To spur action on killer flu, a dire ´call to arms´

By Marian Uhlman

Philadelphia Inquirer


Consider this scenario: A lethal new flu virus emerges to claim millions of lives and sicken millions more. Many patients can´t get ventilators or drugs because of an international shortage.

Hospitals are so packed that schools turn gymnasiums into makeshift wards. Bodies pile up because people are dying faster than they can be buried. Food is scarce. The worldwide economy is paralyzed.

Sound far-fetched? It´s all too plausible, says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

The United States is poorly prepared to confront a potential influenza pandemic that some experts believe could be brewing in Southeast Asia, Osterholm writes in today´s issue of the New England Journal of Medicine, which commissioned the piece.

The country could lessen the magnitude of a pandemic if it acts now, Osterholm said. He called for a "worldwide influenza Manhattan Project" to produce and deliver a vaccine. And the public, industry and government all need to intensify planning and help the health system avoid a disaster, he asserted.

"I am not trying to scare people out of their wits," said Osterholm, a former bioterrorism special adviser to the current Bush administration. "I am trying to scare them into their wits."

His ominous tone follows months of escalating alarm from global officials that the avian flu virus circulating in Asia could create a medical catastrophe.

Even if the world escapes a pandemic now, experts say, it is only a matter of time before some flu strain causes mass death.

"It is a very high-profile call to arms," said Neil Fishman, director of infection control for the University of Pennsylvania Health System. "We are unprepared."

Osterholm - Minnesota´s state epidemiologist for 16 years - has a good record on prognostications. He predicted that a mosquito-borne illness would arise before West Nile did. And he warned about bioterrorism before anthrax turned up in letters.

Osterholm said a flu pandemic was inevitable - part of a cycle that has been repeated 10 times in the last 300 years.

"It is like hurricanes if you live on the Gulf Coast," he said.

World health officials now are closely monitoring the H5N1 avian flu virus, which experts worry could mutate and spread easily. So far, the H5N1 strain mainly has infected people in Southeast Asia through direct contact with chickens and birds.

Compared with typical flu viruses that cause about 36,000 deaths a year in this country, H5N1 is potentially more serious because it would be new and people would have no immunity.

An H5N1 pandemic "could rival those of 1918, when more than half the deaths occurred among largely healthy people between 18 and 40 years of age," Osterholm wrote.

Even an all-out effort to fight a pandemic would likely fall short in the near term because of a lack of medical supplies, he wrote. For example, the United States would lack enough mechanical ventilators to treat the flu´s victims. And a vaccine for a new strain would take at least six months to develop.

Detailed plans also need to be developed by every school board, business and state legislature.

"I don´t think we can wholesale prevent a pandemic," said Eddy A. Bresnitz, New Jersey´s state epidemiologist. But "we can prepare ourselves better to mitigate the impact."

Here are some problem areas:

VACCINES

Vaccines likely would be in short supply and only a fraction of the population would be inoculated, Osterholm said.

It´s also unclear who would be first in line: the old or the young? Should medical workers and police officers be first?

Making flu vaccine today is antiquated and still uses chicken eggs in the manufacturing process. Osterholm said the goal should be developing a vaccine in cell-based cultures that would protect against all types of influenza.

Bruce Gellin, director of the National Vaccine Program Office, said the United States awarded a $97 million contract to Pennsylvania-based sanofi pasteur to hasten development of a cell-culture flu vaccine.

The National Institutes of Health this spring started testing a vaccine against H5N1.

"There is a lot more to do," Gellin said. "I actually think a lot has happened."

ANTIVIRALS

These drugs will likely also be in short supply. Of the available antivirals, Tamiflu - the generic is oseltamivir - appears to be the only one effective in treating the avian flu strain now circulating in Asia, Fishman said.

But the United States is far behind other nations in stockpiling antivirals.

The federal government last year bought 2.3 million flu treatments to stockpile from the drug´s maker, Roche. By comparison, the United Kingdom has requested 14.6 million treatment courses to cover 25 percent of its population, he said. France has asked for 13 million doses to treat 20 percent of its citizens.

Roche is planning to start producing Tamiflu in this country this fall, a Roche spokesman said.

SURGE CAPACITY

Everything from face masks to hospital beds will be hard to get. "People shouldn´t expect the public-health knights to ride in on white horses from the state or federal level," said New Jersey´s Bresnitz.

Many efforts must be spearheaded locally, he said, such as ensuring that people have enough to eat.

Hospitals will be overwhelmed. "We don´t have enough beds in the Delaware Valley," said John J. Kelly, chief medical officer at Abington Memorial Hospital. "The desire to reduce health-care costs has taken the fat and the meat. We are now down to the bone."