A Journey Through The World of Pandemic Influenza

Viral Sovereignty

 

This morning we have an excellent offering from The Washington Post:

'Sovereignty' That Risks Global Health

By Richard Holbrooke and Laurie Garrett
Sunday, August 10, 2008; B07

Here's a concept you've probably never heard of: "viral sovereignty." This extremely dangerous idea comes to us courtesy of Indonesia's minister of health, Siti Fadilah Supari, who asserts that deadly viruses are the sovereign property of individual nations -- even though they cross borders and could pose a pandemic threat to all the peoples of the world. So far "viral sovereignty" has been noted almost exclusively by health experts. Political leaders around the world should take note -- and take very strong action.

The vast majority of repeated avian flu outbreaks the past four years, in both humans and poultry, have occurred in Indonesia. At least 53 types of H5N1 bird flu viruses have appeared in chickens and people there, the World Health Organization has reported.

Yet, since 2005, Indonesia has shared with the WHO samples from only two of the more than 135 people known to have been infected with H5N1 (110 of whom have died). Worse, Indonesia is no longer providing the WHO with timely notification of bird flu outbreaks or human cases. Since 2007, its government has openly defied International Health Regulations and a host of other WHO agreements to which Indonesia is a signatory.

[…]

A year ago, Supari's assertions about "viral sovereignty" seemed to be odd yet individual views. Disturbingly, however, the notion has morphed into a global movement, fueled by self-destructive, anti-Western sentiments. In May, Indian Health Minister A. Ramadoss endorsed the concept in a dispute with Bangladesh. The Non-Aligned Movement -- a 112-nation organization that is a survivor of the Cold War era -- has agreed to consider formally endorsing the concept of "viral sovereignty" at its November meeting.

 

I, along with my fellow PanFlu bloggers [see sidebar] have repeatedly commented on this issue, and I welcomed this piece by two rather "Big Hitters", Mr. Holbrooke and Ms. Garrett. My first post on "viral sovereignty", Viral Cold War, expresses my own, still operative, opinions on the issue.

 

Also from the WP article…

In this age of globalization, failure to make viral samples open-source risks allowing the emergence of a new strain of influenza that could go unnoticed until it is capable of exacting the sort of toll taken by the 1918 pandemic that killed tens of millions of people. As the world learned with the emergence of severe acute respiratory syndrome (SARS) -- which first appeared in China in 2002 but was not reported by Chinese officials until it spread to four other nations -- globally shared health risk demands absolute global transparency.

There is strong evidence from a variety of sources that forms of the bird flu virus circulating in Indonesia are more virulent than those elsewhere and in a few cases may have spread directly from one person to another. The WHO has tried for two years to accommodate Indonesia, without success. Under pressure from scientists worldwide, Indonesia agreed in June to share genetic data on some of its viral samples but not the actual microbes. Without access to the viruses, it is impossible to verify the accuracy of such genetic information or to make vaccines against the deadly microbes.

Outrageously, Supari has charged that the WHO would give any viruses -- not just H5N1 -- to drug companies, which in turn would make products designed to sicken poor people, in order "to prolong their profitable business by selling new vaccines" (a charge oddly reminiscent of the plot of John le Carré's novel "The Constant Gardener"). The WHO has elicited pledges from the world's major drug companies not to exploit international repositories of genetic data for commercial benefit, but this has not satisfied Indonesia.

[…]

The failure to share potentially pandemic viral strains with world health agencies is morally reprehensible. Allowing Indonesia and other countries to turn this issue into another rich-poor, Islamic-Western dispute would be tragic -- and could lead to a devastating health crisis anywhere, at any time.

 

Many of the consequences of the Cold War were morally reprehensible. That is not a "catch phrase" but the simple truth of the past follies of our governments.

 

Have we learned nothing?

 

Apparently not.

 

SZ

Australian GP’s and a severe pandemic

 

Today a story is circulating around the cyber flu community about another sector that will likely suffer a dangerous level of "job abandonment".

 

From News.com.au [excerpted]:

GPs refuse to treat bird flu patients

By Tory Shephard August 05, 2008 12:01am

BIRD flu will hit Australia but some GPs will refuse to treat patients - preferring to keep themselves and their families safe, research shows.

Others say they are unprepared to deal with the "horror" situation and hope it never happens, although experts say it is a matter of "when", not "if" disaster strikes.

Research in the latest Medical Journal of Australia shows only one of the 10 South Australian GPs surveyed felt prepared for a pandemic.

The report's authors said the doctors "felt their responsibility to themselves to stay healthy and to protect their families outweighed their responsibility to continue working".

Australian Medical Association state president Dr Peter Ford said most doctors had received no formal training in dealing with a flu pandemic.

