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emerging from birds or animals is a veterinary virus and in many countries the Ministry of Agriculture may refuse permission for the virus to be brought into the country unless to a veterinary institute. Obviously, a contradictory viewpoint is that once an avian virus is recovered from a human then it could be viewed as a human virus. These apparently small questions of ownership can impede work on the in uenza A (H5N1) and other emerging viruses. Mathematical models can be developed during this viral interpandemic time and these have proved their worth in attempts to avert large outbreaks of SARS. Where countries are contiguous with open borders, such as the E.U., it is most important that national pandemic plans are interchanged. A new factor is the growing recognition by the WHO that it can exert huge economic pressure for countries to take zoonotic outbreaks of in uenza seriously. Scientists and virologists took a noninterventionalist approach in the previous pandemics of the twentieth century. However, the WHO is now acting very quickly and the central hypothesis is that unless a pandemic can be stopped very early it will never be stopped. This explains the huge interventions in Southeast Asia in 2003 2005 to kill over 200 million chickens to prevent an emergence of chicken in uenza A H5N1 virus and, similarly, the killing of 20 million chickens in Holland to prevent in uenza A H7N7. Should a policy of encircling vaccination of chickens also be carried out together with human distancing or quarantine, it is possible that a potential outbreak in humans could be aborted or at least delayed so that enough vaccine could be manufactured. Some scenarios for vaccine and antiviral use in a pandemic or threat situation are summarized in Table 13.5. Probably the most important contribution to public health is the buildup and stockpiling of antiviral drugs, which can then be used to blunt the effects of the rst wave of an outbreak and give opportunities for a new vaccine to be made. It is not widely appreciated that there could be a long delay in the manufacture of a stock of antiviral drugs. The new NIs have a life span, in bulk, of 20 years or more, so chemical stability does not present a problem. The problem is the complex chemical synthesis, and without a designated factory to produce the drug beforehand, the world production capacity will remain miniscule and totally inadequate in a world, or even national, threat situation. It could be argued very strongly that the single biggest investment in public health at present would be the establishment of a reserve of anti-in uenza drugs. To give some urgency to planners the situation can be viewed from another direction. When the pandemic or bioterrorist attack arrives and the hospitalizations and deaths begin to mount, who is going to be the messenger that the scienti c and medical community knew about the drug and vaccine shortage but failed to act Some governments including New Zealand, Australia, Japan, the United States, and the European Union are now beginning to stockpile NIs. Since there are only 16 subtypes of in uenza A virus, it would also seem sensible and strategic to prepare this number of experimental vaccines using a representative virus strain of each subtype and to obtain preliminary evidence of immunogenicity. Such vaccine virus could be used, at the very least, as an early release vaccine for health care workers, nurses, and doctors. It could be viewed as a community
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302 WORST CASE SCENARIO The new virus spreads rapidly and widely in the populations, causing illness at least as severe as in most in uenza A epidemics. Advantages Disadvantages Disadvantages Potential for the population to feel abandoned by their leaders in the medical care and public health system. Potential criticism of process and decisions when identifying most important persons to be vaccinated or protected with antivirals. Without bene t of antivirals Resources otherwise used and vaccine, morbidity and for vaccination might be probably mortality are high. applied to strengthening Strain on the health care health care delivery system services is severe, with to dealing with large reduced staff and increased numbers of severe cases. demand. National economy is seriously affected. Public fear and protest are likely. Disruption of vital community Impact of virus on most of the population remains severe, functions, including health and many of the problems care delivery, is minimized. expected under Option 1 would still be expected to occur.
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