Friday, January 25, 2013

The Coming Influenza Pandemic Part V

In Parts I-IV I discussed the biology, morphology, etiology, genetics and ecology of influenza, the various influenza pandemics that have occurred over the past century and the current socioeconomic factors that increase the likelihood and potential severity of another deadly flu pandemic. In Part V, I further examine these socioeconomic factors and propose some solutions.

Over the past several decades there has been a dramatic decline in public health funding and infrastructure which could exacerbate any pandemic. Vaccine technology has changed little since the 1950s, and is still done in eggs, a slow process that is prone to contamination.3(139) Even with modern technology, however, we have lost much ground in the last 30 years. In 1976, there were thirty-seven flu vaccine manufacturers in the U.S. Today there are less than four.3(p140)  Worldwide, there are only 12 flu vaccine manufacturers and 95% of the stock goes to the wealthiest countries, even though the majority of victims will likely be in the developing world.3(p159)

The war on terror has taken funding that could be used for critical pandemic research and redirected it toward research on rare or non-existent diseases such as smallpox. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, said that a flu pandemic was greater threat than a bioterrorist attack.3(p171) 758 researchers, including 2 Nobel laureates, signed a petition claiming that the war on terror, and it’s obsession with exotic pathogens had caused a 27% decline in federal grants for research on immediate threats such as tuberculosis, malaria and influenza, that kill millions of people each year.3(p170)

As a result of HMO streamlining, many hospitals have been closing. Those remaining open have reduced the number of unused beds to as close to 0 as possible, thus leaving no space for new patients in a disaster, terrorist attack or pandemic (but maximizing profits). Between 1990 and 1997, for example, Los Angeles lost 17% of their available hospital beds due to streamlining, while a 2003 survey of hospitals found that 90% of U.S. emergency rooms were “seriously understaffed and overcrowded.”3(p132) Additionally, millions of American remain uninsured or lack paid sick leave, which results in sick people continuing to work where they infect their coworkers.

Lastly, there is a growing anti-vaccination hysteria that threatens us all by discouraging people from getting vaccinated. Yet flu vaccines typically produce strong immune responses in 70-90% of those who have been vaccinated.11 However, there are several caveats to this. Flu vaccines take up to two weeks to stimulate complete immunity.11 For some patients, particularly young children, up to two doses may be required.11 In the time it takes to develop immunity, a person can be infected and become sick. This might lead one to believe that the vaccine made them sick. In reality, influenza made them sick before the vaccine was able to protect them. Therefore, getting vaccinated early, before the height of flu season, is critical to self-protection. Also, if a high enough percentage of the population is vaccinated, there will be very little, if any, of the pathogen circulating in the population, thus further reducing the chances of infection. This is called herd immunity and occurs when 70% of population is immunized.13(p792) 

One reason people fear vaccines is that there have been several notable correlations documented between vaccines and alarming side-effects. However, correlation does not equate to cause, and in virtually every case, the correlations were coincidental; not causative.

In 1976, several people developed Guillain-Barre syndrome (GBS) after getting vaccinated for swine flu. Many people assumed that the vaccine was responsible. Guillain-Barre is a neurological autoimmune disease that sometimes follows infection with Campylobacter jejuni and influenza.11 It is also very rare, occurring in approximately 1 out of every 100,000 people. The number of people who contracted GBS during the 1970s swine flu vaccination program was not significantly higher than normal. The CDC believes that there may have been 1 additional GBS case per 100,000 during the 1976 vaccination program, yet no scientific evidence has confirmed this.11 The most likely explanation is that the few cases of GBS that did occur, would have occurred anyway.

Even when vaccines are available and desired, poor Americans have less access. Only 39% of African American seniors get vaccinated annually, while 71% of white seniors get vaccinated. This is one reason why seasonal flu is still so deadly in the U.S.3,(p35-6)
From Wikipedia

What Can Be Done?
While another deadly pandemic is likely, there is much we can do now that was not possible in 1918. Vaccine, antiviral and antibacterial technology is far more advanced than it was then. With sufficient funding, we should be able to develop vaccines against Highly Pathogenic Avian Influenza (HPAI) strains like H5N1 and make them available to people throughout the world. We also need to provide more funding for antibiotic development to fight the various bacteria that cause deadly secondary infections associated with influenza and governments should stockpile Tamiflu and provide it to people early, when it is effective at stopping influenza.

