The fire next time: Pandemic flu, bioterrorism, and ghost of SARS
The fire next time: Pandemic flu, bioterrorism, and ghost of SARS
Whether from man or nature, one calamity informs the next
Although the various scenarios are markedly different, the massive national effort to meet the threat of pandemic influenza the last few years has generally better prepared public health and the medical system against bioterrorism, experts note.
The possibility that avian influenza A (H5N1) may mutate into a strain easily transmissible between humans has forced the health care system to look at critical issues like surge capacity, infection control measures, educating staff, allaying fears and dealing with shortages of critical equipment such as mechanical ventilators.
"People have had to do a lot of work preparing for a pandemic and that will serve bioterrorism preparedness as well," says Eric Toner, MD, senior associate at the Center for Biosecurity at the University of Pittsburgh Medical Center (UPMC). "The issues raised for pandemic flu with regards to protecting health care workers with additional protective equipment [e.g., N95 respirators] would be applicable to some bioterrorist agents that are contagious such as smallpox, viral hemorrhaghic fevers, or pneumonic plague."
In addition, there is some overlap with regard to the need to cohort patients and enforce respiratory etiquette at the triage level. "All of those infection control measures would apply to any respiratory contagious illness, whether flu or bioterrorism," he says. "In addition, all of the issues related to surge capacity — at least surge capacity within the walls of the hospital — apply."
Regardless of the agent and its origin, tough questions remain about how to expand the number of hospital beds, ensure adequate staff to provide care and accumulate the necessary stockpiles of medication and supplies.
"These issues all overlap," Toner says. "The difference is that we would expect in most bioterrorism scenarios the whole country would not be affected at one time. With a pandemic, we do expect that more or less the whole country will be affected simultaneously. It makes some of the surge capacity issues a little bit different, but nonetheless there is a lot of similarity."
Indeed, even the most dire bioterrorism scenarios usually envision some initial local event, holding out the hope of containment in a city or area that is presumably already suspected to be on the prime target list for terrorists. But even a pedestrian seasonal flu virus — let alone a pandemic bug for which there is likely to be no direct vaccine match initially — can appear in disparate regions with near simultaneity. That means even the least desired target on our bioterrorists' list is about as likely to face pandemic flu as the next locale. If all are vulnerable, all must be ready. Therein lies the problem.
"Hospitals have done a lot of work in preparing for a pandemic, but there is an awful lot yet to be done," Toner says. "Some of the problems are insufficient funding and just that hospitals are overwhelmed on a day-to-day basis just managing a flood of patients with meager resources. Some of it has been that there hasn't been sufficient guidance that's really practical at the ground level. Progress is being made at a pretty good rate, but if a severe pandemic were to hit it would still be catastrophic."
True enough no doubt, but some places will be much more prepared than others for an unusual reason. They have — to borrow the term made famous by the novel The World According to Garp — been "pre-disastered." What group of hospitals, for example, is more prepared to deal with pandemic flu than those in Toronto? The hard lessons learned there have been shared with all in the stinging final report on severe acute respiratory syndrome (SARS), but clinicians and public health workers there have been through a fierce trial that no drill can simulate. Game speed — not practice speed — the coaches call it.
"Any time professionals and decision makers go through an actual emergency, they are gaining real-life experience that can be redeployed in a new situation that they hadn't envisioned in the first place," says Monica Schoch-Spana, PHD, senior associate at the Center for Biosecurity at UPMC.
Thus, whether designed by man or formed in nature, the current calamity informs the next. "[In 2001,] there was a major fire in a train tunnel in the city of Baltimore," she says by way of example. "That crisis brought together public health, emergency management, and the mayor and his staff in a way that equipped them much better to deal with the [subsequent] anthrax letter attacks. So it's building up those trusting relationships, getting more experience communicating with a concerned public and the media that are directly transferable across different extreme events."
A medical anthropologist, Schoch-Spana notes that it was no coincidence the federal government recently decided to use hurricane rankings to classify future pandemics. "The decision by federal health officials to characterize pandemic flu in terms of severity like a hurricane is driven by historical events," she says. "Americans, even those who don't live in hurricane-prone regions, came to understand just how strong an effect a hurricane could have through Katrina. I think that they were trying to find a way to define the range of possibilities to an American public most of whom have not lived through even a moderate pandemic flu. They seized on a familiar metaphor."
To take the comparison between bioterrorism and pandemic flu full circle, it must be noted that some have argued that influenza would make an ideal biological weapon.1 This concern became less theoretical last year, when researchers successfully reassembled the legendary 1918 influenza viral genome and published the results for consideration by friend and foe alike.2,3 Among those questioning the wisdom of that decision was Kenneth Alibek, MD, PhD, DSc, former chief scientist and deputy director of bioweapons research in the former Soviet Union. Now in the department of molecular and microbiology at the National Center for Biodefense at George Mason University in Washington, DC, Alibek says the Soviets were always interested in weaponizing 1918 flu. It has been argued that influenza would not make a good bioweapon since it could not be controlled once released, and even if you developed a vaccine the weaponized virus still would be subject to ongoing mutation. Nevertheless, Alibek says the sheer virulence and transmissibility of the 1918 strain make it attractive as a bioweapon.
