University at Albany Center for Public Health Preparedness

Avian Flu: The State, National and Worldwide Response

Original Satellite Broadcast: 09/08/05

Moderator: Good morning. Welcome to the University at Albany Center for Public Health Preparedness Grand Rounds Series. I'm Robert Westphal and I'll be your moderator today.

Our program today is on Avian Influenza: the State, National and Worldwide Response. Before we begin, we would like to remind you that we will be taking your calls later in the hour and our toll free number is 800-452-0662. You may also send your questions in by fax at 518-426-0696. Also, we would like to ask you to please take a moment at the end of the broadcast to fill out your online evaluation because your feedback's very helpful in the development of our future programs. Nursing contact hours, CHES and CME credits are available for participation in this program. Today our guests are Dr. Barbara Wallace, Director of the New York State Department of Health Bureau of Communicable Disease Control and Dr. Perry Smith, Director of the New York State Department of Health Division of Epidemiology. Thank you both very much for joining us today. It's nice to see you again, and it's an important topic. Just so people know, we're going to divide the program in half. So I'm not going to be ignoring anybody, but Dr. Barbara Wallace is going to start. And, Dr. Wallace, perhaps to begin with, if you could tell us where are we today with regard to Avian Influenza - what's going on?

Dr. Wallace: Thank you, Bob. Well, certainly the events in the last few years in Asia and Europe with these human cases of Avian Influenza have highlighted the potential for a pandemic.

Moderator: There's a lot being said about influenza these days, in spite of what's going on in the rest of the world. What are the main items that we'd like to get through today that you'll address for us?

Dr. Wallace: Well, I'll be discussing initially the clinical aspects of influenza, briefly the public health impact and then moving on to Avian Influenza and how Avian Influenza could translate into a pandemic. And, then, Dr. Smith will follow with pandemic response components and planning efforts including issues such as surveillance, vaccination, antiviral use and other public health interventions, such as travel restrictions, isolation, quarantine, et cetera. I will start by saying influenza, most people are familiar, is an acute febrile respiratory illness that affects the nose, throat, bronchial tubes and lungs. Epidemics are caused by two types - Influenza A and Influenza B. Type A causes moderate to severe illness, can infect persons of all ages, can also infect animals, as well as humans and there are subtypes. In contrast, Influenza Type B, is a much milder illness, usually affects children, and does not infect animals, so it's a little bit more stable virus than Influenza A. And then there is a Type C, but not important from a public health point of view. Influenza occurs worldwide. It causes considerable morbidity and mortality each year.

Moderator: Most of the people in our audience probably already know that it's the A virus that's of most concern to us. Tell us a little bit about the structure of the Influenza A virus and how that relates to our public health concerns.

Dr. Wallace: Right. Well, it's a complex virus and it's categorized into subtypes based on proteins on the surface of the virus. And there are two types of proteins, Hemagglutinin, which is oftentimes abbreviated as H. or H.A., and there are sixteen types of Hemagglutinins. And this allows the virus to attach to the host cell. And then there's the N. type of protein - Neuraminidase, and there are nine types of those. And that allows the virus to penetrate through the host cell. And it's different combinations of the H 's and N 's that make subtypes. And there are three current subtypes that infect humans and that is H1N1, H3N2, and H1N2.

Moderator: So all these names that we see are based on what the H. and the N. antigens are on the surface of the virus itself.

Dr. Wallace: That's correct.

Moderator: What about the major symptoms? We all talk about flu-like symptoms, but what really are we talking about?

Dr. Wallace: Right. Well, I'm sure most people have experienced this themselves firsthand -- fever, muscle aches, head ache, a lack of energy, loss of appetite, sore throat, possibly runny nose, it's really characterized by very sudden onset of fever and body aches that last about three to five days. And then there's a period of a much longer lack of energy and a cough that can last for a couple of weeks as well. And it's a little bit of a clinical challenge in the winter because symptoms are very similar to other circulating viruses, such as adenovirus and RSV - respiratory syncytial virus. I should also mention that there are some serious complications from flu, including viral and bacterial pneumonia, some central nervous system side effects or complications, encephalopathy and seizures. And, then, also it can cause complications -- an exacerbation of somebody's underlying medical problem, exacerbation of asthma or congestive heart failure.

Moderator: So it's a really serious problem. We talk sort of benignly about flu-like symptoms, but it can lead to some serious and long-term effects. Stomach flu - is that anything real?

Dr. Wallace: Right. Well, it's somewhat of a misnomer. I think people refer to any G.I. illness that causes vomiting, diarrhea, nausea as stomach flu. And this is caused by a variety of viruses and bacteria. Influenza virus can cause diarrhea, particularly in children. However, influenza is really respiratory illness with fever.

