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Avian flu prompts pandemic planning but system is far from ready

From the June ACP Hospitalist, copyright © 2007 by the American College of Physicians.

By Jennifer Kearney-Strouse

Avian flu is still more of a threat than a reality—but if a pandemic does hit, the U.S. health care system is far from prepared, according to an infectious diseases expert who spoke at Internal Medicine 2007 in April.

A major challenge, said John G. Bartlett, MACP, is determining the best way to prepare for an event that may never happen. "We don't know if avian influenza is ever going to be a pandemic. It could remain in birds and periodically attack a human—that's what it's done so far," said Dr. Bartlett, professor and chief of Johns Hopkins University School of Medicine Division of Infectious Diseases.

To be classified as a pandemic, a virus must meet three conditions: a vulnerable population, the ability to attack a human and efficient person-to-person transmission. While the avian influenza strain H5N1 meets the first two conditions, Dr. Bartlett called the last criterion the virus's "Achilles heel."

"There has been human-to-human transmission, but it's not sustained and it's not efficient," he said.

H5N1 was first identified in poultry in 1997 and has infected just 288 people since then. Some feel that since H5N1 hasn't made a broad jump from birds to people in 10 years, it might not ever do so.

"But I think the concern is, well, maybe it will," Dr. Bartlett said, and even if it doesn't, another strain may. "There's a whole bunch to pick from," he said. "The avian flu menu is huge."

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John G. Bartlett, MACP

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Why worry?

Dr. Bartlett pointed out that 2006 saw the largest number of avian flu cases so far in humans, and the mortality rates don't seem to be going down. "It's the highest mortality by far of any influenza that we've ever had," he said.

Another cause for worry is the uniform severity of the disease, Dr. Bartlett said. Most flu strains cause both mild and serious cases, that is, some infected persons get only a mild cold while others get very sick. This isn't true of H5N1: Everyone who gets it becomes seriously ill, and experts haven't been able to find any milder variants.

"They've looked hard for this. These are the best skilled people we have who are doing serologic tests, a lot of virology. They quite frankly can't find a benign form of this disease," Dr. Bartlett said.

Because the U.S. has so far remained free of avian flu and all cases have occurred in remote parts of the world, there's an assumption that inferior medical care in other countries is causing the high mortality rates, Dr. Bartlett said.

"Some people have said. . . 'They're not really equipped like we are,' " he explained. "But I have to tell you, many of the places that are getting these cases have systems of care that are every bit as good as you can get anyplace in the United States. We can't do any better than they're doing."

H5N1 could be especially deadly for several reasons, Dr. Bartlett said:

• Unprecedented range in poultry. "You have never heard about an avian influenza that caused so much death, rapid death, in birds as this one," Dr. Bartlett said. H5N1 is now endemic in parts of Asia and in the three places that did eradicate it—Hong Kong, Japan and Vietnam—it's now back.
• Wide species distribution. "It's been found in birds, cats, pigs, humans and horses," Dr. Bartlett said.
• High mortality. The mortality rate of the 1918–19 influenza pandemic was 2.4%. The mortality rate for the known cases of H5N1 is 60%.
• Human-to-human transmission. Although human-to-human transmission is not yet efficient, it has occurred, Dr. Bartlett said. Some people who have contracted H5N1 have had no contact with birds at all, and 10 outbreaks have occurred in families.

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Getting ready

In the 1918 epidemic, St. Louis had a plan while Philadelphia did not, and mortality rates in Philadelphia were much higher. While planning is still regionally based, the CDC is trying to standardize the process and has issued guidelines asking states to prepare based on the following assumptions:

• An attack rate of 30% in adults and 40% in children, with the elderly, infants, pregnant women and people with chronic conditions at particular risk;
• An incubation period of two days;
• Outpatient care sought by 50% of those infected;
• Two persons infected by each infected person;
• Viral shedding beginning one day before symptom onset and peaking at day two;
• Six to eight weeks' duration in each community.

The government has also stressed that outbreaks will be virus-dependent and that states should plan for both milder and more severe viruses.

But planning alone won't solve the problem, Dr. Bartlett said. Using the parameters established by the federal government, he estimated that an outbreak of avian flu similar to the 1918-19 pandemic would require 50 to 100 times our existing resources. According to a recent article in Biosecurity and Bioterrorism, however, 30% of U.S. hospitals lose money while the rest operate at only 1.9% profit. In addition, 45 million people are uninsured, 48% of emergency departments are at capacity and the number of hospitals, beds, and emergency departments overall is decreasing nationwide. There's also a shortage of personnel.

"We're not very well prepared to take on a new load of almost anything," Dr. Bartlett said.

Most pandemic flu plans call for community mitigation, such as quarantine and social distancing, once an outbreak hits. This means that sick people and their families should stay at home, schools and workplaces should close and all public gatherings should be canceled in an attempt to contain infection.

But these precautions are a tough sell to the American public, Dr. Bartlett said, citing surveys in which 40% of Americans report that they won't stay at home no matter what the government or health officials say.

"You tell Americans we have to stay home, and we don't march to those orders very well at all, especially if you don't have good scientific evidence that it works," he said.

The World Health Organization has said that quarantine is inefficient and impractical, as is screening travelers, Dr. Bartlett said.

"It didn't work in SARS, and nobody thinks it's going to be useful here," he stated.

The same goes for social distancing, a measure that often creates new problems, Dr. Bartlett said. Closing the subway in New York City, for example, would make it harder for 4.7 million people, including health care workers, to get to work, leaving hospitals even more understaffed.

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Working toward a solution

Dr. Bartlett cited six areas to consider when planning for an avian flu pandemic:

1. Vaccine development. "I don't know anybody in the field who would put this anywhere other than way at the top [of the priority list]," Dr. Bartlett said. The goal is to be able to produce a national supply with a good antigenic match within six months after a new variant of the virus is identified.

2. Diagnosis. There's a strong need for a fast, simple, inexpensive test that can be used at the point of care.

3. Community mitigation. Public health officials should review current policies, like isolation and social distancing, and make sure to take the consequences into account.

4. Funding. The CDC has said that each hospital in the U.S. should spend $600,000 getting ready for pandemic flu. But hospitals are unlikely to do this on their own for something that may never happen. "This is going to have to come from some sort of budget allocation," Dr. Bartlett said.

5. Community response. The importance and potential impact of avian flu must be brought home to the community, not just to health care workers. "We've really got to get everyone involved," Dr. Bartlett said.

6. International response. Planning should extend to the global community as well, Dr. Bartlett said. "[Smallpox] was an incredible demonstration of the whole globe working together to get rid of one of its greatest pests," he said. "The hope is that this kind of pandemic would get that kind of collegiality and collaboration back again and make this very much of a global activity."

Although avian flu may never hit the U.S., being ready for a pandemic has innate advantages, Dr. Bartlett said.

"If we learn how to take care of pandemic flu, we'll be ready for some other pandemic that comes to us totally unannounced," he said. "We need to be ready for a huge hit on the health care system."

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated