Most influenza experts agree that sooner or later another flu pandemic will occur —

a global outbreak of a new, highly contagious influenza virus for which people have little or no immunity. They also agree that if the next pandemic is caused by the currently circulating H5N1 avian (bird) flu, it could be as deadly as or even more deadly than the 1918 H1N1 Spanish flu, which infected more than one-third of the world’s population and killed as many as 100 million people.¹ The massive loss of life from the 1918 influenza pandemic is almost unimaginable. Yet today a similar pandemic with the same rates of infectivity and mortality would result in more than 2 billion infections, with 180 million to 360 million deaths worldwide. In the United States, the 1918 virus killed 650,000; a proportional number of deaths with today’s population would be nearly 2 million.^2,3 Two other but less lethal pandemics occurred in the 20th century, one in 1957, the Asian Flu (H2N2 virus), and the other in 1968, the Hong Kong Flu (H3N2 virus).⁴

Influenza pandemics tend to occur with some regularity every 20 to 30 years. They can occur whenever the following three conditions are met: 1) There must be a new influenza virus that is highly pathogenic for humans; 2) the virus must be genetically unique — one for which the human population has no preexisting immunity; and 3) the virus must be easily transmitted from human to human.^2,3

H5N1 on the move

The H5N1 virus, which has spread in bird populations across Asia and into Europe and Africa, has met the first two conditions for a pandemic. Only sustained, efficient human-to-human transmission is missing. The H5N1 virus has a genetic resemblance to the H1N1 Spanish flu virus and causes clinical symptoms that appear to be identical, but with a higher mortality rate. Mortality is over 50%, making the H5N1 virus the most lethal form of flu that humans have ever experienced.³

Each year in the United States, the “common” flu causes 30,000 to 50,000 deaths.¹ The virus nearly always kills the very young and very old, with a low frequency of deaths for all ages in between.⁴ In contrast, nearly half of the influenza-related deaths in 1918 were in young healthy adults 16 to 40 years of age, and 99% of all deaths occurred in people younger than 65.^3,4,5 The highest death rate occurred among pregnant women: As many as 71% of those infected died.³

Most of the deaths were caused not by the flu itself, but by a powerful over-reaction of the immune system called a “cytokine storm” that damaged the lungs, causing them to become inflamed and filled with fluids, blood, and dead tissue.³ It seems that even higher levels of cytokines have been found in victims of the H5N1 bird flu, and the mortality rate of over 50% is about 20 times higher than that for the influenza of 1918 despite access to modern antiviral and antibacterial drugs and ventilator support.^4,6,7

Why was the 1918 pandemic Spanish flu virus (genetically similar to today’s H5N1 virus) so much more deadly than the 1957 and 1968 pandemic viruses? The answer may be in how the viruses originated. The 1918 virus was caused by an H1N1 bird flu virus that managed to jump directly to humans, in which it developed the ability to spread person to person without first combining with a human flu virus. In contrast, the less deadly 1957 and 1968 pandemics were caused by human viruses that reassorted and swapped genes with the bird flu viruses.⁴

No one knows whether the currently circulating H5N1 virus will reassort with a human virus and cause a more minor pandemic similar to the ones in 1957 and 1968 or whether it will evolve into a form that can be transmitted easily among humans, resulting in an influenza pandemic as deadly as or even more deadly than the 1918 event. However, if a pandemic virus similar to the 1918 virus does emerge in the near future, will we be prepared on a hospital or personal level? The answer on the hospital level is clearly no, for the following reasons:

Vaccine. We cannot depend on the availability of an influenza vaccine for the H5N1 virus. No pandemic vaccine is now available, and an influenza vaccine cannot be manufactured until the virus completes its mutation cycle to allow for sustained, efficient human-to-human transmission. Once this new strain is identified, the U.S. Department of Health and Human Services estimates that it will take six to nine months before the first dose of pandemic vaccine can be manufactured. But developing a vaccine is not the only problem. The U.S. production capacity for vaccine is extremely limited by the egg-based technology developed in the 1950s that relies on inoculating the circulating strain of influenza virus into fertilized eggs laid by hens under hygienic conditions.^3,8 Even if all goes well with vaccine production, only 37.5 million Americans could be immunized during the first year of a pandemic, and it will take three to five more years to produce enough vaccine for all Americans.^2,3

