Fatal Flu

A historic pandemic like that of 1918 is likely, perhaps as soon as this winter, and unless you're a health or government worker, no one's planning to save you.

Qinghai Lake is a long way off the beaten path, but in August and September the huge salt lake in northwest China is a great place for bird-watchers, as hundreds of thousands of migratory waterfowl rise and wheel above its shallow, fish-rich waters before beginning long journeys back to their winter feeding grounds in Europe, Alaska, and Australia.

This summer, they leave behind a less edifying sight: thousands of birds, dead and rotting, washing up on the Qinghai beaches. Tests show that the birds died from infection with a virulent strain of avian influenza that goes by the designation A (H5N1). This is very bad news for breeders of domestic ducks, geese, and even chickens, because their closely confined flocks can be devastated by infections from their wild cousins from afar.

It is even worse news for humans, because this strain of "bird flu" also kills people. In 1997, half a dozen residents of Hong Kong succumbed after picking it up from infected domestic birds. After a brief reappearance in 2003 in Hong Kong, H5N1 broke out with a vengeance in early 2004 in Vietnam and Thailand, killing thousands of domestic fowl, requiring the destruction of millions more, and killing 23 people—more than half of those who became infected. Scariest of all, the Southeast Asian outbreak provided evidence for the first time that people were not just catching the flu from birds but from each other.

World health experts have been issuing ever more alarming warnings that the H5N1 flu strain, if it becomes easily transmissible between humans, could sweep the world in a matter of months, as did the last big pandemic flu outbreak in 1918–19, which killed more than 20 million people worldwide, up to 700,000 of them in the U.S. Until last year, though, health officials found it difficult to get the attention of politicians in a position to act. Even before the Qinghai outbreak, there was indirect evidence that avian flu was well established in China, but the Chinese government, following the same if-you-don't-mention-it-it-will-go-away policy that allowed the SARS virus to spread unnoticed, won't talk about it. Scientists who asked to study live Qinghai birds, to see if they were carriers of H5N1, were told to mind their own business. And, of course, the highest authorities in the U.S. have been preoccupied with more urgent issues, like Terri Schiavo, school prayer, and gay marriage.

Nonetheless, growing pressure from the scientific and health communities has slowly forced the issue on authorities. Scientist-bureaucrats ranging from Anthony Fauci, the infectious-disease chief of the National Institutes of Health, to Centers for Disease Control and Prevention Director Julie Gerberding recently issued warnings that the threat of a pandemic outbreak is both severe and immediate. Even President Bush's choice to head the Department of Health and Human Services, Mike Leavitt, chosen primarily for his reputation as a ferocious welfare and health care "reformer," has begun to beat the drum to attract attention to the possibly imminent threat.

But even before last year's outbreak in Asia, a lot of basic work behind the scenes had been done to prepare some nations, if not the world at large, for a superepidemic that could begin as soon as this winter and is almost certain to hit within five years. Although this planning as been ill-supported, underfunded, and poorly coordinated, the fact it's happening is good news. The bad news is that, so far, virtually all the preparation, including that in metropolitan Seattle, has been done to ensure that society at large survives the devastating impact, with little attention paid to helping individuals improve their chances of survival.

Geese at Qinghai Lake in northwest China, where thousands of birds have died from avian influenza.

(China Photos / Getty Images)

Pandemic influenza is a worldwide threat, but fighting an out-break has to happen country by country, town by town. The people charged with developing a local response in this area are headquartered in a warren of anonymously comfortable offices on the 12th floor of the Wells Fargo Tower in downtown Seattle. A conference room off the lobby is walled on three sides with tables of organizational and procedural charts and decision "trees," all in print small enough to challenge even the clear-sighted.

It's an impressive display, but closer inquiry reveals that the work of Public Health–Seattle & King County's medical preparedness section has really only begun. Headed by Michael Loehr, who came to head the office after two years managing King County's blanket emergency-preparedness plan, the office first had to establish liaison—and credibility—with leaders and personnel in some 40 municipalities and a dozen or more state and regional agencies. "Since 9/11, police and fire and emergency workers all around the county had expanding emergency capacity, buying new equipment," says Loehr. "They expected us to give them guidance, and we were absolutely not ready. Next, we have to build up our health care coalition"— there are 20 medical centers countywide, dozens of group practices, and thousands of individual physicians—"to plan how to cope with a 25 percent to 30 percent infection rate, a several-hundred percent rise in inpatient demand, a third of staff and medical personnel out sick at any one time."