 

I have touched on this issue several times (as have others around Flublogia).

Pandemic Dominoes: HCW's stand at the Apex

For the Greater Good

For the Greater Good II

 

I have also previously quoted this from the AMA:

AMA policy document "Physician Obligation in Disaster Preparedness and Response" adopted in June 2004:

National, regional, and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future. (AMA 2004)

 

The above bolded sentence cannot be any plainer.

 

The article Australian article further states:

The report's authors said the doctors "felt their responsibility to themselves to stay healthy and to protect their families outweighed their responsibility to continue working".

 

Everyone who provides a critical service to, and interacts with, the wider community, doctors, nurses, firefighters, EMT's, police, to name the most obvious, will have to make the choice about whether or not to work should we suffer a severe pandemic. Those that make the choice to work will no doubt make that choice each day the danger exists.

 

It will be a tough decision for most, but certainly not all.

 

It is important to realize that doctors and nurses did not "sign on" to risk their lives wantonly when they chose their professions. I would hazard the bet that most chose their professions out of a deep respect for health and life, even their own, most especially their own, if they are worth their parchment.

 

To expect someone, anyone, to step into harm's way we assume an obligation to make them as safe as we can while they do so. We do this with our first responders via training, equipment, and their fellows who valiantly stand at their sides (or backs) while danger presents.

 

During a severe pandemic (should we have one) who will equip our medical workers to stand in the face of infection? Who will "stand beside them"?

 

Until we can answer those questions, and provide the means and materials to those answers, we have no right to expect anyone to aid strangers at the risk of their own lives. Keep that in mind as you read the following, also from the Australian article:

 

Australian Medical Association state president Dr Peter Ford said most doctors had received no formal training in dealing with a flu pandemic.

[…]

Vaccine expert Professor Nikolai Petrovsky, Flinders Medical Centre's director of endocrinology, is working on vaccines to protect against bird flu. A lack of funding and of political will means the whole health system is unprepared for a pandemic that is already "overdue", he said.

"The reality is that we will be hit by an influenza pandemic at some point. But we don't know if it will be this year or in 50 years' time so governments are loathe to spend the money and the effort when they don't know," he said.

 

Those last two paragraphs could be applied to any number of countries, not just Australia. And, equally as damning, to most states, counties, municipalities, and districts (or a country's equivalents).

 

I wish I had an easy answer to offer up, unfortunately, I don't. There are no easy answers, and there certainly aren't many inexpensive ones either. We must have the wisdom and foresight to prepare those we will hope to see in our moments of greatest need by providing them the means to be there safely.

 

Even if it costs money.

*********

 

I've said it once or twice before, and I always suffer an internal cringe when I do:

 

As the mother of a police officer I have moments of very selfish "not my son" when I think about the possibility of his being hurt in the line of duty and not receiving medical care. When I am being brutally honest with myself – and with you – I admit that his life is far more valuable to me than yours.

 

My son "signed on" accepting the "normal" risks his profession carries, something his father and I are both appreciative of since we both wore the uniform ourselves. We, as his parents, understand that what can be done to guard and protect him is being done, or will be done, should the worst happen, and yes, we understand – and accept – that a positive outcome is not always guaranteed. However, things change when not everything that "could be done", is not.

******

 

Before we blissfully assume others have a self-sacrificing "obligation" to risk themselves we need to ask what we are "obligated" to do in return. If you're honest with yourself, as honest as I have been with you, you will know that we, the collective "we", have done pathetically little, nor have "we", the electorate, demanded anything from those in positions to effect what needs done.

 

"We" just blissfully assume all will be well and fine because someone else has an "obligation".

 

Please think about what I've said here.

 

Please consider adding your "voice" to the chorus against dangerous assumptions; ask that we adequately protect those we want to be there during our times of need.

 

Please.

 

SZ

 

Introducing my new Pandemic H5N1 blog

Today I introduce my new blogging home A Pandemic Chronicle .

For the month of August I plan to post my blogging efforts here at Journey as well as at my new site A Pandemic Chronicle, but after this month I will only be posting at APC and Journey will go dormant, though still accessible. I have imported all of Journey's posts into my new blog but I did not want to invalidate all of the old links and refs to Journey so I will maintain it as a historic repository.

I did not decide to make this move without consideration for the issues of discontinuity but what I – and my readers – will gain by moving to a WordPress platform should help offset the "costs" associated with such a move.

Although I have yet to figure out how to get a "Contact Me" function up and running I'm working on it (in my spare time of course).  In the meantime, if anyone has any feedback or suggestions (like how to do a Contact Me form) I can be reached at the following email address: sophiazoe AT me DOT com [replace AT with @, and DOT with . ]  It's easy to remember, even for me.

