How to fight a pandemic

Monday, July 10, 2006 | 7:13 a.m.

After months of planning, research, conferences and, yes, large doses of buck-passing and hand-wringing, here is the best advice to protect yourself and others should avian influenza mutate into the world's next pandemic:

Stay at home, cover your mouth when you cough and wash your hands.

A year after what might best be called bird-flu frenzy or "panic-demic" - fueled in part by thousands of newspaper, magazine and television stories - the preferred method to avoid catching or spreading such an illness mirrors advice you could get from your family doctor (or your mother) about avoiding the common cold.

Health officials agree the above recommendations seem simplistic, but they say that shouldn't diminish their potential for effectiveness.

"These are tried and true methods, and we know they work," says Von Roebuck of the Centers for Disease Control and Prevention in Atlanta. "That doesn't mean as a pandemic evolves and we have a better idea of what we're dealing with, there won't be other recommendations, but these are solid."

Meanwhile, researchers look for a vaccine, and the CDC helps states coordinate planning for a worst-case scenario and manages distribution of the nation's limited supply of Tamiflu, which can help lessen flu symptoms if taken early enough.

Preparedness levels vary from state to state - and within some states. One group studying how each state is progressing ranks Nevada in the top half.

Still, lacking strong federal leadership in planning, state and local governments are much like diners choosing a main dish to go with the egg roll and fried rice. Some choose to stockpile Tamiflu, while others, such as Clark County, aren't convinced that is the way to go.

Nebraska, considered a leader by the CDC in planning for a pandemic, has selected temporary sites for field infirmaries. The only site identified so far in the Las Vegas Valley is at Nellis Air Force Base, and it was selected under a Veterans Administration plan, not the county's.

Much else about the bird flu, its deadly potential and the best way for health agencies to plan for and respond to a potential pandemic, however, remains open to questions - and debate.

For example:

Which level of government should be responsible for protecting America's populace?

At a Nevada pandemic flu summit in February, state and local health officials received a sobering message from Michael Leavitt, secretary of Health and Human Services:

"In the event of a pandemic, don't expect help from the federal government."

And while Nevada's Division of Health is the ultimate state authority on such issues, it has deferred responsibility on this matter to local government in the three largest counties - Clark, Washoe and Carson City. Bill Hale, the state agency's planning and assessment manager, delivered a message similar to Leavitt's when he met with local officials:

"We told them that at least initially, we are all on our own."

The allocation of resources and personnel would begin locally, Hale says, then spread outwardly to county, state and federal government agencies, based on availability.

Jeff Levi, executive director of Trust for America's Health, a nonprofit, nonpartisan organization, is critical of the federal government's approach, saying it should provide more direction, planning and funding.

In the absence of such guidance, states have been left to develop their own plans. Some, such as California and Nebraska, have taken an aggressive approach and allocated millions of dollars for comprehensive programs and equipment. The California legislature just approved a budget that sets aside $220 million for disaster preparedness.

Nevada has chosen to focus on communication, education and dispersal of medication, while placing less emphasis on such hot-button issues as the purchase of antivirals and surge capacity - the sudden influx of large numbers of ill or infected patients into the health care system.

So, how well prepared are Clark County and Southern Nevada hospitals?

While many Nevada hospitals are privately owned, officials say a "demonstrated spirit of cooperation" exists among the hospitals and with government agencies.

A facilities advisory board, comprised of the county's hospital executives, meets regularly to discuss a variety of issues, including emergency procedures.

All Clark County hospitals have also submitted pandemic preparedness plans to the Southern Nevada Health District that focus on pandemic preparedness.

A draft of the plan submitted by University Medical Center outlines areas of concern and identifies the responsibilities of key personnel.

Issues addressed by UMC include the surveillance and detection of an infectious agent, critical patient-care needs, bed availability and staffing. It also has a protocol in place to identify and designate additional areas of the hospital for temporary treatment and isolation, as necessary. The admission and discharge of noncritical patients and restriction of visitors are also addressed.

Hale, of the state Health Division, said coordination between Clark County and its hospitals is a good example of proactive cooperation that should be copied throughout Nevada.

And he pointed out that, in an emergency, the state can take action to ensure mandatory compliance by all of its hospitals:

"I believe most hospitals would stand up in any event. If, for whatever reason, we didn't have cooperation and it was for the public good, steps could be taken, either through the executive branch or the judicial branch of government, to provide what is best for the entire population."

This authority could extend to the movement of patients, supplies and medical personnel, according to Hale, and could be transferred to the county if necessary.

Should Nevada and local agencies be stocking up with Tamiflu?

There is currently no vaccine for avian influenza, and experts anticipate it will be at least 2010 before one is developed.

In the absence of a vaccine, the CDC recommends the use of antivirals to control symptoms. The CDC's Roebuck said Tamiflu (osteltamivir) is the best treatment currently available if administered within 48 hours of the first symptoms. The CDC has also identified the drug Relenza (zanamivir) as a treatment option, but 80 percent of the government's stockpile will be Tamiflu.

Roebuck said the federal government had 5.1 million doses of Tamiflu available as of May 11. It will purchase an additional 16.4 million doses by the end of the year and 24 million more doses next year for a total of just over 45 million - or enough for about one in seven Americans.

Nevada's portion will be 334,139 doses by the end of 2007. The state has about 2.4 million residents, 1.7 million of them living in Clark County.

