Annual Meetings 2009: H1N1 Update Press Briefing

Annual Meetings 2009
H1N1 Update Press Briefing
October 4, 2009

MR. HAY: A very good afternoon, everyone, and thanks very much for coming along to our global pandemic flu update. Let me just introduce our panel members.

On my immediate right is Dr. Julie Hall, who is an expert on the spread of influenza and other disease. She is the Senior Technical Expert on Influenza with the UN System, and she is here representing the World Health Organization today; so, welcome Dr. Hall.

On my immediate left is Joy Phumaphi. She is Vice President of the Human Development Network at the World Bank which is coordinating the World Bank's response to the H1N1 problem.

And on her immediate left is someone who will be familiar to a good many of you, I imagine. He is Dr. David Nabarro, the UN Senior Influenza Coordinator and someone with whom the World Bank has worked very closely with avian influenza as well and previous pandemic threats.

So, what I propose we do is start off with Dr. Julie Hall, who is going to tell us where we are up to at the moment with H1N1 prevalence. We are approaching a period of peak new infections in Northern Hemispheric countries. She is going to tell us a bit about that and why in particular it seems that young children are especially susceptible to the physical effects of H1N1.

DR. HALL: Thank you very much for the opportunity to speak before you today.

I am speaking on behalf of the whole of the UN, but will be using information and data from WHO. The purpose of the presentation today is to give you a brief update of the current situation and then to look into the future in terms of some of the assistance that has been requested by countries, particularly low-resource countries, and where we think things might be going over the next six to twelve months.

This is as of the 20th of September. This is taken from WHO data, and it is showing the current hot spots for pandemic influenza.

As you can see on the map there, the very large dots are the areas that are reporting and have reported the highest numbers of deaths, but as you can see, pretty much every country is now colored in, indicating that cases have occurred in those countries.

This map shows just how quickly this virus has spread around the world. The 1918 pandemic took 18 months to circumnavigate the planet. This virus, within three months, over 100 countries have been affected, and we have had reports from some of the smallest little countries in the world and in the Pacific that the virus has now reached them.

What we saw initially and over the summertime was that the highest impact was in the very well-developed, well-resourced countries; but what we are seeing now is that the virus is beginning to penetrate into some of the poorest communities in the world, and we are anticipating that we may well see a somewhat different pattern of impact once this virus starts to take off and those explosive outbreaks occur in some of the poorer communities in the world.

The reason why we are saying this is that H1N1 pandemic influenza is quite different from seasonal influenza. For the majority of people who fall ill with H1N1, they do suffer a flu-like illness, and the vast Annual Meetings 2009 majority of them will recover by simply staying and home and not needing to seek medical care. But what is different about pandemic influenza is the age groups that it is affecting. Seasonal influenza, the normal winter flu, is on the whole an old person's disease with very young children affected as well.

But pandemic influenza, as you can see from the charts here, is a young person's disease. The bars in black and gray show the proportion of deaths that usually occur in those different age groups starting at zero on the left-hand side there, going all the way up to over 80. And you can see that it is a U-shaped curve, with most of the deaths occurring in the very, very young or the very old.

But pandemic influenza, we can see that that "U" is being switched upside-down, and where we are seeing the majority of cases and the majority of deaths is in young people and in working-age populations. So, really quite different in terms of whom it affects and whom it kills, quite different from seasonal influenza.

And for people who die of pandemic influenza, these people are dying very quickly. They are capturing the virus and within days are really quite severely ill and going downhill very quickly, as a result of mostly the effects of the virus itself, as opposed to seasonal influenza, where it is usually secondary bacterial infections that are causing the deaths. So we are concerned particularly in countries that have young populations what the impact of this virus is going to be like.

And even in the U.S.--this is data from the outbreak that they had earlier this year--we are seeing that for under-16-year-olds, that young population, most of whom normally with seasonal influenza, have a very short illness--we are seeing that even this year, when there was only an end-of-season, relatively small outbreak in the U.S., this peak in childhood deaths.

