A Killer Flu?

I S S U E R E P O R T
A Killer Flu?
Scientific Experts Estimate that “Inevitable” Major
Epidemic of New Influenza Virus Strain Could Result in
Millions of Deaths if Preventive Actions Are Not Taken
TRUST FOR AMERICA’S HEALTH IS
A NON-PROFIT, NON-PARTISAN
ORGANIZATION DEDICATED TO
The seasonal flu kills approximately 36,000 to 40,000 people and hos-
SAVING LIVES BY PROTECTING
pitalizes more than 200,000 in the United States each year.1 Annually,
T H E H E A L T H O F E V E R Y
influenza costs the national economy over $10 billion in lost productivity and
COMMUNITY AND WORKING TO
direct medical expenses.2 Many view the flu as a relatively predictable and
MAKE DISEASE PREVENTION A
NATIONAL PRIORITY.
manageable health threat.
Recently, however, health experts worldwide
I In the U.S., projection models predict that
have been sounding the alarm about a differ-
a pandemic may cause over a half a million
ent type of flu. They warn of the “inevitable”
deaths and two million hospitalizations.5
emergence of a new, severe strain of the flu
I The estimated economic impact of a pan-
virus against which people have no immunity
demic flu outbreak in the U.S. today,
to protect them.3 This could result in a rapidly
based on projections from the relatively
spreading, worldwide epidemic of this new
mild 1968 flu epidemic, would be $71.3 to
potentially lethal strain of the disease, which
$166.5 billion due to death and lost pro-
scientists refer to as a “pandemic.”4 New strains
ductivity, excluding other “disruptions to
of the flu traditionally emerge in animals, often
commerce and society.”6
in poultry and pigs, and then as the disease
ACKNOWLEDGEMENTS:
develops over time, it can become transmitted
The U.S. would be impacted by the global
This report is supported by
to humans. The severity of an emerging pan-
implications as soon as a pandemic out-
the Benjamin Spencer Fund
demic would be determined by the particular
break occurred in any part of the world due
in loving memory of
strain of the new form of the virus and how eas-
to the interdependence of economies.
Benjamin, whose compassion
ily contagious it proves to be in humans.
Sectors, such as hospitals and the health
for others continues to guide
care system, which rely on supplies manu-
The World Health Organization (WHO),
and inspire us.
factured in other parts of the world, includ-
Centers for Disease Control and Prevention
ing Asia, would feel immediate repercus-
(CDC), and other health authorities believe
JUNE 2005
sions and supply shortages. Travel restric-
that the emergence of a pandemic flu could
tions, possible limitations on public gather-
P
be devastating to world health and econom-
REVENTING EPIDEMICS.
ings and events, and other measures taken
P
ic stability.
ROTECTING PEOPLE.

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IN A MAY 2005 NEW
to limit the spread of disease would also
I As of June 17, 2005, this "bird flu" virus
have rapid and far reaching repercussions.
has killed 54 individuals and has spread
ENGLAND JOURNAL OF
Since a pandemic could likely result in polit-
rapidly among bird populations.10
MEDICINE ARTICLE,
ical and economic destabilization, particu-
I As of April 2005, the strain seems to be
DR. MICHAEL
larly in developing countries, it poses seri-
exhibiting a mortality rate of over 50 per-
ous national security concerns for the U.S.
OSTERHOLM, DIRECTOR
cent in humans. Experts are concerned
OF THE CENTER FOR
Based on historical trends and projections,
that when the mortality rate decreases,
virologists and epidemiologists predict a
the virus’s transmission rate will increase.
