I have managed to engage the equivalent of the Surgeon General of Austria in an email-exchange about pandemic flu. He has responded immediately to my mails and we’re having a kind of back and forth exchange. I’m trying to convince him that they need to tell the citizens of Austria to prep. He just countered that Austria has enough antivirals for everyone so there is no need to worry about the few weeks (!) we would have to wait until a vaccine has been produced. I already told him that it would take longer, might not be possible, etc, but I need to counter his argument about anti-virals! HELP NEEDED FAST!
Delphina…I am not Monotreme or Medical Maven, but anti-virals are not going to be the silver bullet if H5N1 becomes the next pandemic flu. There are numerous clades ( strains ) of H5N1 currently circulating. Some of these have already shown some resistance to our current anti-virals. The antivirals that are showing some help in treating H5N1 are only useful if administered in the first, early stages of the disease. Most people won’t get the antiviral early enough to be of much help.
Here are a few quotes from Dr. Mike Olsterholm, and I’ve included who he is:
Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota and associate director of the Department of Homeland Security’s National Center for Food Protection and Defense, said a potentially deadly bird flu pandemic is coming.
….Dr. Michael Osterholm’s presentation on an avian influenza pandemic to members and guests of the World Affairs Council of Ventura County…
He doesn’t know when or where it will land in the United States, but, he said, a serious effort should be mounted “right now” by federal, state and local agencies to prepare for it.
“If the pandemic is caused by H5N1, the avian influenza virus strain currently circulating in Asia, it could kill as many as 1.9 million Americans and infect 30 to 60 percent of the population,” he said, adding that H5N1 is the most powerful influenza virus detected in modern history…..
For people who doubt the looming danger, Osterholm said, “I wouldn’t bet my family’s life that it’s not going to happen.”
Currently, there is no bird flu vaccine, he said.
“We’re still using 1950s vaccine,” he said. “Over the decades there has been only one major modification to it. And H5N1 vaccine research results generally have been disappointing….
When the pandemic hits, what will it be like?
“Imagine a 12-to-18-month global blizzard,” he said…
Individuals and families should stockpile a six- to 12-week supply of food and water in their homes, he said. Business and education areas must prepare to protect employees and students.
There has already been spotty resistance to tamiflu found in certain strains. That is always a possibility that would heavily increase if the whole population is on the drug. I was not aware that Australia had vaccine production if they are waiting for it from other countries its going to be a very long wait indeed. I cant see a country shipping out vaccine until all of its citizens are vaccinated. He is looking at well into a year once its made a year or so into the pandemic. A few weeks is a drop in the bucket.
From Cidrap..Center of Infectious Disease Research & Policy
Stockpiling of Antiviral Agents If H5N1 avian influenza escalates into a pandemic, stockpiles of antiviral agents may be used for treatment and to curtail spread through prophylaxis targeted to exposed persons.
HHS hopes to have a stockpile with enough treatment courses for 20 million people by the fourth quarter of 2006 (see November 2, 2005, CIDRAP News story). According to the US federal pandemic influenza plan, HHS eventually hopes to assure a large enough stockpile of antiviral agents to treat 25% of the US population (75 million courses) (see References: HHS: Pandemic influenza plan 2005 [Supplement 7]). Currently, the federal government is planning to purchase 44 million treatment courses for the national stockpile and is encouraging the states to add 31 million treatment courses to their individual stockpiles. The federal strategy is to allow states to purchase antiviral agents for state stockpiles at a federally negotiated price, with a 25% federal subsidy. In July 2006, HHS announced a contract with GlaxoSmithKline (GSK) that will allow states to add zanamivir to their federally subsidized antiviral stockpiles (see Jul 21, 200, CIDRAP News story). The federal government also plans to establish and maintain a federal stockpile of 6 million antiviral treatment courses to be used for containment efforts (see References: HSC [Homeland Security Council] 2006). In April 2006, Roche (maker of Tamiflu) completed development of a rapid-response stockpile of 3 million treatment courses to be made available to WHO for initial pandemic response (see References: Roche: Rapid response stockpile of Tamiflu now ready and available to the World Health Organisation [WHO]). Roche also has committed to providing 2 million additional treatment courses by the end of 2006 to be used at the discretion of WHO in those developing countries most likely to be affected by an influenza pandemic. In May 2006, WHO updated its pandemic influenza draft protocol for rapid response and containment (see References: WHO: Pandemic influenza draft protocol for rapid response and containment). One of the cornerstones of the protocol is deployment of the Roche international antiviral stockpile to be used initially for targeted antiviral prophylaxis (for known case contacts) and for mass antiviral prophylaxis as needed (either by offering prophylaxis to the affected population within a radius of 5 to 10 km from each detected case or covering at risk populations in defined administrative areas). Even though antiviral stockpiles are considered to be an important strategy for pandemic preparedness, a number of caveats exist regarding their use during a pandemic.
