewing the situation in different countries within the World Health Organization, and we give a global assessment. But we would encourage each country to look at their own situation to make a national assessment on severity; and in continental countries ? big countries - they may even consider look at what would be the severity at sub-national level.
Dr Fukuda:
Just to amplify a little bit. Some of the things we looked at are the clinical features of the infection ? how many people do develop serious illness and death and so on ? and when we look at it that way, one of the things that we see clearly from most places is
that most of the people develop illness that is self-limited. They do not need specialized medical care, they get better. And this is really what happens to the vast majority of people. However, we also know that there have been a number of people who have developed serious illnesses ending up on respirators, having respiratory failure, and we also know a number of these serious cases have ended in death. And so, when we looked at that, we saw that while some of these are occurring in different age groups, really the predominant number of serious illnesses are taking place in younger people. So this is different from what we see with regular seasonal influenza. Moreover, we saw that about half of these take place in people who were previously healthy and do not have any pre-existing conditions. Another thing we looked at when we spoke with the countries was really to ask them questions about how are the health systems coping, how are they able to take care of people and in general, there are places where the health systems clearly have been stressed, but in general the health systems have been able to cope. So by looking at a group of considerations like this, we felt that the level of assessment at this time appropriately is ?moderate? but as the DG mentioned there are a couple of things that we want everybody to understand. One is that severity can change over time. What we see now is not necessarily what we will see in a few months or later in the year. This is one important point. The second important point is that severity can reflect a number of different things: it is partly what the virus does, but it is partly the populations. So as the DG mentioned, we know that in the Southern Hemisphere there are populations which are younger, which have high levels of poverty in some areas, which have high levels of chronic diseases, and we know that if a virus that has a mild effect in a well-off populations goes to such populations, sometimes it can be more severe than what we are seeing. We know that there can be variations from place to place and these are things that we are aware of now and that we are concerned about. What we are going to do is monitor this closely, we need to monitor it on a global level, we also know that local and national authorities need to monitor it at their level because what they see in one location may be different than in another location.
Question:
You have mentioned that an important message you want to convey that we should help developing countries which are not prepared. So in what way can we help them and another question is in this pandemic situation, what are you going to recommend about the vaccine ? the balance between the seasonal vaccine and the pandemic vaccine?
DG:
Thank you very much and yes, for countries, actually since day one of the emergence of this new virus, WHO has been working with our Collaborating Centres and with our development partners to provide technical support to our countries and that includes
investigation on the ground, as in the case of Mexico for example, and we also sent laboratory diagnostic kits to the laboratories around the world to enhance their ability to make prompt and quick diagnoses, and we of course help to train their people and we will continue to do that. We also have ? within the donation of antivirals ? we have despatched to 121 countries in WHO so that resource-poor countries have a stock pile of antivirals for use, should the virus arrive at their doorsteps. On the subject of vaccine, we have been in regular discussion with the vaccine manufacturers of the world, both in developed as well as developing countries. We were given to understand that they are close to the end of finishing their seasonal influenza vaccine production. So, they are prepared to start full-scale production of the H1N1 pandemic vaccine. Now, clearly, making the vaccine is a business decision and that is why some of them actually started earlier. There are vaccine companies that do not make seasonal influenza vaccine, so they have already started production, and there are also vaccine companies who have several plants, so some plants are making the seasonal vaccine and the other is moving getting ready to make the pandemic vaccine. So, it is a patchwork of different approaches, but at the end of the day, it is very clear now that WHO has made the announcement of Phase 6, we will get in touch with them urgently and assist them in any way we could, because we need to also bring together the regulatory authorities to look at what are some of the road blocks, so that we can help to fast track the registration so that vaccines that are safe, effective can be made available as soon as possible.
Question:
I just wanted to clarify, where do we stand on the creation of a vaccine? How do we go down from here? In the sense that we are now at 6, we cannot go higher, how can we go lower?
DG:
Well, let me answer a couple of comments and then I invite my vaccine expert, Dr Marie-Paule Kieny, she would be able to give you more details on the vaccine question. You are absolutely correct, I mean at least there is equity now: no country has pandemic
vaccine for the next few months because normally it takes about 4 to 6 months to make vaccine. For the next 3 months or so, definitely before September, no country would have vaccine . Even when we get into September and beyond, there will be limited supply of vaccine, and the challenge for the world is to look at who should get the vaccine and within a country, again which groups get the vaccine, so on that I turn over to Marie-Paule Kieny, to give more details on the vaccine.
Dr Marie-Paule Kieny:
Yes, the vaccine manufacturers are standing ready to start producing since quite a number of weeks now. They have all of them have received the vaccine virus, which is the starting material, which allows them to go into large scale preparation. A very small number has been able to start, the other ones ? we have discussed ? will be starting next week or the week after that, so it is really the quick scaling up of production and we expect, as the Director-General said, to have the first doses of vaccine available somewhere in September. I cannot give you exact dates because it is a question of seeing how the preparation goes and how the regulatory authorities review the dossier. We must say also that at that period of time the number of doses of course will be very small and only by coming weeks and months there will be an accumulation of vaccine. In terms of recommendation for user vaccine, WHO is following the situation that is developing now in the Southern Hemisphere and also the situation of the Northern Hemisphere. When enough evidence is available in the coming weeks we will make policy recommendations on which group, which population should be prioritized for the use of the first doses of vaccine.
