Health Community Focused on Influenza Threat, Government Response Lacking
Recent studies questioning vaccine and anti-viral effectiveness combined with the ongoing Avian influenza threat raises alarm in public health community.

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By Michael Long

Already on high alert over the last few years with fears of a potential influenza pandemic, the public health community received another jolt last week from the respected medical journal The Lancet, which published analyses showing that the influenza vaccine is much less effective than commonly thought and that recent influenza strains have become resistant to the most widely available antiviral medications.

The studies come at a time when public health officials are issuing dire warnings about the potential for an influenza pandemic, which could occur if the current strains of avian influenza (H5N1) were to mutate enough to allow human-to-human transmission. The world community is at a critical juncture where increasing the resources expended to prevent an outbreak from happening in the first place as well as building a better infrastructure to respond to potential outbreaks could save hundreds of millions of lives. Right now, it does not appear that the response has matched the threat.

Current Anti-Flu Tools Ineffective?

The Lancet study on vaccine effectiveness, conducted by an Italian research group known as the Cochrane Vaccine Field, analyzed data from a large number of past studies of the vaccine. They found that in the elderly population (65 and older) living in the general community, the vaccine did not reduce the number of confirmed cases of the flu or flu-like illness, but did reduce hospitalization from flu or pneumonia by 26% and death from all causes by 42%.

While these reductions are far from insignificant, lead researcher Tom Jefferson, MD, highlighted the fact that we cannot rely on the vaccine to do all of the prevention work in high-risk communities. In a statement, he commented, “We need a more comprehensive and perhaps more effective strategy in controlling acute respiratory infections, relying on several preventive interventions that take into account the multi-agent nature of infectious respiratory disease and its context (such as personal hygiene, provision of electricity and adequate food, water and sanitation).”

In a separate study also published in The Lancet last week, researchers from the Center for Disease Control and Prevention (CDC) announced that currently circulating strains of influenza are increasingly resistant to adamantane, one of the most commonly available anti-viral drugs used in the treatment of influenza.

Dr. Rick A. Bright and colleagues at the CDC analyzed data collected by the World Health Organization over the last ten years. At the start of the period (2003-2004), only 0.4 percent of influenza samples displayed resistance to common anti-virals. By the end of the period, that number had jumped to 12.3 percent.

New Anti-Virals in Short Supply

The rapid emergence of drug-resistant strains of influenza is of particular concern to the global health system because many poor countries, where an influenza epidemic is likely to hit first and hardest due to sanitation, agricultural practices and other factors, have relied on these cheaper antiviral medications to stem the transmission of the disease. Richer countries are currently stockpiling supplies of the newer, more effective (and more expensive) Tamiflu.

In a positive move,possibly made to forestall other countries from invalidating its patents, Tamiflu manufuacturer Rochee announced earlier this year that they were donating 3 million doses of the drug to the World Health Organization for a rapid response stockpile that could be used to save lives and reduce transmission if an outbreak of the avian influenza does occur. Roche is rapidly ramping up production facilities to supply demand from wealthy countries who are stockpiling enough anti-viral medication to cover 20-40 percent of their populations.

The U.S. currently only has 2.5 million doses of the drug and will have to wait at least a year if not more to fulfill its goal of stockpiling 20 million doses.

Creating a Vaccine Against Avian Influenza

In the face of the decreasing effectiveness of widely available anti-virals and newly raised doubts about the effectiveness of the influenza vaccine, drugmakers and governments are hurriedly developing a vaccination plan to deal with avian influenza. Two weeks ago, the US Department of Health and Human Services (HHS) announced that they had given a $100 million contract to the drug company sanofi-aventis to manufacture a version of the avian influenza vaccine for 20 million Americans. The vaccine showed effectiveness in a very small trial announced earlier in the year.

