Bird Flu and You

Is Hawai’i ready for a pandemic such as bird flu? That depends on you.


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photo: Getty Images

Bird flu. It’s in the news all the time, emerging in one new location after another around the world. With each new case, our anxiety grows. What if it gets worse?

Or worse, for us, what if it gets here? The Islands have a small and isolated resident population visited by millions of travelers every year, all flying in on wings of either aluminum or feathers. Should one of those visitors harbor a serious viral illness, are we prepared?

The Hawai‘i state Department of Health (DOH) does have a plan. You can read it yourself at the DOH’s reassuring Web site, www.hawaii.gov/health. What you need to know is that should a virus show up that spreads easily from person to person, a big part of the plan is you—doing the right things at the right time.

In Hawai‘i, the authorities’ main tasks include detecting an emerging pandemic, containing the disease and protecting their own ability to remain functional and effective. Recently, the state Legislature appropriated $11 million to upgrade the existing surveillance system and link it with community hospitals. “Part of surveillance involves getting data from the hospitals as rapidly as possible,” says Dr. Chiyome Fukino, director of the state Department of Health. Private doctors already send specimens from patients suspected of having the flu to the Department of Health for screening of Avian Flu A (H5N1), commonly dubbed “bird flu.” By better coordinating with the hospitals, leaders will be able to understand the extent of the pandemic, how it is changing along the way, and whether treatments are effective. The system in place is “fair,” says Fukino. “But we need to enhance it.”

Dr. Richard Friedman, chief medical officer and vice president for medical affairs at The Queen’s Medical Center, says that emergency systems were reviewed and updated when SARS became a threat, and are rehearsed two times per year. Now the hospital is working with the state to make sure isolation protocols are set, and they have stockpiled enough face masks and antiviral medications. Should a crisis prevent health care workers from staffing the hospital, there is an “emergency call-in system” that recruits doctors and nurses from other hospitals and the Mainland for brief stints. “The truth is, H5N1 is a flu, and we deal with [a flu] every winter,” Friedman says. “We’ve always been able to handle it.” People can take precautions by getting flu vaccines every year, and informing their doctors if they come down with something.

First, it’s worth taking a look back to understand why “coming down with something” can be the first step down a dangerous road. Here’s a guide to understanding, and preparing for, bird flu:

A TRAGIC HISTORY

Imagine 1918. The world has just made it through a World War when a deadly influenza strikes. In a matter of months, the Spanish flu, as it was called, spread to one-fourth of the population of the United States and one-fifth of the world, and the virus killed more Americans than perished in all of the wars of the 20th century combined.

Only 87 years have passed since 20 to 40 million people worldwide (some sources put that number even higher) died from a pandemic that originated in birds.

Now another avian influenza—potentially catastrophic to humans—is proving resilient as it traverses the world. Hawai‘i’s proximity to Asia, where the virus originated, could put Island residents on the front lines. It might disappear, be little more than a minor inconvenience or lead to disaster.

WHAT IS A “BIRD FLU”?

According to the Centers for Disease Control and Prevention (CDC), there are three types of influenza viruses: A, B and C, and humans can be infected with all of them. Influenza A viruses infect birds, often making wild game sick, but usually killing domestic poultry. Only influenza A viruses are further classified by subtype on the basis of two proteins: hemagglutinin (that’s what the H stands for), and neuraminidase (the N). The one experts are most worried about is A(H5N1). There are as many subtypes of the illness as there are mathematical combinations of the hemagglutinin (16) and neuraminidase (nine) numbers.

How do the experts know when birds are sick? A “low pathogenic” virus might cause ruffled feathers or decreased egg production. The “highly pathogenic” form attacks multiple internal organs and has a mortality rate that can soar to 100 percent within 48 hours. Birds infect each other via saliva, nasal secretions and feces. As it spreads, it can mutate into a more deadly strain.

The incubation period is typically three to four days, but in a highly pathogenic strain, the virus will replicate faster, meaning less time from exposure to sickness.

WHERE IS IT OCCURRING, AND WHO'S AT RISK?

Hawai‘i residents need to be especially wary in August, when migratory birds start flying south from the Arctic Circle, carrying disease with them.

It’s likely the virus will be introduced to the United States this year. But if it remains contained in birds, it will not evolve into a crisis, simply because the poultry industry in the United States keeps chickens in well-maintained indoor facilities run by owners who practice excellent hygiene, says Duane Gubler, director of the Asia-Pacific Institute of Tropical Medicine and Infectious Diseases at the John A. Burns School of Medicine, and a 24-year veteran of the CDC in Atlanta. Poultry owners’ livelihoods are at stake, so they will “hunker down and probably implement a lot of infection-control measures,” adds Gubler.

They’ve certainly had ample warning. Globally, health officials have culled hundreds of millions of poultry to eliminate avian influenza. But here’s what really worries the experts: The virus emerged in Hong Kong in 1987 and killed six of the 18 people it infected. The CDC worked with leaders in Asia and thought they had destroyed the virus. In 2003 it re-emerged and has moved rapidly since then. Viruses usually “stick around for a year or two, then disappear,” says Gubler. “But this one is still going strong, and it seems to be intensifying.”

Outbreaks have occurred in Asia (Cambodia, China, Indonesia, Japan, Laos, South Korea, Thailand, Vietnam), Europe, the Middle East and Africa, according to the CDC and the World Health Organization. Exposure to infected animals, live or dead, their secretions or excretions, and involvement in the mass slaughter of potentially infected animals, put people at risk.

The World Health Organization has confirmed more than 190 cases of human infection with bird flu viruses, reported in Azerbaijan, Cambodia, China, Egypt, Indonesia, Iraq, Thailand, Turkey, and Vietnam. So far, more than half of the people infected have died, and most are young, previously healthy adults. They usually perish rapidly from multiple organ failure. Gubler says that strong epidemiologic evidence indicates the virus has passed between humans, but the circumstances remain unknown. Though it’s clear people can get the disease from treating infected people, it has not, to date, spread quickly and easily among humans.

The CDC notes that a global pandemic could occur if three conditions are met: a new subtype of influenza A virus is introduced into the human population; the virus causes serious illness in humans; and the virus spreads easily from person to person in a sustained manner.

WHAT ARE THE SYMPTOMS IN HUMANS?

Fever, cough, sore throat, and muscle aches are typical. Others include eye infections, pneumonia and severe respiratory diseases. Symptoms may vary, depending on the type of virus.

WHAT'S HAPPENING NOW?

Hawai‘i has garnered national attention recently for its surveillance system and quarantine areas at Honolulu International Airport, which was one of only eight quarantine stations nationwide when SARS hit in 2003. Now it’s one of 18 across the country, with a leadership team and staff.

However, proper screening for potential illnesses requires testing. And testing means obtaining a mucus swab from an individual. Without a clear threat, this must remain a voluntary act. But if an outbreak occurs, personal choice will take a back seat to efforts that will halt the spread of the illness. The CDC “is empowered to detain, medically examine or conditionally release individuals reasonably believed to be carrying a communicable disease,” according to the organization’s literature. Ethical and logistical questions loom large, of course, and “it is the most severe power we will ever use,” says CDC spokesperson Jennifer Morcone.

Gubler says the introduction of avian influenza to Hawai‘i by humans on an airplane is “remote,” though he admits “this is the scenario we’re all most worried about.” If this happens, a crisis is almost guaranteed. “Because once the horse is out of the barn, I suspect our surveillance systems are not going to be good enough to pick it up immediately; a lot of people are going to get through.” If this happens, community physicians will play a key role as they identify and isolate infected people.

WHAT'S DIFFERENT NOW?

In general, the world knows a lot more about preventing the spread of infection than it did in 1918 during the Spanish flu pandemic. Instant communication also means the world can implement those methods of prevention more quickly. In addition, it’s likely our population has developed some immunities in the passing decades.

A new lab at Hawai‘i’s Department of Health allows health professionals to test mucus samples for the virus, yielding more rapid results than samples previously sent to Atlanta. At press time, a sophisticated lab was almost ready to open at the John A. Burns School of Medicine research building in Kaka‘ako, where scientists could establish the avian flu virus subtype—an important step in administering appropriate treatment.

The National Institutes of Health contracted with large vaccine manufacturers that are developing an avian flu vaccine. However, scientists weren’t sure what strain to prepare a vaccine against, so they used the Indonesian and Vietnamese avian flu strains. Gubler says that while the vaccine is “probably not as good as they anticipated,” it will guard “against severe disease.” Unfortunately, the regular flu vaccine that many people update each flu season does not protect against avian influenza. Antiviral medications, such as Tamiflu, could help mitigate illness and possibly be used for prevention.

NOW, ABOUT THAT PLAN ...