INFECTIOUS DISEASE
new flu pandemic will emerge three to four
RESEARCH AND POLICY
I Health officials are concerned that the
times each century.8 Health officials around
avian virus could become more conta-
AT THE UNIVERSITY OF
the world are troubled by the severity of the
gious among humans, and that it could
“avian flu” circulating in Asia, which scien-
MINNESOTA, WROTE
remain in a strain against which humans
tists refer to as the H5N1 flu strain. They
THAT “EVEN A RELATIVELY
have no natural resistance.
fear this avian flu could become the next
‘MILD’ PANDEMIC COULD
pandemic for humans. The regional direc-
I CLSA Asia-Pacific Markets, the Asian
KILL MANY MILLIONS OF
tor of the WHO for the Western Pacific
investment banking arm of Crédit Agricole
region stated in February 2005 that the
of France, estimates that avian influenza
PEOPLE” WORLDWIDE.7
“world is now in the gravest possible danger
has already cost the impacted region in
of a pandemic.”9
Asia $8 to $12 billion, mostly from lost rev-
enue from poultry and related industries.11
I AM ACUTELY AWARE OF THE DISASTER THAT A PANDEMIC COULD CAUSE.
MANY OF US ARE PARTICULARLY WORRIED ABOUT H5N1 AVIAN INFLUENZA VIRUS,
“ANDWE’RERIGHTTOWORRY. ITHASINFECTEDATLEAST89 HUMANBEINGS
AND KILLED MORE THAN HALF. THERE IS A CHANCE THAT THIS VIRUS COULD CAUSE
THE NEXT PANDEMIC12”
– U.S. Department of Health and Human Services Secretary Mike Leavitt, May 16, 2005
MAJOR FLU OUTBREAKS OF THE 20TH CENTURY13
1918 – The “Spanish” flu pandemic killed
triggering global concern until all samples
500,000 in the U.S., 50 million worldwide.
were accounted for and destroyed.14
1957–58 – An outbreak spread from
1968–69 – The “Hong Kong” flu, the most
China across the globe, killing approxi-
recent pandemic, affected millions world-
mately 70,000 in the U.S. In April 2005, a
wide and disrupted world economies.
company testing laboratory proficiency
1997 – The first identification of the avian
mistakenly distributed samples of this pan-
“bird” flu, which remains active in Asia.15
demic strain to laboratories worldwide,
“SINCEJANUARY2004, EVENTSAFFECTINGBOTHHUMANANDANIMALHEALTHHAVEBROUGHT
THE WORLD CLOSER TO AN INFLUENZA PANDEMIC THAN AT ANY TIME SINCE 1968. WHEREAS PAST PAN-
DEMICS HAVE CONSISTENTLY ANNOUNCED THEMSELVES WITH AN EXPLOSION OF CASES, EVENTS DURING
2004, SUPPORTED BY EPIDEMIOLOGICAL AND VIROLOGICAL SURVEILLANCE, HAVE GIVEN THE WORLD AN
UNPRECEDENTED WARNING THAT A PANDEMIC MAY BE IMMINENT. THEY ALSO HAVE OPENED AN UNPRECE-
DENTED OPPORTUNITY TO ENHANCE PREPAREDNESS ”
.
– Report by the WHO Secretariat, April 200516
2

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While experts predict a pandemic flu is
I Recommendations for improved pandemic
“inevitable,” subsequent deaths in the United
readiness.
States predicted to be over a half million peo-
Overall, the report finds:
ple are not. Increasing federal leadership,
converting national and state pandemic
I Despite the health and economic
influenza plans into operational blueprints,
implications of such an event, pandemic
procuring adequate antiviral medication for
planning efforts are lagging in the U.S.,
treatment, and putting a process in place
especially when compared to the United
now for rapid influenza vaccine approval are
Kingdom and Canada.
all steps that should be taken immediately.
I The U.S. has not assessed or planned for
Protecting the U.S. and the world against the
the disruption a flu pandemic could
threat of a pandemic would, at the same time,
cause both to the economy and society as
better prepare countries for threats posed by
a whole. This includes daily life consid-
infectious illnesses, including the intentional
erations, such as potential school and
spread of disease by terrorists. The threat of a
workplace closures, potential travel and
pandemic influenza outbreak was highlighted
mass transit restrictions, and the poten-
by the U.S. Department of Homeland Security
tial need to close stores resulting in com-
(DHS) as one of 15 disaster planning scenar-
plications in the delivery of food and
ios for which the U.S. should be prepared.
basic supplies to people. Daily life and
economic problems would likely emerge
In order to help understand the current sta-
in the U.S. even before the pandemic flu
tus of U.S. preparations and highlight ways to
hit the country due to the global interde-
improve them, in the following report, Trust
pendence of the world economy.
for America’s Health (TFAH) provides:
I
I Aspects of the planning process, such as
A state-by-state examination of potential
ensuring vaccine and antiviral capabili-
deaths and hospitalizations due to a flu
ties and surge capacity readiness, are
pandemic based on model estimates;
incomplete or fragmented.