Moderator: How long can someone with influenza infect other people - how long is the transmission period?

Dr. Wallace: Well, first the incubation period is very short for flu. On average it's two days from your time of exposure to onset of symptoms, it can range from one to four days. And influenza is challenging, because you can be infectious prior to the onset of symptoms - so one day prior to the onset you can be communicable and your peak communicability is usually the first few days of illness, correlates with your temperature, and usually subsides by your fifth to seventh day of illness. In children it can be much longer. They can be communicable ten or more days during their illness.

Moderator: And how is it transmitted? Some obvious ways but some may be not so obvious.

Dr. Wallace: Right. Well, the studies are tricky trying to determine the transmission routes and there are several possibilities. Contact, droplet, and droplet nuclei - also referred to as airborne transmission can occur. The exact contribution of each is, like I said, not known. However, certainly during inter-pandemic periods, during a normal flu season, droplet transmission is felt to be the most important. So this would occur during close contact with somebody - within three feet, coughing, sneezing, or talking to someone.

Moderator: What about the role of what we call in public health fomites? Glasses, doorknobs, I'm thinking of the elevator button in Hong Kong Hotel Metropole, remember the SARS outbreak? Can the virus live outside the body like this and be transmitted to other people?

Dr. Wallace: Well, it can. The survival depends on the surface. On somebody's hand it's fairly short lived, a matter of a few minutes, but hand washing is still very important during the flu season, to prevent transmission. On hard surfaces such as plastic, stainless steel, et cetera, it can be much longer, up to a day, the virus can survive.

Moderator: And what is it about the flu virus that makes it of such interest to public health? Why is it such a public health issue?

Dr. Wallace: Well, certainly we have epidemics of flu each year and there is always the potential for a pandemic. Even during a normal flu season, there's considerable mortality from flu - approximately 36,000 deaths nationwide. This compares to approximately 40,000 deaths due to motor vehicle accidents. So definitely a major public health impact. It occurs in all ages, but most of the mortality is in older individuals - those sixty-five years and older. Very transmissible, approximately five to twenty percent of individuals during the flu season might develop influenza. And we see very high attack rates in congregate settings such as nursing homes.

Moderator: So every year we sort of have an epidemic or an outbreak of flu, but this year and for actually the past couple of years we've been talking a lot about pandemics. We don't usually do that. What is bringing us to focus so much on pandemic flu concerns now?

Dr. Wallace: Well, as I mentioned earlier, certainly the situation in Asia where we've seen human infections due to an avian strain of influenza occurring. And this is concerning, because pandemics occur when there is the emergence of a new virus to which the population has no immunity - which would be the case with H5N1. Most severe pandemics occur when both the H. protein and the N. protein change. Asia's been the source of many outbreaks in the past for a couple of reasons. One is that the virus can be found year round, where here in the United States it's mainly a disease of the winter months. Also, there is very close proximity of humans living very close with poultry, birds and pigs which provides the opportunity for the virus to mix and for a new subtype to emerge.

Moderator: So the influenza virus is capable of change, sometimes rapidly, and I guess there are so many different ways it can change. How do we know what's going to affect public health? What changes are we watching for in public health and what are the problems they bring?

Dr. Wallace: Well, there are two ways that the influenza virus changes. One is called antigenic drift. And that's what we see year to year. It is very small changes in the virus occurring over time where a new strain replaces the previous circulating strain. And your antibodies may not be effective against the new circulating strain. And that's why individuals can be infected with flu in multiple years. It's also why we change the flu vaccine every year to match the current circulating strain. Now, the second type of change is called antigenic shift, and this is a much more dramatic, abrupt change. It occurs when there is a new strain or very novel subtype occurring. And this is what results in a pandemic.

Moderator: It's gotten to be not exactly trite, but people say about a lot of things “it's not a question of if, it's a question of when.” And when did we last see a flu pandemic? This is not something within everybody's most immediate experience.

Dr. Wallace: Right. Well, there were three major pandemics in the Twentieth Century. I think the most serious one and people have heard of the 1918 Spanish Flu. Then, also, in 1957 the Asian Flu, and then 1968 the Hong Kong Flu. All of these resulted in considerable mortality, morbidity worldwide, above and beyond the number of deaths we see in a normal flu year.

Moderator: We've made some medical progress, though, since those times. Will modern medicine have a major deterrent effect on the severe problems coming from flu? What's going to shape up now that we have more antibiotics and maybe fewer hospital beds, but that's another question we'll get to later.