So, the UN System with WHO and the World Bank have undertaken a survey of the least-developed countries and the GAVI-eligible countries, so some of the poorest countries in the world, to try to estimate what the essential needs are to be able to ready their systems and to be able to cope with the potential impact of the pandemic as it begins to penetrate into those communities and as we see temperatures cool, particularly in the Northern Hemisphere.

And two major groups of support were requested--one, essential pharmaceuticals, particularly vaccine, antivirals, and antibiotics. And in response to the report that was put out requesting this kind of support, we have already seen that quite a number of countries have offered to donate or set aside some of their national stockpile of vaccines, and some countries are also donating antivirals, and there has been a very encouraging response from the manufacturers who are donating up to 150 million doses of vaccine, and large numbers of antivirals have also been donated.

But in addition to the essential pharmaceuticals, many countries have requested support with strengthening their systems. We have seen the impact in Southern Hemisphere countries with really quite significant strains on health care systems, so other developing countries have recognized this and are requesting support in strengthening health care response, communications, the whole of society ensuring that essential services can continue, and a variety of other issues as well.

So, it was a very brief introduction to the current situation, and some of the requests that we are receiving from developing countries to help them cope with what we expect in terms of an increased impact of this pandemic.

MR. HAY: Many thanks, Julie. I'm sure we'll have questions for you later. So, it has gone around the world in three months; extraordinary.

DR. HALL: It certainly went to at least--extremely quickly, yes.

MR. HAY: Extremely quickly. And I know that in Mexico at the moment, we are seeing outbreaks of fairly severe respiratory disease, which is another of the symptoms of H1N1.

DR. HALL: That's correct. We saw earlier this year the first waves hitting some of those more developed countries, and now the countries in the Northern Hemisphere are beginning to experience what they think is the second wave. So, September/October is usually the very, very beginning of influenza season in those countries, but already we are seeing the U.S., many European countries, Japan and Mexico reporting over the past few weeks a sudden increase in cases.

MR. HAY: I know the Mexican Finance Minister, Mr. Carstens, wanted to be here today. He sends his regrets. He has been detained in the IMF Committee for a while longer. So we will miss him, but we will certainly be keeping a sharp eye on events in Mexico.

David Nabarro, Julie Hall has told us that we are starting to see vaccine donations from rich countries to poor, clearly very encouraging but not enough vaccines are finding their way to countries in need.

DR. NABARRO: Thank you, Phil.

First of all, the vaccines are only starting to become available now. When you get a new virus, there is an interval during which vaccine production occurs. But what we have seen is that of all the manufacturers, there is a willingness to make available vaccine for developing countries, and there is also from many countries, as DR. HALL has said, a willingness to donate. But we still, even when we add together what we know is going to be made available, are aware that there will only be enough for a small percentage of the population of developing countries. So the challenge during the next few weeks is to build up the solidarity between wealthy nations and poor nations to ensure that adequate vaccine is made available so that it can reach health workers and other essential personnel in developing countries in time to help them as the next waves of the pandemic reach them and affect the well-being of their populations.

We also feel a need to see cash donations to enable countries to get themselves prepared, to communicate with their people, to establish better-functioning health systems that can withstand the impact of large numbers of cases of influenza and also to ensure that nations themselves can continue functioning under the onslaught of what will be a high-incidence disease.

For this, we are involved now in intense discussions with governments so that they can find ways to make the resources available in ways that don't just deal with this pandemic but help to create greater capacity to deal with future public health emergencies like this one.

MR. HAY: All right, so that's on the vaccine front. One of the things that seems to get missed in a lot of the coverage of this is do we also have enough stocks of medicines, antiviral medicines, for treating H1N1, obviously, Tamiflu being the most famous one everyone knows about. Where are we up to with stocks of medicines?

