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Preventing the Big One Requires Two-Pronged Attack on Flu

Author: Laurie Garrett, Senior Fellow for Global Health
November 16, 2004
USA Today


Concern over the flu-vaccine shortage misses the point: In no year have we manufactured sufficient vaccine to slow a major influenza pandemic, and thanks to a combination of biological obstacles and drug-company disinterest, it is unlikely we will be ready for the next Big One.

Though the economy has globalized, we still go about the business of flu defense one nation at a time. Most nations have never had the luxury of influenza vaccination.

Last week, the World Health Organization (WHO) held an emergency summit of vaccine makers and health officials in Switzerland to discuss this year's shortages and the implications for a true influenza crisis. The summit's conclusion: Things are bad, and they may get a lot worse. WHO estimates that in a good year, the world produces 260 million flu-vaccine doses. But almost all of those go to the wealthiest 5% of people on the planet -- most of whom live in the USA, Canada and Europe. That the United States faces a shortfall this year merely means that we are getting a taste of what billions of people in the world experience routinely.

The U.S. Department of Health and Human Services' (HHS) report in August on pandemic-influenza preparedness does little more than fine-tune a business-as-usual national approach. Flu plans in other nations are even less inspired.

About time for a change

This must stop. For two decades, I have been attending meetings in the United States where scientists warned that it is only a matter of time before the Big One -- another supervirulent influenza akin to the 1918 killer that claimed 50 million lives -- emerges, circulating the planet in a matter of jet-fueled hours, rather than the months required a century ago.

Even the U.S. vaccine industry could not produce sufficient supplies under such urgent circumstances to cover our needs, much less assist our neighbors and allies. What is required is a two-pronged approach: Improve vaccine output, but also attack the flu at its source.

Flu vaccines are hard to make, cannot be stockpiled and must be newly designed and manufactured annually. In our globalized world, the pace of genetic change in the influenza population has escalated to the point where it is no longer possible to make a monovalent vaccine, or one that targets a single type of flu: Typically we now make trivalent vaccines, which are considerably more expensive and difficult to produce.

Combined, the entire vaccine market for all types of immunizations used in the world brings in less profit than any one top-selling drug, even a blockbuster such as Prozac. In the absence of new methods of making and paying for flu vaccines, we can't begin to dream of adequate national vaccine protection, much less global.

Meanwhile, danger lurks. Avian influenza has surfaced in 10 countries, killing 32 people and 120 million domestic birds -- either because of the flu or culling to stop its spread. If one of those strains manages to change genetically into a human-to-human transmissible influenza, it is possible the world might again face a pandemic crisis.

That is why we urgently need to rethink the entire global influenza approach -- one that looks at how we can stop the flu at its source.

Influenza is an aquatic-bird virus that finds its way from migratory ducks and geese to human beings via livestock in southern China, Hong Kong and occasionally Thailand and Vietnam. In its aquatic-bird form, the virus is harmless to humans. But in southern Asia, migratory birds commonly poach food from farm animals, passing their flu viruses onto chickens and ducks.

Eventually, the flu passes from poultry to Asian pigs and horses, acquires genes that enhance the infection of mammals, becomes a humanly infectious microbe and BINGO: We have another epidemic.

Danger in China

Until last year's SARS epidemic shamed China into taking seriously its role as a public health citizen in the world, Beijing's leadership was reluctant to acknowledge the country's key ecological role with regard to influenza. That is beginning to change, but time is short: While China and the rest of the world dither in a business-as-usual mode, the risk of pandemic flu is rising because Chinese people are getting wealthier. With wealth comes increased chicken and pork consumption, spawning vast poultry farms through which flu viruses rage like brush fires on a parched California hillside.

President Bush should call upon the world to take a global view of the crisis. He should instruct the State Department, Agriculture Department and HHS to work with China and its neighbors to develop safer ways to raise and slaughter millions of ducks, chickens and pigs every year, and keep migratory birds away from livestock.

The U.S. pharmaceutical industry should be encouraged to collaborate with its Chinese and Hong Kong counterparts, with an aim toward immunizing farmers, animal handlers and consumers at the source, before the flu globalizes.

And on the home front, the president simply has to stop dodging the explosive issue of how to create incentives in the pharmaceutical industry that lead to the production of low-profit products that save the world, not just handfuls of lucky Americans, Canadians, Europeans and Japanese.

Laurie Garrett is a Pulitzer Prize-winning journalist and senior fellow for global health at the Council on Foreign Relations.

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