Dr. Wallace: Right. Well, the impact certainly depends on the virulence of the circulating pandemic strain when it happens. But we do have medical technology that wasn't present during the previous pandemics - antivirals and as you said, better supportive care for people who are infected. This slide compares the pandemic that occurred in 1918 to a pandemic that would occur in 2000. Certainly there's a lot more people, so the impact could be much more severe. Also it's important to note that transportation really will affect the way this virus circulates the globe. Years ago, people traveled slowly by boat, you know, automobile, et cetera, and it could take months for a strain that emerged in one part of the world to circulate to another part. As we saw with SARS, a new virus or a new strain could circulate in a matter of days with aircraft, et cetera.

Moderator: There's a famous line from a Harvard professor who said those that choose to ignore history are doomed to repeat it. Do we have any lessons from previous pandemics might enable us to make a prediction about when the next big pandemic might come to affect us?

Dr. Wallace: Well, predictions are difficult and, as you said, most public health officials feel like it's not if but when. This time line shows the emergence of new subtypes of influenza A. viruses and how they triggered pandemics - the H1 in 1918, H2 in '57 and then H3 in 1968. Usually when a new strain emerges in a pandemic, it continues to circulate for many years afterwards. But you also can see in more recent years we have had new subtypes not commonly known to infect individuals, the H7, H5 and H9 subtypes, which are very concerning that these could potentially cause a pandemic.

Moderator: This past spring there was a case of direct person to person transmission of one of the strains of Avian Influenza, H5N1, I guess, and previously that had only occurred between animals and people who were closely involved with them. We have a film clip we'd like to show you now that generated a lot of concern at the time - and then we will come back and discuss more about this. We offer you this film clip courtesy of CBS News and we thank you for it.

(Film clip)

Moderator: Well, this was a bit startling for everybody and made it sound as though it might be the moment that we were all worried about. Do you have any comments about this process? Is it really underway? Did that really start it in terms of human to human transmission? And here are we with that question?

Dr. Wallace: Right. Well, it's definitely concerning, although it's unfortunate that since that case there's really been no sustained person-to-person transmission of H5N1 - which would be needed in order to trigger a pandemic. However, we do have H5N1 in poultry occurring in many countries including Thailand, Vietnam, Cambodia, Malaysia, China, now Russia - and possibly other countries. It's now considered an endemic infection in poultry in Asia. The majority of H5N1 cases to date have been people who have had direct exposure to either waterfowl or poultry. And, again, there have been some reports of person-to-person transmission - very limited - the one you just saw on the clip and some others under investigation, but nothing sustained at this point. They're also able to look at the virus and genetic components, and they've been able to see that these have all been made up by avian genes to date. So we haven't had any mixing with human genes and avian genes for flu - which would be more concerning because a reassortment like that would make it more transmissible person-to-person.

And this slide here shows the human cases of H5N1 to date that have occurred from 2003 through August of 2005. And as you can see, there are four countries that have reported human cases - there have been a total of one hundred and twelve cases, fifty-seven deaths, for a case fatality rate of fifty-seven percent.

Moderator: Just to emphasize though, these were not directly human-to-human transmissions expect for the one or two that we know about. These were from people working closely with the animals.

Dr. Wallace: That's correct. And the questions about the cases that come to attention are obviously the more severe ones. So this is a very high case fatality rate, whether it remain that high needs to be determined.

Moderator: You mean the less severe cases wouldn't tend to get reported?

Dr. Wallace: That's right. At this point.

Moderator: Well, we've had a lot of warning time, we have been talking about this for some period now. Do we have a plan? What's going on at a national level? We've looked a little bit at the world level now, but what's going on at a national level in terms of developments to deal with these issues?

Dr. Wallace: Right. We'll, you're correct that there has been a lot of activity, globally, also in the U.S. and New York State. Briefly, I'll mention the World Health Organization - they do have a pandemic preparedness plan. They revised it recently and it is on their website - which is shown on the slide here. It was revised to incorporate some new pandemic phases, to reflect what's happening in Asia. It's the recognition that these new subtypes, human infection with Avian Flu have repeatedly exposed or caused disease in humans and that there are some actions we should be doing now during this pandemic alert period. Also, I think the SARS experience was very important for public health. It showed the importance of worldwide surveillance and very rapid communication. I think we feel like flu would be very difficult to prevent or stop the transmission - unlike SARS - which we were able to do to some degree because SARS is a very different disease than flu. SARS has a much longer incubation period, people are communicable, their greatest communicability is well into their illness - so isolation, quarantine, et cetera, is much more effective. Flu is going to be very difficult with such a short incubation period and people being infectious prior to the onset of symptoms.

Moderator: You said for about a day actually prior to symptoms.

Dr. Wallace: Right. So I think the ability for us to stop the transmission of a pandemic flu would be very difficult or impossible. But, again, I think there are still global surveillance and communication steps that would buy us time in order to produce a vaccine, to mobilize efforts - if a pandemic strain was recognized.

Moderator: Could you take a moment to put us in the pandemic phase you think we are in now? W.H.O., as you indicated re-did their organization of phases of the pandemic. And where are we located on that grid right now?

Dr. Wallace: Well there are different pandemic periods - there's the inter-pandemic period, the pandemic alert period, and then the pandemic period. And within those periods there are phases and we are at least in phase three right now. Where there has been a human infection with a new subtype, there's been either very limited person-to-person spread. So we are right now in the pandemic alert period.

Moderator: It sounds different from the old one where you were in zero until things really got bad, now we are already in three of four.

Dr. Wallace: That's correct. I think that's why they re-did the phases again to emphasize things that should be done at this point.

Moderator: What about here in the United States, what's going on here? Obviously you guys have been very busy upstairs and around the country other people are involved - the Department of Health and Human Services. Others?

Dr. Wallace: Well, certainly at the Federal level there has been a lot of activity, and the Department of Health and Human Services has written an influenza preparedness and response plan that's available on their website. The plan is very detailed and helpful, and describes the federal level activities that would occur during a pandemic, including coordination, command & control issues, and actions of the different federal agencies such as the C.D.C., D.H.S., Food and Drug Administration. Also, it goes through the legal authorities for pandemic response action such as quarantine, state of emergencies, et cetera. The plan also includes descriptions of current infrastructure and technology, such as flu vaccine manufacturing, guidance and strategies for response actions and supporting rationales - which would include issues of infection control. And then also is a table of specific actions that would be done at the Federal level by agencies and by the pandemic phase that we're in.

Moderator: I think when we close, we'll be able to share a website where people can take a look and find some of these materials for their planning purposes. So, we've talked a little bit about the worldwide problem of Avian Influenza, the worldwide response in terms of W.H.O., and a little bit about the Federal response here in the United States. Let's focus down now and turn to our other guest, Dr. Perry Smith from the State Health Department's Division of Epidemiology to talk to more about the planning that's going on right now in New York State - which is probably being emulated in other states around the country.

Dr. Smith: Thanks, Bob. That's right. A lot of the comments that I will make about the planning in New York really apply to every other state that's going through exactly the same process. So we share many of the same issues. But in New York, we have been working over the last several months - even the last couple of years in terms of putting down on paper and conceptualizing specifics regarding how we will respond to a pandemic when it occurs. And we have a draft plan in New York, as do all the other forty-nine states, which is in evolution. So, one point I would make up front as we talk about planning - is that no plan is ever finished. The plans are always changing and that's because our state of knowledge and state of preparedness changes. And we'll talk some more about the details of what's changed recently in terms of advice coming down from the Federal or W.H.O. levels, which affect our planning locally. The New York State plan is organized into five sections which are shown on the screen. We have a command & control section, surveillance & laboratory, testing section, vaccine antiviral delivery, emergency response and communications. And each one of these has a work group - an extensive group of people from throughout the department that are working to put the pieces together. And, so, that is ongoing work and even as we speak it's being changed based on new information that comes in almost every week from the Federal level.

Moderator: Plans certainly are a work in constant progress, as I recall as well. So, this is carried right down to your active work within the Division of Epidemiology and in fact the whole State Health Department. What do you think about when you know local health folk look at this and there will be time for comments and questions…

Dr. Smith: Absolutely there'll be time for input and questions and comments. I might point out that much of the planning for pandemic flu is already going on at the local level in collaboration with the state through our bio-terrorism preparedness. Many of the issues are the same in terms of emergency response. And, so, it's not as if the pandemic flu plan is drastically different. But we plan to have a draft available for much wider distribution to the local health departments and other partners in New York State for their response to some of the details that are in there as we move forward. And that'll be happening soon. One of the ways the plan is organized is that it addresses actions to be taken at the state and local level by pandemic stage, so we really get into a lot of detail -- that's where we really welcome input from the local health departments and others.

Moderator: I noticed on the list of those five major activities - the first one was about command and control which sounds more like a military term. How does command and control translate to public health activities - what does it mean for public health people?

Dr. Smith: Well, we in public health don't generally think of ourselves as organized in a strict military command structure. But, actually, in an emergency it's very important -- the way military command or incident command structure works is critically important to responding in an emergency so that everyone knows what their role is, and everyone knows who's making the decisions, how decisions are made - and who needs to be involved with decisions. So, this section of the plan addresses and outlines who's going to be doing what, within the state health department, what our roles will be, how the decisions will be made and how we will relate to the Governor's office, for instance, and our state emergency management office, as well as the section addresses certain legal issues that will come up. What is the legal authority for quarantine and isolation and all -- the questions that will be asked -- we're trying to get those down on paper and address those at this time, and also help ensure the key stakeholders are informed about what their role is as well.