DR. NABARRO: In the presentation, Phil, that Julie just gave, she pointed out that there are needs for several million doses of antiviral medicines and that we have had some donated by pharmaceutical company Roche, and we have also had some donated by governments, but the total estimated requirement is around 78 million treatment courses. So far, we can only really count on having 13 million, so there is quite a big gap in Tamiflu, and that's something that we are working on intensively right now.

There are also other needs for other medical requirements in developing countries and also basic issues like soap and other materials with which people can wash their hands to maintain hygiene. I think sometimes we forget just how tough it is to ensure that diseases like influenza, particularly this highly infectious pandemic influenza, can be kept under control in highly-populated regions of developing countries with limited access to water, to soap and other basic needs.

MR. HAY: Let me ask you one more thing before I turn to Joy Phumaphi.

DR. NABARRO: These are difficult issues for governments, they are difficult issues sometimes also to cover in the media, because we are talking about threats that are really very unpleasant, but at the same time, we can't state with any certainty whether these threats are going to become real.

But here is the situation. We have a highly pathogenic bird flu virus still circulating in several countries. We have worked hard to control it. There have been incredible efforts, a lot of them supported by the World Bank, to make certain that the bird flu virus can be gotten under control and to improve the safety of poultry-rearing, because this was one of the environments in which the virus was circulating.

And our concern now is that this bird flu virus H5N1 and the current pandemic virus H1N1 could somehow come together with the genetic material re-assorting between the two viruses and create something that would have very unpleasant consequences for humanity.

I can't tell you, nor can anyone else tell you, whether this is highly likely or in the realm of extremely unlikelihood, but it is a sufficiently worrying possibility that we have to work very hard to try to either prevent it from happening or, if it does happen, to be able to respond very quickly. And that is one of the issues that my colleagues and I are working on very hard is trying to make certain that we are prepared for the recombination of material between different influenza viruses and the possible consequences that they could cause for humanity.

MR. HAY: David Nabarro, thanks very much.

MS. PHUMAPHI: I think what is important for us to recognize as a global community is that influenza pandemics disrupt people's lives. It is not just a question of how many lives are lost, but by compromising the health and well-being of a population, the pandemic takes both the infected and the healthy out of the workplace, because when they are infected in the workplace, the healthy are scared of coming to the workplace, and they stay at home, and sometimes they stay at home in order to take care of the infected. They take them out of the workplace. They take them out of the classroom where they are getting educated. They take them out of farming activities where they are producing food for their families. They take them out of trading activities, and they take them out of development and livelihood activities. And where do they take them? They turn to clinics, to health facilities which are already straining from other challenges in the health sector. They take them into the sick room where they need to be taken care of. They need medicine, they need drugs that are expensive.

This is the impact in the low-income countries that we must worry about. It is not just about how many lives are lost.

This is the situation that the low-income countries face.

When H1N1 hit, we had been building capacity in countries to combat avian flu together with our partner countries and together with UN [inaudible] and technical agencies. So the question that we should be asking ourselves as well as what is the impact on the low-income countries is what can we do to help them be better prepared. I don't know whether you would like me to answer that, Phil.

MR. HAY: Please.

MS. PHUMAPHI: What we had already started to do was to strengthen the health systems of these countries in order to enable them to cope with a large number of patients and the large amount of knowledge that is actually required to prevent the spread, to detect early, to treat and to care for patients, and also, of course, for the large amount of capacity-building that will have to be built in the laboratories and in vaccine preparedness.

To enable the required rapid scaling up and overall preparedness to occur, we at the Bank have been contributing to this first of all by reallocating uncommitted funds in all the low-income countries. We have deliberately expanded the Global Program for Avian Influenza Control and Human Pandemic Preparedness Response from $500 million to $1 billion, and we have expanded it to the end of 2010, because we want to make sure that we get over this period of the threat of this new epidemic.

