Disaster Relief: Avian Influenza

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Guest: Dr. Eric Larson – Emergency Medicine, MUSC

Host: Dr. Linda Austin – Psychiatrist, MUSC

Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. Eric Larson, Director of Disaster Preparedness here at the Medical University of South Carolina. Dr. Larson, let’s talk about a really scary situation, which is the possibility of an epidemic of Avian Flu; avian influenza. How likely is that to happen?

Dr. Eric Larson: Well, you know my job is to prepare for disasters, so the approach I take is that it’s going to happen, or there’s a good possibility that it will happen. Certainly, I’ve been trained enough to look at what the experts think. Unfortunately, it ranges from, it’s inevitable, per some experts, to I doubt it, but it could happen, to other experts.

Right now, avian influenza; or better known as bird flu, doesn’t transmit very well from person to person. For example, if one person catches it, a family member is unlikely to get it. It is only transmitted, right now, from birds to humans. So if you don’t have close contact with live birds, and you’re not in Southeast Asia, you’re not going to get avian influenza.

The concern is that influenza virus mutates easily. And if it mutates where it can go from one person to another person, much like seasonal flu, it can spread rapidly. With avian influenza, it has a high mortality rate because people haven’t been exposed to it before. And what they’ve found is that avian influenza actually tends to kill younger healthier people. With seasonal influenza, which, every year, is a bit of a tragedy, because it kills up to 20,000 a year, it tends be the very old and the very young; the weakest of the population. With avian influenza, because it causes such an amazing immune response in healthy people, healthy people tend to be the ones who succumb to the disease.

Dr. Linda Austin: I don’t follow that. Explain that some more. Why would a healthy person tend to succumb?

Dr. Eric Larson: Because healthy people tend to have a robust immune system. So, the robust immune system sees the virus invading the body, and attacks the virus with a certain amount of vigor. While it’s attacking, there’s collateral damage, so to speak. It hurts other parts of the body. And with the inflammation that occurs in the body, the body shuts down.

Dr. Linda Austin: So, because the damage is done by the immune response itself? Is that right?

Dr. Eric Larson: That’s exactly right.

Dr. Linda Austin: Do I have that right?

Dr. Eric Larson: That’s exactly right.

Dr. Linda Austin: Okay.

Dr. Eric Larson: Say your friend has a mosquito on their head and you use a baseball to kill it, you may hurt your friend.

Dr. Linda Austin: I see.

Dr. Eric Larson: It’s the immune system going after the virus that ends up hurting your body.

Dr. Linda Austin: I see. Okay. How many cases have there been to date, or let’s say within the last couple years, of bird flu in human beings?

Dr. Eric Larson: Well, the CDC maintains a website on that, about PanFlu, or avian influenza, and so does the World Health Organization. The last time I looked, I believe there are 568 cases in the last five years.

Dr. Linda Austin: And primarily in Asia?

Dr. Eric Larson: It’s only been in humans in Asia, with a rare exception in the Middle East.

Dr. Linda Austin: So, those people have contracted it, then, from birds, right? What kind of birds?

Dr. Eric Larson: It’s mainly birds that are raised for food. Chickens tend to be the main ones. But you can get it from other foul. There’s been one reported case where they think it’s gone person to person, which the World Health Organization reported. But other than that, everyone else that’s gotten it got it from birds.

Dr. Linda Austin: Now, most people know that influenza tends to mutate. We have different strains of flu every year, right? So, we have a different vaccine from year to year?

Dr. Eric Larson: Yes.

Dr. Linda Austin: But, has bird flu persisted so that every year there are cases of bird flu, and it keeps mutating from year to year?

Dr. Eric Larson: It hasn’t actually mutated much from year to year. Right now, the vaccine, actually, doesn’t cover avian influenza. It is a bit of a different strain than the one that the immunization covers. In addition, we don’t get immunized with bird flu right now because it hasn’t been tested, and it’s not a real threat to our population. As I mentioned earlier, with seasonal influenza, over 20,000 people die per year from seasonal influenza. Those are the people we have to target.

The 500+ number I gave you, that’s over a five-year period, so, roughly, 100, or 200, people in Southeast Asia are dying from this per year. No one in the United States has died from it; therefore, we’re not immunizing our population against a disease that hasn’t occurred in our population. What we’re trying to immunize against is seasonal influenza, which is, once again, killing up to 20,000 people per year, and infecting numerous others.

Dr. Linda Austin: So, in other words, it’s a different family of influenza that’s mutating, somewhat, year to year, but has not made that leap of mutating in such a way that it’s transmitted from person to person?

Dr. Eric Larson: That’s exactly correct.

Dr. Linda Austin: Okay. But it’s still persisting year to year and, probably, there are mutations that are going on without us necessarily recognizing them?

Dr. Eric Larson: Absolutely. And it’s being maintained in the bird population. We [humans] just tend to be an occasional victim of avian influenza.

Dr. Linda Austin: I see. Now, I’m sure scientists are tracking it in the bird population though? Is that right?

