2001499 health and human services transcript pandemic flu call 05-17-2006

FTS-HHS-ACFModerator: Allison Hertel

05-17-06/1:00 pm CTConfirmation #8052430

FTS-HHS ACF

Moderator: Allison HertelMay 17, 20061:00 pm CT

Coordinator: Welcome and thank you for standing by. At this time all participants’ lines

will be open and today’s conference is being recorded. If you object you may

disconnect at this time. Now I’ll turn today’s meeting over to Ms. Allison

Hertel you may begin.

Allison Hertel: Thank you hi everyone. First of all I just wanted to check and make sure

Patrick are you on the call?

Patrick O’Carroll: Yes I am can you hear me okay.

Allison Hertel: Okay great. So we’re going to go ahead and get the call started. And just so

you all know the call is being recorded and transcribed. And eventually we’ll

post that to our Web site. So for people that may be interested but have missed

the call they’ll be able to access the information.

And secondly I sent out an email last night that included the PowerPoint

presentation and a couple of resources. And I know that some people did not

get the information because of the size of the document. So I’m just going to

give you an email address right now.



And if you did not get the information you can contact Renee and she will

email it to you. I’m actually facilitating this call from Fairbanks. I’m working

with some grantees in Alaska right now. So I want you all to know that you

can get the information.

So if you did not get the PowerPoint you want to email Renee - its R-e-n-e-e

dot Andrae a-n-d-r-a-e at ACF as in Frank dot HHS as in Sam dot gov. And

then if for some reason you didn’t get that her phone number is 206 615-3648.

You can put your phones on mute by pushing star 6. And then (unintelligible)

to unmute. I’m going to go ahead and introduce Patrick O’Carroll is with

Public Health Service. And he’s the regional administrator for region ten.

And so he’s going to do the PowerPoint piece of the presentation. And then

we’re going to just discuss - have an open discussion and talk about

(unintelligible) and also the resource list. So Dr. O’Carroll I’ll turn it over to

you.

Patrick O’Carroll: Okay hi everybody and thanks Allison for setting this up. This is a little

awkward in that it’s going to be tricky I think to keep everybody on the same

slides with me. So if you get lost - every once in a while I’ll try to indicate

where I am and we’ll give you guys a second to catch up.

I have this annoying tendency when I drive my own slides and have a series of

clicks to make things happen on the same slide. So it isn’t just a question of

saying next slide. I’ll try to say when to hit the enter button if you will.

But those of you who have the slides from last night if you could go ahead and

load them now. And then once you’ve got…



Patrick O’Carroll: Go ahead and load up now and press the F5 key which launches slide show. It

should show an old graph - sort of CPA colored graph that says pandemic

influenza from 1918 and 1919.

And now if you press the enter key what I’ll do is run through the talk. And

I’m thinking probably half an hour is the most it will take maybe less. And -

but if you want to stop me in the middle feel free to just start talking out loud

and I’ll stop and we’ll take questions. Also we’ll have a discussion.

So press the enter key and you should see an outline at the top. Basically what

I would like to do is to try to indicate what all the fuss is about. I mean all of

the sudden we’re all talking about it and money is coming and the president is

giving some press conferences and issuing plans.

So I would like to sort of indicate why now and what’s all the fuss about. And

then I would like to give you some background and context on not only the

disease of influenza but also the disease of bird influenza - Avian influenza

which most of us have never through about in our careers not being bird

specialists.

Then I’ll do a quick snap shot of where we are at the moment - or at least as of

a couple of days ago. And finally we’ll finish up by what’s being done by

people in the public health community which of course hopefully includes you

guys. And then what you all can do to protect yourselves and also in your

professional work environments what you can do there.

So that’s what we’re going to do today. If you press the enter key again you

should see a picture of National Geographic Magazine. And this is October



2005. And when you see something like this in National Geographic you can -

you get the idea that something is amiss.

Hit the enter key again you should see a picture of Oprah talking to somebody

who’s an expert in various kinds of scary diseases including Anthrax and that

sort of thing. When you see experts on Oprah talking about flu you know

you’re serious.

Press the enter key again and you should seethe soon to be highly awarded

work of art known as fatal contact bird flu in America. Which is a movie that

was on just recently and was really a kind of laughably extreme version of

what might happen with (unintelligible).

So I hope all of you have the good judgment not to watch that movie. Or if

you did I hope you like me were laughing through most of it the absurdity in

it. But it really is not something that you want to take to the bank that was

kind of a silly production.

All right if you press enter you’ll get to slide called influenza scary facts. I’m

going to go through these one by one and again I press the enter key each time

to share the bullet with you. You’re welcome to skip ahead if you want to see

what’s coming.

But these facts are real these are not - and they are scary. So these things

aren’t an exaggeration these are things that we just have to deal with. Press

enter you’ll see the first bullet it says that in 1918 the so called Spanish flu

which actually did not originate in Spain killed 675,000 Americans.

