Avian influenza – some good news?

June 2006

For a change, there appears to be at least a modicum of good news on the avian influenza scene.

The outbreaks in avian species in countries where outbreaks have been rampant appear to have subsided somewhat, and are considerably less prominent than three to six months ago. This is most likely due to seasonal factors, suggesting that avian influenza is subject to the same kind of environmental influences as “seasonal” influenza. This notion will be supported if avian influenza outbreaks resume in full force next fall or winter.

A second piece of apparently good news is the fact that the spring migration of birds from Africa to Europe failed to yield the expected numbers of H5N1-infected birds. Because of the dramatic spread of H5N1 virus westward across Asia and into Europe and Africa last fall, it had been widely expected that migratory birds over-wintering in Africa would become infected, and bring large amounts of H5N1 virus into Europe this spring. This has evidently not happened, at least on the scale predicted, so that a number of European countries have now relaxed their regulations on breeding, controlling and exporting poultry.

A third piece of good news is that H5N1 virus has still not been detected in North America; no one knows, of course, how long that salubrious state of affairs will persist. I certainly don’t wish to give the impression that it would be disastrous if the virus did appear here, I fully expect that it will.

The Implementation Plan

Meanwhile, in May the Homeland Security Council, through the White House, released the National Strategy for Pandemic Influenza Implementation Plan, which provided many of the specific tasks and details of the federal plan that were not spelled out in their initial plan released last November.

According to a release from the Center for Biosecurity of the University of Pittsburgh Medical Center, the positive aspects of the new federal plan include the detailed assessment of the consequences of a 1918-style influenza pandemic, the specific tasks and metrics that will guide government action, the specific actions and decisions that will be made at each stage of a pandemic, and specific contingency planning suggestions for businesses.

The perceived shortcomings of the plan were spelled out as well and include, among others, the lack of an aggressive plan for pandemic vaccine development, insufficient funding for many aspects of the plan, more guidance and funding for hospitals, some implausible or even adverse containment strategies, and a clearly articulated plan for preventing and containing avian influenza spread in poultry.

Problems with the plan

There are two problems with the federal plan that merit further discussion. First, hospitals seem to have fared especially poorly in federal thinking, as outlined in the Implementation Plan. Perhaps this should not be surprising, since so few people in the federal government seem to have a deep understanding of hospitals and the problems that they face. Nonetheless, it is a huge oversight considering the central role that health care institutions will be expected to play in the event of a pandemic. Given the marginally sufficient staffing levels, the noteworthy lack of surge capacity, “just-in-time” supply chains, and minimally sufficient ICU-support capability, U.S. hospitals are ill-equipped today to see the country through even a mild pandemic, let alone one of 1918-level severity.

The message to hospitals, to quote again from the Clinicians Biosecurity Network of the University of Pittsburgh Medical Center, is: “you are on your own!” Federal funding for hospital preparedness is not likely to appear anytime soon, if ever, and hospitals will therefore need to make their own preparedness plans and investments. State and local health departments will need to ensure that hospital preparedness plans are in place or at least underway on an individual hospital, community-wide, and regional basis.

Hospital solvency, or rather the lack thereof, will be a real issue in the event of a pandemic; certainly most not-for-profit hospitals are barely breaking even or are losing money; even for-profit chains have little money to invest in pandemic preparedness. In the event of a pandemic, many if not all elective procedures may need to be curtailed, thus cutting off a dependable supply of income, and replacing it with mostly Medicare/Medicaid reimbursement that will not even come close to covering hospital costs. Absent federal help, many hospitals will simply not survive.

A second problem with the federal plan that others and I have addressed before is the lack of truly global thinking, as exemplified in the pandemic vaccine preparation and stockpiling plans. The federal goal seems to be to vaccinate first 20 million, then 60 million, and then every citizen of the United States. (Nothing is being said about immigrants, legal or illegal!) After that goal is met, thinking seems to end abruptly. Only now is planning getting around to employing adjuvants in immunogenicity trials of H5N1 vaccines, and that only after unrealistically high levels of H5 hemagglutinin were required to produce what was believed to be a protective level of HI antibody.

Vaccine needs

A goal more truly befitting the richest country on earth, should be to not only protect our own population, but also to have large quantities of vaccine to export to other countries that have no vaccine production capability. This would need to be done in concert with other North American, European and world influenza vaccine manufacturers with the goal of supplying as much pandemic vaccine as can be delivered to people to prevent a pandemic that could so easily be a global catastrophe.

This point of view has been articulated both in this column, in peer-reviewed journals, and within the federal research establishment by David Fedson, MD, and others, but so far any sense of urgency in the pandemic vaccine plan still seems to be lacking.

On the scientific front, there have been some recent developments that may help in better understanding the transmission patterns and pathogenesis of avian influenza. Space does not permit further discussion of these findings in this column. I will address these in a subsequent issue.