Dr. Eric Larson: Yes, they are. And there’s an immunization for birds to prevent avian influenza.

Dr. Linda Austin: Are those immunizations routinely given?

Dr. Eric Larson: They certainly are, especially in countries that are affected. There’s a massive buildup to try to prevent this from becoming a person-to-person disease. Therefore, if we can stop it from being spread from birds, and we can eradicate in the bird population, then we don’t have to worry about humans becoming infected.

So, yes, they are immunizing numerous birds. Unfortunately, in Southeast Asia, some of the economies aren’t as robust as ours and, therefore, they don’t have as many resources as we do to provide the immunizations to the birds.

Dr. Linda Austin: So, I gather, then, that, in terms of trying to prepare for a what if situation, you’re preparing for a very unlikely situation. But, if it were to happen, it would be a dreadful disaster.

Dr. Eric Larson: It could certainly be a dreadful disaster.

Dr. Linda Austin: Paint us a scenario of what could happen if that mutation were to occur.

Dr. Eric Larson: The worst case scenario; what they say, is that up to 50 to 70 percent of the population could become infected. The reason a lot of us will become infected is because we’ve never been exposed to this virus before. So, we don’t have any immunity to this virus. With what we’ve seen so far, with bird flu, with the high mortality rate, with 50 to 70 percent of people being infected, a large percentage of them could then go on to become critically ill, and numerous people will die. They say up to 25, 30, percent.

Dr. Linda Austin: Can you describe the course of the illness in human beings?

Dr. Eric Larson: The course of the illness starts very similar to influenza; like the flu that you get any other time. It starts with a little bit of the sniffles, then high fever, muscle aches, and a dry cough. From there, though, unfortunately, the immune system overreacts somewhat and you get a pneumonia-like picture and your lungs shut down, and you can no longer breathe, and need support there.

Dr. Linda Austin: So, if the mutation were to occur, and we were to begin to seeing human to human transmission of influenza, would it then be too late to develop a vaccine? What would be our options at that point?

Dr. Eric Larson: Well, the government is now trying to develop a vaccine that works in humans. The thought is, once it starts transmitting human to human, that will be stepped up, and we’ll have the exact strain we need for the vaccine. So, vaccination is one option.

Dr. Linda Austin: But it’s impossible to prepare for that at this point because that hasn’t happened, so we can’t identify the strain; we can’t project what that strain might be? It’s too early, right?

Dr. Eric Larson: Right. Some scientists have guesses on what strain is going to jump, and they’re preparing for that. Is that going to be the right strain? Who knows? So, there are some preparations. But, until it happens; you are correct, we can’t be entirely prepared.

So, besides immunizations, there are other things. There are antiviral medications that they use, and have used, in some people that have gotten avian influenza, such as Tamiflu, that has been heard in the press, and whatnot. And, the government, including DHEC, is stockpiling some Tamiflu.

Dr. Linda Austin: What other precautions are we taking here in Charleston in case this should happen?

Dr. Eric Larson: Well, we’re working closely with the local government, with DHEC, to figure out what to do when avian influenza hits. Unfortunately, we really can’t count on federal government and those sorts of supplies because when avian influenza does hit, it’s going to hit the entire nation. There’s not going to be a lot of shifting of supplies from one area to another. Everyone’s going to be affected. So, we’ve got to respond locally. We’ve got to be prepared locally.

What we’re doing right now is trying to decide, when people become ill with avian influenza, that we need to separate them from the general population. We still need to run our hospital. We’re still going to have people who need transplants. We’re still going to have people who’re having heart attacks. We’re still going to be having people who’re getting other illnesses. We don’t want to expose those otherwise non-infected people to people with avian influenza. If they come in without avian influenza, we don’t want to expose them to the same bug as the people with avian influenza.

So, right now, we’re looking to find a separate area to house people with avian influenza, train some of our medical staff to specifically treat people with avian influenza, and then treat them in a different area. In addition, we’re stockpiling supplies to protect those healthcare workers who are brave enough to help take care of the population who comes down with avian influenza.

Dr. Linda Austin: So, I’m imagining now that they might have special hoods and gloves, and sterile techniques, and so forth, is that right?

Dr. Eric Larson: That’s exactly correct. We call that personal protective equipment, or PPE. And, yes, we are stockpiling PPE for people who come in to take care of people with avian influenza, with influenza-like illness.

Dr. Linda Austin: Have you identified a cadre of workers who have volunteered to do that?

Dr. Eric Larson: We are working on identifying a cadre, yes. And it’s going to be heavy in people in the mercy department.

Dr. Linda Austin: Right. And I would imagine even that is difficult to project, because if it doesn’t happen for six months, or a year, people’s personal situations can change very much, and make them more or less willing to volunteer.

