Disease impact would ripple through the economy with disastrous effect. With everyone from air traffic controllers to truck drivers out sick, just-in-time inventory chains might collapse, while schools and day-care centres might close for weeks. (Technological evolution has overtaken Barry’s concerns on internet ‘last mile’ connectivity and working from home, and ‘vital’ or ‘front line services’ have been maintained very well).


With the emergence of H5N1, the inherent threat of the scenario above caught the attention of large companies and Governments; businesses began working on supply chains and continuity plans, governments in developed countries began pouring money into pandemic preparedness, including basic research, vaccine production, and drug stockpiles. They also looked at non-pharmaceutical interventions (NPIs) – what to do without drugs. This brought together people from backgrounds in history, laboratory science, public health, international relations, mathematical modelling and politics. (Barry worked for several years on the projects). Planners had prepared for things such as a Cat 5 hurricane but were thrown off-balance by the 2009 H5N1 swine flu outbreak. This mildest ever pandemic still taught them new lessons, including a rethink of NPI policy.


The 2009 pandemic killed ‘only’ an estimated 150,000-400,000 worldwide, with about 12,000 US deaths. The average age of victims was only 40 (80% under 65), whereas seasonal flu outbreaks see up to 650,000 deaths in the 65+ bracket. But this experience should reassure no one. Where are we now (2009) and what are the lessons?


It’s worth understanding the commonalities of the pandemics we have information on: 1889, 1918, 1957, 1968, and 2009.


All five came in waves. Some investigators think the 1918 virus circulated in humans for several years before mutations allowed it to spread easily. The 1889 pandemic virus did follow this pattern, generating 2 ½ years of sporadic outbreaks around the world, including London, Berlin and Paris, before becoming a full pandemic in the winter of 1891-92.


The 1968 pandemic gave us the H3N2 virus and this has continued to cause the most severe disease of several circulating influenza viruses ever since. This virus mutates rapidly prompting an official to quote “When you’ve seen one influenza season, you’ve seen one influenza season”.


THE 2009 PANDEMIC KILLED ‘ONLY’ AN ESTIMATED 150,000-400,000 WORLDWIDE, WITH ABOUT 12,000 US DEATHS. THE AVERAGE AGE OF VICTIMS WAS ONLY 40 (80% UNDER 65), WHEREAS SEASONAL FLU OUTBREAKS SEE UP TO 650,000 DEATHS IN THE 65+ BRACKET.


There is an answer to all this: a universal vaccine that works against all influenza viruses (the current aim in 2020). Current vaccines target hemagglutinin, the antigen most exposed to the immune system (looks like the head of a broccoli). Unfortunately, these vaccines target the head portion, which mutates rapidly, and often without interfering with the functioning of the virus, which is why influenza vaccines are not particularly efficacious. Effectiveness between 2003 and 2017 ranged from 10% to 60%, though still preventing millions of cases and thousands of deaths. Other parts of the virus, the stalk, are ‘conserved’ and shared by most influenza viruses. Current vaccine research is trying to incite the immune system to go after the stalk, for obvious reasons, which would be the ‘holy grail’.


If a universal vaccine was easy to develop, it would have been done by now. However, it has not been helped by a lack of funding and resources (though not anymore!). Note, prior to the emergence of H5N1 the US was spending more money on the West Nile virus that killed 294 in its worst year than on Influenza which was killing some 56,000 Americans p.a. That has changed now and significant progress to a universal vaccine has been made.


ASIDE FROM VACCINES, HOW PREPARED ARE WE FOR A NEW PANDEMIC?


The good news: The WHO and governments have developed a good surveillance system. The problem is it is incomplete and dependent on government cooperation. In 2003, the system did pick up SARS, which was originally thought to be a new influenza virus and contained it. But SARS was easy to contain. As it was, the world was put at risk by China, which allegedly initially lied and hid the disease. China is now better prepared but it is still not fully transparent.


Whilst surveillance matters, giving early warning and allowing a vaccine hunt to begin, the vaccine itself is the main defence against pandemic. Time is important, even a few weeks can make a massive difference.


32 | ADMISI - The Ghost In The Machine | Q2 Edition


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