Swine Flu Pandemic Summary

Introduction The purpose of this document is to provide an overview of the impact of an influenza pandemic on individuals and on the population as a whole in the United States. Important footnotes are hyperlinked if there is public access to them.

Disclaimer There is no way to predict the future with any certainty, because every influenza virus strain, especially those causing pandemics, behaves a bit differently. Even the World Health Organization has commented on this problem in a briefing given on 5/18/09.1 Under the heading of Key Uncertainties, they listed • •

“The only thing certain about influenza viruses is that nothing is certain. It remains uncertain how fast the new influenza A (H1N1) virus will spread throughout the world and whether it will become widely established.”

Historical Overview George Santayana said “Those who cannot remember the past are condemned to repeat it.”2 This is particularly true when it comes to pandemic preparedness. Many resources about the Spanish Influenza Pandemic of 1918 are easily available online with some basic searching that provide some insight to the severity of this problem. For a relatively brief paper, read “1918 Influenza: the mother of all pandemics”3 by Dr. Jeffery Taubenberger, one of the leading virologists in the world. For greater depth, John Barry’s book The Great Influenza4 that provides a very detailed historical account of the pandemic in 1918.

1

Margaret Chan et al., Summary report of a High-Level Consultation: new influenza A (H1N1) Geneva, 18 May 2009 (Geneva: World Health Organization, May 18, 2009). 2

George Santayana, Introduction and reason in common sense, 2nd ed. (New York: Scribner, 1922). 3

Jeffery K Taubenberger and David M Morens, “1918 Influenza: the mother of all pandemics,” Emerging Infectious Diseases 12, no. 1 (January 2006): 15-22. 4

John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague In History, 1st ed. (Viking Adult, 2004).

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H1N1 Spring Experiences in Mexico and the United States One only needs to look at what has happened in North America recently to get an understanding of what could develop as a pandemic unfolds. At this point, the US has likely only been the tip of the iceberg. In Mexico, a number of public gatherings have closed during the peak of the first wave, including churches5 and sports venues6. In May, emergency departments (EDs) had seen increases in volumes by 50-75%.7 It is important to remember that these volumes were increased before this had become a major problem. Many of the people who were overcrowding EDs are what are referred to as “the worried well.” These are the people who think that they may have been exposed or have become diseased during a disaster, terrorist incident, outbreak or other similar event. They flood hospitals out of potentially unfounded concerns for their own health which limits access to those that have true emergencies. Think of the impact of a pandemic in the fall. EDs could be swamped with both people with true serious complications of or health risks associated with influenza. In addition, there could be greater numbers of the worried well simply because we will be moving into the routine cold and influenza season and people will assume they are infected with H1N1 when they may have normal seasonal influenza. Unless one is seeking care at an ED for a life-threatening emergency, the waits could be incredibly long, if not completely unbearable.

The Omen of the Southern Hemisphere and Developments in the Northern If the rationale for ED overcrowding is insufficient, all one needs to do is look to events that are occurring in the Southern Hemisphere, which is in the midst of their normal seasonal influenza pattern. Argentina is a particularly good example at this time because they have the third highest number of deaths in any country, trailing only the US and Mexico. This high level of impact from the disease in a country in the southern hemisphere makes a good case study for anticipating what may happen in the US this fall.

5

“Swine flu outbreak,” The Guardian, April 26, 2009, sec. World News.

6

“Swine Flu Hits Mexico” - Photo Essays – TIME. It should be noted that the soccer game was a sellout although it would be really hard to determine that from the picture. 7

Maryn McKenna, “''Worried well' overload gives taste of pandemic scenario,” CIDRAP.