Phase two planning entails reaching out to major employers to encourage them to develop measures to continue to operate during a medical emergency. That is expected to take another year or so. Plans to alert and prepare the average citizen are so far limited to producing posters and public-service announcements reminding us of the importance of frequent hand washing and covering one's mouth before coughing.

If that sounds to you like a pretty inadequate response to preparing for a possibly imminent deadly epidemic, you're right. Funding for public health nationwide has been shrinking for decades. The preparedness section's work is done on an annual budget of a little more than $3 million, two-thirds of it in the form of a grant from the federal Centers for Disease Control (CDC). That, says James Apa, Public Health–Seattle & King County's communications director, goes to cover "surveillance, planning, risk communications, lab capacity, and training efforts for public-health emergencies," with more than $800,000 specifically earmarked "for development of mass dispensing capability, specifically for large-scale anthrax events." That's a fairly broad mandate for a full-time staff of nine. If it weren't for the federal government's sudden interest in emergency planning and preparedness, spurred by 2001's anthrax scare and 9/11, they would certainly be trying to get by on a whole lot less. Even with as many as 50 other employees of the public health and other county departments contributing at least part time to the effort, the danger confronting us is orders of magnitude greater than what's envisioned to respond to it.

King County epidemiologist Dr. Jeff Duchin: "Do you shut down public transit?"

(Laura Schmitt)

How to evaluate the cost of a catastrophe that hasn't occurred? Analogy. Briefly summarized, the human toll of the 1918–19 flu pandemic came to more than 20 million dead worldwide, 600,000 to 700,000 in the U.S., and 1,600 in Seattle—all in less than a year. Assuming an exact replay of 1918, the comparable numbers today would be 50 million worldwide, 2.2 million in the U.S., and 25,000 in Western Washington. But no two flu epidemics are alike, and most of the differences we can see between 1918 and today are not in our favor.

On the plus side: Communications are incomparably faster today. Most communities in 1918 didn't know the flu was coming until it was entrenched. But travel has speeded up as well, with millions climbing aboard planes every day to travel to the opposite end of the Earth. In 1918, doctors had vaccines, though not enough or vaccines effective enough. Still, the shocking number of deaths reflected a U.S. mortality rate of "only" about one in 125. Today, the death rate in human H5 infections so far has been one of every two people infected— so bad that outbreaks have tended to be self-limiting, because victims, avian or human, tend to die before they have much chance to infect those around them.

But the influenza virus is constantly evolving, in infectivity and virulence. (See "Flu's Fluidity") Just last week, a team at St. Jude's Children's Research Hospital in Memphis, Tenn., announced findings that the strain of H5N1 that wreaked havoc in the duck pens of Southeast Asia in 2002 has lost virulence among its web-footed hosts, while ramping up infectivity and remaining lethal to any chickens in the neighborhood. It's just such a change in human hosts that could turn H5N1 from a hit man among infections into a mass murderer. As for the economic consequences, they are incalculable but surely would be catastrophic. It's estimated that the three-month outbreak of a similarly contagious and sometimes fatal respiratory illness, severe acute respiratory syndrome (SARS), in 2003 cost Canada well more than $1 billion U.S., two-thirds of that in Toronto alone.

An experimental flu vaccine aimed at H5N1 is being tested, but the virus could evolve too fast.

(Alex Wong / Getty Images)

One has to sympathize with teams like that of the medical preparedness section. Faced with a threat like this, the man and woman on the street look to the medical authorities for help to ensure they and their loved ones survive. But professional plague planners have to look at the big picture—not just the human cost of an epidemic but its structural and economic costs as well; not just the impact on single communities but the social and political upheavals it can bring about in whole nations. What this boils down to in practice is that for local planners, preparing for pandemic influenza has very little to do with saving any given individual human life and a great deal to do with preserving human institutions—hospitals, public safety, commerce, transport, and government in general.

A good example of where the human factor comes into the preparation equation is the planners' casual use of the word "triage." The American Heritage Dictionary defines triage as "a process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment." Medics at the front during World War I, when the term first came into general use, had a more trenchant definition: "You lot: cuppa tea and back to the trenches. Those poor sods over there, make 'em comfortable and leave 'em to heaven. Now let's see what we can do to put the rest of 'em back together."

