Q&A: Preparing for a Flu Pandemic

Germany has decided to confine all live poultry birds to their pens across the country.

A gaggle of geese at a poultry farm in Hamm, Germany, Oct. 20. Germany has decided to confine all live poultry birds to their pens across the country. Reuters hide caption

itoggle caption Reuters

In a two-part report, public health experts answer listeners' questions about the threat of a potential flu pandemic. The H5N1 avian flu virus has led to the deaths of 150 million birds, either through infection or culling to prevent the spread of the virus.

So far, the virus appears to be primarily spread through bird to bird contact. Some people have become infected, but the number has been relatively small, with 118 confirmed illnesses and 61 fatalities. The virus has yet to appear in birds or humans in the United States. The threat, which world leaders and health officials alike are taking very seriously, is that the virus could mutate and become easily transmitted between humans.

In part one, Dr. Hon Ip of the U.S. Geological Survey's National Wildlife Health Center answered listener questions about the virus and how it's spread. In part two, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, answers questions about government preparations for a potential pandemic, and what individuals can do to protect themselves against an infectious disease. NPR's health editor, Joe Neel, also answers questions on flu treatments.

Q&A with NIAID Director, Dr. Anthony Fauci

Q: How well prepared is the U.S. for the bird flu compared to other countries? — Jerry Amos, Hollis, New Hampshire

A: I think we can say with confidence that no country is adequately prepared at this point for a bird flu if it comes in its most fulminate form. If you look at what we're doing versus other countries I think we are clearly as prepared, or better prepared, than any other country in the sense of our attention to it and the issue of having a vaccine in hand, although we have not been able, for a variety of reasons, to produce enough (vaccine) to the point where we would feel confident. No one is adequately prepared at this point, but we are not any worse prepared than any one else.

Q: Are first responders being trained to deal with a potential emergency? — Rich Clark, Cold Spring, New York

A: First responders of emerging infectious diseases are being trained as part of even a broader program of how to handle emerging diseases. For example, the SARS experience was very very important in not only being a manifest of how training helped handle it, but also, it was experience to be gained for a future approach toward emerging and re-emerging infections. So yes, they are being trained, but we need to do a lot more.

Obviously, we are not where we need to be. It gets to the ability to respond to a natural catastrophe in general. When you have catastrophes that are moderate in their impact, or localized or regional in their impact, you can certainly handle them better than something that is essentially omnipresent. One of the concerns when you're dealing with a pandemic influenza is that there really isn't any nation or region that is adequately prepared for an overwhelming health crisis like this. Hospitals certainly don't have the surge capacity to be able to take care of millions more sick people in an abrupt manner. Those things we certainly have to work for, and they're not there right now.

Q: As a public school teacher, I'd like to know what emergency plans, if any, school districts have. Should each district have its own plan, or should we rely on the state or federal government? — Valerie Agramonte, Marietta Georgia

A: The Centers for Disease Control and Prevention are working with the state and local health authorities to have them come up with their plan. A general national plan is soon to be released, but as important as that is to have the individual state and local public health authorities have their own plan of how they're going to handle that.

Q: As a nurse with some education in epidemiology, I wonder if and how emergency management of a serious bird flu epidemic would be handled. Do we have a plan for mobilization of medical forces, quarantine, triage? — Claire Molner, Proctor, Vermont

A: On the issue of quarantine, the president signed an executive order not too long ago, adding a pandemic influenza to the list of quarantinable diseases. The ability to respond in a surge capacity at the state and local level is not where we all want it to be but it is certainly better than it was a couple of years ago. In preparation for a biodefense type of approach, you might recall that a few years ago resources — and we still need to do more — were given to the states to try and prepare for these public health emergencies and certainly a pandemic flu would fall right under the category of a public health emergency.

I think there's a lot of misconception about what quarantine really is. There's quarantine of a plane that comes in with someone who may have been onboard who is sick, and others on the plane have been exposed, and you don't know whether they're sick. So you quarantine the plane, or you quarantine the ship.

The other is a situation where you have a localized outbreak in a particular town or a particular city. You might want to restrict movement in and out — even if it's on almost a voluntary basis, it doesn't necessarily have to be enforced — to try and get people to restrict their movements. You can do other public health things that don't constitute quarantine, by restricting access to certain public places.

