A Journey Through The World of Pandemic Influenza

A Pandemic Seminar in Mobile Alabama, US

Alabama's agency for Influenza Pandemic Emergency Preparedness held a seminar in Mobile aimed at nurses, social workers, and emergency first responders describing what a 1918 style pandemic (our last severe pandemic) could mean for the US. That translates to roughly 100 million people falling ill and a potential of 1.9 million dead, with each state suffering their statistical percentage.

The Press-Register report of the seminar is one of the few that I have read that states the situation law enforcement may well find themselves in during a severe pandemic.

[snip]

Lt. Joseph McClellan of the Alabama Department of Homeland Security said that law enforcement agencies and other first responders have to prepare to lose about half their work force because they will either be sick or caring for dying relatives.

It's unclear if crime will increase, but it certainly won't decline, he said.

"Bad people will take advantage of good people during bad times," McClellan said.

Security will need to be provided for mass burial sites, hospitals and pharmacies as fear and chaos could take hold of the community, McClellan said. Officers will have to reprioritize their calls; burglaries and robberies may not be on the top of the list.

While looking over various agencies' plans, McClellan said he's found that too many call for support from Alabama State Troopers.

"There aren't enough state troopers to fill those spots," he said. Those plans need to be changed, he said.

 

In late 2006 I posted my assessment of Law Enforcement during a severe pandemic here and again here. Since law enforcement is also near and dear to me I pay extra attention when the issues of policing and pandemic meet.

Unfortunately, in the year and a half since I wrote those entries the only thing that has really changed when it comes to law enforcement's planned response to a severe pandemic is that now they are planning to plan instead of being blissfully ignorant. That means, to put it bluntly, that now they are informed but still lacking in any meaningful preparations, although they plan to plan.

There are a few exceptions of course, but the vast majority still feel that they will handle a pandemic as they handle every other "incident"… they will do what needs to be done.

Someone needs to tell the rest that doing what needs to be done presupposes personnel to do the "doing". And as it stands currently that means doing it without adequate personal protection against infection, no vaccine, no prophylactic antivirals, no proper and modern medical treatment should they become ill or injured. And last, the very real likelihood of having no available and timely "backup" from fellow officers should they find themselves in an "Officer Needs Assistance" situation.

 

As the mother of a patrol officer under 30 years old I take these issues personally. It's hard to get more personal than a threat to one's own child. To help him meet the threat of what he may face as a cop during a pandemic I have taken it upon myself to make sure he has the means of protecting himself from infection as well as anyone can and still perform their public functions. But I know there is nothing I can do to protect him from potential injuries sustained in the performance of those duties. Injuries, perhaps life-threatening, that will likely go medically untreated, or at best, inadequately treated.

I have come to question whether I will support his decision to remain on patrol or if the "mother" in me will over ride my sense of civic duty and encourage him to be one of the many who will refuse to put themselves in such a tenuous and precarious position. When I am being honest with myself there is no question: I value my son's life far, far more than I value the property or life of some anonymous stranger.

If strangers want to be protected those strangers need to demand that their local law enforcement agencies adequately prepare for a severe pandemic. Otherwise, well, those strangers may find they have to protect themselves.

It's as simple as that.

 

SZ

Mixed Messages: Thermometers and Mass Graves

There are times when I find it difficult to remain gracefully dispassionate, especially when I come across something that I believe to be not only egregiously ignorant, but also a danger to the public. What makes today's topic so angering is the latest on the Influenza Pandemic front out of Ireland.

From IrishMedicalNews.com:

Flu medication stock-up advise

For all Ireland's high profile stocking up on antiretrovirals, each household will be urged to have the humble thermometer and paracetamol or ibuprofen in the event of a flu pandemic, according to a new Government handbook.

An introductory handbook on the Government's emergency planning plan, distributed recently to households across the country, says that while there will be more worldwide flu pandemics, the time and severity of their occurrence and the age groups on which their impact will be most severe cannot be predicted.

However, every household in the country will receive a leaflet before the pandemic reaches Ireland advising the measures including stocking up on a thermometer, paracetamol/ibuprofen, that should be taken. The Government will advise citizens to begin these preparations if and when the WHO confirms that a pandemic is imminent.

The guide also advises buying enough food and other supplies in advance of the pandemic to last "you and your household for at least one week", and advises awareness of hygiene measures to prevent infection.

Under the plan, the handbook says it is essential that people with flu symptoms stay at home while the indications persist, unless they receive other advice from a telephone hotline, which will be set up to provide advice and support, or from official Government announcements through the media.

The PDF of the handbook may be found here for those who wish to verify, as I did, that this is not a misquote but what is really being said.

