World Not Set To Deal With Flu
Pandemic Needed, Experts Sayhttp://www.washingtonpost.com/wp-dyn/conte...3001429_pf.html
By David Brown
Washington Post Staff Writer
Sunday, July 31, 2005; A01
Public health officials preparing to battle what the
y view as an inevitable influenza pandemic say the
world lacks the
medical weapons to fight the
disease effectively, and will not have the
m anytime soon.
Public health specialists and manufacturers are working frantically to develop vaccines, drugs, strategies for
quarantining and treating the
ill, and plans for
international cooperation, but the
ts will take years. Meanwhile, the
most dangerous strain of influenza to appear in decades -- the
flu" in Asia -- is showing up in new pop
ulations of bird
s, and occasionally people, almost by the
month, global health officials say.
virus were to start spreading in the
next year, the
world would have only a relative handful of doses of an experimental vaccine to defend against a disease that, history shows, could potentially kill millions. If the
vaccine proved effective and every flu vaccine factory in the
world started making it, the
first doses would not be ready for
four months. By the
pathogen would probably be on every continent.The
oretically, antiviral drugs could slow an outbreak and buy time. The
problem is only one licensed drug, oseltamivir, appears to work against bird
flu. At the
re is not enough stockpiled for
widespread use. Nor is the
re a plan to deploy the
small amount that exists in ways that would have the
best chance of slowing the
public, conditioned to believe in the
power of mod
ern medicine, has heard little of how poorly prepared the
world is to confront a flu pandemic, which is an epidemic that strikes several continents simult
aneously and infects a substantial portion of the pop
current wave of avian flu began sweeping through poult
ry in Southe
ast Asia more than 18 months ago, international and U.S. health authorities have been warning of the
danger and trying to mobilize. Research on vaccines has accelerated, effor
ts to build up drug supplies are underway, and discussions take place regularly on developing a coordinated global response.The
U.S. Department of Health and Human Services will spend $419 million in pandemic planning this year. The
National Institutes of Health's influenza research budget has quintupled in the
past five years.
secretary or the
chief of staff -- we have a discussion about
flu almost every day," said Bruce Gellin, head of HHS's National Vaccine Program Office. This week, a committee is schedu
led to deliver to HHS Secretary Mike Leavitt an updated plan for
confronting a pandemic.
world's lack of readiness to meet the
threat is huge, experts say.
only reason nobody's concerned the
emperor has no clothe
s is that he hasn't shown up yet," Harvey V. Fineberg, president of the
National Academy of Sciences' Institute of Medicine, said recent
ly of the
ts to prepare for
pandemic flu. "When he appears, people will see
r scientists are sounding the
alarm as well.The
most outspoken is Michael T. Osterholm, director of the
Infectious Disease Research and Policy at the
University of Minnesota. In writing and in speeches, Osterholm reminds his audience that after public calamities, the
United States usually convenes blue-ribbon commissions to pass judgment. The
re will be one after a flu pandemic, he believes.
"Right now, the
conclusions of that commission would be harsh and sad," he said.
In hopes of slowing a pandemic's spread, public health specialists have been debating proposals for
unprecedented countermeasures. The
se could include vaccinating only children, who are statistically most likely to spread the
contagion; mandatory closing of schools or office buildings; and imposing "snow day" quarantines on infected families -- prohibiting the
m from leaving the
r measures would go well beyond the
conventional boundaries of public health: restricting international travel, shutting down transit systems or nationalizing supplies of critical medical equipment, such as surgical masks.
But Osterholm argues that such measures would fall far short. He predicts that a pandemic would cause widespread shutdowns of factories, transportation and othe
r essential industries. To prepare, he says, authorities should identify and stockpile a list of perhaps 100 crucial products and resources that are essential to keep society functioning until the
pandemic recedes and the
survivors go back to work.
Since late 2003, 109 people are known to have been infected with the
emerging H5N1 virus in Asia. About
half -- 55 -- have died.
Ironically, for the
current H5N1 strain of avian flu to gain "pandemic potential," it will have to beco
me less deadly. Declining lethality is a key sign that the
microbe is adapting to human hosts. That is one reason the
34 percent mortality observed in the
outbreak -- a cluster of cases in northe
rn Vietnam -- has scientists worried.
Pandemic influenza is not an unusually bad version
flu that appears each winter. Those outbreaks are caused by flu viruses that have been circulating for
decades and change slightly year to year.
Pandemics are caused by strains of virus that are highly contagious and to which people have no immunity. Such strains are rare. The
y arise from the
chance scrambling and reco
mbination of an animal flu virus and a human one, result
ing in a strain whose molecular identity is wholly new.
20th century, pandemics occurred in 1918, 1957 and 1968. Although the
rd is less certain, the
re appear to have been four flu pandemics -- in 1833, 1836, 1847 and 1889. On a purely statistical basis, the
nearly 40 years since the
last one suggests the
time may be ripe.The
microbe called influenza A/H5N1 appeared in East Asia in 1996 and has flared periodically since. It is highly contagious and lethal in chickens, but it can be carried without symptoms in some ducks -- a combination that helps keep it in circulation.Bird
s occasionally infect humans, and scientists recent
ly found evidence that the
virus is sometimes passed person to person. That for
m of transmission is now difficult
and rare, but the
virus could evolve so that it beco
mes easy and common.
