The public health experts at Effect Measure have been following the discussion over what to call the world-wide epidemic, and interpreted the WHO press briefing like this: “everyone, WHO included, thinks a pandemic is well underway.” But they look to deeds, not dictionaries for solutions to an outbreak that has infected a reported 27,737 people worldwide:

Meanwhile we now have the long predicted influenza pandemic. It’s neither so scary nor so benign that we can afford to either hide under the bed or ignore it. What we must do is roll up our sleeves and manage the consequences.

The question of what the word “pandemic” means has gotten so entangled in the media coverage of the outbreak that The New York Times yesterday dug into the history of the term, revealing that the public health community hasn’t yet agreed on how to define it:

The word implies the rapid spread of an infectious disease to many countries in different regions, hitting each with more or less the same severity. But in fact, severity varies — not all people are infected at the same time, and not every country need be affected.

And there can be many other factors, including the numbers and percentages of people falling ill and dying; a population’s vulnerability to the disease, based on previous rates of infection; and the quality of health care facilities and disease monitoring systems.

Not least is that scientists do not know precisely how pandemics arise, what fuels them, why they vary in their lethality, why some occur in waves and why they stop.

Complicating matters further is the fact that the term gets applied to health problems like obesity and heart disease—very different from the international influenza outbreak.

Instead of tweaking the current alert system, the Effect Measure editors recommend an “up-to-date information” system. Sharing data in real time on the Internet would be helpful not just for national health systems, but would also allow media outlets to spend more time and effort looking at what is happening, rather than having to worry so much about what to call it. Fortunately, the Obama administration understands the issue clearly and has requested nearly $12 billion in additional funds to handle the ongoing outbreak, which has infected 13,217 people and killed 27 in the United States.

Image: CDC

But pharmaceutical interventions have their limits in the face of an outbreak, explained Jason Schwartz recently in Science Progress, and there are simple, swift public health solutions to stopping the spread of disease like isolating exposed individuals. Schwartz wrote that the severity of the current outbreak depends on how promptly infected populations are separated from healthy, unexposed populations. A public education initiative on isolation may not be headline material, but it reduces transmission rates—hence the raft of school closings across the country.

On the other hand, a universal vaccine would provide years of protection from all types of flu, Pollack explains. It would also eliminate the need to guess which strains should be included in a seasonal vaccine—a decision that makes or breaks a vaccine’s efficacy. This solution is especially appealing because of its cost effectiveness for countries that cannot afford annual vaccinations.

Despite the promise of these approaches, both face obstacles in implementation. Voluntary, and especially involuntary, isolation and quarantine policies are controversial because of potential individual liberties violations. As well, a universal flu vaccine will take years to create since the influenza virus mutates much more rapidly than that of measles or polio. It would take six months just to produce the first doses of a vaccine aimed at swine flu, but isolation strategies work immediately.

Image: AP.

The detective work, still underway, indicates that the virus is “almost equidistant to swine viruses from the United States and Eurasia…It doesn’t have any close relatives.” Donis says this suggests that the genetic mixing (which Aysha Akhtar explain in her article, “Flu Farms?“) probably didn’t happen in Mexico. Donis explains: “The amazing thing is the hemagglutinins [proteins on the surface of a flu virus] we are seeing in this strain are a lonely branch that have been evolving somewhere and we didn’t know about it.”

The exclusive interview is worth a full read.

Simply put, the antiviral drugs and vaccines that have been the focus of much pandemic planning and media attention are of limited use or unavailable during this pivotal early stage of the current outbreak. We have badly needed a fuller, more frank national discussion of the importance and ethics of other methods that can limit the spread of the virus in communities and worldwide. These strategies include voluntary and involuntary social distancing, which reduces transmission by, for example, closing schools or other locations where large groups assemble; isolation; and quarantine. Developing thoughtful policies and broad support for them is difficult enough in the absence of an imminent public health emergency. Attempting to do so in the midst of an unfolding outbreak and resulting media frenzy is all but impossible.