Still, influenza is not likely at the top of anyone's list of bioterrorism concerns, particularly since it a seasonal killer that we face annually with a striking complacency. In any case, preparing for a pandemic flu essentially takes the origin question out of the equation, Schoch-Spana adds. "Conversations about influenza mostly turn on it being a naturally occurring outbreak, simply because pandemic flu is a regular occurrence," she says. "The origin doesn't really matter; it's the management challenges that are extreme if it is a novel strain. Pandemic flu is a great example of an extreme public health emergency. There are certain scenarios that could involve release of a biological agent among civilians that could create a similar effect."
In a published analysis applying the historical lessons of the 1918 pandemic to bioterrorism, Schoch-Spana argues that it is critical to characterize the outbreak accurately and promptly.4 In 1918, poor disease reporting systems seriously hampered the ability of public health officials to keep the public informed and to manage the outbreak. Influenza was not a reportable condition before the outbreak, and no well-developed system existed through which federal, state, and local health entities could sketch the course of the disease, she found.
"The question of whether things are getting worse or better is a constant for everyone, including the professionals who are trying to control the crisis and the people who are living through it," she says. "The more capacity that we have to describe the crisis as it is unfolding, resolving or fully ending the better."
Another lesson from 1918 is to earn public confidence in emergency measures, preferably before an event occurs. In the 1918 pandemic, some community members embraced public health measures to control flu, but others resisted orders seen as inconsistent, burdensome, or contrary to common sense or deeply held values, she found.
"Whether you are talking about an act of bioterrorism, pandemic flu or any other large-scale outbreak of infectious disease, you will always get a higher degree of collaboration, understanding, and even forgiveness for how things turn out if there has been more upfront interaction with the public," she says. "Starting pre-event makes a great deal of sense. Apart from mass communications, you also want to be reaching out to civil society institutions — communities of faith, professional societies of all kinds, trade unions — all of the different organizations that people belong to in their local and work communities. Include those institutions in emergency planning, [outlining] what will be required of the government and what will be required of community groups."
Shadow of Katrina
In the aftermath of Hurricane Katrina, another lesson from 1918 seems particularly apt: Guard against discrimination and allocate resources fairly. Though there were many displays of sacrifice and courage, the 1918 pandemic also "pitted groups against one another in an effort to assign blame or to protect access to limited resources. Rumors circulated in the United States that German spies, some disguised as doctors and nurses, were spreading flu and that Bayer aspirin, a German product, was infected with flu germs," Schoch-Spana found.
Racial and class distinctions became an issue in the 2001 anthrax attacks, when questions arose about the perceived discrepancies in the measures taken to protect postal workers vs. U.S. senators. "We are now living in a post-Katrina context as well," she says. "These kind of large scale crises don't happen in a vacuum. We have longstanding concerns regarding health disparities in the United States. Past events really do shape people's levels of trust in the folks in charge of managing the crisis. I don't think nationally we have adequately publicly addressed these issues of disparity with regard to Katrina. I think that is going to be hanging over the heads of politicians and emergency managers in a pandemic flu context or any other [emergency]."
The social disparity issue — the "haves" and the "have-nots" if you will — could play out in another context with pandemic flu. Though some national supplies will be available, federal planners have essentially left it to individual states to stockpile antivirals such as Tamiflu. Such drugs could lessen the severity of infections and protect key groups such as health care workers in the absence of a vaccine. Yet states have been left to their own devices — and budgets — in deciding how much of the drug they should stockpile. As a result, during a pandemic some states will be more adequately supplied than others.
"Some people have said that all of the stockpiles of Tamiflu ought to be national," Toner says. "That gets away from the states having to make the in-the-field decisions. I think there is merit to that argument but that is not the way it was set up. Right now, there is a relatively modest national stockpile, but the states have to pitch in and do their part. It's not just with stockpiling antivirals, it is also trying to organize their hospitals. Some states are quite proactive, others are coming along quite reluctantly. States that haven't prepared are going to be bad places to live and to be hospitalized in when a pandemic happens."
The situation is somewhat reminiscent of the Atlantic Storm bioterrorism exercise in 2005, which showed that world leaders with limited smallpox vaccine would be reluctant to share it after an attack ensued.
"I don't expect governors will share their state stockpiles [of Tamiflu]," Toner says. "I don't think it will happen. If a state has not stockpiled, they are going to be in trouble."
References
- Madjid M, Lillibridge S, Mirhaji P, et al. Influenza as a bioweapon. J R Soc Med 2003; 96:345-346.
- Taubenberger JK, Reid AH, Lourens RM, et al. Characterization of the 1918 polymerase genes. Nature 2005 Oct 6; 437 (7,060):889-893.
- Tumpey TM, Basler CF, Aguilar PV, et al. Characterization of the reconstructed 1918 Spanish influenza pandemic virus. Science 2005; 310(5,745):77-80.
- Schoch-Spana, M. Implications of pandemic influenza for bioterrorism response. Clin Infect Dis 2000; 31:1,409-1,413.
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