Bird Flu: "This thing just continues to march"

The CP interview: Dr. Michael Osterholm of the University of Minnesota's Center for Infectious Disease Research and Policy talks about the flu bug that could bring the world to its knees

The second thing is, we're using the same dosage levels we use for H3N2 [seasonal flu]. This is a very different virus. We may have to double the dosage for twice the length of time. We have anecdotal data on people who got the drug early and appeared to do better, but then, after the typical five-day course was stopped, they died on day ten.

The problem we have is not whether Tamiflu is available and will work, but can you get it soon enough and in high enough amounts? How do you get the drug to somebody in the first 12 hours of their illness? The second thing is, when people talk about having 20 million or 40 million protective doses, what does that mean? If we're going to have to use twice the dose for twice as long, that means maybe you've got one-fourth as much of the drug you think you have.

That's the story on H5N1 and Tamiflu. I think it can work, but it won't work the way we're approaching it.

In the next five years, with [Tamiflu manufacturer] Roche outsourcing all of the production they can, our best guesstimate is that—using the old, low dosage standards—we could probably produce enough Tamiflu to treat about 7 percent of the world's population in the next five years, because of the precursor chemicals needed and the complicated nature of making this stuff. That's the sum total of production capacity. It's no panacea.

CP: How would you rate the public health infrastructure in the U.S. for its ability to deal with massive numbers of very ill people? You wrote in the NEJM last year that our system lacks "surge capacity" to deal with a lot of sick people at once—why is that?

Osterholm: It's much deeper and bigger than the public health system. It's really the total care system. For example, I talked [in that article] about the 105,000 mechanical ventilators? On any given day, 70,000-80,000 of them are in use, and in a normal flu season we butt up against the 100,000 mark. We have no excess capacity there whatsoever. Just right here in our own Twin Cities, we've reduced intensive care beds by 20 percent in the last four years, as a matter of cost containment.

We'll run out of masks and respirators overnight, because it's a global just-in-time supply chain. There are two manufacturers who have the largest share of the market there, but with virtually no surge capacity. We'll run out of IV needles. We'll run out of IV bags. We'll run out of drugs very quickly. Remember I talked about the 80 percent offshore figure? Go to the Society for Health Care Pharmacists' website and you'll see what I'm talking about.

So the whole medical system will collapse, at a time when we still need drugs for heart attacks, cancer, and everything else. We'll be in freefall. That may sound scary, but it's a reality. And unlike Katrina, where the hurricane did some of the destruction and separated people from health care through evacuation or otherwise, the same thing's going to happen here in every city, town, and village in this country as well. We're all going to need things at the same time, and there won't be any products.

At this Business Continuity Summit we just had, we actually had a major discussion in which a lot of voices expressed concern about the internet—that it doesn't have the backbone and elasticity that everyone thinks it has, and just a limited surge could bring down the internet.

Right after Katrina, when FEMA was trying to rescue itself, they put out a call for anyone who had a refrigerated truck unit to come and sit in one of several parking lots in the Gulf states down there, in case they had 10,000 bodies, etc. A contingent of them went. Not all of them, by any stretch of the imagination. Within 72 hours, major food manufacturers throughout the United States reported that they couldn't ship their goods. They had no trucks. We have a razor-thin capacity in this country right now on virtually everything. They had to get FEMA to release the trucks.

Cities like Seattle have already come to the conclusion they won't be able to have refrigerated trucks, because of that issue. For their work with corpse management, for example, they've already mapped out where every one of the ice arenas in Seattle is. Because you won't be able to bury people, either. In 1969, during the last pandemic, the average time from when a casket was made until it was in the ground was about six months. Today it's a little over a month, and in some areas of the country it's less than that. There's no surge capacity in casket manufacturing. Today, crematorium space in this country is a just-in-time situation too. This means we would quickly run out of the ability to handle bodies in a timely, respectful way. That's in a moderate pandemic, not at all like 1918. Everything now is done on the basis of just-in-time delivery systems.

Now, think about Katrina. As horrible as it was seeing the Superdome, seeing shots of bodies rotting would kind of take you over the top. What really offends the sensibilities of most Americans is when you see the dead handled in a disrespectful manner. I worry that one of the tipping points in a panic/fear situation over pandemic flu would come when we can't, in a timely way, handle the bodies or get them into cold storage. Those are issues we haven't dealt with at all.

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