The current pandemic of H1N1 influenza highlights vulnerabilities in the world’s plans for dealing with widespread health emergencies, but also offers opportunities to better prepare for more deadly epidemics that will surely arise in the future, experts said at a recent symposium held in New York City.
The 16 October meeting, sponsored by the Council on Foreign Relations and the journal Science, brought together experts on science, economics, public health and foreign relations to assess the impact of the flu pandemic and future implications.
Good vaccines have been developed against the 2009 H1N1 flu, but there are problems making enough of them and getting them distributed prior to expected peaks in the flu season in many countries. And while citizens in developed countries benefit from increased vaccine availability and advanced health care systems, said the symposium speakers, developing nations remain largely unprotected and vulnerable to the full impact of a pandemic.
Laurie Garrett, the Council’s senior fellow for global health, said the world is still learning about the novel H1N1 flu, often referred to as swine flu, since its appearance earlier this year. “There’s a great deal of uncertainty about this flu pandemic,” she said. “One thing is certain: It is a worldwide event and it is occurring in the dawn of our age of globalization.”
Jon Cohen, a correspondent with Science, said there has been some confusion about this flu outbreak because the World Health Organization’s declaration of an H1N1 pandemic was based on the virus’ infectivity and spread but not its lethality.
“‘Pandemic’ doesn’t really reflect severity,” Cohen said, noting that while novel H1N1 can be deadly, it isn’t nearly as severe as H5N1 avian flu which kills 50 to 60% of the people it infects. Although the novel H1N1 has led to many hospitalizations and killed thousands, it has not, as was feared would happed with a bird flu pandemic, inundated emergency rooms or caused millons of deaths. As a result, a growing number of people are questioning whether to get vaccinated, he added.
Peter Palese of Mount Sinai School of Medicine in New York, an expert on flu viruses, said this pandemic flu virus has many of the characteristics of regular seasonal flu, which may explain why the older population is more immune to it. But people forget that seasonal flu is a severe disease that causes 30,000 deaths and 200,000 hospitalizations each year in the United States alone.
Arnold Monto, an epidemiologist at the University of Michigan, said flu pandemics in 1957 and 1968 also had characteristics associated with seasonal flu, such as being more lethal to those with existing health risks, the elderly and the very young. The new flu behaves somewhat differently, he said, by being extremely infectious but possessing high rates of mortality mainly in a small percentage of children, 20- to 50-year-olds, and pregnant women. The true mortality rate of the virus could be partly masked by modern emergency medicine, including intensive care units with ventilators and artificial lung machines designed for infants and children.
The most effective way to stop a flu epidemic, or at least blunt its effects, is through vaccination, specialists said.
“It’s very clear that vaccination is the best defense we have against pandemic influenza,” said Lone Simonsen of George Washington University’s Department of Global Health. “In fact, when you have a pandemic unfolding and really high transmission rates, it becomes very hard to mitigate with any other strategy than that.”
Vaccines against the pandemic H1N1 flu are safe and effective, although it has proven more difficult than anticipated to produce them quickly in the quantities desired, the experts said.
“The vaccine against the 2009 [flu] is very, very good because it’s very close to the actual strain which is circulating,” said Palese. “With influenza, one always has the problem that the vaccine may not be against that particular strain which is circulating but something which was circulating last year or two years ago. So that’s not the case with the 2009.”
Even if vaccine supplies do not match demand until after flu peaks in many areas, it will not be too late to get immunized, according to the symposium speakers. The United States is now experiencing the second wave of an outbreak that began last spring, and there is the possibility of a third wave coming early next year. Experience with past pandemics shows that sometimes successive waves can prove more dangerous and lethal than earlier ones, they said.
Pandemics can have enormous economic impact in addition to health consequences, both locally and globally, according to another group of experts.
Depending on the severity of the disease and the sustainability of its economic effects, such as worker absenteeism and disruptions in the production and shipping of goods, a pandemic can take a heavy toll on the economy at the global, regional and national levels, said Andrew Yanzhong Huang, director of Global Health Studies at Seton Hall University.
Huang said that according to a recent study, if 25% of the U.S. population gets sick for a sustained period, it would severely hamper the country’s fuel and food supply, and the national economy.
Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, said the world’s economy has changed significantly since the last pandemic and must be taken into account in planning responses to epidemics. The global economy is now so interlinked, he said, that exaggerated responses to a health crisis, such as closing borders, quarantines, and trade and travel restrictions can trigger widespread economic disruptions.
“We in the health-care area already are very concerned because the vast majority of critical pharmaceutical products—and devices that we use in the intensive care wards, the products that we use in infection control, like masks, respirators, gowns and gloves—are largely made outside the United States,” said Osterholm, who addressed the meeting by telephone.
Hospitals and health departments have virtually no stockpiles of supplies and even common drugs, such as insulin and sedatives, which are largely made in—or have basic ingredients supplied by—countries such as China and India.
“When we have a whole worldwide pandemic and everybody’s drawing down those same resources at the same time, it’s kind of a perfect storm,” said Osterholm. “What will the global supply chain mean when the developing world can’t respond as, say, a country like ours can?”
These supply issues are not just international. In the U.S., coal supplies half the electricity used and it has been a just-in-time delivery product for power plants that only keep a few days supply on hand, Osterholm said. “Yet, we had no plan, internally, for how to prioritize if those 5000 miners in the Wyoming-Montana area, that supply half the coal in the United States, were to get infected. They were not even on anyone’s vaccine priority list.”
Global interdependency also affects vaccine production and vaccine sharing between the developed and the developing world. Currently, wealthier countries pay for and get the vast majority of the world supply of vaccines, with production capability concentrated in the developed world, the experts said.
There are strategic economic and political reasons for the developed world to share the vaccines and antiviral drugs with the developing world, said Huang, but little agreement on a practical way to do so.
Former U.S. Ambassador John Lange, who helped negotiate national and international strategies for dealing with pandemic flu during the George W. Bush administration, said he believed developed countries had a moral obligation, as well as practical reasons, for helping poorer people of the world have access to vaccines. As a start, he said, the United States has brokered an agreement that now includes 11 countries that have agreed to donate 10% of their vaccine supply to the World Health Organization for distribution in developing countries.
Several speakers at the event questioned why it had taken the U.S. so long to commit to the donation. “If this were H5N1 or even something not as bad as H5N1, would your government have felt that it could say, let's broker a deal and give away 10 percent of our vaccine in wartime?” asked Helen Branswell, a medical reporter for The Canadian Press who has been covering the international vaccine negotiations. “I'm not certain how hard—or how easy it will be to deliver on that in a time when things are more difficult.”
Even with that infusion of vaccine, the WHO effort would only supply enough to inoculate 2% of that population, focusing on health workers and other essential personnel, said Lange, a senior program officer at the Global Health Program of the Bill and Melinda Gates Foundation. Another way to increase access would move more vaccine production to the developing world and increase the consumption there of seasonal flu vaccines. With facilities in place, Lange said, production could be ramped up in the event of a pandemic so that more vaccines could be available locally.