One thing at which WHO is spectacularly successful -- sending mixed messages. In October avian influenza was a major public health threat and the world needed to do more.
While the deadly bird flu virus has not spread as widely as feared in Africa, vigilance is still needed across the world to counter its advance and deal with its impact on humans, the United Nations coordinator for the disease said today, expressing in particular "very great concern" over Indonesia, where practically the whole country has been affected. (UN's David Nabarro, October 2006)
Now we are on the verge of having an effective vaccine:
The world's ability to produce vaccine to combat a pandemic resulting from H5N1 bird flu has greatly increased over the past year, with the first doses theoretically possible within three months after the virus mutates into a strain easily passed among humans, experts said Friday after a meeting at the U.N. health agency.[snip]
Industry has been increasing its capacity and now has production processes up and running that could be switched from seasonal flu vaccines to the pandemic vaccine at short notice, with the possibility of making 1 billion doses a year, said Gust, a vaccine expert at the University of Melbourne, Australia. That would be enough to protect 500 million people, because each would probably need two doses.
"The current number is a quantum leap ahead of where we were a year ago," Gust said. He predicted that "the gap between what is currently possible and what is desirable in terms of protecting the entire planet will continue to be reduced over the next year or two." (USA Today)
These statements aren't inconsistent, of course. One could read the second as a new mood of optimism. In fact that's exactly how most people will read it, despite the fact that the fine print isn't quite so encouraging.
First, we don't know how effective the new vaccines are in protecting against the disease. All we know is some are now fairly effective at raising antibodies. We assume that translates into actual protection, and it likely does. Since there is even some controversy about the population effectiveness of seasonal vaccines, this isn't a guarantee.
The words seem to have been carefully chosen:
For the first time, results presented at the meeting have convincingly demonstrated that vaccination with newly developed avian influenza vaccines can bring about a potentially protective immune response against strains of H5N1 virus found in a variety of geographical locations. Some of the vaccines work with low doses of antigen, which means that significantly more vaccine doses can be available in case of a pandemic. (Reuters)
In other words, we once weren't sure a vaccine was possible at all. Now we are convinced we might have some vaccines that are potentially protective.
Second, as WHO notes, we are desperately short of productive vaccine capacity. The most optimistic current estimates, assuming a rapid switch from seasonal vaccine production to pandemic strain vaccine production, is about a billion doses in a year, or enough to vaccinate about 500 million people with two doses each. After a year. Given time and investment that capacity can be ratcheted up. Given time. And given investment. Why the optimism, then?
"What has been achieved is extraordinary. It is probably unprecedented. The mood has changed dramatically," said professor Ian Gust, an Australian microbiologist who has chaired all three sessions, which are also attended by companies.
"15 months ago, we were not even sure we were going to be able to make a vaccine in any time frame," he told journalists. (Reuters)
Hmmm. I suppose if you didn't think you could make a vaccine at all and now you discover, gee, maybe we can make one, you'd be happy. But the distance between what we have now and what we would need should a pandemic occur in the next two, three or even five years, seems very large indeed.
The developing world is increasingly concerned about the availability to them of a vaccine manufactured in the developed world but using vaccine seed strains from their citizens. Recently Indonesia started playing hardball by refusing to release isolates for candidate vaccine strains without an agreement the vaccines would be available to them. They have agreed to resume sharing viral isolates pending a satisfactory agreement about vaccine access in the event of a pandemic. Agreements aside, I wonder how much confidence anyone has in rich country generosity with very scarce vaccine stocks if a pandemic occurs in the next three years.
So we don't know if it will work (evidence suggests it might), but we do know we won't have enough of it for years to come. At least not enough for you.
Meanwhile, thanks for the "good news" headlines. Remember it's not what you say to people that counts. It's what they hear. In terms of keeping the focus on what needs to be done, in this case No News might have been Good News.
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So even the "positive spin" good news is: "...the first doses [are] theoretically possible within three months after the virus mutates into a strain easily passed among humans..."
Wow. Three months to produce "the first doses" of something that might work in quantities that will probably be inadequate. Sweet!
This seriously looks like a terrible-news story that the spin doctors got their hands on.
