Maybe not what you think. Read on.
The WHO pandemic influenza draft protocol for rapid response and containment released on 27 January was a giant step in the right direction. Here’s why.
Several important facts previously obscured by silence points were made clear.
WHO has decided in principle that rapid response and containment is worth a try. (The architect of that decision may be Shigeru Omi, WHO’s Western Pacific regional director, who has been prominent of late in promoting the need for a rapid containment force.)
[WHO]
“Containment of a potential pandemic has never been attempted; the world has never before received an advance warning that a pandemic may be imminent. The practical and logistics challenges are formidable and success is not assured. Nonetheless, the strategy should be pursued for several compelling reasons.”
Four reasons are given: first and foremost, successful containment might avert millions of deaths and untold economic loss. The other reasons are more or less valid if not quite so compelling.
(The WHO strategy of rapid containment is predicated / rationalized to some extent on “decisive public health actions” in 1997 and 2003 that contained SARS outbreaks.)
Not the much anticipated declaration of Phase 4 Pandemic Alert, this draft protocol is an important declaration nonetheless. By making it public, WHO is either bidding for global authority to initiate and manage rapid containment, or they’re being pushed forward in that capacity by unseen authority.
It’s still not clear what actual global authority might attend WHO’s bid for it. It was recently suggested on FluWiki that WHO’s late arrival in Turkey and its seemingly inadequate readiness to go there may have provoked calls for an EU rapid response force. But it so happens the EU was considering a “Civil Protection Mechanism” before the Turkey outbreak that the outbreak must have hastened.
MEMO/06/50 Date: 27/01/2006 Questions and Answers on the EU’s Civil Protection Mechanism
In any case, uncertainty as to WHO’s global authority may be substantially resolved circa 6 to 10 March 2006 at a “…global meeting in Geneva to reach agreement on all fundamental concepts and critical procedures.”
The draft protocol for rapid response and containment bravely indicates WHO’s present rapid response and containment capabilities are minimal by comparison to the operational requirements of some future intervention of reasonable scale. If Turkey had been the signal of sustained human transmissibility, WHO would have had no chance to contain it.
So here WHO has come clean a bit. While bidding for the containment management contract, they’ve indicated that containment is a good idea, promoted its necessity, admitted they haven’t had it covered, and admitted furthermore, that if they can get international agreement and cooperation between now and March, it’ll take at least six months to build an organization and capability some assumed they had six months or more ago.
Furthermore, recognizing the inherent difficulty of getting unreserved cooperation and building flawless working relationships throughout the world, WHO has presented its bid for pandemic authority as a carrot and a stick. Their message is clear: play ball or else. Cooperate or die.
I like that: hardball: brutal honesty at a time when it’s never been more needed; in many ways, the most significant mission statement to be issued by any organization in years.
Stepping up to the task, WHO bids to be like Commissars attached to the Russian Army. (In the words of Buckaroo Bonzai, “No matter where they go, there they are”.) This is no baloney, folks, like putting the Red Cross in charge of the war effort, it’s unprecedented in recent history, if not history, full stop. All past alliances are distant analogs to this.
WHO’s draft protocol gives us significant clues to their sense of what might be possible and practical. It tells of a Tamiflu / antiviral blanket to be thrown over the quarantine zone, including this:
[WHO]
“The stockpile will increase by an additional 1 million doses by the end of February 2006, and reach a total of 3 million treatment courses by May 2006.”
So it seems WHO’s Global Tamiflu Stockpile could be increasing, at least in the near term, at the rate of 1 million treatment courses per month.
[WHO]
“The drugs will be provided to ill persons for treatment, and to persons without symptoms for prophylaxis. Doses and duration of treatment will be based upon the most up-to-date information available at the time. Prophylaxis will continue for at least one week after the last day of the infectious period of the most recent case. It is anticipated that quarantine and prophylactic use of antiviral drugs will continue for 4 to 6 weeks and possibly longer.”
With treatment and prophylactic use of antiviral drugs thought to continue for 4 to 6 weeks and possibly longer, this statement sheds light on the theoretical limits of a WHO area quarantine. First impressions suggest WHO would battle an outbreak in a rural area, (eg, Eastern Turkey), but not in a major city such as Hong Kong, Jakarta or Istanbul. What that means exactly remains to be seen, as what WHO might actually do would follow developing capabilities, but for now, this draft protocol gives us public notice of reasonable expectations. That’s a giant step in the right direction for WHO, and we should hope successive amendments to the draft protocol are made public as they inform the containment plan.
