UK preparedness for pandemic influenza
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39205.591389.80 (Published 10 May 2007) Cite this as: BMJ 2007;334:965
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests