Thus far this week, I’ve discussed the history of pandemic influenza in general, and avian flu in particular. I’ve discussed some issues that must be addressed to prepare us for a pandemic, and the groundbreaking resurrection of the Spanish influenza virus. Today I want to end the series with a look at how prepared we currently are as a nation, and highlight some personal preparedness steps you can take.

If you recall from Tuesday, the first outbreak of H5N1 was back in 1997. The anthrax attacks were in 2001. Surely by now we’re prepared for some kind of serious, large-scale, biological event, right?

The Feds: “um, er, the dog ate my homework?”

The U.S. is still working on finalizing its Pandemic Influenza plan, which it keeps promising will be done “soon.” But scientists are a bit skeptical…

“We need more than just a plan; we need the resources to actually activate it,” said Jeffrey Levi, a pandemic specialist at the Trust. “The real test of the plan will be whether it comes with dollars attached.”

The current draft of the administration’s plan fills several hundred pages. It describes the role of the federal government in coordinating the response to a flu pandemic and outlines steps to be taken at all levels of government before and during an outbreak.

In addition to production and stockpiling of vaccines and antivirals, the plan seeks to conduct research, prepare public education campaigns and develop ways for hospitals to handle large numbers of patients.

Recent events have at least gotten the politicians on both sides of the aisle to start speaking. (And reportedly, Bush even read The Great Influenza over his August vacation). Another Republican, Senate Majority leader Bill Frist has suggested a 21st Century “Manhattan Project” to deal with pandemic influenza:

I speak of substantial increases in support for fundamental research, medical education, emergency capacity, and public health infrastructure. I speak of an unleashing of the private sector and unprecedented collaboration between government and industry and academia. I speak of the creation of secure stores of treatments and vaccines and vast networks of distribution.

Above all, I speak not of the creation of a forest of bureaucratic organization charts and the repetition of a hundred million Latinate words in a hundred million meetings that substitute for action, but action itself — without excuses, without exceptions — with the goal of protecting every American and the capability to help protect the people of the world.

I call for the creation of the ability to detect, identify, and model any emerging or newly emerging infection, present or future, natural or otherwise — for the ability to engineer the immunization and cure, and to manufacture, distribute, and administer what we need to get it done and to get it done in time.

This is a bold vision. But it is the kind of thing that, once accomplished, is done. And it is the kind of thing that calls out to be done — and that, if not done, will indict us forever in the eyes of history.

Democratic Senate leader Harry Reid said:

Perhaps the only thing more troubling than contemplating the possible consequences of an avian flu pandemic is recognizing that neither this nation nor the world are prepared to deal with it.

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Given the very real possibility of an outbreak, its potentially severe consequences, and our relative lack of preparedness, we need to take immediate action on several fronts to prepare this nation and the American people for a potential outbreak and to reduce its impact should it occur.

On September 29th, the Senate approved $4 billion to buy antivirals and to fund “other measures” (including surveillance, vaccine development, and state and local preparedness) to ready for a pandemic. However, it’s not certain this will pass through Congress, as Alaskan Senator Ted Stevens threatened to block the money, as the avian flu “has not yet become a threat to human beings.” With all due respect, Senator Stevens doesn’t get it. Whether the current H5N1 is the next pandemic, or whether that burns out and another virus comes along in 5 or 10 years, we need to be prepared. Preparedness takes money. You’d think some politicians would learn the benefits of an “all hazards approach” to disaster preparedness, but unfortunately, far too many are stuck with the “just in time” model. “Just in time” will be too late for an influenza pandemic.

Even if the money is provided, there are no guarantees that the U.S could even get a stockpile of Tamiflu, made by Swiss pharmaceutical company Roche. Roche has set up a first-come, first-serve waiting list for the drug, and sources have reported that the U.S. is nowhere near the top of the list. Currently, we have about 2 million doses in stock; ideally, they want 20 million doses or more. Secretary of Health and Human Services Michael Leavitt has said they should have ordered it earlier, and he “doesn’t know” why that wasn’t done.

Pandemic czar Stewart Simonson doesn’t seem to know, either. Simonson was brought on board by former HHS Secretary Tommy Thompson; Simonson was Thompson’s former legal counsel in Wisconsin. His official job is to “coordinate interagency activities between HHS, other federal departments, agencies, offices and state and local officials responsible for emergency preparedness and the protection of the civilian population from acts of bioterrorism and other public health emergencies.”

The scary part is that even if we have plenty of Tamiflu, we can’t be 100% sure it would work. A strain of H5N1 isolated from Vietnam earlier in the year was reportedly resistant to Tamiflu, although the accuracy of those reports remains in question.

So what about the vaccine?

There has been some progress with an H5N1 vaccine. Clinical trials are already underway for a vaccine produced by Sanofi Pasteur. Another vaccine by the same manufacturer was tested earlier in the year, but was made without an adjuvant (a chemical added to the vaccine preparation to further stimulate the immune system). For that vaccine, in order to be effective, 12 times as much vaccine was needed compared to the regular influenza vaccine. Additionally, MedImmune, the company which makes the nasal FluMist vaccine, has announced that it will work with the NIH to develop a library of vaccines for more than a dozen strains of H5N1. FluMist is a live attenuated vaccine; the avian flu vaccines by MedImmune will also be live. MedImmune’s Kathleen Coelingh suggests that even if the vaccine isn’t a perfect match to the circulating strains, having a live vaccine can elicit cross-protective immunity; enough to help in a pandemic situation. However, it will take years for this project to reach fruition.

