June 27, 2005
Yet Another Avian Flu Preparedness Warning Report

Trust for America’s Health joins the list of organizatons warning about the potential danger of an avian flu pandemic in humans. PDF format)

WASHINGTON, June 24, 2005 – Trust for America’s Health (TFAH) today released state-by-state projections that found over half a million Americans could die and over 2.3 million could be hospitalized if a moderately severe strain of a pandemic flu virus hits the U.S. Additionally, based on the model estimates, 66.9 million Americans are at risk of contracting the disease. The study also found that the U.S. currently only has stockpiled 2.3 million courses and has placed orders for an additional three million courses of antiviral pharmaceuticals (produced as Tamiflu by Roche Pharmaceuticals), which would likely be available in 2006. This would be enough to cover 5.3 million Americans, leaving over 60 million who could be infected and would not be able to receive medication before an effective vaccine to combat the flu strain is identified and produced.

TFAH’s numerical projections are included in a new report, “A Killer Flu? ‘Inevitable’ Epidemic Could Kill Millions.”

“This is not a drill. This is not a planning exercise. This is for real,” said Shelley A. Hearne, DrPH, Executive Director of TFAH. “Americans are being placed needlessly at risk. The U.S. must take fast and furious action to prepare for a possible pandemic outbreak here at home.”

“The Government Reform Committee has held several hearings over the last few years to let people know that the flu is not something to take lightly,” said U.S. Congressman Tom Davis (R-VA), Chairman of the House Government Reform Committee. “TFAH's report clearly demonstrates that the emergence of a pandemic flu could exact a tremendous toll on U.S. health and economic stability. In order to identify problem areas and prioritize planning and response efforts, the Committee will hold a hearing next week on the threats posed by a potential flu pandemic.”

Dr. Hearne will be testifying Thursday, June 30th, before the House Government Reform Committee on U.S. preparedness for pandemic and annual flu. Some of the TFAH report’s other findings include:

  • While estimates find that over two million Americans may need to be hospitalized during a pandemic outbreak, the U.S. currently only has approximately 965,256 staffed hospital beds.
  • The U.S. has not adequately planned for the disruption a flu pandemic could cause to the economy, daily life, food and supply distributions, or homeland security.
  • The U.S. lags in pandemic preparations compared to Great Britain and Canada based on an examination of leadership, vaccine development, vaccine and antiviral planning, health care system surge capacity planning, coordination between public and private sectors, and emergency communications planning.

TFAH provides a series of detailed recommendations to help ensure the U.S. is better prepared regardless of whether a pandemic occurs as soon as this year or in several years. With a crisis looming, the U.S. plan for the pandemic should be finalized and the President should designate an official with authority to coordinate the U.S. response across federal agencies. Other top level recommendations include taking:

  • Immediate steps of outbreak tracking, stockpiling medical supplies, and developing emergency communications plans;
  • Intermediate steps of stockpiling additional antivirals and developing surge capacity plans for hospitals and health care providers; and
  • Longer range steps to increase vaccine production and the development of new technologies for vaccines.

I figure, humans being humans, we'll have a big pandemic and millions will die and only afterwards all the recommendations about building more rapid vaccine production technologies, stockpiling of medical supplies, and better methods of reducing human-to-human transmission will be implemented. The warnings coming from infectious disease experts and others are being discounted as the standard exaggerated doom and gloom fare of coming disasters.

The full report projects a high economic cost from a pandemic. (PDF format)

The estimated economic impact of a pandemic flu outbreak in the U.S. today, based on projections from the relatively mild 1968 flu epidemic, would be $71.3 to $166.5 billion due to death and lost productivity, excluding other “disruptions to commerce and society.”6

Note the real possibility that the avian flu could have a higher lethality rate than the 1918 flu. So the economic costs, number of hospitalizations, and total deaths could be much greater than the estimates provided above.