Public health officials have long warned that antiviral drugs such as Tamiflu will be of uncertain value in a pandemic. Early evidence suggests that the current swine flu shows some susceptibility to this class of drugs. However, the modest benefits they provide for most influenza viruses, coupled with the rapid spread of the present threat suggest that antiviral stockpiles will be of limited use in reducing the extent or severity of this outbreak. Similarly, talk of a swine flu vaccine is highly premature, as it will require at least six months to produce the first doses of a new vaccine, a time frame identical to the forecast for an avian influenza vaccine. For this reason, several hundred million dollars in government contracts have been spent on so-called “pre-pandemic” avian flu vaccines, products intended to provide some benefit until a specific vaccine can be produced at the start of a pandemic. The rapid emergence of swine flu renders this option moot for the current outbreak.

In either case, producing sufficient pandemic flu vaccine doses for large numbers of Americans, let alone international populations, would take years, even if significant financing, production, safety, and distribution challenges could all be resolved successfully and quickly. Moreover, the unintended consequences of the 1976 swine flu vaccination program, which resulted in far more vaccine-related injuries and deaths than confirmed cases of the disease itself, is a clear reminder of the perils of a rapid mass vaccination effort against a threat of uncertain severity.

The limited value of pharmaceuticals and vaccines in the early stages of a potential influenza pandemic is well known to public health officials and diligent readers of the vast planning documents issued by the federal government since 2005. Instead, the severity of swine flu or any potential pandemic will be determined in large part by how quickly those infected or exposed are identified, located, and separated from the healthy. This is the decidedly low-tech but life-saving work upon which many of the achievements of public health in the past century have been based. Evidence from past pandemics, most notably research by Howard Markel and colleagues on the 1918-19 influenza pandemic, has shown the positive effects of such non-pharmaceutical interventions for those communities that used them early and extensively in disease control efforts.

The public stance of federal pandemic preparedness, however, has been overwhelmingly centered on vaccines and pharmaceuticals. Hardly a month has passed since 2005 without press releases announcing new contracts to fund several generations of pre-pandemic vaccines, additions to antiviral stockpiles, or further modifications to the complex framework developed to allocate scarce supplies of vaccines and drugs fairly and effectively. In this context, it is no surprise that media coverage of the current swine flu outbreak has repeatedly turned to vaccines, with health officials asked to explain if there is a vaccine available, why there is not, and when one may become available.

In contrast to vaccines and antivirals, discussions of the role of social distancing, isolation, and quarantine in pandemic influenza response have most often been buried deep within government websites or little-publicized reports. While a significant public engagement effort was developed to build support for vaccine and antiviral allocation strategies, no comparable program has aimed to educate Americans on the importance of non-pharmaceutical interventions in limiting the impact of an outbreak. This is unfortunate, as widespread public support for voluntary isolation and quarantine programs is critical for their success, while also reducing the likelihood that far more controversial and ethically problematic compulsory measures may be required.

How might this disparity in attention be explained? The medical profession and the general public have long been transfixed by the potential for “wonder drugs” or “magic bullets.” The allure of scientific innovation as the key to preventing mass casualties in a pandemic is understandably difficult for politicians or scientists to resist. Announcements of sizable contracts to develop and produce new vaccines or the image of a national stockpile ready to be deployed in a crisis are far more likely to attract headlines than, for example, a public education project on the benefits of simply staying home from work when showing flu-like symptoms during an outbreak. The development and production of drugs or vaccines also bring economic benefits to participating companies and their communities, part of the profitable, if not somewhat opportunistic, industry emerging around pandemic preparedness.

Beyond these cultural, political, and economic explanations for the focus on vaccines and drugs, non-pharmaceutical interventions have been largely overshadowed in pandemic planning likely because the mere suggestion of isolation and quarantine programs is certain to be controversial and alarming. Even if such programs were voluntary in all but the most severe and limited circumstances, the word “quarantine” calls to mind scenes from the movies of entire communities cordoned off and placed under military control—like in the 1995 movie Outbreak. These unrealistic fictional depictions, coupled with documented historical abuses of quarantine powers by public health officials, create considerable challenges for public health officials charged with organizing non-pharmaceutical interventions and building support for their use as part of effective and just disease control strategies.

