EIIP Virtual Forum Presentation — May 18, 2005

Pandemic Flu
Historical and Hospital Perspectives

Linda A. Smith, MD, FACEP
Medical Director, Emergency Preparedness Program
Alaska State Hospital and Nursing Home Association

Avagene Moore
EIIP Moderator

The following version of the transcript has been edited for easier reading and comprehension. A raw, unedited transcript is available from our archives. See our home page at http://www.emforum.org

[Welcome / Introduction]

Avagene Moore: Welcome to the EIIP Virtual Forum! We are so pleased to see you here today. Please note that Lori Wieber is assisting me today. Today's topic is "Pandemic Flu: Historical and Hospital Perspectives." If you have not read the background materials, including our speaker's bio, please do so after today's session.

It is my pleasure to introduce our guest today. Dr. Linda Smith is the Medical Director for Alaska's Emergency Preparedness Program where she provides medical oversight to program activities. She works closely with Public Health and Emergency Managers to establish response protocols for events such as mass casualty incidents and pandemic flu planning activities as they relate to hospital participation and preparation. Please see Dr. Smith's bio for more of her background. She is quite an accomplished person in her field.

On behalf of the EIIP, we welcome you to the Virtual Forum, Linda. Now I turn the floor to you.

[Presentation]

Linda Smith: Thank you very much for attending today’s discussion on Pandemic flu. I hope that today’s subject matter helps to reveal some of the concerns that the CDC and the health care community have regarding the potential emergence of a pandemic flu.

As many of you know the CDC and Public Health have recently taken a very proactive position in preparation for a pandemic flu threat that, by all accounts, appears to be well overdue. Dr. Julie Gerberding, head of CDC, addressed the American Association for the Advancement of Science on February 21, 2005 in a plenary speech and stated that scientists expect that an avian flu virus that has swept through chickens and other poultry in Asia will genetically change into a flu that can be transmitted from person to person (1).

The genes of the avian flu change rapidly and experts believe that it is highly likely that the virus will evolve into a pathogen deadly for humans. She made further reference to the pandemic flu of 1918 in her remarks. The flu of 1918 ("Spanish flu") was also felt to be a deadly pandemic flu that mutated from birds and spread to humans and resulted in the deaths of somewhere between 20 and 100 million persons worldwide (2).

In order to fully understand the implications of the statements made by Dr. Gerberding, it would be useful to review some background information on the pandemic flu of 1918 that was responsible for the loss of so many lives and now serves as the template for preparation for pandemic flu nearly 100 years later.

In the spring of 1918 flu struck in the town of San Sebastian, Spain striking predominantly healthy young adults. Nearly simultaneously in the United States, a thousand workers at Ford Motor Company in Detroit were sent home with the flu, and some 500 of 1900 prisoners at San Quentin Prison in California were also struck with flu. British, American, French and German troops all reported excessive numbers of illnesses during this time frame. Asian populations were also reported to have experienced flu - like illness.

Very little detailed information on the flu of 1918 is available even today from foreign countries since a news blackout was in effect for all countries involved in the war effort at that time. In fact, it is highly likely that the "Spanish flu" was named as such since Spain was not involved in WWI and did not have a news blackout in effect. As the summer arrived the flu disappeared. However, in the fall of 1918 this flu returned almost simultaneously in the three separate locations of Sierra Leone, Freetown British colony of West Africa; Brest, France – the disembarkation sight of American troops; and in Boston, Massachusetts at Camp Devens – the embarkation site of American troops deployed to France to fight in WWI (3).

By September of 1918 the Hospital at Camp Devens that was built to a capacity of 2000 inpatients was flooded with 8000 critically ill and dying soldiers. Four prominent physicians were dispatched by the U.S. Surgeon General to Camp Devens to evaluate and report on the outbreak of disease. A description by one of the Doctors who was the former President of the American Medical Association and had experienced the devastation of typhoid fever and innumerable deaths of soldiers in the Spanish - American war sums up his observations in the quotation that follows (4):

"…hundreds of stalwart young men in the uniform of their country coming into the wards of the hospital in groups of ten or more. They are placed on the cots until every bed is full yet others crowd in. Their faces soon wear a bluish cast; a distressing cough brings up the blood stained sputum. In the morning the dead bodies are stacked about the morgue like cord wood. This picture was painted on my memory cells at the division hospital, Camp Devens, in the fall of 1918, when the deadly influenza virus demonstrated the inferiority of human inventions in the destruction of human life."

Cities such as Philadelphia reported as many as 759 deaths on a single day of October 10th and 2600 deaths the week of October 25th, 1918. Cities all across the United States and around the world experienced an illness that took countless lives, orphaned an unknown number of children and nearly brought the war effort to a halt.