So, check it out already!  [ remember to update your bookmarks]  I hope you like what you find as far as presentation and functionality goes. 

SZ

Influenza, bacterial pneumonia, and our elders

 

Tonight I am going to post as a follow-on to one of FM's posts today [here].  Although he did an excellent job of bringing the issue before us, I have a bit more to say on the subject. Vaccines and vaccination are an integral part of pandemic considerations and plans so they are subjects that are somewhat “near and dear” to my heart. But first a bit of a digression.

 

 

I believe in vaccines in general, believing they are of immeasurable benefit to a population as a whole, and to the individuals who receive them. 

Are they effective for 100% of those who receive one? No. The immune response a vaccine produces can, and does, vary by individual, and cohort generalities exist. The article that inspired this post is about the weak immune response in frail elderly folk who receive a vaccination against influenza. The very young (who generally have not had influenza) also produce a weaker immune response, that is why their shot is delivered in two doses separated by a month. The first shot “primes” the immune system, the second produces antibodies at a presumptive level of protection.

Are they 100% safe and free of side effects for 100% of those who receive one? No. Nothing in this world is safe for every single person drawing breath. The level of risk – on average – for each individual receiving a vaccine is directly correlated with the length of time the vaccine has been given and the number of people who have received it. The ancillary: The longer a vaccine has been available and the greater number of people having received it might well find those 1-in-100 million who will have a meaningful adverse reaction.

Do they prevent the scourges of past generations? Yes. Have they enhanced quality of life and extended life expectancy? Yes – on both counts. Proof of these statements are the fact that I grew up without having to face the threat of polio or smallpox, and my son never had mumps or chickenpox.

 

 

Please feel free to skip the references, I've only included them in the interest of thoroughness.

 

On to today's news item…

Flu Vaccine Doesn't Protect Seniors From Pneumonia
Older, frail folks are more susceptible to flu and its complications, researchers say.

By Steven Reinberg
HealthDay Reporter

THURSDAY, July 31 (HealthDay News) -- Flu vaccine may not protect older people from pneumonia once they get the disease, researchers report.

Older, frail adults are more susceptible to getting the flu, even if they have been vaccinated, and once getting the flu, they are more susceptible to such complications as pneumonia. It had been thought that flu vaccine would prevent flu -- and pneumonia -- across all groups of seniors, but this benefit appears to be largely confined to younger, healthier seniors.

"In seniors, flu vaccine was not linked to a reduced risk of pneumonia," said lead researcher Michael L. Jackson, a postdoctoral fellow at the Group Health Center for Health Studies in Seattle.

Continues….

 

This article references a newly released finding published in the Lancet…

The Lancet 2008; 372:398-405

DOI:10.1016/S0140-6736(08)61160-5 

Articles

Influenza vaccination and risk of community-acquired pneumonia in immunocompetent elderly people: a population-based, nested case-control study

Dr Michael L JacksonPhD

[Excerpted]

Summary

Background

Pneumonia is a common complication of influenza infection in elderly individuals and could therefore potentially be prevented by influenza vaccination. In studies with data from administrative sources, vaccinated elderly people had a reduced risk of admission for pneumonia compared with unvaccinated seniors; however, these findings could have been biased by underlying differences in health between the groups. Furthermore, since most individuals with pneumonia are not treated in hospital, such studies should include both outpatient and inpatient events. We therefore assessed whether influenza vaccination is associated with a reduced risk of community-acquired pneumonia in immunocompetent elderly people after controlling for health status indicators.

Findings

1173 cases and 2346 controls were included in the study. After we adjusted for the presence and severity of comorbidities, as defined by chart review, influenza vaccination was not associated with a reduced risk of community-acquired pneumonia (odds ratio 0·92, 95% CI 0·77–1·10) during the influenza season.

 

 

The problem (as defined by me of course) with this finding and the resultant reportage is that in our "sound-bite" world the issue will not receive a critical and thorough airing.

 

My first (of several) problem with this paper is that there is no mention of the parties involved having been vaccinated against bacterial pneumonia.  If the main aim of an influenza vaccine is to prevent pneumonia wouldn't getting a pneumonia vaccine be of benefit as well?

 

Secondly, it is known that although an influenza vaccine will not always prevent infection, it will attenuate severity of illness.  This gets a bit "fuzzy" when we consider the differences between H1N1 and H3N2.  The former produces a (generally) milder illness, the latter, more (generally) severe.

The Journal of Infectious Diseases 2005;192:249–257

© 2005 by the Infectious Diseases Society of America. All rights reserved. 

