Tuesday, November 13, 2012

Paper: Are We Prepared For A Pandemic In Low Resource Communities?



# 6713


One of the hard truths about pandemics is that they tend to disproportionately affect developing nations and low resource communities.


Back in 2006 we looked at a study that appeared in The Lancet that predicted, based on the 1918 pandemic experience, that a modern pandemic of similar virulence could claim 62 million lives, and that 96% of those deaths would occur in the developing world.


Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918—20 pandemic: a quantitative analysis

Prof Christopher JL Murray DPhil , Prof Alan D Lopez PhD, Brian Chin ScB, Dennis Feehan AB , Prof Kenneth H Hill PhD


The authors cited as much as a 30-fold difference in mortality rates around the world in 1918. Countries in Asia, Latin America, and Sub-Saharan African were particularly hard hit.


Some of the reasons behind this disparity included.


  • lack of access to adequate medical care
  • weak public health infrastructures,
  • housing conditions and population density
  • nutritional status and
  • co-existing medical conditions.


For the most part many of these conditions still persist, plus developed nations today are more likely to have earlier access to antibiotics, antivirals, and eventually vaccines. Leading the authors to write:


This analysis of the empirical record of the 1918—20 pandemic provides a plausible upper bound on pandemic mortality. Most deaths will occur in poor countries—ie, in societies whose scarce health resources are already stretched by existing health priorities.



A grim scenario, and part of the rationale behind the creation of a program called the H2P  (Humanitarian Pandemic Preparedness) Initiative geared towards promoting community & district-level pandemic flu preparedness and response in developing countries.



H2P (which began in 2007 & ended in 2010) was a joint effort by NGO’s and partner organizations, including USAID, IFRC, CORE Group (including American Red Cross, CARE, & Save the Children), AED, InterAction, & several UN agencies, including WHO, WFP, & UN OCHA.


During the 2009 pandemic I highlighted the H2P initiative’s efforts several times (see here, here, and here), and over the years have had occasional correspondence with Eric Starbuck at Save The Children, who was the H2P’s Public Health Advisor with the CORE Group.


I mention this past association because Eric is the lead author on a paper that appears today in the Journal Influenza and Other Respiratory Viruses, that looks at the challenges (and provides some solutions) for helping low resource communities deal with an influenza pandemic.


The full article is available online, and is well worth reading in its entirety. 


Are we prepared to help low-resource communities cope with a severe influenza pandemic?

Eric S. Starbuck, Rudolph von Bernuth, Kathryn Bolles, Jeanne Koepsell

Article first published online: 12 NOV 2012

Recent research involving lab-modified H5N1 influenza viruses with increased transmissibility and the ongoing evolution of the virus in nature should remind us of the continuing importance of preparedness for a severe influenza pandemic.


Current vaccine technology and antiviral supply remain inadequate, and in a severe pandemic, most low-resource communities will fail to receive adequate medical supplies.


However, with suitable guidance, these communities can take appropriate actions without substantial outside resources to reduce influenza transmission and care for the ill. Such guidance should be completed, and support provided to developing countries to adapt it for their settings and prepare for implementation.

View Full Article (HTML)     Get PDF (71K)


In regions where antivirals, antibiotics, and vaccines (and even basic nursing care) may be unavailable, the only realistic protection against an influenza pandemic is the implementation of NPIs (Non-Pharmaceutical Interventions). 


We’ve talked about NPIs many times before, but primarily in the context of a developed or industrialized community.


NPI’s and Influenza

Our First Line Of Defense
Study: Effectiveness of NPIs Against ILI's


As Eric and his team point out:


Nonpharmaceutical interventions (NPIs) to reduce influenza transmission at the household level may include keeping a distance from others, washing hands, covering one’s cough, and isolation of the ill.


However, several of these NPIs may not be very feasible in some settings, such as those with poor access to water or where many families live in small one-room dwellings.


Experience during the 2009 pandemic indicates that communication materials, such as those encouraging the practice of these NPIs, need to be adapted, tested, and approved for local use ahead of time. The absence of standardized, pretested messages was a challenge in 2009


A few samples of the type of guidance provided by H2P to low resource communities include:





The authors conclude:


We believe that detailed authoritative guidance for resource-poor settings on NPIs to reduce influenza transmission at community level in a severe pandemic should be developed.


In addition, support should be provided to governments in developing countries to adapt this and other important guidance to their settings and plan to roll it out if needed.


We are not aware of ongoing efforts of this kind, but believe that this should be an urgent priority. We are concerned about this apparent gap in the most basic kind of preparedness for a severe pandemic.



It doesn’t take a pandemic to put people living in low resource communities at greater risk. That happens every day.


Agencies like the Red Cross, Red Crescent, CARE, Save The Children, UNICEF, and others are working around the world on a daily basis to combat poverty and disease, and are going to be on the front lines during any pandemic.


They could use your support.


These NGO’s do a great deal with very little, and even small donations can help make a difference.


A final note: For those curious about my mention in the acknowledgements section of this paper, I assure you my contribution was small, and unworthy of mention (but I’m appreciative, nonetheless). When asked, I suggested to Eric that the Journal Influenza and Other Respiratory Viruses might be interested in his paper.

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