Lessons learned from the 2009 influenza A(H1N1) pandemic at EU level

On 1 and 2 July 2010, an international conference on lessons learned from the 2009 Influenza A(H1N1) pandemic was organised jointly by the Belgian Presidency and the European Commission (EC) in Brussels. More than 300 scientists, communication specialists and decision-makers from all Member States, EU's Candidate Countries, the EC, the European Parliament, the European Medicines Agency, the ECDC, the WHO, representatives from the USA, Canada and some neighbouring countries had the opportunity to listen to high-level presentations and to debate on four themes: surveillance, multi-sectoral aspects, medical measures and communications.

In the field of surveillance, presentations from countries and ECDC showed that the existing and well established national influenza surveillance networks did not collapse and worked quite well by providing reliable and useful data. Aside for the surveillance of clinical and virological data from primary health care which were of particular value, an accurate estimation of severity was considered as a priority by the conference. In this way, data collections were implemented during the influenza pandemic by Member States and sent to ECDC, like Severe Acute Respiratory Infections (SARI) reported by 11 EU countries. However, although notification of SARI cases was useful even if not comprehensive, it has shown limitations, in both data from hospitalisation and death, especially when a denominator was needed. In ad-dition, mortality data were slightly misleading as 2009 pandemic Influenza A(H1N1) laboratory-confirmed deaths were reported to ECDC while excess deaths related to influenza without any laboratory confirmation were previously used from observational studies during seasonal outbreaks, with much higher figures in the latter in comparison with the former. Moreover, these misleading figures have hidden the true pattern of mortality during this influenza pandemic, e.g. 77.5% of related-deaths occurred in hospitalised patients aged less than 65 years old, while more than 90% of deaths occurred in the elderly during seasonal flu.

The importance of sero-epidemiology in the field of influenza control and management was also highlighted, especially with the significant number of asymptomatic patients. Previously, serology was used in research activities and never in routine surveillance. This gap was also due to the absence of standardisation and the necessary time and resources consumed while all laboratories were actively busy with diagnostics and characterisations. Less demanding, reliable and comparable tests should be developed in the future. This is also in line with the conclusion from the conference which recommended the collection of a minimum set of epidemiological and virological data in order to help decision-makers, and to avoid excessive pressure on surveillance centres.

Finally, better assessment and prediction of the impact, not only medical, of both pandemic and seasonal influenza were considered as priorities. In this way, the use of mathematical modelling, especially when there is no evidence, would be of particular value.

Regarding multi-sectoral aspects, medical measures and communication, generic Business Continuity Plans, joint purchasing procedures and eventually strategic approaches for establishing the necessary relationships and trust with journalists were recommended. A need for better cooperation between public and private sectors was also identified and it was agreed that vulnerabilities and interdependencies of socio-economic sectors could be minimised by EU. The conference agreed that this pandemic has clearly illustrated the challenge in risk communication. The diversity in Europe inevitably leads to different perceptions of risk among the public and experts, and it was suggested to better involve the scientific community and civil society. The aim must be that risk is understood and trust maintained. For citizens, public health experts and policy makers, taking informed decisions relies on independent and transparent scientific information.

This conference provided key-messages that were presented to an informal meeting of the Employment, Social Policy, Health and Consumer Affairs Council (EPSCO) that was held just a few days later, on 6 July, convening EU Ministers of Health. This latter meeting issued priorities for the management and control of an influenza pandemic in the future and for health security in EU as well. Regarding the lessons learned from the 2009 influenza A(H1N1) pandemic, the Council recognised the need to stay alert, to strengthen the EU preparedness on pandemic influenza and to improve cooperation and coordination. In these roles, the importance of the ECDC, the EMA and the WHO was particularly emphasised.

Regarding health security in EU, the Council prolonged the mandate of the Health Security Committee (HSC) by strengthening coordination, surveillance and analysis capacity for health threats. The Commission was invited to revise the EU Pandemic Preparedness Plan taking account the lessons learned in coherence with the International Health Regulations (2005), and to ensure that the response is flexible to the severity of the threat. The commission was also invited to develop a joint mechanism for vaccines procurement and to improve the fast registration of vaccines.

In conclusion, as already underlined by previous Czech and Swedish Presidencies, improvement of the cooperation and the coordination of preparedness and measures taken was again highlighted by the Conference on lessons learned from the 2009 Influenza A(H1N1) pandemic, co-organised by the Belgian Presidency in July 2010. Besides communication issues that dominated the public debate, lessons learned essentially focussed on essential indicators in surveillance, in particular the measure of severity, and appropriate response to the influenza pandemic.