Tuesday, July 29, 2014
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Bird flu preparations hard to pin down

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Robert Einweck heads up emergency planning for Ramsey County. He holds an old "Quarantine" sign, which was used commonly up until the late '50s to protect against communicable diseases. (MPR Photo/Bianca Vazquez Toness)
State health officials are preparing for a worst-case scenario, in case a flu pandemic reaches Minnesota. They say one in four Minnesotans -- more than a million people -- could become sick.

This week, China identified its first human cases of bird flu. The virus hasn't arrived in North America yet. So far, It can only spread from infected birds to people, not person to person.

But public health officials are concerned. Minnesota public health and public safety officials say it's hard to prepare when there's so little known about the threat.

St. Paul, Minn. — Barb Nelson is looking for help. She recently sent out 15,000 letters that start like this.

"Dear health professional, all Minnesota communities need all health professionals to volunteer their skills in the event of public health emergency," the letter reads.

Nelson is a nurse and works in Ramsey County's public health department. She's heading up a new team of volunteers, started after Sept. 11, 2001. The specter of avian flu has motivated her to reach out for more volunteers -- everyone from psychiatrists to dental hygenists.

"We don't know what the public health emergency will be, but we know we need every single public health professional available," says Nelson. "If we need a mass dispensing, or if we need to provide vaccines or prophylaxis to the ... people in our community, we would need as many volunteers as we could."

Barb Nelson hopes for 400 volunteers. So far, More than 100 people have responded to her letter. They'll join a list of 200 medical volunteers the county has on call for an emergency.

Six counties in the metro area are doing this same thing -- writing to their residents who have health backgrounds, hoping they'll come through in a pinch.

That's because the biggest challenge in preparing for a pandemic -- or any public health emergency, for that matter -- is staffing.

The letter doesn't mention anything about avian flu, or what exactly the volunteers would be doing. Perhaps that's because it's hard to imagine a pandemic.

Robert Einweck heads up emergency planning for Ramsey County. His office is modern, with large colorful paintings hanging on the walls. But on one wall, there's a poster, brown with age, that reads "Quarantine."

Until about the 1950s, these signs would warn people of the lethal secrets inside a home -- diptheria, scarlet fever, or typhoid. Those diseases went off the map in the U.S. years ago.

If there's an avian flu outbreak, Einwick and the county will be in charge of enforcing a quarantine on anyone exposed to the virus.

"Our interest in doing this is to do as little intrusion as possible. Would we have signs like that around? I hope not," says Einweck.

Einweck says the county would bring food and other supplies to quarantined homes, so the residents wouldn't have to leave. And the county would get court orders to force people to stay at home if necessary. But he doubts it would come to that. Many people voluntarily submitted to quarantine during the SARS scare a few years back.

"Ideally we'd like that to be as voluntary as possible. Our experiences with SARS in Toronto, for example, was -- I think it was well in excess of 24,000 individuals needed to be put into quarantine because of exposure to SARS. I think virtually all, save about 20 or a dozen people, stayed at home," says Einweck.

President Bush has proposed spending billions of dollars to develop the right vaccine against a pandemic flu. But that won't happen until the existing virus, the H5N1 strain, mutates and begins to spread from person to person. That hasn't happened yet.

The state's epedimiologist Harry Hull says it would take at least six months after an outbreak to produce a good quantity of vaccine.

If we only had one ventilator, and we had five people that needed that ventilator, how would we decide how that ventilator got used? That's a terrible burden for a health care provider.
- Dr. John Hick, HCMC

The federal government has suggested who should get the vaccines first. Health care professionals and emergency first responders rank at the top of the list. Hull says there are important questions we could be answering now. But, we haven't yet.

"How do we keep society running? Should priority be given to people working for the electrical utilities, or people working for the gas companies or ambulance drivers?" Hull asks. "There's not a consensus on that yet."

There are lots of medical questions wihout answers, too. Hull says it's hard to know who will be most vulnerable to a pandemic bird flu. The president's plan assumes it will be the typical groups -- the elderly and babies younger than 2 years old. They're the ones who typically die in greater numbers during regular flu season.

But the flu pandemic of 1918, which killed nearly 700,000 people in the U.S., was hardest on young adults. Healthy people between the ages of 20 and 30 died in large numbers.

"Those kinds of uncertainties -- of not knowing exactly what's coming, exactly how infectious it is, exactly what ages are going to be infected -- means that plans we make are general rather than specific, and will change to meet the exact nature of the threat becomes clear," says Hull.

What happens once people are sick? How will the state decide who should get care? It won't.

"Those decisions are going to be made at the physician and hospital level," says Hull. "Because the state government is not going to be in the emergency room, saying this person gets treated and this person doesn't. It's going to be the people there in the emergency room who trying their best to save everybody."

In one of the intensive care units at Hennepin County Medical Center in Minneapolis, most of the patients are using ventilators to breathe. Nurses here monitor two patients each, while in the rest of the hospital nurses are in charge of six patients.

This is where you go when you need a lot of care and may die without it. Most of the beds are full, and doctors say during a regular flu season, they run out of room.

That's why Dr. John Hick says a major pandemic would crash the hospital system. He's in charge of emergency planning at Hennepin County Medical Center, and leads a consortium of hospitals in the metro area. Hick says Twin Cities hospitals have space for 5,000 patients. That's a far cry from the 750,000 people expected to come down with flu in the Twin Cities if there's a pandemic.

Dr. Hick wants the state to create treatment guidelines in the event of pandemic bird flu. But instead, he and his colleagues have developed procedures for who gets care, and the use of precious lifesaving resources.

"If we only had one ventilator, and we had five people that needed that ventilator, how would we decide how that ventilator got used? That's a terrible burden for a health care provider," Hick says. "So we really have developed some frameworks to use as much science as we can, to decide this person is going to benefit from a ventilator and this person is likely to die, regardless of whether they get a ventilator or not."

Hick says it would be hard for people to understand that modern medicine can't save people from a flu pandemic.

"They come to the hospital and see lots of machines that go bing, and ventilators that we can put you on, because we've done such an amazing job at reducing mortality," says Hick.

And that may make it even harder to stomach Dr. Hick's advice. He says unless you're critically ill, or the hospitals and clinics are dispensing anti-viral drugs, you should just stay at home in the event of a flu pandemic.

Hick says the health department will distribute just-in-time primers on how to care for your family at home, if there's a pandemic outbreak. That will include advice on how to avoid spreading the virus around the house, although he says that will be hard to avoid.

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