[Paleopsych] Foreign Affairs: Michael T. Osterholm: Preparing for the Next Pandemic
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Michael T. Osterholm: Preparing for the Next Pandemic
http://www.foreignaffairs.org/20050701faessay84402/michael-t-osterholm/preparing-for-the-next-pandemic.html?mode=print
First, the summary from CHE:
The Chronicle of Higher Education: Magazine & journal reader
http://chronicle.com/prm/daily/2005/06/2005062901j.htm
Wednesday, June 29, 2005
A glance at the July/August issue of Foreign Affairs: Coping with the
coming pandemic
An influenza pandemic is coming, writes Michael T. Osterholm, director
of the Center for Infectious Disease Research and Policy and a
professor in the School of Public Health at the University of
Minnesota at Minneapolis.
"The signs are alarming," he says, as the number of human and animal
infections caused by a virulent strain of bird flu known as H5N1 "has
been increasing; small clusters of cases have been documented,
suggesting that the virus may have come close to sustained
human-to-human transmission; and H5N1 continues to evolve in the
virtual genetic-reassortment laboratory provided by the unprecedented
number of people, pigs, and poultry in Asia."
If a pandemic struck today, it would probably kill hundreds of
millions of people and ravage the world economy. International borders
would close, and there would be severe worldwide shortages of
influenza vaccine, other medicines, and a wide range of commodities,
"including food, soap, paper, light bulbs, gasoline," Mr. Osterholm
argues.
In short, he says, panic would ensue. It's urgent that world leaders
develop an "initiative to provide vaccine for the entire world,"
stockpile "critical health-care and consumer products and
commodities," and assess "the vulnerability of the global economy to
ensure that surges in demand can be met," he writes.
"Time is running out to prepare for the next pandemic," Mr. Osterholm
warns . We can't stop it from hitting, he says, but if we act now, we
may be able to reduce its impact.
The article, "Preparing for the Next Pandemic," is online at
[54]http://www.foreignaffairs.org/20050701faessay84402/michael-t-oster
holm/preparing-for-the-next-pandemic.html
--Gabriela Montell
_________________________________________________________________
Background article from The Chronicle:
* [55]Taking Aim at Bird Flu (3/18/2005)
References
55. http://chronicle.com/weekly/v51/i28/28a01401.htm
E-mail me if you have problems getting the referenced article.
---------------------------------
From Foreign Affairs, July/August 2005
_________________________________________________________________
Summary: If an influenza pandemic struck today, borders would close,
the global economy would shut down, international vaccine supplies and
health-care systems would be overwhelmed, and panic would reign. To
limit the fallout, the industrialized world must create a detailed
response strategy involving the public and private sectors.
Michael T. Osterholm is Director of the Center for Infectious Disease
Research and Policy, Associate Director of the Department of Homeland
Security's National Center for Food Protection and Defense, and
Professor at the University of Minnesota's School of Public Health.
FEAR ITSELF
Dating back to antiquity, influenza pandemics have posed the greatest
threat of a worldwide calamity caused by infectious disease. Over the
past 300 years, ten influenza pandemics have occurred among humans.
The most recent came in 1957-58 and 1968-69, and although several tens
of thousands of Americans died in each one, these were considered mild
compared to others. The 1918-19 pandemic was not. According to recent
analysis, it killed 50 to 100 million people globally. Today, with a
population of 6.5 billion, more than three times that of 1918, even a
"mild" pandemic could kill many millions of people.
A number of recent events and factors have significantly heightened
concern that a specific near-term pandemic may be imminent. It could
be caused by H5N1, the avian influenza strain currently circulating in
Asia. At this juncture scientists cannot be certain. Nor can they know
exactly when a pandemic will hit, or whether it will rival the
experience of 1918-19 or be more muted like 1957-58 and 1968-69. The
reality of a coming pandemic, however, cannot be avoided. Only its
impact can be lessened. Some important preparatory efforts are under
way, but much more needs to be done by institutions at many levels of
society.
THE BACKDROP
Of the three types of influenza virus, influenza type A infects and
kills the greatest number of people each year and is the only type
that causes pandemics. It originates in wild aquatic birds. The virus
does not cause illness in these birds, and although it is widely
transmitted among them, it does not undergo any significant genetic
change.
