"Preparing for the Next Pandemic"

Michael Osterholm, director of CIDRAP, has an excellent perspective piece in last week's New England Journal of Medicine, "Preparing for the Next Pandemic".

Here are some notes and highlights:

•    Typical annual US domestic death toll from flu is 30,000 to 50,000, with global toll 20-30 times higher.
•    “Today, making the 300 million doses of influenza vaccine needed annually worldwide requires more than 350 million chicken eggs and six or more months.”
•    Even if we develop a more capable, faster alternative, we must assure the production capacity for sufficient doses for a global population.
•    If a pandemic hit tomorrow, vaccine production in the following six months would be limited to at most one billion monovalent doses.  Because effective vaccination often requires two doses, we could thus protect at most only 500 million people.
•    Just in time economics also used to plan critical care facilities and equipment.  We do not have sufficient numbers of ventilators, for example, to handle a surge of flu victims.
•    “We have no detailed plans for staffing the temporary hospitals that would have to be set up in high school gymnasiums and community centers – and that might need to remain in operation for one or two years.  Health care workers would become ill and die at rates similar to, or even higher than, those in the general public.  Judging by our experience with [SARS], some health care workers would not show up for duty.  How would communities train and use volunteers?  If the pandemic wave were spreading slowly enough, could immune survivers of an early wave, particularly health care workers, become the primary response corps?”
•    No significant planning about use of antiviral agents.  (From my work with Bio-ERA, it is clear that there are even contradictions in the way US and Canada are stockpiling Tamiflu and vaccine.  The US has minimal stockpiles of the antiviral drug, but has already ordered large numbers of vaccine doses, while Canada has stockpiled lots of Tamiflu but is waiting on the vaccine.  I have to wonder how this might affect epidemiolgical dynamics across the border.)
•    “The current system of producing and distributing influenza vaccine is broken, both technically and financially.  The belief that we can greatly advance manufacturing technology and expand capacity in the normal course of increasing our annual vaccination coverage is flawed.  At our current pace, it will take generations for meaningful advances to be made.”
•    Osterholm argues for cell culture based vaccine production.
•    Notes that in 1968, during most recent pandemic, China’s population of humans was only 760 million, of pigs only 5.2 million, and of poultry only 12.3 million.  Current populations are humans 1.3 billion; pigs 508 million; and poultry 13 billion.  “Similar changes have occurred in the human and animal populations of other Asian countries, creating an incredible mixing vessel for viruses."

Well done, Dr. Osterholm.