Public health in emergencies: transatlantic experiences

4 April 2006

The European Policy Centre held a Policy Dialogue on Public health in emergencies: transatlantic experiences. The speakers were Frank Rapoport, Partner, McKenna Long & Aldridge; Robert Shotton, Director in the European Commission’s Directorate-General for Health and Consumer Protection; Moya Wood-Heath, Civil Protection/Emergency Planning Adviser from the Red Cross EU office in Brussels; Marc Ostfield, Senior Advisor on Bioterrorism, Biodefense and Health Security, US Department of State; Steve Bice, a Senior Manager at Battelle Corp. and Former Director of the National Stockpile Division, US Centers for Disease Control and Prevention (CDC); Dan Gold, Senior Vice President, Pharmaceutical Operations, at Rockville, Md.-based Human Genome Sciences Inc; John Martin, Director, World Health Organization at the EU; and Mark Rhinard, Senior Researcher, Swedish Institute of International Affairs. EPC Senior Adviser Eberhard Rhein chaired the meeting.

Frank Rapoport said the outbreak of bird flu in some parts of the world had prompted the US government to realise that it lacked the necessary countermeasures - specifically, medicines and vaccines - to protect its population.

Last summer, US President George Bush signed into law Project BioShield, providing new tools to protect Americans against a chemical, biological, radiological or nuclear attack. Among these is a $6 billion fund allowing the government to enter into contracts with pharmaceutical manufacturers for vaccines. Under such deals, if companies develop a drug accepted as part of the national stockpile, the government will guarantee to purchase it. The law also allows the government to accept a drug before it has been approved by the US Food and Drug Administration, albeit with some restrictions.

Some progress has been made in purchasing and stockpiling the first cure for anthrax developed by Human Genome Sciences, as well as a treatment for acute radiation sickness caused by a “dirty bomb”. However, the US programme has been slow to get off the ground and the Bush Administration has been criticised for not doing enough.

EU perspective

Robert Shotton outlined the preparations being made by the EU institutions to cope with a human influenza pandemic.

First, the EU decided a few years ago to establish a Centre for Disease Control and Prevention in Stockholm (which is not yet fully operational) to take charge of medical and scientific research in communicable diseases; networking across the 25-nation bloc; building a consensus on medical and non-medical responses to medical emergencies; and conducting a review of Member States’ preparedness plans.

The Commission is also working on contingency plans in case large numbers of staff are unable to report for work, and seeking to establish accelerated budget and other decision-making procedures to use in an emergency situation.

Mr Shotton said it was essential to define what a crisis is - and the difference between an ‘emergency’ and an ‘event’ - and who would activate these special procedures. There are also templates of messages to go out to the media.

Important lessons came out of a series of “exercise” drills based on a human flu scenario. These included the fact that all important phone numbers tend to be stored on computers, which would not be available if information technology systems were down, underlining the need for communication capabilities to be backed up.

As far as EU Member States’ are concerned, most have tried to identify a clear person - a so-called ‘flu czar’ - who would be in charge of coordinating the response to an emergency. This would include dealing with both health and non-health aspects, such as police and security services. An important part of this, said Mr Shotton, is getting the flu czars to work together.

EU governments are also discussing the production of vaccines with the pharmaceutical industry, with both sides recognising that they would need to work together to stamp out the first signs of a pandemic by dealing with ‘hot spots.’ However, some Member States are readier than others, with some hoping to ‘free ride’ any EU distribution network.

On the international front, the EU has pledged to help the countries most at risk, such as China and Vietnam. However, many issues remain to be tackled, such as what kind of travel advice should be issued to EU nationals in parts of the world where there was a flu outbreak should they be ordered or advised to return home or stay where they are to contain the crisis?

Another difficult but important task is to prepare the media to provide sound health advice and minimise panic. “We can prepare but this is going to be a difficult thing to manage,” admitted Mr Shotton.

Human versus animal health

An important distinction must be made between the EU’s powers in human health and animal health. In the former, the Union does not have strict legal or budgetary instructions to act if Member States are unwilling to work together. However, when it comes to animal health, the EU has very extensive powers and can, for example, order Member States to cull birds.

Avian flu is currently a serious problem, “totally disastrous” for the poultry industry, with reported cases in some 13 Member States. “We expect many more outbreaks,” said Mr Shotton, adding that the first priority should be to protect the health of poultry workers and the rural population living in affected areas. Although there have been no proven human cases so far, there is a “real risk” of one or two isolated cases.

NGO perspective

Moya Wood-Heath addressed the role to be played by non-governmental organisations (NGOs) and specifically the Red Cross/Red Crescent during health emergencies.

NGOs have a different status in different countries: in some, they play a role in the health infrastructure, while in others they have a purely support role. Because a flu pandemic or other health emergency would overstretch any country’s resources, many would be dependent on volunteer organisations for additional help. “Massive events require a massive response,” said Ms Wood-Heath, especially in local communities.

Key considerations include whether or not to evacuate and where evacuees should go; identifying those who need help (such as the elderly and those living alone) and communicating with them; and deciding what kind of shelters to set up (short term or long term) and where.

Rather than deal with these problems as they arise, it is advisable to plan as much as possible in advance. Providing a framework for action is the responsibility of governments and EU institutions, but all actors - including NGOs - have different contributions to make.

The Red Cross/Red Crescent is the world’s largest independent humanitarian network with more than 100 million members and 183 million national societies, each of which is independent but works on a common set of principles. It performs different roles in different countries but, as a general rule, does not differentiate between responding to emergencies and development; in other words, it remains in countries once emergencies are over.