Moderator: In public health, in fact to some degree in a lot of medicine, we're so used to doing things by consensus, and we form work groups and studies and we come back with recommendations and we try and get everybody to buy in, but this is really different. This is command and control and somebody has to be in charge. But as you go along with this, how will people know what's happening? How's public health going to keep track of this and know when different steps need to be implemented?

Dr. Smith: Well, one of the cornerstones of public health information is surveillance. And so a very important ingredient in our plan is what we're going to do to track the epidemic and respond to it. And part of that, obviously, is laboratory technology in terms of making accurate diagnosis. So the second section of the plan really goes into some of these details. It updates our surveillance guidelines for local health departments, so they know what we need to do to track the epidemic. It also outlines many of the field activities, the bread and butter work that public health does in terms of identifying cases, identifying contacts, instituting isolation and quarantine - which will probably be important measures early in the pandemic. After the pandemic has evolved and there are many, many cases - isolation and quarantine may be less effective as a strategy, but early on when there are just a few cases we'll be doing that. The section also addresses laboratory surge-capacity issues and protocols for when to submit specimens and what the laboratory expects to be able to accept specimens.

Moderator: So, basically we're relying on good old standard, old fashioned public health infrastructure and surveillance as the first critical task.

Dr. Smith: Uh-huh.

Moderator: It's been interesting that despite or in addition to all the other wonderful things we have going in modern medicine that we come back to this and in fact I guess in the SARS outbreak it was pretty critical also.

Dr. Smith: Right.

Moderator: Maybe tell us a little bit about surveillance activities in New York State?

Dr. Smith: Well, I suspect our public health audience - knows a lot about what's going on with flu surveillance already. We in New York do what all the other states do in terms of having some fairly crude indicators of flu activity. Up until December of this year, we did not have influenza as a reportable, communicable disease. But in December of this past year we made laboratory confirmed flu reportable, and we did that partially in response to the apparent growing threat of a pandemic, where we needed more information. So, in New York we have instituted selective laboratory reporting of positive flu tests as a marker of flu activity. We also now track hospital admissions with laboratory confirmed flu, as well as pediatric deaths. So, three indicators of flu activity. In the event of a pandemic, those recommendations and the way we do surveillance will undoubtedly evolve, but that is the current situation in terms of what we're doing in New York for tracking flu.

Moderator: And it used to be that you just monitored hospital-acquired and nursing-home-acquired infections primarily, right, as reportable influenza cases in the old days?

Dr. Smith: That was -- well, we still do.

Moderator: And these are in addition. I understand.

Dr. Smith: Yes, we still monitor outbreaks in nursing homes, as well as we have the sentinel physician measuring influenza-like illness. And as an example we can show you the results of laboratory-confirmed, flu-hospitalized patients from this last season - a nice epidemic curve that indicates flu activity from this new reporting system. And it correlates very nicely with all the other indicators that we have for flu activity. So, this is an example of the way we track flu, and we post this weekly during flu season so that our local health department partners know what's going on. And this will continue, obviously, in the face of a pandemic - with probably even more heightened surveillance activities and more frequent updates than weekly.

Moderator: So, we have a markedly increased level of awareness, I think, around the country, and clearly increased surveillance going on at all the state levels. So if there's time you would think we would find something. And now we're talking about vaccination programs if and when possible and we're talking about antivirals. Can we turn to that a little bit and talk about our interventions as things draw closer?

Dr. Smith: Well, you've touched on the cornerstone of the way we address influenza - which is through prevention, through vaccination, and also a prophylaxis or treatment using antiviral medications. And, so, a major section of the New York plan addresses the vaccine and antiviral delivery. And this section includes issues of prioritization of who is going to receive these because at first in the epidemic there won't be enough to go around to everybody instantaneously. So we will probably be - undoubtedly be setting priorities. We also have the issue of distribution of the vaccine or antivirals. How are we going to get it - how are we going to get it out to the field? How are we going to administer it in mass clinic settings? Then, after doing that we have to track adverse events. This will be a new vaccine because it will be a new flu strain - so we will need to monitor any adverse events that occur from this - so we have set up systems for tracking adverse events and tracking where the vaccine supplies are. So, all of these capabilities are outlined in the plan and we have a lot of this underway already. Last year - with the flu vaccine shortage - we got a lot of experience with tracking vaccine availability and limited supplies, so we already have some experience with that.

Moderator: We probably should focus a little bit on the vaccine because everybody's recognized that we don't have a vaccine. I can't remember when it was - but a couple of months ago there was a report from Dr. Fauci who said that the initial trials of an Avian Influenza vaccine looked pretty promising but it was a pretty small trial. But there's a lot more to getting this to where we want it than just having a couple of good trials. And I think maybe this would be a good time to elaborate on that a little bit if you would.