Antivirals ‘worthless’ for H5N1

Antiviral drugs. If taken daily during the time of exposure, the antiviral drug oseltamivir (Tamiflu) is about 60% effective in preventing seasonal influenza. The drug also has the ability to reduce the severity of seasonal influenza if taken within 48 hours of onset. However, no evidence exists that the drug is beneficial for pandemic influenza, especially if a patient develops a cytokine storm as seen in recent H5N1 infections.¹ In fact, a Vietnamese physician who has taken care of 41 patients with H5N1 flu reports that antivirals, specifically oseltamivir, are “worthless” against the H5N1 virus.³ Nevertheless, lacking any better options, neuraminidase inhibitors — oseltamivir and zanamivir (Relenza) — are the drugs of choice for treatment of H5N1 influenza, and both are in short supply. The U.S. government is creating a stockpile of antivirals as part of the Strategic National Stockpile. This antiviral stockpile was to reach an estimated 26 million antiviral courses (oseltamivir and zanamivir) by the end of last year. At least 20 million of these treatment courses are to be allocated to states in proportion to population. Up to 6 million courses are reserved for possible opportunities to quench isolated outbreaks through communitywide preventive administration (mass prophylaxis).⁸

Even with 26 million treatment courses, there will not be enough antivirals to treat and provide prophylaxis for the healthcare workers, emergency medical providers, and other pandemic health responders who will be asked to care for flu victims.²

Not only will antivirals be in short supply; a strong possibility exists that other medication shortages will occur during a pandemic. Over 80% of raw materials used for pharmaceutical products come from outside the country. If international supply chains are disrupted, most of our drug supplies will be at risk.⁹

Hospital beds/supplies. In a severe pandemic, millions of desperately ill people needing hospitalization will quickly overwhelm the healthcare system to the point of collapse. There will be an immediate shortage of hospital beds; critical supplies (surgical gloves, masks, gowns, IV bags, and antibiotics); and trained staff to care for patients.^3,6 For example, in the United States, there are about 965,300 staffed hospital beds — not nearly enough.³ During the peak week of a pandemic, the following numbers of staffed beds and ventilators would be needed in the United States for influenza patients alone:⁶

• 191% of current non-ICU beds
• 461% of ICU beds
• 198% of all available ventilators

Projections of hospitalizations are only estimates. However, the gap between our current resources and our needs is staggering. These numbers assume that 25% to 30% of the U.S. population will fall sick and that illnesses will be spaced over eight weeks. It is expected that even in the peak weeks of a pandemic, no more than 10% of a community’s population will be ill at any one time.^3,10

Our healthcare system is poorly prepared to handle a disaster. Managed care and cuts in government reimbursement have financially squeezed hospitals. Nearly one-third of U.S. hospitals are losing money, and another third operate at or near the break-even point.¹¹ What’s more, a study by the Institute of Medicine found that the U.S. emergency medical system does not have the capacity to respond to large disasters or epidemics and is on the verge of collapse. In the 10 years studied (1993-2003), 703 hospitals accounting for 198,000 beds and 425 emergency rooms closed. During this same period, the demand for emergency services increased 27%, from 90.3 million to 113.9 million visits a year.¹¹

Unless the government significantly increases funding to hospitals for pandemic preparedness, hospitals will not have enough money to pay for the added beds, stockpiles of personal protective equipment (PPE) and other basic supplies, or staff education and training.⁶ It would take an estimated $1 million per average hospital (164 beds) for realistic hospital preparedness. The total needed for the nation’s 5,000 general acute care hospitals is about $5 billion.⁶

Faced with possible healthcare capacity problems, the United States may face having too few resources for too many patients. This will require the rationing of care and the associated ethical dilemmas.

Field facilities

Finally, in the absence of sufficient hospital capacity, it’s likely that alternate medical facilities will be established to take care of those who are too sick or unable to care for themselves or for those who do not meet the criteria for hospital admission in a rationed-care environment. National response plans call for establishing alternative, nonhospital field medical facilities staffed by volunteers to treat thousands of victims of large-scale events. Federal planners assume that trained and competent healthcare workers will volunteer to staff these facilities. But where will these volunteers come from during a pandemic?

Ventilators. Most patients with bird flu have required intensive care and ventilator support within 48 hours of hospitalization.¹² Since bird flu causes the alveoli to fill with fluids and collapse, patients require mechanical ventilation to get oxygen into the bloodstream. Currently, there are 105,000 mechanical ventilators in the United States, and on any given day 75,000 to 80,000 are in use. An estimated total of 742,500 ventilators would be needed over the entire course of a serious pandemic similar to the Spanish flu pandemic.³ In addition, since respiratory therapists typically manage mechanical ventilation, additional ventilators will not be helpful unless we can find the staff to operate them.

