Are We Ready for an Avian
Flu Pandemic in America?

YOWUSA.COM, 21-March-2006
Dale Caruso

…Continued

"First let’s lay out the basic scenario. I am assuming a serious pandemic, with all non essential travel shut down for the duration (kiss your vacation goodbye), with both infected individuals and any individuals who have come into contact with them instructed to quarantine themselves, or being forcibly quarantined themselves.

Welch likened the situation to that in wartime. "Government will concentrate on keeping key infrastructure operating. Power, sewage, water, emergency services and food distribution. Distribution of most goods through the system will be discontinued, since people can be asymptomatic and still carriers, it will be decided to keep any cross-country travel to a minimum. Most retail outlets will close, either voluntarily or by government fiat. Food will be trucked either into distribution centers or into supermarkets which agree to stay open and will be rationed out exactly as in wartime. As such a black market will certainly appear."

Osterholm, adds; "If an influenza pandemic struck today, borders would close, the global economy would shut down, international vaccine supplies and health-care systems would be overwhelmed, and panic would reign."

Preparing for the Unthinkable

So how can we prepare? Osterholm says "One key step is to rapidly ramp up research related to the production of an effective vaccine, as the Department of Health and Human Services is doing. In addition to clinical research on the immunogenicity of influenza vaccines, urgent needs include basic research on the ecology and biology of influenza viruses, studies of the epidemiologic role of various animal and bird species, and work on early interventions and risk assessment."

In November of 2005, Ambassador Sichan Siv appeared before the United Nation’s Economic and Social Council, on Avian Influenza. At that meeting, Siv said that "The United States is determined to deal with public health threats such as this one, in close collaboration with other countries and relevant international organizations, non-governmental organizations (NGOs), and private sector partners.

If unchallenged, a human influenza pandemic arising from H5N1 avian flu would become a clear and present danger across health, economic, social, and political sectors. On November 1, President Bush released the United States National Strategy for Pandemic Influenza. (Ed note: It can be found at www.pandemicflu.gov.) This strategy will guide my government in finalizing its pandemic preparedness. We urge all countries to put national plans in place immediately and to coordinate closely with their neighbors." In short the "National Strategy for Pandemic Influenza" outlines a three-pillar approach to preventing a major disaster.

• Pillar One – Preparedness and Communication: In this stage the focus is on educating the public about the risk of a pandemic flu and producing and stockpiling vaccines and antiviral medications so that people will be prepared if a pandemic breaks out.
  
  
• Pillar Two – Surveillance and Detection: The best offense is a good defense. This pillar focuses on monitoring the incidence of the virus overseas, an early warning system to prevent the virus from entering the country, and initiating vaccinations.
  
  
• Pillar Three – Response and Containment: In the event that a pandemic flu enters the U.S. and outbreaks begin, the focus will shift to slowing and preventing the spread of the flu to lessen health, social, and economic impacts. Authorities will have the power to limit nonessential movement of people, goods, and services to and from outbreak areas, limit social gatherings, and even call for quarantines.

But Osterholm says while this "Strategy" is a start and he emphasizes only a start, "Equally urgent is the development of cell-culture technology for production of vaccine that can replace our egg-based manufacturing process. Today, making the 300 million doses of influenza vaccine needed annually worldwide requires more than 350 million chicken eggs and six or more months; a cell-culture approach may produce much higher antigen yields and be faster.

After such a process was developed, we would also need assured industrial capacity to produce sufficient vaccine for the world's population during the earliest days of an emerging pandemic.

Beyond research and development, we need a public health approach that includes far more than drafting of general plans, as several countries and states have done. We need a detailed operational blueprint of the best way to get through 12 to 24 months of a pandemic."

But what if the next pandemic were to start tonight? "If it were determined that several cities in Vietnam had major outbreaks of H5N1 infection associated with high mortality, there would be a scramble to stop the virus from entering other countries by greatly reducing or even prohibiting foreign travel and trade. The global economy would come to a halt, and since we could not expect appropriate vaccines to be available for many months and we have very limited stockpiles of antiviral drugs, we would be facing a 1918-like scenario."

Welsh adds, "If you think that such a pandemic is likely to occur then the steps you should take are much the same you would take for any natural disaster. Because the banking system will likely be shut down during the crisis (and bank machines will likely not be restocked even if they do not go down due to loss of system personnel) you should have a stock of money at home to allow you to buy whatever you need which is available. If you can arrange to have independent power generation, you should do so. You should have a good supply of canned food and water. Make your estimate of how much you need and double or triple it. Others will not have planned and you do not want to find yourself not being able to help friends, family and neighbors. In addition you will want to have tradeables available for the black market. Money will be a poor second to having goods people want. In this regard stocking up on some medical items such as surgical masks and OTC medicines will be especially wise. I’m not encouraging profiteering, but you will need something you can trade which people want. Badly."