But another issue that I would like to emphasize is that it is not just a question of us looking at the country as a whole, looking at what we should do as a global community--this is everyone's responsibility, which we do not often talk about. Every company, every employer, that employs human resources or human beings or workers in the prime of their lives has a responsibility to keep them in the workplace, because this is what defines livelihood and economic growth in countries. And the work that they should be doing in this is participating and making sure that they have preparedness plans themselves as companies and as employers across the globe.

I'll just give you a little example. In the Bank, we have been compiling an Influenza Pandemic Physicians Reference List for our workers. We have been preparing educational events and making plans for seasonal flu vaccinations for our staff and for their families. We have been doing internal communications extensively across the institution to make sure that everybody knows what to do, how to get support, and how to ensure that they protect themselves, and also make sure that they support the governments and the communities in which they live and which they are working in these preparedness activities--and I think this should be everybody's responsibility; it is not just the responsibility of the governments.

Joy Phumaphi, thanks very much. You are making a very good point there. We know it is coming. Look at the map of the world that Julie showed us. What we heard from David was that we have vaccine stocks, obviously not enough, and we may not have enough drug treatments as well, Joy making the obvious point that it is affecting low-income countries more heavily than better-off, wealthier counterparts, and they have business continuity. We don't have the luxury here of thinking, well, it might not come this season. It is coming, is the bottom line.

So, we have heard our presentations. Are there any questions?

Theresa Bolsa [ph.], please--and wait for the microphone. We are televising this.

QUESTION: Theresa Bolsa [ph.] with EFFE

For Mr. Nabarro--

MR. HAY: Ah, there you are.

QUESTION: For Mr. Nabarro, you mentioned the possibility of trying to prevent this recombination of viruses, their recombination. How do you prevent that, and also, how do you prepare for that?

QUESTION: In Mexico, the economic problem comes after the authorities didn't know what the threat was--I am Alicia Salgado from Mexico, Excelsior. In Mexico, the most economic impact comes after authorities didn't know what the danger was, and neither did WHO know about this virus. But do you think in this second wave, there could be other social isolation measures that really were the main problem in our country, that dampened one percent of the GDP. Is it possible to see it again? How much does it cost in any other country?

The other question is why doesn't the WHO, or even these international organizations, deliberate about the possibility to freeze or to free the patents of the virus production and even the antivirals and antibiotics? If there is a problem of production, could it be produced in other countries all around the world.

MR. HAY: You both ask very penetrating questions there.

David, let's start with you. How do we stop the combination of avian influenza and pandemic H1N1?

DR. NABARRO: Thank you.

We have been doing an enormous amount to try to control H5N1 ever since we started to see that virus, we were concerned that it might be able to recombine with a seasonal influenza virus or any other influenza virus to become one that is able to infect large numbers of human beings. So this has been on our minds for some years, and that is why we have worked so hard to try to control it. And I am really pleased that t his year, the H5N1 situation is much, much better than it was two or three years ago.

Secondly, we need to be on the lookout for individuals who do have co-infection and also be ready to pick up any changes in the virus very quickly. And I am very glad to say that already, there have been some signs of people noting the possibility of coexistence of H5N1 and H1N1 and working on it quickly. I don't want to be too precise, because I don't know the full details, but I can tell you that that alertness is there.

And what will occur when it happens? Well, that shifts me in a way to second question and enables me to stress what I believe now, picking up on what Joy has just said, is the absolute priority for all countries.

The second is to help societies be ready to handle the economic, social, and humanitarian impact of pandemic influenza. Mexico faced huge challenges as a result of the economic impact. I believe that every country needs to be aware that a big wave of an influenza pandemic does require the whole of government to be involved, the head of government to be involved, all sectors of society to be involved, because it is only then that the action can be taken quickly enough to mitigate these serious economic consequences. And I really do hope that other countries do not have the challenges that Mexico had earlier this year, but I suspect they will and that we do need to learn from your experience and in particular from the bravery and courage of your political leaders who took the action that they did.

