HEALTH & SCIENCE

Planning for next flu pandemic still a tough sell

Readiness for a large-scale influenza outbreak, considered the No. 1 threat to public health, is attracting more attention with the increased emphasis on bioterrorism preparedness.

By Victoria Stagg Elliott, AMNews staff. July 1, 2002. Additional information

When Health and Human Services Secretary Tommy Thompson announced the release of bioterrorism planning money to Illinois last month, he mentioned anthrax but spent more time talking about how the funding could prepare the public health infrastructure for a flu pandemic.

"This money is to build a local state public health system that is second to none," said Thompson, speaking at Cook County Hospital in Chicago. "One that will not only meet the needs of bioterrorism ... but also infectious diseases such as a pandemic flu."

This is just one example of something that many public health officials say is a silver lining to the events of Sept. 11, 2001, and the anthrax attack that followed. The emphasis on developing a response to bioterrorism has meant more money to enable the public health infrastructure to address both human-created and natural disasters.

"Preparing for pandemic flu and bioterrorism relate so closely in terms of figuring out how to expand the number of hospital beds, how emergency rooms can function, how to detect the agent and how to do syndromic surveillance to detect unusual increases," said Arnold S. Monto, MD, director of the Michigan Bioterrorism and Health Preparedness Research and Training Center, who has long been involved in the state's flu planning.

But public health officials have long struggled to sell to likely responders the need to prepare for a large flu outbreak, much like the ones that swept the country in 1968, 1957 and 1918. A national plan has been bogged down in politics since the early 1990s, although a draft is now awaiting approval at the Dept. of Health and Human Services.

Only 13 state health departments have completed plans, while another 20 more are working on them, according to the Centers for Disease Control and Prevention.

"We're getting there," said Raymond Strikas, MD, medical epidemiologist at the CDC's National Immunization Program. "But for some states, it's not a priority. They don't have the resources to do it."

Experts say it has been tough to get influenza on top of the agenda because of perceptions that it is a mild disease. Activity of the virus has also been low in the past couple years, and the last pandemic is a distant memory that has long been superseded by the swine flu scare of 1976. That year, the CDC warned that a deadly pandemic flu was on the way. Millions were vaccinated, but the onslaught never materialized. More people suffered vaccine adverse reactions than developed influenza, and David Sencer, MD, MPH, then head of the CDC, lost his job. He says he stands by the decisions he made, but those working on this issue say it set them back.

"That really hurt us in the influenza world because it hurt credibility," said Dr. Monto, who is also a professor of epidemiology at the University of Michigan School of Public Health in Ann Arbor.

No one knows when the next true pandemic will hit, but no one believes that we're currently ready. It is generally viewed as overdue, but there is a lot of fear that it might stem from the avian flu virus which decimated poultry stocks and killed six people in Asia in 1997. There were no direct human-to-human transmissions, but there is also no vaccine if the virus does develop that ability.

"Flu is the most dangerous thing we face in public health," said James Steele, DVM, MPH, former assistant surgeon general and professor emeritus of public health at the University of Texas Health Science Center at Houston.

There are also concerns about whether the medical infrastructure will be able to care for millions felled by the flu during a pandemic, particularly since so many hospitals have closed over the past few decades.

"We should have put them into mothballs instead of tearing them down," said Dr. Steele.

And many question whether enough vaccine could be made to interrupt outbreaks or if it could be delivered to those who need it most in a timely fashion.

"Influenza could be a very potent disrupter of community and the nation," said Dr. Sencer who is now retired. "You have to have a plan."

Much of the catastrophe planning applies to an influenza outbreak, but the flu is different in one important aspect. Most disasters tend to be local, and resources are often available from across the country and around the world to help recover. When the pandemic hits, everywhere will be affected and most areas will have to suffice with what they've got on the spot.

"When we had ice storms, electricians came from as far away as Florida to help us out," said Kathleen F. Gensheimer, MD, MPH, state epidemiologist with the Maine Dept. of Human Services. "During a flu pandemic, we would have to rely on local resources."

But most admit that despite the absence of a national and some local plans, the United States may not do too badly when the next flu pandemic hits. Technology, vaccines, medicines and surveillance systems are vastly improved since 1968 and certainly since 1918.

"If you look over the years from one pandemic to the next, you see the mortality has gone down, so it's not all bad news," said Dr. Monto.

"Our population, however, has also gone up. We should prepare, but the question is: for what? Should we prepare for a 1957, which was an average pandemic? Should we prepare for 1968, which was a milder pandemic, or should we prepare for 1918, which was a near catastrophe? Or should we prepare for an avian influenza outbreak which would be a total catastrophe?"

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Spanish flu, 1918: 500,000 deaths
Asian flu, 1957: 69,800 deaths
Hong Kong flu, 1968: 33,800 deaths

Source: Centers for Disease Control and Prevention

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CDC pandemic influenza page (http://www.cdc.gov/od/nvpo/pandemics/)

WHO Influenza Pandemic Preparedness Plan (http://www.who.int/emc-documents/influenza/docs/index.htm)

Report (GAO-01-4) "Influenza Pandemic: Plan Needed for Federal and State Response," October 2000, in pdf (http://www.gao.gov/new.items/d014.pdf)

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Copyright 2002 American Medical Association. All rights reserved.