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A weapon the world needsBoth bottom-up and top-down planning is needed to prevent a global economic disaster. Michael T. Osterholm calls for action at all levels.

Influenza experts are more worried thanever about the next pandemic. It could becaused by H5N1, the avian flu strain of such

concern in Asia; it could even rival the devas-tation of the 1918 Spanish flu pandemic.Whatever form it takes, it is sobering to realizethat when the last pandemic emerged in 1968,in China, the nation’s human population was790 million and the poultry population 12.3million; today those numbers are 1.3 billionand 13 billion, respectively. Similar changeshave occurred in other Asian countries, creat-ing an incredible mixing vessel for viruses. Apandemic could be unleashed tomorrow or inten years from now, but the scene for a poten-tial catastrophe is already set.

Every year, seasonal influenza A kills up to1.5 million people around the world as the dis-ease migrates between the Northern andSouthern Hemispheres1. Current efforts toreduce this global death toll largely involve thedelivery of roughly 250 million to 300 milliondoses of influenza vaccine to the most vulner-able residents in a dozen or so industrialnations. Those fortunate enough to receivevaccines represent less than 5% of the world’scurrent population of 6.5 billion people.

Vaccination is the only meaningful weaponto combat the next pandemic. But the egg-

produced influenza vaccine is based primar-ily on 1950s technology, which means pro-duction could not be immediately ramped up if a global flu pandemic became reality. The 20-year struggle by public-health offi-cials in industrial nations to increase private-sector vaccine production for seasonal fluepidemics is a tale of ‘two steps forward andone step back’. Overall, our poor vaccine man-ufacturing infrastructure, together withnational and international failures to push foruniversal vaccinations, has left the masses vulnerable to annual flu and, worse, the nextflu pandemic.

Plan for actionWhat should we do? The World Health Orga-nization (WHO) recently issued a revisedglobal influenza preparedness plan that pro-vides recommendations for national mea-sures before and during a pandemic2. It ismeant to help countries develop or updatetheir national flu preparedness plans. TheWHO’s plan primarily targets public-healthofficials, although an executive summary has been produced for senior policy-makers who may have a public-health background.Although the WHO’s document is a helpfultool for those responsible for preparedness at

the national level, it falls far short of what isneeded at either the ground level (local day-to-day planning) or at the international level(long-term planning). But it is critical to con-sider all three perspectives when planningpreparedness and response strategies. Unfor-tunately, all other national and state plans suffer from similar failings.

The WHO’s national-level recommenda-tions are non-specific in nature. For example,the ‘Phase 2 health system response’2 advisesthat countries “verify availability and distribu-tion procedures for personal protective equip-ment and antivirals, and for vaccine, for theprotection of persons at occupational risk”;and that they “consider measures to imple-ment”. But such recommendations assumethat protective equipment, vaccines andantivirals will already be available. They alsodo not address the difficult ethical questionsabout allocation: who should get priority forreceiving these potentially life-saving productsif they exist in limited supply?

Such issues are central to the internationaland ground-level perspectives, both of whichhave been neglected in planning for pan-demic flu in most countries. If we are reallyserious about preparing for a flu pandemic,regardless of whether it begins tonight, next

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year or ten years from now, we must flesh outand act upon the critical needs at these otherlevels.

At the international level we must put theavailability of a pandemic vaccine at the top of the list. Other priorities include makingeffective antivirals and protective masks avail-able. Unfortunately, most industrial countriesare looking at the vaccine issue throughmyopic lenses. The primary question seems to be: how do we get enough vaccine in thefirst months of the pandemic to protect ourcitizens?

For a classic public-health approach thisperspective makes sense. Countries such asthe United States, which have aggressiveinfluenza vaccine research programmes, are to be commended. However, a purelynational approach fails to consider the natureof the modern world — a world of globallydistributed just-in-time inventories foralmost all consumer products, includingmedical supplies. The world today is muchmore vulnerable to the collapse of trade thanit was in 1918.

Wake-up callThe arrival of pandemic flu will trigger a reac-tion that will change the world overnight.There will be an immediate response fromleaders to stop the virus entering their coun-tries by greatly reducing and even ending foreign travel and trade — as was seen in partsof Asia in response to the severe acute respira-tory syndrome (SARS) epidemic. These effortsare doomed to fail given the infectiousness ofthe virus and the volume of illegal crossingsthat occur at most borders. But governmentofficials will feel compelled to do something todemonstrate leadership. Individual communi-ties will also want to bar ‘outsiders’. Global,national and regional economies will come toan abrupt halt.

