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EDITORIALS: Richard Coker UK preparedness for pandemic influenza BMJ 2007; 334: 965-966 [Full text]

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Planning for global resource triage in the face of a pandemic

Daniel J. Barnett, Saad B. Omer, David P. Fidler, Ran D. Balicer, James G. Hodge, Jr.   (15 May 2007)

Please operationalise the frontline response

Gail L Thomson   (16 May 2007)

Difficulties in Facing Pandemic Influenza

Robert E Kahn, John Godfrey PhD OBE   (16 May 2007)

Planning for global resource triage in the face of a pandemic 15 May 2007
Daniel J. Barnett, Johns Hopkins Bloomberg School of Public Health,Baltimore, Maryland, USA, 21205 Johns Hopkins Bloomberg School of Public Health,Baltimore, Maryland, USA, 21208, Saad B. Omer, David P. Fidler, Ran D. Balicer, James G. Hodge, Jr. Send response to journal: Re: Planning for global resource triage in the face of a pandemic	In his recent BMJ editorial describing readiness challenges in the UK for pandemic influenza, Coker suggests that planning for scarce resource triage in the face of a pandemic requires greater clarity and is “not simply an abstract moral dilemma”.1 We agree and further argue that this real dilemma remains unsolved at the highest levels of international planning. The European Centre for Disease Prevention and Control recently reported that Europe remains two to three years away from a state of preparedness for an influenza pandemic.2 Such projections from the developed world are concerning in the shadow of an influenza pandemic characterized by the World Health Organization (WHO) as “inevitable and possibly imminent,”3 and amid recent models4 of the disproportionate impact of the next pandemic on the developing world. Previous modeling has shown that a massive and focused use of antivirals and vaccines in places where flu may originate – likely developing countries – is vital to mitigating a pandemic.5 This strategy presupposes that available limited resources (e.g., medicines, supplies, public health interventions and personnel) will be fairly distributed in developing countries. This presumption is presently unrealistic. The potentially rapid dissemination of a pandemic strain and its projected impact on developing countries narrow the margin for error in allocating limited resources. Maximizing the utility of these resources is critical. In recognition, developing nations have begun to evince distrust of the developed world’s commitment to pandemic vaccine research.6 “Global solidarity”7 on pandemic influenza planning is essential at a time of unprecedented need. The current milieu substantiates setting international public health priorities through governance strategies on the allocation of scarce resources between donating and recipient countries during any global public health emergency. Global Resource Triage To the extent that developed countries struggle to stockpile sufficient levels of antivirals for their own populations, their use in other countries will be closely scrutinized. Governments that donate antivirals will, in all likelihood, condition when and how developing countries can use donated drugs. Donating countries’ main objective in donating resources is to slow disease dissemination outside the initially affected country or region. However, how recipient countries prefer to use these allocated resources may differ from donating countries’ strategies. Recipient countries may strive to minimize morbidity and mortality in all or specific population groups, as well as to maintain public order. A recent analysis of pandemic preparedness plans worldwide frequently noted three goals of pharmaceutical interventions: reduction of morbidity and mortality (21 plans), continued maintenance of essential services (13 plans), and minimization of social and economic impacts (13 plans).8 The overarching goal for the early pandemic phases in WHO’s global influenza preparedness plan is to coordinate maximum international efforts to delay or possibly avert a pandemic. Within this context, WHO seeks to identify needs and encourage international assistance to resource-poor countries. Yet, its plan contains no specific guidance on allocating the scarce resources needed to achieve WHO’s strategic objective. It merely encourages countries to reduce disease burden in the initial outbreak locations, which will contain or delay the spread of infection. We face the problem of scarce resource triage in a context in which donating countries retain effective control over limited resources, recipient countries retain sovereignty over capabilities, and WHO (or another international intermediary) is responsible for setting global allocation priorities. From Conundrum to Consultation However difficult, the global public health community must delineate epidemiological, legal, and ethical principles supporting a multilateral framework through which States, international institutions, and non-governmental organizations can allocate and administer scarce resources during global public health emergencies. A starting point could be a WHO expert consultation that analyzes substantive and procedural aspects of this problem and develops the framework for effectuating global resource triage in global public health emergencies. This framework is accentuated in light of WHO’s and Indonesia’s work to craft “Material Transfer Agreements” for pandemic influenza vaccine. WHO leadership is needed to foster a constructive dialogue among states, international institutions, and non-state actors to find common ground that tempers ideology and politics with epidemiology and ethics. In addition to convening health experts and policy makers, the consultative process and subsequent dialogue should involve partners from other parts of national governments such as the finance ministry and the military. Decisions should be based on or informed by the best available science. Tensions between national sovereignty, security, and cross-border trade interests of participating countries must be addressed to maximize global efforts to decrease the impact of public health emergencies, such as pandemic influenza. Public health experts and politicians are cognizant that the microbial world will force our political institutions to face a global reckoning when the next virulent pathogenic strain threatens the security and prosperity of the world’s populations. Before the reckoning comes the responsibility to prepare, even when the preparations expose disconcerting truths about sovereignty, inequality, and poor public health capacity. References 1. Coker R. UK preparedness for pandemic influenza. BMJ 2007;334:965-966. 