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Preparing for a Local Crisis within a Global Pandemic Symposium Introduction
by Robert D. McEvoy
Symposium Moderator
A June 4, 2006 New York Times article by Donald G. McNeil Jr. attempted to identify the limited amount of information that forms the basis for the World Health Organization Pandemic Alert System Warning Level, which is now “No or very limited human-human transmission” The European Centre for Disease Prevention and Control’s new Risk Assessment, published on June 1st, has, however, alerted European Union members as follows: “The present increased human exposure means European Union members must intensify their preparedness for a pandemic.” McNeil, in his New York Times article, also quoted ECDC’s Dr. Angus Nicoll who said: “We are probably also underestimating the extent of person to person transmission.” My research assistant recently reported on the question of where we are in the science of identifying a pandemic. What caught my attention was the startling quotation in his work as follows: ”On December 9, 2005 Guan Yi, a virologist from the University of Hong Kong, and one of the world’s leading experts on bird flu, disclosed that China has the H5N1 virus all over the country.” He indicated that Dr. Yi said: “Quite honestly, some provinces have the virus and they still haven’t announced any outbreak. I can show direct evidence even though China is still trying to block my research. The government doesn’t do any surveillance studies, but they say there is no outbreak.” On June 13, 2006, Bloomberg reported the following: “Indonesia has among the highest highly pathogenic avian influenza risks and lowest capacity to respond, the World Bank said in a report released in the capital, Jakarta, yesterday. The H5N1 virus is now considered endemic in poultry in most provinces in the country, but surveillance coverage is limited and generally unreliable to detect outbreaks.” Should we be concerned with the questionable reporting which results in the WHO warning level, which drives our response? On a recent Oprah Winfrey television program, infectious disease expert, Dr Michael Osterhholm said: “This is not a probability issue. It’s going to happen. What we don’t know is what strain it’s going to be or when it’s going to happen. It could be tonight. It could be 10 years from now, the bottom line is we have a lot to do to get better prepared.” Is there a credibility issue which is delaying preparedness actions? HHS Secretary Michael Leavitt, who has been in H5N1infected countries, is seriously warning the U.S. He recently said: “This pandemic will happen with certainty.” Preparing for a Local Crisis within a Global Pandemic The President introduced the National Strategy for Pandemic Influenza with his letter in which he closed as follows: “Together we will confront this emergency threat and together, as Americans, we will be prepared to protect our families, our communities, this great nation and the World.” The WHO, in their publication, Responding to the Avian Influenza Threat- Recommended Strategic Actions, said “In view of the immediacy of the threat, WHO recommends that all countries take urgent action to prepare for a pandemic.” The New England Journal of Medicine, a distinguished medical publication as you know, led its March 2006 issue front page editorial with: “Vaccine Against Avian Influenza – Race Against Time.” Secretary Leavitt was very specific in his May 25th testimony before the US Senate Committee on Aging. He said: “In the event of a pandemic, infection control practice and social distancing measures (such as school closures, cancellation of public gatherings, etc), and antiviral drugs will be the first line of defense before a vaccine is available and could limit and delay the spread of the pandemic. Currently the Strategic National Stockpile (SNS) has over 5 million treatment courses of antiviral drugs on hand. On March 22nd I announced the purchase of additional antiviral drugs that could be used in the event of a potential influenza pandemic. With these purchases, the SNS will have 26 million treatment courses of antiviral drugs that will be available to the states when an influenza pandemic is imminent. Our strategy is to procure an additional 24 million courses of antiviral drugs through FY 07 and FY 08 funds and to offer a 25 percent federal subsidy for state purchases of another 31 million treatment courses. This additional money will be needed to meet our goal to have enough antivirals for 25% of the population during a pandemic. Congressional support of $2.3 billion for the second year of the President’s Pandemic Influenza plan will be critical to meet this goal.” This means to anyone who is following the worldwide state of readiness that Secretary Leavitt is striving to build our antiviral defenses and is hoping that Congress will appropriate $2.3 billion in 2007 funds to bring the stockpile to a much higher level. Today’s 5 million treatment course level , would cover only 2% of our population at a time when the annual flu season is approaching, which is when a mutation of the bird flu virus with the seasonal influenza virus is more likely and a pandemic could initiate here. On March 16th, Faces in the News reported that Roche, manufacturer of Tamiflu, had manufacturing capacity “well in excess of all its government purchases” On March 17, I emailed the Congress as follows: “This morning’s Medical News Today article identifies that the UK, France, Finland, Iceland, Ireland, Luxembourg, Netherlands, New Zealand, Norway and Switzerland have ordered enough Tamiflu to cover 20 to 40% of their populations. (WHO recommendation) . . .” On June 16, Forbes reported under AFX News Limited, that “ Shanghai Pharmaceutical received approval from the State Food and