U.S. Super-Flu Plan Reveals Gaps in Readiness

Pandemic Flu Plan Includes Vaccine Rationing, Quarantine, School Closings

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Aug. 26, 2004 - Like a recurring nightmare, there's going to be another worldwide super-flu outbreak. Now, the nation's new emergency plan tells us what to expect.

It's not a pretty picture. As things stand, the plan notes, a serious flu pandemic would cause "substantial disruption of society and commerce."

Outbreaks of a super-flu -- known to public health experts as pandemic influenza -- sweep the globe whenever a brand-new human flu bug evolves. The last one, the 1968 Hong Kong flu pandemic, killed some 34,000 Americans -- half as many as died in the 1957 Asian flu pandemic. The record goes to the 1918-1919 Spanish flu epidemic, responsible for 675,000 U.S. deaths and more than 50 million deaths worldwide.

We're overdue for another one, experts say. And there are some nasty bugs brewing across the globe. Most worrisome is the H5N1 bird flu, still wreaking havoc on Asian poultry. This bug infects humans - with a scary death rate - but hasn't yet learned how to pass from human to human.

If it does, or when another flu bug breaks out, the U.S. will have a plan to deal with it. Secretary of Health and Human Services Tommy Thompson today announced that a draft version of the plan is open for 60 days of public comment.

"This plan will serve as our roadmap on how we as a nation, and as a member of the global health community, respond to the next pandemic influenza outbreak, whenever that may be," Thompson says in a news release.

Quarantine, School Closings, Vaccine/Flu-Drug Rationing

If the disease is as bad as the 1918 Spanish flu, the plan envisions drastic measures. For example, people might be quarantined -- that is, have their movements or activities restricted. Quarantine would usually be at home, but might be in a "dedicated facility," the plan notes. Quarantine might apply only to certain individuals or might be applied to specific populations or even entire geographical areas.

But health departments would implement such drastic measures only when necessary. When is that? The plan spells it out. In doing so, it offers a peek at exactly what officials expect to happen in the event of a flu pandemic.

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Phase Zero: Birth of a Bad Bug

The first phase of the plan goes into effect when a human being somewhere in the world comes down with a new flu bug. That's already happened this year with the H5N1 bug. As the plan calls for, the CDC quickly swung into action, getting to work on developing lab tools for identifying and growing the bug in culture. Plans already are under way to help manufacturers come up with vaccines.

Phase 0, level 2 has already happened, too. That's when two or more people get the bug, but when it's still not clear that person-to-person transmission is possible. At this stage, vaccine preparation should be under way. Despite technical obstacles, vaccine candidates against H5N1 and other nonhuman flu bugs are being developed for eventual human tests.

Phase 0, level 3 is confirmed person-to-person spread of a new human flu. That has not happened with the bird flu bugs now circulating. When this happens, the plan calls for serious action. If human-to-human spread is outside the U.S., point-of-entry control activities are called for. If it's already in the U.S., speeding vaccine development and bulking up the supply of flu drugs become high priorities. Isolation and quarantine of cases and their contacts would begin immediately. National flu surveillance plans would go into effect. The assistant secretary for public health emergency preparedness would issue "a pandemic alert." Regular news briefings would begin.

Phase 1: The Bad Bug Breaks Out

Phase 1 starts when the new flu bug causes several outbreaks in one country and spreads to other lands. If it looks like the bug causes severe disease and death in at least one segment of the population, phase 1 activities begin:

  • The Health and Human Services (HHS) secretary declares a U.S. pandemic.
  • The HHS asks for funds to buy and speed production of pandemic flu vaccine.
  • The Surgeon General's office mobilizes its Readiness Force.
  • The CDC and the HHS assess the need for, and effectiveness of, patient/contact isolation, quarantine, and travel restrictions.
  • Flu drugs in the national stockpile are distributed; more drugs are purchased.
  • "Priority groups" - those most at risk of infection, and those with jobs crucial to public health, safety, and domestic security - get the vaccine.

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Phase 2: The Bad Bug Spreads Across the Globe

Phase 2 means the bug has spread so far that multiple countries experience outbreaks. At this point, the plan notes, "community health resources, both human and material, are likely to be severely stressed or overwhelmed."

Shifting resources between states will be difficult or impossible, either because there is no extra supply or because areas not yet hard hit will want to hang on to what they've got in case things get worse.

There will be a huge demand for flu drugs. This demand will very likely outstrip supply. And there will be a huge demand for flu vaccine. But the vaccine takes at least six months to make, and people likely will need two doses for full protection. Meanwhile, the sheer number of sick people will likely overwhelm hospitals and health-care professionals.

"When the vaccine becomes available it will be in short supply relative to demand," the plan notes. "The limited availability of preventive and therapeutic interventions, along with possible limits to access to clinical care, could lead to public concern and substantial disruption of society and commerce."

At this point, the plan emphasizes the need to provide health care within communities and for making sure scarce drugs and vaccines go to those who truly need them the most. At this point, the plan calls for public health agencies to pull out all the stops.

Phases 3-5: End of the First Wave, Braving the Second, Seeing an End

Eventually, the first wave of the flu pandemic passes. But historically, this first wave is followed three to nine months later by a second wave of outbreaks. These usually are less severe, but still quite deadly. The plan calls for using this time to vaccinate more people and to rebuild drug stockpiles and health-care capacity.

Finally, at phase 5, the pandemic is over. This is no time to rest, the plan says. It's time to assess what went wrong, what went right, and to use the lessons learned for the inevitable next new super-flu.

SOURCES: Pandemic Influenza preparedness and Response Plan (Draft), Department of Health and Human Services, August 2004. News release, Department of Health and Human Services.

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