Preparing for a Pandemic

The Agency's Response

The threat of pandemic influenza received increasing media coverage during the year. This reflects the developing situation in Asia, Africa and now Europe where highly pathogenic avian influenza/A H5N1 has been identified in wild birds, and outbreaks of the virus have been reported in poultry flocks. Since the resurgence of the virus in late 2003, there have been 226 human cases of infection with H5N1, which have resulted in 129 deaths*.

*June 2006 Source WHO

The Health Protection Agency is coordinating many different activities that contribute towards the UK 's influenza pandemic preparedness. Our response to pandemic influenza is directed by the Influenza and Respiratory Virus Programme Board (IRVPB). The Local and Regional Services (LARS) Division Pandemic Influenza Implementation Group is responsible for implementation issues involving frontline Health Protection Units (HPUs) and regional teams. The Emergency Preparedness Response Division develops training for health professionals, and designs and conducts exercises to ensure that local health services are prepared for when pandemic influenza occurs. Recognising the growing importance of pandemic influenza preparedness, the Agency established a Pandemic influenza Office sited at the Centre for Infections in October 2005.

The Agency's work on pandemic and avian influenza is co-ordinated by the Office. It is supported by many teams and individuals across the organisation and works with national and international experts.

The Agency is responsible for coordinating, developing and distributing guidelines and algorithms to colleagues within the organisation and to partners in the NHS and other organisations. For example, the alogorithm for management of returning travellers guides staff through the assessment of a patient with a fever returning from an area of the world where H5N1 is known to be present. It is frequently updated to reflect the changing situation of poultry outbreaks and isolated cases of avian influenza/A H5N1 in wild birds.

The guidelines range from the Agency's Pandemic Contingency Plan to specific pieces of guidance for distinct groups and settings. The Agency Influenza Pandemic Contingency Plan and the Department of Health Influenza Contingency Plan were revised in October 2005, to reflect the new World Health Organisation (WHO) phases and revised health impact projections. A further substantial revision of our plan is currently underway.

Specific guidance is being developed for funeral directors, prisons, and local authority domiciliary services, among others. All the guidelines draw from the same evidence base to ensure consistency. We produce them in conjunction with the appropriate professional and occupational bodies to ensure the information is relevant and focused. All guidance is shared with the Devolved

Administrations and the Department of Health in England to help coordinate preparedness across the UK .

Staff across the Agency are kept informed of developments through the regular Influenza Pandemic Preparedness Update newsletter, prepared and distributed by the Pandemic Flu Office. Agency staff are able to pose operational and scientific questions to an 'Ask the Experts' section of the newsletter. Guidance for the public is available on our website: (www.hpa.org.uk/infections/topics_az/influenza).

A database to record initial human cases of pandemic influenza in the UK has been developed by the Agency. Training sessions across LARS have begun to roll out across England and it is being shared with the Devolved Administrations to ensure a UK-wide system. A module is being developed for the database which will allow collection of data on Avian Influenza outbreaks in poultry and any human contacts associated with such events.

At local level, frontline Health Protection Units are closely involved in developing multi-agency plans for responding to pandemic influenza across local health and public services. Planning advice and assistance are also offered to business and public utilities.

Internationally, the Agency works closely with WHO and we helped to set the new phasing of the WHO Pandemic Influenza Plan. A continuous watch on the developing situation worldwide is maintained through links with WHO, the newly-established European Centre for Disease Prevention and Control (ECDC) and contact with partners in the Global Health Security Action Group of G7. The Pandemic Office monitors all relevant websites daily to ensure the Agency keeps abreast of develops worldwide.

Agency experts also work closely with other countries to strengthen worldwide preparedness. This has included providing UK-based training for international laboratory staff and sending experts on short visits to overseas locations, including Ukraine, Turkey, Geneva and Turkmenistan. Two Agency physicians are among 10 European experts selected by ECDC to sit on a European-wide scientific panel on influenza.

