With H5N1 on the rise, are we prepared for a flu pandemic?

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Re: With H5N1 on the rise, are we prepared for a flu pandemic?

Outbreak: Preparing for a flu pandemic

By Michael Mager/Features Editor

http://www.cleburnetimesreview.com/siteSearch/apstorysection/local_story_268173348.html

Editor?s note: This is part two of a three-part series.

By the time Hurricane Katrina stormed ashore, Gulf Coast residents, scientists and government officials had known for years that the landfall of a major hurricane would likely wreak havoc. This was especially true in New Orleans, which is largely built in a bowl that lies below sea level and depends on a complicated system of aging levees to keep water from flooding the city. Yet, when Katrina?s powerful sea surge inundated large parts of the region, causing the frail levees to fail, there was major loss of life, a significant blow to the economy and a long period of civil anarchy in the streets of the Big Easy. There had been years to prepare a plan against such a catastrophe.

A great deal of the blame for a lack of preparedness and a seemingly uncoordinated response to the catastrophe was placed first at the feet of the federal government and later at the feet of state and local officials. Large parts of the Gulf Coast still are unrepaired and the ability of the levees to hold back the waters of Lake Ponchartrain are still suspect. Many believe that the government is not looking down the dark barrel of yet another, possibly more perilous, disaster and the question remains, ?Are we ready??

Unlike the tragedies of Hurricane Katrina and the devastation of the Sept. 11 terrorist attacks, which were largely local and regional, if the nation is forced to deal with a pandemic as vicious as one avian flu might bring about, the crisis will not be a local, a statewide or national one: It will likely be a worldwide crisis.

?A pandemic of avian flu could result in 350 million deaths globally,? a State Department report says.

How prepared will we be? How well coordinated will the response be? How well have we learned from past disasters and pandemics?


The Spanish flu

In the pandemic of the so-called Spanish flu of 1918, an estimated 50 million people died. And the world population was considerably smaller then. The world was not as urbanized as it is today. There also was no such thing as fast intercontinental transportation to carry those people who had the virus across vast distances in hours. According to the World Bank, a pandemic of the same scope of the Spanish flu would cost the world economy somewhere in the trillions of dollars.

Jim Higgins, a doctoral candidate at Lehigh University in Pennsylvania, has been researching that pandemic. In an article on the Science Daily Web site, he claims that there are lessons that we can learn from that tragic outbreak of the early 20th century.

?Most communities were woefully unprepared for the health crisis they faced,? said Higgins. ?Those cities that passed muster, relatively speaking, had been building a strong medical infrastructure for decades, and had sound public health policies based more upon science than politics. I?m not sure that?s the case today.?

He said he is increasingly concerned by what he sees as a divided ?health care system where the best, state-of-the-art care is available to some, but not to others at the lower end of the socio-economic spectrum.? He finds himself wondering what will happen when those hospitals that do have a limited number of beds for lower-class and uninsured patients run out of those beds, while those that cater to the insured and financially fortunate accept new patients. According to the National Center for Political Analysis, one forth of all Texans do not have health insurance. How will those uninsured individuals receive the care they need?

Scenario

Experts at the Centers for Disease Control in Atlanta have worked out a possible scenario for an avian flu pandemic. At a certain point, most likely during the 2006-07 southward bird migration, the H5N1 virus will be discovered to have reached the wild bird population in North America. Birds that had been living and breeding in the northern parts of North America will make their yearly trek south to warmer climates. Some of them will have come from Asia, where the virus has already been found and millions of birds have already died.

Along with the migrating birds will likely come the viruses the birds host. The viruses living in these birds will likely be passed on to other birds that are native to North America, domestic flocks and animals that prey on those birds in the wild. Not all birds who harbor the virus become ill or die because of it. Some are carriers and simply pass it along to other birds. It is possible that, as in Asia, there will be some infection of humans who come into contact with infected birds or bird droppings, resulting in some illness and possibly death. However, if the virus? nature changes so that it becomes communicable from human to human, the disease might begin to spread as quickly as the human flu does.

According to the World Health Organization, ?Prompt and accurate reporting of H5N1 influenza cases to [the World Health Organization] is the cornerstone for monitoring both the global evolution of this disease and the corresponding risk that a pandemic virus might emerge.?

Doctors in the United States are required by law to report incidents of the flu to the CDC so that, if a pattern of infection from the H5N1 virus begins, the CDC will be able to notify the White House and the president will then institute the government?s action plan.



The plan

The federal plan calls for doses of flu vaccine, broad spectrum antibiotics and the anti-viral drugs oseltamivir and zanamivir (better known under the brand names Tamiflu and Relenza) and other medical supplies to be sent beforehand to each state under armed guard. Stored at a number of undisclosed, secure locations, those medicines and supplies will be stockpiled and kept safe to use. Each state will have sufficient materials to set up a number of pre-determined local centers, each of which will be given the go ahead to open with a command from a local judge. In the case of Johnson County, that person would be County Judge Roger Harmon. The vaccine doses will then be distributed to these centers, again by armed guard. The human flu inoculations will first be given to first responders and their families. First responders include police, fire, emergency and medical personnel.

?We have more than enough (flu vaccine) to go around,? said Gerald Mohr, Johnson County emergency management coordinator. ?We shouldn?t run short. Johnson County is pretty well prepared.?

Judge Harmon agreed.

?Johnson County was the first in the state to determine that these centers would be situated at schools,? Harmon said. ?Schools are ideal places for mass inoculations. They all have gymnasiums, people know how to find them and they all have kitchens to feed the workers who will be there over a long period of time. There are a lot of counties that are following our lead and making their schools their centers. We don?t want anyone to know which schools we?ve designated, though, for obvious reasons.?

?Gerald Mohr,? Harmon said of his colleague, ?is the perfect person for this job. He?s sharp as a tack and he?s got his heart in it. He knows what he?s doing.? Both Mohr and Harmon have modeled a county-wide response to a pandemic on federal guidelines issued to help deal with a biowarfare scenario in which a biological agent such as smallpox is let loose on the country by terrorists. In fact, much of the money supporting the county?s preparations for a pandemic come from the Department of Homeland Security.

There are, however, a few flies in the ointment. First of all, even though Tamiflu and Relenza have been shown to be effective against this form of H5N1 in mice with two human-sized doses a day, much more may be needed for an infected adult human. Also, there is not enough of these drugs to go around. An article in Scientific American said that treating 25 percent of Americans would require more than the number of doses stockpiled. It would take 130 million doses to protect all health care workers and first responders in the country. According to the Department of Homeland Security?s paper on avian flu, as of September 2005, the total number of doses available was about 22 million. Additionally, there are those who should not take the medicine for medical reasons; there will also undoubtedly be some people who will refuse the drug for one reason or another.

According to the Centers for Disease control, if the patient comes for treatment beyond a 48-hour window of opportunity, it?s not likely the drugs will work. Next, because flu viruses are ever-changing, it is not known if the vaccines presently under development will work against new strains of flu. The same is true of broad-spectrum antibiotics which, while they do not have any effect on viruses, do control secondary bacterial infections that set in once the body?s immune system is compromised. Finally, there is the question of maintaining law and order during a time of widespread fear and illness.

?That,? said Harmon, ?is the thing that scares me the most. I worry about what will happen if our first responders go down with the flu and I worry about whether or not we have the resources to maintain law and order if they do. That?s the part that keeps me up at night.?

According to World Health Organization statistics, avian flu thus far appears to be a very lethal killer. Of those who have been infected, approximately 50 percent did not survive. In other words, once it is spread, it will likely kill more than half those it infects. Fortunately, it does not yet seem to be transmissible from one person to another, only from an infected animal to a human who comes into contact with that animal. As a comparison in mortality, the much-dreaded smallpox, for the most part, has a mortality rate of about 30 percent. If a pandemic of a human-transmissable form of avian flu does occur, the potential losses from the disease alone could be very high. What Harmon and others are worried about is how to keep associated, non-disease-related deaths and injuries at a minimum. If the social chaos and civil disorder that followed the devastation of Hurricane Katrina is an example of what could happen, then keeping numbers of non-disease-related deaths low might be challenging, considering that there may be only a possible skeleton crew on duty. According to both Harmon and Mohr, the challenge becomes greater still in a vast and essentially rural place like Johnson County.


