Public enemy number one

December 1, 2006

Governments are ill prepared for a global bird flu pandemic and are doing nothing to ensure that the people of the rich world do not abandon those of the poor to die - as some experts fear. Becky McCall reports

If a global bird flu pandemic breaks out, poor countries could see many in their population left to die as richer vaccine-producing countries close their borders and focus on national concerns, experts warn.

Eighty-six per cent of the world's population live in countries that do not produce bird-flu vaccines. Scientists think that governments in vaccine-producing countries will face internal political pressure to nationalise their product and prohibit exports. This could create a global political, economic and public health crisis.

David Fedson, founding member of the International Vaccine Supply Task Force and a retired professor of medicine, says: "The UN Security Council won't help. Norway won't send its Army into the Netherlands to seize vaccine, and Argentinians are not going to raise the Belgrano and set sail for the vaccine manufacturers in Liverpool."

Already, international fault lines are appearing. Countries in South-East Asia, where bird flu originated, have raised concerns about sending new strains of the virus to Western laboratories. Indonesia, for example, is very reluctant to send any new strains. This reticence is stalling research.

James Robertson, principal scientist at the UK's National Institute for Biological Standards and Control, says serious obstacles exist at the research and development stage of vaccine development with identifying new strains and surveillance of viruses.

"Identification and ownership of the virus lie behind the problem associated with the lack of an effective routine surveillance system,"

Robertson says. "Countries in South-East Asia are concerned that once they have sent a virus sample to the West, they will lose their rights to vaccine production, the associated profits and the authorship of related publications. As a result, we have no system for monitoring and dispatching the virus strains across the globe."

Fedson says that a global treaty is needed to force governments to come together to prepare for a flu pandemic. He says the priorities of the governments of rich countries are reflected in those of the World Health Organisation and adds that the amount of money donated to the WHO to fight a flu pandemic has been "laughable".

Fedson is worried that governments are twiddling their thumbs. He says that officials lack the imagination to contemplate a scenario in which a significant proportion of the global population perishes.

His views drew great support at the Second Influenza Vaccines for the World Conference, where nearly 600 world flu experts met to discuss preparedness for a global pandemic.

Fedson, who has researched adult vaccines in academe and industry, says the world ought to be prepared for an outbreak. He refers to Blaise Pascal, the 17th-century French physicist and philosopher, who said that it was better to believe in God than not to, just in case He existed. "There are things we can do now that we couldn't do with past pandemics," Fedson says. "There are scientific advances and technological capabilities for building the human and social infrastructure needed for delivering vaccines. For us to have these tools and not to use them in a co-ordinated fashion is truly unforgivable."

Part of the problem, he says, is people's refusal to envisage worst-case scenarios, particularly in the West. "It's hard to live moment to moment with an overwhelming feeling of tragedy and oblivion, but the probability that there will be another flu pandemic is 100 per cent. Too many people are in denial."

He draws parallels between the risk posed by climate change and the need for those at the highest political levels to recognise the threat of a flu pandemic. The recent Stern report acknowledges serious high-level concerns about the possible impact of global warming and says that the international community has failed to act together to tackle the issue. "In a flu pandemic, the impact will become very clear and similarly severe in all countries. Unlike climate change, a pandemic will have a very compressed timescale," Fedson says.

The 1918 flu pandemic, the 20th-century's worst, killed up to 5 per cent of the world's population - between 50 million and 100 million people, according to estimates by historians. Given that there has been a threefold increase in the global population since then, an equivalent threat today could kill between 150 million and 300 million people.

Fedson points out that this is 1,000 times more people than were swept away in the Indian Ocean tsunami of Boxing Day 2004 and more than the total number of people killed in all wars and by murderous governments throughout the 20th century. "It would also happen in one to two years rather than over 100 years," he adds.

Mathematical models show that if human-transmissible avian flu broke out in South-East Asia today, it would take about 60 days to reach US shores. It is doubtful whether the world could cope, given current levels of preparedness. "Nobody is working together - there is no international agency that is able in a firm way to deal with this global issue," Fedson says.

Because the world now is much more urbanised than it was in 1918, a pandemic today could spread faster than the 1918 outbreak did. Many cities have more than 10 million residents. In Lagos and Bangkok, for example, people live cheek by jowl, and the virus would pass easily from one person to another.