Some countries could be politically destabilized by the effects of a flu pandemic. Though I'm going to go out on a limb here and guess that in Africa with so much disease already a flu pandemic might seem like nothing out of the ordinary.

The U.S. would be impacted by the global implications as soon as a pandemic outbreak occurred in any part of the world due to the interdependence of economies. Sectors, such as hospitals and the health care system, which rely on supplies manufactured in other parts of the world, including Asia, would feel immediate repercussions and supply shortages. Travel restrictions, possible limitations on public gatherings and events, and other measures taken to limit the spread of disease would also have rapid and far reaching repercussions. Since a pandemic could likely result in political and economic destabilization, particularly in developing countries, it poses serious national security concerns for the U.S.

Those who think the threat of the avian flu is overblown need to learn about the larger historical context: Influenza pandemics have occurred regularly in human history and statistically speaking we are overdue for the next one.

Based on historical trends and projections, virologists and epidemiologists predict a new flu pandemic will emerge three to four times each century.8 Health officials around the world are troubled by the severity of the “avian flu” circulating in Asia, which scientists refer to as the H5N1 flu strain. They fear this avian flu could become the next pandemic for humans. The regional director of the WHO for the Western Pacific region stated in February 2005 that the “world is now in the gravest possible danger of a pandemic.”9

We currently run the risk that the avian flu will not only be the next pandemic but that it will be much more lethal than the average pandemic.

The economic disruptions of a pandemic would reach the United States rapidly due to the interdependent nature of economies.

The U.S. has not assessed or planned for the disruption a flu pandemic could cause both to the economy and society as a whole. This includes daily life considerations, such as potential school and workplace closures, potential travel and mass transit restrictions, and the potential need to close stores resulting in complications in the delivery of food and basic supplies to people. Daily life and economic problems would likely emerge in the U.S. even before the pandemic flu hit the country due to the global interdependence of the world economy.

Put aside for the moment the medical issues (e.g. virus manufacture, acute patient care, drug production, medical supplies shortages, and so on). Think about the problem at the level of human organization to reduce pathogen transmission in ways that minimize economic disruption. We have the potential to develop and find ways to carry out economic functions with less human-to-human exposure. The development of procedures and products, the training of work forces, and the purchase of key pieces of capital equipment could reduce the amount of human contact involved in most types of economic activity. This would simultaneously reduce the rate and extent of spread of the pandemic virus and reduce the size of the economic disruption caused by the virus.

The rate of infection of the population might be between 25% and 50%. But with better economic organization and practices human-to-human contacts and transmission could be greatly decreased.

  1. The WHO has estimated that there would be a “contraction” rate of 25 percent for this flu strain. This means they warn that countries should be prepared for approximately 25 percent of their populations to get sick from the pandemic virus. Other scientists have estimated that up to 50 percent of countries’ populations could become infected.
  2. The current strain of the avian flu is viewed as significantly more lethal than the 1968 pandemic flu strain. A high-level pandemic, such as the 1918 pandemic, is considered to be six times more lethal than the 1968 flu.19 The projections below reflect a mid-level estimate of a three times higher rate. These numbers are reflected in the “Projected Dead” column in the table below. The range of estimates, from low level to high level severity death rates, can be found in Appendix A.
  3. Due to the severity of the avian flu strain, experts also believe that it would result in a much higher hospitalization rate than estimates using the 1968 strain. The estimates below, in the “Projected Hospitalizations” column, reflect a mid-level estimate of a three times higher rate. A more virulent strain of flu, changes in medical care and treatment procedures, and an aged population are all factors behind this projection. The range of estimates, from low level to high level severity hospitalization rates, can be found in Appendix A.

For Americans who become infected their odds of getting anti-viral medication will be less than 1 in 12. For people on most other countries their odds will be much lower. For anyone who has stockpiled your own personal Tamiflu supply your odds of getting anti-viral treatment are excellent - unless you tell too many people about your stockpile and someone steals it.