 

Advising action only after the WHO declares an Alert Level Four pandemic threat will no doubt ensure that just about every household in Ireland will be out trying to purchase supplies at exactly the same time. As someone who is threatened with hurricanes on a regular basis I can attest to what it is like when many people attempt to buy the exact same supplies at exactly the same time. There just isn't enough supply to meet demand.

However, the entire timing strategy could prove to be naively misguided as publicly Ireland's Office of Emergency Planning is telling everyone that there will be time for everyone to become prepared (buy that thermometer and fever reducer). What if there's not?

What if an influenza pandemic bursts upon the world much as SARS did in 2003? Not an unreasonable question as influenza spreads much easier from person to person than SARS did, and we could find ourselves in the grips of said pandemic even before WHO has time to verify and announce its arrival.

Well actually, Ireland does have plans in place to deal with an unprepared public should a severe pandemic befall the world. This from NewsLetter.co.uk February 9, 2007:

Straw poll on grave crisis

A straw poll among district councils across Northern Ireland
yesterday revealed they are planning for at least 20,000 extra
graves to cope with a possible flu pandemic. Ian Starrett, Johnny Caldwell, Laura Murphy and Philip Bradfield report on how different councils are managing.

Continues….

 

Since the advice given to the Irish people, diligently mailed to every household, is so meager, and by any logic ridiculously inadequate, it's a good thing the district councils have planned to bury so many.

But it begs the question: Why is the official assumption that they will need those mass graves and yet the only advice they are giving their citizens is to purchase a thermometer and fever reducer? Would it not be wiser to advise people to stock up on a few more weeks of food so they don't have to be out and about possibly becoming infected, and a few more medical home treatment items?

Could it be that Ireland's Office of Emergency Planning has decided that the only effective action any citizen can effect is to depend on the Office of Emergency Planning? And that when they are exhausted and depleted it's just easier to toss the flu victims into those well thought out mass graves? Do the planners in the Office of Emergency Planning think their constituents are that stupid and personally incapable as to have no need of genuine guidance and advice? It certainly appears that way to me.

 

Officials are preparing for the range of severity of a potential pandemic, from mild-to-severe; meanwhile they are telling the public it will be little more than an inconvenient case of "the flu". Well, OK, they are not saying that explicitly, but it is what their message implies.

 

I would suggest that the citizens of Ireland politely suggest where the Office of Emergency Planning can stuff those thermometers.

 

SZ

A Brief Personal Note

Once again we have hired someone to take the Head Accountant's position at my "day job". His report date is this coming Monday morning. Once again it is my hope that my life will get back to what passes for normal, although it will still be hectic for a month or three as the New Guy is brought up to speed and we work on two major projects that have had to be side-lined as we struggled along with only the two of us running the department.

Heck who knows? Maybe this guy will actually have the gumption and courtesy to show up.

At this stage that's all I'm asking… just show up.

 

SZ

Update: Japan’s Pre-Pandemic Vaccine

Updating yesterday's posting about Japan's plans to administer their stockpiled human H5N1 influenza vaccine to 6,000 health care professionals and quarantine officials a new story hit the wires today [thanks unpathedhaunts @ FluWiki] introducing the idea of expanding their preemptive vaccination program into the general population.

From the Daily Yomiuri Online and The Associated Press

Vaccinations for new flu strains eyed for public

The Health, Labor and Welfare Ministry on Wednesday began a feasibility study on inoculating the general public with avian influenza vaccine to prepare for the possible outbreak of a new strain of pandemic flu, sources said.

Under the ministry's current plan, the vaccinations for 10 million people engaged in occupations maintaining social functions, such as police officers and those working for water and electric utilities, will start in fiscal 2009.

Hoping to eliminate concern over a possible epidemic, the ministry also will discuss whether to include the general public in the vaccination plan.

The ministry currently stockpiles sufficient avian flu vaccine concentrate solution for 20 million people and has already indicated that it would increase the amount of the stock.

However, expanding the vaccination to the public at large could cause social confusion over possible side-effects.

The ministry, therefore, will discuss the target population and timing of vaccinations, among other issues, after examining the safety of the inoculation, according to the sources.

Even people who have been vaccinated will likely develop symptoms in the event of an outbreak of a new type of influenza from any source, avian or otherwise.

Taking these factors into consideration, the ministry plans to inoculate 6,000 people who wished to receive flu vaccinations by the end of March next year. Falling into this category are doctors and quarantine officers who will most likely come into contact with patients.

The vaccination will be administered on a clinical test basis as a preemptive measure against the possible outbreak of a new type of flu.

If the vaccination proves to be effective, the ministry plans to expand the program to 10 million people in preparation for an epidemic.

