The Lancet 2006; 367:1374-1375 April 17, 2006
DOI:10.1016/S0140-6736(06)68512-7
Influenza pandemic preparedness: gauging from EU plans Kennedy F Shortridge a b
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The world is on an influenza knife-edge. The possibility of avian influenza H5N1 virus converting into a pandemic form in human beings is an imminent threat. Then again it might not assume pandemicity for some time, or not at all. A vexing problem, all the more so since this is the first time the world has had the opportunity for real preparedness for an influenza pandemic?9 years in fact. It was in 1997 in Hong Kong that an early avian H5N1 relative signalled the virus's pandemic capabilities.1 So, how is the world shaping up for influenza pandemic preparedness?
In today's Lancet, Sandra Mounier-Jack and Richard Coker2 review preparedness plans of a group of technologically advanced countries?25 European Union (EU) countries, two EU accession countries, and two non-EU European countries. Importantly they also give a guide as to how countries outside this arena are faring.
Not surprisingly ?governmental commitment?is high and preparedness?broadly good.?2 That is fine. Although most countries have an immunisation strategy for a pandemic H5N1 vaccine, the hard reality is that plans have been drawn up without a commercially available vaccine. Recently reported vaccine trial studies highlight immunogenicity problems.3 Moreover, multiple genetic and antigenic lineages of H5N1 complicate vaccine candidacy.4 Because immunisation is the most effective mechanism for blunting a pandemic, it would seem wise to reconsider plans as there may not be a vaccine available at whatever time a pandemic might arise.
There is also concern that antiviral drugs?the use of which is advised in all countries' plans?may not necessarily be the magic medicine to stop the virus once human-to-human transmission is underway. Only 13 countries acknowledge starting stockpiling?and their approaches are a mixed bag (besides the problem of availability). In southeast Asian cases, high-level resistance to oseltamivir, a neuraminidase inhibitor and antiviral front-runner,5 probably contributes to planning uncertainty even though delays in starting treatment might have been an important factor. The optimistic question is whether this pattern of antiviral behaviour will change for the better in the conversion of H5N1 from avian to human pandemic form. The antiviral area needs maximum concentration of effort.
The maxim that ?each man is his own safety officer? could tip the scales in the overall effect of a pandemic. Early adoption of preventive and hygiene measures recommended by governments for every individual are paramount. Avoidance of crowds and social distancing are key elements here. But how might one manage this in large cities where supermarket shopping for food is the norm? There is a compelling need for governments to get these safety messages across to all levels of the public.
Unforeseen problems lie ahead. There are many ?what ifs?. Earlier promiscuous genetic behaviour6,7 raises the possibility of H5N1 presenting as pandemic virus HxNy with different surface antigens, perhaps at a point way distant from the southern China epicentre, or two pandemic viruses could arise in the same time frame in widely different locations. Way out? My mantra on pandemicity remains?expect the unexpected. Indeed another virus, say H9N2, could usurp H5N1 for pandemicity.8
Other problems?medical, distribution of medical supplies, essential services, quarantine, civil order?may be listed under the broad umbrella of confidence. These are grey areas in countries' plans, yet it is here that the public's confidence in governments and agencies can be easily eroded, particularly in a rapidly evolving situation. Failure to have financial contingencies in place, or appearance of counterfeit medicines, will exacerbate any such erosion. The mass media has an essential role in conveying information responsibly.6 Neither they nor the public can cope with uncertainty, preferring news in tidy understandable bundles, which is not always possible. Official spokespeople need a thorough understanding of the problem and must display tact, particularly in this era of internet communication.
Mounier-Jack and Coker are to be congratulated for taking stock of the EU's plans. Much has happened since Belshe's Comment on the need to beef up the research infrastructure in readiness for a future pandemic,9 but still more needs to be done, both scientifically and in the spirit of cooperation for the common good. The H5N1 virus has exposed human vulnerability. A tricky fellow indeed.
I declare that I have no conflict of interest.