Another term in common usage is "surge." With a tsunami, the height and intensity of a wave is a major indicator of the damage it does. There's no way to reduce the height of a tsunami, but even without medications or vaccines, there is a way to affect the impact of an epidemic surge, by spreading it out, slowing the rate of infection as it passes through the population, reducing its peak intensity—and thereby its heaviest impact on hospitals and emergency personnel. But slowing the rate of infection doesn't have much effect on how many people get sick or how sick they get when they do, only on how long it takes for them to come down with the disease. The hospital might be less stressed, but in the end, pretty much the same number of people sicken and die.

The only real way to slow down an epidemic is to reduce the number of contacts between sick people and well people. And since people with flu are infectious for a day or more before they know that they're sick, the best way to reduce contact is to prevent it altogether. In 1918, Seattle Mayor Ole Hanson was credited with keeping the city's disease and death tolls far below San Francisco's simply by shuttering schools, theaters, and other public places. He was persuaded to leave restaurants and shops open, but he was widely vilified by fellow public officials and business leaders for closing the other places and left the city soon after.

If you think we're more enlightened today, think about what ticket holders would say if King County Executive Ron Sims canceled Paul McCartney's Nov. 3 appearance at KeyArena. If the SuperSonics' season was put on indefinite hold. If Belltown clubbies were forbidden to gather in crowded, smoky rooms to hear their favorite bands. How effective do you think the ban would be?

Thanks to a little-noticed change in the state's legal code, local officials have clear authority to quarantine infected individuals and those they've been in contact with. But even with increased authority to enforce "reduced contact," the challenges facing local government and institutions are almost insurmountable. "Public transit is clearly an area full of opportunities for infection," says King County epidemiologist Dr. Jeff Duchin. "So do you shut down public transit and have everybody jump in their cars instead? Schools are also a place where influenza spreads very easily. So you shut down school; who stays home with the kids, and for how long?" What about the homeless—the walking wounded, who would turn downtown Seattle, with its free-to-all buses, into what one might call a rolling hot zone?

Almost worse than a recalcitrant public is a passive reaction from other public agencies. Repeated calls to Seattle Public Schools about influenza preparedness finally produced a statement from the press office that "the schools depend for guidance in such a situation on the public-health authorities." Inquiries of other public bodies produced much the same response. The county's medical preparedness section also has its work cut out for it trying to mobilize business support for emergency programs. Steve Wilhelm reports in the current issue of the Puget Sound Business Journal that the preparedness folks have yet to receive a single proactive inquiry about flu from the business community.

Of all the major institutions in the county, the University of Washington appears to be by far the best prepared, with separate though cooperating offices on the upper campus and at University Hospital developing concrete plans in the event of an epidemic. "Our system has been growing since [the 1950s'] civil-defense days," says Tamlyn Thomas, the UW Medical Center's emergency management coordinator. "Since 9/11, we've looked at our systems again and again, but the SARS scare gave us real-world, high-level requirements to aim for—not just ventilation and isolation but, for example, transportation of patients sick and well from one location to another." The UW system looks to public-health authorities mainly for negative assistance. "When an epidemic strikes, people tend to rush to hospitals. We hope public health will keep people informed, tell them when to go to a hospital and when to stay home."

"Keep people informed"—easier said than done. Since there's no official channel for health information dispersal, public-health authorities, like other public officials, depend almost entirely on the media to spread the word, and the media have pretty much only two volume settings: inaudible and deafening. Seattle Weekly employees are probably better informed than most information consumers about health news, but in an informal office survey last week, nine out of 10 didn't know that the 2005 flu season might be out of the ordinary, or might call for any special behavior on their part. Even if you've noticed the occasional inside-the-newspaper items documenting the slow spread of avian flu in humans across Southeast Asia, you might not realize the global significance, what it might mean for you and your loved ones in the very near future.

Planning to fight the flu in Seattle, from left: James Apa, Dorothy Teeter, and Michael Loehr.

(Laura Schmitt)

Talking to public-health officials about coping with a flu epidemic, one is struck by how their planning is dominated by caring for the already ill and how little is directed at prevention. Without persistent questioning, one might never learn that there are ways to reduce one's chance of becoming ill and of mitigating the illness once it's struck. The biggest reason for this fatalistic acceptance seems to be the dogma that the only real way of preventing death and illness from influenza is through vaccines, and that there's no way to produce an effective vaccine for a particular strain of influenza until an epidemic is well advanced.

Until recently, the dogma remained true, but primarily because no one was working very hard to disprove it in practice. But the avian flu threat is so great that vaccine business as usual is no longer an option. Last year, the National Institute of Allergy and Infectious Diseases announced a little-noticed contract with two major vaccine producers to begin development of an "investigational" vaccine based on H5N1. Recognizing that H5N1 would continue to evolve in its bird hosts, scientists hoped that a vaccine based on a partial immunological match with the wild virus would convey at least some protection against infection.

