Influenza Pandemic: Are we ready?

Published on April 19, 2005 - As if Aids, dengue fever, malaria and a host of other diseases weren’t enough for over-burdened public health programmes, a new challenge has emerged. When it arrives, it could prove more deadly than all the others. For the first time in history, however, science has provided warning signs, allowing us to prepare. So are we ready? This is the first of a three-part series.

Influenza is an ancient disease that never ceases to surprise us, reads the opening line of Dr Prasert Thongcharoen’s seven year-old book “Influenza”. Now, he fears the next surprise is right around the corner and most people have no idea of the potential catastrophe it represents.

Dr Prasert, 71, one of Thailand’s leading microbiologists, points out that three to four times every century a new bird-flu virus, for which humans have not yet developed natural immunities, enters the population. “Scientists all know the next influenza pandemic is coming,” he says. “We just don’t know when.”

Some estimate that as many as 100 million people died of the Spanish flu in 1918; one to four million during the Asian flu of 1957 and 1958; and a further one to four million during the Hong Kong flu of 1968 and 1969.

Scientists fear that the present H5N1 strain of bird-flu virus that has so far killed 52 people in Vietnam, Thailand and Cambodia and forced the culling of more than 60 million chickens in Thailand alone, poses a significant risk to humans, potentially in line with the Spanish flu.

The virus is now endemic to the region, increasing the likelihood that it could develop the ability to spread within the human population. Seventy per cent of people known to have caught the virus have died.

Thailand is at stage two of a three-stage, pre-pandemic alert system used by the World Health Organisation (WHO). This means a new virus has been identified, has infected more than one person, but has not yet developed the capacity for human-to-human transmission.

WHO officials estimate that as many as 100 million people could die, should an H5N1 pandemic occur.

During the Spanish flu, one in every five Thais fell ill, and one in every 100 died. Mortality figures were much lower during the Asian and Hong Kong flu epidemics, but millions still fell ill. One in 20 Thais sought medical attention during the three-month outbreak of the Asian Flu.

H5N1 is not the only concern either. The potential for a pandemic is escalating dramatically. From 1960 to 2000 there were just 18 outbreaks of avian influenza with a high capacity for causing disease, leading to the loss of about 23 million birds. From 2000 to 2004 there were 15 outbreaks affecting 200 million birds.
In addition to the H5N1 virus, there have been four other new avian-flu strains affecting humans since 2000. This is why the WHO and others are urging countries to develop pandemic preparedness plans.

“One would think that following Sars (Severe Acute Respiratory Syndrome), in 2003, the government would have invested in researching and preparing for emerging transmissible diseases, but that doesn’t seem to have been the case,” says Dr Kritaya Archavanitkul, a sociologist at Mahidol University’s population and society research institute.

It was not until this January that the Cabinet approved specific plans to address the threat to achieve “efficient pandemic preparedness within one year”.
Some health experts who reviewed the national strategic plan for influenza pandemic preparedness say it offers a good framework, but question how well it will be implemented.

“I’ve also heard there are internal differences within the government about the necessity of such a plan,” says Dr Somsak Chunharas, secretary-general of the National Health Foundation. “It sounds to me like the government is trying to put it off.”

Indeed, a major premise of the Thai strategy is for the fundamentals of preparedness to be worked out by the various ministries and among the provinces themselves. So far, this has been slow to happen.

“Obviously (as a doctor), I know that (the risk of) a pandemic is something that we must pay attention to, but I’ve neither seen nor heard anything about a national preparedness plan, or how we fit into developing our own plan,” says Dr Pitinan Najrujiroj, deputy permanent secretary of the Bangkok Metropolitan Administration.

Chiang Mai Governor Suwat Tantipat is equally unfamiliar about the national preparedness effort.

“I haven’t heard about the pandemic plan,” he says, “but if someone like the WHO has issued warnings, we must take it seriously.” Dr Preecha Prempree, an architect of the national plan, acknowledges that some coordination is still lacking.
“We sent out our plan to everybody as a model for them to write their own action plans. It’s really out of our hands now. We really don’t have the resources to determine how and if such plans will be produced.

“There is no deadline for them either,” he continues, “but we did give them a checklist to make sure they didn’t forget anything.”

Meanwhile, Dr Preecha and his team have been trying to organise exercises. However, their first drill, which was scheduled to take place last month in Lopburi province, was postponed because of changes in Cabinet positions.

“We were supposed to be a pilot area and we were getting ready for it [the exercise],” says Wichai Srikwan, Lopburi’s governor. “Now I don’t know when it will happen.”

The removal of Deputy Prime Minister Chaturon Chaisang from the task of overseeing bird-flu controls and pandemic preparedness took many by surprise because he had developed a thorough understanding of the issues.

“They removed the man who knew what to do,” Prasert says. “Now, someone else will have to start all over again.”

Lopburi’s awareness of the preparedness plan is clearly an exception. For example, one critical aspect of the plan calls for coordinated efforts to maintain “internal peace and security”. Dr Preecha says that once a major flu pandemic arrives in Thailand, it is likely that areas will be quarantined, transportation will be restricted and shopping centres will need to be closed to impede the spread of the virus.

So far, however, the military, which was so visible during the tsunami recovery effort, is not aware of the pandemic preparedness plans.

“We know we will have to take care of our own people first and administer to the soldiers and their families’ needs,” says Colonel Kobpanya Wongwisetkit, director of the medical division, Supreme Commander’s Office. “But we have not yet been directed to undertake any specific response training. Of course should we be directed to do so, we will.”

The need for additional resources for preparedness has not gone without notice in Parliament. The pandemic threat will be the main topic of a two-day seminar being hosted by the Parliament for officials from Asean countries, beginning today.

“We need much more coordination,” asserts Senator Dr Malinee Sukavejworakishe. “The government will not be able to handle this alone. Preparedness means planning, communicating and practising, but very few people know what’s going on. If we can't coordinate a national effort to develop a plan, how can the public feel any confidence in our ability to coordinate a response once the crisis is upon us?”

Because the majority of new influenza strains emerge in Asia, where large human populations live closely with domestic birds and animals, countries in the region are vital to the overall state of global pandemic preparedness, says William Aldis, WHO representative in Thailand.

“If there’s an absence of that [preparedness planning], we could be in serious trouble,” he states.

“Thailand is on the right path to put a plan in place.”

Thailand’s pace toward pandemic preparedness is not unique. Many Western countries have plans in place, and in the region the Philippines, Hong Kong, Singapore, Malaysia and Thailand have plans, at least on paper.

“The completion of a strategic plan is a great start, but we have a long way to go before we can declare ourselves prepared,” warns Dr Somsak of the National Health Foundation. “The government has many plans, but what matters is whether they are tested and operational.

“If you want to know how effective Thailand is in disease control, just look at our failure to get rid of cholera and dengue fever. Mosquitoes are easy to control, as many countries have shown, but we still have regular dengue outbreaks here.”

Dr Kamnuan Ungchusak, director of the epidemiology bureau and an architect of Thailand’s preparedness plan, has a final word for preparedness planners: they need to be ambitious.

“We can’t say we will get ready in five years,” he says, “otherwise nothing will get done now.”

Nantiya Tangwisutijit
The Nation