Direct transmission from the birds to humans has not been
demonstrated, but when a virus is transmitted from wild birds to
domesticated birds such as chickens, it undergoes changes that allow
it to infect humans, pigs, and potentially other mammals. Once in the
lung cells of a mammalian host, the virus can "reassort," or mix
genes, with human influenza viruses that are also present. This
process can lead to an entirely new viral strain, capable of sustained
human-to-human transmission. If such a virus has not circulated in
humans before, the entire population will be susceptible. If the virus
has not circulated in the human population for a number of years, most
people will lack residual immunity from previous infection.
Once the novel strain better adapts to humans and is easily
transmitted from person to person, it is capable of causing a new
pandemic. As the virus passes repeatedly from one human to the next,
it eventually becomes less virulent and joins the other influenza
viruses that circulate the globe each year. This cycle continues until
another new influenza virus emerges from wild birds and the process
begins again.
Some pandemics result in much higher rates of infection and death than
others. Scientists now understand that this variation is a result of
the genetic makeup of each specific virus and the presence of certain
virulence factors. That is why the 1918-19 pandemic killed many more
people than either the 1957-58 or the 1968-69 pandemic.
A CRITICAL DIFFERENCE
Infectious diseases remain the number one killer of humans worldwide.
Currently, more than 39 million people live with HIV, and last year
about 2.9 million people died of AIDS, bringing the cumulative total
of deaths from AIDS to approximately 25 million. Tuberculosis (TB) and
malaria also remain major causes of death. In 2003, about 8.8 million
people became infected with TB, and the disease killed more than 2
million. Each year, malaria causes more than 1 million deaths and
close to 5 billion episodes of clinical illness. In addition, newly
emerging infections, diarrheal and other vector-borne diseases, and
agents resistant to antibiotics pose a serious and growing public
health concern.
Given so many other significant infectious diseases, why does another
influenza pandemic merit unique and urgent attention? First, of the
more than 1,500 microbes known to cause disease in humans, influenza
continues to be the king in terms of overall mortality. Even in a year
when only the garden-variety strains circulate, an estimated 1-1.5
million people worldwide die from influenza infections or related
complications. In a pandemic lasting 12 to 36 months, the number of
cases and deaths would rise dramatically.
Recent clinical, epidemiological, and laboratory evidence suggests
that the impact of a pandemic caused by the current H5N1 strain would
be similar to that of the 1918-19 pandemic. More than half of the
people killed in that pandemic were 18 to 40 years old and largely
healthy. If 1918-19 mortality data are extrapolated to the current
U.S. population, 1.7 million people could die, half of them between
the ages of 18 and 40. Globally, those same estimates yield 180-360
million deaths, more than five times the cumulative number of
documented AIDS deaths. In 1918-19, most deaths were caused by a
virus-induced response of the victim's immune system -- a cytokine
storm -- which led to acute respiratory distress syndrome (ARDS). In
other words, in the process of fighting the disease, a person's immune
system severely damaged the lungs, resulting in death. Victims of H5N1
have also suffered from cytokine storms, and the world is not much
better prepared to treat millions of cases of ARDS today than it was
85 years ago. In the 1957-58 and 1968-69 pandemics, the primary cause
of death was secondary bacterial pneumonias that infected lungs
weakened by influenza. Although such bacterial infections can often be
treated by antibiotics, these drugs would be either unavailable or in
short supply for much of the global population during a pandemic.
The arrival of a pandemic influenza would trigger a reaction that
would change the world overnight. A vaccine would not be available for
a number of months after the pandemic started, and there are very
limited stockpiles of antiviral drugs. Plus, only a few privileged
areas of the world have access to vaccine-production facilities.
Foreign trade and travel would be reduced or even ended in an attempt
to stop the virus from entering new countries -- even though such
efforts would probably fail given the infectiousness of influenza and
the volume of illegal crossings that occur at most borders. It is
likely that transportation would also be significantly curtailed
domestically, as smaller communities sought to keep the disease
contained. The world relies on the speedy distribution of products
such as food and replacement parts for equipment. Global, regional,
and national economies would come to an abrupt halt -- something that
has never happened due to HIV, malaria, or TB despite their dramatic
impact on the developing world.