Too Little Too Late?

Michael Osterholm paints a very grim picture if we experience another pandemic, "... owing to our global "just-in-time delivery" economy, we would have no surge capacity for health care, food supplies, and many other products and services. For example, in the United States today, we have only 105,000 mechanical ventilators, 75,000 to 80,000 of which are in use at any given time for everyday medical care; during a garden-variety influenza season, more than 100,000 are required. In a pandemic, most patients with influenza who needed ventilation would not have access to it.

We have no detailed plans for staffing the temporary hospitals that would have to be set up in high-school gymnasiums and community centers — and that might need to remain in operation for one or two years. Health care workers would become ill and die at rates similar to, or even higher than, those in the general public. Judging by our experience with the severe acute respiratory syndrome (SARS), some health care workers would not show up for duty. How would communities train and use volunteers?"

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If the pandemic wave were spreading slowly enough, could immune survivors of an early wave, particularly health care workers, become the primary response corps? Osterholm has is doubts,

"Health care delivery systems and managed-care organizations have done little planning for such a scenario.

Who, for instance, would receive the extremely limited antiviral agents that will be available? We need to develop a national, and even an international, consensus on the priorities for the use of antiviral drugs well before the pandemic begins. In addition, we have no way of urgently increasing production of critical items such as antiviral drugs, masks for respiratory protection, or antibiotics for the treatment of secondary bacterial infections. Even under today's relatively stable operating conditions, eight different anti-infective agents are in short supply because of manufacturing problems. Nor do we have detailed plans for handling the massive number of dead bodies that would soon exceed our ability to cope with them."

"The real economic fallout" says Ian Walsh, " will be determined by politics, not economics per se. The political decisions made will determine the fate of entire industries, of trade and travel for some time to come."

The Sky is Falling, The Sky is Falling

Since it first emerged in 1997, avian influenza has become deadlier and more resilient. It has infected 109 people and killed 59 of them. If the virus becomes capable of human-to-human transmission and retains its extraordinary potency, humanity could face a pandemic unlike any ever witnessed.

Scientists have long forecast the appearance of an influenza virus capable of infecting 40 percent of the world's human population and killing unimaginable numbers. Recently, a new strain, H5N1 avian influenza, has shown all the earmarks of becoming that disease. Until now, it has largely been confined to certain bird species, but as we can see, that may be changing.

Laurie Garrett, Senior Fellow for Global Health at the Council on Foreign Relations and author of The Coming Plague and Betrayal of Trust, says that, "The havoc such a disease could wreak is commonly compared to the devastation of the 1918-19 Spanish flu, which killed at least 50 million people in 18 months. But avian flu is far more dangerous. It kills 100 percent of the domesticated chickens it infects, and among humans the disease is every bit as lethal.

Since it first appeared in southern China in 1997, the virus has mutated, becoming heartier and deadlier and killing a wider range of species. According to the March 2005 National Academy of Science's Institute of Medicine flu report, the "current ongoing epidemic of H5N1 avian influenza in Asia is unprecedented in its scale, in its spread, and in the economic losses it has caused."

In short, doom may loom. But note the "may." If the relentlessly evolving virus becomes capable of human-to-human transmission, develops a power of contagion typical of human influenzas, and maintains its extraordinary virulence, humanity could well face a pandemic unlike any ever witnessed. Or nothing at all could happen."

She says that scientists cannot predict with certainty what this H5N1 influenza will do. "Evolution does not function on a knowable timetable, and influenza is one of the sloppiest, most mutation-prone pathogens in nature's storehouse."

Such absolute uncertainty, coupled with the profound potential danger, is disturbing for those whose job it is to ensure the health of their community, their nation, and broader humanity. According to the Centers for Disease Control and Prevention (CDC), in a normal flu season about 200,000 Americans are hospitalized, 38,000 of whom die from the disease, with an overall mortality rate of .008 percent for those infected. Most of those deaths occur among people older than 65; on average, 98 of every 100,000 seniors with the flu die. Influenza costs the U.S. economy about $12 billion annually in direct medical costs and loss of productivity.

Yet this level of damage hardly approaches the catastrophe that the United States would face in a severe flu pandemic. The CDC predicts that a "medium-level epidemic" could kill up to 207,000 Americans, hospitalize 734,000, and sicken about a third of the U.S. population. Direct medical costs would top $166 billion, not including the costs of vaccination. An H5N1 avian influenza that is transmittable from human to human could be even more devastating: assuming a mortality rate of 20 percent and 80 million illnesses, the United States could be looking at 16 million deaths and unimaginable economic costs. This extreme outcome is a worst-case scenario; it assumes failure to produce an effective vaccine rapidly enough to make a difference and a virus that remains impervious to some antiflu drugs. But the 207,000 reckoning is clearly a conservative guess.

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