Wednesday, Nov, 9, at 3 p.m. ET

Scientists Fear Possible Flu Pandemic

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Dr. Michael Osterholm
Director, Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota
Wednesday, November 9, 2005; 3:00 PM

Dr. Michael Osterholm , director of the Center for Infectious Disease Research and Policy (CIDRAP) and former advisor to then-HHS Secretary Tommy G. Thompson on issues related to bioterrorism and public health preparedness, was online Wednesday, Nov. 9, at 3 p.m. ET to discuss the avian bird flu and fears that it could become transmissible between humans and lead to a flu pandemic.

The transcript follows.

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Washington, D.C.: Dear Dr. Osterholm, Is the potential avian flu pandemic more worrisome than that of 1918 because there are so many more immuno-compromised people in the world? Some developing countries have well over 10% of their populations infected with HIV/AIDS. What might be expected in such a circumstance? Have scientists and doctors considered the implications of millions of people with suppressed immune systems? Thanks.

Dr. Michael Osterholm: The first consideration for understanding the potential for pandemic influenza is to realize that like hurricanes, earthquakes and tsunamis, they occur. There have been ten influenza pandemics in the last 300 years, and they clearly date back to early Greek literature. So there should be no debate about whether pandemic influenza will occur in the future. The question that we all have today is whether the current H5N1 influenza virus, often referred to as the bird flu virus, is the likely source of the next pandemic. The most honest answer that we as scientists can tell you is that we don't know. However, having said that, there are many ominous signs that indicate that it very well could be the source for the next pandemic and could begin at any time. The 1957 and 1968 pandemics occurred as the result of an avian influenza virus combining with a human influenza virus to form a third influenza virus capable of infecting humans. This process is known as reassortment. Until recently, we believed that this was the most likely way for a new influenza virus that can be readily transmitted between humans to be created. However, research done by Dr. Jeffrey Taubenberger of the Armed Forces Institute of Pathology and other colleagues have clearly demonstrated that the 1918 virus jumped right from birds into humans as a readily human-to-human transmitted infectious agent. Today we are very concerned that the H5N1 virus circulating in wild and domesticated birds in Asia is moving genetically towards a human-to-human transmitted agent and could result in a 1918-like pandemic. If this happens, we expect that the illnesses that we see among those infected with H5N1 virus will be similar to those individuals who were infected in 1918 and the limited number of humans who have been infected with H5N1 to date. Many of the deaths that occurred in these populations resulted from the explosive growth of the virus in humans and a subsequent cytokine storm. A cytokine storm is the release of a chemical in the body that stimulates the human immune system to respond to the virus infection. In these serious illnesses and deaths, it's actually been an over vigorous immune response elicited by this infection that result in the organ damage and ultimately the death of the individual. Ironically this means that those with the strongest immune systems may be at highest risk for a serious outcome if infected with the H5N1 virus. At the same time, it is surely possible that those with weakened or immature immune systems, such as the very young or very old, and those with underlying immune conditions, may experience serious illness associated with the annual influenza illness, which often involves damage to the respiratory tract and subsequent secondary bacterial infection.

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Reston, Va.: Dr. Osterholm,

Thank you for taking my question. Has there been any hypothesis on where the first sustained human-to-human cases might occur?

Vietnam presently has the highest incidence of bird-to-human, but with the spread of the H5N1 virus to other regions of the world, does that mean that there is equal chance of the first out-break of the mutated virus to occur anywhere where there was H5N1 present?

Dr. Michael Osterholm: The underlying driving force for the H5N1 virus to mutate into a readily transmitted human-to-human influenza virus will continue to occur where the highest levels of virus transmission among birds occurs; this is clearly in Asia. Today there are many billions of domestic poultry and ducks in China and the other countries of Southeast Asia. In many instances, these birds are living in close proximity to millions of people. This situation will not occur in other areas of Asia or Europe because of the greatly reduced size of the poultry flocks, or because they are housed in secure buildings where wild birds, even if infected, will not have direct contact with those birds. Therefore the genetic roulette table for influenza virus mutation will likely continue to be primarily in Asia.