Work has also been moving forward on a influenza vaccine targeted at other viral proteins, rather than the viral hemagglutinin and neuraminidase that are currently targeted. Again, while those are in the pipeline, it will take years of development until they are approved—if they work at all.

The Q word

President Bush has recently said that American troops may be used to enforce quarantines in areas suffering from influenza outbreaks. Such an action would require a change in law, and would be a shift in the way quarantines have been handled since the inception of the United States. It also brings to mind images of the movie “Outbreak.”

Would large-scale, forced quarantines even work in today’s world? Keep in mind that quarantines are for exposed, but still healthy, individuals. In this era of email, cell phones, and text messages, a “heads-up” notice could be sent in minutes, before officials had time to locate everyone who had potentially been exposed. The population is exceedingly mobile; most people could hop in a car, or on a bus, plane, or train in no time. If even a small proportion of them flee into an uninfected area, the net result could easily be to make the situation worse than it had been previously. This is yet another area where we need an evidence-based plan prior to proceeding.

What YOU can do

First and foremost, not be overly worried. Predicting outbreaks is an inexact science, to put it mildly. Anytime we deal with living targets, and especially with ones that can evolve as rapidly as influenza viruses, things get messy. We can’t simply appeal to the laws of physics in order to anticipate what trajectory the virus will proceed along. So, do what you can, educate others, but take the sage advice of the Hitchhiker’s Guide, and Don’t Panic.

Second, wash your hands. It’s not sexy advice, I admit. But ever since Semmelweis, it’s been the smartest thing a public health professional can advise. And really, many of us still don’t do it correctly. It is recommended to wash with soap and running water for at least 20 seconds. I know that when I’m in public restrooms (and I work within a hospital building!), I very rarely see people wash that long. So, be a bit more contientious when you wash. Teach your children to do this as well: have them count to 20 or sing their ABC’s while washing their hands. If you’re not around a faucet, hand sanitizers with 70% ethanol are also effective. (To my knowledge, Triclosan, the other common ingredient in hand sanitizers, has not been proven effective at killing viruses–so watch the ingredients and stick to alcohol).

If you’re sick, please, please, please stay home. Adults are contagious for ~5 days and children for up to 21 days after becoming sick. Don’t go and expose others when you’re coughing, sneezing and hacking all over the place.

Avoid touching your eyes, nose, and mouth. Again, think about how many times you do this every day. This is one way influenza can enter a body. Also, re-train yourself not to cover your mouth with your hands when you cough: use a tissue, or the crook of your arm—something that won’t come into contact as often with surfaces, or with other people.

Get a flu shot. No, it won’t protect you from “bird” flu, but should that virus spread, it will prevent you from being co-infected with both viruses and passing along any potential recombinant viruses. And remember, even garden-variety influenza kills 36,000 a year in the United States: that’s nothing to sneeze at. (Groan).

Get stocked up. You should always have a supply of food, water, medications, and basic household necessities on hand in the event of any kind of disaster–including ones caused by infectious agents. We’re all susceptible to either hurricanes, or earthquakes, or tornadoes, or blizzards, or floods, or [insert your favorite disaster here], so there’s no excuse to not be ready.

Additional steps to take should a pandemic occur

Avoid sick or dead birds, especially wild birds.

Avoid close contact and shaking hands.

Don’t share eating utensils, glasses, etc.

Disinfect surfaces with a 1:50 bleach or 70% alcohol solution. Solution must remain on surface for at least 2 minutes. (Use 1:5 bleach solution with 10-15 minutes contact time should be used for surfaces contaminated with body fluids).

More suggestions can be found here on the flu wiki.

A Closing Plea

Finally, in the long term, one thing you can do is make prudent use of your vote, and your voice. The public health infrastructure in the United States has been seriously underfunded for many, many years. In addition to the regular hot-button issues, investigate how public health-friendly your candidate is the next time you vote. Lobby your current legislators (Senators here, find and contact your Representative here) for more money for surveillance and vaccine development. Let them know this is an important issue to you. Write letters to the editor of your local paper to raise awareness in the general public. Even if this pandemic doesn’t emerge, improvements in our preparedness capability and vaccine manufacturing procedures will only put us ahead of the game the next time a deadly influenza virus—or any other infectious agent–emerges.

Thanks for reading!

Other posts in the series:

Day 1: History of Pandemic Influenza.

Day 2: Our adventures with avian flu.

Day 3: Challenges to pandemic preparedness

Day 4: 1918 influenza virus reconstructed

More resources on pandemic influenza:

  • CIDRAP Pandemic influenza news
  • Infectious Disease Society of America (IDSA) Pandemic/Avian flu
  • CDC’s site on Avian flu
  • Flu wiki