Dr. Eric Larson: Exactly. We’ve also, because it could be, potentially, such an overwhelming illness, started looking into other providers that we normally don’t think of as healthcare providers. Such as, we would assume, if avian influenza is to hit bad, the medical school and the nursing schools will shut down. So, maybe nursing instructors, who used to be nurses but now just teach classes, they could come in and help out. Maybe the doctors who now teach classes could come and help us out, because they’ll no longer be teaching classes. Outpatient clinics won’t be running; there won’t be elective surgeries happening as much, so maybe we could bring some of those people in to help out. We’re not really sure how it’s going to work, but we’re working on those plans.

Dr. Linda Austin: Hmm, boy, that sounds like a very interesting, but very challenging, task. It also strikes me that it’s a sort of thing that may be very different in theory than what might actually happen if there was an epidemic. That is, it’s one thing to theoretically volunteer. It’s another thing if we were in the middle of a major epidemic and people were dying.

Dr. Eric Larson: That is a very good point, and one that we’re looking into. There have been historic perspectives on that way back, even including when the plague hit in the middle ages to when SARS hit Canada. What did healthcare providers do when their own lives were endangered? Some people showed up to work, some people fled. The American Medical Association has a policy that says we are obligated to help society and patients. That’s what we signed up to do. We are given the responsibility to care for our patients. We’re also given the right to earn income and be held in high esteem by society. With that come certain risks.

Is the AMA ethics policy then going to keep a physician and/or nurse at their station when they could risk their own lives and their families’ lives? I don’t know. I suppose, though, that is where planning is key. If I can assure them that we have prepared for this, and that we understand the virus, and we know how to protect them with personal protective equipment, and we have that personal protective equipment available, hopefully, then, they’ll stay.

Per our plans, resources are going to be prioritized to the people who get ill after staying to take care of ill people: i.e. we may have limited ventilators. We may have limited Tamiflu. If you’re providing services to ill patients, and then you, yourself, become ill, and/or your family members do, you’d be first in line to get those resources.

Dr. Linda Austin: So, I would think, then, that might be an impetus to be one of those people. If you knew that your family members, for example, would get top priority, well, that’s a pretty positive kind of incentive, I would think.

Dr. Eric Larson: I hope so.

Dr. Linda Austin: What are our resources in terms of numbers of ventilators, supplies of Tamiflu, etc, for the population at large?

Dr. Eric Larson: Well, that’s a really good question. We try to maintain a list of different resources we have available. We don’t have the exact numbers: i.e. the Department of Health and Environmental Control maintains some of those supplies, including Tamiflu. The VA hospital maintains some supplies. We don’t have exact numbers there. MUSC maintains some supplies. And, working with the entire community, we know where the supplies are. I’m just not exactly sure of the number of those supplies. If it’s the worst case scenario, we’re eventually going to run out of supplies. We do our best to maintain a stockpile though.

Dr. Linda Austin: Has there been discussion; well, I’m sure there’s been discussion and conversation, have there been decisions made about how to decide who gets supplies, if not everybody can get supplies? I mean, age-wise, do we make those decisions on the basis of family responsibilities? You know, would somebody with young children be first in line over someone like me, whose family is grown? I would think that would be logical, but a difficult conversation to have. How has that discussion gone?

Dr. Eric Larson: We are in the midst of that discussion right now. And, certainly, there are a lot of different points of view with the ethics of who gets resources and who doesn’t get resources. Do we decide who’s most valuable to society and try to save them? We don’t have the answers yet, and we’re working on it. It has to be transparent. People have to have buy-in. And these decisions have to be made before it happens. It can’t be made on the fly. It can’t be made by the frontline providers. That would leave too much stress on them, and that would leave too many inconsistencies in how it is done. So, we’re working on that. We’re hoping the state is going to come in and help us with it, and that it’s going to be a statewide policy: so, they say, state of South Carolina, here’s how we do it. It would be difficult if it was region to region. If Charleston said, well, if you’re over 55, we’re not going to give you many supplies, but Columbia puts it at 60, I’ll tell ya, if I’m 57, I’m going to drive to Columbia.

Dr. Linda Austin: Right.

Dr. Eric Larson: So, hopefully, it’s going to be statewide, maybe even national.

Dr. Linda Austin: Now, surely, someone listening to this, maybe, is thinking, huh, I invest in other sorts of insurance, maybe I should look into getting a respirator to have around the house, just in case. Are people thinking in that way? And, if one wanted to get such supplies, what would you get, and how expensive would that be?

Dr. Eric Larson: Boy, I’ve never heard that, actually. I don’t know where you would get those. I guess, suppose, any medical supply store would be able to provide you with that. They have many cheap portable respirators that are in the low hundreds of dollars. Then comes the problem with the personnel to run the thing and the expertise to take care of you from there. So, that’s the first time I’ve ever been posed with that question.

Dr. Linda Austin: Hmm. Something to think about though.

Dr. Eric Larson: Right.

Dr. Linda Austin: Maybe for another podcast.

Dr. Eric Larson: I’d like it.

Dr. Linda Austin: Thank you, Dr. Larson.

Dr. Eric Larson: Thank you.

If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you’d like to schedule an appointment with one of our physicians, please call MUSC Health Connection at: (843) 792-1414.

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