DoD Officials Prepare for Possible Pandemic

FORT SAM HOUSTON, Texas, March 1, 2006 – Defense Department officials are working to create a pandemic influenza plan in time for the Department of Homeland Defense's end-of-March deadline, a DoD medical official said Feb. 27.

The plan will lay out the department's roles and responsibilities in varying stages of an avian influenza -- or "bird flu" -- outbreak, both at home and overseas, said Ellen Embrey, deputy assistant secretary of defense for force health protection and readiness, during a Joint Operations Medical Managers Course in San Antonio.

DoD's work is a coordinated, integrated effort to ensure the department is fully enmeshed in the national pandemic planning process, Embrey said. "We've been working on and implementing training and policy guidance to make sure we're prepared globally," said Embrey, who is responsible for the department's medical readiness. "We have to ensure we have the surveillance in place, installation preparedness, global understanding and a stockpile of necessary components to mount an effective medical response. It's an enormous task."

The DoD plan will be one part of an overall federal government plan, Embrey said, adding that the Department of Health and Human Services, the lead for U.S. government response, and Department of Homeland Security, responsible for nonmedical response, also play a key role in the nation's preparedness for an outbreak. "It's a team effort," Embrey said. "The DoD has a unique set of assets that, when needed, could be used to support the national response."

Under the broad DoD plan, each command also will have its own implementation plan, a tasking that touches every installation throughout the world. The overarching goals in this planning effort are to preserve operational effectiveness and protect those most at risk. "Along with the overreaching department plan, each combatant commander must have a plan in place to address pandemic influenza, a potentially very infectious disease," Embrey said. "Some people may be sick for a while, and the commanders have to project how this could affect their ability to perform the mission."

The collaborative planning effort will wrap up in a few weeks, and then "all the hard work will become apparent," Embrey said.

Ongoing collaboration between military services and federal agencies is indicative of an ongoing commitment for the Defense Department to work toward an "interoperable and interdependent future," Embrey said.

"We need to start with 'morphing' work being done in each service. We aren't fully integrated as a community and we need to come up with a model that works for all of us," she said.

The joint environment is most evident in the medical arena, Embrey said, a trend based on a DoD focus to provide "world-class medical care when needed anywhere in the world."

The battlefield offers an example of the need for joint interoperability, she said. When servicemembers are injured in combat, they are administered care by a medic, whether Air Force, Navy or Army, then evacuated by a Navy helicopter or Army Humvee to a forward surgical team, which exists in all services. Once stabilized, they are brought to the next point of care, if needed, by an Air Force fixed-wing aircraft back to a major medical facility, such as the Army's Brooke Army Medical Center in San Antonio or Walter Reed Army Medical Center in Washington, D.C.

"For us, it's making sure the capabilities we have in each service are interchangeable, so, for instance, any service's medic can operate the same equipment. We don't want to have to learn new equipment when time is of the essence," Embrey said. "Through joint training, standardization and combining and making efficiencies where we can, we can ensure top quality care anytime and anywhere."

Statistics already point to the high standard of medical care for servicemembers supporting operations Enduring Freedom and Iraqi Freedom. "It's amazing; we have the lowest (rate of) disease (and) non-battle injuries of any war," Embrey said, adding that servicemembers supporting OEF and OIF visit a doctor two to 2.5 times a year on average. "I go to the doctor more than that," she said. In comparison to the OIF/OEF numbers, servicemembers at home average seven doctor visits per year.

"The survival rate is unbelievable," she continued. "This is a direct result of the great capabilities of the services put together. They are doing a great job."

When people think of joint, Embrey said, they should also think beyond the military services. "It's also about engaging our coalition partners; it's a truly international effort," she said, "and, one of the department's biggest ongoing challenges, and commitments."

Embrey urges everyone to visit the DoD Deployment Health and Family Readiness Library at http://deploymenthealthlibrary.fhp.osd.mil/, which includes information for clinicians, servicemembers, unit leaders, veterans and their families on deployment-related health issues. "It's a one-stop shop to learn about what the department is doing in the health and readiness arena," she said.

'Military-style' flu network call

BBC

Wild birds, including swans, have been hit by avian flu

A military-style surveillance network should be set up in developing countries to identify early signs of a human flu pandemic, US doctors say.

The labs should be modelled on ones set up after World War II, they add.

The call, by US military doctors, is made in an article published in the journal Nature.

In addition, UK scientists are to investigate if there are gaps in the scientific understanding of flu and how it spreads across the world.

What we want to be sure of is that we use as much expertise as possible to identify any gaps in our understanding. Sir John Skehel, Medical Research Council

The doctors want to see a network of rapid-response laboratories set up based on US Naval Medical Research Units (NAMRUs), which were put in place after WWII to protect American service men and women from infectious diseases overseas.