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Dr. Michael Osterholm: The important point to remember is that once the virus becomes a capable of being readily transmitted between humans, it doesn't matter where you are in the world. Humans will carry it via airplanes, ships or automobiles the most distant parts of the world almost overnight. Of note, for much of the world humans will actually be responsible for transmitting the virus to otherwise healthy bird and pig populations.

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St. Cloud, Minn.: We should certainly be prepared for influenza pandemics. Nevertheless, most of the pandemics during this century have been considerably less virulent than the one in 1918. Can we predict how serious the next one will be? Are there good reasons to think it will be as serious as the 1918 influenza pandemic? Or do we not know?

Dr. Michael Osterholm: As noted above, our concern about an H5N1 virus causing a 1918 like pandemic has nothing to do with the fact that that was the most severe pandemic within the past 100 years. Some have suggested that should a 1918 like virus begin to circulate around the world, causing another pandemic, the outcome would be very different because of our modern healthcare systems and the fact that we have many drugs and medical interventions that were not available in 1918. For most of the world, this is simply not the case. The vast majority of the 6.5 billion people on the face of the Earth today do not have any access to intensive care or medicine. In addition, for most of the developed world, we too will not have access to mechanical ventilators, drugs, or other medical interventions that we might expect. We have little to no surge capacity or the ability to care for large numbers of new illnesses in any of our healthcare facilities today. For example, in the United States, we only have 105,000 mechanical ventilators in our hospitals. Today an average of more than 80,000 ventilators are in use every day and during the regular influenza season we find almost all of the 105, 000 mechanical ventilators in use. Our national strategic stockpile maintained by the federal government has only an additional 4500 mechanical ventilators for use in an emergency. We will run out of mechanical ventilators overnight. This is true for many of our antibiotics and antiviral drugs, as many of these are made outside of the United States in a single plant and where the raw ingredients needed to make the drugs come from many other countries. With the first onset of pandemic influenza, I believe many of our borders will be closed to transportation and commerce and in this global just-in-time economy, many essential products and services will disappear overnight. Finally, even with the President's recent initiative to bolster our vaccine and drugs research and production, we will not see the fruits of those efforts for more than 5-10 years to come. That means many healthcare workers will be asked to treat infectious patients with influenza without the benefits of either vaccine or drug treatment. The only things they will have left to protect themselves will be respirator masks. Again, because of the global just-in-time economy where two companies own a very large percentage of the international market share for production and sales of masks, and which have virtually no surge capacity for production, we will soon also run out of them. Finally, our hospitals, which are now operating in an almost constant full capacity, will not be able to handle the surge of patients with influenza. Therefore already many communities are planning for the care of these patients in auditoriums, gymnasiums, and even arenas where many cots can be lined up in endless rows. When one considers the above information, how can anyone think that this will be a whole lot different than 1918.

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washingtonpost.com: There are some that say this pandemic will never happen. Could this be one of those things that unnecessarily scares people?

Dr. Michael Osterholm: Again, better reminds all the readers that pandemics, like earthquakes, hurricanes and tsunamis, do occur. What we don't know is when they will occur. I don't agree with those who might suggest that we are due another pandemic, because they don't necessarily happen on any one schedule. For example, in the last 300 years, there have been ten pandemics that have occurred an average of 22 years apart but the range between pandemics was 9-48 years. We just don't understand what ultimately causes the virus to move from wild birds to humans and become a readily transmitted infectious virus. There are some who have claimed that the 1918 experience was unique because of the First World War, where soldiers were crowded into trenches throughout Europe. They have suggested that these conditions in essence precipitated the virus into becoming a much more dangerous virus. This simplistic overview is simply not correct. For example, most people are unaware that the first wave of the 1918 virus in Europe actually went through the citizens of Switzerland and caused devastating illness and death in that country before it was ever a serious problem in our troops in the war. Second of all, even if crowding, such as might be found among the soldiers was an important consideration in the evolution of this virus, one need look no further than the squalor conditions of today's developing world to understand that there are many, many more people living in even worse conditions today than there were in 1918. So in a sense the idea that 1918 was an aberration, given a unique set of circumstances at the time, simply does not hold water. Finally when one goes back and closely examines other pandemics that occurred since the 1700s, it's clear that other ones also were potentially as serious as the 1918 pandemic, it's just that they occurred in a much smaller world population and that transportation was very different then than it is today. So while we know in our modern history the 1918 pandemic was very different from the two subsequent pandemics, we can't say that it was unique. To me this means that we have no choice but to be prepared for the potential for a 1918-like pandemic today and hope that we're wrong. If the next pandemic, which might begin tonight, next year, or even ten years from now is a milder event than the 1918 situation, we can all take comfort in having been better prepared than we needed to be. On the other hand, if in fact it is a similar situation to 1918 and we're prepared for something much less catastrophic than that, our world leaders, scientists, and even the private sector will be held accountable for why we didn't heed the warnings of both our past and our science of the current time to have better prepared us to respond.