An estimated 500,000 U.S. Citizens died in 1918 from a flu that was 25 times more deadly than the ‘regular flu.’ Such an impact did it have that the average life span in the United States fell by 12 years from 1917 to 1918 (5). If a flu of similar lethality were to strike the United States today, an estimated 1.5 million Americans would lie dead at its conclusion (6).

Still, you may ask, "How does a flu that stuck 87 years ago pertain to the avian flu of today?" The answer lies in the retrospective review of two other flu outbreaks that occurred in 1957 and 1968.

By 1957 the World Health Organization (WHO) had a virological monitoring and early warning system in place for the detection of flu outbreak that identified an influenza epidemic in Hong Kong and Singapore (Asian flu 1957). The virus was analyzed and identified as a new virus subtype later genetically identified as a mutation of an avian type of flu (H2N2). Samples of the virus were distributed to vaccine manufacturers throughout the world but production was slow and the volume produced was woefully inadequate for population-wide vaccination. Measures to delay the spread such as quarantine and closing of schools and other public events seemed to only delay the inevitable. Adequate medical and hospital services were the greatest challenge. This flu strain was considered to be much less virulent than the 1918 strain and resulted in approximately 70,000 deaths in the United States (CDC) and 2 million deaths worldwide.

The pandemic of 1968 was even milder than that of 1957 and was again identified as a novel subtype (H3N2) of avian origin. The virus was initially identified in the United Kingdom in mid-July but was traced in origin to south-eastern China. The spread of the virus was worldwide and rapid however the lethality or mortality was relatively low resulting in approximately 34,000 deaths in the United States (CDC) and only a million estimated deaths worldwide.

In summary, the last three pandemics had in common the following features (6):

1. Rapid surge in the number of cases over a very brief period of time

2. A ‘sneak-preview’ springtime appearance followed by a recurrence with a much more lethal form of the virus with those effected in the spring being spared in the later outbreak (or second wave)

3. Animals, particularly birds, seem to serve as the reservoir for viral replication and mutation for these viruses

4. Milder forms of the virus are characterized by more severe disease and increased numbers of deaths at extreme ends of the age spectrum

5. Lethality in the non-traditional age groups, namely young adults is a major determinant of the overall impact of the virus.

6. Most pandemics appear to originate in Asia in populations who live in close proximity to poultry and pigs.

So, with this information in hand, let’s now look at the present outbreak of the avian influenza. In December of 2003 veterinarians reported a large number of chicken deaths in a commercial poultry farm in Seoul, South Korea. The strain was identified as H5N1.

This particular strain, an avian flu, was known to infect humans in a previous but much smaller outbreak of the Hong Kong flu in 1997 in which 6 of 18 victims who contracted the disease died. During this outbreak in 1997, 1.5 million chickens were slaughtered and the progression of disease among humans was halted.

The striking feature of that flu was the presence of a primary "viral pneumonia" which occurred directly as a result of the avian strain. This is in contrast to bacterial pneumonia that is sometimes seen as a secondary complication of usual flu strains. Bacterial pneumonias have a high rate of successful treatment with antibiotics, whereas antibiotics serve little if any use in viral pneumonia.

During the outbreak of 2003/2004 more than 100 million birds have been sacrificed or died in order to control the outbreak. The disease appeared to be under control until the virus emerged again in June of 2004 and continues to this day despite efforts to curtail its spread.

The reported death rate from this outbreak is somewhat variable depending upon the location of the disease but statistics reported from the WHO website (7) thus far are as follows:

(Data from WHO: Cumulative number of confirmed Human Cases of Avian Influenza A/(H5N1) since January 2004)

Efforts to stop the spread of the disease are of global implications. Health care organizations across the world are pooling resources, manpower, and brain power to control the outbreak and monitor the potential for human to human transmission. This is being accomplished by a several pronged approach including intensified surveillance and faster reporting.

Molecular characterization of the virus is occurring much quicker and development of a pandemic vaccine is underway. Governments have agreed upon the safe slaughter of poultry, limitations of human and occupational exposure to poultry. Infection control in health care settings has been improved and stockpiling of anti-viral drugs has begun.

Despite these efforts, all of the ingredients for a pandemic flu remain. We have a highly pathogenic virus that is known to infect humans. It originates from poultry in Asia which has been the source of at least two, if not three major pandemics previously. This particular strain of flu is known to mix readily with other types of viruses in order to mutate and enhance its survivability. This predisposes the current circulating strain of avian influenza to a significant antigenic shift which has the potential to render the immune system of the human population markedly unprepared to combat the new strain of infection which would result in increased numbers of those infected and potentially increased numbers of those dead and or disabled.

