E-DRUG: MSF interview on global response to Influenza A(H1N1) pandemic
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Also available at:
http://www.msfaccess.org/main/access-patents/medical-need-not-purchase-power-should-determine-the-global-response-to-the-influenza-a-h1n1-pandemic/
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Medical Need Not Purchase Power Should Determine the Global Response to
the Influenza A (H1N1) Pandemic
- An Interview with Dr. Christophe Fournier, President of MSF
International Council
In this interview, Dr. Fournier describes why a global response to the
H1N1 pandemic must in the short term focus not only on vaccination, but on
reducing mortality worldwide by emphasizing the identification and
treatment of the most severe cases; and argues why access to the vaccine
in the future must be based on medical need, not purchasing power of
wealthy countries.
Is Influenza A (H1N1) affecting people in the developing countries where
Doctors Without Borders/Medecins Sans Frontieres (MSF) is working?
In Africa, a dozen countries, from South Africa and Sudan to the Ivory
Coast and Ethiopia, have reported confirmed H1N1 cases. Some African
countries have not declared any cases, but this must be considered
cautiously as laboratory test confirmation is not available in many
countries. In other countries where MSF is working in South America and
Asia, cases have been declared almost everywhere, including in Sri Lanka,
Myanmar and Afghanistan.
MSF teams have not yet confirmed cases in our programs nor have we seen a
rise in respiratory infections that could indicate undetected cases.
Overall the number of cases declared by African countries is still low for
the time being. It is difficult to predict when the outbreak will spread
further, but we need to be mobilized and ready.
What is the potential for a massive impact of the disease in poor
countries?
First of all, we have to recognize that there remain many uncertainties
about this pandemic. We have to be cautious in predicting what might
happen, but as medical professionals, we must also be vigilant in
preparing for possible scenarios.
This is a new virus against which humans, especially the young, appear to
have no immunity. So the number of people who will be contaminated is
likely to be very high. Some epidemiologists are predicting that as much
as 30 percent of the population worldwide could become infected, with a
death rate of as high as 0.5 percent.
Although this flu is relatively mild at this point, it is difficult to
determine how lethal it is because the number of cases is probably being
underestimated. But even if we conservatively assume a death rate that
does not exceed 0.1 percent of those affected, it will likely lead to
significant numbers of deaths if severe cases are not identified and
treated. High risk populations such as young children, pregnant women, and
those with underlying chronic illnesses and compromised immune systems
will be the most affected.
What should be the priority in responding to the pandemic in poor
countries - vaccination or treatment?
Medically the only appropriate way to respond to a pandemic is on a global
scale. Those most at risk of dying from the disease should be the highest
priority for vaccination and treatment – no matter where they live.
Based on our experience, the appropriate strategy in an epidemic is
two-fold: first, strengthen hygiene and infection control measures to
prevent the virus from spreading, and, second, treat patients to limit the
number of deaths. However, in the case of this virus, which is
transmitted extremely quickly and easily, the effectiveness of isolating
infected patients is no longer an option. The most affected countries,
such as the United States and the United Kingdom, quickly abandoned such
a strategy.
Vaccinating is also one way to halt the spread of the virus. But in this
case we must question the impact of a vaccination campaign on the
epidemiological curve once the epidemic is already advanced. The virus
continues spreading quickly and, possibly, kills patients even in the
midst of efforts to reach the most at risk and organize mass vaccination
campaigns.
In the case of H1N1, the vaccine is not ready yet. It is currently in the
clinical development phase and will not be available for mass production
until September. It is therefore quite likely that the vaccine won't be
ready to help seriously tackle the first wave of the epidemic.
If we want to reduce the mortality that will be caused by the H1N1
pandemic, we cannot rely on the vaccine. We must focus on identifying and
treating the most severe cases.
If we want to treat the severe cases most at risk of death, in particular
those with bacterial acute respiratory secondary infections, standard
antibiotic and, when possible, oxygen will have to be available in great
quantities everywhere. Given the rapid spread of the pandemic and the many
unknowns, doctors must be prepared for a massive influx of patients.
The lack of health care workers, medicine and supplies in many countries
where we work is a legitimate cause for grave concern. Preparedness for
people who become seriously ill should be a top priority.
Are you saying we will not be able to rely on vaccines to help tackle the
epidemic in the coming months?
The answer is quite simple: There will not be enough vaccine to meet the
needs in poor countries in the coming months. That is why our focus now
should be on identification and treatment of the sickest cases, not on
waiting for the vaccine.
