Bird Flu
By Bradford Frank M.D., M.P.H., M.B.A., Thu Dec 8th

Very often when people begin to learn about bird flu, they jumpto the conclusion that because medicine has advanced by quantumleaps since the 1918-19 influenza pandemic (global epidemic),there is nothing to worry about. They are certainly right aboutthe advance of medicine, which has been extraordinary by anymeasure. Unfortunately, when it comes to dealing with a bird-flupandemic, these advances fall short in many areas. To name themost significant: 1.Bird flu is caused by an influenza virus,for which there are only four approved antiviral agents in theU.S. The virus has extensive resistance to two of thesemedicines already, and resistance might develop in the remainingtwo once they are used more widely in a pandemic. The tworemaining medicines, Tamiflu (oseltamivir) and Relenza(zanamivir), are in extremely short supply and, even withplanned increases in their manufacture, will remain in shortsupply for many years to come. These medicines must be givenwithin 48 hours of the onset of symptoms, which can be difficultto accomplish for a variety of reasons. Even when they areavailable and given on time, their effectiveness is less than100 percent. And because bird flu is very different than theusual influenza we are used to, higher doses given for longerperiods of time may be necessary for optimal effect. 2.While wehave many wonderful antibiotic medicines, these are noteffective against bird flu, because antibiotics treat onlybacterial infections, not viral infections. Antibiotics can beused to treat bacterial infections that develop after viralinfections have damaged the body, allowing bacterial infectionsto "take over." This can happen, for example, when viralpneumonia turns into bacterial pneumonia. However, this did nothappen in the 1918-19 Spanish flu to any extent, nor in the 2003SARS pandemic, and it doesn't appear to be a significant factorin the deaths that have occurred so far from bird flu. Hence allour sophisticated antibiotics will not be of much help with birdflu. 3.The most common cause of death from the 1918-19influenza pandemic, the SARS pandemic, and from bird flu isacute respiratory distress syndrome (ARDS). The viruses fromthese diseases cause severe damage to lungs, which results inARDS. Numerous treatments have been tried but generally havefailed. Patients with ARDS require mechanical ventilatorysupport, meaning they need to be on a mechanical respirator.These are expensive machines, and the supply in the UnitedStates is only slightly above demand during the normal fluseason. Simply put, when the bird-flu pandemic strikes, therewon't be enough of these machines, and so people who developARDS will not have access to this potentially life-savingtreatment. 4.There won't be enough isolation rooms to place thelarge numbers of patients with bird flu in, which will result inmore people becoming ill through exposure to people with birdflu. Likewise, there won't be enough of some medical equipment,because of increased demand for some items coupled withdecreased supply--because of our reliance on a global supplychain, foreign manufacture, and just-in-time delivery. Therewon't be enough personal protective equipment (such asdisposable gloves, N95 face masks, gowns, face shields orgoggles, head caps, and shoe covers), which will increaseexposure and infection. 5.During the coming pandemic, therewon't be enough beds in hospitals for all the sick people withbird flu. Makeshift "hospitals" will have to be establishedoutside of existing hospitals to care for all the ill patients.6.An effective vaccine has yet to be developed, and the chancesthat one will be developed before a pandemic emerges arepractically nonexistent. Once a vaccine is developed, it will bemonths into the pandemic, and many people will already havebecome ill. Because we have no natural immunity to this newvirus, we might need two immunization shots to developsufficient immunity. This makes implementing an immunizationprogram more difficult, and decreases the amount of vaccineavailable for everyone. Vaccines, like antiviral medicines, arenot 100 percent effective in either preventing infection orminimizing symptoms once infected. A startling new report (a)found only limited benefit from influenza vaccines: "In peopleover 65, the vaccines 'are apparently ineffective' in theprevention of influenza, pneumonia and hospital admissions,although they did reduce deaths from pneumonia a bit, by up to30 percent." According to the Influenza Vaccine Supply (IVS)International Task Force, "Whatever scenario, even the mostoptimistic, the worldwide [vaccine] production capacity will

