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Michael Osterholm, Infectious disease expert & Waukon native provides a reality check

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  • Michael Osterholm, Infectious disease expert & Waukon native provides a reality check

    Infectious disease expert, Waukon native Michael Osterholm, provides a reality check for locals on the bird flu

    by Sandra Knebel

    Making a local presentation on avian flu ... As part of his presentation at Veterans Memorial Hospital Friday, July 14 to community leaders, healthcare professionals, and emergency management personnel, Waukon native Michael Osterholm, PhD, MPH, explained how a bird flu becomes a people flu. According to Osterholm, it’s time the world prepares for the worldwide spread of the avian flu. He said, “This is the one topic that keeps me up at night.”

    Pandemic: an epidemic over a wide geographic area that affects a large proportion of the population.

    As fears and expectations of the impending bird flu pandemic become more and more prominent in the news, the director of the Center for Infectious Disease Research and Policy (CIDRAP) and associate director of Homeland Security’s National Center for Food Protection and Defense, Waukon native Michael Osterholm, told healthcare professionals, community leaders, and those in emergency management positions at a Friday, July 14 meeting, that a flu pandemic is a risk of "one". [Mellie: probability of 1.0 means 100% certain there will be a flu pandemic.]

    At the meeting held at Veterans Memorial Hospital in Waukon, Osterholm said, “It’s going to happen. It’s not a matter of if - it’s a matter of when, where it starts, and how bad it’s going to be. This is the one topic that keeps me up at night.” As the presentation progressed, it became very apparent that this present day adaptation of the Chicken Little story has a different twist - for about two and a half percent of the global population, the sky will, indeed, be falling.


    Osterholm’s two-page list of educational, medical, and professional accomplishments qualifies him as an expert on the subject. In addition to his work at CIDRAP, Homeland Security, and a variety of other related agencies, Osterholm served for 24 years in various roles at the Minnesota Department of Health (MDH). For 15 years he was state epidemiologist and chief of the Acute Disease Epidemiology Section.

    He has led numerous investigations of outbreaks of international importance, including foodborne diseases, the association of tampons and toxic shock syndrome, the transmission of hepatitis B in healthcare settings, and HIV infection in healthcare workers.

    Osterholm has been an international leader on the growing concern regarding the use of biological agents as catastrophic weapons targeting civilian populations. In that role, he served as a personal advisor to the late King Hussein of Jordan. He is a frequent consultant to the World Health Organization (WHO), the National Institutes of Health, the Food and Drug Administration, the Department of Defense, and the Centers for Disease Control and Prevention. Dr. Osterholm has received numerous honors for his work.

    Coincidentally, Osterholm hails from Waukon, where he graduated from high school. He is currently building a home in so he can turn to its trout streams when he needs a break from his schedule that takes him all over the world to meetings with national and international leaders.


    The pending pandemic is different from most influenzas of the last 300 years because, according to Osterholm, it is an H5N1 avian virus - as was the one that caused the 1918 Spanish influenza pandemic. That was also a strain of bird flu.

    Osterholm explained the difference between a regular flu - so-called seasonal influenza - that hits the U.S. each year and other strains that are present in birds and other animals, such as pigs and horses. Seasonal flu viruses constantly change, requiring vaccines to be frequently updated even though some characteristics pass on to the next year’s virus.

    There are lots of flu strains in birds, wild birds being the ultimate reservoir for the influenzas people catch. Most often those strains don’t even harm the birds, but can cause significant illness and death when they get into domestic poultry. The strain that has health workers worried right now - called H5N1 - has infected poultry across several countries. People who have had close contact with sick birds have gotten sick and are dying at an increasing percentage.

    Osterholm’s supporting graph at the presentation showing reported human cases of the H5N1 influenza from 2000 to 2006 had significant impact. The number of cases reported has increased over the last six years. The ratio of deaths related to the cases reported has also increased. More than half the people infected now die.

    So far the H5N1 bird flu hasn’t spread widely among humans. That is expected to change. According to Osterholm, there are several ways the H5N1 can mutate into a virus that does spread and is foreign enough that people's immune defenses can’t fight it. When that happens, he says the virus will spread across the world (causing a so-called pandemic) and even strong, healthy people will become sick and die.

    Another significant difference in the bird flu is the age group expected to be most affected. Generally illnesses more severely affect the very young and the very old. The bird flu is expected to have the most impact on adults in the 20-40 year old range. The reason is that a developed, healthy immune system is an Achilles heel when attacked by H5N1. The fit body produces an army of anti-bodies and disease-fighting cells in an attempt to kill off the invading virus. But this causes massive, fatal collateral damage as the battle rages and the lungs and other organs are terminally wounded.

    As Osterholm explained it, the curve of influenza deaths by age at death has historically been U shaped, exhibiting mortality peaks in the very young and the very old, with a comparatively low frequency of deaths at all ages in between. In contrast, age-specific death rates in the 1918 pandemic exhibited a distinct pattern that has not been documented before or since: a “W-shaped” curve, similar to the U shaped curve but with the addition of a middle peak of deaths in young adults (ages 20-40). Overall, nearly half of the deaths in the 1918 pandemic were in young adults 20-40, a phenomenon unique to that pandemic year and a phenomenon that is expected to associate with the pending pandemic.


