Influenza Pandemic Preparedness: Legal and Ethical Dimensions

Severe acute respiratory syndrome garnered public attention because it was novel and its potential for transmission was unknown. However, the SARS corona virus is significantly less virulent than pandemic influenza infections. The Spanish influenza pandemic of 1918 caused over twenty million deaths in a world with less than one-third of its current population. Modern epidemiologists now estimate that over fifty million people died, about half of whom were in the prime of their lives. As John Barry explains in his recent book, "One cannot know with certainty, but if the upper estimate of the death toll is true, as many as 8 to 10 percent of all young adults then living may have been killed by the virus. And they died with extraordinary ferocity and speed." (1) Influenza pandemics have occurred roughly two to three times per century. Research has identified three essential prerequisites: the emergence of a novel viral subtype in animals (typicaLly swine or poultry), viral replication that causes disease in humans, and efficient human-to-human transmission. Since 1997, the first two prerequisites--a novel viral strain in animals and a "species jump" from animals to humans--have been met on four occasions. The most recent episode occurred in 2004, when H5N1 influenza was found in Viet Nam and Thailand. The outbreak resulted in the culling of large chicken populations, including on farms in the United States. There is now intense interest in influenza preparedness, with major planning initiatives being undertaken by the World Health Organization and Institute of Medicine. (2) (A disclaimer is warranted here: I am working with WHO on revising the International Health Regulations and on influenza preparedness, and with IOM on influenza preparedness, but the views I express here do not necessarily reflect those of WHO or IOM.) The Potential for pandemic spread of a "fit" influenza strain (as well as other novel infections, both naturally occurring and intentional) leads to intriguing ethical and legal questions about public health interventions that could severely disrupt trade, economics, travel, and personal liberty. National and global public health agencies have mooted a wide range of interventions. Animal-human interning. A critical early prevention strategy is to control animal populations and avert the species jump. Close proximity of animal and human populations poses a high risk. Strategies to diminish the risk include separating animal and human populations; bolstering occupational health and safety in animal work (including infection control and disinfection); and controlling diseased or exposed animal populations. But the international community faces daunting problems in implementing these strategies. The Codex Alimentarius Commission administered by WHO and the Food and Agricultural Organization (FAO) regulates food hygiene and labeling rather than animal/human interchange. Sovereign nations, moreover, have economic incentives to continue intensive farming and food distribution. Premature intervention can have profound economic implications, yet weak or tardy intervention might devastate both animals and humans. Surveillance. Surveillance of novel infections in humans offers the possibility of an early warning and a quick response. Experts recommend various surveillance activities, many of which were used in the 2003 SARS outbreaks: testing and screening; health questionnaires, notices and declarations; fever monitoring; and reporting and monitoring trends. The WHO's draft revised International Health Regulations (IHR) would facilitate surveillance through country notifications, reports from unofficial sources, and real-time event management. Global surveillance could further benefit from "small-world networks" consisting of health professionals, scientists, and non-governmental organizations continuously monitoring disease threats. But while surveillance is an essential public health strategy, even modest measures entail government collection of sensitive health information and can therefore impinge on personal privacy. …