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Spokane Valley, Wash.: Most of the material I read on preparing for a pandemic concentrates on the health care aspects. What about the aspects relating to maintaining civil order and economic stability during a sustained pandemic events? How do you plan to communicate with the people and maintain trust? How can you support local governments in setting up ways to provide free supplies of face masks, hand cleaners, sanitation supplies, etc? How can you help figure out ways to keep infected families supplied with food and medicine during a pandemic, so they don't have to go to grocery stores? Or if they do have to go to stores, how can you reduce disease transmission? How can communities organize to support all the people, especially the disabled, elderly and other vulnerable populations? How can telecommunications help in maintaining civil order over a sustained period? What type of volunteer public safety resources would help in preventing public panic? What prior training would be needed? Can the Federal government help with preparation costs?

Dr. Michael Osterholm: This question is right on target. It is obvious that the health care concerns in treating the influenza patients is very important. However there are many other considerations for pandemic preparedness that have received limited if any attention. Today in this global just-in-time economy, companies are punished both by investors and tax laws for having any excess capacity or inventory. In fact many companies highlight their ability to provide a just-in-time delivery based on just-in-time production. In addition, we truly live in a singe global economy where many of the essential products and services that we count on every day come from somewhere outside the United States. Many of these originate, for example, in Asia. When the first days of pandemic influenza occur, I believe that borders will be closed to both people and goods, either as a voluntary decision or as mandated by governments. When this happens, these complicated supply chains for many of these goods will collapse. As I noted above, we will soon run out of the masks that our healthcare workers and anyone else trying to reduce their risk of influenza will need. Presently all of these masks are made outside of the United States and have complicated and long (multiple country) supply chain. One area that we must consider are other drugs that are supplied by the pharmaceutical industry. Today many of the essential drugs that we need every day in this country for treating other infectious diseases, cancers and chronic diseases, originate from long and complicated supply chains spanning multiple countries and are actually produced in a location outside of the United States. We have done little planning to assure that these drugs will not suddenly be in short or absent supply. This is a serious concern given that even today we have many serious drug shortages that occur in this country when a simple manufacturing problem occurs in a plant many thousands of miles away from this country. Same thing is true for many other essential products and services. Today we have an international food supply that is also largely based on a just-in-time delivery system. Will we be able to grow process and move food both around the world and within this country? How will be respectfully, in a timely manner, handle the bodies of those who died both of influenza and the other deaths that occur every day in this country. In 1969 the average time from a casket being built to being buried in the ground was six months. Today it is slightly under three weeks. Again there is no surge capacity for many of the essential services and products we require. This is one area that our government, the other governments around the world and the private sector must address as soon as possible. What are those essential products and services that we will need to maintain from around the world for a 12-18 month period in the face of a pandemic? This is a critical part of preparedness that has been missed by most planning agencies and the private sector and is a serious hole in our current efforts.

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Dr. Michael Osterholm: Pandemic influenza will occur again in the future. Whether it's H5N1 or some other influenza virus that emerges, whether it happens tonight, next year or ten or fifteen years from now is all unknown. However, any preparedness activities that we embark upon today will never be wasted because we will use them someday. What I fear is that we will find ourselves much like the man who will attend his 25th annual class reunion tomorrow and decides that he must lose 55 lbs. The best he can do is get a suit that fits, shine his shoes, get a haircut and have a smile. The potential for pandemic influenza to be a catastrophic event in our human history is just too great of a risk for us to wait until the night before to get prepared. While this may all sounds scary to those reading this, our job in public health today is not to scare you out of your wits, but to scare you into your wits. We need you to let your federal, state, and local leaders, including those both elected and in the private sector, know that planning at the international, national and local level must be one of our highest priorities.

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