Quarantine and communication

A quarantine is a prescribed period of time in isolation to keep a disease from spreading. The word dates back to the time of the plague in Italy when people were kept restricted to their home for 40 days to halt the transmission of the disease. It is widely assumed that a brief quarantine might be the only effective way to limit the march of a human-transmissable avian flu once it gets started.

There has never been a national quarantine, so no one really knows what the public response might be to such an order, which would, necessarily, come from the White House. In the past, individuals have been quarantined, but never whole cities, states or countries. If children could be kept home from school, workers home from their jobs, ships from docking and planes from landing and so on for two to three days, it might be possible to staunch the spread of the disease. The question is, though, will people willingly stay home and stay away from work to stop the spread of the flu? In large cities, this might be easier to do than in small, rural areas with limited police presence. How would such an order be enforced and by whom?

Because of Johnson County?s close proximity to a major metropolitan area, Harmon worries that there could a mass exodus of people seeking to flee the cities to our north for the more sparsely populated areas like Johnson County.

?How will we keep them out?? Harmon asked. ?There is no model for anything like that. I can see a scenario where we could have infected individuals looking to protect their families by heading off into the country by turning onto I-35 heading south. In the best of circumstances, we simply don?t have the manpower to stop them all from coming here.?

Although such a quarantine would likely be effective in slowing the progress of a pandemic and although the quarantine would only need to last 48 to 72 hours, both Mohr and Harmon express doubts that there would be 100 percent cooperation on the part of the public.

They also agree that cooperation and communication are crucial in coordinating the effort to keep the spread of the flu in check.

Mohr indicates that the area is working hard to complete a communications system that will keep all first responders on the same frequency, thus addressing a major problem that cropped up as the result of Sept. 11 and again in the wake of Hurricane Katrina.

County Medical Examiner Arthur Raines has been pushing for the purchase of technology to do just that. For his part, Harmon is making sure that all of the communities in the county are aware of and familiar with the national, state and local protocols if a state of emergency is declared.

It is anticipated that there will be a high demand for medical services with the onset of a pandemic such as avian flu.

?We have only a limited capacity to help here,? said Michael McEachern, safety manager at Harris Methodist Walls Regional Hospital in Cleburne. ?We don?t have a huge emergency room, so we?ll probably handle only the sickest people. We keep refreshing our stockpile of things that have a limited shelf life, like surgical masks. Because they?re able to filter out particles as small as viruses, those will probably be in very high demand.?

Another thing that McEachern wonders about is the inevitable buildup of bodies.

?We don?t have much of a morgue here,? he said. ?I guess we?d be forced to use things like refrigerator trucks or the refrigeration at retail stores and distributors.?

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Re: With H5N1 on the rise, are we prepared for a flu pandemic?

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Schools, Red Cross positioned to combat avian flu

Editor?s note: This is part three of a three-part series. Parts I and II published on Sept. 17 and 24.

Published: October 02, 2006 10:52 am

http://www.cleburnetimesreview.com/homepage/local_story_275105237.html?keyword=leadpicturestory

On New Year?s Eve, 1999, millions of people anxiously waited to see what chaos would follow when computer clocks ticked over into the year 2000, fearing Y2K?s wrath. Many people hedged their bets that nothing would happen by stocking up on candles, bottled water and canned food. Fortunately, the candle makers, water bottlers and food canners did quite well and nothing terrible occurred.

There is, however, a difference between this once-in-a-millenium event and the fears surrounding a possible pandemic of avian flu.

The difference is that the winter months always bring with them some strain of epidemic flu.

The World Health Organization states that avian flu (H5N1) has caused the deaths of millions of birds worldwide and has shown that it is a killer of deadly efficiency when humans have been in contact with infected birds.