Thirdly, about access to medicines, I am happy to say that on the issue of Tamiflu, the manufacturer very quickly gave production rights and sub-licenses to a number of manufacturers throughout the world, which meant that actually, the manufacturing capacity is considerable, it is highly widespread, and it means that the medicines are available at relatively low cost, much lower cost than the basic price from the manufacturer in Europe.

The issue is still that somebody has to buy it, and we are still need the resources to buy it, which is one of the reasons why countries are talking to the World Bank about being able to reallocate some of their existing health projects so they can stock up on the necessary Tamiflu.

MR. HAY: Okay, David, thanks very much.

Let me bring in Julie. The question was about Mexico. Obviously, the Mexican Government received lots of plaudits for the way that, once it was detected, social distancing and other techniques, they were able to make it burn out fairly quickly. Presumably, other countries have learned from this. We now know a lot more six, eight months on than we did before.

DR. HALL: Absolutely, and I think I would reinforce what Dr. David Nabarro said about the courage and the responsible nature in which the Mexican Government responded early on to a situation at that point that was really quite unknown; so the response to an unknown situation is often quite different from a response a situation once you start to know a little bit more about what is going on.

The fact that Mexico responded in the way that it did, was very open with the information, has certainly helped a lot of countries to be able to prepare, to detect things early, and to be able to put in place fairly measured responses to the situation.

We still face a situation where this virus could change, it could alter. It is somewhat unpredictable, and we may face a situation in the future where we are back once again facing degrees of uncertainty where the response has to be from a public health or public safety point of view a response that really takes into account the unknown nature of it and has a fairly hefty response to that.

In terms of social distancing measures, we have certainly learned a lot from this pandemic. WHO now has guidelines about particularly school closures and their potential uses under different circumstances, but we have also understood a lot more about some of the consequences of school closures as well.

So I think the message here really is that early in a crisis when things are unknown, we had a government, the Government of Mexico, that had a very aggressive response to that--a very appropriate, aggressive, and responsible approach--was able to share information that helped countries to then moderate their responses in the future.

But we aren't out of the woods yet, and we do need to recognize that the virus could indeed change, the impact could be different, and some of those social distancing measures may well be needed in other countries in the future.

MR. HAY: Julie, thanks.

Joy, it makes me come back to your point about stronger health systems, and obviously, disease surveillance systems are really crucial because we may be dealing with H1N1 now, but Lord knows what viruses are coming down the road in our general direction.

MS. PHUMAPHI: That is quite true, and like my colleagues, I would really like to applaud Mexico. I mean, it was extremely brave, and it cost the country a lot, but at the time, the contribution that the actions Mexico made to the global community and the global economy was enormous. But I think there are very important lessons. One important lesson, of course, is that we have to act together. Strengthening the capacity of developing countries is not easy, and we do need commitment particularly from the private sector when it comes to patents and manufacturing, and I think that issue is extremely important.

We have an equally challenging position with the vaccine, and I think what is equally important is for us to be able to appreciate that perhaps it is time that developing countries build into their medical training systems and their service delivery systems better pandemic preparedness mechanisms, and that preparedness for influenza pandemic actually strengths the ability of the country to deliver a more robust health service even without a pandemic. I think this is really what we should emphasize here, because people should not think that we are wasting money. If there isn't an epidemic, the health system will not be servicing anybody. But we are actually talking about strengthening laboratory support services, and this is service that you need in other to save mothers' lives for MDG-5 and newborns' lives for MDG-4. So it is really an investment that is going to make sure that there is a sustainable health system and not just help us to combat this epidemic or any other epidemic.

MR. HAY: Joy, thanks so much.

On the way over here, we were all saying that it couldn't be happening at a worse time, since right now we are in the middle of a sustained global economic slowdown, and we are still trying to dig out from the effects of the food and fuel crises, so just that general point--these things often come at the worst possible times, and I think that's where we're up to right now.

Let me take the gentleman behind you, Theresa. I don't want to play favorites.

Please.

QUESTION: Chris Surmack [ph.] with the German Press Agency DPA. You mentioned the serious economic consequences of this possible outbreak. I was just wondering to what extent you have been able to or you can quantify the costs that are associated with the coming outbreak.