Switzerland also is considering conducting a preemptive vaccination for the general public, but has yet to introduce it.

 

The Health Ministry is laying groundwork to see how effective their stockpiled vaccine is in the first 6,000, then if proven effective the 10 million who are classed as critical infrastructure personnel, then, (or at the same time as the 10 million, the story is a bit fuzzy on the timing here) 10 million of the general population.

Japan has a population of roughly 127 million so if they vaccinate the entire 20 million it is about 15.5% of their population. While the percentage of total population is impressive in and of itself, the fact that their critical infrastructure personnel will be protected is even more so. A severe pandemic would likely be a terrible, frightening, and profoundly stressful situation, having no public utilities or fresh food shipments would likely cause unimaginable cascading misery and unnecessary deaths over and above the pandemic proper.

 

This proposed program of advanced protection for an uncertain future threat is interesting when one compares what Japan is exploring and a recent report by CIDRAP's Maryn McKenna:

Flu vaccination still a challenge for hospitals [US].

Apr 9, 2008 (CIDRAP News) – Healthcare institutions still face significant hurdles in getting their staff members vaccinated against seasonal influenza, and fear of flu infection and caring for sick family will keep many staff home during an influenza pandemic, according to research released this week,

Four teams of researchers reported at the 18th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America, held in Orlando, Fla., that large proportions of hospital staff believe that flu vaccine causes influenza or triggers other side effects. Others believe that previous bouts of flu have made them immune to contracting the flu again.

Continues….

 

After reading Ms. McKenna's report I was left shaking my head in stunned sadness. Sad because I'm fairly confident that even if my government were as proactive as Japan's (and they are not by a long and wide margin) most of those offered this advanced protection in the US would decline the vaccine.

In fairness, many are not as big a fan of vaccines as I, some after rationally weighing the pros and cons, but many due to simple misinformation and downright ignorance of the facts. It's the latter that causes the dismayed shaking of the head.

 

If trained healthcare professionals can be so ignorant of such simple facts what hope the general public?

Not for the first time I find myself envious of Japan.

 

SZ

Japan and Pre-Pandemic Vaccination

Japan announced today that they are moving forward with plans to vaccinate medical staff and quarantine officials with their stockpiled pre-pandemic vaccine against H5N1. 

[Thanks to Pixie @ FluWiki] From Reuters Japan to vaccinate medical workers for bird flu:

Japan plans to vaccinate 6,000 medical workers and quarantine officers with stockpiled bird flu vaccines to check their effectiveness and possible side-effects, the health ministry said on Tuesday.

The plan, which follows suggestions made by some lawmakers and experts that vaccinations take place before a feared flu pandemic, will be submitted to a panel of experts for approval on Wednesday, an official said.

If approved, vaccination will take place before the end of the fiscal year in March 2009, and mark the first case in the world in which the vaccines -- based on strains of the H5N1 virus from China and Indonesia -- have been given to such a large group of people prior to a possible pandemic.

[continues at link]

 

I have been a proponent of pre-pandemic vaccination of as many Health Care Providers, First Responders, and critical infrastructure personnel as possible for about as long as the concept has been floating around.  I do always caveat that support though with the stipulation that the vaccine not contain any adjuvant, as I believe they are an unnecessarily dangerous inclusion for healthy younger adult, a wild card that even I am not willing to gamble on.

 

By protecting the Front Line we protect the maximum number of those who will need them to be on post should the pandemic happen.  The currently unanswerable question is just how much protection will be afforded to those who receive the pre-pandemic strain of vaccine.

Under normal circumstances vaccines are meant to convey immunity to a disease.  Unfortunately it is the current assumption that vaccination with a mismatched strain of H5N1 will not convey immunity.  So, with the stockpiled pre-pandemic vaccines the bar has been considerably lowered; it is simply hoped that it will greatly reduce the severity of illness in those that receive it, full immunity being viewed as unattainable.

No one assumes that the virus that attains the means to transmit from human-to-human [H2H] will be the same strain [closely matched on a genetic and/or amino acid level] as the stockpiled vaccine.  Since influenza undergoes rapid changes, and H5N1 is demonstrating a propensity for regional specificity, there is a strong possibility the strain used for the vaccine will be significantly different than the eventual (should it be eventual) pandemic strain.

The level of protection will be measured by the amount of antibodies that those who receive it produce.  Unfortunately, with the human H5N1 vaccines approved thus far there has been a discouraging weak immune response, which is why those who are in development and production, as well as those in procurement, are eying the adjuvants so strongly.