The draft protocol states:
“Containment will be strongly considered in the following circumstances:”
“An influenza virus isolated from an ill person has a haemagluttinin gene derived from a nonhuman influenza virus and one or more internal genes derived from a human influenza virus.”
“Epidemiological evidence indicates that infection from a novel influenza virus has been transmitted from an index case to five or more secondary cases.”
“Epidemiological evidence indicates that infection from a novel influenza virus has been transmitted from three or more secondary cases to tertiary cases.”
“Other evidence strongly suggests that efficient and sustained person-to-person spread of a novel influenza virus is occurring.”
The draft protocol further states:
“ International field teams will be deployed to a country only at the request of that country.
Each team will be configured to address the tasks at hand, but a typical team may consist of … epidemiologists (some with clinical backgrounds) and laboratory testing experts.
Thus, if any one of the four criteria for considering containment give sufficient grounds; if three of the four criteria cited don’t involve lab testing; and if a WHO International field team includes epidemiologists and laboratory testing experts, then a field test regime / criteria might be made much more fit to the purpose of prompt, effective containment.
Learn to love the WHO? That remains to be seen, and there’s plenty more to be done, but their bid for power is giant step in the right direction.
Nice analysis. As noted in our discussion in another thread, there’s more to pandemic preparedness and management than updating the internet table on their website. But what’s left out in the analysis is how extrodinarily high the barriers are to doing this. Just a few examples:
Note that WHO doesn’t have the infrastructure to do this. They’ve raised expectations, though. Let’s see what they do regarding deliverables and metrics to measure quality.
how can they contain an outbreak ? The key is early identification, but I can’t see any activities in this direction. Also, they seem to intend to keep this identification secret. Maybe because that makes quarantine easier ? But that means, that we have less time to prepare or relocate.
One reason I have been so pointed in my criticisms of the Director-General and his pandemic czar is that I don’t want to imply that I think everyone at the WHO is incompetent (or worse). I think the WHO has done a lot of good and the rationale for this type of organization is strong. Shigeru Omi is one of the people at the WHO that I like. I agree with Dubina that draft protocol for rapid response and containment is a step in the right direction. I suspect that there are factions at the WHO, some motivated by a desire to do their best to prevent or at least delay and ameliorate the effects of a pandemic and others who are amoral careerists motivated solely to please their political masters. The question is: How to help the former do their job? I think shining a bright light on the latter is one way to help.
gs,
“how can they contain an outbreak ? The key is early identification, but I can’t see any activities in this direction.”
You’ll find it by looking in “cooperate or die”.
[WHO]
“Early containment of an emerging pandemic virus represents an opportunity to stop or delay an event of predictably severe consequences for human health and the global economy, and this opportunity must be seized, even in the absence of any guarantees of success.”
“Successful containment will be difficult to achieve and will succeed only if a strategy for rapid response and containment is integrated into existing national pandemic preparedness plans. Success further requires that first detection of a “signal” of improved transmissibility of the virus be followed, within days to a few weeks, by full implementation of containment measures. If implementation takes place outside this narrow timeframe, the chances of success are substantially reduced.”
“Develop, through a coordinated international approach, the capacity to rapidly detect, assess, respond to and, if possible, contain, the earliest emergence of a pandemic virus.”
Overall concept
“Countries will be responsible for conducting surveillance to monitor for signals that may indicate that a novel influenza virus has begun to spread from person to person and thus trigger the intervention. Potential signals include the identification of a virus with certain genetic features, the detection of certain epidemiological patterns, or an unforeseen combination of laboratory and epidemiological findings. In line with requirements set out in the International Health Regulations (2005), the country is expected to report the event to WHO within 24 hours.”
Primary responsibilities
3. Stockpiles
Wait, that’s not all !
“Ideally, all stockpiles will contain essential supplies in addition to antiviral drugs. The ideal inventory will vary depending on circumstances in individual countries and regions. For containment purposes, WHO proposes that strong consideration be given by all stockpile controlling authorities to include the following:”
Personal protective equipment (PPE) kits consisting of:
“Containment will not be attempted in the following circumstances:”
“There is no laboratory confirmation (PCR, virus isolation or seroconversion) of infection caused by a novel influenza virus.”
“The distribution of cases of infection caused by a novel influenza virus occurs over an area that is considered too large to implement quarantine or in a population that is too large to be covered by available supplies of antiviral drugs.”
“The time from onset of the index case to implementation of quarantine and administration of antiviral drugs is considered too prolonged (greater than 6 weeks).”
