vaccine, particularly during the initial phase of a pandemic. David Fedson advises that efforts toward pandemic vaccine development should initially focus on producing the largest possible supply of pandemic vaccine as quickly as possible. Europeans will most likely pursue this goal by developing a low-dose adjuvant pandemic vaccine, which differs from the strategy that will be undertaken by the National Institute of Allergy and Infectious Diseases in the United States. He also describes the potential advantages of engineering viral seed strains with reverse genetics and urges a quick resolution to the ongoing dispute regarding ownership of intellectual property for this technology.

Given these obstacles to the timely production of pandemic vaccine, it is also imperative to develop near-term strategies to address a pandemic threat without recourse to vaccination. Dr. Fedson recounts recent findings suggesting that prophylaxis with statins or other commonly available therapeutic agents, which have recently been found to reduce serum concentrations of several inflammatory mediators, might mitigate the clinical course of human influenza. He suggests next steps in pursuing this idea, but it is not without risk or controversy. For example, a recent case study describes a patient undergoing therapy with two statins (cerivastatin and bezafibrate) who developed acute renal failure due to rhabdomyolysis only after being administered an influenza vaccine; similar cases had occurred in several patients receiving this combined therapy who had contracted influenza (Plotkin et al., 2000). Researchers have also reported that the in-vitro treatment of macrophages with another statin (lovastatin) did not decrease tumor necrotic factor (TNF) production, as would be expected to occur with lovastatin-induced immunosuppression, but instead resulted in increased production of TNF (Monick et al., 2003). The apparent contradiction between this observation and the reports cited by Dr. Fedson may be explained by tolerance induced in vivo subsequent to lovastatin-induced TNF production, or perhaps by differences between the long-term and acute effects of lovastatin.

A second, more widely accepted strategy for coping with pandemic influenza in absence of vaccine is described in the subsequent review by Frederick Hayden, which focuses on the potential role of currently available antiviral drugs in such a pandemic response. However, as this review makes clear, a variety of supply and distribution problems must be solved before this promising strategy could be implemented.

Although the American health care system is overwhelmingly privatized, little attention has yet been paid to private medicine’s potential role in preparing for pandemic influenza. This chapter concludes with a description of the status of pandemic planning within the private health care system, and suggestions for ways that private health care organizations could contribute to pandemic preparedness at all levels of government.



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