ST: I wouldn't say that. There has been progress on vaccines. It just isn't that significant in comparison to where we would need to be if a pandemic occurred in the next three years. That's a reflection of how far we needed to go.
"15 months ago, we were not even sure we were going to be able to make a vaccine in any time frame," he told journalists.
This kind of statement is essential to leadership.
A re-examination of what the World Health Organization was saying in Dec 2005-Jan 2006 would be useful at this point...
...If I remember correctly, the message was and I paraphrase...'don't worry, be happy'...it really isn't going to happen anyway. We really are only trying to make it look like we are doing something. How do you like us so far?
"All we know is some are now fairly effective at raising antibodies. We assume that translates into actual protection, and it likely does."
In general an antibody response does not ensure protection...that is why so many vaccine research efforts go in the garbage can.
H5N1 is not your regular, run of the mill virus. I believe this may be a once in 2000 biological asteroid...I don't think at this point, we should take anything for granted...
...let them demonstrate this humoral response is protective with a series of strains evolving over a year rather than a strain frozen in a lab somewhere...removing the viruses most effective tool.
'ON the verge', is that the same as 'nearly dead'� Or 'almost pregnant'� Or maybe both?
There will be no "rapid switch from seasonal vaccine production to pandemic strain vaccine production" if by pandemic vaccine we mean not just a vaccine with the pandemic strain but something that will actually make a difference to the outcome of a pandemic (I think they call it 'combat a pandemic' in the usa today article).
Cos however we work the arithmetic, you will not get the numbers needed by boosting seasonal flu uptake, which has been the pipe-dream of governments who want to appear to be doing something, as well as the WHO. Current seasonal flu vaccine distribution for ALL of SE Asia is in the order of 250,000. If you give all of that to Indonesia and no other country, that's enough to vaccinate 1 in 1000 Indonesians. Hmmm, you think that might be enough to build herd immunity? Let's say that happens at 1 in 3 having immunity, we are talking about > 300 times (not percent) increase. Anyone want to place a bet on how many pandemics from now would Indonesia be able to achieve that?
But, of course, officials can get manic-euphoric at "greatly increased" ability to make a pandemic vaccine if they ignore the existence of Indonesians and others in that category, and just focus on making "enough for domestic use". But wait, didn't somebody say back in vaccine 101 class that you needed a seed strain to make a vaccine? Oh yeah, we forgot, the Indonesians were going to lay down their lives and give us their samples so we can save our kids.
Of course. Like they owe us what?
I think my good friend David Fedson sums it up best "We should have seen this coming, folks."
There will be no pandemic vaccine (by my definition) until we switch off the autopilot called 'boosting seasonal vaccine uptake' and switch on our BRAINS!
The saddest part of that is, they talk about every latest technological breakthrough with awe and excitement, when the technology already exists to make billions of vaccines in a space of weeks. Granted, we still need to do a whole load of trials, but the biggest barrier to having pandemic vaccines for the whole world is not technology, but the regulatory sclerosis and ostrich-like mindsets of officials at the FDA, EMEA and the WHO.
Maybe the Indonesians are really doing us a favor. By showing up the nakedness of you-know-who, maybe they can actually embarrass our officials enough for something to happen?
Or have I joined the manic-euphorics?
As flublogians we thirst for truth, where the majority of civilization are content with denial. And the poverty factor plays a heavy hand in all decisions.
I have little faith in the way people would act or what they'd do if they were told the whole story, and then took it seriously. Over-reaction no doubt and then we'd be in a sticky situation. Perhaps better to be in that sticky situation though as opposed to not.
What is a percentage, even a guess, of how many people are aware of the possibility of a pandemic? We have six billion people on this globe, is that number correct?
Thank you Revere for two very succinct analyses of H5N1 news.
When AIDS appeared more than two decades past, I applied growth formulae and became v. concerned. I recall many commentators of the time repeating for the next several years that discovery of a vaccine was "imminent".
As I understand, what is being said is "we have a procedure for making an H5N1 vaccine that might work, and with existing manufacturing capacity, we have the ability to produce that vaccine for ~10% of the world population each year." Personally, I am ecstatic. A solution is now proven (probability 95%?) to exist, and what remains is mere improvement or expansion of existing technology. Compare with AIDS, where, after nearly 25 years, the best medical advice is, don't engage in sex, and if you catch it, well we can keep you alive (potentially infecting other people) for an extra ten years or so.
