1. Strengthening intersectoral influenza surveillance and response
WHO perspective and gaps
2-3 October 2017 Washington, D.C.
N Aspen Hammond │Global Influenza Programme (GIP) │Genevan | Country

2. Strengthening intersectoral influenza surveillance and response
Outline
Global context:
One Health at WHO
Current zoonotic influenza situation
Resources
Joint External Evaluation (JEE)
Zoonoses guide
Gaps
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

3. Strengthening intersectoral influenza surveillance and response
Global context
To address WHO’s perspective, I will start with a description of the context in which this work is important. I will discuss examples of WHO’s approach to One Health in general and then a review of the current situation regarding zoonotic influenza.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

4. One Health at WHO
To effectively detect, respond to, and prevent outbreaks of zoonoses and food safety problems, epidemiological data and laboratory information should be shared across sectors.
Government officials, researchers and workers across sectors at the local, national, regional and global levels should implement joint responses to health threats.
Strategic/policy collaborations with international agencies and partners
Technical collaborations with international agencies and partners
Disease-specific cross- sectoral technical projects
The following are examples of work in each category.
Strategic/policy collaborations with international agencies and partners:
Tripartite agreement
Joint ministerial process (HLTM 2011)
Operationalizing One Health
Strengthening health security (IHR)
Technical collaborations with international agencies and partners:
GLEWS
OFFLU-WHO collaboration
GISRS network
Disease-specific cross-sectoral technical projects:
Tripartite Four-Way Linking Project for HPAI H5N1
More details on a few of the examples to follow.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

5. One Health: Strategic/policy collaborations
The Tripartite agreement 2010
Commitment to collaborate when the interaction between animals, humans, and environment impacts human health, animal health, and global health security
Principle: Build on existing infrastructure and health systems
Created a supportive environment to engage ministers to collaborate.
Outlines common areas of work to build upon.
The three organizations have worked together for over 60 years. A formal concept note was signed by the three directors general in It is to be updated shortly with a renewed endorsement of the importance of the tripartite agreement. Zoonotic influenza is cited frequently as a success and a model for future work.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

6. One Health: Strategic/policy collaborations
Operationalizing one health 2010
Identify clear and concrete actions to move the concept of One Health from vision to implementation.
Outlines economic benefits of collaboration.
Seven specific activities were identified as being critical steps in the roadmap to implementation.
Specific activities:
Training
One Health Global Network
Information Clearing house
Needs Assessment
Proof of Concept
Capacity Building
Business Plan
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

7. One Health: Strategic/policy collaborations
Joint Ministerial Process 2011
Provide more specific rationale and tools to implement cross- sectoral activities in countries.
Outlines key elements of effective cross-sectoral collaboration
Supporting elements
Operational elements
Key supporting elements
1 Political will and high-level commitment
2. Trust
3. Common objectives and priorities
4. Shared benefits
5. Strong governance structures, aligned legal frameworks,
and recognition of existing international standards
6. Adequate and equitably distributed resources
7. Identification and involvement of all relevant partners
8. Coordinated planning of activities
9. Guidance on implementation of cross-sectoral collaborations
10. Capacity development
11. Strong and effective health systems within the individual sectors
Key operational elements
A. Joint cross-sectoral coordination mechanisms
B. Routine communication
C. Joint simulation exercises
D. Data sharing
E. Joint risk assessment
F. Active cooperation on disease control programmes
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

8. One Health: Strategic/policy collaborations
International Health Regulations
2005, World Health Assembly adopted the International Health Regulations (2005) which subsequently entered into force on 15 June To prevent, protect against, control and provide a public health response to the international spread of disease … and …avoid unnecessary interference with international traffic and trade. State Parties are required to develop certain minimum core public health capacities.
From the IHR briefing: The global community has a new legal framework to better manage its collective defences to detect disease events and to respond to public health risks and emergencies that can have devastating impacts on human health and economies. The successful implementation of the IHR (2005) by the countries that have agreed to be bound by them (States Parties) and WHO, will contribute significantly to enhancing national and global public health security.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

9. WHO support for IHR implementation
Identify gaps
Action plan
Implementation
IHR Monitoring and Evaluation Framework
Annual reporting (self assessment)
Review after acute public health events
Simulation exercises
Joint External Evaluation
Provide guidance on development of national action plans
Provide guidance on the implementation of these capacity strengthening plans
Implementation of IHR at the human-animal interface
Guidance for zoonoses
Joint risk assessment tools
IHR-PVS bridging workshops
One Health training
WHO assists member states in identify gaps in implementing the core capacities as required in the IHR. Countries then develop national action plans and prioritize the areas of work. WHO, with its regional and country offices, provides assistance and guidance in implementing the plans and building capacity. There is joint guidance from OIE and WHO for good governance at the human-animal interface.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