 

The pre-pandemic vaccine is a gamble.  It's a gamble to stockpile a potentially useless vaccine.  It's a gamble to give it before a pandemic presents itself, after all, the next pandemic may never happen, or it may not happen for any number of years, or even a decade or two, and the antibodies produced from vaccine wane with each passing month.   It's a gamble that there will be no adverse reactions for a percentage of those receiving the vaccine, a risk that goes up as the number of recipients goes up.

Will Japan's gamble pay off?  Almost certainly if a pandemic happens in the next year or three.  In and of itself that makes the gamble worthwhile.  Japan's existing policy is to vaccinate when the World Health Organization (WHO) raises the pandemic alert level from 3 (current) to 4.  Should the proposed plan be approved the initial administration will happen while the world is still in pandemic threat level 3.  Further, should the plan go forward Japan will be the first nation in the world to do so.  Will others follow?  I can only hope, since time may well not be on our side.  It takes boldness to be the first, it takes decidedly less to follow a sound and reasoned example.

 

I applaud Japan's Health Ministry for the bold initiative to protect those who will be on the forefront of an outbreak.  Since it takes roughly a month for the body's production of antibodies against influenza to be meaningful pre-administering the vaccine has a huge timing benefit.  Those on the front lines will not have to wait, or be needlessly unprotected, even though this is an admittedly a probable nominal level of protection.

I think of the level of protection along the lines of the bullet-proof vest my son dons prior to every patrol shift.  While the vest does not offer 100% protection against a bullet, it is far better than nothing, and it greatly reduces his odds of being the recipient of a fatal gunshot wound.  And, let's be honest here: when we are talking life-and-death, it's the "fatal" part that carries the most weight. 

Whether a wound or illness it's easier to stand on that ever so important to society Front Line if those standing know that recovery is the most likely outcome should the protection they have been issued (vest or vaccine) prove to be less than that Golden One Hundred Percent. 

 

Sometimes in life "recovery" is the best we can hope for because prevention is beyond the moment's reality.  With this gamble Japan is not only grasping its best current hope for the individual, but also for the nation as a whole, that it will be recovery, and not a fatal blow, that is faced should a severe pandemic happen anytime in the near term.

A Disturbing Glimpse into another Reality

Last July I did a piece on pandemic influenza and megaslums in which I briefly touch on the issue of megacities and the mega-slums attached to them and life for those dwelling in them. Today while I was buzzing around the net catching up on the happenings in the world I happened to visit CNN.com, something I haven't done in many months as I generally avail myself of other news portals. There I found a special feature titled Orphaned Boy Lives in Garbage Dump by Dan Rivers. I knew instantly what the story would be about as it is a story that is repeated on the outskirts of nearly every megacity in world.

The CNN piece happens to be about a seven year old boy in Bangkok, Thailand named Khin Zaw Lin.

He doesn't know how old he is, but he thinks he's 7. His name is Khin Zaw Lin. He's lived in a garbage dump virtually his entire life.

I find Lin walking in a festering landscape of rotting food, plastic bags and junk at the Mae Sot garbage dump in Thailand near the Thai-Myanmar border. His parents are long gone. His home is a makeshift shelter made from salvaged bags, cloth and wood.

Lin is one of about 300 refugees in the dump who survive on other people's trash. Many are children. Some are women with babies.

Their daily routine follows the same pattern: They mill about the dump, waiting for the next truck to arrive, hoping for enough discarded food to get them through the day.

Lin pokes through the rubbish with a machete. He says he collects bottles and plastic for three cents a sack. He shows me his feet, which were filthy and ribbed with cuts.

He tells me through an interpreter that he can't afford shoes. He walks barefoot through the treacherous landscape.

Continues…

 

No one has hard numbers about how many Thrown Away Children existing on their society's refuse exist throughout our world as they are willfully ignored by their governments and societies even in times classed as "normal". It would be no stretch of the imagination to assume that they are not considered in their society's pandemic plans (such as they may or may not be), and further assume that many, if not most, will be uncounted victims of a future pandemic.

These children are not only unnumbered, but will be un-ministered to, and then un-mourned should they pass from their mean and meager existence as a wave of disease passes over them and their reality.

 

Mr. Rivers closes his story with these paragraphs:

I thought I had become accustomed to the grinding poverty I had encountered in parts of Asia. I've met my fair share of children who are denied the luxury of hope. But Lin's story angers me. I feel close to losing all objectivity.

Near the end of my meeting with Lin, I ask his adopted mother if she, and Lin, would ever escape the rubbish dump.

Her answer is as hard as the world she and Lin inhabit.

"Never."

 

Should I happen to face a severe pandemic in my future I hope that I have the presence of mind to remember that no matter how bad it might be, it could be worse, I could have been born into young Lin's reality.

 

SZ