In a statement announcing the contract as well as another contract with GlaxoSmithKline to purchase an anti-viral called Relenza, HHS Secretary Mike Leavitt commented, “These countermeasures provide us with tools that we have never had prior to previous influenza pandemics. Never before have we possessed the wealth of knowledge on the problem and the ability to prepare for it. These new contracts are part of our aggressive, multi-pronged approach to planning for pandemic influenza.”

World Governments Failing to Stop Avian Flu at the Source

The global community needs to immediately address the shortfall in funding for preventive agricultural actions in poorer countries. This week, the United Nations’ Food and Agriculture Organization (FAO) announced that it had only received $20 million of the $100 million in donations needed to implement poultry vaccination and surveillance programs in countries such as Vietnam and Indonesia. The funding shortfall comes at the same time that Indonesia has reported additional human deaths from Avian Influenza, bringing the region’s death toll over 60 this year.

In a statement calling on the world’s government to increase their focus on the source of a potential avian influenza pandemic, the FAO’s Chief Veterinary Officer Joseph Domenech commented, “"It makes sense to stockpile antiviral drugs to protect humans against a potential avian influenza pandemic, but at the same time we have to contain the virus at source, in animals, to reduce the risk to people.”

US Government Capable of Response to Pandemic?

As we watch the bird flu story unfold at the same time that we see the failure of the U.S. government at all levels to respond adequately to the natural disaster of Katrina, a reasonable person should be thinking about whether there are individual steps that should be taken against a potential influenza pandemic.

Recall when Americans began gathering individual stockpiles of the antibiotic Cipro following bioterror scares. We watched last year as people lied about their medical condition or used connections with doctors to get an influenza vaccine when the supply was limited.

Will individuals start gathering expensive anti-viral medications even when they are not sick? I don’t know what would happen if you went to your doctor right now and asked for Tamiflu, but I would not be surprised if people are already doing this. What are the ethical implications if wealthy Americans start stockpiling these drugs and the poor, who already live and work in less sanitary conditions, are left without?

Hopefully, the threat of a pandemic will force the national and global governments to create a viable public health response that will obviate the need to answer these questions.

We aren’t seeing that response yet.

In a disturbing report recently aired by ABC News' ‘Primetime,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy, commented on the potential impact of an avian influenza pandemic, "If you look at the expected number of deaths that could occur in cities across the United States, we are wholly unprepared to process those bodies in a dignified and respectful way. We will run out of caskets literally within days."

If the CDC officials are willing to use this kind of language on national television, someone needs to stand up and demand that additional resources are marshaled to prevent the devastating scenario that many informed members of the health community fear could happen.

While we worry about the potential impact of a mutated avian influenza pandemic, we still have to think about reducing the annual toll that influenza takes on our most vulnerable citizens.

Public health officials are calling on at-risk groups to get vaccinated. Everyone else should be washing their hands often and staying home when sick.

Getting a Flu Shot This Year

Due to ongoing supply challenges to the regular influenza vaccine supply, the CDC is recommending that only “high priority” groups be given the vaccine before October 24, 2005, after which time everyone can be vaccinated.

Although recent studies have questioned the efficacy of getting vaccinated, they still found that the vaccine can reduce your risk of death by almost half if you are above 65. So if you are in a high-risk group, you should talk to your doctor about getting vaccinated this fall.

High Priority groups include:

-people aged 65 years and older, with and without chronic health conditions
-residents of long-term care facilities
-people aged 2–64 years with chronic health conditions
-children aged 6–23 months
-pregnant women
-health-care personnel who provide direct patient care
-household contacts and out-of-home caregivers of children less than 6 months of age


What else can you do:

-If you are sick, stay away from other people. If your child is sick, don’t send them to school. If you are sick, don’t go to work.
-Keep your distance from people who are visibly sick
-Cover your moth when you cough and wash your hands frequently
-Maintain your overall health


Resources:

Centers for Disease Control and Prevention. Influenza Information Page

Food and Agriculture Organization of the United Nations. “Global Strategy to bird flu in animals faces serious funding gap.” (9/26/05)