Published: September 25, 2006 05:33 pm            

Outbreak: Preparing for a flu pandemic

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.”



Michael Mager can be reached at 817-645-2441, ext. 2338, or

features@trcle.com.

        

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