MR. HAY: Well, let me just see if our panelists want to add anything. I think the situation is still so fluid. Obviously, we have seen in the case of Mexico economic costs involved with tourism, with aviation, and lots of other of their support industries. I think in terms of hard, concrete numbers, we still look at other countries, I think, to show us the impact of that data.

MS. PHUMAPHI: No, I can only add that again, it is not easy to predict how much it will cost each country, because it will depend on the robustness of the health system for the country, how much you need to invest in there.

David's group and WHO are doing a lot to try to push down the price of the drugs which are required and the vaccines which are required, and the more they push the prices down, the drugs are costing countries now much less than they cost Mexico when Mexico was hit. So we are hoping that some of these steps that we are taking will continue to push the price down.

The one thing that we cannot push down will be the impact on economic growth, so no matter how--the only way we can push it down is by being better-prepared so we can get over the epidemic--the pandemic--as quickly as we can. I think that is where we need to focus, on minimizing the costs. But I think the Mexico costs should scare us enough. If we aren't scared by a 3 percent decline in economic growth, I don't know what will scare us. But even 0.,7 percent, which is sort of minimum, is also scary, particularly for now, when we are trying to recover from the global recession, and even a 0.1 percent increase in economic growth is a boom for a lot of countries right now. So we can really not afford to lose any more than we absolutely have to because of this recession.

MR. HAY: Certainly in the case of New Zealand, which went through a very sustained outbreak earlier--in their winter, of course; the summer in the Northern Hemisphere--the New Zealand Government did say that it would slow down their eventual recovery from recession. So just really to echo Joy's point that it really doesn't help in terms of economic performance.

QUESTION: I wonder if you have any forecasts--if the flu follows a similar pattern, if you have any forecasts of how many countries could be affected in the next few months and people infected and also the number of deaths.

You also mentioned that there is no room for complacency. Do you see that happening now?

Thank you.

MR. HAY: Theresa, let me bring in Julie Hall, who I'm sure will refer to her map. We have heard talk from WHO that we are just on the cusp of a big peak in new infections. To go to Theresa's question, what does that mean? Are we likely to see all countries seeing H1N1 outbreaks to some degree?

DR. HALL: Yes. I think the one thing that is predictable about influenza is that it is very unpredictable, so it is actually quite difficult to forecast what may happen in the future. We have seen this very rapid global spread of the virus, so we do believe that no corner of the planet is safe from the virus; it will most certainly reach every community at some point.

Exactly what it does when it reaches those communities is very difficult to predict. We have seen some areas even in the last few months where the virus has affected a community but the rate of transmission has been relatively steady, so what we haven't seen are big booms or big peaks; and then, other parts of the world where there has been a dramatic peak. And certainly if you get a sudden escalation in cases, no matter what the final death toll is, that sudden strain on health care systems can cause a major impact irrespective of what the final outcome is.

So, we do anticipate that it will continue. WHO has said that this is an unstoppable virus; it will continue to transmit. It will eventually reach every community in the world, but exactly how it affects those is very difficult to tell.

However, based upon what we know about what has happened in well-resourced countries, we know the virus can put significant strain on health care systems, we know that the virus is a significant threat to pregnant women particularly, we know that it is the young people and the working-age people who seem to be most affected by it--infected and affected by it.

So we can put all of that together to build a scenario where we can really justify the need for increased readiness and increased strengthening of systems, particularly in countries that already have high rates of underlying medical conditions, have very large young populations, and large numbers of pregnant women.

MR. HAY: Julie, thanks.

Dave Nabarro, the whole thing about complacency--24-hours-a-day television and newspaper headlines--is it the case that we are complacent because we aren't at the peak of new infections yet and that we seem to have almost a case of amnesia, that we need to be in the idle of the crisis before we actually motivate ourselves to respond appropriate?