The closest the world has come to this scenario in modern times was
the SARS (severe acute respiratory syndrome) crisis of 2003. Over a
period of five months, about 8,000 people were infected by a novel
human coronavirus. About ten percent of them died. The virus
apparently spread to humans when infected animals were sold and
slaughtered in unsanitary and crowded markets in China's Guangdong
Province. Although the transmission rate of SARS paled in comparison
to that of influenza, it demonstrated how quickly such an infectious
agent can circle the globe, given the ease and frequency of
international travel. Once SARS emerged in rural China, it spread to
five countries within 24 hours and to 30 countries on six continents
within several months.
The SARS experience teaches a critical lesson about the potential
global response to a pandemic influenza. Even with the relatively low
number of deaths it caused compared to other infectious diseases, SARS
had a powerful negative psychological impact on the populations of
many countries. In a recent analysis of the epidemic, the National
Academy of Science's Institute of Medicine concluded: "The relatively
high case-fatality rate, the identification of super-spreaders, the
newness of the disease, the speed of its global spread, and public
uncertainty about the ability to control its spread may have
contributed to the public's alarm. This alarm, in turn, may have led
to the behavior that exacerbated the economic blows to the travel and
tourism industries of the countries with the highest number of cases."
SARS provided a taste of the impact a killer influenza pandemic would
have on the global economy. Jong-Wha Lee, of Korea University, and
Warwick McKibbin, of the Australian National University, estimated the
economic impact of the six-month SARS epidemic on the Asia-Pacific
region at about $40 billion. In Canada, 438 people were infected and
43 died after an infected person traveled from Hong Kong to Toronto,
and the Canadian Tourism Commission estimated that the epidemic cost
the nation's economy $419 million. The Ontario health minister
estimated that SARS cost the province's health-care system about $763
million, money that was spent, in part, on special SARS clinics and
supplies to protect health-care workers. The SARS outbreak also had a
substantial impact on the global airline industry. After the disease
hit in 2003, flights in the Asia-Pacific area decreased by 45 percent
from the year before. During the outbreak, the number of flights
between Hong Kong and the United States fell 69 percent. And this
impact would pale in comparison to that of a 12- to 36-month worldwide
influenza pandemic.
The SARS epidemic also raises questions about how prepared governments
are to address a prolonged infectious-disease crisis -- particularly
governments that are already unstable. Seton Hall University's
Yanzhong Huang concluded that the SARS epidemic created the most
severe social or political crisis encountered by China's leadership
since the 1989 Tiananmen crackdown. China's problems probably resulted
less from SARS' public health impact than from the government's failed
effort to allay panic by withholding information about the disease
from the Chinese people. The effort backfired. During the crisis,
Chinese Premier Wen Jiabao pointed out in a cabinet meeting on the
epidemic that "the health and security of the people, overall state of
reform, development, and stability, and China's national interest and
image are at stake." But Huang believes that "a fatal period of
hesitation regarding information-sharing and action spawned anxiety,
panic, and rumor-mongering across the country and undermined the
government's efforts to create a milder image of itself in the
international arena."
Widespread infection and economic collapse can destabilize a
government; blame for failing to deal effectively with a pandemic can
cripple a government. This holds even more for an influenza pandemic.
In the event of a pandemic influenza, the level of panic witnessed
during the SARS crisis could spiral out of control as illnesses and
deaths continued to mount over months and months. Unfortunately, the
public is often indifferent to initial warnings about impending
infectious-disease crises -- as with HIV, for example. Indifference
becomes fear only after the catastrophe hits, when it is already too
late to implement preventive or control measures.
READY FOR THE WORST
What should the industrialized world be doing to prepare for the next
pandemic? The simple answer: far more. So far, the World Health
Organization and several countries have finalized or drafted useful
but overly general plans. The U.S. Department of Health and Human
Services has increased research on influenza-vaccine production and
availability. These efforts are commendable, but what is needed is a
detailed operational blueprint for how to get a population through one
to three years of a pandemic. Such a plan must involve all the key
components of society. In the private sector, the plan must coordinate
the responses of the medical community, medical suppliers, food
providers, and the transportation system. In the government sector,
the plan should take into account officials from public health, law
enforcement, and emergency management at the international, federal,
state, and local levels.