Wasn't there a model recently that showed that sharing vaccine with developing countries was one way to reduce deaths in developed countries?
Not that I have much hope this will impact policy, at least in the U.S. Even assuming policy-makers were aware of this prediction, I don't think it would matter. Our country has shown little propensity towards acting in our own enlightened self-interest, and our leaders little interest in leading us that way.
Lea - 6.5 billion humans - 75 million additional each year as well. 3 billion live on $2 a day or less. In 1918 the world population was 1.8 billion. Perhaps even more significant than the increase in people is the increase in swine and chickens. I saw the numbers once and the increase I think was on the order of 10 fold to the human tripling. One site says that 46 billion broiler chickens are slaughtered each year - Add to that all the egg chickens and H5N1 has lots of potential hosts eh?
Daily births in the world 364,000 - deaths 152,000 - 212,000 more humans for the planet so support each and every day
http://www.census.gov/cgi-bin/ipc/pcwe
Thank you K.
caia: I think it was Vittoria Colizza's model in PLoS Medicine a couple of weeks ago. I read it. Interesting in several ways. I was going to post on it, but then decided to post on Marc Lipsitch's antiviral model, and then I thought, wouldn't it be interesting if I led people through it paragraph by paragraph. Yeah. I have now drafted five posts and am still in the middle of the Methods section. I'm now wondering if anyone would read it.
Revere - Post it, I'll read it. ;^)
Pneumonia shots are available now.Would this not provide some protection as both illnesses often occur together.
Back a few months when there was the scare because Indonesian family members transmission seemed to imply H2H2H, there was, as I recall, a report that the US government flew quite a lot of Tamiflu to Jakarta.
My recollection is that when the cycle of infection ended (P2P2P then stop) then the scare ended. It was later theorized that there might have been some sort of family predisposition to infection.
But (if my recollection is correct) the US government actually did act on that occasion (not necessarily altruistically), perhaps just anticipating that the best strategy to stop a pandemic was at source.
Wayne, getting the Pneumovax now would be a good idea. (Saying you want it in case of pandemic is sometimes not a good idea) I did see some recommendation that MA increase the number of people, especially living in institutions, who've had the pneumonia vaccine, if only to reduce complications from influenza (and other diseases) at a time when no medical care/imported meds will be available to treat preventable cases of pneumonia.
There is also a pediatric version of the vaccine.
Avoiding panflu infection looks to be a matter of life or death, so,
make preparations to be able to do that, also,
but meanwhile, having the protection provided from the vax is helpful for many years (isn't it also against some forms of meningitis, and blood poisoning, not just pneumonia?)
Make sure you're up to date on all of your shots (how would you be able to get a tetanus booster, ect, during a panflu year?)
Many things could become problems; how are they going to keep the power grid up, and make rabies vaccine, and the vaxes "travellers" need in "less developed" countries?
We're all going to be in a "less-developed" country once pandemic breaks out.
:-/
Wayne: You are correct. I believe the New England state epidemiologists recommend getting both flu and pneumovax, but you'll likely have to ask for it as primary care docs don't usually bring it up. It's definitely a good idea.
bar: There was indeed a report that the US sent some of its stockpile to Indon at the time of the Karo cluster last year. I was never able to get details on it. Anyone else (beyond the sketchy reports we posted here at the time)?
Thank you for your reply to my question on getting the pneumovax shot. Perhaps I was lucky or I have a good doctor but I simply asked for the shot along with my fiu shot and he said sure ok.I am now trying to persuade the rest of my family to get the shot but many people simply do not take this Bird Flu threat seriously.
Revere: I had the feeling that whoever in the US shipped the Tamiflu was being very quiet about it. I remember thinking that when I noted that it wasn't reported until several days after the delivery. I can think of a reason why they might have been surreptitious about that delivery. That reason is why I watch your site.
Sorry, the links to my post didn't work.
Fedson's quote is from Helen Branswell's article here http://bodyandhealth.canada.com/channel_health_news_details.asp?news_id…
And the link to the Flu Wiki forum on 'Enough Pandemic Vaccines for the whole World?' is here http://www.newfluwiki2.com/showDiary.do?diaryId=878
The US did send part of its own tamiflu stockpile to an undisclosed location in the Pacific at the time, in anticipation of possibly helping the Indonesians should the outbreak go further. It actually was not very quietly done. Mike Leavitt announced it at one of the WHO meetings, very high profile. I emailed one of his aides for confirmation of the story, and he did confirm that the media reports were correct.
I don't believe it was ever deployed though.
Before you jump out to get the pneumovax let me warn you. That shot HURTS. I was also told to schedule it for a weekend vaccinaton. I did and it took my arm (not me) out for a day and a half. Numbness down to my fingers, but hey guess what ? Old Randolphus hasnt had even a sniffle this season so far. Next door neighbors got terribly sick over Xmas and the school was closed for three days for a flu epidemic after everyone came back. But them Krugers were alive and kicking. The kids and wife had both shots flu and p.vax. They were a little icky in January but not enough to take them down. All in all though, that p.vax is one baddassed shot and even though it hurt like hell I would do it again.
Revere, is there a booster for that p.vax or am I truly good to go until I am 65? I can afford a sore arm every year or so if it produces the effect that it has.
(did some place think taking anti-inflammatories at the time of getting vaxed didn't help one of the shots for something - flu?- "take"?)
MRK I don't recall it being that bad, but
I'm 46 today and I don't think I'd have to wait until I'm 65 to get another.
-Revere, tell me if I'm recalling this incorrectly -
(A doc I know said the increasing reactions to the pneumovax seem to be mostly in the elderly and ill; that can't make antibodes well anymore? Maybe I'd be good for 10 years and then could get another pneumovax?)(Civilization permitting...)
With regard to the pneumovax vaccine I read somewhere that there were two versions of it, one that contains potentially harmful mercury and one that doesn't, and that you should specifically request the one that doesn't. If anyone knows about that a few words or a link would be much appreciated.
Revere If you found Vittoria Colizza's model worth taking paragraph by paragraph, I bet there are a bunch of people here who'd be interested in your take. I don't know much about that study in particular, but generally speaking, if you find it worth writing, I'll probably find it worth reading. :)
Randy I had the pneumovax over a year ago, and IIRC, they said I wouldn't need it again for 5-10 years. (Pneumonia strains don't mutate at the rate of flu viruses, apparently.) I also don't remember it being particularly painful, as vaccinations go.
Oh shit. They poisoned me with mercury! Only kidding. No I did specify that to the agency for myself and all my people and family. EVERYONE but a 19 year old hurt, went numb a little or in varying degrees very tingly in the arm and fingers.
Seriously though, no one who took it has been more than just a tad ill. Snotty noses a little but no take downs for the flu bed. They took both shots for the better part though. I only took the p.vax.
Tamiflu is in high supply in Indon, Taiwan, China, Macau, Vietnam (remember the visit by the HHS secretary?), Phillipines, Laos, Cambodia. Flown to the old Clark Airbase in the P.I. it has been shotgunned out now to just about everyone and in quantities to be able to throw a blanket over an outbreak. Now it would be nice if the stuff just worked. Nothing I have seen ever indicated it did anything or change definitively an outcome. Revere....anything on that?
Regarding the pneumovax, can kids (age 12 and above) get the same innoculation dose as adults? Thanks.
I dont know what the dosage is for kids and what defines what a kid is for this. My kids got it so I guess the protection level grows with them. My youngest is 13 and he got it. Revere?
Yes, OK for children over 2 years. Same dosage, I believe.
revere: I'll assume your silence on the mercury situation means you don't think there's any possibility of danger from vaccines that contain mercury. I myself haven't read a whole lot about that but I know some people do think there is a danger and someone on one of the flu boards said there were two versions of the pneumovax, one with and one without.
Jon: I think non mercury preservatives would be better, just on general principles. Having said that, I don't see much evidence that thimerosol is causing a problem. I base this partially on what I have read on the subject and also on close colleagues who are either world authorities on mercury (and who are quite aggressive about its dangers) or world authorities on autism. That's the best I can do at this point.
Thanks.