Aug 26, 2004 (CIDRAP News) – Federal health officials today released a lengthy plan for dealing with the potentially overwhelming threat of an influenza pandemic like those that occurred three times in the last century.
A flu pandemic today would find the nation unprepared to respond immediately with an effective vaccine or adequate supplies of antiviral drugs, says the plan released by the Department of Health and Human Services (HHS). Such an event could put a crushing burden on the healthcare system and disrupt transportation, business, and public safety, the document states.
The draft plan describes numerous steps to take before and during a pandemic. "This plan will serve as our roadmap on how we as a nation, and as a member of the global health community, respond to the next pandemic influenza outbreak," HHS Secretary Tommy Thompson said in a news release. "Our proposed strategy draws upon the wealth of experience and knowledge we have gained in responding to a number of recent public health threats, including SARS and avian influenza."
Flu pandemics struck three times in the 20th century, the release notes. In 1968 the Hong Kong flu caused close to 34,000 deaths in the United States, and in 1957 the Asian flu killed about 70,000. The most deadly pandemic, the Spanish flu in 1918 and 1919, sickened 20% to 40% of the world's population and killed about 675,000 people in the United States alone, according to HHS.
Flu viruses change slightly each year, requiring annual modifications in the vaccines used against them. In contrast, HHS says, "A pandemic influenza virus is one that represents a major, sudden shift in the virus' structure that increases its ability to cause illness in a large proportion of the population." Disease experts fear that such a shift could occur if the H5N1 avian influenza virus currently circulating in East Asia combined with a human flu virus, spawning a new variety that could spread easily from person to person.
The Pandemic Influenza Preparedness and Response Plan, as it is called, includes a 55-page main document and 12 "annexes," which provide guidance for state and local health departments and private healthcare organizations as well as technical information on various preparedness topics. HHS is inviting the public to comment on the plan within the next 60 days.
The nation's first pandemic preparedness plan was developed in 1978, not long after the swine flu cases and vaccination campaign in 1976, according to the document. The plan was last updated in 1993. HHS calls the new plan an "evergreen" document—one that will be constantly modified as new developments warrant.
The report cites five grim characteristics of a flu pandemic that guided the planning: simultaneous outbreaks in communities nationwide; an overwhelming burden of ill persons requiring hospitalization or outpatient medical care; likely shortages and delays in the availability of vaccines and antiviral drugs; disruption of national and community infrastructures including transportation, commerce, utilities and public safety; and global outbreaks.
The plan says it's impossible to predict the overall impact of a pandemic on the nation. But it cites estimates published in 1999 of 89,000 to 207,000 deaths, 314,000 to 733,000 hospitalizations, and 18 million to 42 million outpatient medical visits.
Vaccination is the primary tool for fighting a flu pandemic, but it takes 6 to 8 months to produce a vaccine for a newly identified flu virus, the document says. Thus it's not likely that a vaccine will be ready when a pandemic first emerges. In the early stages, the nation will have to rely on antiviral drugs, "quality medical care," and infection control measures to keep the virus from spreading.
Antiviral drugs such as amantadine and oseltamivir can reduce the severity of flu when used preventively or given within 48 hours of illness onset. But, the plan says, the supply of these is limited and cannot be rapidly expanded because there are few manufacturers and the production process is slow. Oseltamivir was added to the Strategic National Stockpile of drugs last year, and HHS is continuing to study how best to use antivirals in a pandemic, according to the plan.
Once a vaccine does become available in a pandemic setting, the demand is likely to far exceed the supply at first, the document states. Consequently, the vaccine initially will have to be reserved for certain groups, such as healthcare workers, people providing essential public services, and those with certain medical conditions. Other decisions about who should have priority for vaccine will depend on the pattern of the pandemic and may not necessarily be the same as for annual flu vaccination.
HHS expects that in a pandemic, vaccine shortages could spawn a "gray market" with high prices for some vaccine doses, as has happened in some recent years. The agency is considering several options for buying and distributing vaccine. The government could buy all the available vaccine and then distribute it to state and local health departments, or the country could rely on a mixed public-private system or on the present, primarily private system of vaccine purchasing and distribution.
The plan says disease-control measures other than vaccines and antivirals could also be used to fight a flu pandemic. For example, usual infection control measures would be helpful in hospitals. However, because people can carry flu viruses without being sick, efforts to keep the viruses out of the country or limit spread in the community are not very effective. On the other hand, if a new virus strain didn't spread quite as readily, measures such as screening travelers, closing schools, and quarantining exposed people could help, the report states.
The plan says that HHS must help state and local governments and the healthcare system plan for a pandemic in view of the likelihood of illness among healthcare workers and shortages of hospital beds and medical equipment and supplies. "Health care facilities may need to be established in nontraditional sites to help address temporary surge needs," the plan states.
The document recommends taking numerous preparedness steps during "inter-pandemic" periods. For example, in the vaccine arena, the plan calls for developing libraries of novel influenza strains that could cause a pandemic and preparing reagents to diagnose infection. The plan also calls for efforts to develop a vaccine targeting an unchanging portion of the flu virus, which would sidestep the need to modify the vaccine every year and possibly permit the establishment of a vaccine stockpile.
Some of the other recommended measures include:
- Strengthening global human and veterinary surveillance of influenza
- Increasing US influenza surveillance to a year-round effort
- Developing investigational vaccines for selected novel influenza strains and evaluating them in clinical studies
Disease expert Michael T. Osterholm, PhD, MPH, director of the University of Minnesota Center for Infectious Disease Research and Policy, publisher of this Web site, said he hopes the new plan will spur state and local officials and the healthcare system to recognize the serious threat of a flu pandemic. He said he has contributed to federal preparedness efforts for pandemic flu over the years but was not directly involved in producing the latest plan.
"The important message is that this plan lays out in substantial detail what needs to be done at the federal, state, and local level to better prepare us for a potential pandemic of influenza," Osterholm said. "It really calls upon state and local officials, together with healthcare providers and the healthcare system, to come together and take this seriously—that in fact a pandemic is going to occur.
"We're talking about the possibility of 3% to 5% of the population getting ill and dying. Even with this plan, will we be able to get the kinds of hard-to-conduct planning activities moving in state and local areas? It would be unfortunate if state and local officials say, 'Here's a federal plan, we don't have to do any more.' This is just a start."
Aug 26 HHS news release
Main body of preparedness plan