Dr. Smith: Sure. There are a number of thorny issues surrounding vaccine -- the availability of vaccine. Because this will be a new pandemic viral strain, the vaccine has to be formulated so that it addresses the new strain. And when that new vaccine is available is unknown at this time. The second issue is who is going to own it and distribute it? Generally in the United States, most influenza vaccine is in the private sector and distributed via doctors in their private offices - not through the public health infrastructure. In an emergency pandemic situation, it's very likely that the government will take over the supply, but the details of that are not in place at this point. And then the third thorny issue is what is going to be the guidance for who's going to get it? So, in order to address this in the plan, what we've done and what the other states and the national government has done, is made some assumptions. That is, we're assuming that under pandemic situations, imported vaccine will not be available - that we're going to be relying on what's domestically available in the United States for our own citizens. It's also likely that two doses will be needed instead of one dose. We usually get one flue shot each fall - but in a pandemic, we're probably going to need two doses. And no one knows when the vaccine will be available, but because it has to be developed and newly devised, it'll probably take four to eight months after the pandemic is recognized before the vaccine is available.

Moderator: What about the timing between the two doses - is it one month later or two months later?

Dr. Smith: Yes. They're separated by several weeks, and it's likely to be one month.

Moderator: So that adds another layer to the planning, staging.

Dr. Smith: Right. Currently, the U.S. manufacturing capacity is limited to Sanofi - which has the only completely domestic supply chain. And currently they estimate that its sufficient to deliver about five million doses a week. So if you stretch that out and do the calculations, the implication is that only about one percent of the population may be protected per week once the vaccine becomes available. This is pretty grim news for most people, if they haven't heard this before. But I do want to stress that a lot has been done to address this kind of Achilles heel in our planning. The Federal Government, first of all, has made money available to Asia to increase surveillance activities and has sent people over to Asia to beef-up surveillance of Avian flu - so that we have more warning if a pandemic appears to be occurring. So, we're hoping to maximize the lead time through this mechanism. HHS has also increased funding to ensure year round availability of eggs. Eggs are needed for the production of flu vaccine and there've been issues of egg shortages which has interrupted flu vaccine production at times. So in order to ensure that that's not a problem, they have taken steps to do that, as well as increase our domestic flu vaccine production, as we talked about a minute ago. Also, the NIH, as you have alluded to, I believe, is sponsoring an Avian Influenza vaccine trial. And so that is looking good. But it's not known at this point whether that vaccine would protect against whatever strain evolves to cause a pandemic, but that is being worked on very rapidly. And then, lastly, there are number of strategies to increase the use of available vaccine by using lower doses or by using alternate, interdermal modes of injections, so that may be we can spread what is available amongst more people. So, there are a lot of tactics, lots of strategies, to try to address some of these major problems in terms of vaccine availability.

Moderator: It sounds like the beginning or the end of a difficult novel - that when you get down to that one percent part - could be quite a story. Early on there were concerns that because this was an avian strain that you couldn't use eggs to grow the virus in, but they solved that problem with some biochemical manipulations, right? If you kill the source of your growth, I guess, it wouldn't be a good idea. So, we need to be setting priorities for vaccination. But who's going to set them and will people go at it sort of like we talked about with smallpox? Will there be ring vaccination groups - you identify cases and surround them with vaccinated contacts. Is that what's going to happen or is it going to be different?

Dr. Smith: The approach to influenza has to be different than smallpox. Ring vaccination will not work for some of the reasons that Barbara mentioned. Flu is transmissible even before symptomatic disease - there's not long incubation period. So for a number of reasons ring vaccination is not going to work. A lot of progress has been made in terms of thinking through the prioritization for vaccination process. The two considerations that will guide the prioritization are number one - reducing health impact, and that means vaccinating staff in the healthcare system and patients who are at highest risk of complications. And then the second consideration is reducing social and economic impacts by making sure that our public protectors - our police, our firemen, et cetera, are protected. So by using that as guidance, we -- and the Federal Government and Federal Advisory Committees have actually proceeded to set forward a priority scheme. And our plan is incorporating the national recommendations on that.

Moderator: So there's been a national task force to look at these very issues and they meet regularly?

Dr. Smith: Well, in fact just last July the National Vaccine Advisory Committee met with the ACIP - the Advisory Council for Immunization Practices - and issued a tiered approach - a prioritization for the use of vaccine in a pandemic setting. I think we have a slide that shows the current top elements or levels for prioritization with some numbers there. You can probably see that the top level is healthcare involved with direct patient contact and essential support. And it estimates the number of persons that would be vaccinated in each group. This top priority adds up to about forty-six million folks, but this doesn't show the whole prioritization scheme. But we have made a lot of progress in the last year in our thinking through of this particular issue.

