Doctors brace for possible avian flu pandemic

OB/GYN News, Nov 1, 2005 by Sharon Worcester

Warnings of a potential avian influenza pandemic have the nation and medical community on alert--but those who would be on the front lines appear to be taking the threat in stride.

One of the few concrete steps that physicians can take at this time is to ensure that patients are vaccinated against conventional influenza strains, said Donald M. Poretz, M.D., vice president of the Infectious Diseases Society of America. (See box.)

There doesn't appear to be--and there shouldn't be--major fear or panic in the United States regarding a pandemic at this point, he told this newspaper.

However, European Union (EU) public health experts are alerted by the confirmation of the World Health Organization that the H5N1 strain of the influenza virus has been isolated in poultry in Turkey and Romania, bringing the disease to Europe's doorstep. Among the steps taken by the EU is a ban on imports of live birds, poultry meat, and other poultry products from Turkey and Romania, according to the EU Web site.

"We need to look at the information objectively, and not emotionally. I don't believe anyone can make a statement as to whether or not there will be a pandemic, but the likelihood is that there will be at some point, so one has to be prepared," said Dr. Poretz, professor of medicine at Georgetown University in Washington.

Doug Campos-Outcalt, M.D., said that "everyone I know is fatalistic about it. Everyone knows it's coming, but it's difficult to prepare for."

Beyond hygiene measures, such as hand washing and covering one's mouth when coughing or sneezing, most preparations for a pandemic are "out of the hands of ordinary physicians," said Dr. Campos-Outcalt, chair of the department of family and community medicine at the University of Arizona, Phoenix.

The watch-and-wait mode is an appropriate place for physicians to be right now, said Bill Hall, a spokesperson for the Department of Health and Human Services.

HHS is maintaining open lines of communication with public health departments, and through those departments is working to keep physicians informed of world events related to the spread of avian influenza--particularly the H5N1 strain that is rampant in Asia, has spread to numerous other areas, continues to mutate, and has jumped from birds to multiple other species. While there is a sense of urgency, there is, at this point, no influenza strain that is causing a pandemic, thus there is no alert to physicians with regard to a pandemic, Mr. Hall said in an interview. In fact, he said, the only panic occurring is the panic by the media.

As for recent news coverage of a leaked draft of the federal government's pandemic preparedness plan, which indicates the country is alarmingly unprepared for such a pandemic, Mr. Hall said the report has undergone and will continue to undergo revisions as the situation evolves.

The final report is anticipated, but won't be hastened in response to the flurry of media reports about the draft copy. "What drives us is not the media, but global health, and being as prepared as possible for a pandemic," he said.

According to information from the World Health Organization, IDSA, and various research projects, the H5N1 avian influenza strain does appear to have the potential for developing efficient person-to-person transmission capability, which it currently lacks, and which could be the bridge between the current situation and a future pandemic. Should the virus obtain this capability, H5N1 could circle the globe within weeks or months, and could kill as many as 150 million people, according to a WHO estimate.

This scenario is the source of the sense of urgency that Mr. Hall mentioned.

At press time, WHO had confirmed 117 cases of human infection with H5N1 influenza, with cases in Vietnam, Thailand, Cambodia, and Indonesia. Human-to-human transmission has been documented in only two of those cases--both from a single household in Vietnam. The fatality rate among these cases is over 50%.

Infection in animals has been more widespread. The virus' ability to mutate and infect additional species, including cats, leopards, tigers, and pigs, is another source of that urgency, as are the findings of a study of the 1918 influenza pandemic, which killed about 50 million people.

Researchers completed the virus coding sequence for the responsible virus and discovered that like H5N1, the 1918 strain was a bird flu that infected humans (Science 2005;310:77-80).

The findings, coupled with the apparent staying power of the H5N1 strain (it has been circulating since 1997) and the fact that many experts say an influenza pandemic is overdue (such outbreaks occur about every 30 years, and the last one occurred 37 years ago) contribute to the urgency in preparing for a pandemic.

The U.S. State Department recently hosted a meeting of senior health officials from nearly 70 countries to address the need for improved communications and efforts to prevent a pandemic.

Further, the Bush administration and Congress are considering spending billions to stockpile the antiviral drug Tamiflu, legislation has been introduced that would further ramp up vaccine production and pandemic preparedness, and the National Institute of Allergy and Infectious Diseases has teamed with MedImmune Inc. to develop and manufacture new influenza vaccines, including vaccines against high-priority strains such as H5N1.