I A state-by-state examination of capacity
I The failure to establish a cohesive, rapid,
to treat citizens with recommended
and transparent U.S. pandemic strategy
antivirals based on model estimates;
could prove a major weakness against a
I A review of U.S. and state pandemic
virulent and efficient virus -- putting
readiness, including a comparison to
Americans needlessly at risk.
other nations’ progress; and
I would like to emphasize that although we cannot be certain exactly when the next
influenza pandemic will occur, we can be virtually certain that one will occur and that the resulting
“morbidity, mortality, and economic disruption would present extraordinary challenges to public
health authorities around the world.”
– Dr. Anthony S. Fauci, Director, National Institute of Allergy and Infectious Diseases, National
Institutes of Health, Department of Health and Human Services 17
Today, many influenza experts, including those at CDC, consider the threat of a serious
influenza pandemic to the United States to be high. Although the timing and impact of an influenza
“ pandemic is unpredictable, the occurrence is inevitable and potentially devastating.”
– Dr. Julie Gerberding, Director, CDC18
3

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Model Estimates of the Impact of a Severe-Strain Flu Virus Epidemic
In order to illustrate the potential severity of a
2. The current strain of the avian flu is
pandemic outbreak in the U.S., the chart
viewed as significantly more lethal than the
below uses one model based on assumptions
1968 pandemic flu strain. A high-level
from the current avian flu outbreak.
pandemic, such as the 1918 pandemic, is
Scientists have used a number of different
considered to be six times more lethal
models to estimate the scope and impact of
than the 1968 flu.19 The projections below
the emergence of a new strain of the flu. The
reflect a mid-level estimate of a three times
basic U.S. planning model is based on
higher rate. These numbers are reflected
assumptions from the 1968 “Hong Kong”
in the “Projected Dead” column in the
pandemic flu, which was considered to be rel-
table below. The range of estimates, from
atively mild. Experts also have predicted
low level to high level severity death rates,
higher and lower estimates based on different
can be found in Appendix A.
sets of assumptions. The numbers below
3. Due to the severity of the avian flu strain,
adapt the model to reflect moderate assump-
experts also believe that it would result in a
tions for the current avian flu threat.
much higher hospitalization rate than esti-
1. The WHO has estimated that there would
mates using the 1968 strain. The estimates
be a “contraction” rate of 25 percent for
below, in the “Projected Hospitalizations”
this flu strain. This means they warn that
column, reflect a mid-level estimate of a
countries should be prepared for approx-
three times higher rate. A more virulent
imately 25 percent of their populations to
strain of flu, changes in medical care and
get sick from the pandemic virus. Other
treatment procedures, and an aged popu-
scientists have estimated that up to 50
lation are all factors behind this projection.
percent of countries’ populations could
The range of estimates, from low level to
become infected.
high level severity hospitalization rates, can
be found in Appendix A.
POTENTIAL IMPACT: STATE BY STATE ANALYSIS
To assist state and local health agencies with pandemic readiness, CDC developed a computer model
(FluAid 2.0) that generates mortality, hospitalization, and outpatient rates for different age popula-
tions on a state-by-state basis.20 FluAid derives its default numbers from the 1968 Hong Kong pan-
demic, which had a relatively minor impact on the U.S. According to Dr. Keiji Fukuda, the Chief of
Epidemiology and Surveillance Section, Influenza Branch at CDC’s National Center for Infectious
Diseases, a high severity pandemic, similar to the 1918 pandemic outbreak, may have a mortality rate
of six times the 1968 pandemic.21 To estimate the potential impact from a H5N1 pandemic on the
U.S., the following projections multiplied the default FluAid mortality rate for each state and each age
group by three (the mid-point between the default numbers and the possible six times mortality
rate); hospitalization rates are also three times the default FluAid number.