Even if all companies that are currently able to produce this vaccine
assigned their full production capacity to the task, they would still not
be able to produce enough vaccine for people in resource poor settings.
And wealthy countries in North America, Europe and elsewhere have already
ensured that they will have access to at least 90% of the vaccine
production for this year by making pre-purchase deals with the main
producers.
We are seeing that purchase power, not medical need, is driving rich
countries to monopolize access to the vaccine before it has even been
produced.
The vaccine will clearly not be the solution to reducing deaths from this
pandemic in the short term. Instead, we need to step up global efforts on
case recognition and treatment.
What is being done to secure wider access to the vaccine for the future?
Two years ago, the WHO called for global solidarity regarding flu
response, but the process largely failed as it was impossible to get
consensus on a global flu preparedness plan. Instead, developed countries
have taken a unilateral rather than a global approach. In the face of a
global pandemic, this is unacceptable.
Now the WHO is scrambling to secure a meager part of the vaccine
production for poor countries. WHO Director General Margaret Chan has so
far managed to negotiate a donation of 10 percent of the production of the
vaccine by GlaxoSmithKline and Sanofi-Aventis to be allocated to the
developing world, out of which the first 50 and 100 million respectively
will be a donation to WHO (Novartis has refused). But this is far from
enough of what is needed and there is no clarity on how these donations
will be distributed or whether the prices charged for any remainder will
be affordable to those in need.
The first 150 million doses of the vaccine that have been donated will
only be ready in six months. So again it is questionable that this vaccine
will have a significant effect on the epidemic before the end of the year
and given this delay, vaccination is not an immediate strategy.
Faced with this vaccine shortage, the WHO is advising poor countries to
vaccinate health workers first, while wealthy countries are also focusing
on vaccinating wider vulnerable groups. This approach is not only
inequitable, it is medically unsound when taking into account the global
scarcity of the vaccine. The strategy should be to use the vaccine we do
have available to vaccinate the most vulnerable worldwide versus seeing
what “spare capacity” is leftover once the wealthy countries have used
what they want.
World leaders and the WHO have a responsibility to avoid a two-tiered
response to the pandemic. Rich countries, the pharmaceutical companies and
the WHO must work to facilitate access to the vaccine based on medical
need, not purchasing power.
More must also be done to increase vaccine production for the future.
Vaccine makers in India and elsewhere are working on vaccines, but could
use some technical assistance to speed up the process. WHO needs to
increase support to those companies in developing countries ready to
produce the vaccine including reviewing and proposing ways to remove any
intellectual property or technological know-how barriers to production.
Developed countries must support this process, rather than block attempts
to remove such barriers as they have in the past.
But again, I stress that with the current vaccine capacity, our efforts
should be on identifying and treating those who fall seriously ill from
the virus. The vaccine will not be the solution in the short term,
nevertheless the potential scope of this pandemic requires us to act now
for both the short and long term.
Given these uncertainties and limitations, what are MSF's priorities?
Based on assessments from the field, our objective is to provide as much
support as possible to existing medical teams, particularly where the
health system is weak and fragile, to help them deal with any possible
influx of patients, set up treatment management systems that we have
already planned and ensure that patients suffering from other illnesses
are not forgotten.
We are giving priority in emergency preparedness in order to be able to
support the early detection and treatment of severe cases. We expect to
concentrate on vulnerable populations that may be seriously affected,
particularly infants, pregnant women, and patients with underlying chronic
illnesses or who are immuno-suppressed.
Our priority is to provide high-quality care to our patients by treating
symptoms and prescribing antibiotics. Antivirals like oseltamivir,
marketed as Tamiflu but also produced as generics and prequalified by WHO,
have limited effectiveness unless administered within 48 hours of the
illness appearing. We will therefore make limited use of them,
particularly as the patients we see in our programs often wait a long time
before seeking treatment.
Finally, even beyond the destitute circumstances people face in the
contexts where we work, we must remain vigilant and responsive when facing
such an extensive pandemic. Given its twists and turns, and its severity
even in the best-prepared and wealthiest countries, we cannot possibly
state that the provisions taken today will be effective tomorrow.
-ENDS-
James Arkinstall
Senior Communications Officer
Medecins Sans Frontieres - Campaign for Access to Essential Medicines
www.msfaccess.org
Follow us on Twitter: http://twitter.com/MSF_access
+33 1 40 21 2837 (office)
+33 6 13 99 7751 (mobile)
James.ARKINSTALL@paris.msf.org