<!--start simple-tail=-->References
1. Claas ECJ, Osterhaus ADME, van Beek R, et al. Human influenza A H5N1 virus related to a highly pathogenic avian influenza virus. Lancet 1998; 351: 472-477. Abstract | Full Text | PDF (87 KB) | MEDLINE | CrossRef
2. Mounier-Jack S, Coker RJ. How prepared is Europe for pandemic influenza? Analysis of national plans. Lancet 2006; 367: 1405-1411. Abstract | Full Text | PDF (91 KB) | CrossRef
3. Treanor JJ, Campbell JD, Zangwill KM, et al. Safety and immunogenicity of an inactivated subvirion influenza A (H5N1) vaccine. N Engl J Med 2006; 354: 1343-1351. CrossRef
4. Chen H, Smith GJD, Li KS, et al. Establishment of multiple sublineages of H5N1 influenza viruses in Asia: implications for pandemic control. Proc Natl Acad Sci USA 2006; 103: 2845-2850. MEDLINE | CrossRef
5. de Jong MD, Tranh TT, Khanh TH, et al. Oseltamivir resistance during treatment of influenza A (H5N1) infection. N Engl J Med 2005; 353: 2667-2672. CrossRef
6. Shortridge KF, Peiris JSM, Guan Y. The next influenza pandemic: lessons from Hong Kong. J Appl Microbiol 2003; 94: 70S-79S.
7. Li KS, Guan Y, Wang J, et al. Genesis of a highly pathogenic and potentially pandemic H5N1 influenza virus in eastern Asia. Nature 2004; 430: 209-213. CrossRef
8. Peiris JSM, Yuen KY, Leung CW, et al. Human infection with influenza H9N2. Lancet 1999; 354: 916-917. Abstract | Full Text | PDF (26 KB) | MEDLINE | CrossRef
9. Belshe RB. Influenza as a zoonosis: how likely is a pandemic?. Lancet 1998; 351: 460-461. Full Text | PDF (51 KB) | MEDLINE | CrossRef
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DOI:10.1016/S0140-6736(06)68512-7
Influenza pandemic preparedness: gauging from EU plans Kennedy F Shortridge a b
See Articles
The world is on an influenza knife-edge. The possibility of avian influenza H5N1 virus converting into a pandemic form in human beings is an imminent threat. Then again it might not assume pandemicity for some time, or not at all. A vexing problem, all the more so since this is the first time the world has had the opportunity for real preparedness for an influenza pandemic?9 years in fact. It was in 1997 in Hong Kong that an early avian H5N1 relative signalled the virus's pandemic capabilities.1 So, how is the world shaping up for influenza pandemic preparedness?
In today's Lancet, Sandra Mounier-Jack and Richard Coker2 review preparedness plans of a group of technologically advanced countries?25 European Union (EU) countries, two EU accession countries, and two non-EU European countries. Importantly they also give a guide as to how countries outside this arena are faring.
Not surprisingly ?governmental commitment?is high and preparedness?broadly good.?2 That is fine. Although most countries have an immunisation strategy for a pandemic H5N1 vaccine, the hard reality is that plans have been drawn up without a commercially available vaccine. Recently reported vaccine trial studies highlight immunogenicity problems.3 Moreover, multiple genetic and antigenic lineages of H5N1 complicate vaccine candidacy.4 Because immunisation is the most effective mechanism for blunting a pandemic, it would seem wise to reconsider plans as there may not be a vaccine available at whatever time a pandemic might arise.
There is also concern that antiviral drugs?the use of which is advised in all countries' plans?may not necessarily be the magic medicine to stop the virus once human-to-human transmission is underway. Only 13 countries acknowledge starting stockpiling?and their approaches are a mixed bag (besides the problem of availability). In southeast Asian cases, high-level resistance to oseltamivir, a neuraminidase inhibitor and antiviral front-runner,5 probably contributes to planning uncertainty even though delays in starting treatment might have been an important factor. The optimistic question is whether this pattern of antiviral behaviour will change for the better in the conversion of H5N1 from avian to human pandemic form. The antiviral area needs maximum concentration of effort.