The national stockpile is being stored at 11 regional sites, which should make it available within 12 hours anywhere in the country.

The federal government has given states the option of purchasing a portion of 31 million additional doses this year, and will provide a 25 percent subsidy. This would allow Nevada access to an additional 235,416 doses.

The original July deadline to commit to buying the additional doses has been extended by 30 days.

But Nevada's health officials seemingly do not share the CDC's enthusiasm for Tamiflu, and while some states have already designated funds for the purchase, Nevada has not.

The CDC's Roebuck offered no opinion on Nevada or other states so far passing up the Tamiflu at a discount: "We are not giving guidance on how they are going to respond and what they are going to respond with."

Nevada officials point to both a lack of available funds and uncertainty about the effectiveness of the drug.

Tamiflu costs $20 per dose, which would cost more than $4.7 million for the extra allotment.

"We do not have the money and quite frankly, we don't think this is the answer," said Jane Shunney, public preparedness manager at the Southern Nevada Heath District.

She said the drug's effectiveness is unproven in a pandemic situation and that the county has chosen to focus its limited resources on other areas of preparation.

Sheila Leslie, who chairs the Nevada Assembly's Health and Human Services committee, agreed.

"I have to go with what the experts have told me," said Leslie, D-Reno. "The people I have talked to say it's not a good use of the money."

In light of the reluctance by the state or county health departments to purchase the antivirals subsidized by the federal government, Nevada has begun to offer the drugs to other health care agencies.

There is already a limited supply of Tamiflu in the state.

Hospitals and pharmacies keep the drug in stock as a treatment for more common flu strains that threaten annually. In a pandemic, however, that supply would be quickly depleted.

Some state legislators say that instead of committing so much money to an unproven treatment, the state should develop a plan with more flexible spending options.

Leslie and Assemblywoman Barbara Buckley, D-Las Vegas, plan to introduce a bill next year to establish a fund for health emergencies. Leslie said the fund would be "in the millions" and be used to provide an initial response to a health emergency.

There are no state funds currently set aside for pandemic flu preparedness, she said. The federal government gave Nevada $1 million for preparedness earlier this year, and the state recently submitted a request for an additional $880,331, of which $578,438 would go to the Southern Nevada Health District.

With no vaccine and no effective treatment for symptoms, what happens if you get sick?

Neither Clark County nor the state has identified temporary sites to accommodate a large influx of patients. The inability to address this problem, known as surge capacity, is a serious concern for some.

"We could be overwhelmed immediately," Leslie said. "With so many people that are so sick, there will be a huge need for these facilities."

Nevada's pandemic response plan estimates that as many as 22,000 people statewide could require hospitalization and more than 740,000 would need some type of outpatient care.

About 70 percent of the state's residents are in Clark County, but there are only 3,462 licensed hospital beds here, according to the Health District.

Officials admit that with most hospitals in the valley usually at or near capacity, very few beds will be available in a pandemic. While hospital pandemic plans include steps to create some additional space, it clearly would not be enough.

There is also a critical shortage of some medical equipment, including ventilators, which officials say would be essential in a pandemic.

The vast majority of Nevada flu victims would be voluntarily quarantined in their homes, both state and county health officials said. They said seriously ill people would not be left at home, but admit the current plan does not provide a suitable alternative, based on the projected numbers.

Officials at both the CDC and the state Health Department estimated a pandemic could have several waves and last for up to two years. And they reluctantly acknowledged that the lack of hospital beds is a real concern.

How serious is the threat of avian influenza?

The inability so far of researchers to develop an avian influenza vaccine makes the threat of a deadly outbreak very real, health experts and officials say.

"It's not a question of if we will have a pandemic, but when," said Hale, of the state health division. "History has shown it will happen again, and whether it's bird flu or something else, we've got to prepare for that."

Avian influenza is an infection caused by viruses that occur naturally among birds.

Wild birds worldwide carry the viruses in their intestines, but usually do not get sick. The virus is contagious, however, and domesticated birds that become infected through contact with wild birds can become very sick or die.

In recent years, there have been cases of bird-to-human transmission of the H5N1 virus overseas, primarily in Asia. A total of 227 cases, resulting in 129 deaths, have been reported since 2003. No cases have been identified in the United States.

There are six stages of pandemic alert. The threat for a bird-flu pandemic is currently at stage three, which is identified by human infections with a new mutation and little or no human-to-human spread.

Phase four is characterized by evidence of increased human-to-human transmission, while phase five has significant transmission between people. Phase six is a full-blown pandemic with sustained cases of human-to-human transmission.

Last month the World Health Organization confirmed a case of human-to-human transmission in an Indonesian family. Health officials are divided about how this could affect the spread of the disease.

While they agree that human-to-human transmission could cause the virus to escalate to a pandemic rather quickly, most say this appears to be an isolated case.

"I would say that right now we are between stage three and four," Hale said.

The virus has been at stage three for more than two years, but experts say the jump from stage four to stage six could be quick.

"That is my understanding." Hale said. "Once human-to-human transmission begins, things could escalate rapidly."

There is also a chance that the virus might never go beyond stage three.

And health officials are quick to point out that avian influenza is just one possible pandemic.

Many CDC projections are based on previous outbreaks, including the Spanish flu pandemic of 1918. Almost 700,000 people in the United States and as many as 40 million worldwide died from that virus and millions more became seriously ill.

The 20th century saw three pandemics. The other two were not nearly as deadly as the Spanish flu.

archive