Not If, But When: Preparing for the Next Flu Pandemic

Many scientists believe it's not a matter of if, but when: At least one worldwide flu epidemic (referred to as a pandemic) is likely to occur during this century; some experts estimate that up to 500,000 Americans (including about 8,000 in Wisconsin) could die. Millions more would have the flu but survive, although many would require medical attention, and as many as 2 million could require hospitalization.

The central culprit in this disaster is thought to be a type of avian influenza, commonly called "bird flu." The most recent avian influenza virus that has caught worldwide attention is called the H5N1 virus.

"Experts agree an influenza pandemic is inevitable," notes a 2004 preparedness report by the Wisconsin Department of Health and Family Services. "No one knows when the next influenza pandemic will occur. However, when it does occur, it will be with little warning ... Outbreaks are expected to occur simultaneously throughout much of the nation, preventing relocation of human and material resources. An influenza pandemic will occur in multiple waves." And its effects will extend beyond health consequences: The Centers for Disease Control and Prevention (CDC) estimates the economic loss associated with the next pandemic will be in the billions of dollars.

"The concern is preparedness," says Ralph M. Schapira, MD, Professor and Vice Chair of Medicine at the Medical College of Wisconsin. A specialist in pulmonary and critical care medicine, he also is a participating in the Department of Veterans Affairs (VA) preparation for the inevitable influenza epidemic as well as other disasters that would have an impact on public health, including man-made disasters such as terrorism and natural events including hurricanes, tornadoes, floods and earthquakes. His responsibilities include training health care professionals, police and other community officials in preparing for how such events would affect the health care system.

VA Leads in Preparedness Planning
"As the country's largest public health system, the VA will play a critical role in providing support to the general public in the event of such public health emergencies," he says. "With the latest avian flu, there have already been 235 confirmed deaths from the virus, primarily in Asia, and typically among people who have close contact with birds that carry the virus. So far, there has been no human-to-human transmission of this bird flu - but eventually, it is believed this will happen, triggering a worldwide pandemic."

Bird flu is not transmitted by eating fowl, he adds. In addition to Asia, avian influenza viruses have been found in birds in Russia, Romania and Egypt. No vaccine against the newer avian influenzas has yet been proven to work in a large outbreak, although one was recently approved by the FDA.

The 20th century saw three flu pandemics - 1918, 1957 and 1968. According to the Wisconsin influenza preparedness document, the infamous "Spanish flu" of 1918-19 was responsible for millions of deaths worldwide, primarily among young adults. Several years ago, a public television documentary described how rapidly people succumbed to the 1918 flu. In some cities, the number of corpses piled up so suddenly, health officials were unable to cope with burying the dead in a timely fashion, creating a further public health crisis.

"It affected 30% of Americans, and 700,000 died in this country," Dr. Schapira says. "Global death estimates range up to 40 million or more." By contrast, today, in a normal winter, about 36,000 Americans die from influenza and its complications, according to the CDC.

Mortality rates associated with the Asian flu pandemic of 1957 and the Hong Kong flu of 1968, however, were reduced in part by the use of antibiotic therapy for secondary bacterial infections and aggressive supportive care of infected patients. Antibiotics to treat secondary infections might not be as effective today in the event of an avian flu outbreak, Dr. Schapira says, in part because their overuse has triggered bacterial infections that resist some commonly used antibiotics. But modern antiviral drugs may be effective, and medical care is more advanced.

Framework for All Communities
"One of the lessons learned from those earlier flu episodes was the importance of being prepared for future public health disasters that challenge the medical system's ability to provide care," he says, although in the four decades since the last major influenza outbreak, organized preparedness planning languished in the United States, but that is changing around the country.

"What really focused attention on preparedness were the attacks of 9-11-01, Hurricane Katrina, and the Asian tsunami," Dr. Schapira says. "With Katrina, especially, the local health care system in New Orleans was devastated, and it still hasn't recovered."

"Now we have a framework for response for disasters," he says. Spearheaded by the US Departments of Health and Human Services, Homeland Security and the CDC, there is a federal disaster plan and every state has a plan to respond to a flu epidemic, a terrorist attack or a natural disaster. Dr. Schapira serves on a national VA Steering Committee that meets to discuss emergency response and engage in drills and exercises for a variety of scenarios.

"The challenges health officials from across the country face in the setting of a major health care disaster include the surge of affected patients to hospitals that are already limited in capacity on a good day," Dr. Schapira says. In addition to caring for those who are ill, there will be demands from "the worried well and family members of those who are ill."

In the worst-case scenario, "There will be social and economic dislocation," Dr. Schapira says. "People who must become caregivers won't be able to work. Hospitals must cope with a shortage of staff, plus a shortage of supplies, medications and equipment. Police will have to work to control the surge of patients and protect pharmacy supplies of antiviral drugs, for example."

As part of his efforts in emergency and disaster preparedness, Dr. Schapira, with the support of the Medical College and VA, recently spent several weeks at Hebrew University School of Medicine/Hadassah Hospital in Israel, where he participated in a disaster preparedness training program. The experience, he says, made him profoundly aware of the immense complexities in preparing a society for a disaster that would have the potential to overwhelm the nation's health care system.

Ralph M. Schapira, MD, practices at the Froedtert & Medical College Pulmonary Medicine Clinic and the Milwaukee VA Medical Center.

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.