Projections of deaths and hospitalizations from an H5N1 pandemic are only estimates.
Variables including the virulence of the virus, its attack rate, and the success of preventative
and controlling measures (including the use of antiviral medication and the development of a
vaccine) would influence the actual total. While the mortality estimate provided below -- a
U.S. death toll over a half a million persons -- varies from some other experts’ forecasts, all
projections agree on a critical point: the risk of a pandemic is serious enough to justify urgent
steps to improve U.S. ability to fight this virus if it starts to spread.
It is also important to note that planning and accommodating for the surge of sick patients presents
a separate, massive challenge to the health care system -- a consideration that the projected death
toll should not overshadow. The impact of over two million hospitalized patients would test and pos-
sibly overwhelm the surge capacity of hospitals nationwide. For instance, according to the American
Hospital Association, in 2003 there are only 965,256 staffed hospital beds in registered hospitals.22
4

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TABLE 1: Potential Pandemic Influenza Deaths and Hospitalizations
From a Mid-level Pandemic Flu*
State
Projected Dead
Projected Hospitalized
Number of Cases
Alabama
8,886
38,591 1,079,789
Alaska
886
4,558
152,328
Arizona
9,223
39,675
1,138,742
Arkansas
5,350
22,660
630,705
California
60,875
273,090
8,067,075
Colorado
7,192
32,978
973,161
Connecticut
7,054
29,932
817,465
Delaware
1,507
6,560
182,895
District of Columbia
1,155
4,974
132,241
Florida
35,737
142,386
3,663,486
Georgia
13,655
62,912
1,871,561
Hawaii
2,446
10,571
296,651
Idaho
2,279
10,157
302,558
Illinois
23,720
103,738
2,973,962
Indiana
11,817
51,711
1,466,027
Iowa
6,233
26,090
713,106
Kansas
5,373
22,946
654,335
Kentucky
7,930
34,748
977,031
Louisiana
8,334
37,148
1,087,942
Maine
2,651
11,333
310,513
Maryland
9,958
44,500
1,273,572
Massachusetts
13,136
56,038
1,529,313
Michigan
19,622
86,005
2,443,473
Minnesota
9,304
40,786
1,171,387
Mississippi
5,362
23,531
682,625
Missouri
11,274
48,240
1,350,515
Montana
1,804
7,787
219,703
Nebraska
3,441
14,697
414,218
Nevada
3,243
14,455
419,202
New Hampshire
2,333
10,301
293,177
New Jersey
16,980
72,791
2,013,212
New Mexico
3,244
14,504
432,438
New York
37,701
162,490
4,534,307
North Carolina
14,987
65,637
1,856,296
North Dakota
1,371
5,795
160,221
Ohio
23,197
99,979
2,796,583
Oklahoma
6,833
29,376
829,273
Oregon
6,724
29,047
810,872
Pennsylvania
27,185
112,658
3,004,915
Rhode Island
2,234
9,263
246,857
South Carolina
7,474
32,983
940,045
South Dakota
1,559
6,599
184,493
Tennessee
10,875
47,678
1,342,050
Texas
35,124
160,648
4,859,834
Utah
3,393
15,906
514,787
Vermont
1,185
5,213
147,245
Virginia
13,104
58,872
1,683,499
Washington
10,910
48,610
1,402,591
West Virginia
4,049
17,014
453,947
Wisconsin
10,620
45,842
1,292,419
Wyoming
915
4,086
119,936
U.S. Totals
541,433
2,358,089
66,914,573
* Projections are based on CDC’s FluAid 2.0 program. The estimated deaths are for a pandemic strain three times more
lethal than the 1968 pandemic, on which the default FluAid numbers are based. The hospitalization rate is three times
the default 1968 rate. The Dead and Hospitalized numbers represent the most likely FluAid projection at a 25% rate of
contraction. The Number of Cases is the projected number of residents contracting the flu, based on a 25% rate of con-
traction. State population numbers are from FluAid, using U.S. Census data gathered in 1999. Updated population data
were not used to ensure consistency with estimated Dead and Hospitalized numbers.