Q: My question is, what as a family can one do to prepare? Is there a preparation kit or a Web site with any preventative measures that one needs to take? — Tom Pritchard from Atlanta, Georgia

A: The Web site that is most commonly used is the CDC Web site. But if you listen to the CDC recommendations about how you handle any communicable disease that is communicable by respiratory spread — be that seasonal flu that we get confronted with predictably every year or a pandemic flu — they are fundamental basic public health issues. Handwashing, covering your nose and your mouth when you sneeze or cough. If your child gets sick, don't send him to school. If you're sick, don't go to work. Avoid crowded places where people are confined in an indoor space. These are general fundamental public health measures that any family can prepare for.

Q: What about a vaccine, is there anything on the horizon that would be viable? — NPR's Melissa Block

A: The U.S. government, the Department of Health and Human Services through the NIH, isolated an H5N1 virus about a year and a half ago from a North Vietnamese patient who was infected from a chicken, made a vaccine and began vaccine trials. The first stage of which shows the vaccine is safe and actually capable of inducing an immune response that is predicted to be protective against this particular virus. One of the sobering issues associated with this is that the dose required to induce that level of immune response is considerably higher than the standard dose that we use with seasonal flu, which compounds a problem that exists with production capacity. So it's less an issue of, "do we or do we not have a vaccine," than it is, "can we produce enough vaccine to make it available for virtually any one who needs it?" And right now the answer to that is no, and that's something we're working on.

Q: If a vaccine is not available for the general population and a pandemic does develop, what are recommendations for every day life in a big city? Are any face masks on the market effective against viruses? Should disposable gloves be used as much as possible? — Paul Lester, Houston, Texas

A: There are fundamental public health issues that will be triggered into effect if there is a pandemic or a major threat of a pandemic. They're simple things: hand washing, covering your nose and your mouth when you sneeze and cough. Viruses are transmitted from person to person in droplets and also in an aerosolized spray. Aerosolization is a finer way of the virus to spread, and there are masks that are effective against that form of transmission. Some masks are pretty good against droplets, such as the standard surgical masks, but if you really want to get the aerosolization protection, there's a mask called an "N95" that's specially fitted to you. When you get it fitted correctly it works, but that's not something you want to do now. It's totally unnecessary.

Q: If there is a flu pandemic, do we pull our kids from school? — Troy Brown, Phoenix, Arizona

A: I think those recommendations — at what point would you want to keep children out of school — will be very clear from the CDC. But that would be just a recommendation. It's the state and local health authorities that really have the ultimate authority to keep children out of school.

So I think it's going to be a collaboration of recommendations from the federal government and also independent implementation from the state and local health authorities.

Q: My wife and I are going to China in a few months to adopt a child. What do we do if an outbreak of bird flu occurs while we are there? Could we be prevented from returning to America if an outbreak occurs in China? — Andrew Holdun, Glendale, California

A: That's a lot of "ifs," and I would say that if they're planning to go to China to adopt a child, go. There's not a large chance that you're going to have a widespread outbreak in China. Remember, there have now just been 118 confirmed cases with 61 deaths. A lot of people have gotten exposed to those sick chickens, so it's very very inefficient in its ability to spread from person to person. I would not be concerned if you have to go for something as important as adopting a child of what's going to happen if there's an outbreak there. I think that's such a small chance that they shouldn't even consider that.

Q: If we do become ill, should we report it, and to whom? — Ben Laimon, North Potomac, Maryland

A: From an epidemiological standpoint, there's no indication that pandemic flu or bird flu is in the United States. There are bird flus that circulate all the time, but H5N1 is not here in the United States. Certainly if somebody just starts sneezing and coughing, you're not going to want to overwhelm the system by calling it up. If there is detection of the H5N1 virus in this country, public health authorities, particularly the CDC, will be tracking that very carefully, I can assure.