Moderator: It's a big issue and obviously there's a lot to do there. The sooner the influenza might arrive, however, the worse off we might be. What about turning now to the discussion about the use of antivirals, which also is not exactly going to solve all of our problems, if I understand the logistical situation properly?

Dr. Smith: That's correct. Our vaccination strategy kicks in months after - probably - the onset of the pandemic. So our first strategy until vaccine is available is to use antiviral medications. And these also raised some of the similar thorny issues. That is, how much will be available? Will it be available to the public sectors as opposed to the private sector, and what guidance will there be on how to use it? I think folks are probably aware that we have two classes of antiviral medications - the adamantines which include amantadine. That group are not effective against Avian Influenza, so we're really dependent in terms of antivirals on using the neuramidase inhibitors. And the one that is probably best suited to our needs, to address this need, is also Tamivir which can be taken orally and is available for kids, as well as adults. And so actions have been taken to stockpile it. The Strategic National Stockpile currently has approximately two million courses of treatment - a five-day treatment. They also are stockpiling rimantadine, but for pandemic flu that would not be helpful. The antivirals in the private sector are estimated to be one to two million courses of oseltamivir, and currently oseltamivir production is being made in Switzerland, so they're trying to establish a U.S. chain of production for domestic use as well.

Moderator: If we've got limited supplies of all these things, how can public health people work with their community and political leaders to deal with some of the situations that sound like they're going to pop up? There has to be some planning in that regard as well, I would suspect.

Dr. Smith: Again, similar to vaccine, the strategy for the use of antivirals has been thought through a lot at the national level. Generally speaking, you can use oseltamivir for treatment or for prophylaxis. But in the event of a pandemic - where there's a broad need of oseltamivir - prophylaxis requires a lot longer and higher use of the antiviral than does treatment. As we said, treatment is just for five days. So the general approach for pandemic planning is that we will use oseltamivir for treatment, and as long as there's limited supply we're recommending the treatment be used for those who come down with illness within the first forty-eight hours of symptoms. Now, there is a role for prophylaxis in restricted settings and that would be, for instance, high risk or critical service groups - small groups of people that really need to be protected who are serving the ill, as well as probably the use in institutional settings where post exposure or prophylaxis may be needed to prevent spread. But we're primarily going to be using oseltamivir for treatment.

Moderator: So this is where public health and some of the community people are going to have to get together and talk about the groups who are going to be able to get this if it's a limited supply - to keep things working - including the hospitals. What major points might we need to keep in mind with regard to patients?.

Dr. Smith: Well, hopefully we won't totally run out of antivirals, but that remains to be seen. As I say, there is actually talk within our state, as well as other states to stockpile oseltamivir at the state level in addition to the federal level. But healthcare response is a major issue that's another major section in our plan. And it addresses issues such as surge capacity - lots of persons going to the hospital. How will our hospitals manage and address the ill? How will they triage patients and make decisions about where they should go? How will we address all the questions that hospital personnel will have? They'll be concerned about their own health and their family's health and infection control issues. So all of those issues are very real and important, and are being addressed in our plan, as well as nationally. There are also issues of mass mortality, and with some of the estimates of the number dead - how are we going to address that issue? And then also just keeping track of our resources - where are the hospital beds that are open, where are our ventilators that will be needed, who has the capacity to accept more patients? That will be a state role and we are making plans for that as well.

Moderator: So, briefly, can you summarize what you see as the challenges with regard to the health care?

Dr. Smith: Well, unlike other emergencies or catastrophes -- which are usually geographically confined - pandemic flu is going to be worldwide. So, we will probably not be able to turn to another state or the United States won't turn to other countries because everyone's going to be in the same boat. The other thing to expect is that hospital staff - healthcare givers will be affected just like the rest of the population. They're going get sick - so there will be a limited ability to call up reserve staff. And that's going to be a major challenge.

Moderator: Certainly will. We're at the point in the show now when I want to remind you that we're ready to take your calls. The toll free number for you to use is 800-452-0662 or you can send your written questions by fax to 518-426-0696. Maybe as we wait for questions, try and draw this to a close, can you make some predictions for us about what's going to happen here? Are there some possibilities that you can sketch out that might help people in their planning?

Dr. Smith: Actually the CDC has come up with some software called Flu Surge, which makes it easy for states and localities to make some case scenarios. If we were to make a kind of worst case scenario where we assume that thirty-five percent of the population was going to come down with pandemic flu - which is not an unreasonable worst case scenario - and assume that it hits all at once - such as over a six-week period. Then we could expect that there'd be approximately fifteen thousand hospital admissions and almost four thousand deaths per week in New York State - excluding New York City. We're talking catastrophic scenario. On the other hand, that's the worst case scenario. If we make assumptions that aren't so grim - that is a lower attack rate of fifteen percent spread out over twelve weeks, and less intense - the estimates go down to about a thousand hospital admissions and four hundred deaths per week. But still, that is worrisome as well.