beclearly insufficient in case of pandemic." 7.Shortages ofnurses and other healthcare personnel will be significant,because of overexposure to people with bird flu--and thus ahigher illness and death rate among healthcare workers, andbecause a high proportion will simply decide not to come towork. A similar situation occurred in New Orleans duringHurricane Katrina when 250 members of the police department(one-sixth of the force) abandoned their jobs during thehurricane and flooding. It also happened in Toronto during theSARS outbreak, when some nurses and other healthcare workerssubmitted their resignations (although many were persuaded tostay). The shortage of nurses, which is already a big problem inthe United States, was highlighted recently by Keji Fukuda ofthe influenza branch of the Centers for Disease Control andPrevention (CDC). According to Fukuda, scientists are racing toprevent what could be millions of deaths from a flu pandemic,but what could trip them up is the simple lack of nurses andhospital beds. He said, "No matter how good medical technologyis, if we don't have healthcare workers to care for sick peopleand hospital beds to put them in, it's not a good situation."And it's not only the limited numbers of nurses--it's also aquestion of whether or not healthcare workers would come to workduring a bird-flu pandemic. A recent article (b) reported thedisturbing findings of a survey of 6,000 healthcare works in andaround New York City:

"One assumption blown away by Hurricane Katrina is that ifgovernment does nothing else, at least it protects people'shealth and safety.

The Mailman School of Public Health at Columbia University inNew York City set out to look at how many healthcare workerssaid they would show up for work, depending on the type ofemergency. There was some good news: 87 percent of 6,000 workerssurveyed in 47 facilities in and around New York said they wouldbe able to go to work in the event of a mass casualty incident,and 81 percent for an environmental disaster. Only 61 percent,however, would show up for a smallpox epidemic, just 48 percentduring a SARS epidemic and 57 percent during a 'radiologicalevent.' That's a problem, isn't it? Less than half of healthcareworkers expect to work during a SARS [or bird-flu] epidemic, andless than two-thirds if terrorists set off a so-called dirtybomb in the financial district. 'Although we might assume thathealthcare employees have an obligation to respond to thesehigh-impact events, our findings indicate that personalobligations, as well as concerns for their own safety, play apivotal role in workers' willingness to report to work,' saidKristine Qureshi, a researcher in the epidemiology department atColumbia." And so "modern medicine," no matter how advanced,will clearly have difficulty dealing with a bird-flu pandemic.In a sense, the next pandemic could very well be analogous tothe Hurricane Katrina situation, with mass confusion, lack ofresources, visible dead bodies, acts of cowardice and acts ofheroism, financial disaster, panic, and every emotionpossible--nothing like we are used to witnessing in America;shocking. Partly because of the limitations of both governmentand healthcare capabilities, individuals need to prepare for thecoming bird-flu pandemic themselves. There are four specificareas that must be addressed, as I have written in an earlierarticle (which can be accessed on our Web site.) (a) RosenthalE: 2 Studies Find Flu Treatments Fall Far Short. InternationalHerald Tribune. September 22, 2005. Available at:http://www.nytimes.com/2005/09/22/health/22flu.html?th&emc=th.Accessed on September 23, 2005 (b) Olmsted D: Health wrap: ofdisasters and diseases. Monsters and Critics News, September 9,2005. Available at:http://news.monstersandcritics.com/health/article_1047166.php/Health_Wrap_Of_disasters_and_diseases. Accessed on September 15,2005

Bradford Frank, M.D., M.P.H., M.B.A. The Frank Group P.O. Box138 Lakewood, NY 14750 http://www.AvoidBirdFlu.com

About the author:Bradford Frank, M.D., M.P.H., M.B.A. Dr. Frank graduated fromthe University of Colorado with a B.A. in chemistry and his M.D.degree. He completed two residencies, one in family practice andone in psychiatry. He is board certified in psychiatry as wellas addiction medicine and geriatric medicine, and is a clinicalassistant professor at the University of Buffalo School ofMedicine and Biomedical Sciences, Buffalo, N.Y. He has amaster's in pub