Flu season is coming. It?s never failed to come. It arrives every year. According to the Centers for Disease Control, on average, 20,000 Americans die each year as the result of complications from the flu. What is unknown is when or whether the avian flu will join forces with genetic material from human flu to become a ?superflu? that will cut through the population like a sickle. Survival in the teeth of such a possible pandemic could depend upon individual and family preparedness in addition to the preparedness of the federal, state and local governments said Johnson County Red Cross office manager Janel Holt.

Preparation

?If you rush to the stores when the first reports come of a rampant flu infection, you may find that you are too late,? Holt said.

She should know. She?s seen quite a bit of disaster in her position.

?Make a disaster plan for yourself and for your family so that everyone will know what to do if you become sick. Of course you should also consider what you?ll need to do to prevent becoming sick,? she said.

Even though no one is absolutely certain a pandemic of the H5N1 strain of virus will come, Holt said such preparedness will be a good exercise in protecting people against any disaster.

In the U.S. government?s avian flu policy paper, ?Planning For a Pandemic,? the government takes into account a number of givens, including these:

• Susceptibility to pandemic influenza will be universal.

• Efficient and sustained person-to-person infection will signal an imminent pandemic.

• About 30 percent of the overall population will become infected; illness will be highest among school-aged children (about 40 percent).

• Some will become infected but will not develop significant symptoms. However, such people can and will transmit infection to others.

• While the number of patients seeking medical care isn?t predictable, in previous pandemics about half of those who became ill sought care. This percentage might be higher, given there are some effective antiviral medications.

• The rate of serious illness, need for hospitalization and death is going to depend upon how virulent the pandemic is. It is impossible to predict which groups will most be at risk, but the public can be assured that included in that list will be the elderly, newborns, pregnant women and those who have a compromised immune system.

• The rate of absenteeism in businesses and in government will depend on the severity of the pandemic. The absentee rate may reach 40 percent when both the ill and caretakers for the ill are counted. Certain public health measures such as school closings, quarantine and ?snow days? will increase the rate of absenteeism.

• People who become ill may shed virus (spread virus particles) and can transmit infection for a half or whole day before the onset of illness. Viral shedding and the risk of transmission will be greatest during the first two days of illness. Children shed virus over a longer period of time and also have a hard time controlling their secretions, so they pose a greater threat of transmission than adults.

• On average, each infected person will infect approximately two other people.

• Epidemics will last six to eight weeks in affected communities.

• Multiple waves of illness are likely to occur. Each wave will likely last two to three months. The largest waves have historically come in fall and winter, but they are not limited to those two seasons.

A family plan

Holt said a good family disaster plan should include specific instructions about a chain of command if one or both parents are incapacitated, phone numbers to call (assuming that telephone service is not also disrupted), special rules to be followed during the emergency, and so on. There should be consideration given to the kinds of foods that will be stored, including favorite snacks, the medicines that may be needed and things needed to pass the time enjoyably in the absence of electricity. Common sense parts of the plan should also include escape routes and what children should do if separated from parents.

An ounce of prevention

The quote from Benjamin Franklin?s ?Poor Richard?s Almanac? suggests that ?an ounce of prevention is worth a pound of cure? couldn?t be more relevant. Whether there is an outbreak of a lethal strain of influenza or the more annoying annual flu season with its sneezing, coughing aches and fever, in many cases influenza can be avoided.

A great deal is known about how flu viruses are transmitted. In general, viruses are very hard to kill. Place them in sub-zero environments and they survive. They can also survive outside their host on non-porous surfaces for as long as 30 days. Avian flu is resistant to most of the antiviral drugs on the pharmacy?s shelf. The nature of viruses is that they are constantly changing or mutating in order to adapt to a hostile environment, so that those methods used to kill a particular strain of virus today might not work in the future. According to the CDC, while the human body builds up an immunity to viruses it is exposed to, H5N1 hasn?t been around long enough for humans to develop an immunity to it. It also hasn?t been around long enough for us to formulate a vaccine to prevent it.

