Avian flu threat intensifies need for preparedness (IDSA annual meeting)

It's only a matter of time before there's a pandemic of something.

By Amy Snow Landa — Posted Nov. 21, 2005

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Amid the growing international focus on vaccines and antiviral stockpiles to combat a predicted flu pandemic, a top global health official is underscoring the critical role to be played by doctors and nurses on the front lines of health care delivery.

Pharmaceutical interventions will be essential, but they aren't going to solve the problem on their own, according to Klaus Stohr, PhD, head of the World Health Organization's Global Influenza Programme.

"In the end, the effectiveness of the intervention all depends upon the physician, the hospital, the nurse and the technical equipment available at the local level," he said in a speech delivered at the Infectious Diseases Society of America's annual meeting Oct. 6-9 in San Francisco.

Although drugmakers are ramping up production capacity and nations are scrambling to stockpile the antiviral drug Tamiflu (oseltamivir), there simply will not be enough vaccine and drugs for everyone who needs them, Dr. Stohr warned. "We believe that if a pandemic comes, there will be a significant dependence on primary health care and hospital services for symptomatic treatment."

There also will be a heavy reliance on nonpharmaceutical interventions, such as quarantines, voluntary home stays and protective face masks to prevent the spread of infection, he said. "These barriers will be the ones to slow down the spread and help reduce morbidity and mortality."

Dr. Stohr's remarks at the IDSA meeting coincided with published reports that the deadly Spanish flu pandemic of 1918-19 first developed in birds and was similar to today's H5N1 avian flu virus, raising fears among national and international policy-makers that H5N1, like the earlier strain, could turn into a global human pandemic. Discoveries that the avian flu virus now has spread beyond Asia and as far as Turkey, Romania and Macedonia also have increased anxiety levels.

These and other developments suggest that H5N1 is accelerating its potential to cause an influenza pandemic, Dr. Stohr said. The virus is not just expanding its geographic reach, "it's increasing its pathogenicity."

By late October, global health officials feared that the deadly virus would jump next to East Africa, where countries are almost completely unprepared to control outbreaks. The virus also appeared to be flaring up again in Asia, where Thailand reported in October its first human cases of H5N1 in more than a year. So far, human cases of H5N1 infections remain limited to four countries in Southeast Asia, where the virus has caused at least 62 deaths. But experts warn that if the virus mutates into a form that is easily transmissible between humans, it is likely to spread rapidly with devastating consequences.

The need for speed

A significant aspect of avian flu is that its rate of transmission appears to be only two days, said Barry Bloom, PhD, dean of the Harvard University School of Public Health, who also spoke at the IDSA meeting. By contrast, the timeline for SARS was six to eight days.

"When one thinks of bird flu, with a serial interval of two days, I would like to be pre-armed with immunization, if I have a choice, rather than worry about recovering from an infection," Dr. Bloom said. Currently, there is no licensed vaccine that is considered effective in protecting humans from the H5N1 strain.

But experimental vaccines are undergoing human clinical trials, said Robert B. Belshe, MD, director of the Center for Vaccine Development at Saint Louis University School of Medicine. They include both active vaccines and live, attenuated vaccines.

One challenge, though, is predicting exactly which strain is going to emerge as a human threat. "Selecting a strain today may be a problem," Dr. Belshe warned.

According to Dr. Stohr, an effective vaccine is certainly not going to be available in the first three months of a pandemic outbreak, which is the length of time in which the virus is likely to spread worldwide. Even during subsequent months, the world's vaccine supply will be inadequate because of limited production capacity.

Without a vaccine, it is hoped that antiviral drugs could be used effectively to treat symptoms in patients who become infected with H5N1 and as prophylaxis in areas of pandemic flu outbreak. WHO has developed a "rapid response stockpile" of these treatments that it plans to deploy quickly to such areas in an effort to contain the virus and prevent it from spreading.

The intervention would need to be quick to be effective, Dr. Stohr said. "The window of opportunity to extinguish or eliminate the pandemic virus is very narrow -- between 20 and 30 days from when the virus emerges until the time it's too late."

In the scenario he outlined, at least four to five days will elapse between the onset of symptoms in patients infected by the pandemic flu strain and when they are admitted to the hospital. It would take several more days -- possibly a week or more -- to determine a diagnosis, conduct a field investigation and characterize the virus.