0022-1899/2005/19202-0008

DOI: 10.1086/430954

Influenza Virus Neuraminidase Contributes to Secondary Bacterial Pneumonia

Ville T. Peltola, et al.

Influenza A virus causes epidemics annually and pandemics several times a century. Two subtypes of influenza A virus, H3N2 and H1N1, are presently circulating in the human population. Epidemics caused by H3N2 are associated with higher mortality in human populations than are epidemics caused by H1N1 or influenza B virus.

[snip]

The level of NA activity decreased in influenza viruses isolated from 1957 to 1968 and increased again in those isolated from 1968 to 1997. This trend in NA activity correlates with the observed historic mortality caused by H3N2 influenza viruses, which was highest in 1957, decreased during the next decade, but increased again during the 1990s (table 2). Low levels of NA activity in the influenza viruses circulating in 1968 is consistent with lower mortality from this pandemic, compared with that in the 1957 pandemic or during the epidemics caused by H3N2 influenza viruses during the 1990s. It has been suggested that conservation of the N2 NA in the influenza viruses circulating in 1968 resulted in relatively low mortality during this pandemic, but this does not explain why influenza viruses circulating later that had no antigenic shift in HA or NA caused higher mortality. The N2 NA in the influenza virus circulating in 1997 had the second highest level of NA activity, and this influenza virus caused the highest mortality during an epidemic since the 1957 pandemic.

 

The years encompassing the vaccine effectiveness analysis had a considerable amount of H3N2 circulating.

Another recent finding that sheds light on the effectiveness (or not) of vaccines:

The Journal of Immunology, 2006, 177: 7811-7819.
Copyright © 2006

Cyclooxygenase-2 Inhibition Attenuates Antibody Responses against Human Papillomavirus-Like Particles1

Elizabeth P. Ryan, et al.

Vaccination to generate protective humoral immunity against infectious disease is becoming increasingly important due to emerging strains of virus, poorly immunogenic vaccines, and the threat of bioterrorism. […]The widespread use of nonsteroidal anti-inflammatory drugs and Cox-2-selective inhibitory drugs may therefore reduce vaccine efficacy, especially when vaccines are poorly immunogenic or the target population is poorly responsive to immunization.

 

And this…

The Journal of Infectious Diseases 2002;186:341–350

© 2002 by the Infectious Diseases Society of America. All rights reserved.

0022-1899/2002/18603-0006$15.00

DOI: 10.1086/341462

Lethal Synergism between Influenza Virus and Streptococcus pneumoniae: Characterization of a Mouse Model and the Role of Platelet-Activating Factor Receptor

Jonathan A. McCullers and Jerold E. Rehg

A lethal synergism exists between influenza virus and pneumococcus, which likely accounts for excess mortality from secondary bacterial pneumonia during influenza epidemics. Characterization of a mouse model of synergy revealed that influenza infection preceding pneumococcal challenge primed for pneumonia and led to 100% mortality. This effect was specific for viral infection preceding bacterial infection, because reversal of the order of administration led to protection from influenza and improved survival. The hypothesis that influenza up-regulates the platelet-activating factor receptor (PAFr) and thereby potentiates pneumococcal adherence and invasion in the lung was examined in the model. […] The model of lethal synergism will be a useful tool for exploring this and other mechanisms underlying viral-bacterial interactions.

 

Attempting to pull it all together:

Elderly have a reduced antibody response to vaccinations.

Our circulating H3N2s have undergone a change for the worse when it comes to mortality. 

Our influenza vaccine is given intramuscularly and the antibodies produced are the ones that have a lesser effectiveness at warding off illness [humoral vs. mucosal], and you must add to that the fact that the longer the time frame between inoculation and infection, the less effective these lesser effective antibodies become.  The study offered no hints as to the lapse of time that may or may not have been at play.

The population analyzed tends to be on anti-inflammatory and/or COX-2 inhibitor medications, often at high levels.

Even a vaccine attenuated infection of H3N2 in a frail elderly person would seem to indicate a high level of risk of a secondary infection of pneumonia.

 

All-in-all, the issue is extremely complicated and our knowledge is evolving, as evidenced by the myriad refs I had to pull to make that point. 

 

The effectiveness (or not) of a vaccine should not be reduced to statistical analysis of cases that were not even lab confirmed to be influenza. 

Nor should effectiveness be written off when there are simple change-ups (no anti-inflammatory drugs for two weeks following immunization, intranasal vs. intramuscular inoculation) that might dramatically improve antibody response.

 

But none of that will even enter the picture as we all read the headlines Flu vaccine doesn't protect… and those that already don't believe in vaccine efficacy and overtly fear the miniscule risk(s) of receiving them will feel vindicated and supported in their (ill-informed) opinions and choice of abstention.  And that "personal" choice places us all – and our children – at greater risk.

