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The Chain ReactionPandemic Flu and the Medicines Supply Chain

Michael Young

MPI Department of Health

PDIG Summer Symposium

Thursday 5th June 2008

(with thanks to Health Protection Agency and MICE Associates)

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The Brief from PDIG

1. Flu Pandemic Myth or Reality?

2. How will the Supply Chain cope?

3. Key Strategic measures which will affect the whole Supply

Chain?

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Section 1 - Myth or reality?Seasonal, avian and pandemic influenza:

Based on presentation given by Dr Nick PhinPandemic Flu OfficeHealth Protection Agency, Centre for Infections23rd January 2008 – Exercise Chain Reaction Briefing

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The Influenza Paradigm

• There are known knowns - there are things we know we know.

We also know there are known unknowns, that is to say, there are some things we do not know.

But there are also unknown unknowns – the ones we don’t know we don’t know.

Donald Rumsfeld

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Overall clinical attack rate in previous pandemics

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1918 NewYork State

1918Manchester

1918Leicester

1918Warrington& Wigan

1957 SELondon

1957 SouthWales

1957Kansas City

1968Kansas City

cli

nic

al

att

ac

k r

ate

(%

)

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Pre-requisites for pandemic influenza

‘PAN’ (all) ‘DEMOS’ (people) = an epidemic that affects all people

• New influenza A sub-type: Haemagglutinin (H)unrelated to immediate (pre-pandemic)predecessor.

• Little or no pre-existing population immunity

• Causes significant clinical illness

• Efficient person-to-person spread

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Public Health Measures(hygiene; masks; distancing;

infection control, etc.)

Antibiotics

Antivirals

Pre-pandemic vaccine?

Pandemic Specific Vaccine

Defence in layers

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Personal Hygiene

• Respiratory hygiene (“sneeze in your sleeve” – USA CDC; “coughs and sneezes spread diseases” UK DH)

• Virus survival on ‘soft furnishings’ (such as sleeves) is relatively short

• Hand washing – evidence in school settings

• Adherence

• As yet, no embedded UK culture outside ‘health’

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Pandemic Vaccine

• It may take 4-6 months or longer to produce a vaccine

• Unlikely to be available during early stages of a pandemic

• Not enough for everybody – production capacity

• Benefits of pre-pandemic vaccine?

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Likely shape of the first Wave

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Lessons learned from the past and the current situation in South East Asia

• maximum recorded interval between pandemics is 39 years – it could be

soon (but it remains unpredictable)

• the likely origin will be SE Asia – but we can’t say for sure

• global spread will be rapid – we either prepare now, or risk being caught

by surprise

• may be several epidemic waves; first may be ‘milder’ than subsequent

ones – sustainability and resilience will be key issues

• excess mortality and morbidity difficult to predict but may be high (but it

doesn’t follow that the next pandemic will be like 1918)

• overall population clinical attack rate is likely to be 25-33%

• there may be a shift towards younger age groups in terms of severity and

mortality – with implications for business workforce

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Section 2 – How will the UK medicines supply chain cope?

Context

• In normal times we can experience shortages

• Pandemic Flu may be global sustained threat

• Most production is overseas

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DH - mitigating actions so far

• National Pandemic Planning including

– Antivirals – Stockpiles currently being increased to cover 50% of

population

– Antibiotics – Stockpile being created of 14.8 million courses

– Possible Amendments to Medicines Legislation Consultation – response

just published and next step agreed

• Exercise Chain Reaction (ECR) commissioned and held (facilitated

by HPA and MICE Associates)

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ECR Background

• Exercise Chain Reaction (ECR) – held 30th January 2008

• Looked at effect of pandemic influenza on community pharmacy supply

chain

• Wide and high level representation from manufacturers, distributors,

community pharmacy and dispensing doctors, associated pharmacy

services and Government departments.

• Sessions on prescription sizes, panic buying, fuel supply difficulties, staff

shortages

• Report on ECR from Health Protection Agency

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1st HPA inject re panic buying

• Play HPA DVD Bulletin 2 – re panic buying

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ECR players concluded

• Immediate shortage likely and concern relating to impact

on price

• Different mitigating options need to be considered

• Increase stocks – either nationally or encourage

individuals to create their own buffers at home?

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2nd HPA inject re staff absence

• Play HPA DVD – Bulletin 4 – re staff absences

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ECR players concluded

• Need for Business Continuity Planning• Identify key staff• Need for training and multiskilling• Identify key tasks• Need for remote working• IT infrastructure

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Issues raised by ECR players (1)

• Need to maintain normality: - manufacture, distribution, supply and

prescribing

• Likely to be increase in demand for some medicines which could lead to

shortages

• Some current production on two year cycles

• Request for central co-ordination to support planning for priority products

• What if country with manufacturing HQ promotes restrictive practice?

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Issues raised by ECR players (2)

• Distribution – Fuel and security issues + possible need for joint

distribution arrangements to ensure all pharmacies covered?

• Would DH request comprehensive review of legal and regulatory

frameworks and establish emergency triggers to allow flexibility?

• Need to understand impact of trigger points in other countries

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Issues raised by ECR players (3)

• Supply and prescribing – need to keep to normal

patterns (one month preferable) to support stable supply

chain

• Need for guidance for professionals and public on what

to expect and how to act to mitigate possibility of

shortages.

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Summary - Section 3The key strategic measures that will affect

the whole supply chain?• ECR Report being reviewed by DH

• DH legislative amendments – Summary of responses to initial

consultation published and next steps technical consultation to take place

over the summer, led by MHRA

• DH Pandemic Influenza National Framework and supporting guidance

• Business Continuity Plans – Are public organisations DH/SHAs/PCTs and

private companies sharing their plans and co-ordinating action and

resilience?