8. Country responsibilities in a containment situation
“If a containment effort is undertaken, the country, in consultation and collaboration with the WHO field team, will be responsible for the following:”
“Implementation and maintenance of quarantine of all persons and vehicles around the area of the outbreak.”
“The size of the quarantined area is expected to vary depending on the specific situation. If the area or size of the population within the quarantine zone appears to be too large for available staff and supplies, an immediate consultation will be held between the field team, national authorities, and WHO to decide whether to terminate containment procedures or whether to proceed.”
gs, first think of the phrase “fit to purpose”. Containment of a local / rgional / national / transnational influenza pandemic has never been attempted before, never even imagined, I suppose. This draft protocol tentatively identifies some things that must happen for containment to have any chance of success. Some of those things, particularly the transnational coordination and cooperation items, would be exceeding difficult to plan and affect. As a plan, though, it’s fit to purpose. Now, given that plan, WHO will be challenged to find definitive ways to make it work. Nindful of the gravity of the situation and its own nascent organization, WHO has challenged individual states to organize and cooperate in their respective self-interests. The message to countries is clear: be prompt and be forthcoming or you get the snietzel. For that matter, we all get the snietzel.
I see nothing to indicate “identification would be kept secret”. Indeed, I’m not sure what you mean by that.
(Someone else who knows the expression “It’s had the” (proverbial) “schnitzel” !
When Dr. Osterholm said, if it happens this year, “We’re all screwed” he might have said, “We’ve all had the schnitzel!” )
And we’ll all have the schnitzel whenever it happens if we don’t cooperate !
“We’re all in this together” has never had more meaning than now.
“– Consideration should be given to stockpiling a small number of ventilators (for example, 10 to 20) regionally. However, if ventilators are stockpiled, then the groups maintaining the stockpiles must also plan for having respiratory staff and technicians available to use and maintain these machines plus all associated supplies needed to use these machines.”
This is the first mention of having equipment and personnel for critical support in any plan (I have read dozens) I have seen. Even the best critical care nurses and respiratory therapists will be lost in this kind of setting. WHO/HHS/NIH/FEMA/XXX needs to train local medical teams how to use the equipment in the setting of mass casualty care.
Related to ventilators and other critical support:
8. Country responsibilities in a containment situation
If a containment effort is undertaken, the country, in consultation and collaboration with the WHO field team, will be responsible for the following:
The size of the quarantined area is expected to vary depending on the specific situation. If the area or size of the population within the quarantine zone appears to be too large for available staff and supplies, an immediate consultation will be held between the field team, national authorities, and WHO to decide whether to terminate containment procedures or whether to proceed.
The drugs will be provided to ill persons for treatment, and to persons without symptoms for prophylaxis. Doses and duration of treatment will be based upon the most up-to-date information available at the time. Prophylaxis will continue for at least one week after the last day of the infectious period of the most recent case. It is anticipated that quarantine and prophylactic use of antiviral drugs will continue for 4 to 6 weeks and possibly longer.
Examples include the provision of necessary support (food, water, medical care, shelter, mental and psychological support) and ensuring the safety of people within the quarantine zone.
Nobody would tolerate the idea of a military-enforced quarantine ring without assurances that those inside the ring would not be hung out to dry. Despite that obvious fact, nobody’s made that committment until now. Nobody’s had enough gumption to mention containment and quarantine in the same breath.
They should say “temporary quarantine” or even “temporary, hotel-like quarantine”. We want to stop the disease and treat people well. A matter of perception, really, but it would work for me.
Yes, the draft protocol requires some thinking between the lines, but I think it’s a very smart document. A good (new) start, for sure.
dubina: your posts are so long. Few people will read it all. The signals, how to detect them early ? They must encourage people to immediately report birdflu-like symptoms and sick birds and to isolate themselves. That involves more telefones, information campaigns, laws to punish those who don’t report early or who infect others carelessly. “identification would be kept secret” because that could make it easier to contain the initial outbreak. If it’s made public, people might try to flee from the region. WHO doesn’t say this, but it could be part of the plan nevertheless. Some recent statements of WHO seem to indicate this.
gs,
“dubina: your posts are so long. Few people will read it all.”
I’m not bothered. Some people will. I do what I do; you do what you do…our respective strategies and styles. I sometimes stuggle to understand what you have in mind, but generally I get it.
Live and let live, Podner; this ain’t no beauty contest.
“No beauty contest”.
I personally have a hard time with lenghty posts, even tho’ I’m interested.
Suggestion:
This may take two minutes from the author and save 30 minutes x 1000000 readers.
These are just aproximate figures. I hope you’re all used to that! :)
closed for volume issues. Note date of last post.