    Why was the 1918 flu that the pending flu is likened to so deadly? Osterholm said that for more than half a century the answer was unknown. Then in the late 1990’s researchers extracted genetic material of the virus from victims who died in the pandemic and were buried in permafrost in an Alaskan village where flu killed 85% of the adults. The low temperatures had contributed to the preservation of some of the bodies.

    Comparisons with known flu viruses in humans, pigs, and birds suggest that some genes of the 1918 virus came from birds. Other scientists then were able to show that the amino acid sequence of hemagglutinin protein from the 1918 virus had several changes from other flu viruses that may have helped it to easily bind and invade human cells, and that made the virus look different enough from earlier flu virus strains that people had no immunity.


    The H5N1 bird flu has not yet been found in the U.S. either in birds or humans. The spread of the virus through wild migratory bird populations is plausible, according to Olsterholm’s graphics of the migratory paths of birds. But that is probably not the route the virus will take. In today’s world people who have the virus can fly across continents in less than a day.


    There will be no H5N1 vaccine available for at least the first six months of the outbreak because, according to Osterholm, it will take that long to identify the virus strain and cultivate the vaccine. That’s because the H5N1 bird flu virus is fully expected to be unlike any of the flu viruses in recent years for which vaccines were developed. Beyond that, Olsterholm says, there is limited worldwide capacity for vaccine production. For the United States, this is a multi-pronged problem. First, dozens of companies have abandoned flu vaccine production in recent years because it’s a difficult business with low profit margins.

    Explaining the difficulties in producing vaccines, Osterholm said a years old process is still being used that involves processing millions of chicken eggs in laboratories. Technicians inject a strain of the flu virus in the fluid in the embryo of the chicken egg and then it has to incubate for several months. Part of the problem is that companies will not be able to produce enough vaccine fast enough.

    In addition, 80% of drugs utilized in the United States are made off-shore. Should a deadly virus hit and spread around the world, Americans could find themselves at the back of the line for any new vaccine developed to combat it. Should a vaccine become available, the void in U.S.-based production of vaccines could create a major problem.

    If the figures projected by Osterholm prove true, however, goodwill between countries wanting to share the vaccine will not be the real issue. The bottom line is that international governments will have limited resources to respond to “everywhere and to everything” for 12 to 18 months - the life expectancy of the pandemic. Osterholm has, himself, had meetings with drug company representatives as part of the offensive measures the government is taking to address the problem and create a pandemic flu plan; however, it appears that the U.S. vaccine manufacturing capacity domestically is not what it will need to be. At full capacity, it is unlikely that drug companies could produce enough vaccine for the nearly 300 million Americans.


    Illness is Part I of a chain reaction that will begin with the pandemic.

    To reduce costs, company production systems are very often geared to just in time (JIT) delivery of materials, supplies and even services. [...Part II] JIT saves space and simplifies production scheduling because items are scheduled to arrive just when they are needed rather than sitting on the shop floor waiting to be used. The drawback with JIT is that it leaves a firm without a buffer stock of inventory, which, although expensive to store, can help tide a firm over shortages and disruptions.

    Governments may have limited resources to respond for 12-18 months. Business continuity planning is, therefore, crucial. Availability and transport of food and other products of necessity may become extremely limited, if not cut off.

    Osterholm said he had not seen or heard of any credible estimates of the economic impact to banking, the stock market, or other monetary avenues which the public relies upon for savings, investments, etc. It can be assumed that, like Katrina, ATM’s and other quick money resources may be unavailable.


    Health care and death management will be a huge issue. Health leaders admit they have a long way to go in preparing for a pandemic. Hospitals will not be big enough for the number of patients. Occupancy rates at many hospitals already run over 90 percent. Hospital equipment will be in short supply. Osterholm said filling the need for ventilators may be the toughest challenge. Machines that help patients breathe will be in high demand. The entire U.S. supply of ventilators is only reported to be slightly more than 100,000.

    With the number of deaths expected, Osterholm colored a picture that was not rosy. If the rate of death peaks at 2.5% (the percentage most often predicted,) the message is simple - no matter what emergency arrangements are put in place, there are likely to be substantially more deaths than can be managed within the current timescales. An excerpt from the Minnesota Department of Health Pandemic Influenza Plan Technical Section on the care of the deceased provides an example:

    “On average funeral homes will have a surge of up to five times their normal business at the same time they may lose 40% of their staff due to illness or other responsibilities. Buildings may need to act as temporary morgues and central collection points to process the dead until such time as mortuaries are able to recover from the surge…. Temporary burials may be required until such time as final disposition can be planned by the next of kin and accomplished by the funeral home of choice.”