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The Economic Un-Stimulus Package Businesses across Argentina are having major problems as people limit their activities in public resulting in 50% reductions in trade in some sectors of the economy.8 Businesses and schools have chosen to close and others have been required to do so by municipal government.9 Factories are closing for weeks. These impacts are not just limited to South America either. Businesses are being impacted by 10% absentee rates in Australia at the beginning of the onslaught of the pandemic.10 This rate will likely continue to climb. Britain is having similar problems with a tripling of absenteeism due to influenza in workplaces even though the estimated number of cases in the country has only doubled.11 School Closings One particular problem for individuals and businesses is the impact of school closings. Many people only think about the impact of having to stay home from work with a sick child. What happens when a school closes for a couple of weeks (or longer) as a measure to prevent the spread of influenza? Are most families prepared to absorb that loss of income? It is particularly important for families to start preparing mitigation plans now by arranging child care plans when an event like this occurs this fall. People should also consider some redundancy in these plans because of the possibility that a care provider may become ill themselves or need to care for an ill family member. Assume though that many families don’t make these types of plans and have to have one of the parents providing care. Don’t forget the problems that arise in single-parent households. What is the impact on businesses? It may not be as crucial in some economic sectors, but what about in areas that support areas of critical infrastructure like police, fire, emergency medical services, health care, utilities and others? Think of hospitals as an example. Given that they would already be strained by increasing numbers of patients, how will they function when many of their staff are absent while at home caring for children? The reality of school closings has drawn closer because the World Health Organization gave recommendations on July 21st around closing schools and

8

“Argentine businesses struck by swine flu” Financial Times, July 8, 2009, sec. Americas.

9

Vicente L Panetta, “Schools, businesses close in Argentina for flu,” The Associated Press, July 11, 2009. 10

Kate Sikora, “Absenteeism at record levels in Australia due to flu | Business | News.com.au,” news.com.au, July 10, 2009. 11

“Swine flu work absences 'triple in a week' - Telegraph,” The Daily Telegraph, July 22, 2009, sec. Health.

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businesses during a pandemic.12 These guidelines increase the chances of local and state public health departments taking these types of measures. Hospitals Another problem hospitals would face around staff shortages will be due to staff fears about getting infected. This threat has already started emerging as nurses at a hospital in Northern California filed a complaint with California OSHA around the availability of N95 masks.13 Stockpiles of these masks in many hospitals were quickly reduced early this year as this virus began to emerge. The CDC recommendations at this time call for the use of these respirators by health care workers when entering the rooms of these patients.14 Until these recommendations are changed, health care providers will continue to rapidly burn through these supplies. While it makes sense to use extra caution by using these masks while characterizing the true nature of the spread of the virus, it could put the health care workers in jeopardy later this fall and winter as supplies are depleted unless there are tighter controls for appropriate use, such as during aerosol generating procedures. Hospitals in the Southern Hemisphere are beginning to prepare for the influx of influenza patients. Hospitals in both Argentina and Chile have either delayed or cancelled almost all of their elective procedures.15, 16 So what does that mean for most people? Maybe nothing. However, what if one sustains an injury that requires surgery? Think about something as common as a cartilage tear in the knee or ligament rupture. Those can both be excruciatingly painful but they are not considered emergent procedures. Anyone who needs this type of procedure would not get it. A big problem for hospitals is that they already operate on very thin margins. Elective surgeries are a major source of revenue that lets them provide many of their other services. If a pandemic with many waves unfolded over the course of a 12

“Consider Closing Schools To Slow Swine Flu Spread Says WHO,” Medical News Today, July 21, 2009. 13

California Nurses Association, “Nurses File Cal-OSHA Complaint After Hospital Refuses to Supply Swine Flu Masks for Units with Infected Patients.” 14

“Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Influenza A (H1N1) Virus Infection in a Healthcare Setting,” CDC H1N1 Flu. 15

Associated Press, “Argentina delays surgeries to cope with swine flu,” Taiwan News, June 23, 2009, Online edition, sec. Health. 16

Abigail Wilkinson, “SWINE FLU DELAYS 5,000 OPERATIONS IN CHILE,” The Santiago Times, July 10, 2009, sec. News in Chile and Latin America.

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year hospitals would take a significant financial hit. Many of them currently are teetering on the edge of insolvency. An event like this would force many to close or reduce the number of services they provide or put them into receivership.

Mortality The mortality rate in Argentina at this time is 2.7% and 2.0% in Chile.17 The most concerning part of this is that the deaths are disproportionately high among the young and healthy. Pregnant women and those with other underlying medical conditions are also at risk. This is the same type of pattern that was seen during the Spanish Flu. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists have already urged pregnant women to wear masks in public and to try to work from home.18

The Virus Action of the Virus A paper posted online prior to publication in Nature19 indicates that the H1N1 virus is behaving differently than common seasonal influenza strains. Influenza normally infects the upper respiratory tract. This virus seems to infect the lower respiratory tract where it can damage the alveoli, which are the air sacks in the lungs where the oxygen and carbon dioxide exchange occurs with the blood. This is another similarity to the Spanish Flu pandemic in 1918. A military physician at Camp Devens, just outside of Boston in September 1918, describes what this is like. “This epidemic started about four weeks ago, and has developed so rapidly that the camp is demoralized and all ordinary work is held up till it has passed....These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they very rapidly develop the most viscous type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves. We have been averaging about 100 deaths per day, and still keeping it up. There is no doubt in my 17

“Argentina sees significant rise in swine flu deaths,” France 24.

