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Planning for pandemics

July 22nd, 2005

The news of deaths from bird flu in Indonesia is pretty scary. Although, as I’ve mentioned recently Indonesia has made a lot of progress in many respects, the handling of this threat so far seems to show the worst of both worlds: all the ill ffects of authoritian habits combined with the timidity of weak politicians. There have been a lot of coverups, and an unwillingness to tackle the necessary but unpopular task of slaughtering affected flocks of birds. Things seem to be improving now, but there’s a long way to go.

It seems very likely that, sooner or later, bird flu will make the jump that permits human-human transmission, and quite likely that a major flu pandemic will result. The world, including Australia, is very poorly prepared for this. One thing we could do to prepare is to adopt a national program encouraging annual flu vaccinations for everyone, instead of just for limited categories of vulnerable people.

The main benefit of this is not that the shots would provide immunity against a new and deadlier flu variant (though there might be some limited benefit of this kind) but that we would have the infrastructure, production facilities and so on to undertake a mass vaccination against such a variant if it arose. As it is, it seems likely that many countries will be scrambling to get access to an inadequate world supply of vaccines, but if Australia and other developed countries ramped up normal levels of production, it would be much easier to generate extra supplies for our neighbours.

I haven’t looked into it, but my guess is that, even without considering the possibility of a pandemic, the benefit-cost ratio from such a measure would be pretty high. Flu is very costly in economic terms, and I suspect that, if pain and suffering were thrown into the balance, a program of universal free vaccination would come out looking pretty good.

Update There’s lots of good background in Foreign Affairs. A piece by Michael Osterholm reprinted in the AFR Review section recently, is very good and stimulated my thinking on this topic.

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  1. Albatross
    July 22nd, 2005 at 21:25 | #1

    There’s even more background at Flu Wiki – http://www.fluwikie.com/

  2. Harry Clarke
    July 22nd, 2005 at 22:45 | #2

    Good early responses to epidemics also include actions by the local GP. ‘Have you travelled recently?’ should be drilled into their vocabulary. Of course the local GP (like the school-teacher) is constantly pressured with requests for such ‘low cost’, well-meant interventions but I think it is worthwhile. John emphasises preparedness but also speed of response is crucial as is concentrating efforts around areas where infections first emerge. Local efforts can be surprisingly effective given the easy-to-imagine network effects. There is even a mathematical theory of the role for local actions.

    With greater international mobility greater risks but perhaps greater resistance also. And medical knowledge has advanced so far along with the ability to plan. Yet future influenza or other epidemics a certainty so a worthwhile idea. A case for taxing international tourism and travel to account for the external costs of travel? It is a difficult computation since its a standard nasty problem — a small probability of a large cost.

    By the way John the general case for early interventions in health is harder than it looks. I have done a bit of work on public health case for early screening of type 2 diabetes. The intervention cheap but lots of wrong positives and a question about the effectiveness of early diagnosis. Lots of people with high blood sugar don’t get it and even with respect to those diagnosed not great evidence that the diagnosis reduces long term complications that seem associated with the really big costs. Screening to sort out high risks almost always makes sense. Some of these same issues arise with respect to epidemics I think.

  3. Albatross
    July 22nd, 2005 at 22:58 | #3

    Phil Adams had a segment on LNL on Wednesday 20th ( http://www.abc.net.au/rn/talks/lnl/s1418730.htm ). You can find an MP3 there for download which is worth listening to if you can put up with PA’s laboured breathing adjacent to the microphone.

    For those who cannot bring themselves to visiting the old Commie’s site a useful link is W.H.O Influenza Centre ( http://www.influenzacentre.org )

  4. July 23rd, 2005 at 03:12 | #4

    Not really keen on the idea of a needle every year, but Im a baby when it comes to getting shots.

  5. July 23rd, 2005 at 05:43 | #5

    And even more background here at this blog specifically set up to cover the issue.

  6. July 23rd, 2005 at 15:36 | #6

    JQ, do you know why sheep stealing used to be a capital felony? Because when you stole a poor man’s sheep you might be literally tipping him over the edge of survival, things were so harsh in those days. That’s why the “necessary” eradication of the Haitian Creole Pig for hygiene was so harsh for their owners.

    Viewed in that “let them eat cake” light, it should be clear that your recommendation is the moral equivalent of “…deaths from AIDS… an unwillingness to takle the necessary but unpopular task of slaughtering affected homosexuals…”

    It’s not that I’m accusing you of meaning any life threatening harm, any more than the well meaning US slaughterers of Haitian peasants’ only means of survival. But that’s what these birds are in Asia, and that is what makes their politicians reluctant about it.

    And don’t start talking about compensation or replacement of stocks. That doesn’t work, in the sense of maintaining the peasants’ viability (see Haiti again).

  7. the commenter formerly known as anon
    July 23rd, 2005 at 16:07 | #7

    Seem’s like Mark Culley’s intro to the Adelaide Festival Ideas did reflect the outlook of at least one speaker:

    Choose your ribbon colour, be it green (global warming), red (war), grey (ageing), or black (pandemic disease).

    We’ve now had everything but ageing from Quiggin this week. Can we look forward to something dire on the oldies soon?

  8. kyangadac
    July 25th, 2005 at 01:33 | #8

    Couple of salutary points about the effectiveness of public health controls.

    Current flu vaccines will provide no protection against avian flu (that’s the great threat) – a vaccine against H5N1 is being developed by Chiron and Aventis – 16,000 to 20,000 doses are being produced. That will make a difference. The death rate from cases of H5N1 seen so far is about 50%.

    Micheal Osterholm mentions tamiflu – but a quick check reveals that although it may be of benefit – there are plenty of indications that resistance will readily develop and this drug will probably only be useful for the first wave of an epidemic. The current price for 10 tablets is 65 UK pounds. So I can’t see the government stockpiling anymore than is needed to protect politicians and their mates.

    The outbreak of SARS in Hong Kong demonstrated how quickly a flu like virus can spread even with quick responses from health authorities. In the case of bird flu it seems likely that there will be multiple and widespread outbreaks (its spreading through ducks an chickens and possibly other birds.) Compare this to the civet cat thought to be the source of SARS.

    Airport based quarantine is likely to slow international spread. But the spread through China and indonesia is likely to be explosive. Indonesia is relatively more open than China which means that public education and warnings are likely to be more effective in Indonesia.

    The Chinese Communist Party will porbably lose power following a catastrophic outbreak of flu. There are plenty of indications that the repression following the Tien An Min square massacre is beginning to loosen up. A predictable consequence of the last 20 years of economic growth. A catastrophic outbreak of influenza may be all it takes to blow the lid off.

    Much of the stuff about borders closing in the article by Osterhome is alarmist claptrap. Certainly there will be panic and disruption, but it will be pointless to try to blockade countries or to put up the barriers. How do you stop Australians returning home, for instance. Is this a a job for DIMIA?

    Oh and BTW Albatross, AFAIK Phillip Adams was never a a member of a communist party.

  9. conrad
    July 25th, 2005 at 09:16 | #9

    kyangadac, I think you are overly paranoid about causes of bird-flu and underly paranoid about how many people will die.

    First of all, bird-flu is nothing like SARS. SARS is quite hard to spread, whereas bird-flu just floats through the air, put there by people who can show no symptoms. Hence a few thousand vaccines are likely to make almost no difference to anything, apart from the people lucky enough to get one. Infection rates are likely to be in the hundreds of millions (as is typical of flu — meaning anyone in a big city is going to have a great deal of difficulty trying to avoid it, unless they lock themselves in their house), although generally the strains lose potency when they infect so many people (although that still might mean 10s of millions of people die). The 50% rate is also probably an over-estimate even for the current strain, as some people catch the virus but don’t show extreme symptoms (and that is true of SARS too), as was shown by an examination of people from the Dutch outbreak of bird-flu some years ago.

    The other thing is whether governments can do anything about it. If you look at the probability of things happening, then it is probably very little, unless expensive drastic changes to farming methods are made, which poor governments don’t have the money for anyway.

    For instance, lets say that the average farmer who has grade 3 education has a 50% chance of not doing anything before it is too late (or, for that matter, the average greedy Western-world farmer). THere is still a 50% chance he does. Lets now say the corrupt offical above him whose job it is to report to the next corrupt offical has a 30% chance of not doing anything. The chance of the virus not spreading is now only 35%. If you now add a few layers of corrupt officials, then the probablility of it even reaching a level where anyone can do anything about it reduces again and again. Thus whether you live in Indonesia, China, etc. isn’t going to make much difference to whether you are likely to get exposed to it.

  10. kyangadac
    July 27th, 2005 at 01:40 | #10

    conrad

    I should have indicated (heavy irony) when i wrote that 10,000 to 20,000 vaccines ‘would make a difference’.

    I was looking in the library today and in the 1919 flu epidemic they attempted to quarantine Australia and it didn’t work. The flu arrived in Melbourne on Jan 6 although the first official notification was Jan 23 it was in Sydney by 26 Jan, in February an outreak started in Newcastle and by the end of March it had spread throughout Australia along the railway lines. Of course there weren’t many cars in those days. Death rate was 20% amongst the most vulnerable which was adult males (20 – 40 years)!

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