| Home > Events > Disease, Disaster, and Democracy, 2006 > Conference Speakers > Eric Toner What Would a Modern-Day Flu Pandemic Look Like?
Eric Toner Speaker biography | Transcript | Audio Summary
Dr. Eric Toner, an emergency medicine physician with expertise in disaster preparedness, predicted the epidemiological impact of an influenza pandemic today, and discussed whether medical and public health interventions (e.g., vaccines, antivirals, disease containment measures) might influence these outcomes. The 3 flu pandemics of the 20th Century (1918, 1957, and 1968) suggest that pandemics happen quickly and affect many communities simultaneously. In 1957, it took only 2 months for the outbreak to become nationwide. With regard to the severity of a new pandemic, the U.S. Department of Health and Human Services (HHS) has instructed the nation to plan for a 1918-like pandemic. According to HHS, the difference between a "severe" pandemic (as occurred in 1918) and a "moderate" pandemic (as occurred in 1968) would be an 11-fold increase in hospitalizations, ICU (intensive care unit) admissions, and deaths. These national estimates are for the pandemic as a whole. In reality, the pandemic will move across the country in waves. Not all flu patients in the U.S. will be sick at once. Thus, individual communities should calculate the health burdens of an outbreak based on their populations and locally-available medical resources. This estimate is possible by using HHS assumptions and FluSurge software from the Centers of Disease Control and Prevention (CDC). In a severe pandemic, local hospitals can expect patients to exceed their life saving capacity-represented by the number of beds and mechanical respirators-by several hundred percent. Toner then asked, is it realistic to expect public health interventions to thwart the impact of a novel flu virus? He discussed the potential benefits of the following controls and concluded that they cannot stop the spread of a novel flu virus. At best, they may slow the spread of disease, although this is not yet proven. Moreover, the economic and societal costs of many containment efforts may far exceed the potential benefits. - Vaccines: Because the flu virus is constantly changing, vaccine developers cannot predict the pandemic strain in advance. Consequently, vaccine cannot be made or stockpiled in advance. Limited manufacturing capacity and antiquated production technology also mean that vaccine will become available slowly and incrementally. Finally, once produced, the efficacy of a new vaccine is never certain.
- Antivirals: Limited supply and production capacity mean that widespread prophylaxis is not practical. Also, viral resistance may develop, the dosage and duration of treatment vary from strain to strain and the timing of antiviral treatment is critical.
- Disease containment: Such measures might include isolating the sick, identifying and quarantining those exposed, restricting travel, closing schools, avoiding crowds, applying respiratory etiquette, washing hands, and using protective masks. Several features of flu make it particularly hard to contain through these methods. A very short incubation period (2 days) means there is no time to trace contacts or implement quarantine. A very short time between generations (2-3 days) means flu spreads rapidly, leaving little time to implement geographic controls. In addition, some degree of asymptomatic spread may mean that isolation would be only partially effective.
Toner also reviewed how medical interventions might influence the effects of pandemic flu on a community. Flu patients would be treated under normal standards of care and other healthcare services would go on unaffected, argued Toner, ONLY IF there were unlimited surge capacity in the healthcare system. The current status of U.S. hospitals suggests that this is not the case: - 30% of U.S. hospitals lose money, and those that are profitable have operating margins averaging 1.9%.
- There are 45 million uninsured people in the U.S. and $25 billion/year of healthcare expenditures are uncompensated.
- There is a shortage of 100,000 RNs (8% of workforce).
- 48% of emergency departments are at or over capacity.
- 46% of emergency departments spent time on diversion due to lack of ICU beds, general beds, staff, and overcrowding.
In conclusion, Dr. Toner listed the most likely dilemmas that communities will face when trying to prevent additional infections and care for large numbers of sick people in a pandemic: - Allocation of scarce supplies of vaccine and antivirals,
- Rationing scarce life saving medical resources (e.g. ventilators),
- Ensuring similar levels of health care in hospitals throughout a community,
- Limiting access to other health care,
- Implementing community-wide disease controls like isolation.
Summary by Eric Toner, MD |
