Feds inoculate themselves against criticism

By Owen Dyer

Bashing the government is always fun and usually easy, especially when you have an opinion column to write. Even the best governments — and let's face it, ours is a lot better than most — are notoriously short-sighted when it comes to facing longterm threats like asteroid impacts and global warming. The potential for a new flu pandemic is just the sort of threat that generally slips under a government's radar. So it hurts just a little to have to say this, but Canada's plan for dealing with bird flu is — actually pretty good.

We've heard many dire warnings from experts about the possible impact of this disease. We've also heard a few dismissive comments from other experts accusing the WHO of crying wolf. No doubt there is a fair degree of hyperbole on both sides. But we do know this — pandemics have happened before, we still have no cure for the flu, and even the common garden variety of the disease kills about 8,000 Canadians a year.

If the doomsayers are wrong and we follow their advice, we may end up spending several tens of millions of dollars on antivirals that could very well end up gathering dust. But if the naysayers are wrong and we follow their advice, we may end up losing 11,000 to 58,000 citizens to the disease, according to Health Canada estimates.

Considering the furor in the States over the recent shortfall in flu vaccine, which became a political football in the last presidential election, it's hardly surprising that Canada's federal and provincial governments have chosen to hedge their bets and stock up on antivirals. By the end of March, the Canadian stockpile stood at 16 million doses of oseltamivir, and the buying may not stop there.

The dilemma facing the Public Health Agency of Canada, which coordinates the national response to SARS and pandemic flu, is that it must prepare for a disease that doesn't yet exist. The H5N1 virus that has proven so deadly to a few unlucky people in Southeast Asia isn't the strain that might flash around the world killing millions, because it does a poor job of jumping between humans. The fear is that genetic mixing and matching with other flu strains in human hosts will produce a strain with the transmissibility of normal flu, but the virulence of bird flu.

That's why the government has chosen not to stockpile H5N1 vaccine, even though we do have such a thing. The Americans, by contrast, are supplementing their antiviral purchases with large-scale production of H5N1 vaccine.

It's noteworthy that when this difference in approach was pointed out to Dr Klaus Stohr, head of WHO's influenza program — a man who certainly does not underestimate the threat — he answered that vaccine stockpiling would be redundant in Canada, given the other measures our country has taken.

Chief among these measures is a plan to accelerate production of a vaccine once we've identified the strain. In October 2001, the federal government announced a 10-year contract with ID Biomedical to assure a state of readiness in case of an influenza pandemic. The contract requires that ID Biomedical develop the infrastructure and capacity, in Canada, to provide 100% of domestic vaccine needs in the event of an influenza pandemic.

Normally, this would take up to a year, but Health Canada believes it can cut four months off that lead time by testing and licensing a precursor vaccine now. The Canadian trials will look at adjuvants that boost immune response in the hope of stretching antigen stocks further. And crucially, the production facility, which will need to be a high-biocontainment plant, is already being built. Health Canada believes that the entire population could be immunized within 10 months of an outbreak. If a pandemic strain is closely related to the current bird flu, that time could be cut further.

Compare this to the US approach on H5N1 vaccine. They are buying two million doses, not nearly enough to cover even their 13 million health workers. The likelihood is that the vaccine will be ill-suited to any emerging pandemic strain — though it might be usable as a primer, authorities would still need a tailored vaccine for the booster. And despite the warnings of experts following last year's vaccine shortfall, the US government is still doing little to encourage a domestic vaccine industry. Producing vaccines in the US remains commercially non-viable, and their supplier is none other than Canada's ID Biomedical. In fact, if a pandemic strikes and hangs around for a year, Canada's foresight could leave us the world's sole exporter of pandemic flu vaccine.

This brings us to the matter of what measures are in place to protect us in the first vital months of a pandemic. The Public Health Agency stresses that its plan is three-pronged, relying on vaccination, public health measures, and antivirals. Since the SARS outbreak, Canada has done a good deal to improve mechanisms for reporting and quarantining infectious disease, and money is available to get public health messages to the public. But all the hand-washing in the world won't stop the flu from making its deadly rounds.

Which brings us back to antivirals. Canada's 16 million doses of oseltamivir represent a good start — bigger than Britain's much-vaunted stockpile, which stands at 14.6 million doses for a population twice as large. And Canada has other, much smaller stockpiles held by provincial governments and the Defence Department. Canada is also about to buy four million more doses of amantidine, ineffective against bird flu but not necessarily against a pandemic strain, on the principle that it's a bad idea to put all your eggs in one basket.

But at a dose a day, the existing stockpile can only protect about three million people for one week, when it will take months for a vaccine to arrive. And it won't even do that, because the priority will be prophylaxis of health workers. Even if the entire current stockpile were given to health workers, it would only cover 380,000 for six weeks. And that just isn't enough.

Canada probably hasn't finished buying antivirals, and nor should it, because these numbers represent the only serious yet rectifiable flaw in the pandemic plan. Buying 100 million doses would cost the country about $250 million, but even if the pandemic never materialized it wouldn't be money wasted, because the drugs have a long shelf life and could be used in future years against regular flu. So we're on the right track, but we need to go further.