We also work closely with representatives of the Health Protection Organisations of the Devolved Administrations to ensure coordination of UK-wide pandemic influenza contingency planning activities.

 

Training Front-line Staff

The Agency has developed an e-learning training package through Doctors.net on the signs, symptoms and treatments for avian influenza. The course was launched on the Doctors.net website in November 2005 and since then more than 14,000 GPs have successfully completed the module to broaden their skills base.

The course presents doctors with mock cases of patients who might turn up at their surgery, including a holidaymaker returning from Thailand with flu-like symptoms and a patient worried by the recent media coverage on bird flu demanding to be vaccinated. GPs must correctly diagnose each patient and decide on a course of action which includes appropriate treatment, whether they should be referred to hospital or told to stay at home and whether to alert the local health protection unit.

 

Vaccines for Humans

Experts from the Agency's influenza laboratory at the Centre for Infections (CfI) are involved in the development of human vaccines for two strains of avian influenza thought most likely to be involved in pandemic influenza.

In November 2005, Agency staff released details of a 'custom built' virus it had helped to develop, which was to be the first step in the development of an H7N1 vaccine. The virus was created in conjunction with experts from the European Union and pharmaceutical company Sanofi Pasteur as part of a European-Community funded project.

The virus, called 'RD-3' was created using a technique called 'reverse genetics'. This process is easier, safer and quicker than the traditional seed virus production method of injecting live influenza virus into eggs. The technique could also lead to quicker production of vaccine in the event of pandemic influenza. Sanofi Pasteur is currently using RD-3 to produce a prototype H7N1 vaccine and, later in 2006, Agency researchers will analyse the results of a planned Phase I study.

The influenza team has also been analysing H5 vaccine trials from Europe and Australia since October 2005. The European H5 vaccine data have been analysed and accepted for publication, and analysis of Australian H5 vaccine data has already been presented internationally. These early and key results will guide further vaccine development programmes.

CfI contains one of only two labs worldwide approved by WHO to analyse vaccine trial material. Laboratory work involves establishing and validating the effectiveness of both 'reverse genetic' created vaccine strains and traditional wild type H5 strains. Blood samples are used to test antibody responses and this requires specialised high-containment laboratories.

Data derived from these analyses are used to decide what formulas and doses of vaccine are most appropriate for potential H5 vaccines. Work is underway at present to establish the degree of cross reactivity to different H5 strains offered by vaccination with the existing candidate H5 strains.

 

Laboratory Monitoring/Diagnosis

In 2003, a team working in the Respiratory Virus Unit at the Centre for Infections (CfI) developed a sensitive and specific test for H5N1. In 2005, the test was rolled out to a network of 18 Health Protection Agency and NHS laboratories across the UK and one laboratory in Dublin , Ireland . The intention was to enable testing for H5N1 in the pre-pandemic period and possibly for early cases in Phase 6. Currently the network of laboratories can be used to test returning travellers and people with poultry contact who have potentially contracted H5N1 infection.

A specialist training course for Local and Regional Services laboratories was held in June 2005, and an external quality assessment carried out during October 2005 indicated that the process is robust and working well. These laboratories are now able to produce reliable H5N1 test results for the Agency and the NHS.

Regions also developed their own on-call arrangements, drawing up agreements with neighbouring laboratories to provide such support in some cases. The Local and Regional Services Division (LARS) has also arranged reliable courier systems to transport samples. This was originally set up to take specimens to CfI and was extended to take specimens from any NHS hospital to the nearest Agency laboratory in the scheme. This is a significant development for the Agency and reflects a huge amount of effort by both LARS and CfI laboratories.

A secure website was also established which enables the laboratory network to share data and allow ongoing technological development. A monthly teleconference also provides a meeting place for the laboratory network to update and exchange information. Having this coordinated operational network also enables new developments to be rapidly introduced and disseminated.

Information on pan-European and national influenza exercises is the Emergency Planning and Response Section.