Wednesday, March 23, 2005

Preparing for a pandemic: GMAFB

In a companion post (here) we drew up a quick "To Do" list for preparing for a pandemic on a local level (the only level that counts for preparation). It is interesting to compare this to the "immediate action" items proposed by the Infectious Diseases Society of America (IDSA) this week, as reported in Medical News Today:
Immediate action is needed to prepare the United States for a deadly pandemic of influenza, the Infectious Diseases Society of America (IDSA) is telling policymakers.

In meetings with congressional and administration leaders, IDSA has explained that the H5N1 “bird flu” spreading in Asia has the potential to develop into a pandemic like the one that claimed more than half a million American lives in 1918. Even if this strain does not emerge as a pandemic, infectious disease experts agree that another flu pandemic is just around the corner. The U.S. Centers for Disease Control and Prevention (CDC) predicts even a “mild” pandemic could kill at least 100,000 people if the nation is not prepared.

“This year's serious problems with flu vaccine supply showed us just how unprepared we are,” says Andrew T. Pavia, chair of IDSA's Pandemic Influenza Task Force. “If this had been a pandemic year, we would have been in serious trouble. Now is the time to fix these problems and develop the ability to respond, before the pandemic strikes.”
Good start. Let's look at IDSA's "seven steps to prepare for a flu pandemic" (my comments indented and small text):

1. Secure vaccine and antiviral supplies. Enough vaccine and antivirals need to be in place before a pandemic strikes, as well as a plan to distribute them. IDSA is calling for a stockpile of antiviral drugs that is adequate to treat at least 50 percent of the U.S. population.
This seems infeasible if you don't have a vaccine and won't have one until you know the nature of the pandemic strain. Nor is there the vaccine capacity in the US for this. The same goes for antivirals. This recommendation calls for 150 million courses. It is estimated that there are only 6 million courses in the US currently and we are competing with the rest of the world for the very limited production capacity of a single company (Roche in Switzerland). Unless there is an immediate move to make production license free and allow any company in the world to produce it, the cost is prohibitive at Roche's prices (~$75/10 day course of treatment or $300 for 6 week prophylaxis). Worse, if the US were to buy up the supply at that price there would be nothing left for the rest of the world. There is also no infrastructure for delivering them in the "pay for play" US health care system.
2. Strengthen liability protections during emergency outbreak response. In case of a declared influenza emergency, it will be vital to immunize and treat large numbers of people. Even rare adverse reactions associated with a therapy would become more common when millions are treated. Health care workers and medical facilities administering emergency therapeutics, as well as the companies that make them, should be protected from lawsuits stemming from these adverse events so long as they follow standard medical and manufacturing procedures. A fund should be established to cover the medical costs and lost earnings of anyone who develops complications due to vaccination or treatment.
Why do we always socialize the losses and keep the profits private? Let's socialize both the losses and the profits. I'm sick of hearing about "liability" barriers. How about "affordability barriers" for a change?
3. Require health care workers to be vaccinated. Unfortunately, health care workers caring for sick people often spread patients' infections. To prevent unnecessary deaths and disease, an annual flu vaccination should be mandatory for all health care workers who have contact with patients.
Vaccinated with what? There is no H5N1 vaccine at the moment. The question of priority for antivirals is important and is raised in my post.
4. Strengthen education. Health care workers and the public need to better understand the seriousness and potential impact of an influenza pandemic, as well as how to prevent and treat it.
You might start by educating our public health non-leaders. Education is always good. Yawn.
5. Create financial incentives. Most pharmaceutical companies have left the vaccine business because demand is extremely unpredictable. Even this season, after starting out with a shortage, millions of doses of flu vaccine will likely be thrown away. To secure vaccine supplies for the future, the government needs to guarantee it will buy a set amount of vaccine each season, and buy back a percentage of unsold vaccine at the end of the season.

Also, the United States does not have the manufacturing capacity to produce enough vaccine and antivirals to meet its needs in a pandemic. Tax credits should be offered to encourage companies to build new manufacturing facilities in this country so that the United States is not dependent on foreign suppliers. Tax incentives and patent extensions should be available for companies that research and develop new anti-flu therapies.
See number 2, above. If the pharmaceutical companies don't find this profitable, that's their choice. Let's produce this with public monies and public production facilities.
6. Strengthen federal agencies' responses. The Food and Drug Administration should “fast-track” vaccine and antiviral review, and streamline regulation of the manufacturing process. Congress should increase CDC's budget for global surveillance to detect influenza strains with pandemic potential. The U.S. Department of Agriculture should develop a plan for culling poultry or other livestock and compensating farmers in the event of a pandemic, if necessary.
How about strengthening the backbone of our public agencies?
7. Improve coordination, communication, and planning. The Department of Health and Human Services should develop a detailed plan to coordinate pandemic response at all levels, from local to national to international, including links between federal authorities and clinicians throughout the country.
Yawn. There have been many draft plans, needs assessments, efforts to improve communication, etc., etc. The sound of spinning wheels is deafening.
"IDSA is working with congressional leaders to integrate these recommendations into bio-preparedness legislation now being considered on Capitol Hill. The Society is working to achieve bipartisan support for this effort."

My (unprofessionally phrased) response? Give me a Fucking Break! (GMAFB)