The world population density coupled with international travel is occurring in unprecedented numbers. In the May 1, 2005 issue of "In Focus" (WHO bulletin), an estimated 2-50 million deaths are estimated to occur if this strain of avian influenza evolves to pandemic proportions under these conditions (8).

The implications for hospital systems if such an event occurs are staggering. Our current hospital system is already seeing marked increases in Emergency Department visits as a result of significant numbers of hospital closures and decreases in available hospital beds. Reports of "overcrowding" in hospital Emergency Department (at or over capacity) range from 19% in rural hospitals to as much as 48% in urban hospitals (Lewis Group). Wait times in an Emergency Department (National Center for Health Statistics) as of 2002 were estimated to be 3.2 hours on average (9). Since then, the numbers of hospital beds has continued to decline and staffing of hospitals by Registered Nurses has fallen by at least 25%. The overall result is fewer beds with fewer staff, and longer wait times for evaluation and or admission. This is the situation without a pandemic flu.

In short, should a pandemic flu strike, the hospital systems of the United States are not in a position to provide the "expected" standard of care to which the American public has become accustomed. Not only are staffing ratios inadequate to address such a surge of patients, but the closure of hospitals has resulted in inadequate space available to care for such large numbers of ill, critically ill, and dying patients. Supplies, including vaccines, anti-viral medications, ventilators, and medicinal items for supportive care would be delayed in manufacturing, and short in supply. For hospitals that are literally fighting on a day to day basis for financial stability, planning for pandemic flu (which may arguably never come to fruition) seems a daunting and unrealistic task to administrators who face ‘real’ and current day to day challenges of running a health care facility.

The bulk of the burden for preparation has therefore landed in the laps of Emergency Planners and Public Health officials who provide invaluable resources for planning for such "surge" events. Recent efforts by Public Health have resulted in improved electronic communications, comprehensive disease analysis and disease surveillance. This has dramatically improved our abilities to respond to outbreaks as was evidenced in the recent SARS pandemic. Further efforts by the U.S. governments to improve availability and rapid production of vaccine are also under way and will require collaborative efforts by governments, academia, and industry.

In summary, all of the ingredients for a pandemic flu exist at this time. Historical perspective indicates that these conditions were also present in prior pandemic outbreaks with similar strains of virus. While much work has been done to prepare for such an outbreak of illness, still more work remains on many fronts to fight what could conceivably be a devastating outbreak of avian influenza.

In the words of Dr. Lee Jong-wook, Director General of the World Health Organization, "The unpredictable nature of influenza viruses makes it impossible to know whether recent events will turn out to be another close call with a dangerous virus, or the prelude to the first pandemic of the 21st century. Should the latter event occur, the world will find itself warned far in advance, better prepared than at the start of 2004, yet still highly vulnerable."(6)

Thank you for your attention. I have added the bibliography for you as follows:

BIBILIOGRAPHY

1. The American Association for the Advancement of Science, plenary speech, Dr. Julie Gerberding, February 21, 2005.

2. (Patterson, K. David, and Pyle, Gerald, F., "The Geography and Mortality of the 1918 Influenza Pandemic," Bulletin of the History of Medicine, vol. 65 (1991), pp 4-21.)

3. Crosby, Alfred W., "America’s Forgotten Pandemic: The Influenza of 1918." Cambridge University Press, 2003, pp. 37-41.

4. Kolata, Gina, "Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Causes It." Simon & Schuster, 1999, pp.16. (Quotation from Colonel Victor C. Vaughan)

5. World Almanac, U.S. Life Expectancy (statistics for 1917 & 1918)

6. World Health Organization (WHO) "Avian Influenza: assessing the pandemic threat." January, 2005 pp.5-62.

7. WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1 since January, 2004.

8. WHO, In Focus. "Governments in dilemma over bird flu," May 1, 2005.

9. National Center for Health Statistics, 2002.

I will now do my best to address any questions that you might have. I turn you back to our Moderator.

Avagene Moore: Thank you. Linda is here to answer your questions. I am sure you have several questions for her.

[Audience Questions & Answers]

Question:
Ed Pearce: Is Alaska making an effort to include the private sector in pandemic preparedness efforts?

Linda Smith: Good question Ed. Involving the private sector is proving to be one of the more difficult tasks. We have developed a "critical infrastructure group." It is composed primarily of private sector interest groups--groups like oil gas, electric, water, hospitals, transportation. We all have input into decision-making.