Ms Wood-Heath said that during an emergency, it is important to focus on citizens’ ability to cope, rather than perpetuate the myth of the helpless victim. This means assessing local strengths and priorities, and helping societies to become more resilient.

The International Federation of Red Cross and Red Crescent Societies (IFRC) influenza initiative has set up a task force to lead preparations and provide guidance on what to do in the event of a human or avian flu pandemic. Among other things, the task force is examining what key messages to get out during an emergency, medicines and vaccines, communication strategies and ethical issues. The initiative aims to involve all elements of society in the planning process in every country.

Governments should also involve NGOs in emergency planning and response. “If you don’t make use of them, you will waste them and you won’t provide an effective response,” warned Ms Wood-Heath. The Red Cross/Red Crescent in turn works together with other groups including the EU’s humanitarian aid arm, ECHO, the private sector, and even the military, which is likely to play a greater role in dealing with future emergencies.

US perspective

Steve Bice explained why stockpiling and preparedness are important.

While preparing for emergencies was unpopular in economic terms (why, for example, should the government spend billions of dollars on a future vaccine which may or may not work?), Mr Bice argued that it was a cost-effective mechanism - not just for the US but for the rest of the world. Currently, medicines/vaccines are “just in time" inventions, but, as the situation following Hurricane Katrina showed, it is the chronically ill who most at risk during emergencies (with, for example, diabetes patients not having access to their medicines). A synergy between the public and private sector was essential, with the private sector often proving the best partner for governments in such situations.

In terms of when countries should start stockpiling vaccines etc., Mr Bice said it was “already too late”. This was not meant to discourage efforts, but merely to emphasise the importance of starting now. He suggested that the EU consider stockpiling, although he acknowledged that it was already far ahead of the US in interacting with private-sector partners.

Overstretched military forces mean that governments will be even more dependent on NGOs in responding to public health emergencies in future. “I don’t think you can count fully on the military,” said Mr Bice.

Unfortunately, governments are not very good at identifying out their requirements. They may, for example, order a number of doses of a vaccine, but forget about ordering syringes or other equipment needed to dispense it.

Marc Ostfield suggested thinking about public-health emergencies in terms of three boundaries: 1) international (“we need to be working across borders”); 2) across disciplines; and 3) public-private partnerships, which he sees as the most challenging (“I rarely talk to people outside government,” he admitted).

Responses to public health emergencies mirror the four pillars of biodefence; namely: 1) threat awareness; 2) prevention and protection; 3) surveillance and detection; and 4) response and reaction. All four require working across borders, disciplines - from agriculture, public health and science and technology to the military, among others - and the public and private sector. Arguing that the public-private dialogue needs to go beyond the pharmaceutical industry, Mr Ostfield asked where transportation and energy suppliers had been during discussions on public health emergencies, since both would play a critical role.

He lamented the fact that the private sector was missing from some of the exercises to plan for emergencies, so government “pretended” that it knew the sector’s wants or needs. “We need those players in the room and at the table,” he insisted. For example, the US Department of Health and Human Services has no trucks of its own, so would depend on the private sector during emergencies.

Getting medicines to areas in need is also an important international consideration. On an international level, the US and other G8 countries have formed a bioterrorism expert group.

To improve preparedness, Mr Ostfield suggested buttressing national and international efforts to identify outbreaks; boosting interaction and cooperation across the public and private sector and different disciplines; and increasing military and civilian interaction. It is in the explicit interest of nations to help one another, and to develop and test their communication strategies. The anthrax outbreak in the US was an example of “risk communication gone bad.”

Dan Gold said the US anthrax outbreak had demonstrated that pharma companies need a “market pull,” or incentive, to develop drugs for stockpiles; in other words, they need to have a well-defined market and to know what kind of timeline they are working under.

The need for stockpiling was made clear in the anthrax outbreak in Washington, D.C. in 2001, when several grams of anthrax were released through the mail, necessitating a clean-up costing more than $1 billion.

The disease is spread by spores, and the most fatal version of which is the rare pulmonary version (which killed half of the 11 that were infected in 2001); in the late stages, antibiotics and vaccines are no longer effective. Although it is relatively easy to develop vaccines, by the time many patients presented themselves to health authorities it was too late. In addition, some patients did not take the antibiotic for long enough to wipe out dormant spores, which germinate for about 40 days.

Human Genome Sciences, a biopharmaceutical firm with a number of products in clinical development, has the capacity to produce hundreds of thousands of doses annually, but the factories themselves take five to six years to develop, making it impossible to create additional capacity once an outbreak has begun. In conclusion, Mr Gold emphasised that national stockpiles should include anthrax countermeasures.

The big picture

Setting out the global picture, John Martin said the United Nations’ systems were about to be “quite radically upgraded”. This will include revising international health regulations in 2007 following substantial negotiations between governments. The UN National Assembly has also passed a resolution recommending that members upgrade security and safety measures in public health laboratories. The WHO has a system in place designed to pick up and verify information on potential problem areas 24 hours a day.

WHO is also working closely with the pharmaceutical industry, with more than 600 public-private partnerships. Mr Martin said preparing for public health emergencies required a global approach, adding: “Unless all countries are safe, no country is safe.”

Mark Rhinard said societies around the globe face a huge challenge in dealing with an increasing number of threats, and neither side of the Atlantic had all the right answers. Crisis management, he concluded, its not just something you do, but an entire way of thinking.