18

Kate Benson, Julie Robotham, and Alexandra Smith, “Swine Flu: Pregnant Women Should Wear Masks, Stay Home,” July 17, 2009, sec. Wellbeing. 19

Tasushi Itoh et al, “In vitro: and : in vivo: characterization of new swine-origin H1N1 influenza viruses” Nature (July 13, 2009).

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mind that there is a new mixed infection here, but what I don’t know.”20 It is important to remember that he is describing deaths in young, healthy military recruits for World War I. Examination of the lung tissue of those that died resembles that which would be expected among victims of pneumonic plague or chemical weapons exposure.

Transmission of the Virus Influenza viruses are normally spread by large droplets within a few feet of the person who is ill or by acquisition from surfaces, called fomites, where these droplets have landed and been picked up by the hands of another person. There is also a small proportion that is spread directly though the air. There are some who are concerned that this virus may have more of an airborne component than normal but more evidence around airborne spread is needed at this time.

Mutation and Hybridization Mutation Influenza is a negative-stranded RNA virus. The most important part of that characteristic is that they mutate quite readily. This can allow for small or major changes towards a more or less dangerous strain of the virus. It could become more virulent or transmissible or less so. It is somewhat up to chance to determine what will happen over the course of time. Hybridization The same characteristics that make influenza viruses prone to mutation make them prone to hybridization as well. This property is perhaps the most frightening thing about H1N1, which seem to be transmitted quite readily from person to person. If it were to hybridize with H5N1 (avian influenza), we would likely have a monster on our hands that would completely change the world as we know it. Unfortunately, the genetic characteristics of H1N1 and H5N1 are somewhat similar, so hybridization is a distinct possibility. The death rate from avian influenza varies a bit between 50-70%. Think of the outcome of that if 30% of the world population were to become infected like in 1918. The current estimate of the world population is 6.7 billion. If one-third of them were to become ill, that would be 2.2 billion people sick. Assuming 60% of them would die, that’s that over 1.1 billion deaths. That’s too big a number to grasp. What would that be like within a particular community? Look at the Twin Cities metro area as an example. There are 3.2 million people in this area. That would mean 1,066,667 projected illnesses and 640,000 deaths. If those deaths were evenly distributed over a six month period, that would mean about 3,500 deaths per day or roughly 146 per hour in the metro area alone. Remember though, that 20

“The Great Pandemic: The United States in 1918-1919: Massachusetts.”

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is deaths that are primarily due to influenza. That doesn’t account for deaths that are secondary to the impact of influenza, like food and medicine shortages, power failure, and infrastructure failures. Epidemics and pandemic have a curve shape to their impact, something similar to a bell curve. That means that at the tails the death rate would be lower but in the middle it would be phenomenal. Look at the current graph of influenza activity in the US.21 The typical bell shape pattern is present but the H1N1 activity is also indicated starting at week 17 of this year. This type of pattern is not usually seen during the summer. The main point though is that there are typically a stretch of a few weeks during each wave where illness and death will peak over normal rates. In addition, pandemics generally come in waves. Look at the pattern that occurred with the Spanish Influenza pandemic in 1918. There were three distinct waves that occurred during that time. A relatively mild one occurred in the spring, the major secondary one in the fall, and a moderate tertiary wave the EID 12(1):15-22 following spring. A simple extrapolation from this indicates we would see 3-4x as many cases this fall as we did in the spring. However, given our society is considerably different from that in 1918, this could change dramatically as well. Things that could cause a steeper pattern to the curve with higher numbers of cases include rapid global transportation, high population density in cities and tightly sealed buildings with considerably lower amounts of fresh air compared to buildings used in 1918.