Question:
Sunny Ahn: Linda – can you talk more about the developments in electronic communication you mentioned earlier – what are the means at which you are getting important messages out?

Linda Smith: We are working right now with the Health Alert Network through Public Health as our primary info system for notification. It has some faults though, like lack of a feedback loop to know who has received the notice. We are also developing a real time talk group, which means we are basically encouraging ERs, Public Health, and EMS to work together on special protocols to communicate much more effectively.

Question:
Avagene Moore: Linda, are all the states taking similar actions (i.e., your response to Ed's question)? Are the states collaborating with each other and how?

Linda Smith: We are getting better at it. For example, we are working on transfer protocols to the lower 48 by identifying those individuals who would take patients and establishing tabletop drills to include them in our planning.

Question:
Michaela Kekedy: We have plans to put a centralized dispatch center for Fire & EMS into a local hospital and are looking at policies and procedures. What signs should we look for in an outbreak as a trigger to move our people from the hospital to another location to continue operations?

Linda Smith: Good question Michaela. I'm not sure I completely understand your question though. Most dispatch is not directly involved or near patient areas so they should not be vulnerable (per say) to infectious outbreaks.

Michaela Kekedy: With the anticipated activity at the hospital and the risk of transmission of the flu from person to person, we would want to minimize the risk to our personnel.

Linda Smith: Agreed. We have selected a separate site on campus as a back up and have trialed it with exercises over the past several months. The trigger would be primarily initiated by the staff's comfort level.

Question:
Ed Pearce: Can I send you an email to obtain contact information for the critical infrastructure group? We have a regional public / private group addressing the issue as well. I'd like to share ideas.

Linda Smith: Thanks Ed. Please do. lapollo15 at gci.net

Question:
Larry Heidenberg: Linda, has Alaska begun thinking about altered standards of care for pandemic flu, as discussed in the recent report from the HHS's Agency for Healthcare Research and Quality's recent report and if so, what modifications has Alaska begun to make for pre-planning?

Linda Smith: We have, yes. We are establishing offsite treatment centers in conjunction with Red Cross and Public Health. This group has identified list of common needs, and locations that might serve our needs. We are establishing MOA's with the sites, and we will try to prioritize needs as the situation arises. It has been a good cooperative effort for all involved thus far.

Question:
Sherline Lee: Is Alaska also addressing the possible scenario that a pandemic strain will not be related to the avian strain currently receiving media attention? (In which case, the availability of the aforementioned vaccine may be delayed further.) In other words, what scenarios are your collaborators considering as part of this preparedness effort for pandemic flu?

Linda Smith: Again another good question. We are trying to look at lots of different scenarios, but I think the basic preparation is similar. Long term staffing solutions and space seem to be the major issues for us and for many. We have decided not to wait for the Emergency System for Advance Registration of Volunteer Health Care Personnel (ESAR-VHP) to establish guidelines for medical assistance, but to create our own. The establishment of offsite treatment locations with other organizations has helped tremendously for space issues. The biggest problem, I think, will be the graceful degradations of care.

Question:
Isabel McCurdy: Linda, since Alaskan cruises originate here from Vancouver, and given the close proximity of Alaska and British Columbia, are you collaborating with our health officials?

Linda Smith: Yes we are, but not to the degree that I should like. The Coast Guard has taken a pro-active role there and is working across borders to establish protocols. Cruise lines have established protocols, but I don’t know how well they are communicating with the Canadian sector about their plans.

Question:
Avagene Moore: The tasks and potential for a pandemic flu seem daunting. Is there also a need for preparing the public? Or is the need more pressing for the health professionals to be prepared?

Linda Smith: Avagene, you hit on a pet peeve. I have a strong sense that Public Health should be doing a lot more public education in this arena. I believe that the public may be deceived as to how well we are prepared to handle such an outbreak. Public education about limitations and potential roles that they as individuals could do for quarantine and isolation should have started a long time ago.

Question:
Larry Heidenberg: A few questions ago you spoke about your concern about the biggest problem being the "graceful degradations of care". Do you believe this will be at all graceful? We recently participated in the TopOff 3 exercise and we found that many things were expected to be happening "notionally" that none of us suspect will occur in real life. How do we prepare to make things at all graceful, as opposed to the sudden drop off we fear may occur?

Linda Smith: I believe that the pandemic (if it occurs) will be more gradual than scenarios project. It will occur over days to weeks and with improved surveillance we should see it coming. But, that doesn't mean we will be prepared for its implications. That is why I think educating the public early about health care limitations and isolation and quarantine are so important.