As of May 2005, the U.S. has stockpiled 2.3 million courses of the antiviral medication Tamiflu, which could be used as a treatment in the event of an outbreak, and intends to order approximately three million more with funds recently appropriated by Congress to total 5.3 million. The WHO is currently estimating that an avian flu epidemic could impact 25 percent of countries’ populations.

In the U.S., this means it could affect nearly 67 million individuals, based on FluAid projections and population numbers. With the current level of the U.S. Tamiflu order, over 61.5 million Americans who could be infected would not receive antiviral medication. If the U.S. orders additional courses of Tamiflu, they would not be available until 2007, unless production capacity significantly changes.

The Brits have ordered enough Tamiflu anti-viral drug to cover a quarter of their population. If the US government decided to do so it would have to wait till 2007 to have the needed number of doses.

Several other countries have already ordered enough Tamiflu to protect between 20-25 percent of their populations in case of an outbreak. The U.S. is already behind in the queue to place an order for the medication, for which there is a single manufacturer worldwide -- Roche Pharmaceutical, which is located in Switzerland. In testimony before the U.S. House of Representatives Health Subcommittee of the Energy and Commerce Committee, the medical director for Tamiflu of the Roche company explained that historically they have not produced the levels of Tamiflu required for global stockpiling. To help accommodate the growing concerns and orders, they have increased production of the antiviral nearly eight-fold since 2003.42

On March 1, 2005, the British government announced that it was taking steps to procure 14.6 million courses of Tamiflu.43 This procurement would cover 25 percent of the British population, the rate WHO has recommended.

Given the current and projected production capacity, if the U.S. did place a large order for Tamiflu, Roche has testified before Congress that it could be the end of 2007 before they could deliver enough to the national stockpile for 25 percent of the population. Thus, antiviral treatment will only be an effective part of the U.S. response if a pandemic does not occur for several years and, of course, if the pandemic strain is responsive to antiviral medications.

This wll create a real problem for the British: People from other countries will try to sneak into Britain in order to be better protected in case they get sick.

The $58 million the US Congress has appropriated for avian flu preparedness is chump change.

The recently enacted emergency supplemental appropriations legislation made available $58 million for the purchase of influenza countermeasures for the Strategic National Stockpile, including, but not limited to, antiviral medications and vaccines. These funds are most welcome, but TFAH believes that Congress should provide additional funds during the FY 2006 appropriations cycle to continue to build the nation’s antiviral stockpiles from the current level of two percent of the U.S. population to cover a higher percentage of the population.

Does the United States have enough medical supplies to handle a large surge in patients?

Does the National Strategic Stockpile Include ALL Necessary Medical Supplies That Will Be Necessary to Respond to a Pandemic? In addition to stockpiling antivirals and vaccines, when they are available, the U.S. must also stockpile critical medical supplies such as masks, gloves, gowns, bed linens, and all other equipment needed to assure that hospitals and other health care providers are properly protected when the usual supply chain is disrupted either abroad or in the U.S.

Let me answer that question: Of course not! This is all the more reason to avoid getting sick in the first place. If you could go live in a cabin in the mountains for a couple of years and see no one other than those who initially travel there with you then you could avoid getting sick and therefore avoid dying.

We also need an enormous amount of face masks and other paraphernalia that the general population will use to avoid transmission of the pandemic influenza strain in public places.

You might need to wait as long 18 months from the time the pandemic begins before you can be vaccinated against the virus.

Is There a Rapid Response Plan to Develop, Test, and Produce a Vaccine? It will take an estimated six to nine months after a pandemic emerges to develop a vaccine. Questions of how to rapidly review and test the vaccine once it is created remain, including concerns about speeding the approval process by the Food and Drug Administration (FDA), liability protection for vaccine manufacturers, and what type of preservative will be used in the vaccine. In addition, industry representatives have suggested that current production capacity is insufficient to meet the demand for a pandemic influenza vaccine, and that it could take 12-18 months to meet appropriate production levels.26

We need to get beyond the old fashioned fertilized chicken egg technology for growing influenza viruses for vaccines. Newer and faster technologies for making vaccines would go far to reduce the size of the disruption and the number of deaths from a flu pandemic.