10. One Health at WHO (Influenza)
Technical collaborations
Disease-specific cross-sectoral technical projects
OFFLU-WHO collaboration and
GISRS network of National Influenza Centres and Collaborating Centres
selection of candidate vaccine viruses for pandemic preparedness
Global Early Warning System (GLEWS)
Joint risk assessments
Joint missions
Joint communications
Disease naming
Tool for Influenza Pandemic Risk Assessment (TIPRA) 4-way linking project for A(H5N1)
This is not an exhaustive list. Across WHO, there are many examples of technical collaborations and disease-specific projects. Highlighted here are examples that touch on influenza.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

11. Strengthening intersectoral influenza surveillance and response
Current zoonotic influenza situation
Discuss the human cases of infection with zoonotic viruses and the particular challenges with influenza.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

12. Current zoonotic influenza situation A(H5N1)
From 2003 through 1 October :
860 laboratory-confirmed human cases of avian influenza A(H5N1) virus infection have been officially reported to WHO from 16 countries; of these cases, have died (53%).
Only 4 cases reported in (Egypt-3, Indonesia-1)
Dramatic decline of reported human cases of A(H5N1) worldwide
No sustained human-to-human transmission.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

13. Current zoonotic influenza situation A(H7N9)
From 2013 through 12 September 2017,
1563 laboratory-confirmed human cases of avian influenza A(H7N9) virus infection have been officially reported to WHO from 3 countries; of these cases, at least 380 have died.
Two cases were reported by Canada and one case by Malaysia. However, these cases were in travellers who likely had exposure to poultry or contaminated environments in China.
The majority of the cases seem to occur between week 51 to week 20 of the following year.
No sustained human-to-human transmission.
Virus appears widespread in poultry population in China. Poultry vaccination campaign underway.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

14. Current zoonotic influenza situation September 2016-current
A(H7N2)
1 human case in the USA in Dec 2016 in an individual who had been exposed to cats infected with influenza A(H7N2) viruses.
This was the first known case of a human infected with an influenza A virus likely acquired through exposure to an infected cat.
A(H9N2)
4 human cases from China; 3 had exposure to poultry or poultry markets.
All were mild infections.
A(H1N1)v
3 human cases in Europe.
2 were hospitalized and all had swine exposure preceding illness.
A(H1N2)v
3 human cases in the USA.
All were mild infections and all had swine exposure preceding illness.
A(H3N2)v
1 human case in Canada and 18 in the USA.
1 case was hospitalized and all had swine exposure preceding illness.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

15. Challenges Diversity of viruses
Widespread and introductions into new geographic areas
Constantly evolving viruses
Reassortment events
Causes severe disease in humans
Little to no population immunity
Food security
Politically sensitive
Influenza fatigue
Humans as sentinels (i.e. LPAI)
Examples of these challenges to follow.
Image courtesy of WHO Collaborating Centre for Reference and Research on Influenza, National Institute of Infectious Diseases, Japan
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

16. Avian influenza reports Sept 2016-Sept 2017
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

17. Geographic spread Influenza A(H5N8): spread in animals
FAO: The role of wild birds in the long distance movement of these viruses is now incontrovertible. 
Influenza A(H5N8): spread in animals
A(H5N8) viruses were detected in China in November 2013, then in Japan and the Republic of Korea in 2014.
In winter 2014, detected in Europe and North America for the first time. Genetic analysis of the isolated viruses confirmed their close similarity to the viruses spreading in eastern Asia.
In summer 2016, detected in a wild bird in Russia along the central Asian flyway and in Europe shortly after. The virus was readily distinguishable from strains of H5N8 virus found in Europe and North America in
In summer 2017, further spread to South Africa and Zimbabwe.
Dong-Hun Lee et al. J. Virol. 2015;89: ;
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

18. Constant evolution A(H7N9) A(H5)
Yang, L et al. Genesis and Dissemination of Highly Pathogenic H5N6 Avian Influenza Viruses. J. Virol. March 2017 91:5 13 e ; Accepted manuscript posted online 21 December 2016, doi: /JVI
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