2. Watson R. Europe needs two or three years to prepare for pandemic flu. BMJ 2007;334:442. 3. WHO, Communicable Disease Surveillance and Response. Avian influenza – fact sheet. http://www.who.int/csr/don/2004_01_15/en/ (accessed February 27, 2007). 4. Murray CJ, Lopez AD, Chin B, Feehan D, Hill KH. Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis. Lancet 2006; 368:2211-8. 5. Ferguson NM, Cummings DA, Cauchemez S et al. Strategies for containing an emerging influenza pandemic in Southeast Asia. Nature 2005; 437: 209-14. 6. Aglionby J, Jack A. Indonesia withholds vital bird flu data. Financial Times, February 6, 2007. http://www.ft.com/cms/s/bd900a94-b55d-11db-a5a5-0000779e2340.html (accessed February 27, 2007) 7. Ferguson N. Poverty, death, and a future influenza pandemic. Lancet 2006; 368: 2187-2188. 8. Uscher-Pines L, Omer SB, Barnett DJ, Burke TA, Balicer RD. Priority setting for pandemic influenza: an analysis of national preparedness plans. PLoS Med 2006; 3: 1721-1727.   Competing interests: None declared
Please operationalise the frontline response 16 May 2007
Gail L Thomson, SPR North Manchester General Hospital M8 5RB Send response to journal: Re: Please operationalise the frontline response	For at least 2 years I have listened to frontline clinicians (including myself) say that they are not being given enough guidance on how to implement the DH pandemic flu guidance and the DH seem to expect the frontline to know what to do and how to do it. We seem to have got too used to being provided with a plan and thinking if we have a plan then surely all will be well. The raw truth is the opposite; the plan is only the beginning, but it is a beginning. As with any outbreak preparedness and response communication and coordination is crucial. There needs to be more dialogue between the frontline and the DH, a working together to operationalise the guidance. This could be an opportunity to build on for future outbreaks or major incidents where a multidisciplinary, emergency response is required. In my response to the DH pandemic flu draft, 2007 I echo Richard Coker's point regarding the need for a system to be in place to allow the frontline to discuss operational issues. For example the WHO SARS clinical network helped to bridge this gap. Something similar could be set up in the UK with a secure web site, and regular regional and national meetings of a clinical network. All efforts should be made to look at how we can strengthen our preparedness resulting in a foundation built on a generic platform but flexible enough to responsd to specific events. Regarding Richard Coker's comment on the likelihood of there being central control and command during a pandemic, the efficiency of this will depend on well practiced lines of communication, which allow for two way lines of communication. Roles will need to be clear e.g. nominated clinicians able to communicate numbers and problems. We should not only expect to communicate problems but also to consider communicating how problems were solved locally, as this information may help others. One thing not addressed is the fears of the healthcare workers. Some have said they may not come to work. The kneejerk reaction is to be cross with them but the wise reaction is to acknowledge these fears and try to put measures in place to deal with them now. Having been involved with responses to outbreaks (VHFs, SARS & AI) over the past 5 years I do appreciate the concerns of the HCWs and they cannot be ignored. Many lessons were learned from SARS by other countries, let us make sure that we learn too. Reference: Health Care workers – a resource worth protecting, BJIC editorial June, 2006, Thomson G Competing interests: None declared
Difficulties in Facing Pandemic Influenza 16 May 2007
Robert E Kahn, Co-ordinator, Avian Flu Action Avian Flu Action, 40 St Stephen Road, Warrington WA5 2BJ, John Godfrey PhD OBE Send response to journal: Re: Difficulties in Facing Pandemic Influenza	The new draft plan published jointly by the Department of Health and the Cabinet Office does indeed strive to set out a framework for tackling pandemic flu at the local level. However, Richard Coker (12 May editorial) is right to point out that if a pandemic does reach the United Kingdom, both international and national leadership is going to be far more significant than local initiatives. Unfortunately, even at the national level, government initiatives in the United Kingdom and elsewhere can do but little to control how serious the impact of a pandemic will be, because governments cannot influence whether an influenza virus will mutate, nor the pathogenicity of any newly formed strain of the virus. The Government advises: “Those who believe they are ill will be asked to stay home in voluntary isolation. Voluntary home isolation may be recommended for close contacts at early stages to contain/slow the spread” (Section 3.2, p. 35). Yet at the same time, in order to ensure rapid access to antiviral medicines, it is proposed that: “In England, plans should assume that a friend or relative will be available to collect the patient’s antiviral treatment course from the designated distribution point on production of proof of identity and authorisation from the coordination centre” (Section 9.9, p. 90). Both proposals are sensible, but they are in direct conflict: the friends and relatives who go out to collect the antiviral medicines will be the same people who should remain in voluntary isolation because of their close contact with those with possible influenza. There are no easy solutions: voluntary isolation is appropriate, yet so is collecting medicine, as well as other activities in support of those who are ill. It is indeed sensible to plan now, rather than panic later. However, the unfortunate reality is that if an influenza pandemic does occur its impact is going to depend largely on questions of virus evolution, rather than local planning. We do not agree that 750,000 excess deaths is the worst case scenario. If it were, the death rate would have to be much lower in a pandemic than in the 172 deaths with the 291 cases so far. Perhaps the individuals who have caught the H5N1 virus so far were those most susceptible to infection and also most likely to die from it. Perhaps the virus will evolve lower lethality, as it would tend to do by natural selection. But it is not safe to assume either possibility. Robert Kahn, PhD Co-ordinator, Avian Flu Action 40 St Stephen Road Warrington WA5 2BJ www.avianfluaction.org John Godfrey, PhD OBE Chairman, European Research into Consumer Affairs 41 Lawford Road, London NW5 2LG Competing interests: None declared