DR. NABARRO: Actually, Phil, I don't think that health ministers of developing countries are complacent about this issue. If we engage in discussions with them, the one anxiety they have is that they will end up getting hit quite hard by another sickness-causing factor, the influenza virus, that this will come on top of existing sickness and will greatly add to the suffering of their people, and they would know that they don't have spare capacity in their health systems to deal with it. They, like us, just cannot predict exactly how bad it is going to be, nor can they predict when it is going to happen.

So, I would not say that there is complacency among developing country leaders, and actually, I also feel that there is not complacency among the leaders of most industrialized nations and also people like the President of the World Bank or the Secretary-General of the United Nations, because they are aware that there are likely to be subsequent waves of illness affecting all nations.

I think the difficulty is that in an era when there are many different competing priorities--disasters occurring in tragic ways in Indonesia and in the Philippines, or a tsunami in the Pacific islands, and other terrible stories coming along--it is quite difficult to maintain the right level of alert about something that is evolving in an inexorable way over a period of months.

But I would like to pay tribute to the media, because we have had sustained coverage of this H1N1 during the last few months with a lot of questions being asked, but still, that is what is right; that is what is necessary. And I hope we can continue to cover the issue whilst at the same time stressing that there are so many uncertainties that it means that governments have to make some pretty difficult choices right now as to what best to do.

I'm sorry I can't give you a prediction as to what numbers of people might be affected or what the costs might be. I think we have learned, as DR. HALL has just said, that predicting about influenza really doesn't help anybody. We have to maintain this recognition that it is unpredictable and come out with a range of possibilities, which is how we are working at the moment.

MR. HAY: So, one of the things we do know--I'll come to you in just a second, Peter--just to have a very quick response on this--we are in wave number two in the Northern Hemisphere. Why is it that influenza pandemics go in waves of three, and why can we look forward to yet another battering perhaps next summer in the Northern Hemisphere?

DR. HALL: The number of waves is certainly not predictable, either. We know from previous pandemics that it has gone in waves. For some countries, it has only been two waves; for other countries, it has probably been more than that. For some countries in the past, everything was over and done with within a year or so; and for other countries, it took three years before things really started to normalize.

Exactly why it goes in waves, we don't know. We know that seasonal influenza has a seasonal pattern to it if you are in the Northern Hemisphere and in the Southern Hemisphere. There is a somewhat seasonality about it in the Tropics. And that may well contribute to times when it is slightly more infectious, easier to spread among people, and times when it is less so.

But what we do know is that when you have a virus for which the majority of the population has no immunity, it is going to take quite some time for it to work through populations, for people to develop immunity, and that often comes in waves and can take two to three years to occur.

MR. HAY: Another fast question--why does winter and the cold, dry months provide such an accelerator to the spread of flu viruses?

DR. HALL: Yes. Nobody knows exactly why it has been hypothesized that the virus likes to be cold, it likes to be dry, so maybe some of the climatic conditions make a difference.

We also know that when it gets cold, people often spend a lot more time in close contact with each other, so that may well be another factor as well. But certainly the weather does appear to make a difference, although we do have that seasonality, and hence the concern that we are now moving into the Northern Hemisphere season.

MR. HAY: Julie, thanks very much.

Peter, you have a question, and we may have time for one more. I am getting an imploring look from the lady from Excelsior.

QUESTION: This is a question reflecting deep ignorance. In the UK, there was huge coverage of the thing very early on, and then, certainly for an old fart like me, who was told repeatedly that I wasn't vulnerable, it seemed like it never happened, yet the thing went through these stages, and the effect on me was to leave me very complacent. And the reason I turned up late is I saw some of what you were saying on the screen in the Press Room, and I thought, Hell, I don't know what I'm talking about.

But what I am saying is if the effect that it had me was that this thing never happened in the UK, then, that is not a helpful environment for the message that you are trying to get out. Is it clear what I'm saying?

MR. HAY: Absolutely.

David--it burned through the UK during the summer, just quite significantly. David?