We also need better ways to reorganize just about every job and economic function in society so that fewer people have to come in contact with each other while they are working, going to school, going shopping, or receiving services.

If a half million or more Americans were at risk from some type of terrorist attack billions of dollars would be thrown at the problem. We should do the same with the avian flu threat. Avian flu is far more likely to kill you in the next 5 years than anything terrorists might accomplish. Our preparations for it should be commensurate with the scale of the threat it poses.

Share |      Randall Parker, 2005 June 27 05:17 PM  Dangers Natural Bio


Comments
jim moore said at June 27, 2005 7:29 PM:

Some ideas on how to reduce the spread of the flu.
1.) Don't send the kids to school.
2.) Home delivery of goods.
3.) If you feel sick don't leave your home.
4.) telecommute (in general use communication technology to replace as much travel as possible)
5.) Wash your hands frequently.

Randall Parker said at June 27, 2005 8:38 PM:

Jim Moore,

Agreed on all those points. Schools are the biggest cause of influenza spread.

The bigger problem is with the workplace.

Telecommuting would be possible for lots of workers. With more of a movement away from paperwork forms and toward electronic forms this could be extended even further.

It is my impression that most of the big call centers which employ larger numbers of employees (e.g. when you call up the phone company or electric company or gas company) currently don't have the electronic equipment or the policies to allow their phone staff to work from home. But they'd be naturals for moving lots of staff home. They can count the number of calls each worker processes and monitor work output electronically. But they'd also need electronic switching of calls to phone lines installed in all the homes. Or they'd have to very rapidly deploy internet phone equipment and have the DSL lines into the home also carry the voice traffic. But working from home to handle phone calls and do database stuff would require lots of the employees getting DSL installed in their homes.

I'm seeing a lot of lead times for manufacturing and installing large amounts of electronic equipment to allow tens of millons of workers to work from home. Some would already have the DSL accounts and home computers necessary to support this. But then security becomes a big issue with viruses on home computers and other people in home residences getting access to information they shouldn't be allowed to see.

I wonder if work places which have large numbers of people sitting at desks could be modified with partitions all the way up to the ceiling to reduce airborne particle travel within offices. How to get the fresh all to each cubicle?

People who do deliveries and otherwise run around in vehicles would need to have their interactions with others at stopping places restructured so that they wouldn't enter into closed rooms or come close to each other.

I see that a lot could be done with deliveries. For example, instead of walking into each office to deliver a package each delivery person would phone in to an office to tell someone to come out to get the package.

Some personal services are hard to do without physical contact. Manicures, hair cuts, and dental work all come to mind. Well, get your teeth fixed before a pandemic.

Engineer-Poet said at June 27, 2005 11:08 PM:

You wouldn't have many dentists in business afterwards, and a lot of urgent work due to neglect.

Most dentists wear masks even today, to protect themselves against things like TB.  If they were among the first to receive vaccine, the risk to and from dental workers would be minimal.

FishEpid said at June 28, 2005 7:25 AM:

Frequent handwashing - YES! Most appear to have assumed that transmission will be mostly by aerosol, which requires close contact between the infectious and the susceptible but ignores the environmental survival characteristics of this virus. I think the evidence suggests otherwise. The virus survives indefinitely in the frozen state (consider for a moment the tremendous expansion of the poultry industry in the H5N1 outbreak countries, how important it is for generation of foreign exchange and where the exported product is going). Most do not know that the virus survives for a week or so on environmental surfaces at room temperature (I didn't note these important facts in the new WikiFlu). Touching a contaminated surface followed by touching of a mucous membrane is likely a more common mode of transmission than contact with an aerosol. Reports in the scientific medical literature on evidence from handwashing studies generally show a good handwashing program markedly reduces the incidence of respiratory as well as gi disease in the treatment (handwashing campaign) compared to the control group, whether the study is done in schools or of military groups. Yet, we do a very poor job of washing our hands, even among the medical community. Considering how and where most people consume their meals (out of household) versus the ease with which hands are washed in that venue. A public campaign to instal sensor-operated handwashing stations in the entry way of all resturants and fast food establishements? Entrances to public buildings? As an enveloped virsu, it should be very susceptible to alcohol-based handrubs. Put packets of alcohol-based handrubs along with the napkins in bags or boxes of fast foods? A good handwashing campaign started now would reduce the economic impact (e.g., days lost from work, hospital visits) from other diseases so transmitted as well as "harden" the population against the introduction and transmission of this agent.

