Preparedness is now "damage control"?

Indonesia, an impoverished country with a rudimentary public health system (2002 allocation 0.72% of gross domestic product) has bird flu in poultry and now likely in humans (via Dow Jones Newswires, no link). After pigs were discovered infected with H5N1 on Java island, blood samples from 63 local poultry workers found at least one with evidence of prior infection (antibodies to the virus in his blood). Confirmation of the result is underway, but it is likely there has been much unrecognized infection here and elsewhere.

That is also the message at WHO's annual governance gathering, the World Health Assembly now meeting in Geneva.

Officials in Thailand believe they will not be able to a detect a pandemic virus until it has reached its fourth line of victims, Kumnuan Ungchusak, head of the epidemiology at the Thai health ministry, told the meeting.

"If we detect it at that point, it would be easy to control, but it if we miss it it could be bad," he said. (Dow Jones Newswire)

WHO is now openly admitting that everyone is unprepared.

Health chiefs today warned of major doubts about their ability to detect and tackle a more virulent and deadly strain of the influenza virus before it spreads globally causing millions of deaths.

The warnings came at a meeting to discuss preparations for a looming pandemic, organised on the sidelines of the World Health Organisation's annual assembly in Geneva.

"We are working on pandemic preparedness on borrowed time," the WHO's top influenza official, Klaus Stohr, told the meeting, reiterating that conservative estimates indicated that up to 7.4 million people might die.

"The objective of pandemic preparedness can only be damage control. There will be death and destruction."

"National pandemic response plans are the key," he said.

National pandemic response plan? What's that? In the US we have a Draft Pandemic Influenza Preparedness and Response Plan from last August. It is very general and state health departments have said not very helpful. Moreover CDC has done little to ramp up public concern about the matter, something that is a prerequisite to kick-starting state and local health authorities besieged by urgent competing demands for shrinking funds. Clearly scaring the public is not much of a concern for an Administration that regularly scares them as a matter of policy.

What about a stock of antivirals, the only therapeutic option at the moment? The Wall Street Journal reports the obvious:

Amid growing fears that an outbreak of avian flu could spark the next flu pandemic, wealth has become more of a factor than need in determining who will get an essential drug.

Richer countries facing little immediate avian-flu danger have moved in recent months to stockpile large amounts of the drug, called Tamiflu. The poorer Asian nations at the epicenter of the threat -- the key staging area for fighting the current outbreak and possibly forestalling the pandemic -- have only small-scale donations of the drug at present and scant resources for ordering large amounts.

WHO recommends enough antiviral (Tamiflu) for one quarter of the population. But the drug is expensive ($39 to treat flu if recognized within 48 hours, the only time the drug is effective for treatment) or about $160 for a 6 week course of prophylaxis. Vietnam, the country with the highest case count and millions of infected birds, has 84 million people but only 2000 treatments. Cambodia's population of 14 million has only 300 courses of treatment, mostly donated.

Roche, the only manufacturer of Tamiflu, has an unknown inventory of the drug and most of that has been ordered by developed countries. The drug has a long production cycle -- 12 months -- and thus the newly increased demand can't be met instantly. However Roche, who reportedly doubled its production this year even without advance orders, has also devised a bulk method to facilitate stockpiling:

Roche has already taken unusual steps to try and increase the drug's availability. For instance, it adopted what it calls a "bucket chemistry approach," offering Tamiflu's active ingredient, a white powder known as oseltamavir, in 15-pound barrels and at half the price of the capsule form. The powder can be dissolved in water and consumed. Tests have shown that this form confers the same protection as the capsule and can be stored longer. A small portion of the bucket form has been ordered.

Sweden has ordered enough for half a million and tens of millions more doses have been ordered by Norway, Canada, Australia, New Zealand, Finland and France. The US has only ordered 2.3 million and may increase that to 6 million (enough for only 2% of our population). The UK is more ambitious with plans a $385 million for a quarter of its population. London wants 100,000 for its police fire and transport workers. WHO is trying to establish a "mobile stockpile" of 120,000.

Some public health authorities believe that a pandemic can be substantially slowed (but probably not stopped) by rushing Tamiflu to an initial outbreak and saturating the surrounding area. Whether this would work or not is unknown and some doubt it (see for example Henry Niman at Recombinomics). Even if effective, since the initial frontlines are likely to be in country's with few resources, the Tamiflu would have to be donated by the developed world:

Ensuring that Tamiflu gets to the front lines of an outbreak is so crucial to containing it that some public-health officials recommend that richer nations donate part of whatever stocks of Tamiflu they accumulate to the countries most affected by avian flu.

"Now that we can do something about it, we shouldn't be sitting on our haunches," said John Oxford, a British virologist whose research showed that Tamiflu was effective against the avian-flu strain. He suggests that wealthier countries set aside 10% or so of their Tamiflu stocks for use in Asian countries.

I think this is unlikely. Countries like the US are going to be scrambling desperately with their own "damage control" necessitated by a lack of due diligence. This was all foreseeable. Why we are in this fix now--and as far as I can see still not getting it in gear--is an example of dereliction of duty, incompetence and hardly what we would expect from a President that conned half the country into thinking he was "keeping them safe." In fact he has put them in mortal danger.