The US has dedicated more than $7 billion (£3.7 billion) to pandemic preparedness, much of it for vaccine development, and it recently gave the WHO $10 million to improve global access to pandemic flu vaccines. In Europe, only Germany has committed public funds - €20 million (£13.6 million) - to clinical trials of pandemic vaccines. Neither the UK Government nor the European Union has spent public funds on clinical trials of pandemic vaccines. Fedson adds: "The amount given to the WHO to deal with this is laughable, and in the UK not £1 of government money has been spent on a clinical trial of an H5N1 vaccine in humans."

Fedson insists that the development of pandemic vaccines must be viewed primarily as a public health issue rather than a vaccine production problem, and that the vaccines must be formulated to provide maximum protection on a population-wide scale, not on an individual basis. "This is an absolute political as well as a public health necessity," he says.

Pandemic preparedness plans generally incorporate three elements: preventive measures such as vaccines; treatments such as antivirals; and social methods of control, for example closing schools and restricting travel. Vaccines are by far the most effective single preventive measure.

Unfortunately, because the strain of virus would be unknown until a pandemic broke out, it is impossible to develop a vaccine until the pathogenic element or antigen is known. However, other closely related vaccines may have been developed and have been shown to confer a significant level of protection. But manufacturers will not invest millions of pounds in a vaccine trial to protect against an unknown virus unless the Government supports them.

The Times Higher asked three influenza pandemic experts to share their thoughts on the state of global preparedness:

* Bram Palache is global public affairs director, influenza vaccines, for Solvay Pharmaceuticals

Palache believes many governments have failed to invest in improving flu control infrastructure and supporting pandemic vaccine research and development.

Differences between the US and the EU illustrate the lack of international cohesion and collaboration. "There are striking differences in terms of investment between the efforts made by the governments of the US and the EU - and this is of considerable concern. Even though the WHO plays an active co-ordinating role, it has no decision-making power, and the implementation of WHO recommendations depends on individual government decisions," Palache says.

From an industry perspective, Palache feels that pharmaceutical manufacturers are taking responsibility and will invest in whatever is appropriate if they recognise a business opportunity.

Given free rein to prepare for the looming pandemic, Palache would convene regional task forces to address the fragmented approach and lack of leadership. These task forces, formed from representatives of ministries of health from various regions of the world, could liaise with a WHO-led international task force that could make recommendations for research priorities and action plans.

* James Robertson is principal scientist at the UK's National Institute for Biological Standards and Control

Robertson, who works at one of the world's foremost surveillance laboratories, oversees observation of the influenza virus for any mutations that could potentially trigger human-to-human transmission.

He says that, despite its potential for destruction, there is no routine international surveillance system for virus mutation for bird flu (H5N1).

This means that by the time a lethal mutation responsible for human-to-human transmission is picked up, it could already have begun its exponential spread. "I am concerned that there could be a delay in getting vaccine strains identified and made when the crunch comes. There is a lack of transparency regarding who gets which strains, who sends them out and so on," he says.

Once the virus has been identified and produced in large enough quantities, vaccine production begins and other potential problems regarding manufacturing capacity kick in. "What company will expand its manufacturing capacity for a pandemic that might never arrive?" he asks.

From a research perspective, he feels that scientists need to know more about the efficacy of vaccines once produced and how much antigen to put into a dose to get an adequate immune response. "We could do with a lot more clinical data to assess this."

* Martin Meltzer is senior health economist at the US Centers for Disease Control

There have been many advances in science and medical interventions, but the world has become a much smaller and busier place since the last flu pandemic of 1968, Meltzer says. "There are more poultry and fowl, more humans and more pigs than ever. These are the mixing-bowl ingredients that produce new influenza strains that humans have not seen before."

Meltzer feels that the research community is as certain as it can be that there will be another influenza pandemic - it is just a question of when.

In each of the three pandemics during the 20th century, 30 to 35 per cent of the population became ill. The difference lay in whether they died as a result. "If the same pattern repeats, then this means that everyone will know someone who will be ill. It will happen within two or three months and it will have an unforgettable impact," he adds.

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