Randall Parker said at June 28, 2005 7:58 AM:

FishEpid,

Your handwashing suggestions are highly excellent. Yes, a lot of transmission occurs via surfaces.

I think it is important that we move away from the lavatory sinks that have hot and cold water knobs that hands have to touch. Those should operate either by foot pedals or by waving a hand in front of an electronic sensor.

I have argued for a reduction in touchable surfaces. Hand rails, arm rests on park benches and on medical/dental/other waiting room chairs, and elimination of other unnecessary touchable surfaces would help a lot.

Also, gloves!

Also, surfaces have to be cleanable. Cloth surfaces are probably bad for this reason.

E-P,

The problem for the dentists is the many month gap before the first vaccines would be available.

A Berman said at June 28, 2005 9:25 AM:

Tamiflu is $65 dollars for a 10-pack dose. Everyone here must know at least one doctor.
No, it won't solve the larger social issue, but it will solve your life/death issue.
Just Do It.

FishEpid said at June 28, 2005 10:50 AM:

With regard to Tamiflu, for a number of reasons I would be very cautious of relying on a single point of control for protection. As an RNA virus, this beast is exceptionally adaptable, three modes if I recall. I suspect that in the face of a pandemic with a large numbers of people taking the drug, some too late, some too little, the probability of anti-viral resistance emerging will not be insignificant. As I haven't read up on the action of this drug, I may be speaking out of turn here but the general paradigm is correct. With such agents, careful implementation of multiple points of prevention and control (think HACCP) are the best protection for populations. The more a population can be "hardened" so the more the R0 reduced, the less likely that an outbreak will occur. Unfortunately, most of the public health approach seems to be asking what do we do after it gets here rather than what can we do ahead of time. Then there is the problem of fradulent drug getting into the distribution system. The mimics are sometimes exceptionally good knockoffs such that only an assay can tell the difference. And where there is a buck to be made, human nature kicks in . . .

Tom said at June 29, 2005 4:49 AM:

Is Roche backordered? If so, that would change the ethical calculus of random people ordering Tamiflu. If not, it's not a bad idea. I can keep it next to my IOSat :) (Actually, I could leave it at home, since the flu epidemic likely will come over time. The IOSat would be needed more immediately. It's at work and in my car).

Nick said at June 29, 2005 7:32 AM:

In the 1918 pandemic, Chicago cops arrested anybody not covering their mouth when sneezing.

It's astonishing how low the rate of handwashing is among medical professionals, and food preparers. We try not to eat out during flu season.

Chris said at July 8, 2005 7:49 PM:

If anyone has read Michael Osterholm's (I pray that the spelling is right), article in Foreign Affairs magazine, it definitely gives a person a reason to think. This publication is not given to hysterics or scare tactics, the publication tends to be staid and focus' on their topic with a narrow beam laser. When I read the article, 1, I was truly impressed at the numbers of dead, 2, the global effect, especially in terms of economies was positively frightening! If the pandemic does materialize as virulent and deadly as some estimates are calling for, then we will definitely be living in interesting times! I pray the man is wrong, I fervently hope that all the scientists are wrong, because if this does come to pass, I predict we will see the very fabric of western civilization begin to unravel.

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