Governments also need to invest in the rebuilding of public health infrastructures, including an increase in available beds and emergency room capacity. However, they also need to do a better job of educating the public on the benefits and safety of vaccines. Lastly, the rich countries need to provide support for better veterinary surveillance in the developing world and all governments need to be completely open and honest about HPAI outbreaks in their backyards.
Image from Wikipedia
 Tamiflu is only known drug that can fight H5N1 influenza. Rapid stockpiling of Tamiflu (enough for 25% of the population of each country) is essential for averting catastrophic losses of human life. 3(p145) Japan has purchased enough Tamiflu for 20% of their population, while Australia only has enough for 5% of their population, and the U.S. only has enough for only 1% of their population.3(p144) Poor countries have asked permission to produce their own generic versions of Tamiflu, but the U.S. and France vetoed the proposal because it would eat into Roche’s profits.3 

Rebuilding public health infrastructures necessarily involves providing affordable and accessible health care to all and the ability to stay home when ill. Short of this lofty goal, hospitals could be required to maintain sufficient unused beds for disasters or pandemics. Effective public health media campaigns, along the lines of anti-smoking advertisements, could be used to educate the public specifically about the safety and benefits of vaccinations  and how to protect oneself against influenza (e.g., frequent hand washing, staying home when sick, coughing into elbow). Much more funding needs to go into influenza research, as well as the development of new antibacterial drugs.
Asian Bird Cull (from Wikipedia)
 While the U.S. monitors its own flocks for HPAI, many developing countries do not.  Most sub-Saharan countries have closed their flu monitoring systems due to lack of financial resources (only South Africa and Senegal still monitor).3(p24)  Monitoring must be dramatically improved in areas with histories of HPAI outbreaks, such as Vietnam, Thailand and China. When there is any indication of an HPAI outbreak, the WHO must be notified immediately. Samples must be provided to experts for identification and, if it is a HPAI strain, the birds should be culled immediately to prevent the spread.

In the developing world, poverty, corruption and poor infrastructure all hamper such efforts. Developing countries also have valid reasons for not cooperating with the international community, even when they have detected an outbreak. For example, they are less able to deal with the financial and nutritional losses caused by a large chicken cull than developing countries. There are also cultural challenges, such as the value of chickens as pets, future dowries, hedges against famine, or, in the case of prize fighting cocks, as ongoing sources of income.

Lastly, the wealthy nations need to move away from the lifeboat ethic that currently dominates their public health planning and recognize that the front line of any deadly influenza pandemic will be the poorest and most socially isolated communities in the world. It will be impossible to contain influenza in these communities and it will spread throughout the world. Providing free or low-cost vaccines and Tamiflu to developing countries will help protect us all.

  1. AVERT, 2009, AVERTing AIDS website, October 28, 2009:
  2. Bartlett, Donald L.,  and James B. Steele, 2004, “The Health of Nations,” New York Times, Oct 24,
  3. Davis, Mike, 2005, The Monster at Our Door, The New Press, New York
  4. Enserink, Martin, 2004, Science, 306, Dec ember 17, 2004
  5. Kash, John C., Tumpey, Terrence M., Proll, Sean C., Carter, Victoria, Perwitasari, Olivia, Thomas, Matthew J., Basler, Christopher F., Palese, Peter, Taubenberger, Jeffery K., García-Sastre, Adolfo, Swayne, David E., and Katze, Michael G., 2006, “Genomic analysis of increased host immune and cell death responses induced by 1918 influenza virus,” Nature. October 5; 2006, 443(7111): 578–581.
  6. Soares, Christine, 2009, “Pandemic Payoff,” Scientific American, November, 2009, p19-20
  7. Various Authors, 2009, “Influenza:,” from Wikipedia, accessed November 7, 2009,
  8. Various Authors, 2009, “Cytokine Storm,” from Wikipedia, accessed November 7, 2009:
  9. Various Authors, 2009, “Black Death,” from Wikipedia, accessed November 8, 2009:
  10. Various Authors, 2009, “1918 flu pandemic,” from Wikipedia, accessed November 8, 2009:
  11. Various Authors, 2009, “Seasonal Influenza: the Disease,” Centers For Disease Control and Prevention website, accessed November 14, 2009:
  12. Wallace, Amy, 2009, “An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All,” Wired, October 19, 2009:
  13. Willey, Joanne M., Sherwood, Linda M., and Woolverton, Christopher J.,  2009, Prescott’s Principles of Microbiology, New York, NY, McGraw Hill
  14. Various Authors, 2009, “Pearl River Delta” from Wikipedia, accessed November 14, 2009:
  15. Various Authors, 2009, “Cortisol,” from Wikipedia,  accessed November 16, 2009:
  16. California Newsreel, 2008, “Unnatural Causes,”  video.  Transcript accessed November 16, 2009:
  17. President’s Council of Advisors on Science and Technology, 2009, “Report to the President on U.S. Preparations for 2009-H1N1 Influenza,” August 7, 2009:

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