Moderator: Big number. It's as scary as one percent. Are there preventive actions that can be taken by people other than vaccines and antivirals? What are some of the basic public health prevention things that people can do with regard to this?

Dr. Smith: There's very little science behind some of this. However, I think the general sense and the approach will be to try to slow the spread of pandemic flu virus early on in the course of the pandemic - to buy time for these response issues we've talked about. So, I think we can expect the travel recommendations that we put in place - if there's an outbreak in one country - there will be travel restrictions. I think we can expect to see early on the isolation of ill persons, the quarantining of exposed persons and probably the closure and canceling of events, closure of schools to try to decrease mixing of the population, so that we slow the -- the transmission. There's also individual actions that persons can take such as hand washing, wearing masks and just decreasing interpersonal public contact - probably reasonable to expect with decreased transmission. But none of these things are expected to prevent a pandemic.

Moderator: Good old standard public health measures like surveillance. Recently in the Gulf disaster, in the New Orleans area and Mississippi, as well as in our own disaster in New York City, almost four years ago now - communications turned out to be a really big issue. And we always tend to leave some of these discussions to the last - but they are critically important. What might you tell us about the role of communications in the planning and carrying out things like this?

Dr. Smith: Well, the communications are a major part of the national planning process, as well as in New York State. We devoted a major section of our plan to communications. And this section really tries to outline the use of social marketing strategies for risk reduction - trying to educate the public on what they can do to protect themselves, and also lays the ground work for getting all of the public information officers at the local health departments and the State and the Governor's offices, et cetera, all speaking with one voice so we have one message instead of contradictory messages. And in that line, we have developed posters, as well as certain public health messages, that are already drafted to pull out when the need arises. So that section of the plan goes into a fair amount of detail.

Moderator: In the case of a pandemic, where can public health workers turned to get more information? We mentioned earlier on that there's a website readily available to everybody with a computer. Again, please call in or fax your questions. We have one here from Rockland County, actually, which asks, “Are there plans to identify possible reservoirs of Avian Influenza such as at poultry farms in New York State?” I guess we turn to our Ag and Markets representative at the table to answer that. Have you heard anything?

Dr. Wallace: Well, I do know that there is an ongoing surveillance program in poultry markets that Ag and Markets conducts - particularly in the metropolitan area of New York City where they do have a lot of live markets. And they do regular testing and that information is shared with public health - if there is a strain identified. So there is currently regular, intensive surveillance going on to identify Avian Influenza in the United States.

Moderator: Another question that relates to what we want to get at in terms of our audience is, in most states, the state and local public health agencies have somewhat different roles. Very quickly, what can you say about what the local health departments need to be doing these days to get ready for pandemic influenza?

Dr. Smith: Yeah. Well, as I mentioned earlier, a lot of what they already are doing will be directly relevant to pandemic flu. So through bioterrorism preparedness planning, I think all local health departments are having table top exercises. Some of them are having field exercises for addressing such things as mass vaccination clinics or mass distribution clinics. They are already planning with their emergency response personnel. So a lot of the activities that will be needed for pandemic preparation are already in place through bioterrorism preparedness. Some of the detailed things that are in the plan that they haven't seen yet in New York, are things that relate to specific forms that we will be using for reporting information and how to submit specimens to the laboratory.

Moderator: So there's a lot for them to do. Is there a place they can stay in touch about this, is there a website for New York State Health Department? How can they keep up with this locally?

Dr. Wallace: Well, I was going to mention first that the DHH plan has a very useful annex. If a state or a locality hasn't looked at that yet - you can get the Federal plan and look at the state and local planning guidance document. That's very helpful. It outlines what local health departments or local jurisdictions should be doing.

Moderator: So they can look at that. That's great. I want to thank you both very much for joining us today and helping with this show. We'd like to thank all of you for joining us today and also ask that you take a moment to fill out your evaluations because your feedback is very helpful for planning our future programs. This program will be available via web streaming along with all our other previous broadcasts - check our website for further details. We hope you'll join us next month on the 13th of October for our program on Law Enforcement and Domestic Terrorism Preparedness. Our speakers will include representatives from the New York State Police Counter terrorism Unit and the FBI, and they'll share information related to upstate New York Regional Intelligence Center - a new development here, dealing with suspicious powders. How do you respond, what protocols do you use and some discussion about forensic epi investigations. Until then, we extend our deep thanks and our best wishes to all the public health officials and first responders who are so actively involved in the aftermath of Hurricane Katrina, our thoughts are with all of you. I'm Robert Westphal. See you next time on the University at Albany Center for Public Health Preparedness Grand Rounds Series.