The doctors from the US Department of Defence Global Emerging Infections Surveillance and Response System have since been working with countries and the World Health Organization (WHO), and have made important contributions to infection control strategies as well the development of vaccines and treatments.

But only a few such labs still operate, with many - such as those in Panama, Puerto Rico, Brazil, Congo, Uganda, Ethiopia and Malaysia closing.

The American doctors, led by Dr Jean-Paul Chretien and Dr David Blazes, argue that a new network of state-of-the art laboratories mirroring the NAMRU model is now urgently needed.

These would support the existing work of the World Health Organization and regional collaborating centres.

It is hoped they would pick up the earliest signs of human-to-human transmission of a pandemic flu strain, which could occur in a very rural area.

Writing in Nature, they said: "The world needs such laboratories now, more than ever, as platforms for sustained epidemic detection and response - for avian influenza, and as-yet unknown diseases.

"The time has come to build on their experience and create a new generation of multilateral, WHO-aligned laboratories as a front-line of defence against future pandemics."

'More weapons'

In a separate development, the Royal Society and the Academy of Medical Sciences is to look at the science which has informed policy development and planning in the UK for what would happen in a flu pandemic, particularly in relation to the avian flu virus H5N1.

It will examine if there are other areas of science, or other pieces of specific research, which can inform such policies and plans for the immediate future and in the longer term.

Particular areas to be examined include whether it would be possible to develop new drugs to give doctors more weapons in the armoury against flu, and if it would be feasible to develop a vaccine which was effective against various strains of flu.

Part of the concern over a flu pandemic is that an effective vaccine could not be developed until a strain which could spread between people emerged.

It will also look at whether scientific 'modelling', designed to show how flu might spread across the world, could be improved - perhaps with information from other areas of science.

Sir John Skehel, director of the National Institute for Medical Research for the Medical Research Council, who is leading the study, said: "What we want to be sure of is that we use as much expertise as possible to identify any gaps in our understanding."

The academies will publish their report in the summer.

Chemotherapy may help human bird flu victims

00:01 02 March 2006
NewScientist.com news service
Lisa Hitchen

Chemotherapy for an immune system disorder might also be effective in treating people infected with the H5N1 strain of bird flu, scientists suggest.

With bird flu's 50% mortality rate in humans, the possibility of resistance to antiviral treatments, no developed human vaccines and the spread bird flu across the globe, new thinking and treatments are urgently needed, argues a team from the Karolinska University Hospital in Stockholm, Sweden.

Their reasoningbeen published by The Lancet – just 10 days after submission – to get the suggestion out to the scientific community as speedily as possible.

Jan-Inge Henter, a paediatric clinical oncologist, noticed that the symptoms of patients infected with H5N1 were very similar to those with an often fatal immune disease called haemophagocytic lymphohitiocytosis (HLH). Indeed, three papers on patients with H5N1 note its symptoms include a profound over-response of the immune system, which also occurs in HLH patients.

The over-production of certain immune messengers, such as interleukin 6, is seen in H5N1 patients and cause of death is often linked to sepsis with multi-organ failure – all symptoms also seen with HLH.

Programmed cell death

But HLH, both in its inherited form and in response to Epstein-Barr virus, can be treated with a cocktail of drugs including a key chemotherapy called etoposide, which kills excess immune cells. When the chemotherapy is given immediately, the treatments increased survival rates from 56% to 90% in comparison with giving treatment at four weeks or not at all, according to one retrospective study of patients with Epstein-Barr-virus-associated HLH.

“Etoposide is an excellent trigger of programmed cell death [in immune cells],” explains Henter.

“So our thinking is that these patients with severe [H5N1] infection, their immune regulation is out of control. We are down-regulating things to kill off some of the cells, to get some kind of balance – there is some logic to how this could work."

Henter is calling on the World Health Organization to recommend scientists conduct research around the hypothesis. He suggests this work could bypass animal models and move directly to patients with H5N1 that have secondary HLH.

Balance of risk

"Etoposide is licensed for this indication, it is well known. The treatment protocol has been used successfully in humans affected by severe virus infections for more than 10 years," Henter told New Scientist. He adds that the drug is widely available and inexpensive.

He concedes it might carry risks for dangerously ill individuals, but points out that people with virus-associated HLH are already at high risk of death if left untreated.

The WHO has yet to formally respond but Nikki Shindo, who leads the WHO’s clinical group on H5N1 told New Scientist that doctors at Yuzuncu Yil University in Turkey debated the use of similar drug regimens when dealing with H5N1 patients from the recent bird flu outbreak there.

At the end of March, the WHO is inviting clinicians from all countries with human cases of H5N1 to discuss the best treatment options.

Journal reference: The Lancet (DOI: 10.1016/SO140-6736(06)68232-9)

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