 

SZ

 

 

 

 

 

 

 

 

 

Insuring the business of HC against Pandemic Influenza

 

Although it's true you can insure just about anything against just about anything, today's news item came as a bit of a surprise:

 

From Marketwatch.com

Lexington Insurance Company Introduces Pandemic Rx

Endorsement to Lexington's Commercial Property Insurance Covers Financial Risks Faced by Healthcare Providers in the Event of a Pandemic Flu

NEW YORK, Jul 31, 2008 (BUSINESS WIRE) -- Lexington Insurance Company, a unit of AIG Commercial Insurance, today announced Pandemic Rx, an endorsement to Lexington's commercial property policy for acute care medical facilities to cover business income loss and extra expenses incurred during a declared pandemic influenza public health emergency (as defined in the policy).

"Because of the complex nature of healthcare economics, a pandemic flu would put tremendous financial strain on healthcare providers. An increase in hospital admissions, expected during a pandemic flu event, could actually result in reduced revenues and business income loss," said Kevin Kelley, Chairman and CEO, Lexington Insurance Company. "In an environment of resource scarcity, elective procedures may be canceled which may then lead to a lower average reimbursement rate for care provided during the pandemic event."

Continues….

 

Back in December of 07 I did a post, Pandemic Accounting, and it addresses why this insurance was brought to market. It is still relevant to the issue and if you haven't read it I [modestly] suggest you do so.

 

I close out that previous post with these words:

 

Even though this article addresses the financial burdens a pandemic will place upon most hospitals the supporting underpinnings are some of the best I have seen outside of dense scientific papers. Admitting it's crass and insensitive to lean on financial concerns to support PanFlu concerns in general when I refer to what will be human lives and miseries, it's as the saying goes—money talks.

The question is—is anyone listening?

 

The insurance industry is listening.

 

SZ

Japan’s H5N1 PanFlu estimates

Many days I am reduced to the briefest peek in on the world of H5N1 and Fla_Medic, along with Crof, are where I usually peek for the news. One of FM's offerings today was a post on Japan's estimates of the possible effects on the business sector should a severe pandemic occur. I would not be exaggerating to say that I was momentarily stunned, in fact stunned incredulity about sums up my reaction.

From the Daily Yomiuri Online:

40% of workers might have to stay home in pandemic

[Excerpt]

Estimates were based on the human suffering figures in government's pandemic relief action plan--revised in October. The plan estimates 25 percent of people would suffer from a new influenza pandemic, with a fatality rate of 2 percent.

I was stunned because I have long admired Japan's approach to the seriousness of the threat posed by a pandemic from H5N1, treating it more as a threat to their nation than a public health issue. As such, they have spent a great deal of energy and funds preparing Japan for the potentials. A few examples are their purchases of Tamiflu, pre-pandemic vaccines, and plans for containment on a national level. Japan has backed up words on paper with concrete actions and embraced some rather radical measures as necessary to their survival.

Given their demonstrated willingness to accept the more severe, but [some would say] less likely, severity assumptions reading 25% ill with a 2% case fatality ratio was counter to everything I had read from their planning assumptions previously.

Several hours passed as I mentally chewed on what could be driving their numbers and then it hit me:

Instead of using ill-informed and wishful thinking figures [as 25% CAR /2% CFR suggest] they quite well may be correct for Japan experiencing a severe pandemic. Japan, having done much already, and plans in place to do much more proactively, will experience a mitigated pandemic while most of the rest of the world will suffer an unmitigated pandemic.

A graphic of a community disease profile between a mitigated vs. unmitigated pandemic [FluWiki]

That graphic, though unproved for a future severe pandemic, speaks volumes in support of Japan's estimates. Doing the "tough stuff" pays off in numbers, both in CAR and CFR.

Lest we forget, those numbers represent people – many in the prime of their lives – which is exactly why Japan takes the threat so seriously, and exactly why they may just hold their numbers down to these percentages that, on their face, seem so unrealistic [and uncharacteristic for Japan].

SZ

Bangkok editorial connects pandemic dots

 

 

From the Bangkok Post [editorial]:

Poor Planning for disaster

Two disturbing reports have just been released by different authorities in the United States and the United Kingdom. Their parallel release is a coincidence, but authorities in nations around the world should be both interested and concerned - and so should their citizens.

Although they approach the problem differently, senior experts in both countries warn that there will be a terrible disaster, count on it, and the US, Britain and the United Nations all are woefully short of being able to cope.