The CDC advises that, for the most part, flu viruses are passed from person to person as an aerosol and that a person is most infectious during the first 48 hours he or she is infected. It is during that time that humans ?shed? viruses. When a person sneezes or coughs, tiny droplets of liquid spray outward. Inside each of these thousands of droplets are millions of viruses, each one capable of infecting another person. In a closed environment in which the same air is re-circulated, the virus has a way in which to spread. An airplane, for example, with sealed windows and re-circulated air is an example of a worst-case scenario. Some of those droplets are going to fall out of suspension in the air and will land on non-porous surfaces such as tabletops, doorknobs, pens and pencils.

The World Health Organization advises that viruses can continue living on those surfaces for upwards of 30 days. In schools, which also often have closed, re-circulated air systems and many non-porous surfaces upon which the viruses can linger, infection and re-infection is chronic during flu season.

Dr. Sharron Miles, executive director for special projects at Cleburne ISD, has worked for the district on avian flu for two years. Preparation for a pandemic is an ongoing process, she said. She said the janitorial staff, teachers and students are constantly being trained to do whatever possible to prevent the spread of pathogens such as the H5N1 virus. Asked how stringent the school system would be about sending home children who are symptomatic, Miles said that there are always those parents who will send their children to school even though they?re sick, but the district?s schools are very conscientious about sending sick children home.

?If a child is ill, we will quarantine them in the nurse?s office until a parent comes to take them home,? Miles said. ?Teachers are another story, though. Most of our teachers hate to not be there, so they tend to come to school even though they?re sick. We try to send them home if they?re ill, though.?

Constant cleaning of the hands helps enormously. Those viruses that are lounging around waiting to hitch a ride at your expense are just waiting for your hands and fingers to touch that surface. Likewise, when you blow your nose or cover your mouth with your hand to stifle a cough, you may be preventing the droplets from spreading one way, but your now-virus-laden hand will spread it instead. Antibacterial soaps are about as effective in fighting as plain soap. Those soaps kill bacteria and not viruses. Unfortunately, Miles said, most schools no longer run hot water in restrooms or classrooms and some classrooms have no running water at all.

?We are constantly working on etiquette as far as sneezing and coughing,? Miles said. ?We have signs in our restrooms reminding children and staff to wash their hands.?

Miles said that, at school, children are taught that, when they cough, they should stifle the cough with their forearm or the inside of their elbow, rather than with their hand.

The Occupational and Safety Hazards Administration (OSHA) has long warned that, if you know you are going to clean up some sort of biological mess, it?s always best to wear disposable gloves. They also advise individuals to not pick up tissues bare handed and, likewise, to not handle trash bags barehanded, either.

The federal position paper on avian flu expresses the hope that those people who become ill will not go to work or to school. That is the idea behind quarantine.

The CDC said schools represent the most virulent vector of infection in any community and the government?s paper on avian flu expresses the hope that school districts will create ?snow days? and call off school and extracurricular events entirely. This may or may not happen, but if it doesn?t, keeping your child home once a pandemic condition is determined is, according to the CDC, the wise thing to do.

While flu vaccines for the H5N1 virus have not yet become available, research is underway to find one that works. In the meantime, the CDC recommends that everyone at least try to get vaccinated against the flu anyway because developing the human flu and then contracting avian flu on top of it could be deadly.

?Preparing for avian flu is no different from preparing for any other natural disaster,? Holt said. ?Have a first-aid kit and lots of bottled water stored, along with foods that are not perishable and that require no cooking. Make sure that you have flashlights and lots of batteries and a radio.?

Holt said she keeps a combination radio and flashlight at home that is powered by winding and not by batteries. ?Make sure you have whatever prescription drugs you need and also whatever over-the-counter drugs you?ll need. Parents of young children should also not forget such things as disposable diapers and non-electronic activities to keep kids busy. Matches also will come in handy,? she added.

Holt said it would also be helpful to keep tissues, plastic bags, plastic gloves and surgical masks on hand. She advises that parents work with their families to create master checklists and include it with any other emergency plan being made. She also stressed it could be life-saving to know how to perform CPR, a skill that is taught on a regular basis by the Red Cross.