With no vaccine, millions of sick, thousands dead
By Carla McClain
ARIZONA DAILY STAR
Temporary morgues will be set up. "MASH" units will appear in city parks and vacant lots. Mass shot clinics will open, controlled by the police or the military. Patients will be kicked out of hospitals. Schools will convert to medical clinics.
More than 9,000 will die. More than a million will get sick. And most will go without vaccine.
That's the scenario likely to unfold in Arizona when - not if, but when - the "big flu" develops somewhere in the world and takes off across the globe, certain to kill millions of people.
With worldwide concern now spiking about a deadly influenza pandemic - a global outbreak of a killer flu virus not seen before but easily spread in humans - the pressure is on to develop detailed plans on how to handle such a disaster.
Although disease experts have warned of this pandemic for several years, the problem finally has hit the radar screens of world leaders - including President Bush - as a lethal strain of avian flu continues to spread out of Asia, into Russia, and now into Eastern Europe.
Despite the mass slaughter of infected birds in these regions, this flu strain - known as H5N1 - persists and, more ominously, is mutating, jumping from birds to pigs, cats, and even humans, with a 50 percent kill rate in the 120 humans it has affected.
However, those humans, all in Asia, caught this flu from infected birds they had handled. H5N1 has not yet developed what is known as "efficiency" - easy transmission from human to human. But if that happens - and many predict it will, and soon - it will threaten the lives of most humans, who have no immunity to it, and could kill at least 10 million, according to the World Heath Organization.
"Nobody knows if that will happen or not, but we are due for a pandemic right about now," said Dr. Eskild Petersen, a worldwide infectious disease specialist at University Medical Center, noting such pandemics occur every 30 to 40 years, with the last one in 1968.
"There is a lot of uncertainty about what H5N1 will do. But if this is not the big one, there will be a big one, and with global travel the way it is today, it will move fast."
Makeshift morgues and MASH units, riot control at vaccination clinics, schools and convention centers commandeered for patients - all are listed as necessary actions in plans drawn up by Tucson hospitals, the Pima County Health Department and the state.
But what stands out in all the plans is an alarming theme - no matter how much we plan or practice, our local health-care system will be "overwhelmed."
"An influenza pandemic is inevitable," states the Pandemic Influenza Response Plan for Arizona. Among the major actions listed in the 45-page plan:
? Rationing antiviral drugs and vaccine to highest-priority people, especially health workers.
? Distributing masks and other protective gear to highest-priority health care workers.
? Mobilizing the National Guard and the military for law enforcement duties.
? Discharging all but the most critically ill hospital patients.
? Setting up temporary health facilities in public buildings.
? Setting up mass vaccination sites.
? Implementing isolation and quarantine as needed.
Knowing she will be on the front lines battling a pandemic when it hits, UMC health care worker Joan Wild endured a nearly hour-long wait in unusually long lines for a regular, seasonal flu shot Tuesday at UMC.
"We all know this shot doesn't cover the strain of a pandemic flu, but I think people here are just being very careful now. Probably fear of the big flu is part of that," said Wild, who works with heart- and lung-transplant patients.
At this point, there is no vaccine to protect humans from the H5N1 avian flu strain, although efforts are under way to develop some, and nations, including the United States, are scrambling to get on the waiting list.
But any vaccine made now may offer little protection in a true pandemic, because the flu strain will mutate. For that reason, all-out pandemic vaccine production won't really begin until the pandemic does, and it will take at least six months after that to get any.
"There won't be nearly enough doses here or anywhere else when the outbreak starts, so we know we're going to see large amounts of illness and death and the overwhelming of our health care system," said David Engelthaler, the state's epidemiologist, who is involved in Arizona's response plan.
The only other major weapon known to work against H5N1 - the anti-flu drug oseltamivir, or Tamiflu - also is in extremely short supply, with no stockpiles in Tucson, and a federal stash sufficient for only about 1 percent of the predicted infected population.
"It doesn't sound good - no vaccine, no effective antivirals. What are we going to do?" Engelthaler asked. "But a couple of years ago, a deadly novel virus popped up with no immunity, and we stopped it dead in its tracks. So, we might be able to do that again."
That virus was SARS - severe acute respiratory virus - that also jumped from animals to humans, killing 750 people in Asia and Canada, before it was controlled.
Mobilizing global cooperation to isolate and quarantine the sick, enacting severe infection controls, and limiting air travel from infected areas meant that SARS never spread to the United States, and it is considered a past threat.
Although President Bush has posed using the military to enforce quarantines of exposed and infected victims, county officials say soldiers more likely will be needed to control mass vaccination clinics - if and when scarce vaccine does arrive.
"Some sort of security will be needed around the vaccine, because there just will not be enough of it," said Dr. Michelle McDonald, Pima County's chief medical officer. In both state and local pandemic plans, the county Health Department is charged with rationing the vaccine to those who need it most.
Instead of forced quarantines, McDonald envisions voluntary "isolation in place" - meaning at home or at work - of infected people until they are no longer contagious.
All Tucson hospitals are ordering vast quantities of protective gear for workers and mobile isolation units for patients, and are studying how to increase the number of ventilators - breathing machines - in Tucson, said Harry Patton, emergency preparedness planner for Carondelet Health Network, owner of St. Mary's and St. Joseph's hospitals.
But even with those efforts, Tucson hospitals, and their staffs, will be overrun beyond capacity in an all-out pandemic, officials admit.
"When it happens, we know we're going to have to triage patients out of here and we're going to have to set up medical facilities off-grounds," said Sandi Baus, director of infection control at Tucson's largest hospital, Tucson Medical Center. "You're going to see a portable MASH-type unit set up across the street in Fort Lowell Park. We'll use rehab hospitals and other places to treat patients."
The overwhelming demands of a flu pandemic are going to force all kinds of ethical, life-and-death decisions on people not used to making them, and hospital committees are working now to try to hash some of these out in advance.
"If you need 2,000 respirators and you only have 200, how do you decide who will get one? Who will get the masks? What is the obligation to treat someone who is infected?" asked UMC's Petersen. "How do we decide who is going to live and who is going to die?"
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