At the same time, it must be acknowledged that such master blueprints
may have their drawbacks, too. Berkeley's Aaron Wildavsky persuasively
argued that resilience is the real key to crisis management -- overly
rigid plans can do more harm than good. Still, planning is enormously
useful. It gives government officials, private-sector partners, and
the community the opportunity to meet, think through potential
dilemmas, purchase necessary equipment, and set up organizational
structures for a 12- to 36-month response. A blueprint forces leaders
to rehearse their response to a crisis, preparing emotionally and
intellectually so that when disaster strikes the community can face
it.
Influenza-vaccine production deserves special attention. An initiative
to provide vaccine for the entire world must be developed, with a
well-defined schedule to ensure progress. It is laudable that
countries such as the United States and Vietnam are pursuing programs
with long-term goals to develop and produce H5N1 vaccine for their
respective populations. But if the rest of the world lacks supplies,
even the vaccinated will be devastated when the global economy comes
to an abrupt halt. Pandemic-influenza preparedness is by nature an
international issue. No one can truly be isolated from a pandemic.
The pandemic-related collapse of worldwide trade and its ripple effect
throughout industrialized and developing countries would represent the
first real test of the resiliency of the modern global delivery
system. Given the extent to which modern commerce relies on the
precise and readily available international trade of goods and
services, a shutdown of the global economic system would dramatically
harm the world's ability to meet the surging demand for essential
commodities such as food and medicine during a crisis. The business
community can no longer afford to play a minor role in planning the
response to a pandemic. For the world to have critical goods and
services during a pandemic, industry heads must stockpile raw
materials for production and preplan distribution and transportation
support. Every company's senior managers need to be ready to respond
rapidly to changes in the availability, production, distribution, and
inventory management of their products. There is no model for how to
revive the current global economy were it to be devastated.
To truly be complete, all planning on international, regional,
national, and local levels must consider three different scenarios:
What if the pandemic begins tonight? What if it starts one year from
now? What if the world is so fortunate as to have an entire decade to
prepare? All are possible, but none is certain.
STARTING TONIGHT
What would happen today in the office of every nation's leader if
several cities in Vietnam suffered from major outbreaks of H5N1
infection, with a five percent mortality rate? First, there would be
an immediate effort to try to sort out disparate disease-surveillance
data from a variety of government and public health sources to
determine which countries might have pandemic-related cases. Then, the
decision would likely be made to close most international and even
some state or provincial borders -- without any predetermined criteria
for how or when those borders might be reopened. Border security would
be made a priority, especially to protect potential supplies of
pandemic-specific vaccines from nearby desperate countries. Military
leaders would have to develop strategies to defend the country and
also protect against domestic insurgency with armed forces that would
likely be compromised by the disease. Even in unaffected countries,
fear, panic, and chaos would spread as international media reported
the daily advance of the disease around the world.
In short order, the global economy would shut down. The commodities
and services countries would need to "survive" the next 12 to 36
months would have to be identified. Currently, most businesses'
continuity plans account for only a localized disruption -- a single
plant closure, for instance -- and have not planned for extensive,
long-term outages. The private and public sectors would have to
develop emergency plans to sustain critical domestic supply chains and
manufacturing and agricultural production and distribution. The labor
force would be severely affected when it was most needed. Over the
course of the year, up to 50 percent of affected populations could
become ill; as many as five percent could die. The disease would hit
senior management as hard as the rest of the work force. There would
be major shortages in all countries of a wide range of commodities,
including food, soap, paper, light bulbs, gasoline, parts for
repairing military equipment and municipal water pumps, and medicines,
including vaccines unrelated to the pandemic. Many industries not
critical to survival -- electronics, automobile, and clothing, for
example -- would suffer or even close. Activities that require close
human contact -- school, seeing movies in theaters, or eating at
restaurants -- would be avoided, maybe even banned.
Vaccine would have no impact on the course of the virus in the first
months and would likely play an extremely limited role worldwide
during the following 12 to 18 months of the pandemic. Despite major
innovations in the production of most other vaccines, international
production of influenza vaccine is based on a fragile and limited
system that utilizes technology from the 1950s. Currently, annual
production of influenza vaccine is limited to about 300 million
trivalent doses -- which protect against three different influenza
strains in one dose -- or less than one billion monovalent doses. To
counter a new strain of pandemic influenza that has never circulated
throughout the population, each person would likely need two doses for
adequate protection. With today's limited production capacity, that
means that less than 500 million people -- about 14 percent of the
world's population -- would be vaccinated within a year of the
pandemic. In addition, because the structure of the virus changes so
rapidly, vaccine development could only start once the pandemic began,
as manufacturers would have to obtain the new pandemic strain. It
would then be at least another six months before mass production of
the vaccine.
