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Not ready for outbreak
Can world avoid flu pandemic?
Kerry Fehr-Snyder
The Arizona Republic
Oct. 4, 2005 12:00 AM
Infectious-disease specialists in Arizona and around the world are planning for a flu pandemic they call inevitable - if not this year, then soon.
But whether their plans can stem a worldwide flu outbreak is doubtful, critics say.
The reasons: advertisement
• A tiny national stockpile of anti-viral medication to treat those already sick or exposed to a pandemic flu strain.
• An insufficient supply of effective vaccines.
• A lack of capacity at Arizona hospitals to handle a big surge of critically ill patients.
Estimates of the potential worldwide death toll from a flu pandemic today range from 5 million to 150 million, according to the United Nations. In the United States, a pandemic could kill 89,000 to 207,000, the Centers for Disease Control and Prevention says.
The most likely source of a pandemic flu now is a virulent bird flu that has killed dozens in Asia who handled infected birds.
State officials have been working on a pandemic flu response for five years, but their plan, like the federal draft plan so far, is skimpy on details. However, the U.S. Department of Health and Human Services is finishing a more detailed plan to be unveiled as early as this week. It may request billions of dollars more from Congress.
Scientists fear the lack of a thorough plan will leave officials and citizens as ill-prepared as the victims of Hurricane Katrina.
"We're way off where anyone thinks we need to be," said Kim Elliott, deputy director of the Trust for America's Health, a non-profit group based in Washington, D.C.
In Arizona, for example, health officials have not stockpiled anti-viral medication because of the cost.
"We don't have the budget or the capacity to have a stockpile of such medication in the state," state epidemiologist David Engelthaler said.
In the event of an outbreak, vaccine and anti-viral medication would be allocated on a priority basis, according to Arizona's draft plan. But the plan doesn't detail criteria.
Among its few specifics, the plan cites several strategies to detect and control a flu pandemic, including:
• Discharging all but critically ill hospital patients to make room for flu patients.
• Expanding mortuary services to handle the dead.
• Ramping up state health lab testing to identify flu pandemic strains.
• Isolating and quarantining residents who are exposed to the virus or are ill from it.
State health officials say they're doing the best they can but may need to ration resources.
"There's a lot of discussions about the ethical use of public health resources during an emergency," said Engelthaler, who helped engineer the state pandemic flu plan.
Setting priorities ahead of time is difficult, especially for the distribution of anti-viral medication and vaccines, said Will Humble, the Arizona Department of Health Services' chief of public health preparedness.
"The whole key to this thing is, it's just like a forest fire. You've got to put it out quickly," Humble said. "Pandemic flu is always an A-list thing with us as far as public health preparedness because viruses from the beginning of time have been nature's Number 1 terrorist."
U.S. officials have stockpiled 2.3 million doses of anti-viral medicine, which must be taken within 48 hours of flu symptoms occurring. The medicine also can ward off infection if enough is taken before exposure.
Federal officials eventually want to buy enough anti-viral medicine to treat 20 million people and inoculate another 20 million with a new flu vaccine now under development. Whether new funding sought from Congress will cover the goal is unclear.
It's also unclear when the vaccine and other experimental vaccines against new flu strains will be available for use, reports the National Institute of Allergy and Infectious Disease, part of the National Institutes of Health. Last week, the federal agency said it will test multiple vaccines against novel strains that could trigger a pandemic.
Federal and state pandemic plans also are vague about who falls into the "priority" group for treatment and vaccines. The draft federal plan, released last summer, doesn't say who should be inoculated and treated first, though the updated plan may do so.
National vaccine advisory groups have recommended health care workers be inoculated first, followed by government leaders and public health workers who are responding to a pandemic. At the bottom of the list are healthy individuals, ages 2 to 64, even though some pandemics struck that age group the hardest.
Topping the recommended list of those who should get anti-viral medication are hospitalized flu patients, health care workers, pandemic health responders and highest-risk outpatients.
A deadly source
The most likely source of a flu pandemic is a deadly bird flu now picking up steam in Southeast Asia. At least 140 million birds in Asia have been slaughtered to prevent the spread of the H5N1 avian influenza strain.
Wildlife experts have not found any birds in North America with the virus, although they are keeping tabs on Alaska, where migratory patterns suggest it would strike first. There is no such surveillance in Arizona.
Health officials are even more concerned about the prospect of people who contract the H5N1 virus at the same time they are infected with another, more common flu virus that is easily spread among humans.