    A continuing statement in the Minnesota plan reads, “Every day in Minnesota, approximately 105 deaths occur totaling approximately 38,000 deaths annually. During a worst case scenario, pandemic flu deaths are estimated to surge an additional 536 deaths per day for eight weeks reaching 30,000 in total.”

    While the above paragraph refers to an eight-week timeline, Osterholm said the pandemic could well come in waves as it did before and last as much as 12-18 months.

    The states and the federal government are planning for the pandemic on the home shores. In other countries plans are also being formulated. As reported in London’s Sunday Times, “The UK Home Office is considering the use of mass graves as a worse case scenario….. 320,000 people in Great Britain could die as a result of a flu pandemic originating from a mutated H5N1 bird flu virus strain. Such a death toll would overwhelm the country’s burial services, resulting in burial and cremation delays of up to four months. A cabinet committee quoted the Great Plague burial pits used during the 17th century.”

    The same report claims local authorities in Great Britain could probably bury and cremate about 48,000 people (who die of flu) over a period of three months. It adds that a 320,000 death toll would push back burial and cremation schedules by 17 weeks (4 months.)” An Oxford, England, paper confirmed the report findings and wrote, “Common burial might involve a large number of coffins buried in the same place at the same time in such a way that allows for individual graves to be marked.”

    In addition to the physical aspects of death management, Osterholm said there will be the related mental toll the deaths will have on family and friends who will be unable to have the closure that services and memorials now provide.


    Osterholm says the Chicken Little story is at one end of the spectrum and doomsday at the other. The truth of what will actually happen, he says, is somewhere in the middle. There is no reason to stop eating chicken.

    Those who are going to travel to countries that have seen bird flu outbreaks (Cambodia, China, Indonesia, Kazakhstan, Laos, Malaysia, Mongolia, Romania, Russia, Thailand, Turkey, and Vietnam) mus make sure their vaccinations are up to date, take plenty of alcohol-based hand gel, and avoid direct contact with poultry. For example, don’t go to bird markets or poultry farms.

    On a less specific nature, BE PREPARED. Osterholm says to look at the Katrina disaster for things that went awry. Twenty to thirty percent of workers may be out at any time due to illness or other family members being ill. That means that supply chains for money, food, electricity, and other necessities may be slowed or halted entirely. Have a family plan in place for alternatives.

    Osterholm, a member of the Health and Human Services Advisory Council on Public Health Preparedness, says to have bottled water on hand and non-perishable food. Have a family plan. There may be mandatory and/or voluntary closings of national, state, and even local borders. Be prepared for public panic. “Imagine,” he said, “a 12-18 month global blizzard.”

    Pay attention to TV specials, newspaper articles, relevant books, Internet and other resources that have already prepared lists of things you can do. Be aware of the conditions that will accompany a pandemic and be aware of options.


    The threat of a deadly global pandemic is real and growing. Expert Michael Osterholm insists it is only a matter of time before the virus makes the jump to a form that puts millions of people at risk and causes death to hundreds of thousand. As has happened throughout history, however, Osterholm says, “Just like every other pandemic in our history, we will get through it. Even under the worst case scenario, the world’s population will survive this pandemic as we have the others. Ninety-eight people out of every 100 will still be alive at the end of the pandemic.”

    The work to be done now on every scale - personal, community, state, federal, and global - is to determine how to minimize the affect the Avian Flu will have on the world as we know it.

    Pandemics are not new

    The Bubonic Plague in AD 541-542 is the first known pandemic on record. At its peak, the plague was killing 5,000 people in Constantinople every day and ultimately killed 40% of the city’s inhabitants. It went on to destroy up to a quarter of the human population of the eastern Mediterranean. A second major wave in A.D. 588 spread through the Mediterranean into what is now France. The estimate was 25 million deaths.

    During the mid-1300s, the Black Death swept through Eurasia, killing one-third of the population by some estimates. The 200 million people who died represented the largest death toll from any known epidemic of any disease. Plague continued to strike parts of Europe throughout the 1400s, 1500s, and 1600s with varying degrees of intensity and fatality.

    The third pandemic began in China in 1855, spreading the bubonic plague to all inhabited continents, and ultimately killing more than 12 million people in India and China alone. In the two years that this scourge ravaged the earth, a fifth of the world’s population was infected.

    In the 20th century, major pandemics occurred in 1918-1919 (the Spanish flu), 1957-1958 (the Asian Flu,) 1968-1969 (the Hong Kong flu), and the 2003 outbreak of the SARS virus. (According to the World Health Organization , a total of 8,098 people worldwide became sick with SARS during the 2003 outbreak. Of these, 774 died. In the United States, only eight people had laboratory evidence of SARS, all of whom had traveled to other parts of the world where SARS was present.)

    The 1918-1919 pandemic started as World War I (1914-1918) was ending and caused from 20 million to 50 million deaths - two to five times as many deaths as the war itself. Statistics indicate that 28% of Americans were infected.

    According to statistics shared by Waukon native Michael Osterholm, PhD, MPH, over the last 300 years, the average time span between pandemics is 24 years.
    Last edited by sharon sanders; July 27, 2006, 03:27 PM.

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