21

CDC, “Influenza Website of the Centers for Disease Control and Prevention (CDC),”

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The Vaccine and Antiviral Problem Vaccines Many people are expecting that a vaccine will be available in time for the worst of the normal influenza season. That has been the message that has come through many media outlets. However, the truth is that a vaccine release date keeps getting pushed back further and further. Now, it may be the end of the year before one is available.22 The other problem is the methods that are used to produce the vaccine. Currently, the only method licensed in the US requires egg-based cultures. The yields of vaccine have been less than one-half of what has been expected.23 Vaccine shortages could occur due political pressures. 80% of the vaccine used in the United States is produced overseas. Foreign governments might succumb to pressure among their population to limit the export of vaccines by pharmaceutical companies to as a means to combat their own domestic pandemic problems. There is historical precedent showing that occurred during prior mild pandemics.24 There is also a possibility of a shortage of syringes and needles to administer the vaccine. The production and distribution systems of products in the US often rely on a just-in-time process. During normal times these methods are adequate but they limit throughput due to many bottlenecks during times of crisis. For example, influenza vaccine delivery this year will require at least double the number of syringes and needles due to separate vaccines for seasonal and H1N1 strains. It has not yet been determined what doses will be required for H1N1 vaccine which means that there could be a need for multiple doses. This has the potential to pose a major problem for vaccine delivery.

Antivirals Antivirals can be used both to prevent and to treat influenza. However, on the prevention side, it would require a significant number of courses of treatment during the duration of a pandemic to provide protection. The supply of antivirals is insufficient to use them in this manner. A more insidious problem though is that strains of H1N1 have been identified that are resistant to one of the common antiviral medications, Tamiflu (oseltamivir phosphate).25 Fortunately resistance has not yet been seen in the other major antiviral, Relenza (zanamavir). 22

“WHO warns of H1N1 vaccine delay - Influenza A (H1N1)” Euronews, July 15, 2009.

23

Helen Branswell, “Swine flu vaccine production hits a snag: yield so far is 'less than optimal',” The Canadian Press, July 13, 2009. 24

Maria Cheng, “Fight for swine flu vaccine could get ugly - Washington Times,” The Associated Press, July 16, 2009. 25

“WHO | Pandemic (H1N1) 2009 briefing note 1,” July 8, 2009.

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Health Care Capacity The US has a critical shortage of staffed hospital beds. There are roughly 956,000 licensed beds but only 707,000 of them are staffed. During the normal influenza season, 96% of those are occupied. If a pandemic of the scale of 1918 were to occur today, roughly 25 million Americans would require hospitalization. There are other problems with health care supply though as well. The national supply of ventilators (breathing machines) is a bit over 105,000. During the normal influenza season, over 100,000 of these are being used. A pandemic mirroring 1918 would lead to a demand for about 12.5 million ventilators in the US. That means that if the waves of a pandemic were spread evenly there is less than a 1% chance of a ventilator being available for a single individual. This problem has been known for a number of years.26 There are about 5000 hospital beds and 533 ventilators in the Twin Cities metro area. In 2008 during normal seasonal influenza the Twin Cities area ran out of ventilators.27 There could be a critical shortage of both this fall which would lead to some ethical dilemmas around the rationing of care.

Broader Societal Impact It is hard to precisely say what will happen around the US if a severe pandemic were to occur. However, it is safe to say that a pandemic similar to that in 1918 will change the world forever. Casket shortages occurred in 1918 and eventually the deceased had to be interred in mass graves. Just think about the impact of tens or hundreds of thousands deaths in the Twin Cities. There is no capacity among funeral homes and cemeteries to handle those kinds of numbers. More importantly, however, what would be the impact on those that live through it? That’s really anybody’s guess but there are some clear dangers that will be posed for the living. If you have not seriously considered stockpiling of some supplies you should get a copy of an article that appeared in the New Scientist where the broader infrastructure collapse potentials are addressed.28

26

Donald G. McNeil Jr, “Hospitals Short on Ventilators if Bird Flu Hits,” The New York Times, March 12, 2006, sec. National. 27

Warren Wolfe, “Ventilator shortage is warning of potential crisis,” Star Tribune, March 14, 2008. 28

Debora MacKenzie, “Will a pandemic bring down civilisation?” The New Scientist, April 5, 2008.

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It is extremely important to continue or begin preparing your family and organization now.

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