Dr. John Blatherwick has a theory on why there are so many reports in the media about infectious diseases. In a March 7 public lecture at Vancouver General Hospital, Blatherwick provided a "short answer": he traced it back to a proliferation of medical journalists about 10 years ago. "The radio stations started getting health reporters," he said. "TV got health reporters. And the newspapers got health reporters. Well, guess what? To earn their living, they have to have a story a day."
The bird-flu story has been hitting the headlines since 1997, when the H5N1 avian influenza subtype killed six Hong Kong residents and infected 12 others. It disappeared for a while, only to return again in 2003 with the emergence of more human cases and deaths in several other countries. The World Health Organization has warned of a possible pandemic that could kill two to seven million worldwide, in the best case, and possibly several million more in a worst-case scenario.
Blatherwick, chief medical health officer with the Vancouver Coastal Health Authority, said these new health reporters can always fall back on this subject if they're running out of material. "If they don't have a story, they go back to the standbys," he said. "These days, it's influenza; it's pandemic planning, and it's avian flu."
He noted that infectious diseases are caused by biological agents in the environment. Blatherwick said people can reduce the risk of infection by frequently washing their hands. "You are the one who decides if you are going to get infected," he told the audience. "One of the things is that happy people don't get sick. So be happy. That's one of the solutions. Besides washing your hands, get happy."
Five days after Blatherwick delivered this upbeat message, a New York Times health reporter found a new angle on the bird-flu story-an angle that could cause some unhappiness among residents of Greater Vancouver. Journalist Donald G. McNeil Jr. acknowledged in his lead sentence that nobody knows if the H5N1 strain of avian flu will mutate into something that could cause a human pandemic. (See Flu viruses described as sloppy, capricious, and promiscuous) McNeil also reported that in a pandemic, there wouldn't be nearly enough potentially life-saving hospital ventilators, which pump oxygen into the lungs. U.S. health-care providers would choose whose life would be extended with a ventilator and who would be denied access and, inevitably, die.
"To some experts," McNeil wrote, "the ventilator shortage is the most glaring example of the country's lack of readiness for a pandemic."
Determining the appropriate number of ventilators is one of scores of pandemic-related issues facing B.C. health-care planners. Dr. Patricia Daly, the VCHA's director of communicable diseases, told the Georgia Straight that it's difficult to decide on these public investments when nobody knows when a pandemic will occur. Should a health authority load up on antiviral drugs that have a five-year shelf life? Would some of this money be better spent on new ways to deliver drugs to highly infectious people? Or should it be channelled into the treatment of chronic diseases?
Daly pointed out that flu treatments are only effective during the first 48 hours of symptoms. But if patients visit hospitals or pharmacies, they could spread the pandemic. "We need to come up with a way of distributing antivirals to people once we start to get cases," Daly said.
The VCHA's Pandemic Influenza Response Plan warns that up to 1.8 million British Columbians may become ill and almost 7,000 may die in a flu pandemic. It also noted that there are only 53 hospital ventilators in the VCHA, which serves more than one million residents from Richmond to Powell River. Providence Health Care, which operates St. Paul's Hospital and Mt. St. Joseph's Hospital, could have 101 "ventilated beds" ready within 72 hours, according to the plan. Figures were unavailable for most VGH departments.
In a phone interview with the Straight, Blatherwick estimated that there are only 135 to 140 hospital ventilators across the entire province. "Ventilators will not play a part in the pandemic because you just won't have enough of them," Blatherwick acknowledged. "The question that I remember during the development of the pandemic-flu [preparedness plan] was, 'How are we going to deal with putting people onto ventilators?' I said to them, 'Folks, they're already full right now.'"
Daly told the Straight that there are no plans to purchase additional machines. "We recognize that we're not going to have enough ventilators for all those we anticipate who are going to need it," she said. "There is going to have to be a triage system. And that's something that isn't in the plan right now. We have had discussions about that. This is a problem that isn't just limited to our region."
Dr. John Blatherwick says people can reduce their flu risk by washing their hands. He also says it's not his job to scare the public about avian influenza.
The Fraser Health Authority serves 1.5 million people living from Burnaby to Hope. Its Pandemic Influenza Preparedness Plan states that a pandemic could result in more than 212,000 people needing outpatient care, more than 6,200 requiring hospitalization, and approximately 2,300 people dying. The FHA plan has no information about the number or location of ventilators in the region.
FHA spokesperson Don Bower told the Straight that this is because the number is "ever-changing" and is "not static". Bower added that during a pandemic, the vast majority of flu patients wouldn't make it to hospitals anyway.
"Most care would be in nontraditional sites," he said.
For his part, Blatherwick isn't losing any sleep over the prospect of a flu pandemic in the short term. "I think the whole thing is an overhype," he said. "I don't blame the media for that. I blame the fact that you will still find people who will say that the next pandemic is imminent-and it's going to be the most horrible thing ever, despite the evidence that would show just the opposite."
Blatherwick said that ventilators, which can cost more than $30,000 each, wouldn't have helped victims of the 1918 influenza pandemic. That particular virus triggered the rapid release of massive amounts of fluid into the chest area, he said.