As of May 2005, the U.S. has stockpiled 2.3
In the U.S., this means it could affect nearly
million courses of the antiviral medication
67 million individuals, based on FluAid pro-
Tamiflu, which could be used as a treatment
jections and population numbers. With the
in the event of an outbreak, and intends to
current level of the U.S. Tamiflu order, over
order approximately three million more with
61.5 million Americans who could be infected
funds recently appropriated by Congress to
would not receive antiviral medication. If the U.S.
total 5.3 million. The WHO is currently esti-
orders additional courses of Tamiflu, they
mating that an avian flu epidemic could
would not be available until 2007, unless pro-
impact 25 percent of countries’ populations.
duction capacity significantly changes.
5

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In an actual pandemic, there would likely be
demic would still spread to the remainder of
geographic concentrations of the disease,
the country. As a result of the pandemic’s
especially in the initial stages of an outbreak.
national scope and lacking a prioritized dis-
U.S. government officials may decide to
tribution plan, these projections assume that
“front-end” target the limited supply geo-
the U.S. would use proportional distribution
graphically in hopes of containing the initial
(based on population) in delivering the
spread. However, it is likely that the pan-
remaining Tamiflu courses.
TABLE 2: State-by-State Capacity to Treat Citizens with
Recommended Antiviral*
State
Number of Tamiflu
Number of Cases
Number of Cases
Courses Available
Without Tamiflu
Alabama
85,525
1,079,789
994,263
Alaska
12,065
152,328
140,263
Arizona
90,195
1,138,742
1,048,547
Arkansas
49,955
630,705
580,749
California
638,956
8,067,075
7,428,119
Colorado
77,080
973,161
896,081
Connecticut
64,748
817,465
752,717
Delaware
14,486
182,895
168,409
District of Columbia
10,474
132,241
121,767
Florida
290,168
3,663,486
3,373,318
Georgia
148,238
1,871,561
1,723,323
Hawaii
23,496
296,651
273,154
Idaho
23,964
302,558
278,594
Illinois
235,554
2,973,962
2,738,408
Indiana
116,117
1,466,027
1,349,910
Iowa
56,482
713,106
656,624
Kansas
51,827
654,335
602,508
Kentucky
77,386
977,031
899,645
Louisiana
86,171
1,087,942
1,001,771
Maine
24,594
310,513
285,918
Maryland
100,874
1,273,572
1,172,698
Massachusetts
121,130
1,529,313
1,408,183
Michigan
193,536
2,443,473
2,249,937
Minnesota
92,780
1,171,387
1,078,607
Mississippi
54,068
682,625
628,558
Missouri
106,968
1,350,515
1,243,546
Montana
17,402
219,703
202,301
Nebraska
32,808
414,218
381,409
Nevada
33,203
419,202
385,999
New Hampshire
23,221
293,177
269,956
New Jersey
159,457
2,013,212
1,853,755
New Mexico
34,251
432,438
398,186
New York
359,142
4,534,307
4,175,165
North Carolina
147,029
1,856,296
1,709,267
North Dakota
12,690
160,221
147,530
Ohio
221,505
2,796,583
2,575,078
Oklahoma
65,683
829,273
763,590
Oregon
64,225
810,872
746,646
Pennsylvania
238,006
3,004,915
2,766,910
Rhode Island
19,552
246,857
227,305
South Carolina
74,457
940,045
865,589
South Dakota
14,613
184,493
169,880
Tennessee
106,298
1,342,050
1,235,752
Texas
384,925
4,859,834
4,474,909
Utah
40,774
514,787
474,013
Vermont
11,663
147,245
135,582
Virginia
133,342
1,683,499
1,550,157
Washington
111,093
1,402,591
1,291,498
West Virginia
35,955
453,947
417,992
Wisconsin
102,367
1,292,419
1,190,053
Wyoming
9,500
119,936
110,436
U.S. Totals
5,300,000
66,914,573
61,614,573
* Tamiflu availability projections are based on state-by-state proportional distribution of the 5.3 million courses of Tamiflu
ordered or currently in U.S. federal government possession. For example, California, with approximately 12% of the U.S. pop-
ulation, receives 12% of the Tamiflu in the above projection. The Number of Cases is the projected number of residents con-
tracting the flu, based on a 25% rate of contraction. State population numbers are from FluAid, using U.S. Census data
gathered in 1999. Updated population data were not used to ensure consistency with estimated Dead and Hospitalized
numbers. The Number of Cases Without Tamiflu is the difference between the other two columns.