First, it is not clear that such agents would be effective against the emergent pandemic strain. Second, even if antiviral agents are shown to be effective, the dose and duration of treatment may be dependent on the virulence of the pandemic strain. Current antiviral treatment recommendations for influenza are based on studies using circulating H3N2 strains and not on potentially more virulent pandemic strains. For example, since H5N1 strains can be highly virulent, higher doses of antiviral agents given for a longer period of time may be necessary for effective treatment. This was recently demonstrated in a mouse model using and H5N1 strain from Vietnam (see References: Yen 2005). Early treatment may also be critical for a successful outcome. Finally, current production capacity for NIs is limited, although Roche has recently ramped up production and anticipates that by the end of 2006, it will have the capacity to produce up to 400 million treatments annually (based on current recommendations for treatment) (see References: Roche: Roche update on Tamiflu for pandemic influenza preparedness). This enhanced production is being accomplished through expansion of Roche-owned facilities and through addition of external production partners from around the world.
delphina – at 09:35, Great job! Is he aware that pandemics can come in multiple waves and can mutate between waves? Do they have enough tamiflu for multiple waves? I was under the impression that it would take at least a month or two to actually begin making vaccine after a panflu begins. And, at present, it will take quite a while to manufacture enough for everyone. Unless they are making the vaccine in Austria, is he a 100% sure that Austrians will be put at the top of the list to receive vaccine? If a severe panflu hits, vaccine distribution is going to become a highly political issue.
Thanks for the help. Any other points I could use?
(Annoyed Max: It’s Austria (Mozart), not Australia!)
Annoyed Max- Not mad yet – at 09:46 I was not aware that Australia had vaccine production 09:46
I believe delphina is talking about “Austria”
Also, are they considering the macro ramifications of a panflu? First, let’s say everyone in Austria gets Tamiflu and is fine but the rest of the world - or even a portion of the rest of the world - does not. Surely Austria does not grow everything it eats and make everything it uses? There will be shortages because of the global effect of a pandemic. International trade could become unreliable and some countries may hold back on exporting food etc.
you might ask him if he’s prepared for the huge influx of people from outside of Austria who may flee their countries in search of Tamiflu.
Delphina - please ask if they have taken actual, physical, delivery of the antivirals in question.
Health officers here say the same thing. The state assures them that they will have antiviral stockpiles. However, unless things have changed recently, the antiviral stockpiles they speak of “having” are only orders for antivirals that the state has placed. Delivery has not yet happened. There is no actual physical stockpile of antivirals at this time.
If this is the case, it means that everyone is hopeful that the orders will be filled, and delivery will be accomplished. When the orders are filled depends on where any given entity is in the order line.
I would be very interested in knowing if your Surgeon General can assure you that he has taken physical delivery of his entire antiviral order, and whether he feels quantities at hand will be sufficient, along with the measure he has utilized to determine that necessary level.
And most importantly, no one knows if Tamiflu will have any benefit in a pandemic flu.
Here in Norway the plan is to use Amantadin as profylaks for keyworkers, and Tamiflu for treatment of population, But everyone knows that the risk of amatadine resistanse is so big that the keyworker will have to use the tamiflu instead, quickly emptying the tamiflu reserve. Real good planning for buisnises and privates will be more helpfull. If the whole population gets 7 simple reusable cloths masks (one for each day of week), and the usage becomes mandatory the spread will be drasticaly redused. Togheter with propper hand hygiene etc. This takes time to plane and educate, so they will have to start now .
lol close enough, its one of those square states in the middle right ;)
Can people get reinfected by a somewhat evolved strain in a second or third wave? If so, even if no resistance had developed, you would need a very large amount of Tamiflu. Also, if Tamiflu is given late, resistance has developed (in some cases) DURING therapy. It would seem risky and foolish to rely on one medicine that might not work and would not, as others have pointed out, deal with any of the trade disruptions likely to occur from other nations supplying food, fuel and other necessaries.
delphina – at 09:35
This will be redundant with the excellent posts above, but just to put it in bullet points:
I recommend the following links (in addition to Flu Wiki, of course):
Pandemic Influenza articles by Michael Osterholm
Ten things you need to know about pandemic influenza (from the WHO)
Just got another mail from him — I’m translating: he says my point that the virus could mutate between waves and no longer be effective is simply wrong. He says that the resistance to anti-virals is currently 1–3% (which he says is less than it is for some antibiotics). He says that there is currently no variant of H5N1 that is resistant to tamiflu. Austria would begin taking anti-virals when the virus is approaching. And the Tamiflu is currently being delivered (now and in the course of the next weeks).