Even if the system functions to the best of its ability, influenza
vaccine is produced commercially in just nine countries: Australia,
Canada, France, Germany, Italy, Japan, the Netherlands, the United
Kingdom, and the United States. These countries contain only 12
percent of the world's population. In the event of an influenza
pandemic, they would probably nationalize their domestic production
facilities, as occurred in 1976, when the United States, anticipating
a pandemic of swine influenza (H1N1), refused to share its vaccine.
If a pandemic struck the world today, there would be another possible
weapon against influenza: antiviral medicine. When taken daily during
the time of exposure to influenza, antivirals have prevented
individuals from becoming ill. They have also reduced the severity of
illness and subsequent complications when taken within 48 hours of
onset. Although there is no data for H5N1, it is assumed antivirals
would also prevent H5N1 infection if taken before exposure. There is
no evidence, however, that current antiviral influenza drugs would
help if the patient developed the kind of cytokine storm that has
characterized recent H5N1 infections. But barring this complication,
H5N1 should be treatable with Tamiflu (oseltamivir phosphate), which
is manufactured by the Roche pharmaceuticals company in a single plant
in Switzerland.
In responding to a pandemic, Tamiflu could have a measurable impact in
the limited number of countries with sizable stockpiles, but for most
of the world it would not be available. Although the company plans on
opening another facility in the United States this year, annual
production would still cover only a small percentage of the world's
population. To date, at least 14 countries have ordered Tamiflu, but
the amount of these orders is enough to treat only 40 million people.
The orders take considerable time to be processed and delivered --
manufacturing can take up to a year -- and in an emergency the
company's ability to produce more would be limited. As with vaccines,
countries would probably nationalize their antiviral supplies during a
pandemic. Even if the medicine were available, most countries could
not afford to buy it. Critical antibiotics, for treatment of secondary
bacterial infections, would also be in short supply during a pandemic.
Even now, supplies of eight different anti-infective agents are
limited in the United States due to manufacturing problems.
Aside from medication, many countries would not have the ability to
meet the surge in the demand for health-care supplies and services
that are normally taken for granted. In the United States, for
example, there are 105,000 mechanical ventilators, 75,000 to 80,000 of
which are in use at any given time for everyday medical care. During a
routine influenza season, the number of ventilators being used shoots
up to 100,000. In an influenza pandemic, the United States may need as
many as several hundred thousand additional ventilators.
A similar situation exists in all developed countries. Virtually every
piece of medical equipment or protective gear would be in short supply
within days of the recognition of a pandemic. Throughout the crisis,
many of these necessities would simply be unavailable for most
health-care institutions. Currently, two U.S.-based companies supply
most of the respiratory protection masks for health-care workers
around the world. Neither company would be able to meet the jump in
demand, in part because the component parts for the masks come from
multiple suppliers in multiple countries. With travel and
transportation restricted, masks may not even be produced at all.
Health-care providers and managed-care organizations are also
unprepared for an outbreak of pandemic influenza today. There would be
a tremendous demand for skilled health professionals. New "hospitals"
in high school gymnasiums and community centers would have to be
staffed for one to three years. Health-care workers would probably get
sick and die at the same rate as the general public -- perhaps at an
even higher rate, particularly if they lack access to protective
equipment. If they lack such fundamental supplies, it is unclear how
many professionals would continue to place themselves in high-risk
situations by caring for the infected. Volunteers who are naturally
immune as a result of having survived influenza infection would thus
have to be found and employed. That means that the medical community's
strong resistance to using lay volunteers, which is grounded in both
liability concerns and professional hubris, would need to be
addressed.
Other unpleasant issues would also need to be tackled. Who would have
priority access to the extremely limited antiviral supplies? The
public would consider any ad hoc prioritization unfair, creating
further dissent and disruption during a pandemic. In addition, there
would not even be detailed plans for handling the massive number of
dead bodies that would soon outstrip the ability to process them.
