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Where Would Pandemic Flu Wreak the Most Havoc?

A virulent flu strain would overwhelm developing countries where health care systems are already floundering

Two nurses observe a young child suspected to have bird flu at an observation room in the Hasan Sadikin Hospital in Bandung, West Java, Indonesia. (© 2006 Budi Yanto, Courtesy of Photoshare)
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This article is from Global Health NOW, a news website and weekday e-newsletter published by the Johns Hopkins Bloomberg School of Public Health.

Influenza preys on weak immune systems—and weak health systems.

When the next flu pandemic hits, a nation’s successful response depends on strong health resources, infrastructure and leadership.

That means many developing countries already struggling to provide adequate health care will likely be overwhelmed. And developed countries—with well-trained health workforces, efficient disease surveillance systems, and advanced health facilities—could be pushed to their limits.

Early detection of a virus is critical in mobilizing an effective public health response, but many low-income countries struggle to comply with WHO influenza surveillance standards. “The identification itself will be challenging for most developing countries,” says Ciro Ugarte, MD, director of PAHO’s Department of Emergency Preparedness and Disaster Relief.

A simple influenza diagnosis won’t suffice; characterization of the strain is required to effectively treat the disease and develop vaccinations, he says. Typical seasonal flu, for example, will not require the emergency measures to reduce transmissions (closing schools or public facilities) that might be necessary in a pandemic.

Ugarte expects significant identification delays in resource-poor nations, where health centers must ship specimens to national or international laboratories for testing. Such delays slowed response to the 2009 H1N1 outbreak, explains Ugarte, when Mexico’s viral samples were first sent to the CDC. Due to the CDC’s backlog, the specimens had to be processed in Canada. “We discovered the very same day that Mexico declared [an] emergency that there were already cases in Brazil and several other countries,” says Ugarte, noting this delayed a coordinated regional response.

It doesn’t bode well for the next pandemic. “It is clear, we will be behind the wave,” Ugarte states, and “the only way to catch up will [depend upon] the capacity of the health services.”

A 2006 Lancet study that estimated deaths in a pandemic on the scale of the 1918 flu predicted 62 million deaths and reflected the chasm between rich and poor countries. More than 96 percent of the predicted deaths would occur in developing countries. The model posited a striking disproportional mortality in the global south due in part to health systems capacity, but also because of the prevalence of pre-existing conditions, like HIV or malnutrition, which increase the risk of death among flu patients.

High-income countries are better equipped to manage an outbreak because their health systems can more easily provide care, such as rehydration, antiviral medication or costly respiratory therapies, explains Paul Spiegel, MD, MPH, director of Johns Hopkins Center for Humanitarian Health. Yet even countries like Canada or the UK, which boast universal health care would struggle against a particularly virulent flu, says Spiegel. “If it’s a highly severe flu pandemic, the amount of people that will need ICU care, the amount of ventilation machines that are needed, will be overwhelming,” he says.

Comprehensive actions plans, based on WHO regulations and evaluations to assess a country’s readiness to respond to an outbreak, are the cornerstone of a coordinated global response, he says. “In some countries, there are insufficient expertise and capacity to fulfill the objectives of the action plan,” says Spiegel. “International organizations, together with those countries who have higher capacity and expertise, need to work together to support those governments.”

Crises also exacerbate existing disparities within countries—a situation that confronts poor and wealthy nations alike. One example of a group poised for inequitable flu treatment: The Rohingya in Burma (Myanmar). “The quality of care that they would be getting in their own country would be very different than a Buddhist majority group,” say Spiegel, “and I don’t think that’s unique to Myanmar.”

In the 2009 H1N1 outbreak, U.S. investigators documented disparities in exposure, susceptibility and treatment among Hispanic and African-American populations. Hispanics experienced disproportional risk to exposure and poorest access to care, while African-Americans demonstrated greater susceptibility to flu complications.

Undocumented immigrants, specifically, may delay or be denied care due to their status, says Spiegel. Treating such groups ultimately serves the nation’s self-interest: “It becomes a necessity to protect your own population.”

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