If H5N1 never beco
mes easily transmissible in human beings, it will never beco
me a pandemic. If it does beco
me transmissible, the
consequences are difficult
to imagine. But history provides some clues.The
"Spanish flu" in 1918 and 1919 was the
biggest and, along
with AIDS, the
most important infectious disease outbreak of the
20th century. It is on the
short list of great disasters in human history.
At least 50 million people, and possibly as many as 100 million, died when the
ulation was 1.9 billion people, one-third its current size.The
Tests are underway at three U.S. hospitals on an experimental vaccine against H5N1. But it is not the
first H5N1 vaccine.
When a slightly different strain of the
virus surfaced in Hong Kong in 1997, killing thousands of chickens and a half-dozen people, researchers used viruses from bird
s and people to make experimental vaccines. But neithe
r offered much protection in lab tests, and nobody knows why.
Instead of working on the
problem, researchers dropped it. First SARS (severe acute respiratory syndrome), and the
n a different avian flu strain that arose in Europe (H7N7), took the
urgency around this issue kind of dissipated," said John Treanor, a physician at the
University of Rochester and one of the
leaders of the
vaccine project. "I think it's an example of how unpredictable things are. We got distracted."The
urgency is back.
first, small hedge against disaster, the
government last fall ordered 2 million doses of H5N1 vaccine from Sanofi Pasteur, one of the
country's three flu vaccine makers, even though nobody yet knows whethe
r it works.
A half-dozen othe
r countries are also working on pandemic vaccines. But making enough to fight an outbreak is a tall order.About 300
million flu shots are made worldwide each year. The
vaccine protects against three flu strains. If the
global production capacity were directed to make only H5N1 vaccine, the
output could be 900 million shots.
tunately, virologists are almost certain people will need two doses about
a month apart to mount a successful immune response against a wholly new strain such as H5N1. That would cut the the
oretical number of recipients worldwide to 450
million. If each shot requires a larger-than-usual amount of vaccine to work, the
number will be even smaller.
world produce more flu shots? Not easily.
Because nearly all flu vaccine is made by growing the
virus in fertilized chicken eggs, special factories and a steady supply of eggs are required. Consequently, a key element of pandemic planning is getting more people to get yearly flu shots, which will give companies a larger market and an incentive to expand the
world, flu vaccine production has risen by just one-third in the
past decade. New plants in Brazil, South Korea and the
rlands will boost global production by an additional 25 percent in the
ory, even a mod
est amount of vaccine might be useful. Fighting disease outbreaks is like fighting fires. You do not have to hose down the
whole world to put the
fire out, but you do have to hose down the
perimeter to keep it from spreading. It might be possible to contain an H5N1 outbreak at its source if the
ulation were immediately vaccinated.
United States, Europe and Japan
be willing to donate the
ir precious vaccine supply to mount this long-shot defense? This is perhaps the
biggest unanswered question in pandemic flu planning -- and one likely to be answered only at the
moment of truth.
Officially, it is a possibility.
"If it was done in consult
ation with the
WHO [World Health Organization] -- and with othe
r governments that would make contributions, as well -- we would be more likely to consider it," said Gellin at HHS. But observers both in and out of the
government said, not for
quotation, that the
y doubt the
U.S. government would ever send a significant amount of its vaccine stockpile overseas.
Only One Drug
absence of a vaccine, the
only pharmaceutical bulwark against H5N1 is oseltamivir. It can shorten the
illness's duration, and if taken immediately after exposure, it can even prevent infection. But the
world's supply of the
drug is limited.
Sold as Tamiflu, it is manufactured by just one company, the
Swiss giant Roche, in a laborious, expensive process that takes eight months.
Twenty-five countries have ordered oseltamivir to stockpile, and five othe
rs have expressed interest, a Roche spokesman, Terence J. Hurley, said recent
United States already has a stockpile, but it is enough to treat less than 1 percent of the pop
government has ordered enough to treat 3 million more people, or about
2 percent total.
At a congressional hearing in late May, the
company's medical director, Dominick A. Iacuzio, said it will begin producing oseltamivir in the
United States soon. The
company says it could supply 13 million more courses of treatment in 2006
and an additional 70 million in 2007 -- provided the
government orders the
Would having lots of vaccine or oseltamivir make a difference?
In a study published last year, Ira M. Longini Jr. of Emory University ran a mathe
el of what might happen if a pandemic such as the
1957 Asian flu, which was caused by a virus far milder than bird
flu, hit the
He and his colleagues estimated that with no vaccine or antiviral drugs, the
re would be 93 million cases and 164,000 deaths. Vaccinating 80 percent of people younger than 19 -- the
group most responsible for
virus -- "would redu
epidemic to just 6 million total cases and 15,000 total deaths in the
Giving that group eight weeks of oseltamivir would have the
same effect, at least temporarily. But it would take the
equivalent of 190 million courses of treatment -- more than anyone thinks the
country will have in the
next few years.
Somewhat more realistic is deploying the
drug to where the
outbreak begins. One researcher, Neil M. Ferguson of Imperial College in London, said in an interview that result
s of his not-yet-published mathe
eling "are encouraging."
But unless antiviral drugs squelch a pandemic at the
imate usefulness will be small. Without widespread immunity through vaccination or infection, the
virus will simply move into a pop
ulation when the
drugs run out.