19. Reassortment events A(H7N9) 2013 A(H5N6) 2014
Reassortment events that have resulted in human infections and in the past month, these are examples of publications on newly detected reassortant influenza viruses.
Zhang R, Chen T, Ou X, et al. Clinical, epidemiological and virological characteristics of the first detected human case of avian influenza A(H5N6) virus. Infection, genetics and evolution : journal of molecular epidemiology and evolutionary genetics in infectious diseases. 2016;40: doi: /j.meegid
Watanabe, Tokiko et al. Pandemic potential of avian influenza A (H7N9) viruses. Trends in Microbiology , Volume 22 , Issue 11 ,
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

20. Strengthening intersectoral influenza surveillance and response
Resources
WHO resources and tools starting with those with broad scope and then discussing influenza-specific ones.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

21. Joint External Evaluation
The Joint External Evaluation Tool is intended to assess country capacity to prevent, detect, and respond to public health threats.
Countries can request a JEE mission to help them identify the most urgent needs within their health system.
The JEE will help engage with stakeholders and partners initiatives to support country outbreak and health emergency preparedness.
In 2015, there was a need for increased transparency and mutual accountability in implementing IHR. Thus, there was a move from ‘exclusive self-evaluation’ to external evaluation .
In 2015, a technical consultation meeting on the IHR Monitoring and Evaluation Framework suggested the development of processes and a tool to conduct joint external evaluation.
This tool is organized in assessing a country’s capacity in three broad categories: prevention, detection and response.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

22. Joint External Evaluation: Zoonotic disease
PREVENT
DETECT
RESPOND
Surveillance systems in place for priority zoonotic diseases/pathogens
Animal health and veterinarian workforce capacity
Mechanisms for responding to infectious zoonoses are established and functional
National lab system evaluation Real-time surveillance Reporting Workforce development
Preparedness Emergency response Risk communications
Examples of technical questions to evaluate detection capacities:
National lab system evaluation
How is laboratory data on zoonotic diseases shared between human and animal health laboratories?
Real-time surveillance
How does the country utilize electronic reporting systems for notifiable diseases for human health and animal health?
Are these systems shared between sectors, or independent?
Does the MoH share laboratory data with other ministries/agencies?
Reporting
What are the mechanisms for public health, animal health and security authorities to make decisions on reporting?
Workforce development
Human resources
Field epidemiology capacity and training
Examples of technical questions to evaluate response capacities:
Preparedness
Does the country have a national public health emergency preparedness and response plan?
Emergency response
Is the organization able to convene participants from ministries and other national and multinational partners as appropriate?
Is there a multisectoral commission or a multidisciplinary emergency response department for public health/animal health?
Risk communications
Are there shared communication plans, agreements and/or standard operating procedures between other response agencies such as … and/or government agencies such as ministries of defence, agriculture, food/drug, etc.?
Is there a mechanism informally or formally to coordinate communication among national stakeholders and response agencies during an emergency?
Have there been incidents where valuable time was taken because of a lack of agreement regarding which agency would respond during an emergency?
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

23. Current zoonoses guide (2008)
Existing tool for collaboration at country level
Developed jointly by animal health and public health sectors (WHO/OIE/FAO)
Practical guidance on:
Setting up a coordination mechanism
Surveillance and information sharing
Coordinated responses
This guidance was developed by the SEARO and WPRO regional offices.
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

24. Updated and expanded zoonoses guide
Under development; expected May 2018
Guide
Specific tools
Existing areas of work
Coordinating mechanism
Coordinated response
Surveillance and information sharing
Risk reduction
To be developed in addition to guide:
Tools for coordination committees
Tools for coordinated investigation and response
Tools for planning and preparedness
Tools for joint risk assessment
Tools for training and workforce development
Tools for risk communication and risk reduction
The updated guidance under development is:
Standard guidance and tools for multisectoral collaboration
Tripartite initiative
Practical, operational
Intended for NATIONAL level application
New areas of work in updated version:
Planning and preparedness
Joint risk assessment for specific threats
Training and workforce development
Risk communication
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

25. Strengthening intersectoral influenza surveillance and response
Gaps
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

26. Gaps Virology-epidemiology link
Tempo-spatial linking of human cases to events in animals
Molecular markers associated with phenotype information, case outcome?
Information sharing
Confidentiality issues
Lack of incentives or mechanisms
True incidence
Capturing all cases?
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

27. For more information www.who.int/influenza/human_animal_interface/en/
Avian and other zoonotic influenza
2-3 October 2017 │ Strengthening intersectoral influenza surveillance and response--WHO perspective and gaps

28. Strengthening intersectoral influenza surveillance and response
Thank you
N Aspen Hammond │Global Influenza Programme (GIP) │Genevan | Country