6

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U.S. Department of Health and Human
Services Draft Pandemic Plan
BEYOND RESEARCH AND DEVELOPMENT, WE NEED A PUBLIC HEALTH APPROACH
“THATINCLUDESFARMORETHANDRAFTINGOFGENERALPLANS, ASSEVERALCOUNTRIES
AND STATES HAVE DONE. WE NEED A DETAILED OPERATIONAL BLUEPRINT OF THE BEST
WAY TO GET THROUGH 12 TO 24 MONTHS OF A PANDEMIC.23 ”
– Dr. Michael Osterholm, Director of the Center for Infectious Disease Research and Policy
In August 2004, the U.S. Department of
health officials. The goals of the plan are to 1)
Health and Human Services (HHS) released a
decrease the burden of disease; 2) minimize
draft plan of U.S. strategy to deal with a flu pan-
social disruption; and 3) reduce economic
demic. The plan, an updated version of a 1978
impact.24 The draft plan is accessible on the
plan, outlines proposed collaboration among
HHS Web site at www.dhhs.gov/nvpo/pan-
jurisdictions, as well as preparedness and
demics.25
Related public comments on the
response guidelines for federal, state, and local
plan were accessible at the site in March 2005.
Questions for U.S. Pandemic Planning Efforts
I Is There Coordination Among Government,
efforts to maximize the on-the-ground abili-
Health, and Economic Infrastructures?
ty to “scale up” capability in a rapid manner.
State, federal, and international efforts must
I Is There a Prioritization of Who Would
be coordinated, with instructions for specific
Receive Antivirals and Vaccines Based on
implementation. Sufficient resources must
a Limited Supply? Specific national guid-
be allocated to match what is needed to carry
ance must be established on vaccine prior-
out the plan.
itization, including developing guidelines
I Does the National Strategic Stockpile
on the use of antiviral drugs and lists of
Include ALL Necessary Medical Supplies
priority groups for vaccine receipt and dis-
That Will Be Necessary to Respond to a
tribution, given that there is likely to be
Pandemic? In addition to stockpiling antivi-
insufficient supplies during a pandemic.
rals and vaccines, when they are available,
I Is There a Rapid Response Plan to Develop,
the U.S. must also stockpile critical medical
Test, and Produce a Vaccine? It will take an
supplies such as masks, gloves, gowns, bed
estimated six to nine months after a pandem-
linens, and all other equipment needed to
ic emerges to develop a vaccine. Questions of
assure that hospitals and other health care
how to rapidly review and test the vaccine
providers are properly protected when the
once it is created remain, including concerns
usual supply chain is disrupted either
about speeding the approval process by the
abroad or in the U.S.
Food and Drug Administration (FDA), liabil-
I Are There Sufficient Surge Capacity
ity protection for vaccine manufacturers, and
Capabilities? A pandemic or other mass-
what type of preservative will be used in the
emergency scenario would overwhelm the
vaccine. In addition, industry representatives
normal operations of hospitals and the
have suggested that current production
health care system. Readiness efforts must
capacity is insufficient to meet the demand
account for massive demand triggered by a
for a pandemic influenza vaccine, and that it
pandemic. Local health officials and first
could take 12-18 months to meet appropriate
responders must be included in planning
production levels.26
7

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I Is There Clear Assignment of Who in the
action plan for what information would
Government Would Control and
be made available to the public and on
Distribute Vaccine and Treatments? Do
what time frame.