DR. NABARRO: Just in reaction to your comment and in reaction, in fact, to many of the comments in this discussion and elsewhere, the one thing that we realized we have to do is to get our communication messages sharper; we have to also repeat them with a much greater degree of consistent regularity. And this is something that colleagues in different parts of our United Nations System and the World Bank are giving very high priority right now--and that very personal feedback that you have just given helps us a lot.

Thank you.

MR. HAY: Let's take the last question, here.

MR. HAY: Absolutely.

QUESTION: And it even impacts the social sense and scares people.

I remember Mexico City with 22 million people, the streets were empty, nobody was in the streets. And that really impacts.

So, are there other measures that countries could take that wouldn’t have this effect ?

MR. HAY: It's a very good question. Let me bring in Julie Hall to answer that. Obviously, hand-washing serves a large number of purposes over and above just the prevention of contracting H1N1. It's a very, very good part of the public health repertoire, anyway.

Julie?

DR. HALL: Yes, I would reinforce that. Some of those things that individuals can do will have multiple benefits, not just for H1 but for other diseases as well. But I think the experience of SARS and the experience of H1 has shown that the social distancing, social isolation measures, can be very economically expensive, and they can also be fairly psychologically expensive as well for communities, for their sense of fear, for all of those sorts of things.

We have learned a lot over the past few years as to which measures are more useful and which measures are less useful, and it is very much a cost-benefit ratio. When you have something that is very unknown, very potentially deadly, communities are often willing and in fact do a lot of that social distancing and social isolation themselves.

So it is about a getting the right balance in terms of the appropriate measures for the different situations, and as I have said, we have learned a lot from the previous experiences. We hope that it won't be necessary for that sort of thing to occur again, but as influenza is fairly unpredictable, we still need governments to be prepared to be able to think through those and decide which measures may or may Annual Meetings 2009 H1N1 Update Press Briefing October 4, 2009

MR. HAY: Thanks, Julie.

David Nabarro, we talk about the globalized economy, we live in a global village. It is equally true that we live in an era of global disease now which is prevalent and can intrude into people’s lives very quickly.

DR. NABARRO: Exactly.

My last comment as I run away is to reflect that actually, we have had to learn as a global community to change the way in which we live in the face of emerging diseases. I would like us to be even more concerned about diseases that can come, as Joy Phumaphi said, from animals. I would like us to be more respectful in the way we look after animals. I would also like us to be more area of the potential for diseases to affect us and to come up suddenly. I think we also need to recognize that there will be times when drastic action, like what your President did, will have to be taken for other diseases in the future. That's the nature of the threat that our world faces and will continue to face.

MR. HAY: Let me leave the last word to Joy Phumaphi.

We would like the low-income countries to be in this same position. I think this is the important message that we must take away from here. Every country should be in the position that Scotland was in, that you were in, that will enable you to have confidence that the health system will sustain this.

We have a small facility in the Bank, which in the past few months, we have had 44 countries come to ask for support. We have a global program that we set up--the one that I talked about, which is $1 billion--we have had 57 countries in addition to the first 44 that have come that I have talked about. We have had 20 countries come to borrow money in order to strengthen their health systems, because they want to be I the position the UK was in. I think this is the important message that we are giving--countries are worried. And it is not just that they are worried about this influenza outbreak, but they are worried that their health systems cannot support health threats, and any health threat that comes can actually break and shutter that system.

So, we would like the strong message that comes out of here to say influenza outbreaks are demonstrating that countries in low-income settings need support, and let us try to respond to that, because otherwise the threat will continue to exist for all of us if we don't control the epidemic in the low-income countries as well.

Thank you.

MR. HAY: Many thanks to my panelists--Joy Phumaphi, David Nabarro, and Julie Hall. I think Julie and Joy can stay behind if you have questions. I know that David has to go off and deal with other crises on his plate at the moment.

[Whereupon, at 2:32 p.m., the press briefing was concluded.]