The maxim that ?each man is his own safety officer? could tip the scales in the overall effect of a pandemic. Early adoption of preventive and hygiene measures recommended by governments for every individual are paramount. Avoidance of crowds and social distancing are key elements here. But how might one manage this in large cities where supermarket shopping for food is the norm? There is a compelling need for governments to get these safety messages across to all levels of the public.
Unforeseen problems lie ahead. There are many ?what ifs?. Earlier promiscuous genetic behaviour6,7 raises the possibility of H5N1 presenting as pandemic virus HxNy with different surface antigens, perhaps at a point way distant from the southern China epicentre, or two pandemic viruses could arise in the same time frame in widely different locations. Way out? My mantra on pandemicity remains?expect the unexpected. Indeed another virus, say H9N2, could usurp H5N1 for pandemicity.8
Other problems?medical, distribution of medical supplies, essential services, quarantine, civil order?may be listed under the broad umbrella of confidence. These are grey areas in countries' plans, yet it is here that the public's confidence in governments and agencies can be easily eroded, particularly in a rapidly evolving situation. Failure to have financial contingencies in place, or appearance of counterfeit medicines, will exacerbate any such erosion. The mass media has an essential role in conveying information responsibly.6 Neither they nor the public can cope with uncertainty, preferring news in tidy understandable bundles, which is not always possible. Official spokespeople need a thorough understanding of the problem and must display tact, particularly in this era of internet communication.
Mounier-Jack and Coker are to be congratulated for taking stock of the EU's plans. Much has happened since Belshe's Comment on the need to beef up the research infrastructure in readiness for a future pandemic,9 but still more needs to be done, both scientifically and in the spirit of cooperation for the common good. The H5N1 virus has exposed human vulnerability. A tricky fellow indeed.
I declare that I have no conflict of interest.
<!--start simple-tail=-->References
1. Claas ECJ, Osterhaus ADME, van Beek R, et al. Human influenza A H5N1 virus related to a highly pathogenic avian influenza virus. Lancet 1998; 351: 472-477. Abstract | Full Text | PDF (87 KB) | MEDLINE | CrossRef
2. Mounier-Jack S, Coker RJ. How prepared is Europe for pandemic influenza? Analysis of national plans. Lancet 2006; 367: 1405-1411. Abstract | Full Text | PDF (91 KB) | CrossRef
3. Treanor JJ, Campbell JD, Zangwill KM, et al. Safety and immunogenicity of an inactivated subvirion influenza A (H5N1) vaccine. N Engl J Med 2006; 354: 1343-1351. CrossRef
4. Chen H, Smith GJD, Li KS, et al. Establishment of multiple sublineages of H5N1 influenza viruses in Asia: implications for pandemic control. Proc Natl Acad Sci USA 2006; 103: 2845-2850. MEDLINE | CrossRef
5. de Jong MD, Tranh TT, Khanh TH, et al. Oseltamivir resistance during treatment of influenza A (H5N1) infection. N Engl J Med 2005; 353: 2667-2672. CrossRef
6. Shortridge KF, Peiris JSM, Guan Y. The next influenza pandemic: lessons from Hong Kong. J Appl Microbiol 2003; 94: 70S-79S.
7. Li KS, Guan Y, Wang J, et al. Genesis of a highly pathogenic and potentially pandemic H5N1 influenza virus in eastern Asia. Nature 2004; 430: 209-213. CrossRef
8. Peiris JSM, Yuen KY, Leung CW, et al. Human infection with influenza H9N2. Lancet 1999; 354: 916-917. Abstract | Full Text | PDF (26 KB) | MEDLINE | CrossRef
9. Belshe RB. Influenza as a zoonosis: how likely is a pandemic?. Lancet 1998; 351: 460-461. Full Text | PDF (51 KB) | MEDLINE | CrossRef
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