plans exist to stockpile stopgap antiviral
I Are There Coordinated Plans for
medications and vaccines, based on the
Monitoring Outbreak and Managing
small supplies of drugs that will be avail-
Containment? Coordinating containment
able versus the expected need and
efforts requires sufficient surveillance and
demand? As was evident in the 2004 flu
tracking systems to monitor and detect out-
season in the U.S. when there was a short-
breaks, infected persons, and the vaccine
age of available vaccine for the annual flu,
supply, as well as the ability to examine the
there is no centralized infrastructure to
readiness of infected survivors to re-enter
control and monitor vaccine distribution.
the workplace. Survivors as a volunteer
I Are There Clear Plans to Communicate
workforce would prove essential to helping
and Inform the Public? Effective response
combat the pandemic, because they will
to a pandemic would require a clear
have developed immunity to the virus.
RECENTLY, THE U.S. GOVERNMENT HAS TAKEN SEVERAL NOTABLE
STEPS TO BEGIN TO PREPARE FOR A POTENTIAL PANDEMIC.
I Congress has been increasingly concerned about the nation’s readiness to respond to
pandemic and annual influenza. Since convening in January, the 109th Congress has held
a series of hearings on issues related to influenza, including:
L May 26, 2005, “The Threat of and Planning for Pandemic Flu,” House Committee on Energy
and Commerce, Health Subcommittee.
L May 4, 2005, “The State of Readiness for the 2005-2006 Flu Season,” House Committee on
Energy and Commerce, Subcommittee on Oversight and Investigations.
L April 12, 2005, “Pandemic Preparedness and Influenza Vaccine Supply -- CDC, NIAID and
the Office of the Secretary of HHS,” House Committee on Appropriations, Subcommittee
on Labor, Health and Human Services, Education, and Related Agencies.
L February 10, 2005, “The Perplexing Shift from Shortage to Surplus: Managing This Season’s Flu
Shot Supply and Preparing for the Future,” House Committee on Government Reform.
I In May 2005, Congress passed supplemental appropriations legislation that made available
$25 million “for a coordinated program to prevent and control the spread of the avian
influenza virus.”27 In addition, $58 million was appropriated for the purchase of influenza
countermeasures for the Strategic National Stockpile. These funds are expected, in part,
to be used to order an additional three million courses of Tamiflu, to bring the U.S. stock-
pile order up to 5.3 million courses of treatment.
I In April 2005, U.S. Senator Barack Obama (D-IL) introduced the AVIAN Act of 2005, pro-
posed legislation that includes a mandate for the federal government to stockpile the antiviral
medication oseltamivir, commonly known as Tamiflu.28
I In April 2005, U.S. President George W. Bush approved use of quarantine in the event of an
outbreak of “influenza caused by novel or reemergent influenza viruses that are causing, or
have the potential to cause, a pandemic,” which includes, but is not limited to the H5N1 strain
of avian flu currently in Southeast Asia.29
I In April 2005, the U.S. Department of State issued an advisory statement about the avian flu
and announced it is taking measures to support the World Health Organization’s (WHO)
efforts to contain the outbreak.30
I In March 2005, in the U.S. Department of State authorization bill (S.600), the U.S. Senate proposed
including $25 million for International Famine and Disaster Assistance to prevent and respond to a
possible outbreak of the avian flu and called for a task force to coordinate U.S. policy.31
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‘WE REMAIN VERY VULNERABLE,’ SUMMARIZED ENERGY AND COMMERCE
C“
OMMITTEE CHAIRMAN JOE L. BARTON [(R-TEXAS)]. ‘THINK OF IT LIKE THIS -- A
BAD FLU OUTBREAK COULD KILL MORE AMERICANS THAN EITHER OR BOTH OF THE
LAST CENTURY’S WORLD WARS.’32”
State Pandemic Readiness
Similar questions can be asked about the level
ent phases of readiness. A recent examina-
of preparedness of state and local governments
tion found that only between 25-30 states have
for a pandemic. America’s public health sys-
made their plans publicly available.33 Making
tem relies on a loosely affiliated network of
the plans publicly available is considered by
approximately 3,000 federal, state, and local
many experts as an essential feature of pan-
health agencies often working with private sec-
demic readiness in order to improve integra-
tor and professional health organizations.
