correspondence
NATURE | VOL 434 | 14 APRIL 2005 | www.nature.com/nature 821
Sir — An influenza pandemic will occur atsome time in the future: having worked onflu viruses since 1959, I am certain of this.If the deadly H5N1 ‘bird flu’ suddenlyacquired human transmissibility, whileretaining pathogenicity, the resultingpandemic would cause millions of humandeaths. If the pandemic were caused byanother bird influenza virus, or if thehuman H2 virus that disappeared in 1968were to return, humanity would still be infor a bad time.
No ‘pandemic vaccine’ could be stock-piled, because of uncertainty about thevirus strain. So what can be done? Schoolclosure, quarantine, travel restrictions andso on are unlikely to be more effective thana garden hose in a forest fire.
There are, however, two safe antiviraldrugs that are effective against all fluviruses, including H5N1. These are theneuraminidase-inhibitors zanamivir/Relenza and oseltamivir/Tamiflu.(Although my crystallization of flu virusneuraminidase led to the development ofthese drugs and I have a financial interestin Relenza, I have none in Tamiflu.)
Tamiflu is a small carbocyclic moleculethat was rationally designed from aknowledge of the X-ray crystal structure of influenza virus neuraminidase. Thevirus needs neuraminidase to escape frominfected cells and spread through the body.The catalytic site of flu neuraminidase,unlike the variable surface antigens, isconserved by all strains of the virus. Tamifluwas designed to fit precisely in the catalyticsite of the enzyme, inhibiting its activity.
To be effective, Tamiflu has to be givenbefore infection, or very soon after flusymptoms appear. The time needed toobtain a prescription is a serious drawback.
Although governments around theworld are reported to be stockpilingTamiflu, their strategies for using it are not clear. Britain is reported to have 14.6 million doses of Tamiflu, enough for a quarter of the population. Australia isreported to have enough to protect 200,000front-line workers prophylactically duringa pandemic: two pills a day for 50 days.
This strategy, I believe, is wrong. Amore efficient use would be to haveTamiflu available over the counter in local
pharmacies, coupled with a rapid, sensitiveand accurate flu diagnostic test. Peoplewith flu symptoms could then goimmediately to the pharmacy, be rapidlytested to see if the infection is influenzaand, if it is positive, be given Tamiflu.
Not only would the infection becurtailed — the person would, on recovery, be immune to reinfection with the same virus.
This procedure could be called‘aborted-infection immunization’ andshould be used in the early stages of apandemic, when no vaccine is available,or in the inter-pandemic period by thosepeople who do not take the vaccine or whoexperience vaccine failure.
The neuraminidase inhibitors exist.They do work. Correct use could beachieved through public education. In apandemic they would alleviate much of theflu victims’ misery, reduce economic lossesand probably prevent deaths.Graeme LaverBarton Highway, Murrumbateman,New South Wales 2582, Australia [email protected]
Changes in China call fornew health solutionsSir — The Commentary article “Lessonsfrom the past” by Z. Dong and colleagues(Nature 433, 573–574; 2005), on China’spublic-health system, has touched upon anurgent issue that may influence the courseof China’s future. Their attempt to applysuch lessons in today’s China, however,may require a deeper look at thefundamental changes that have taken placein the country from one era to the other.
The “glorious beginning” under Mao’sregime might have been due more tototalitarian control, with communitiesisolated and movement restricted, than to the health-care system at that time.Although that may have been more fairthan today’s system, it was at least asinadequate.
The serious medical problems facingtoday’s more open and free China did nothave the chance to flourish during thatearlier period. Contrast the early 1980s,for example, when sexually transmitteddiseases were rare, with the present, whenHIV/AIDS has reached epidemic status inparts of the country.
Prevention is the key to public health.But remedies from the past should not be relied on to solve a crisis today, when
one is confronted with totally differentproblems in a totally different society.Yonghong LiCelera Diagnostics, 1401 Harbor Bay Parkway,Alameda, California 94502, USA
NIH conflicts rules arenot right for universities Sir — We agree with your Editorial “Takinga hard line on conflicts” (Nature 433, 557;2005) that “scientists and institutionseverywhere should be sure that their ownhouses are fully in order”. But the academicresearch community and the NationalInstitutes of Health (NIH) have differentsocietal roles, expectations and regulatoryhistories. These differences are essential to understanding why conflict-of-interestpolicies that apply to researchers employedby the NIH should not be extended to theNIH-funded university community.
Universities’ long-standing interactionswith industry have produced enormousbenefits. Still, the academic communityrecognizes that the US public’s support of academic, and especially biomedical,research depends on maintaining theirconfidence and trust.
Research universities have had policieson faculty consulting with industry for
decades and have gained deep experiencein regulating conflicts of interest across alldisciplines.Theyhavegivenspecialattentionto conflicts in biomedical research sincemandatory federal regulations for NIH-funded academics were published in 1995,enhanced by federal guidelines in 2004.
Academia has used these regulations as the base on which to build more robuststandards, such as those on human researchset out by the Association of AmericanMedical Colleges (AAMC; see www.aamc.org/members/coitf/start.htm). Our 2004survey of medical schools (see Nature 431,725; 2004) indicated that most haveadopted all or substantial portions of theAAMC recommendations, thereby goingwell beyond federal requirements.
However stringent the standards andsupervision, violations will occur. But toreact with overzealous regulations wouldinhibit useful partnerships and the socialbenefits that flow from them. As long asuniversities and medical schools continueto take seriously the enforcement of strictstandards, relationships with industry canbe principled, protective of researchparticipants and scientific integrity andremain capable of withstanding intensepublic scrutiny.David Korn, Susan H. Ehringhaus Association of American Medical Colleges, 2450North Street NW, Washington DC 20037, USA
Influenza drug could abort a pandemicIt should be taken, not pre-emptively, but after infection is revealed by a rapid flu test.
14.4 correspondence MH 11/4/05 5:25 pm Page 1
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