Question:
Lori Wieber: As someone outside of the health profession I am left wondering what role the general citizenry, as individuals, should or could play in preparedness, prevention, and in subsequent response? Can you give some specifics?

Linda Smith: Yes, I'll try. A good example is community Emergency Response teams. There is funding available to start and establish community leaders as volunteers within neighborhoods to establish roles they would or could play to help one another without depending on outside resources. I can get you the info if you would like. Just email me please.

Question:
Isabel McCurdy: Linda, being a health care professional, I have never heard the term "graceful degradations of care." Would you elaborate what it means, please?

Linda Smith: Yes. It is a new term that is emerging in the face of mass casualty care. It refers to the limitations of resources such as nursing, or supplies such as ventilators. It assumes that if 25% of the population is ill (flu) or injured (explosives) we will not have enough resources to go around. In that instance, difficult choices would need to be made as to who gets what. Dr John Hicks from Minneapolis speaks to this in his research.

Question:
Avagene Moore: Linda, how is the global status of the avian flu being monitored?

Linda Smith: WHO has established surveillance sites in several countries overseas. They are monitoring closely flu reports and tracking them within and between countries and families. Additionally I should say that CDC has many surveillance systems here as well.

Question:
Debbie Kim: Could you expand more on the graceful degradation of care? This is an issue I have wrestled with especially in light of JCAHO Standards of Care.

Linda Smith: I guess the question is a bit of ethics really. How do prioritize medications, supplies and care when it is in demand for say several thousand and you can supply it for only a few hundred? Who makes the decisions as to who gets vaccine, or who gets a ventilator when you need a hundred and only have 5? There are models out there to try to help us to decide, but it' really like battlefield medicine. Those that have the most likely chance of survival should be given the available assets. Are we as an American Public ready or willing to accept that? I don’t think so, at least not yet. It is a concept that is very foreign to us and will require a lot of education and difficult decision-making.

Comment:
Debbie Kim: Most HCP's, I think, have had little experience with the military model of triage. Patients and families expect treatment.

Linda Smith: I agree.

Question:
Isabel McCurdy: Linda, didn't that play out given your recent flu vaccine shortage?

Linda Smith: Yes. Interesting that you should bring that up. As soon as there was a shortage, we had a flood of people who never get vaccine come into the ER demanding that they get it. Thank heavens Public Health put out clear guidelines and we were able to stick to them, but the numbers were impressive. Hence my fear that the public will ask the same if the flu has a horrendous pneumonia and ventilators are in short supply, or meds or anti-virals can’t be found.

Comment:
Larry Heidenberg: Public Health here (county-based) saw a major increase in requests for vaccine. We instituted a computer-generated lottery based upon applications received. Even with that, people were most upset, trying to trade their vaccine to someone who they felt needed it "more" even though they themselves needed it. Luckily, we were able to meet the demand completely, in the end, but it was NOT a pleasant experience.

Linda Smith: Very true. Public education needs to be done on a huge scale. We need to be honest with them about the limitations that we perceive, and enlist their help and support in preparation efforts. Of all of the preparation work that is being done, this is the one area that is lacking the most, in my opinion--and the one area in which we could gain so much help and perspective. An educated, insightful community is "enabled" and will be an asset rather than a liability.

Question:
Lori Wieber: I work in EM planning in the critical infrastructure sector. We have kicked ideas around on how we could minimize loss of workforce during a pandemic. It seems to me that business should be very interested in this area. Do you have any thoughts on how this could be accomplished?

Linda Smith: A few ideas. Since we have a statewide exercise coming up in August, we are serving as a prototype for critical infrastructure. I think you will find our efforts published in the next several months. Businesses are interested in keeping workforce active and also in keeping business flowing, so they are very willing partners at the table here in Alaska.

Lori Wieber: Thank you Linda, I will be interested in the outcome of your statewide exercise. Where is the best point to retrieve info once things conclude?

Linda Smith: I would recommend Googling Alaska Shield Northern Edge exercise. That should bring up most of the information. Once we have concluded the exercise I would be willing to share whatever part of it is of interest to folks and is not classified.

[Closing]

Avagene Moore: Thank you, Linda. We greatly appreciate your effort and time on our behalf. I am sure our audience will benefit from the information and experiences you shared with us today. Please stand by a moment while we make some quick announcements.

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Again, the transcript of today's session will be posted later today and you will be able to access it from our home page. An announcement will also be sent to our Mail Lists when the transcript is available.

Thanks to everyone for participating today. We appreciate you, the audience!

Before you go, please help me show our appreciation to Dr. Linda Smith for a fine job. The EIIP Virtual Forum is adjourned! Thank you, Linda!