Even if oxygen had been pumped into the 1918 victims' lungs, Blatherwick claimed that it wouldn't have made it into the bloodstream. "They literally died of drowning: turned black, and that sort of thing," he said.
When contacted by the Straight, the B.C. government and the Public Health Agency of Canada were unable to provide information on the number of hospital ventilators in this province. Despite the apparent shortage in the region, Blatherwick pointed out that VCHA's pandemic- preparedness plan is among the best in North America. He noted with pride that it has been copied by other Canadian regions and by states south of the border. Blatherwick also praised the Public Health Agency of Canada for developing prototype vaccines, which will narrow the time line for developing a real vaccine in a pandemic.
Aggie Adamczyk, spokesperson for the Public Health Agency of Canada, told the Straight that the company contracted to manufacture a vaccine, GlaxoSmithKline, would be able to produce six to eight million doses of a vaccine a month during a pandemic, but only after the product went through the regulatory process. All told, Adamczyk said, "It may take anywhere from four to six months before we do start seeing the first doses being available."
If there is a pandemic in Greater Vancouver, Daly will probably play a key role in trying to contain the carnage. She said that she wrote the chapter on "surveillance" in the VCHA's extensive preparedness plan.
The federal government has responsibility for establishing surveillance networks, which will occur in cooperation with provincial and regional epidemiologists and "sentinel physicians". In the pre-pandemic phase, there will be passive surveillance of travellers returning from areas where there has been an alert issued. There will also be "active" surveillance of health-care-employee absenteeism, among other measures. Once a pandemic is declared, there will be active surveillance of school absenteeism.
Daly noted that the plan, which was released last May, is being updated to incorporate new information in federal and provincial documents. "Some of the things-the priority list for vaccine-that's not determined by us," she said.
The VCHA plan also includes a 34-page chapter on "self care" during a pandemic. It suggests several ways of avoiding infection, including: stocking up on basic items, shopping at stores with smaller lineups, and arranging to pay bills at automated-teller machines or over the phone.
"Influenza virus can live up to 2 days on hard surfaces," it states. "Washing hard surfaces (sinks, counters, etc.) with a disinfectant such as a ten percent bleach solution (one part bleach and nine parts water) will kill the influenza virus. Surfaces that are frequently touched with hands should be cleaned often."
The VCHA's chapter on clinical management and health-care facilities describes how to identify and treat influenza during a pandemic. According to the document, children have the highest attack rates and are "major disseminators" of the virus. Kids between six to 12 months of age have the highest rate of influenza-related serious illnesses.
Another section deals with the psychological and social impact of a pandemic on health-care workers. "They are repeatedly exposed to grisly experiences (e.g. recovering bodies), the powerful emotions and harrowing tales of victims," it states. "Their tasks may be physically exhausting or dangerous in terms of exposure."
Dr. Danuta Skowronski, a physician epidemiologist at the BC Centre for Disease Control, told the Straight that during the 1918 Spanish flu pandemic, there were "desperate pleas" for nurses. She also said that public-health officials will have to plan for alternate care sites, so-called fever clinics. "We'll likely also have to call in retired persons, volunteers, and so on," she added. "Who are they? How can we access them? Those sorts of measures could be undertaken now."
Skowronski claimed there is a need for "clinical champions" to identify issues of concern. She also emphasized the importance of targeting health-care investments in areas that can cause immediate health benefits, such as nursing and vaccinations. She noted that people at higher risk, such as the elderly, are more often killed by secondary bacterial infections in a pandemic. "So if they get their pneumonia vaccine now, that's a dual benefit," she said. "It protects them annually during the winter period and it will also give them added protection during the pandemic."
Daly said that employers should start planning how they will operate at a time when several staff might be off sick. She praised Alcan, in particular, as one large employer that has already prepared an effective plan.
Dr. Janet McElhaney, division head for geriatrics at UBC, joined Blatherwick at the March 7 event at Vancouver General Hospital. During her presentation, she pointed out that the symptoms of flu differ significantly between younger and older people. This could have serious ramifications in a pandemic, when accurate diagnosis becomes even more critical.
McElhaney said that younger people with flu commonly experience severe muscle pain and high, abrupt fevers. Seniors, on the other hand, usually suffer low-grade fevers and mild-to-moderate muscle pain. In addition, she said, a senior can cough for two to three weeks with the flu, whereas this is far less common in younger people.
"The other thing that we find-less frequently but commonly in older people-is they can have a complication of viral pneumonia, which can be very bad," McElhaney said. "There isn't a lot of treatment past 48 hours for that, and they can go on to develop a secondary bacterial infection. And these things are lethal."
The VCHA plan states that there were three flu pandemics in the 20th century. Blatherwick, however, insisted in his March 7 speech that there was only one: the horrible Spanish flu outbreak of 1918. He described the flu outbreaks in 1957 and 1968 as "shifts in the virus" that did not really cause that many "excess deaths".
"I think it's our job to plan," Blatherwick later told the Straight. "It's not our job to scare the population. I'm very careful to say I don't think this is imminent."
For the sake of anyone who might need a ventilator, let's hope he's right.