The UK report, written on the evidence of an investigation by the upper House of Lords, should give the most concern. It centred mainly on the likelihood of a worldwide pandemic of influenza or similar disease. The report says flatly there will be such an outbreak, although of course it cannot say when or what form the disease might take. It could kill 50 million and take a terrible toll on trade, travel and society which would last years if not much longer.

[snip]

The fear of influenza is based on the spread of avian flu through, especially, eastern Asia including Thailand. Some experts argue that the H5N1 virus is not likely to ever be especially dangerous to humans worldwide. But they miss the point that influenza in general is the most likely source of any global illness. It is prudent to prepare for a human outbreak of avian flu. It is absolutely vital to be better prepared for an influenza pandemic.

It should an eye-opener to most that Britain and the United States are undoubtedly among the world's best-prepared nations for natural or man-made disaster. If they are unready and unrehearsed, how about the rest of us?

That there will be a medical pandemic is probably beyond debate. That the nations of the world will again be found wanting in caring for the sick and halting the spread of the disease, is perturbing. That even the WHO is doubted in ability and authority is worrying.

More planning and preparations for disaster management is needed. The tsunami of 2004 proved that even a highly local disaster could quickly overwhelm local response. At one time, Thailand was seriously preparing for an influenza epidemic. The waning bird flu seemed to end such concern. The government has effectively downgraded disaster preparedness officials to almost a non-entity. That may prove a terrible error when - not if - illness spreads globally as during previous flu pandemics.

 

The author's frustration and dismay over Thailand's pandemic preparations is clearly communicated in this piece.

 

Connecting dots of concern expressed by two members of the G8 points out the rarely discussed. Countries that traditionally provide assistance when disaster strikes another will be mired in their own troubles with nothing left over to offer up, irrespective of humanitarian need or tragedy should a severe pandemic happen.

 

SZ

PanFlu Vaccine Allocation Prioritization

 

It is rare that I ever disagree with what one (or another) of the Reveres from EffectMeasure say when it comes to issues of avian influenza or a human pandemic of same. Today, however, I found myself not only disagreeing but also asking myself "are they serious?"

 

The post [here] calls into question why the US military gets a top slot for scarce pandemic influenza vaccine allocation.

Putting frontline health care workers at the top makes sense (NB: I am a health care worker but as a researcher-physician would not be considered "front line," so this isn't special pleading). But why is the military at the top along with them, ahead of many other "mission critical" workers like police, fire and communications? Reading the document provides no obvious answers. The document is replete with claims that the guidance was developed by an open and transparent process with ample opportunity for the public and other stakeholders to comment to the Working Group that drafted the document:

"This guidance is the result of a deliberative democratic process," HHS Secretary Mike Leavitt said in a statement. "This document represents the best of shared responsibility and decision-making." (Reuters)

 

The guidance document [PDF] identifies approximately 700,000 "deployed and mission critical" as a Tier 1 priority group. What is not readily apparent in the Revere post is that there are segments of the military included in Tiers 2 and 3 as well, so the 700,000 are a specific sub-set of the military in its entirety. The operative phrase in the guidance document is "deployed and mission critical".

 

Since this Revere (there is more than one) included a thoughtful, as well as sincere, N.B., I will be include my own: my one and only child is a patrol officer for a small-ish city PD, and under the age of thirty (by several years). I could easily choose to be indignant right alongside Revere, adding my small cyber voice to the public challenge, and the "mother" in me wants to – make no mistake on that. However, from a purely logical, (to say nothing of dispassionate), standpoint, the "deployed and mission critical" military personnel should come before nearly everyone else.

 

Here's the No BS, No Personal Agenda, No Political Axe, No Heart Strings, No Philosophically Enlightened Pacifist – reality: The men and women in the military do not have a choice about whether or not they are going to report to hazardous duty. That contrasts with our doctors, nurses, police, fire, and emergency medical services personnel, all of whom do have that choice.

 

Ethically we are obligated to give military personnel in harm's way (of the pandemic) whatever level of protection (meager or otherwise) we are capable of giving. We have, by way of our government, denied them "choice", and in so doing we assume that moral and ethical obligation. To stint on that obligation would be tantamount to spitting in their faces and then pissing on their graves.

 

No one said the choices that had to be made would be easy. No one said that those choices would be pleasant. The plain and simple fact is that in pandemics people die, many well before their naturally allotted time. Babies, toddlers, children, teenagers, young adults, adults in their prime, middle aged, older, and the elderly are going to die in a severe pandemic (should we experience one). Each one will be tragic and almost assuredly needless.

 

Many things could be done to mitigate the deaths that are likely. They could be done by the individuals themselves, their parents, their communities, their local and state governments. Many things could be done by our federal government as well. Few are doing all they could to mitigate the misery and death that may happen.