I don’t want to irritate this guy (he is actually very polite and it is amazing that he keeps writing back, now from his Blackberry!) — but what should I say to all of this?
delphina – at 10:34 Did you mention problems with international trade? Austria can’t be 100% independent in terms of food and energy production. That is a good reason to stockpile.
Does he plan to dose the population, then, before they become ill?
Again, how much Tamiflu doe he anticipate having on hand, how long will his citizens be taking the drugs? It sounds as if he believes that the actual period of active flu will be very short and sharp (he cannot mean he will cover the population for 6 weeks to 3 months of an active phase).
delphina – at 10:34
It’s true that H5N1 resistance to Tamiflu currently is very low. We don’t know what will happen once it is used on a massive scale, which it certainly will be once the pandemic starts. Certainly the selective pressure on it to evolve a Tamiflu-resistant strain will be enormously increased.
How does he respond to the issue of quantity of Tamiflu? Is he really ordering enough for all Austrians to take for 6 weeks?
It would be great if you could suggest that he invite Dr. Osterholm to give a talk in Austria.
delphina - tell him the reason to advocate prep is to compensate for logical disruption in just-in-time supply chain. Autria may have antivial protection planned, but if pandemic occurs importation of food supplies will likely be disrupted and the population will be at risk. A bottom line is that even is Austria minimizes illness in it’s own population it is powerless to compensate for the global disruption likely to occur in pandemic. Supplies will be disrupted and people need to be able to prepare for that disruption.
one point is that tamiflu works like a “sleeping pillow”. Tamiflu dont fix any of the other problems we may expekt, but when population hears about the tamiflu stockpile, they will forget about the issues, and often mistake it for beein a vacsine, whitch it is not.
Getting firms prepared for telecomuting, involve voulanitar organisatisons in treatment and help etc is essential. No healtcare system can deal with this magnitude. no one! And all those peple will need education and propper equpiment for beeing as safe as possible, if not it will be a “everyone for him self catasthophe”
heh, perhaps direct him to this page :)
It is a government duty (from the money of the taxpayers) - not a citizen one, to cary for all citizens by deposits of strategic stockpiles and special shielded military corps to inoculate vaccines, distribute food and water, medications. Give writed directives to the hospitals for preparing themselves, to every workplace, and to put in place emergence legislation by which the country pass over the pandemic. Remember the 20 century strategic preparations.
tamiflu resistant mutated strain is something this guy should keep in his mind. He needs to talk to some researchers and doctors. He should ask the “workhorses” on this if they are keeping tamiflu on hand for their families and he might be in shock!
delphina: this article says it very clearly, and its from britain. send him the link..
“NHS ‘meltdown’ predicted by Government bird flu report “
http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/08/27/nflu27.xml
Should we not be asking more important questions. Like are they planning on closing their borders? If yes at what point?
Would they use their military to enforce this? Quarenteen questions?
Available data on antiviral resistance include the following: Also from Cidrap..link above
Resistance to adamantanes: For influenza strains in general, transmissible amantadine-resistant organisms are shed by about 30% of patients after 2 to 5 days of treatment. Viral resistance to adamantanes can emerge rapidly because a single point mutation can confer resistance to both amantadine and rimantadine. Despite the potential for resistance, a recent study of H5N1 isolates in Asia found that while most (>95%) of the isolates from Vietnam and Cambodia were resistant to amantadine and rimantadine, those from Indonesia and China were less likely to be resistant (6.3% and 8.9%, respectively) (see References: Cheung 2006).
Resistance to zanamivir: No resistance has been detected in previously healthy patients with influenza who have been treated with zanamivir. One influenza B isolate with reduced sensitivity was obtained from an immunocompromised (post bone marrow transplant) 18-month-old child after 12 days of treatment (see References: Gubareva 1998). Resistance to oseltamivir: Levels of resistance to oseltamivir for currently circulating influenza strains range from 0.4% to 1% in adults and 4% to 8% in pediatric patients. Oseltamivir-resistant H5N1 strains recently have been isolated from several patients in Vietnam. One was a Vietnamese child who received prophylactic treatment with the drug (see References: Le 2005); another report involved two additional patients, both of whom died of H5N1 influenza (see References: De Jong 2005).