tion with other jurisdictions as well as to add a
State governments have primary responsibility
level of accountability. In fact, in comment-
for the health of their citizens under U.S. law.
ing on the draft U.S. pandemic influenza pre-
Therefore, a federal plan without ready-to-
paredness plan, the WHO stated, “We feel
implement state plans would be insufficient.
that in order to ensure broad commitment
for the plan, it is essential to involve the com-
Most states have developed draft pandemic
munity in the planning process.”34
response plans, but they are in widely differ-
CITY AND LOCAL PLANNING: ON-THE-GROUND AND FACING
UNIQUE PROBLEMS
Pandemic planning efforts must incorporate local health departments and first responders in
plan development.
While states have legal jurisdiction to oversee much of a pandemic plan’s contents, local
responders will be responsible for the related operational, on-the-ground implementation.
Surge capacity, antiviral prioritization, and outbreak tracking are among the areas especially
critical to plan for in the local context. Additionally, a highly-dense urban area poses a partic-
ular danger because of the possibility of massive virus transmission.
Local areas, in coordination with state and federal officials, need to prioritize pandemic prepa-
rations to ensure that implementation and first response is as seamless and effective as possible.
WE HAVE TO PLAN FOR THE WORST-CASE EVENT
“
”
– Dr. Jean Taylor, head of Maryland pandemic-planning efforts, Maryland Department of
Health and Mental Hygiene.35
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Vaccine and Antiviral Medication Issues
National planners must focus on questions
given the limited production capacity for
surrounding stockpiling antivirals and stabiliz-
antivirals and vaccines in the U.S. and
ing vaccine development to protect people in
throughout the world.36
the event of an outbreak. This is problematic
THE SHRINKING VACCINE MANUFACTURING MARKET
In 1976, 37 U.S. companies manufactured vaccines. In 2002, there were only three.
Reasons given for the decline are mostly economic:
I Vaccine production can take decades of research and development and, according to
industry estimates, costs about $800 million per licensed vaccine.
I Concerns about liability impact manufacturers’ decisions to avoid vaccine production,
especially after the significant compensation claims that followed the swine flu immu-
nization program in the mid-1970s.
I Some companies also cite insufficient market size as reason to stay out of the vaccine market,
due to the current low incidence of many diseases in the U.S., such as tuberculosis. The flu vac-
cine demand is particularly seen as unstable due to the unpredictability of the size and scope of
the market each year.
I There are only two manufacturers currently licensed to produce influenza vaccines in the
U.S., and a third overseas manufacturer who supplies vaccine to the U.S. One of the U.S.-
licensed manufacturers produces inactivated influenza vaccine and one manufacturer pro-
duces the live, attenuated vaccine administered through nasal spray.37
Flu Vaccine Crisis of 2004
The October 2004 announcement that approximately half of the expected flu vac-
cine for the U.S. would not be available heightened public awareness about the
fragility of the public health system’s vaccine development system and national readi-
ness for a fast-moving influenza epidemic.
In early October, Chiron Corporation announced it would not be able to meet
demand for its flu vaccine after problems at a British plant halted production of mil-
lions of doses. The dose shortage highlighted the fact that the U.S. relies on very
few manufacturers to deliver the country’s “projected need of 100 million doses.”38
As a result, CDC officials were forced to encourage changes in the nation’s distribu-
tion procedures for the flu vaccine supply, reserving doses only for the populations
most in need. This illustrates the lack of coordination for the prioritization and distri-
bution of vaccines, particularly in a crisis.
The shortage resulted in a focus of media and public attention on the issue, long lines
at health clinics around the country, and calls for incentives, liability reforms, and
other measures to encourage a broader range of vaccine producers.
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