In contrast to voluntary programs, compulsory isolation and quarantine force us to examine the tension between individual liberty and the common good in public health, in addition to the contentious political and ethical debate over the role of the state in restricting civil liberties during a crisis. The overwhelming public interest surrounding the 2007 case of Andrew Speaker, the American traveler infected with a drug-resistant form of tuberculosis and placed under a federal isolation order, provided clear evidence of the mass concern such actions can create, even when applied to only one individual. Since then, however, there has been no visible effort to engage stakeholders and the public regarding when similar measures may be required in a pandemic, how their use will be overseen, and why they are critical to preserving public health.

More practically, the reality of our vastly underfunded public health infrastructure makes it difficult to imagine how large-scale social distancing, isolation, or quarantine programs would succeed in the face of widespread public opposition, making preemptive public education programs inseparable from disease control goals. With respect to the eventual allocation of scarce supplies of vaccines and antivirals, pandemic planners have realized the importance of the methodical, thoughtful engagement with stakeholders and the public. An analogous program examining policies for voluntary or compulsory non-pharmaceutical interventions would have been similarly worthwhile.

For the unfolding swine flu outbreak, it is already far too late to begin this vital work. Government officials who are already justifiably concerned about creating unnecessary panic may be forced to introduce targeted social distancing, isolation, and quarantine programs to a public that has heard too little about their tremendous importance and too much about vaccines and antivirals that are barely relevant to the immediate health challenges at hand. Through the efforts of the public health community coupled with a bit of luck, swine flu may dissipate without becoming a full-blown pandemic, giving health policy-makers a second chance to revisit these critical aspects of a comprehensive, just approach to pandemic preparedness.

Jason L. Schwartz is a researcher at the Center for Bioethics and a doctoral student in the Department of History and Sociology of Science at the University of Pennsylvania. He is most recently the author of “Disease Control Policy: Individual Rights versus the Common Good” in the Penn Center Guide for Bioethics (Springer, 2009), from which parts of this essay are adapted.

In an effort to halt the spread of infections, health groups are marking tomorrow, April 25, as the second World Malaria Day. To encourage breakthrough research in public health, the Gates Foundation sponsors a set of $100,000 grants to fund high-risk, high-return pilot studies, some of which focus on on new ways of stopping the parasite which, according to foundation officials, kills someone every 30 seconds.

To highlight some of this research, the foundation hosted a blogger conference call yesterday with three of the grant recipients.

Brian Foy, an assistant professor of Microbiology, Immunology and Pathology, at Colorado State University, used his funding to explore the potential of using endectocides, drugs that combat parasitic worms, to also stop mosquitoes. Malaria takes between 10 and 14 days to develop inside a mosquito before it is transmittable to another person, and that presents a window in which to kill the bugs. Foy tracked mosquitoes in Senegal and found that those that had bitten people taking ivermectin, an endectocide used to combat river blindness, died for up to a week. Thus, the drug has to potential to stop two infections at once.

“If you could just make one of those blood meals toxic to the mosquito, you could kill it before it’s able to transmit the disease,” Foy explained. “These same drugs that people are taking to clear out their worms could also be used to kill these mosquitoes.” His data is preliminary, and dosing would have to be adjusted to ensure that mosquitoes got a fatal portion endectocide but did not develop resistance. Christine Gorman at Global Health Report explains the technique further.

Szabolcs Marka, an assistant professor of experimental astrophysics at Columbia University, took a radically different approach in his preventative experiments. He studied the sensory systems of the mosquito species that are vectors for malaria and designed laser barriers that disrupt the insect’s ability to sense its environment. Flying into the beams, it “experiences a sudden or intense heat wave or light wave that disables it,” Marka explained, which stops it from reaching a human in the first place.

Another major problem is in designing antimalarial drugs that evade resistant strains. Pradipsinh Rathod, a chemistry professor at the University of Washington, looked at elements of the malaria genome that contribute to “hypermutagenesis,” a situation in which an the organism’s DNA mutates at rates so rapid that it dramatically increases the development drug resistance. In a second approach, his team looked at potential compounds that could disrupt the rapid mutation itself, which would provide a way for potential vaccines to remain effective.

Some research indicates that climate change may increase the likelihood of malaria transmission in various parts of the world by making those areas more hospitable to the mosquitoes that carry the parasites. Some of that research is plotted on our Human Toll of Climate Change map.

(Full disclosure: The Gates Foundation has funded grants for education policy work at CAP, but not Science Progress.)

Image: Flicker user bogdog Dan