 

The federal government does not have the responsibility to protect my son; that rests on other shoulders. That responsibility starts as his own, then mine, then his department, then his city, then his state, then, and only then, in the most general fashion, equal with every other citizen and resident of this country, the federal government.

 

Those in the military, especially those deployed, have no rights of self-determination (their "shoulders" carry our "burdens" so there is no room for their own), they often have no family to render them care and protection, they have no local or state government, what they do have however is the federal government – First, Last, and In Between.

 

Morality can vary person-to-person and/or culture-to-culture; ethics, however, are more rigorously defined. Someone could be morally indignant over something that might only produce a bored yawn from me. So, acknowledging Revere's moral indignation over the decision to place the deployed and mission critical military at the top of the allocation recommendation (along with front line medical personnel), I wholeheartedly disagree with it, publicly stated with my own bit of moral indignation tossed in for good measure.

 

Our ethical obligations, on the other hand, are clear – of the Crystal Kind.

 

And, I haven't even touched on the functions those military personnel will be tasked to perform. I'll save that for yet another evening….

 

SZ <Mother of a cop who comes after FL Medical and D&MC Military personnel>

What will it be like?

 

 

What will it be like if/when we have our next influenza pandemic and the public at large discovers the limited initial supply of pre-pandemic vaccine and the first batches to roll off the production line are for specific segments of critical infrastructure? What will we, as individuals, be thinking knowing that the vast majority are not going to receive a vaccine in any timely fashion?

 

Will it come as a shock to most people that they will have to wait for several months – or more?

 

Today from Reuters:

US vaccination plan puts health care workers first

Wed Jul 23, 2008 1:17pm EDT

By Maggie Fox, Health and Science Editor

WASHINGTON, July 23 (Reuters) - Essential health care workers would be immunized first if a flu pandemic broke out in the United States, the government said on Wednesday.

The Department of Health and Human Services released long-awaited details on who would get vaccinated and when if a serious global influenza epidemic emerged.

The plan put a million health care workers, such as emergency room staff and nurses skilled in vaccinating others, at the top. Next were military and "mission critical" personnel, public health workers and hospital and nursing home staff.

All of these play a "critical role in providing care for the sickest persons; highest risk of exposure and occupational infection," the plan read.

[snip]

WAITING MONTHS

Since it would take many months to produce enough vaccine to protect everyone, experts agree a plan is needed to determine who gets the first doses.

The HHS plan designates 700,000 "deployed and mission critical personnel" to follow the key health care workers. After that, 300,000 public health workers, 3.2 million inpatient health care providers, 2.5 million outpatient doctors, nurses and other professionals, and 1.6 million long-term care workers would be next to get the vaccine.

[snip]

Emergency services, law enforcement, makers of pandemic vaccines and drugs, pregnant women and babies and toddlers are also in the first designated groups.

[snip]

Healthy adults not in any other priority group come last.

 

Most people will fall in the later tiered groups, and that is only fair. Those who risk the most, and provide the most benefit to the community as a whole, deserve to be afforded whatever level of protection we can offer them.

 

Human nature being what it is, many will not see the wisdom and fairness of this distribution but hey, sometimes life just isn't "fair". Or, I should say, our operative definition of "fair" given the specific time-place circumstances we are saying "Not Fair!" about. And if we are honest with ourselves we know this to be true.

 

Our officials should be doing themselves [and everyone else in the process] a favor by making every effort to educate the public on the scarcity of vaccine issue(s) before the time comes for the public's shocked and indignant awakening at the dawn of a pandemic.

 

A part of honest and open communication is that all-important COMMUNICATION component. Publishing plans on the internet followed by the odd newspaper article do not constitute "communication"; it constitutes CYA and doing just enough so as not to be guilty of hiding information. I don't believe that is what is consciously being done, but it's also a part of general human nature that in difficult or distasteful situations we tend to do no more than we are minimally required. It's just easier.

 

It's not that I think officials don't know this – quite the opposite in fact – they are well aware. That's what makes their communications failure all the more frustrating, they know what they should be doing, they know the how of it, and they even know the why of it, yet still they fail [see Community Reaction to Bioterrorism: Prospective Study of Simulated Outbreak, here, for just one example of all that in-place knowledge].

 

It's only fair to inform as clearly and as concisely as possible that should a pandemic happen before major innovations in vaccine manufacturing most people will have to manage without a vaccine. It's only fair, not because it will alleviate allegations of unfair practice(s) being leveled by the public, but simply because one should always attempt to be as fair as possible, regardless of our own human natures to want to take the easy way out.

