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State's pandemic simulation keeps things real

First, a big tip o' the cap to my buddy Mike Coston of Avian Flu Diary (http://afludiary.blogspot.com/).  His Saturday blog about the Alabama Public Health pandemic simulation planned for tomorrow is excellent, and needs no interpreting from me.  It makes me want to drive to Montgomery to watch things unfold.

Mike is absolutely right about the apparent turn toward a more realistic (fatalistic?) view of a pandemic.  As tabletop after tabletop unfolds, and the sheer magnitude of even a moderate pandemic becomes apparent, planners take a more (and necessary) pragmatic view of the management of same.  Mike mentions this at the end of his blog, and I absolutely agree.  Those rosy assertions that "So-and-so county is ready for bird flu" are being replaced with a much more sober assessment of what has to be done.

Whether or not anyone in authority is listening is another question.  Here is Mike's blog, reprinted in its entirety.

Alabama Pandemic Drill

Drill will simulate flu pandemic

http://www.al.com/news/birminghamnews/index.ssf?/base/news/1185007621186400.xml&coll=2

Saturday, July 21, 2007

The Alabama Department of Public Health has scheduled an exercise at Garrett Coliseum in Montgomery on Tuesday to simulate an outbreak of pandemic influenza. The one-day drill will simulate a situation in which large numbers of people become ill. Only the sickest patients will be sent to the hospital, and home care will be stressed. An alternative care site also will be set up to care for influenza patients who have no caregivers. Finally, the exercise will demonstrate the distribution of antiviral medications to priority groups.

The Montgomery City-County Emergency Management Agency, Alabama Hospital Association, Alabama Department of Public Safety, local hospitals, American Red Cross, volunteers and health department staff from the Anniston, Mobile, Montgomery and Selma regions are participating.

 Readers of this blog are certainly acquainted with the idea that, during a pandemic, most people will never see the inside of a hospital.   We have roughly 1 million hospital beds in the United States, 90% of which are occupied at any given time,  and a pandemic could simultaneously sicken millions across the nation.  

Even if hospitals could maintain their current staffing levels, something highly unlikely during a pandemic, the surge capacity simply isn't there to handle millions of flu cases.   We haven't the beds, or the personnel. 

At some point, even the sickest of the sick may be turned away from hospitals.    Most people will have to ride out the flu at home, cared for by their loved ones or friends. 

This hospital crisis will affect those without the flu as well.  Anyone who needs hospital care, whether it be for a heart attack, stroke, cancer, or trauma will find that the level and availability of care will be less than during normal times.    Elective procedures may be canceled, and lets face it, going to a hospital filled with sick and infectious people might not be the healthiest thing someone could do. 

The second thing that caught my eye was the statement that antivirals would be handed out to `priority groups'.  

 Exactly what that means is unclear.  But given the limited amount of antivirals we will have available, it isn't terribly surprising.   Whether antivirals are dispensed based on severity of symptoms, or some other criteria, there won't be enough to hand out indiscriminately.  

 Some surprisingly blunt admissions are creeping into the reportage of late.    The sort of things you'd only have read in a blog a year ago.

I wonder if anyone is paying attention?

Thanks, Mike.  Excellent as always.

The news coming out of Egypt today is that of a 25-year-old young woman, stricken with H5N1 avian flu.  What is interesting is the location and time of year.  The young woman lives in Damietta, a bustling port city in the Nile delta, and smack dab on the Mediterranean Sea.

The woman felt a surge of fever Friday and was rushed to hospital.  She was immediately given Tamiflu and is improving.  This is a testament to the active surveillance the Egyptian government has put in place.  It is an equal testament to the U.S. Naval research unit NAMRU-3, which is a recognized WHO world-class influenza typing lab and has never closed since opening over five decades ago. 

I digress here for a reason.  Imagine a United States military lab in Cairo that was not closed, even during the 6-Day War of 1967 or the Yom Kippur War of 1973!  NAMRU-3 is an amazing lab, where bird flu samples are tested and certified to the WHO.  It is a testament to the abilities of the United States Navy and the government at large, and is also a testament to the Egyptian government's recognition of its role in world health and world peace.

Back to the story:  The following is from the Website http://www.touregypt.net/damiettatop.htm , with some edits by me:

The Nile river divides Damietta, which is the Capital of the Egyptian Governorate by the same name ...Mostly Damietta is an industrial center known for its furniture, leathers, textile and sweets industries in addition to dairy products and rice mills. and for its agricultural heritage.  It is also a fishing industry town, with one of the largest fleets on the Mediterranean which accounts for fully half of the fishing boats of Egypt. Finally, it is well known for the port.

Today, Damietta is becoming more and more of a retreat for the people of Cairo who wish to escape the tourist activity of Alexandria and other North coast cities.

Damietta has experienced bird flu before, but human cases tested negative  and the city/governate was declared bird flu-free in the fall of 2006.  Egyptian authorities were not expecting H5N1 to show up at all during the summer months, which makes this case all the more interesting.  H5N1 shows us yeat again that it is one tough hombre; can surface even in hundred degree temperatures; can infect humans by the most bizarre of circumstances; and is defiant of government restrictions.

The Australian newspaper the Daily Telegraph reports: http://www.news.com.au/dailytelegraph/story/0,22049,22118153-5012771,00.html

The infection was a rare human case in Egypt's sweltering summer months.

Egyptian officials had forecast the virus would hide away during the summer following a pattern set in 2006 when human bird flu cases disappeared between May and October.

While bird flu did diminish in Egypt as the weather warmed, human cases have continued to occur sporadically.

Damietta's strategic location, on the Mediterranean, also shows us that the region should brace for pending bad news this fall.  H5N1 continues to confound, to spread, and to smoulder and reappear in unlikely times and in unlikely places. 

www.iht.com/articles/ap/2007/07/22/africa/ME-GEN-Egypt-Bird-Flu.php

www.flutrackers.com/forum/showthread.php?t=26883

A few weeks ago, I endured the fury of many in Flublogia when I called for the appointment of a pandemic Czar to lead the Federal flu planning effort.  My argument was, and is, that a politically-connected person with the right qualifications, working out of the White House, is the ideal choice.

Since then, we have seen the news stories that have come out regarding the politicization of the Office of the Surgeon General, supported by the sworn testimony of four past Surgeons General who served under Presidents Reagan, Bush 41, Clinton, and Bush 43.  Conspicuously missing was Clinton's outspoken SG Jocelyn Elder, who I am sure would have livened up the hearings!

But I digress.  Anyway, I still believe that a Pandemic Czar is the best way to coordinate the slobbering mess that is the Federal Government.  Clearly, however, every effort must be made to de-politicize the Office.  As former Bush 43 SG Carmona testified last week (photo above):  Having partisans censoring every bloody public health message is absurd, and reinforces the melange of mung that the political system has become (my words, not Carmona's, but I'll bet I am not too far off-base). 

Ordering Surgeons General to insert (name of president here) multiple times per page of a speech makes one wonder who won the Cold War.  And censoring medical debate because it might offend someone, somewhere, smacks of the abuses Galileo and Copernicus endured, let alone evoke the image of the Taliban, who are our enemies if I recall correctly. 

So I still call for a Pandemic Czar, but let's also immediately and permanently fix the problem of partisans trying to interfere with medical research and advise. Medicine and science are more important than "staying on message."

It appears this year's seasonal outbreak of influenza is playing Hell with medical response Down Under (the Southern Hemisphere's flu season is now).  We have already witnessed several reports of co-infection of influenza and strep in Australia, with several children dying.  Deaths due to seasonal influenza are not rare; in the US, some 40,000 deaths a year are attributed to seasonal H1N1 and H3N2 influenza.  And those statistics will have to be modified with the recent revelation that influenza can trigger heart attacks.  As a result, seasonal mortality should be doubled, at least.

But in New Zealand as we speak, hospitals are triggering their pandemic response plans, because they are being overwhelmed by the sheer numbers of sick patients with seasonal influenza.  This is not a government response; officially, the Kiwis are still at Yellow.  But the hospitals are going to Code Red, which is their pandemic response for staffing. This response includes cancellation of leave, hiring of retired nurses and desperately trying to open up staffed beds.  To the uninitiated: The number of hospital beds is irrelevant; it is the number of staffed beds that matters.  So in New Zealand, they have plenty of beds, just not enough staffed beds.  And that is exacerbating the current situation there. 

Authorities in Wellington are proclaiming that this year is no different than any other, caused by a lack of qualified nurses.  Why a regular occurrence that threatens the lives of New Zealanders should be treated so cavalierly by not being treated at all is beyond me.  But it again should show that there is zero surge capacity in medicine today, no matter where you live.  Zero, zip, zilch, nada. 

Go into any American emergency room during flu season to confirm my statement.  The walls are lined with sick and coughing patients seeking treatment.  Most are outfitted with masks to try and stop the shedding of virus.  But the fact remains that an influenza pandemic will quickly and totally clog the ability of medical personnel to attend to their needs.

New Zealand is one of those rare countries that has been held up as a Best Practice at pandemic response and mitigation.  Apparently, those salutations and accolades do not reach down to hospital decision-makers who allow chronic shortages of qualified nurses during the peak of flu season.  Is it any wonder, then, that people remain highly skeptical of government and medical response to a pandemic or biological threat?

http://www.flutrackers.com/forum/showthread.php?t=30082

A tip o' the hat to FluTrackers senior moderator Hawkeye for the information.  Just for grins, here is a Kiwi story that predicted this mess:

http://www.newstarget.com/006099.html

The astonishing, but not surprising report from Wageningen University and Research Center, The Netherlands -- published in the August CDC journal Emerging Infectious Diseases -- is a gripping read.

Influenza researchers have suspected for some time that common domesticated animals such as dogs and housecats might be vectors of influenza. 

So, too, does the government of South Korea -- and exercised that belief in horrifying fashion eight months ago, well before scientific research confirmed their actions.  At left is an article from MSNBC, dated Nov. 27 of last year.  The South Korean government made the strategic decision to euthanize every non-human creature within 3 kilometers of any bird cull from confirmed high-path H5N1.

Note that AP story's statement from "animal health experts" that there was "no scientific evidence" that dogs and cats could pass the virus to humans.

Based on the published study, they might want to rethink that statement.  The Dutch researchers concluded that dogs are able to catch H5N1, remain asymptomatic, and shed virus from their nasal passages.  Some dogs did not show antibodies to H5N1 until 14 days into their infection. More importantly, the dogs did not die.  At least, not in the experiment.  The research paper references the common belief held among flu researchers that Thai dogs were/are carriers of H5N1, and references an article confirming Thai dog H5N1 infection in the December, 2006 issue of EID.

The paper also references a particularly stressful experience in Florida over the past several years; namely, the outbreak of H3N8 canine influenza in 2004.  Originally confined to racing greyhounds, the disease spread through veterinary offices and animal hospitals, and led to the temporary closure of dog parks and dog shows across Florida.  Many dogs died.  Here in this study, the story is magnified that the virus was an equine influenza that jumped to dogs.

I quote directly from the study:

Conclusions