Thanks to all of you for your responses. It’s been rather hectic, trying to get your responses, translate them into a coherent text, all the while trying to control my one-year old daughter as she demolished my home office. I tried to counter his faith in Tamiflu as best I could using the info you gave, and suggested he invite Osterholm to Austria. Then, like I was taught to do and like I teach others to do, I repeated my main message: the population should be encouraged to stockpile some food and learn basic hygiene techniques.(That was the original point I wanted to make when I first wrote to him.) I hesitate to send him too many links because I don’t know how good his English is (he might find it tiresome to read it). Maybe, if he responds to my last mail, I’ll direct him to Fluwiki.
delphina - Your Surgeon General is really good at his/her job. You have allowed him to lock you in on the “Tamiflu” issue. Tell him you know all about Tamiflu. Get him off of the Tamiflu track. This issue is bigger than any one medication. Ask him/her how your country plans to support its citizens when there are large shortages of food, water, power and other key medications as well as key personnal due to a pandemic. If it is answers you seek, get your Surgeon General off the Tamiflu subject. gina
Perhaps he can read this thread later?
He may get no advance warning, even if he has enough antivirals to give everyone before they get sick. H5N1 is not monitored adequately, and people are contagious before they look or feel sick.
Air travel may sow pandemic broadcast; before officials realize there is more than just another small h-h-h cluster.
Were any Austrians stranded when airflights were suddenly halted here after 9/11?
Were any non-Austrians stranded when they wanted to leave and get home?
There will be disruption, and people getting sick and dying, and too many people trying to relocate during a crisis.
Does Austria rely on any imports for energy, pharmaeuticals, electronic or machine parts, ect? Pandemic influenza in a form from the current H5N1 could affect the global economy and working sector and essential services for over a year.
We have had months of advance warning; we can’t rely on more, because a large effort is involved to become more resiliant households.
Just because an overdue, smoking, pressured, volcano hasn’t erupted yet, the scientists wouldn’t tell you that means it isn’t going to blow, or that you’d have time to take care of the populace if you wait until the eruption to begin…
Hundreds of millions of dollars spent in developing the pre-pandemic vaccines have yet to produce a product that passes safety and efficacy standards in substantial quantities. H5N1 vaccine recombinants are proving difficult to grow in eggs (the only currently available bulk production method).
We should count ourselves blessed if we saw a vaccine within 6 months of the onset of a pandemic.
This may change with the advent of new methods of vaccine production (cell culture, DNA, etc.) but those technologies are a long way from maturing into an industrial production base.
Even if Tamiflu turned out to be effective - not everyone can take Tamiflu. My daughter had some really bad side effects when she took Tamiflu.
Wathcing, in Texas I have read about the possible side effects. What kind did she have and how did she / you handle them?
WIT, what about Relenza?
Also - the current recommended dosage of Tamiflu may be inusfficient for H5N1 because it so overwhlms multiple systems - there is evidence that you need twice that amount. Does Austria have twice the stockpile? Probably not.
Science Teacher - don’t know - by the time she was diagnosed and started on Tamiflu and then had the reactions - the window of opportunity had closed to try anything else. She has had a LOT of reactions to medicines in the past, so I was not altogether surprised.
NJ Jeeper - my daughter had extreme nausea, stomach pain, a rash and a horrible headache. These were much worse after she took the Tamiflu than before she took it - and she did not have a rash prior to taking the Tamiflu. She itched terribly and felt like throwing up and was doubled over with a stomach ache. We tried increasing her Benedryl to combat the rash and itching and she tried eating crackers before she took the Tamiflu for the stomach ache and nausea, but after 4 doses, she was WAY more miserable with it than without it, and her rash was getting worse, so she just stopped taking it. After reading all of the other possible side effects, and I think there were a bunch of them, I am probably lucky she did not end up in the hospital from the side effects!
Since then, I have talked to several other people who tried Tamiflu and could not take it either.
That is bleak for Tamiflu use for panflu. Since your daughter had a lot of reactions to prior meds and you were not totally surprised, maybe the general population will have less of a reaction.
Still does not lessen what your daughter went thru and I am very sorry for that. It is good we can all share our info. Thanks