Although the disease so far has not been transmitted easily human to human, experts fear the H5N1 strain could mutate after it infects a human or other mammal.
"With enough changes to the virus, it can theoretically maintain its lethality and become more transmissible. And that's what keeps us up at night," said Dr. Andrew Pavia, chairman of the Infectious Diseases Society of America's task force on pandemic influenza.
Pavia told Congress in May that "the United States is woefully unprepared for a pandemic that might occur in the next few years."
Since the strain was first detected in people in 2003, it has infected 116 people, killing 60 in four countries, according to the World Health Organization's most recent count posted Thursday. Experts are worried by the seemingly high 52 percent mortality rate, although it's unclear whether more people with milder cases of the H5N1 flu were ever counted.
Amid the uncertainty of a super bug, many people are frightened.
"I work on this stuff 24/7, and I'm really scared of it," said Elliott, of Trust for America's Health, adding that she keeps a supply of anti-viral medicine, Tamiflu, for her family, at home in case of an outbreak. "You can see this coming. With three pandemics each century, we're way overdue."
It is impossible to determine where a pandemic flu outbreak would occur or how many people would become or ill or die because there are too many variables.
What infectious-disease experts worry about most is that a pandemic would hit young and otherwise healthy adults harder than usual. In an average year, 36,000 Americans die of the flu complications, but most are elderly or have weak immune systems.
By contrast, during the Spanish flu of 1918-19, the immune system of young, healthy adults worked against them, possibly by going into hyperdrive. Their skin often turned blue, they vomited blood and hemorrhaged to death.
The Spanish flu
The Spanish flu occurred at a time when influenza vaccines did not exist; doctors didn't even understand that the flu was caused by a virus back then. But even today, vaccines wouldn't necessarily stem an outbreak because it would be difficult to make enough shots quickly enough to protect vast swaths of society.
Even with the best planning, there may not be enough vaccines to stem the tide of infections in an outbreak, many experts fear. The plan to purchase enough vaccine for 20 million would fall far short of the U.S. population of about 300 million.
The current experimental H5N1 vaccine isn't as potent as other flu vaccines and would require four times as much antigen to stimulate production of antibodies against the strain. Plus, people would need two doses each of vaccine to be protected.
At the most, 5million doses of the vaccine could be produced each month for a total of 60 million doses over a year. That would cover about 30million people, one-tenth of the country's population.
"We're not very prepared today. We don't have adequate supplies of vaccines, and we can't possibly have adequate supplies of vaccine until there are better methods of production and of stretching vaccine supplies," said Marc Lipsitch, an associate professor of epidemiology at the Harvard School of Public Health.
Producing medicine
Developing an adequate supply of anti-viral medicine also is a problem. The medicine would be used to treat both those infected with a pandemic flu strain and those who have been exposed but exhibit no symptoms yet.
The only anti-viral medicine that would work against a pandemic strain like H5N1 is oseltamivir, which is sold by prescription under the name Tamiflu and is made by one manufacturer, Roche.
The WHO is stockpiling the medicine so it can ship it to countries as soon as an outbreak occurs in hopes of controlling it.
Individual countries also are creating their own stockpiles because most experts believe when a pandemic begins, most won't be in the sharing mood and instead will attempt to nationalize their supplies.
Only less than 1 percent of the U.S. population would be covered by the current supply stockpiled in the U.S.
Not enough hospital beds
For their part, hospitals likely would have to discharge all but the most critically ill patients to make room for those sick with the flu in a pandemic.
"The question becomes not how many beds you have but how many beds you can staff," said Dr. Richard Thomas, system director of emergency and continuity management at Banner Health, the largest hospital system in Arizona.
Banner Health is working on a plan that would detail how many beds would be used for critically ill flu patients in a pandemic. It hopes to have the plan ready by November, Thomas said.
In addition to discharging non-critical patients and isolating flu patients, hospitals would cancel all elective surgeries during a pandemic to make way for flu patients and contain the virus' spread.
"We run so close to capacity all the time. I think there will be some very important public health decisions that are made," Thomas said.
Those decisions will be akin to the response to the recent hurricanes that wiped out New Orleans and the Gulf Coast.
"There's no doubt that a pandemic flu is the Category 5 of infectious-disease outbreaks," said Engelthaler, of the state health department.
Elliott, of Trust for America's Health, said she attended a conference recently in which predictions were dire.
"We're watching a pandemic unfold but in slow motion," she said. "Katrina gave us all a real-time wake up call that if you don't prepare, there will be hell to pay."