Drug Administration to Preparing for a Local Crisis within a Global Pandemic produce Tamiflu and expects to start selling it by the end of this month. Yin Qinxie, a spokesman with the Shanghai firm was quoted as saying. Yin added that the domestically made Tamiflu will be about half the price of the drug made by the patent holder, Swiss pharmaceutical group Roche. Roche had earlier authorized Shanghai Pharmaceutical to produce the bird flu drug.” Knowing that emergency personnel will be concerned about bringing H5N1 home to their families, Canada’s large hospitals, in the interest of keeping their medical systems operating, took a major step and ordered 55,000 prophylaxis courses ( 8 weeks) for their teaching hospitals. I calculated the cost of the one Tamiflu pill they will take every day to prevent the disease to be less than $3 (Canadian) Here are some excerpts from Helen Branswell’s excellent May 31st article provided by the Canadian Press and published by CHealth. “It was sufficiently clear to us that this was the best thing to do for our hospitals and for the patients we need to be taking care of that what other people were going to think about it (the decision) or external implications it was going to have just wasn’t relevant, said Dr. Allison McGeer, head of infection control at Toronto’s Mount Sinai Hospital. This is not a decision that was taken on an emotional basis…this was a decision that was taken on cold, hard facts”. She went on to say, ”The decision involves buying enough drug to protect 55,000 employees for 56 days – the rough estimate of what it might take for the first wave of a pandemic to move through the community. (The belief is that Canada’s pandemic vaccine manufacturer, GlaxoSmithKline, will have vaccine ready in time to protect against a second wave of illness).” With a Tamiflu shelf life of 3 years, it won’t be wasted because of its use with seasonal influenza, and the apparent demand driven availability, do you see the issue as I do? We have an HHS Secretary who says it is a first line of defense. We can have emergency personnel coming to work (the Canadian prophylaxis initiative) and have treatment courses for patients, a normal medical procedure. Isn’t this a straightforward way to increase survival during the period before a vaccine is produced? How to make it happen -- consider Congress moving the 2007-2008 proposed appropriation to now (and adding an emergency personnel prophylactic amount) and ordering it the next day so that we have it before a human-to-human mutation in Indonesia or other country, and before the U.S. seasonal influenza period. And a final issue for your consideration: as you know, when a spreading infectious disease occurs, our hospital surge capacity will be critical to our ability to treat the larger amounts of the seriously ill. The testimony of the American Hospital Association, also before the U.S. Senate Committee on Aging, brings us up to date on this aspect of our state of readiness. Nancy Donegan, Director of Infection Control at the very large Washington Hospital Center was the spokesperson for the American Hospital Association. She is highly qualified having also served on the District of Columbia’s Preparing for a Local Crisis within a Global Pandemic Bioterrorism Committee, which she indicated is currently writing the District’s Pandemic Preparation Plan, Her “conclusion” regarding the current state of hospital readiness is as follows: “The recent experiences of the last several years and the information about pandemic influenza now available leads us to recognize our severe limitations in being able to assure our patients, personnel, and communities that we can provide the services needed at the time of pandemic. We recognize that with our own resources, we will not be able to provide enough trained personnel, enough personal protective equipment, enough therapy, or enough ventilators particularly in a pandemic involving prolonged periods of intense demand for services.” The Institute of Medicine’s June 14th report reinforces the AHA conclusion. The report, Hospital-Based Emergency Care: At the Breaking Point summarizes the existing hospital crisis as follows: “Despite the lifesaving feats performed everyday by emergency departments and ambulance services, the nation’s emergency medical system as a whole is overburdened, underfunded, and highly fragmented, says this series of reports from the Institute of Medicine.As a result, ambulances are turned away from emergency departments once every minute on average and patients in many areas may wait hours or even days for a hospital bed. Moreover, the system is ill-prepared to handle surges from disasters such as hurricanes, terrorist attacks, or disease outbreaks.” My wide-ranging comments are meant to set the stage for the papers that follow in this Symposium, but are also intended to spur you to further action than you’ve already taken to prepare for an influenza pandemic. We will start with the excellent research papers and recommendations of Dr. Kirsty Duncan, scientist and author of “Hunting the 1918 Flu: One Scientist’s Search for a Killer Virus.” Dr. Duncan organized and led an expedition to Norway to collect tissue samples from victims who had died in the 1918 flu pandemic and who were buried in the permafrost. In addition to Dr. Duncan providing a scientific and historical foundation for our symposium, I am honored to recognize her courage and dedication which are an
inspiration to all who are racing against the clock to prepare the world for potentially the
worst disaster in modern times.
About the Symposium

Preparing for a Local Crisis within a Global Pandemic is presented as a public service of the
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Imp. 69-73

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