WHO then would have about 10 to 14 days to intervene by broadly distributing antiviral prophylaxis to the affected population. The strategy has never been used and may not be successful, he said. "But we would not be forgiven if we did not try it."

In the meantime, the United States and other nations are racing to increase their own stockpiles of antiviral drugs.

President Bush, for instance, announced Nov. 1 that he would ask Congress for $7.1 billion to begin implementing a preparedness plan. Specifically, the plan would provide $2.8 billion for research to speed vaccine development, $1.2 billion to buy vaccine effective against the strain of avian flu currently circulating and $1 billion for the purchase of antiviral medications.

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20- to 30-day timetable

The timetable for activity of pandemic virus:

Lasts Takes place
Onset to
4-5 days Day 1 to
Day 5
Sampling to
2-4 days Day 6 to
Day 9
5-7 days Day 10 to
Day 16
3-4 days Day 13 to
Day 16
Intervention 10-14 days Day 17 to
Day 30

Sources WHO Global Influenza Program

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Disaster planning can help hospitals be ready

Hospital leaders should be taking certain measures now to prepare for the challenges their institutions are likely to face in the event of an influenza pandemic, according to William Schaffner, MD, hospital epidemiologist at Vanderbilt University Medical Center in Nashville, Tenn.

Hospitals could encounter problems with security if patient demand for vaccines and antiviral drugs becomes greater than the supply, he said. "Biological supplies and antiviral drugs [will be] the Hope Diamond -- they have to be protected and secured."

Dr. Schaffner was one of several speakers who addressed the front-burner issue of pandemic flu preparedness at the Infectious Diseases Society of America's annual meeting this year.

For hospitals, the "single most important thing" is to have a disaster-planning coordinator who can make preparedness -- whether for flu or for flood -- a sustained priority and bring together diverse interests to engage in the planning process.

Live drills are also essential, he said. "Because as you drill, the plan comes off the page and you discover very quickly what works and what does not."

It can be difficult to get physicians to participate in drills that cut into clinical time, he noted, but they should be involved. It's also important to have a "flu team" in place, as Vanderbilt discovered during a severe influenza outbreak last year, he added. Hospitals need to evaluate their surge capacity and antiviral stockpiles.

And finally, it's important to encourage all health care professionals to be vaccinated against seasonal influenza, he said. "While we're planning for a pandemic, we know that influenza will visit us each year."

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Specialists caution against overuse of curbside consultations

In his 28-year career as an infectious disease specialist, Thomas G. Slama, MD, has developed elaborate strategies to avoid getting "curbsided" by other physicians seeking advice on a patient's diagnosis or treatment.

"I have secret ways into the hospital," he told colleagues in a speech at the Infectious Diseases Society of America's annual meeting in San Francisco.

But in the end, his strategies don't work. "I can't hide," Dr. Slama said. He estimates that curbside consultations -- informal and unpaid -- make up about half the consultations he provides each year.

Although he jokes about his efforts to avoid them, Dr. Slama is serious when he says such requests are often inappropriate and should be discouraged. Infectious disease specialists, cardiologists and gastroenterologists tend to get curbsided most often, according to a 1998 study published in the Journal of the American Medical Association.

The most serious problem with these exchanges is they can be dangerous for patients, he said. Information provided by the treating physician is sometimes incomplete, making it difficult for the specialist to give good advice. It's like being asked, "Can you name this tune in three notes?"

In a formal consultation, the specialists have a chance to learn all of the clinical information and to examine the patient directly before offering suggestions, Dr. Slama added.

Sometimes a curbside consultation is appropriate, usually when it involves a straightforward question that can be answered quickly, Dr. Slama said. At those times, an ID specialist should feel free to respond. "But if a case is complex, don't talk," he advised colleagues.

Infectious disease specialists in the audience also expressed concern that curbside consultations result in a significant amount of lost income. Researchers from the University of Vermont College of Medicine reported that these interactions accounted for 22% of the clinical work value performed by their ID unit during a recent six-month period. They estimated that had the curbside consultations been performed as formal consultations, they would have provided nearly $50,000 in additional revenue.

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External links

Infectious Diseases Society of America 2005 annual aeeting, Oct. 6-9 (link)

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