In what must be record time for vaccine development, one of the contractors, Sanofi Pasteur, delivered 8,000 doses of the H5N1 vaccine at the beginning of last March. Clinical testing with human subjects has begun. Eight thousand doses? Well, it's a start, and, as the institute said, unconsciously revealing its priorities, "production of such a vaccine on a commercial scale could be used to protect laboratory workers, public-health personnel, and, if needed, the general public."

Vaccine production is a sleepy and largely neglected branch of the booming pharmaceutical business, but Sanofi Pasteur at least seems to be waking up to its potential. In addition to the contract with the Institute of Allergy and Infectious Diseases, the company is making experimental pandemic-flu vaccine for researchers in the U.K. and France and for the European Union, which has fast-tracked the approval process for such a product. And it's contracted with the U.S. National Institutes of Health to deliver 2 million doses of H5-based vaccine in time for the coming flu season.

Hopeful as these developments are, nobody knows how effective a "generic" H5 vaccine will turn out to be, and even if it proves out, 2 million doses is insufficient to mount more than a pilot vaccination program. Fortunately, those of us who don't qualify as either laboratory workers or public-health personnel have alternative ways to prepare for the worst. Despite the incredible expansion of biomedical knowledge since 1918, only two medications effective against the flu virus have been discovered. Neither prevents infection, but both have been proven to palliate its effects.

One such medication, amantadine, has been known for at least a quarter-century to be effective in hampering virus reproduction and limiting the severity and duration of infections. Unfortunately, some flu strains are already resistant to amantadine, and its severe side effects prevent use by many of the most vulnerable patients, above all the aged. The other medication, oseltamivir, shows much greater promise—or it would if anyone showed much interest in producing enough of it to make a difference.

Available in the U.S. under the trade name Tamiflu, oseltamivir can stop a flu infection in its tracks, if taken within the first day or so of the onset of symptoms (fever, muscle aches, headache). It's not an ideal treatment—it's expensive ($50 and up for a five-day course). It can't be used on infants. And it can't guarantee that you won't come down with the flu again next week. But it's by far the most effective real-time treatment for the flu yet devised for retarding and palliating a flu pandemic.

Oseltamivir also, considering its importance, is in ludicrously short supply. The nonprofit Trust for America's Health reports that as of May, the U.S. had stockpiled 2.3 million "courses" of the drug, and Congress recently appropriated enough money to buy another 3 million courses by 2007. That's 5 million courses to split between the more than 60 million Americans conservatively expected to be infected during a pandemic. If pandemic flu were to hit this year, by the time enough of the drug was allocated to "essential" personnel—hospital employees, police and fire emergency workers, the military, and, of course, most essential of all, high-ranking members of government—there would be essentially none left for private citizens.

So ordinary citizens might want to make some preparations on their own. Oseltamivir, for the moment at least, is widely available by prescription. Properly stored, it has a five-year shelf life. If you have a sympathetic doctor, you might be able to get a prescription before you need it. It might as well spend its time on your shelf as on the pharmacy's. Considering how long it takes on average to get in to see a doctor, that might be your only chance to get the drug into your system in time to do any good. Unfortunately, a study released just last week indicates that in mice, at least, Tamiflu is less than half as effective against H5 as it is against better-known flu strains, so a single course might not suffice to stop progress of the disease.

Self-preparation might extend, too, to something as mundane as protective masks. Public-health authorities are divided about the efficacy of masks in protecting from the flu, and it's true the protection is more for the people around the wearers than the wearers themselves. But protection is protection, particularly around the home, and if you have an emergency supply of water and batteries, you might want to look into getting a supply of masks for the family emergency bin. Hospital-grade masks are expensive overkill; cheap paper masks are totally useless. The World Health Organization says that for individuals, moderately priced masks rated N95 to 100 are the way to go.

Winter 2005–06 might turn out to be a normal flu season, with familiar strains emerging as temperatures fall in temperate climes and people begin to huddle together inside for comfort. If so—and if the World Health Organization's experts have guessed right about which flu strains will predominate this year, and if there's no repeat of the vaccine-production foul-up that left millions of vulnerable Americans unprotected last winter—we can look forward to "only" about 20,000 deaths or so nationwide. But if there's anything certain in an uncertain world, it's a sure thing that whether we're ready or not, deadly flu will soon once again sweep the planet. The geese are already flying.


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