Q: I work as a volunteer social worker. My organization has distributed Tamiflu to each of us — how effective is it with avian flu? — Renee Rivera, Ho Chi Minh City, Vietnam

A: I would tell her not to take the Tamiflu since there is not a threat of human to human spread right now. When you start taking Tamiflu inappropriately, it can lead to resistance of the virus in question to Tamiflu, that's the first thing. As far as how effective Tamiflu is against the serious complications or the serious nature of H5N1, we don't really know. We know Tamiflu works reasonably well in the seasonal flu, the H3N2 flu that predictably circulates each year in this country. It lessens the number of days of symptoms and from a broad stand point, lessens hospitalizations. We don't have hard data because there have only been 118 people infected, and they haven't had a situation where they can give some of them Tamiflu and others not, and compare whether Tamiflu works. We're assuming that it will work with H5N1 with a reasonably good basis for that assumption, but there's no definite proof that it would make a difference with regard to hospitalization or life or death.

Q: My question about the bird flu is how is the government going to prioritize who gets medication out of the national stockpile and what their contingency plans are for getting more of it on short notice? — David White, Statesville, North Carolina

A: Very soon the Medical and Public Health Preparedness Plan for Pandemic Flu will come out and there will be a prioritization and it will be similar to the types of things the CDC has been putting out each year. Particularly if you have a shortage, as we did last year. There's the health workers who get exposed, those who are 65 or older, individuals with chronic disease, pregnant women, people who take care of others in facilities, like nursing homes.

Q: Can I avoid most of the risks if I have funds and space to sequester myself? — Stephanie Beard, Chandler, Arizona

A: Well certainly if you want to put yourself in a sealed compartment with a filter for a season, you can have a better protection against a respiratory virus. That's not practical at all and that's not recommended. I think one needs to see how things evolved, avoid crowded places when there is in fact flu in the community. But talking about sealing yourself in is just not practical.

Q&A with Joe Neel, NPR's Health Editor

Q: There is talk about insufficient vaccine, but if there were sufficient vaccine, do we have enough syringes? — Anne Miller, Coral Gables, Florida

A: There are sufficient syringe supplies. If a pandemic were to develop, there could be shortages of other critical medical items, such as surgical masks and disinfectants.

Q: If this is as dangerous as federal officials say it is, why doesn't the government have all U.S. labs that can, make Tamiflu? — Rick Volante, Tappahannock, Virginia

A: First of all, Tamiflu is only moderately effective against regular flu. It is only effective if it is taken within 48 hours of the onset of flu, and it only shortens the duration of the flu by a day or so. It may reduce the severity of symptoms in some cases. What is not known at all is how effective Tamiflu might be against a pandemic strain of the flu.

The company that makes Tamiflu has said that the manufacturing process is complex and not easily duplicated. Typically, pharmaceuticals are made through a series of chemical reactions in large refinery-type operations. Building such plants takes time and is expensive; retooling an existing plant would take similar expense and time.

Q: What are the "first responders" instructed to do to avoid catching the avian flu; and what can ordinary citizens do to lower the risk of catching it in the event it, or another virus, becomes a pandemic? — Scott Monosoff, Fremont, California

A: Again, we have to distinguish between avian flu, which is carried by birds, and any possible future strain of avian flu that has mutated into a human virus. The avian virus is not present in the Western Hemisphere at this time. The human virus has not appeared anywhere in the world.

Were the H5N1 bird flu to find its way to the U.S., bird handlers and poultry workers would need to take precautions, such as wearing surgical masks, gloves and other protective equipment. Pens, cages, trucks and other equipment would need regular disinfection. Regular handwashing, along with the use of a gel disinfectant would also help decrease the risk. If and when a human strain of this flu virus begins circulating, first responders would need to take similar precautions.

Other strains of flu are constantly circulating among poultry and other birds in the United States. For more information on what people can do to protect themselves, go to the CDC's Web site.

Q: At what point would a flu epidemic be considered a threat to the nation, and therefore, would it ever fall under the jurisdiction of Homeland Security? — Gregory Bowman, Baltimore, Maryland

A: Federal officials are working on a preparedness plan for pandemic flu, but it has not been released yet. The answer to your question will likely be contained in that plan. A search of the Homeland Security Web site turns up many emergency plans related to terrorism, but no specific actions related to pandemic flu.

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