The state’s plan for dealing with a pandemic is there. Various authorities know about it. But successfully executing that plan will depend a lot on you. A serious pandemic could be something like a virulogical Katrina—the authorities can organize, communicate, drop off supplies, tend to the most seriously ill, even enforce quarantines, but ordinary people will have a lot to do to help themselves.

“The role of state government and the health care sector is to get ourselves in order and help the public understand what the issues are,” says Fukino. “That’s why it’s so important to be informed about this and prepare with us. This is not about the health department preparing everyone.”

Fukino urges employees to talk to their superiors about contingency plans. What will it take to run your business? What if people get sick? Or simply don’t come to work? How will this affect the community? At the Health Department, which has 3,000 employees, she says, “we’re not at that stage where we’re totally sure of what’s shutting down and what’s staying open.” Clearly, preparations are not complete.

The Department of Education is still evaluating whether it would cancel school. However, parents should have plans in place in case schools close. Is there back-up childcare? Even more importantly, do you have adequate supplies in case workers can’t stock stores? And most of all, have you and your family rehearsed your plan?

“It’s very hard to stop and pause for a moment and think about the worst case scenario,” Fukino says, “but the reality is, that’s what you have to do.”

WHAT CAN YOU DO?

    • If the virus spreads from person to person, extreme quarantine measures might have to be taken. Everyone will be inconvenienced as residents wait out the epidemic, which might last a couple of weeks, in the seclusion of their homes.

    • Shipping could be disrupted, so it’s smart to stockpile your daily supplies, such as food and medications well ahead of time (before the media sounds the alarm and supplies run short). In the event of an epidemic, stay home, and avoid work, school and public areas, including supermarkets.

    • Prevent all infections by washing your hands with soap—frequently and carefully. Always keep your hands away from your nose, eyes and mouth.

    • As migratory birds pass through the Islands, be aware of all contact with them—dead or alive—and their feces. The CDC says there is no evidence of humans acquiring avian influenza from eating poultry, mainly because heat kills the virus. However, it is important to cook all poultry and eggs thoroughly (the CDC recommends chicken reach a temperature of 180 degrees Fahrenheit). Handle raw poultry with care, as it also carries salmonella. Clean all utensils and cutting boards with soap and hot water immediately after preparation, and, obviously, wash your hands. Again.

    • Hawai‘i has large populations of feral chickens, pigs and boars, all of which could pose a risk. Pigs have receptors that allow them to become infected with both human and avian flu strains. When this happens, the virus can recombine and more easily mutate into a strain that infects humans.

    • When traveling to countries that have experienced bird flu, the CDC advises people to avoid contact with feathers (or importing feather products such as down coats), animals in live food markets and all surfaces appearing to be infected with feces from any animal. And don’t bring home a pet bird—legally or illegally. Reports have surfaced about the virus spreading through the smuggling of duck feet, which can carry the disease even when frozen.

With any luck, you may never need this advice. But since influenza viruses have no cure, information may be your best defense.

BIRD FLU VOCABULARY:

A(H1N1): the deadly Spanish flu of 1918-1919, a bird flu.
A(H5N1): a strain of avian influenza, also found in cats (and other animals that eat birds), pigs and humans. Pigs are of great concern to experts, who call them a “mixing bowl” for viruses.
PANDEMIC: plague; virulent disease found in a large part of the population.
TAMIFLU (Oseltamivir), Relenza (Zanamivir): antiviral medications that might be used to treat bird flu, though their effectiveness is still in doubt, and they are in short supply. These are not vaccines. To date, there is no known vaccine for avian flu. And if the virus mutates, it could render experimental vaccines useless.
ANTIVIRAL: a drug or other agent used to eliminate or inactivate a virus; can be used preventatively, but is most often used to treat people who have already become ill.
VACCINE: a preparation containing weakened or dead microbes that caused a particular disease, given to help stimulate the immune system to produce antibodies against that disease; must be administered to people who have not yet been exposed to the illness.
ADAPTIVE MUTATION OR "REASSORTMENT": the means by which A(H5N1) would improve its ability to transmit among humans. Essentially, this happens when a human or other mammal (such as a pig) is infected with the human and avian viruses simultaneously, and genetic material gets exchanged.
ISOLATION: the CDC describes this as separating persons who have a specific infectious illness from those who are healthy, and limiting their movement to stop the spread of that illness.
QUARANTINE: separating and restricting the movement of people who are not ill but have been exposed to disease and might become infectious, for one incubation period, which could be up to four days. Isolation and quarantine are considered non-pharmaceutical interventions.

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