Critical shortage of staff. During an influenza pandemic, many healthcare providers may choose to stay at home because of family responsibilities, illness, or fear of contagion. In fact, recent surveys in Maryland and New York found that nearly half of public health workers would be unwilling to report to work during an outbreak of an untreatable infectious disease.¹³ For the healthcare providers who do care for patients with pandemic influenza, the risk of infection is likely to be significantly increased by a lack of PPE. Supply chain problems are expected to develop once a pandemic begins, and most hospitals, with their “just-in-time delivery” of supplies, have not stockpiled PPE. Without N95 masks, goggles, and gloves, will healthcare workers put themselves at risk taking care of infectious patients?

Can we prepare?

A major pandemic in the United States will have enormous social and economic ramifications. As workers fall ill, there may be significant disruptions of basic services, such as water, electricity, communication, transportation, sanitation, health services, and food delivery to stores. In fact, our national pandemic flu plan warns that political and economic destabilization might occur along with the shortages of food, water, and other necessities.^3,14

Without a vaccine or enough antivirals for the population, basic public health practices ranging from handwashing to the closing of places where people congregate will be the only defense against transmission of the pandemic flu virus. Social distancing (maintaining a distance of at least 3 feet from other people) will be essential in preventing transmission of influenza since infected people can shed the virus 24 to 48 hours before the onset of influenza symptoms.⁵

Other practical and commonsense measures, such as respiratory hygiene (covering the nose and mouth when coughing or sneezing) and handwashing, are also important. The virus can spread from an infected person at least 3 feet through the air when expelled by coughing or sneezing. It can survive on nonporous environmental surfaces, such as countertops or doorknobs, for 24 to 48 hours and on porous surfaces, such as cloth and paper, for 12 hours.

Frequent handwashing will be extremely important since touching a contaminated environmental surface and then touching the eyes, nose, or mouth can transfer the virus.²

If we assume that a pandemic is going to occur at some time in the future, each individual or family should prepare for a major disruption of goods and services, such as water, power, communications, and sanitation. Banks, government offices, and stores may close, and fuel shortages may occur.¹⁴

Food and water: Food and water supplies may be interrupted and limited. Experts recommend a two-week to one-month supply of food and water for each person.¹⁵ Select foods that do not require refrigeration or cooking, and store water — at least 1 gallon per person per day — in clean plastic containers.

Examples of food that can be stockpiled include the following:

• Canned meat: beef, chicken, ham, and fish
• Dried beans: pinto, garbanzo, white and black lentils, and soybeans
• Oils: canola, sunflower, and olive
• Nuts: cashews, peanuts, walnuts, sunflower seeds, and peanut butter
• Dried fruit: raisins, apricots, prunes, bananas, and apples
• Grains: wheat, rice, and oats
• Dairy: dry milk
• Eggs: dried whole eggs

Other basic household necessities: Stock up on toilet paper, feminine hygiene products, garbage bags, tissues, disposable diapers, bleach, soaps and detergents, toothpaste, and disinfectants.

Medications and first aid supplies: Keep at least a 30-day supply of chronic medications. Have nonprescription drugs on hand, including OTC fever/pain relievers (acetaminophen or ibuprofen), antidiarreal medication, cough and cold medicines, diphenhydramine (Benadryl), vitamins, and fluids with electrolytes. You should also have several thermometers.

Public services: In the event of power outages, you may need a good-quality battery-operated AM/FM radio and a supply of batteries, propane for cooking and a cooking stove, flashlights, candles, matches, lighters, and a manual can opener.

Financial: In the event of bank closures, you may need to have some cash on hand.

Family and friends. Talk with family and friends about how they would be cared for if they got sick or what would be needed to care for them in your home.

Community: Volunteer in your community to help with community preparation for an influenza pandemic.^14,15

If you don’t have a personal or family preparedness plan, take this time to develop one. Basic planning information can be found at www.ready.gov.

The World Health Organization, many countries including the United States, and many hospitals have developed preparedness plans for a future influenza pandemic. Written at the strategic level, these plans can be difficult to interpret and apply at the individual or community level. Experience from other disasters (Hurricane Katrina, for example) has taught us that without detailed plans, required actions may not occur.³

Because the issue of pandemic influenza is so serious, nurses need to be aware of what is really happening with pandemic preparedness in their own hospitals and communities. They also have a responsibility to educate the public about what to expect from the health system during a pandemic. The public must understand that it may be difficult or impossible to access healthcare services and that healthcare provider visits will need to be limited to those that are absolutely necessary.