A vaccine against the pandemic strain pro-duced using current technology would not beavailable for at least six months after the pan-demic starts. And even then, the supply wouldonly be large enough to vaccinate 14% of theglobal population1. Our limited stockpiles ofantiviral drugs and medical ventilators willseem as inadequate as they did in 1918.

But the problem is not just one of death anddisease; trade and economic dependency arealso at risk. The global economy has never beenmeasurably threatened by human immuno-deficiency virus (HIV), malaria or tuberculosisdespite the dramatic impact of these diseaseson developing-world populations, particularlysub-Saharan Africa. The global panic createdby flu will be different. Today, we have virtuallyno surge capacity for any consumer product ormedical service that might be needed duringthe 12 to 36 months of a pandemic.

We must demand nothing less than aninternational effort to develop a new type ofinfluenza vaccine that can be manufacturedon a much shorter timescale. This global

vaccine will require a new method of produc-tion, surge capacity for crises and a detailedplan for distribution. One possibility is tomove away from strain-specific vaccinestowards generic vaccines that can respond toall virus strains.

A vaccine cannot be delivered fast enough toprevent a virus spreading in those countrieswhere the pandemic first emerges. But by vacci-nating people in many more countries we couldminimize its impact: imagine if only 2% of theglobal population became infected instead of50% (as is likely now). The world would recovermuch more quickly from the first pandemicwave, and be in a much better position to dealwith any subsequent waves of infection.

So, although we cannot prevent a pandemicfrom happening, we might be able to change itscourse if we start acting now, and if the pan-demic is still a few years away. But if industrialcountries continue to develop vaccines for just themselves, they, and everyone else, willremain vulnerable to a global economic disas-ter. Even if nations vaccinate their entire popu-lations, they cannot remain isolated from apandemic shock.

Who should be taking the lead on the vac-cine issue? We need bold leadership from thegroup of seven industrialized nations plusRussia (G8) and other developed-world governments. When the G8 leaders next meet in Scotland in July, avian flu will be on theagenda, but major commitments are unlikely.This is not good enough. These nationsurgently need to recognize the economic, andsecurity and health threat that the next flupandemic poses, and invest accordingly.

As well as waking up to reality at the inter-national level, we must also struggle with dif-ficult issues at ground level. For example, there

are no detailed plans in place to staff or equip temporary hospitals, which might be installedin high-school gymnasiums or communitycentres for as long as one to two years. Nor arethere detailed plans on how to handle the deadbodies whose numbers will soon outstrip ourability to process them.

Ethical questions also need to be tacklednow, in a public forum. Who will get theextremely limited antiviral drugs that will beavailable? Any priority setting during the crisis will provoke further dissent and disrup-tion. Both government-sponsored and privatehealth-care delivery systems have conductedlittle planning around this issue.

We also cannot predict how many health-care workers will continue to place themselvesat high risk of infection by taking care ofinfluenza patients, if vaccine and protectiveequipment are not available. Health-careworkers will become ill and die as quickly asthe rest of the public, or even faster, particu-larly if they have limited protective equipment.

It is essential to think now about the possibleuse of lay volunteers in hospitals — especially ofthose who survive the first wave of infection.Such survivors may have gained immunitybefore a vaccine has become available, and maywant to assist clinicians. The strong medicalarguments against using lay volunteers —grounded in both liability concerns and profes-sional hubris — must be addressed.

Time’s upTime is running out to prepare for the nextpandemic. There is a critical need for compre-hensive medical and non-medical pandemicplanning at the ground level (involving manyin the private sector), that goes beyond whathas been considered so far. National, regionalor local plans based on general statements ofintent or action will be meaningless in the faceof a pandemic. Specific operating blueprintsto get through 12 to 36 months of a pandemicare essential. For example, determining howfood might be supplied to local populationswhen transportation and food-processingplants shut down will require a level of plan-ning not yet included in any national orregional plans.

At the international level, world leadersneed urgently to consider what they can donow. When the pandemic hits close to home,leaders will do their best to react and cope. Butreal leadership, particularly by the G8, meansmaking tough decisions now. We must actwith decisiveness and purpose if we are to create a pandemic vaccine that has a chance of making a real difference. ■

Michael T. Osterholm is at the Center forInfectious Disease Research and Policy,University of Minnesota, Academic HealthCenter, 420 Delaware St SE, MMC 263,Minneapolis, Minnesota 55455, USA.

1. Osterholm, M. T. N. Engl. J. Med. 352, 1839–1842 (2005).2. http://www.who.int/csr/resources/publications/

influenza/WHO_CDS_CSR_GIP_2005_5/en

The current practice of using eggs to make fluvaccine is too slow to cope with a pandemic.

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