Lessons from the 2009 pandemic: Insights from Bangladesh, Mexico and Viet Nam
The influenza A(H1N1) 2009 pandemic revealed that WHO and Member States were not fully prepared to rapidly assess the severity (transmission, seriousness of disease and impact) of a pandemic, or to implement risk communications and risk management plans.
Member States had prepared for a pandemic of high severity, and faced difficulties in adapting their national and subnational responses adequately to a more moderate event. Communication was also demonstrated to be of immense importance: the need to provide clear risk assessments to decision-makers placed significant strain on ministries of health; and effective communication with the public was challenging.
In response to lessons learnt from the H1N1 2009 pandemic, a revised approach to global phases of pandemic influenza was developed. The phases, which are based on virological, epidemiological and clinical data, are to be used for describing the spread of a new influenza subtype, taking account of the disease it causes around the world. The global phases have been clearly uncoupled from risk management decisions and actions at the country level. Thus, Member States are encouraged as far as possible to use national risk assessments to inform management decisions for the benefit of their country’s specific situation and needs.
One of the most critical steps in the response to a pandemic is the time when it is declared. The International Health Regulations (2005) (IHR (2005)) guide whether an outbreak is determined to be a pandemic. First, a disease outbreak must be designated a Public Health Emergency of International Concern (PHEIC), meaning it is serious, unusual, and has a significant chance of international spread and may require a coordinated international response. Once the risk assessment and spread are determined to have crossed into two different WHO global regions, the WHO Director-General may make a declaration of a pandemic (based on advice received from a committee of experts from a broad span of disciplines).
The 2009 H1N1 pandemic was the first test of the IHR (2005) since they were revised in the wake of the 2003 SARS epidemic and the H5N1 influenza epidemic - both deadly outbreaks that alerted the world that when it comes to infectious disease, international cooperation is essential. The IHR (2005) requires States Parties to strengthen core public health capacities to detect, assess, respond to and report events that may be public health emergencies of international concern, while at the same time avoiding unnecessary interference with international traffic and trade.
Country insights: Bangladesh
Pandemics by their nature are unpredictable, not only as to timing, but also where they will first emerge. For Bangladesh, 2009 was a lesson learned, said Prof Mahmudur Rahman, Former Director of the National Influenza Centre, Bangladesh. “We were concentrating more on the rural population because it was understood that this pandemic will start from the villages, from the rural community and from the farms where the poultry is reared.”
But as it turned out the virus first emerged in Mexico and then made its way to the United States – and it was from the USA that it came to Bangladesh, said Prof Rahman. A group of 29 Bangladeshi students had been studying in the USA, and when they returned, six were infected. “So, it came from the airport, from the plane, and that was detected by our event-based surveillance.”
As the virus spread, Bangladesh public health authorities traced contacts of those affected, going house to house, putting patients in isolation. The international assistance Bangladesh received in developing its influenza detection and response platform, and guidance from WHO, played a significant role in the country’s response, he said.
Country insights: Mexico
For Mexico, a lesson learned from 2009 is that constant surveillance is critical. “We share information on a weekly basis of an average of twenty thousand health facilities in the country, including in the private sector. That gives us an idea of what's going on in the different areas of the country, in order to focus our activities in those areas that we consider to be of more risk,” said Dr Cuauhtemoc Mancha-Moctezuma, the deputy director general for the National Center of Preventive Programs and Disease Control, Mexico. Focusing on diseases transmitted from animals to humans – zoonoses – is critical, he said. “We have a very strong collaboration with ministries related to animals, production and agriculture.”
Country insights: Viet Nam
Following the 2009 pandemic, WHO supported the country to strengthen its laboratory system, including specimen collection and transportation and implementation of modern diagnostic techniques, and notably, advanced virus characterization at its National Influenza Centres. The country has also trained over 300 health workers from provincial hospitals throughout the country in clinical management of acute respiratory infections.
“What’s next? We need to strengthen the capacity for district hospitals in responding to pandemic influenza, as they are the first line of defense," said Dr Nguyen Van Kinh, the Deputy Director of the National Hospital for Tropical Diseases, Viet Nam. He also noted the need to improve infection prevention and control procedures to stop outbreaks from spreading in hospitals and clinics.