 

Openly admitting, frequently, and via multiple venues, there are no easy fixes or handy stashes of vaccine will produce the greatest potential for educating the public that their wellbeing will be dependent upon their own actions. Focusing on all the wonderful advances on the vaccine front that may not be available in time gives a false impression of supply. Silence in the face of a potentially life endangering belief is akin to validating that dangerous belief.

 

The public must know before they can act, and they must act before there is a pandemic.

 

SZ

Hand washing dramatically reduces disease

 

I recently posted about "germie" ice in restaurants [here] because there are those who seem to have difficulty grasping the concept of washing their hands after certain bodily functions are performed. Today I found a wonderful article about the benefits of hand washing:

In safe hands 
By : KASMIAH MUSTAPHA 
2008/07/21

Poster used in the Cape Town study to educate children on proper ways to wash their hands.

IT's a simple thing to do. 

Yet many tend not to make it a habit to wash their hands — after using the toilet, before and after handling food, or anytime their hands are exposed to germs. 

By using soap and clean water to disinfect, the risk of infectious diseases can be reduced significantly.

Studies show that such diseases are usually spread through hand-to-hand contact.

The germs are spread when people touch food or surfaces that have been handled by dirty hands. Diarrhoea, the common cold, pneumonia and acute respiratory and skin infections are some of the illnesses that can ensue as a result.

Inadequate hand washing and cross-contamination is responsible for as much as 40 per cent of food-borne diseases, including salmonella, hepatitis A, shigellosis, staphylococcus, streptococcus, E. Coli and many yet unidentified and dangerous viral infections.

In a study presented at the 13th International Congress on Infectious Diseases in Kuala Lumpur recently, a strong association with fewer illnesses was found when families practised hand hygiene.

The study's sample consisted of communities living in squatter and residential areas in Cape Town, South Africa. 

[snip]

The communities were chosen based on several criteria: those with only communal access to clean water and communal latrines/buckets (i.e. squatter areas); communities whose under-five mortality rate is at least four times higher than other areas; and areas that spent only 40 per cent of the total health-care expenditure on a public health system that serves 80 per cent of the population, among others.

These communities were taught proper hand washing methods, given "hand washing stations", had their food vendors induced to practise hygienic food preparation and instructed on how to manage communal toilets.

In residential neighbourhoods, the study found there was a 78.5 per cent reduction of respiratory diseases, 77.3 per cent in skin diseases, and 81 per cent in gastrointestinal diseases in children under five years old.

In "shack communities", there was a 56.2 per cent reduction in respiratory diseases, 84.1 per cent in gastrointestinal illnesses and 64.2 per cent in skin infections under the same age bracket.

[snip]

He [Cole, a professor in the Department of Health Science at Brigham Young University] said about 1.9 million die from acute respiratory infections annually, with 70 per cent of them from Africa and Southeast Asia.

The major respiratory pathogens are streptococcus pneumoniae, haemophilus influenzae type B, respiratory synctial virus, parainfluenza virus type 3 and the influenza virus. 

[snip]

Sungai Buloh Hospital head and consultant of infectious diseases Dr Christopher K.C. Lee said that a wide range of non-medical interventions — from personal hygiene to wearing masks, quarantine and the screening of travellers — can potentially reduce the spread of germs.

"Hand hygiene remains a pre-requisite for preventing the transmission of disease," he said.

In H5N1, an influenza virus subtype, hand hygiene, which includes hand washing with soap and the use of alcohol-based hand rubs, is critical to prevent possible contamination of the nose, mouth and conjunctivae by unwashed hands."

He said in public buildings, minimising the exposure of humans to viruses is the key to reducing risks of infection. 

Preventive measures in such places include encouraging frequent hand washing, ensuring the building's occupants and visitors have access to facilities for proper personal hygiene, and ensuring surfaces are cleaned regularly.

"It is so easy to stop the spread of germs and infectious diseases by washing your hands. While many of us do make the effort to ensure hand hygiene, there are also others who take it lightly. 

"We should no longer think of hand hygiene as insignificant."

Continues….

 

There are those who have ridiculed the campaign espousing "hand hygiene" as a vital [and worth trumpeting] part of pandemic NPIs (Non-pharmaceutical Interventions) and, honestly, their little snits of ridicule generally evoke a bit of snit from me, as I believe hand washing to be akin to the First and Last line of defense against pandemic influenza. Of course, there's a whole passel of other things in between first and last – just to be clear on that.

 

We don't fully know the role surface and hand contamination plays in the transmission of diseases in general, and we are even more ignorant when it comes to the transmission of the influenza virus and the degree fomite transference plays. The study this article references may alleviate some of that ignorance – to say nothing of the snits of ridicule.

 

SZ