Avian Influenza: Time for government and business to integrate plans
Dr J Pfinsgraff and S Russ of iJET Intelligent Risk Systems conclude few governments have avian flu pandemic response plans integrated with the business community. A new wave of poultry outbreaks are likely during the first half of 2007 in Asia, Eastern Europe and Russia but current vaccine production is inadequate to protect more than a few of the world's population
Pandemic Preparedness Efforts: Since its first appearance in humans in 1997, H5N1 avian influenza has marched relentlessly across the globe, causing an unprecedented number of outbreaks among birds and hundreds of human deaths. Many countries have successfully eliminated the virus after responding vigorously to infections among poultry, but others struggle to contain outbreaks. Experts point out that a failure by even one country could create a domino effect, quickly reversing any gains achieved over the past year.
Geographic Spread and Human Infections: The first six months of 2006 saw an extraordinary spread of H5N1. Between January and April, H5N1 appeared in 30 new countries in Africa, Asia, Europe and the Middle East. While health authorities struggled to contain outbreaks among birds in newly infected areas, previously infected countries, such as Russia and Indonesia, battled new waves of outbreaks. By August, most of the more than 50 countries affected by bird flu had controlled H5N1, but Thailand, Egypt and Laos were reporting new outbreaks.
At present, areas at greatest risk for the emergence of an H5N1-pandemic strain include Africa (Burkina Faso, Cameroon, Cote d'Ivoire, Niger, Nigeria and Sudan), China, Egypt, Indonesia and the Indochinese peninsula.
The unprecedented geographic spread of H5N1 during the early months of 2006 precipitated an early surge in new human infections. Despite this sharp increase, however, during the last quarter of 2006 officials reported fewer than half the number of cases reported during that same period in 2005.
Vaccine and Antivirals: Public health experts believe immunization against pandemic influenza would offer the best protection against the impact of a pandemic, but current vaccine production capabilities are inadequate to protect more than a small portion of the world population.
Substantial long-term investment in vaccine research and production capacity will be necessary to create a pandemic vaccine in time and in sufficient quantities to significantly decrease the impact of a moderate to severe influenza pandemic.
Scientists believe that two currently available drugs - Tamiflu (oseltamivir) and Relenza (zanamivir) - would be useful in treating and preventing pandemic influenza, but prospective studies are lacking. Moreover, manufacturing capacity for these drugs falls far short of world needs, and the price of Tamiflu is too high for many countries to afford. Similar problems exist for Relenza.
And public health officials have yet to develop plans for efficient distribution of pharmaceuticals - a necessity for this type of drug in which effectiveness requires administration shortly after the onset of symptoms.
To combat the likely shortage of vaccine and antivirals early in a pandemic, public health authorities are exploring the value of non-pharmaceutical methods to diminish the impact of a pandemic, for example, closing schools and canceling public gatherings. Several studies are now underway to determine if non-pharmaceutical interventions could indeed delay or reduce the effect of a pandemic.
Medical Surge Capacity:The medical infrastructures and capacities of all countries would likely be stressed in the event of a moderate or severe pandemic. Even developed countries would face scarcities of medical supplies, personnel and facilities.
To prepare, during 2006 countries began stockpiling medical supplies, devising strategies to co-opt personnel from paramedical fields and developing plans for alternative healthcare sites. Nevertheless, a pandemic has the potential to overwhelm the medical capacity of any community and prevent the provision of medical care that would be expected under ordinary circumstances.
Public health authorities stress that investment in medical infrastructures must be a long-term project that goes beyond concerns about avian influenza. It must allow for an all-hazards response that could apply to a variety of emerging diseases and natural disasters. The investment must also be sustainable. Investment in medical surge capacity is arguably the most important investment a nation or community can make to prepare for a pandemic.
Communication and Pandemic Fatigue: In early 2006, when avian influenza was spreading rapidly across Asia and into Europe and Africa, the media reported daily on the risks of another pandemic. As outbreaks waned, however, the interest in avian influenza declined, and public health officials warn of "pandemic fatigue." They stress that capacity and infrastructure building must be a long-term project, and although a pandemic might not be imminent, it is inevitable.
Although a reduction in outbreaks among poultry might be a sign of progress in controlling H5N1, it does not indicate the elimination of risk. In fact, poultry vaccination may have paradoxically complicated detection of H5N1 and hidden the risk of pandemic influenza.
In the face of a decline in media interest, communication efforts by other sectors must continue to advocate for all-hazards preparedness. An effective response to pandemic influenza will require that businesses and governments have well-developed and rehearsed continuity plans. Public anxiety or misunderstanding will only serve to hinder the effectiveness of the response.
Pandemic Planning: Although nearly all governments have developed pandemic plans, few have begun the process of integrating government response plans with business pandemic planning. That process is complicated by the fact that many businesses have failed to plan. Moreover, failure on the part of one industry sector could create a domino effect, causing additional businesses to fail. Ultimately, pandemic planning must be coordinated at all levels of government, between governments and businesses, among businesses, and across operations within businesses.
Recent U.K. Outbreak: The early February outbreak of H5N1 among poultry in the U.K. came unexpectedly, and scientists have determined that the H5N1 virus was mostly likely introduced to Britain via poultry from Hungary. Researchers found that the virus in Britain is nearly identical to the virus that infected geese in Hungary during January.
Although officials have not determined exactly how trade brought the virus to Britain, there are several possibilities. Turkey producer Bernard Matthews, which also has operations in Hungary, owns the poultry farm that was the site of the outbreak in Suffolk, as well as an adjacent poultry processing plant. The virus might have traveled to the processing plant in partially processed meat from Hungary or on the tires of trucks carrying the products. From the processing plant, human shoes, farm equipment, wild birds or even rodents could have carried the virus to the farm. Officials are also investigating whether improper disposal of waste from the processing plant could have allowed wild animals to come into contact with contaminated products.
The U.K. outbreak demonstrates several points. First, although leaders' first reaction is to blame migratory birds for H5N1 poultry outbreaks, human activities are much more likely to be responsible Secondly, the virus spreads with ease in both developed and developing countries. Strict biosecurity measures are necessary to prevent transmission of avian influenza, and seemingly minor breeches in compliance can spread the virus widely.
Conclusions: Over the past two years, human activities and bird migrations have worked synergistically to allow H5N1 to expand its geographic footprint far beyond Asia. Now widespread poultry outbreaks occur in a seasonal pattern similar to that of human seasonal influenza. Predictions of future outbreaks are imprecise at best, but a new wave of poultry outbreaks are likely during the first half of 2007 in Asia, Eastern Europe and Russia. Undetected outbreaks remain a significant risk in developing regions, including Africa and the Middle East. Expect sporadic human cases to parallel outbreaks in birds. In all areas, improved surveillance - in the wild, on farms and at the borders - offers the best hope for containment of H5N1.
Joan Pfinsgraff, MD, Director of Health Intelligence for iJET Intelligent Risk Systems and Shanna Russ, Editor for iJET Intelligent Risk Systems.