Clearly, an influenza pandemic that struck today would demand an
unprecedented medical and nonmedical response. This requires planning
well beyond anything devised thus far by any of the world's countries
and organizations.
A YEAR FROM NOW
Even if an H5N1 pandemic is a year away, the world must plan for the
same problems with the same fervor. Major campaigns must be initiated
to prepare the nonmedical and medical sectors. Pandemic planning must
be on the agenda of every school board, manufacturing plant,
investment firm, mortuary, state legislature, and food distributor in
the United States and beyond. There is an urgent need to reassess the
vulnerability of the global economy to ensure that surges in demand
can be met. Critical heath-care and consumer products and commodities
must be stockpiled. Health professionals must learn how to better
communicate risk and must be able to both provide the facts and
acknowledge the unknowns to a frightened or panicked population.
If there is a year of lead-time before an H5N1 pandemic, vaccine could
play a more central role in the global response. Although the world
would still have a limited capacity to manufacture influenza vaccine,
techniques that could allow scientists to get multiple doses from a
current single dose may increase the supply. In addition to further
research on this issue, efforts are needed to ensure the availability
of syringes and equipment for delivering vaccine. There must also be
an international plan for how the vaccine would be allocated. It is
far better to struggle with the ethical issues involved in determining
such priorities now, in a public forum, rather than to wait until the
crisis occurs.
Prevention must also be improved. Priority should be placed on early
intervention and risk assessment. And an aggressive and comprehensive
research agenda must be launched immediately to study the ecology and
biology of the influenza virus and the epidemiologic role of various
animal and bird species.
TEN YEARS LATER
If developed countries begin to transform radically the current system
of influenza-vaccine production, an influenza pandemic ten years from
now could have a much less devastating outcome. The industrialized
world must initiate an international project to develop the ability to
produce a vaccine for the entire global population within several
months of the start of a pandemic. The initiative must be a top
priority of the group of seven industrialized nations plus Russia
(G-8), because almost nothing could inflict more death and disruption
than a pandemic influenza.
The current BioShield law and additional legislation recently
submitted to Congress will act to enhance the availability of vaccines
in the United States. This aim is laudable, but it does little to
address international needs. The ultimate goal must be to develop a
new cell-culture vaccine or comparable vaccine technology that works
on all influenza subtypes and that can be made available on short
notice to all the people of the world.
WHAT COURSE TO TAKE?
The world must form a better understanding of the potential for the
emergence of a pandemic influenza strain. A pandemic is coming. It
could be caused by H5N1 or by another novel strain. It could happen
tonight, next year, or even ten years from now.
The signs are alarming: the number of human and animal H5N1 infections
has been increasing; small clusters of cases have been documented,
suggesting that the virus may have come close to sustained
human-to-human transmission; and H5N1 continues to evolve in the
virtual genetic reassortment laboratory provided by the unprecedented
number of people, pigs, and poultry in Asia. The population explosion
in China and other Asian countries has created an incredible mixing
vessel for the virus. Consider this sobering information: the most
recent influenza pandemic, of 1968-69, emerged in China, when its
population was 790 million; today it is 1.3 billion. In 1968, the
number of pigs in China was 5.2 million; today it is 508 million. The
number of poultry in China in 1968 was 12.3 million; today it is 13
billion. Changes in other Asian countries are similar. Given these
developments, as well as the exponential growth in foreign travel over
the past 50 years, an influenza pandemic could be more devastating
than ever before.
Can disaster be avoided? The answer is a qualified yes. Although a
coming pandemic cannot be avoided, its impact can be considerably
lessened. It depends on how the leaders of the world -- from the heads
of the G-8 to local officials -- decide to respond. They must
recognize the economic, security, and health threat that the next
influenza pandemic poses and invest accordingly. Each leader must
realize that even if a country has enough vaccine to protect its
citizens, the economic impact of a worldwide pandemic will inflict
substantial pain on everyone. The resources required to prepare
adequately will be extensive. But they must be considered in light of
the cost of failing to invest: a global world economy that remains in
a shambles for several years.
This is a critical point in history. Time is running out to prepare
for the next pandemic. We must act now with decisiveness and purpose.
Someday, after the next pandemic has come and gone, a commission much
like the 9/11 Commission will be charged with determining how well
government, business, and public health leaders prepared the world for
the catastrophe when they had clear warning. What will be the verdict?
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