Question:
As a follow-up question: how do we go down?
Dr Keiji Fukuda:
In terms of how we go down, I think that there are a couple of parts to this. If we take a look at what is happening right now, we are in a period in which this new virus appeared and it is spreading around the world, and we expect this period in which the virus spreads to go on for some number of months. But at some point, it will become established in most of the countries around the world, which means that there will be a lot of people who will have got infected over the next one or two years, and then we will begin to see immunity build up in the population. We will see that this virus circulates and that it will really become much more like a regular seasonal influenza virus. At that point, all things which go up come down at some point, and so I think a lot of the heightened alert really switches over and makes a transition over to dealing with this as a long-term seasonal influenza virus. The really important point here is that, as we have tried to stress at the outset, when you are talking about pandemic influenza you are talking about a marathon, you are not talking about a sprint. We know that the virus is spreading, we know that we have to deal with this for a while and then we will adjust to it and countries ? everybody will adjust to it.
Question :
Dr Chan, are there any indications so far that the virus may be changing?
Dr Chan:
Based on the evidence that we have discussed, as late as yesterday, from all the countries with the highest number of cases, the virus is pretty ?stable?, shall I put it in quotations, and the virus being analysed and looked at carefully in different countries, they
look very, very similar, but you know you bring up an important point. We need to continue to track this virus and monitor it, and as and at the earliest sign of any change, we need to inform the world and we should never forget ?as we are talking about H1N1 in Phase 6 ? we still have H5N1 in Phase 3 and this is the first time we have two new viruses co-existing at different levels of the pandemic alert. This is an extremely unusual situation and that is why it is incumbent upon WHO working with all my Member States to stay vigilant and alert for the next year or two, or even beyond.
Question:
I have a brief question but ahead of that, Dr Chan, as President of the UN correspondents, many of our members were dismayed at the selective briefing given by your agency earlier this afternoon, which created chaos in many newsrooms around the world. My question following this little protest, is that are Member States under the International Health Regulations (IHR) free to impose voluntarily if they feel like, travel bans and other quarantine measures, or do the International Health Regulations preclude that without notifying other Member States.
Dr Chan:
John, we apologize for that. The buck stops with me. Thank you. I take responsibility, do not give my staff a hard time. You ask an extremely important question. At the early stage when we met with the Emergency Committee, based on the evidence, we made some recommendations. Clearly, no closure of border, no restrictions of travel, and also no trade ban and we make those recommendations. Recommendations are recommendations, and we did see that some countries are not following the recommendations coming from WHO under the IHR. But under the IHR, I have a duty: require them to provide me with the public health justification on taking those actions. And we have done so. We keep chasing after all the countries and ask them to explain why they were doing what they were doing. And I am happy to say that things are getting better, but we must recognize that with a new disease, with a new threat, with a lot of uncertainty, it is not unusual to have a degree of overreaction and in some quarters they described it as panic. I think this is understandable, it is acceptable and we do need to give people the right kind of information to allow them to make that adjustment reaction. And we assume that this is being done very well and the countries are lifting all these bans that they have imposed in early phase. Of course we will continue to work with FAO, OIE and also WTO to impress upon the Member States of the countries that they should really follow our recommendations.
Question :
I have two questions, first since this is the highest level we can get, can we assume that countries are free to break patents, for example for antivirals such as Tamiflu?. And secondly, what is your perception of what can be the impact of this declaration? For
example, in the markets, or in the situation of the world economy that is already in recession. Do you predict that it can even make things worse, or what are your basic recommendations to the market itself?
Dr Chan:
Let me take the second question first. I do not have the crystal ball and I am not an economist. I would not delve into areas in which I have no core competencies. I hope you would accept that. The first question, again I am not exactly an expert on international Property but I can share with you what we have been seeing ? since you mention Tamiflu?. Roche has offered sub-licence to many countries and to many drug companies in some countries. In fact WHO has been inviting generic companies to come forward so that we could assist them with pre-qualification, so that generic medicine, generic oseltamivir, would be available as soon as possible. We are happy to say that we have done one prequalification for a company in India. At this point in time, they are available, both patented medicine as well as generic. I wish to say that Roche has made a donation to us ? 5 million courses ? and I have dispersed all of them to the countries, to 221 countries as I mentioned earlier. I am receiving a second donation in the quantity of 5.6 million doses, part of that is paediatric formulation and on receipt of that donation, over time, we will send them to other countries to make sure they have something in hand to deal with the situation.
Question :
Basically my question was, if we leave aside the rather technical and scientific explanation for what the severity of this outbreak is, can you just explain for the average person how they should be thinking about this. Should they be really concerned, is this
something that they can forget about for now, just some explanation that the average person can understand.
Dr Fukuda:
Let me put it in perspective. This is one of those things that is good for people to know about. For example, it is good to know that there are different diseases and so on. But it is also really good for the average person to put it in perspective. If they develop a
fever and cough, the vast chances is that they are going to do well. What is really important for them to know, if you are a mother, or if you are a family, that if you develop something like this, and then you develop something which indicates that there is something more serious going on, you know you have trouble breathing, or you have those kinds of difficulties, then to go seek medical care. I think that the average person should know about these things, their Government and information services may be providing important information, they are certainly going to read about it in the media, and to have a perspective on it, but definitely not to get overly anxious about it. It is like most things in life, understand it, put it in context, and then you go on with things.
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