Monday, May 25, 2015

Be Prepared For Surprises (Redux)

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WHO IHR Infographic

 

# 10,086

 

Last February, after a year of unprecedented emergence of new flu subtypes, the remarkable and rapid spread of HPAI H5 viruses to Europe and North America, and several months of Egypt dealing with the worst human H5N1 outbreak in history, the World Health Organization released a blunt assessment called:

 

Warning signals from the volatile world of influenza viruses

February 2015

The current global influenza situation is characterized by a number of trends that must be closely monitored. These include: an increase in the variety of animal influenza viruses co-circulating and exchanging genetic material, giving rise to novel strains; continuing cases of human H7N9 infections in China; and a recent spurt of human H5N1 cases in Egypt. Changes in the H3N2 seasonal influenza viruses, which have affected the protection conferred by the current vaccine, are also of particular concern.

(Continue . . .)

 

The entire report is well worth reading, but after warning that H5 viruses were currently the most obvious threat to health, they also advised:

Warning: be prepared for surprises

Though the world is better prepared for the next pandemic than ever before, it remains highly vulnerable, especially to a pandemic that causes severe disease. Nothing about influenza is predictable, including where the next pandemic might emerge and which virus might be responsible. The world was fortunate that the 2009 pandemic was relatively mild, but such good fortune is no precedent.

 

While the point being made here by the WHO is that we could easily be blindsided by a newly emerged or recently mutated influenza strain, that isn’t the only way we can be caught off guard by another global health emergency.

 

There is nothing new in the fact that many countries endeavor to `manage’ the release of bad news to their best advantage, but these past six months have seen an noticeable escalation in `strategic reporting’  from two of the hardest hit bird flu regions in the world; Egypt (H5N1) and China (H7N9). 

 

The size and trajectory of both avian flu outbreaks have been difficult to gauge due to their respective MOH’s decisions to delay, or withhold information.  Neither of which imbues one with a lot of trust regarding what little they do report.

 

The reporting on MERS cases out of Saudi Arabia, quite frankly, won’t win any awards either.   But at least they do report on a daily basis (most of the time).

 

And there are a lot of countries from which we hear little or nothing (think: Indonesia, Cambodia, North Korea, etc.) that may or may not be dealing with outbreaks.   While we can always hope that `no news is good news’, experience has often shown otherwise.

 

Granted,  the WHO, FAO, and other agencies do post outbreak summaries (constrained by whatever information is provided and authorized for release by these reporting countries), but they are often delayed, redacted, or woefully lacking in details (see WHO: A Very Brief H7N9 Update – China).

 

There are legal requirements for reporting, but the reality is, we are a long way from having any semblance of a working,  global, cohesive disease surveillance system.  

 

In 2005 the World Health Organization adopted the IHR (International Health Regulations) that – among other things - requires countries to develop mandated surveillance and testing systems, and to report certain disease outbreaks and public health events to WHO.

 

Although the agreement went into force in 2007, member states had until mid- 2012 to meet core surveillance and response requirements. Most nations failed to meet that deadline, as explained below by the WHO:

 

A majority of States Parties, however, have requested and obtained a two-year extension to this deadline and, in exceptional circumstances, may be granted an additional extension, not exceeding two years.

 

That extension – not to exceed two years – expired last summer, but by February of 2014 the writing was already on the wall, and another 2 year extension was authorized (see WHO: IHR & Global Health Security) pushing the deadline  for final implementation of the IHR to 2016.  

A couple of days ago the WHO tweeted:

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While this year’s WHA has ratified the Committee’s recommendation to extend the deadline to 2016 to all countries that need more time to implement the Regulations, there is already talk of needing another extension. 

 

I suspect when the phrase `herding cats’  was first coined, it was in reference to getting 190 politically motivated member nations of the World Health Assembly to buckle down and actually complete a common (and badly needed) goal.

 

Last February’s WHO warning was specifically about the ability of influenza viruses to evolve unpredictably and surprise us.

 

But the recent lack of transparency in disease reporting from China, Egypt, and elsewhere  - combined with a failure of 2/3rds of the world’s governments to meet the IHR minimum core surveillance and response requirements – means that we have more than a few good additional reasons to heed the caveat:

 

Be prepared for surprises

 

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