Preparing for the Next Pandemic

Michael T. Osterholm

From Foreign Affairs, July/August 2005

Summary:  If an influenza pandemic struck today, borders would close, the global economy would shut down, international vaccine supplies and health-care systems would be overwhelmed, and panic would reign. To limit the fallout, the industrialized world must create a detailed response strategy involving the public and private sectors.

Michael T. Osterholm is Director of the Center for Infectious Disease Research and Policy, Associate Director of the Department of Homeland Security's National Center for Food Protection and Defense, and Professor at the University of Minnesota's School of Public Health.

In short order, the global economy would shut down. The commodities and services countries would need to "survive" the next 12 to 36 months would have to be identified. Currently, most businesses' continuity plans account for only a localized disruption -- a single plant closure, for instance -- and have not planned for extensive, long-term outages. The private and public sectors would have to develop emergency plans to sustain critical domestic supply chains and manufacturing and agricultural production and distribution. The labor force would be severely affected when it was most needed. Over the course of the year, up to 50 percent of affected populations could become ill; as many as five percent could die. The disease would hit senior management as hard as the rest of the work force. There would be major shortages in all countries of a wide range of commodities, including food, soap, paper, light bulbs, gasoline, parts for repairing military equipment and municipal water pumps, and medicines, including vaccines unrelated to the pandemic. Many industries not critical to survival -- electronics, automobile, and clothing, for example -- would suffer or even close. Activities that require close human contact -- school, seeing movies in theaters, or eating at restaurants -- would be avoided, maybe even banned.

Vaccine would have no impact on the course of the virus in the first months and would likely play an extremely limited role worldwide during the following 12 to 18 months of the pandemic. Despite major innovations in the production of most other vaccines, international production of influenza vaccine is based on a fragile and limited system that utilizes technology from the 1950s. Currently, annual production of influenza vaccine is limited to about 300 million trivalent doses -- which protect against three different influenza strains in one dose -- or less than one billion monovalent doses. To counter a new strain of pandemic influenza that has never circulated throughout the population, each person would likely need two doses for adequate protection. With today's limited production capacity, that means that less than 500 million people -- about 14 percent of the world's population -- would be vaccinated within a year of the pandemic. In addition, because the structure of the virus changes so rapidly, vaccine development could only start once the pandemic began, as manufacturers would have to obtain the new pandemic strain. It would then be at least another six months before mass production of the vaccine.

Even if the system functions to the best of its ability, influenza vaccine is produced commercially in just nine countries: Australia, Canada, France, Germany, Italy, Japan, the Netherlands, the United Kingdom, and the United States. These countries contain only 12 percent of the world's population. In the event of an influenza pandemic, they would probably nationalize their domestic production facilities, as occurred in 1976, when the United States, anticipating a pandemic of swine influenza (H1N1), refused to share its vaccine.

If a pandemic struck the world today, there would be another possible weapon against influenza: antiviral medicine. When taken daily during the time of exposure to influenza, antivirals have prevented individuals from becoming ill. They have also reduced the severity of illness and subsequent complications when taken within 48 hours of onset. Although there is no data for H5N1, it is assumed antivirals would also prevent H5N1 infection if taken before exposure. There is no evidence, however, that current antiviral influenza drugs would help if the patient developed the kind of cytokine storm that has characterized recent H5N1 infections. But barring this complication, H5N1 should be treatable with Tamiflu (oseltamivir phosphate), which is manufactured by the Roche pharmaceuticals company in a single plant in Switzerland.

In responding to a pandemic, Tamiflu could have a measurable impact in the limited number of countries with sizable stockpiles, but for most of the world it would not be available. Although the company plans on opening another facility in the United States this year, annual production would still cover only a small percentage of the world's population. To date, at least 14 countries have ordered Tamiflu, but the amount of these orders is enough to treat only 40 million people. The orders take considerable time to be processed and delivered -- manufacturing can take up to a year -- and in an emergency the company's ability to produce more would be limited. As with vaccines, countries would probably nationalize their antiviral supplies during a pandemic. Even if the medicine were available, most countries could not afford to buy it. Critical antibiotics, for treatment of secondary bacterial infections, would also be in short supply during a pandemic. Even now, supplies of eight different anti-infective agents are limited in the United States due to manufacturing problems.

Aside from medication, many countries would not have the ability to meet the surge in the demand for health-care supplies and services that are normally taken for granted. In the United States, for example, there are 105,000 mechanical ventilators, 75,000 to 80,000 of which are in use at any given time for everyday medical care. During a routine influenza season, the number of ventilators being used shoots up to 100,000. In an influenza pandemic, the United States may need as many as several hundred thousand additional ventilators.

A similar situation exists in all developed countries. Virtually every piece of medical equipment or protective gear would be in short supply within days of the recognition of a pandemic. Throughout the crisis, many of these necessities would simply be unavailable for most health-care institutions. Currently, two U.S.-based companies supply most of the respiratory protection masks for health-care workers around the world. Neither company would be able to meet the jump in demand, in part because the component parts for the masks come from multiple suppliers in multiple countries. With travel and transportation restricted, masks may not even be produced at all.

Health-care providers and managed-care organizations are also unprepared for an outbreak of pandemic influenza today. There would be a tremendous demand for skilled health professionals. New "hospitals" in high school gymnasiums and community centers would have to be staffed for one to three years. Health-care workers would probably get sick and die at the same rate as the general public -- perhaps at an even higher rate, particularly if they lack access to protective equipment. If they lack such fundamental supplies, it is unclear how many professionals would continue to place themselves in high-risk situations by caring for the infected. Volunteers who are naturally immune as a result of having survived influenza infection would thus have to be found and employed. That means that the medical community's strong resistance to using lay volunteers, which is grounded in both liability concerns and professional hubris, would need to be addressed.

Other unpleasant issues would also need to be tackled. Who would have priority access to the extremely limited antiviral supplies? The public would consider any ad hoc prioritization unfair, creating further dissent and disruption during a pandemic. In addition, there would not even be detailed plans for handling the massive number of dead bodies that would soon outstrip the ability to process them. Clearly, an influenza pandemic that struck today would demand an unprecedented medical and nonmedical response. This requires planning well beyond anything devised thus far by any of the world's countries and organizations.