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World Health Organization raises level of pandemic alert (4/28)

April 28, 2009
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The current situation regarding the outbreak of swine influenza A(H1N1) is evolving rapidly, according to the World Health Organization. As of April 27, the United States government has reported 40 laboratory confirmed human cases of swine influenza A(H1N1), with no deaths. Mexico has reported 26 confirmed human cases of infection with the same virus, including seven deaths. Canada has reported six cases, with no deaths, while Spain has reported one case, with no deaths.

WHO advises no restriction of regular travel or closure of borders. It is considered prudent for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention, in line with guidance from national authorities.

There is also no risk of infection from this virus from consumption of well-cooked pork and pork products, according to WHO. Individuals are advised to wash hands thoroughly with soap and water on a regular basis and should seek medical attention if they develop any symptoms of influenza-like illness.

The WHO Emergency Committee, established in compliance with the International Health Regulations (2005), held its second meeting on April 27.

The committee considered available data on confirmed outbreaks of A/H1N1 swine influenza in the United States, Mexico, and Canada. The committee also considered reports of possible spread to additional countries.

On the advice of the committee, the WHO Director-General decided to raise the level of influenza pandemic alert from the current phase 3 to phase 4.

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a foregone conclusion.

The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable.

As further information becomes available, WHO may decide to either revert to phase 3 or raise the level of alert to another phase.

This decision was based primarily on epidemiological data demonstrating human-to-human transmission and the ability of the virus to cause community-level outbreaks. Given the widespread presence of the virus, the Director-General considered that containment of the outbreak is not feasible. The current focus should be on mitigation measures.

The Director-General recommended not to close borders and not to restrict international travel. It was considered prudent for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention. The Director-General considered that production of seasonal influenza vaccine should continue at this time, subject to re-evaluation as the situation evolves. WHO will facilitate the process needed to develop a vaccine effective against A(H1N1) virus. The Director-General stressed that all measures should conform with the purpose and scope of the International Health Regulations.

In the 2009 revision of the pandemic phase descriptions, WHO retained the use of a six-phased approach for easy incorporation of new recommendations and approaches into existing national preparedness and response plans. The grouping and description of pandemic phases have been revised to make them easier to understand, more precise, and based upon observable phenomena. Phases 1–3 correlate with preparedness, including capacity development and response planning activities, while Phases 4–6 clearly signal the need for response and mitigation efforts. Periods after the first pandemic wave are elaborated to facilitate post pandemic recovery activities.

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave.

Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave, according to WHO. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature.

In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus, according to WHO. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required.

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