And I am told that is more Americans that have died in the 20th century in all

of the wars we fought in that century combined. That’s an awful lot of people



to die from one disease. And I should say I don’t think there has ever been an

epidemic of any infectious disease that killed as many people as this Spanish

flu did in 1918.

Press enter again and you get another bullet that says there were 40 to 50

million deaths worldwide from that pandemic. Enter again shows you that

influenza pandemics have occurred for hundreds of years. Now you might ask

as I did how do we know that given that we didn’t really have tests for the

virus until the 20th century.

But it is a fairly classic presentation of upper respiratory symptoms. And

people you know having tremendous difficulty breathing and dieing in large

waves in seasonal patterns. And you can see this - it was actually called (grip)

or (greep) in French. The different names around the world but you can see

these epidemics sweeping worldwide just in the contemporary records going

back hundreds of years.

We’ve had three in the 20th century. Bird flu now that you’re hearing a lot

about - this is influenza among birds. The H5N1 strain is spreading rapidly

among birds. And they tell me it’s a relative of this Spanish flu virus. Meaning

it has some biologic similarities to the Spanish flu virus which is something

that has also made people rather worried to the extent that it’s related to the

virus in 1918. That gives us pause.

Hit enter again and it says among persons that have been affected with this so

called bird flu. But when its just humans that H5N1 influenza A there has

been a very high mortality rate. And it’s not just among the elderly but among

previously healthy young adults and children.



And finally another enter key - it indicates that most conditions for pandemic

have been met. If you press enter again you should be on the slide entitled

conditions for a flu pandemic. And this is shown by CDC and by the secretary

many times. And if you think of sort of a set of check boxes that - all of which

have to be satisfied in order to have a pandemic we’ve got most of them.

We’ve got wide spread infection of a new influenza virus sub type in

migratory birds and in domestic flocks. We’ve also found that it can exist in a

variety of hosts not just the single type of bird for example.

We have continued outbreaks among domestic poultry. Some countries have

done quite well recently in eradicating it from their domestic flocks others are

still struggling but its going on. We’ve had infections of mammals - cats and

pigs and humans of course. It can be quite lethal.

Patrick O’Carroll: The evidence that the virus is evolved and changing bit by bit as this virus

always does. And we’ve had sporadic human cases - over 200 cases have been

reported of the avian flu jumping to humans. And in those human cases there

has been a very high case fatality rate.

And that may be exaggerated a bit because there may be some sub clinical

cases that aren’t getting to the hospital and therefore aren’t being counted. But

nonetheless among those that we’ve identified for sure the case fatality rate is

over 50%.

There may have been person to person transmission but certainly if it’s

happening it’s happened very rarely. The only piece that’s missing is that we

do not have a sustained efficient rapid person to person transmission when it’s

jumped to humans. That’s absolutely critical and we’re not going to have a

pandemic if that doesn’t happen.



Having said that if that begins it is likely we will have a pandemic because

influenza travels around the world each and every year. It’s a highly efficient

bug that is spreading from human to human. So thats the last condition for a

pandemic that we’re looking at and that’s what got people worried.

Press the enter key again and it shows you the crude death rate for infectious

diseases of the US in the 20th century. And it’s not hard for even non-

epidemiologists to spot the influenza pandemic there in 1918. That graph

really gives you a sense I think of how dramatic the increase in mortality was.

We have high mortality as you see in 1900 from all infectious disease we’re

systematically doing very well in eliminating mortality of infectious diseases

throughout the century through clean water through safe food that sort of

things. And then the 1918 the influenza pandemic came along and really set us

back.

Press the enter key again and you get an influenza not so scary facts slide that

has a little - cute little chick it’s hard to imagine harming anybody up in the

right hand corner. That was the most innocuous chick photo I could find.

Press the enter key again and you’ll see - these are also facts that are really

worth keeping in mind because a lot of what we read can be so scary. The not

so scary facts are equally true. First of all there is no pandemic of H5N1

human influenza. There have been occasional cases as I mentioned. But there

is no pandemic of human influenza.

Press enter again and you’ll see that in 1918 the terrible infectious disease rate

that you saw that rate was about 950 deaths for every 100,000 people. Well



the flip side of that is that somebody died out of 100,000. That meant that

more than 99% of Americans did not die from infectious diseases that year.

And even if those infected in the US with influenza the death rate they’re

estimating is based on the best data we have was around 2.5%. Now that’s a

terribly terribly high death rate. But at the same time it means again that

97.5% of people who were infected did not die from this infection.

And there has been so much - like that movie Fatal Contact shows villages

wiped out. That it’s really got people unreasonably exercised about this.

Though we should be concerned we don’t want a death rate like we had in

1918. We don’t want the death that we get every year from influenza. So we

do what we can to prevent them.

But we should not kid ourselves that this is the end of the human race. I mean

even the worst epidemic known to human kind left 99% of Americans

surviving. So that’s a fact worth keeping in mind.

Press enter again and you’ll see that the other pandemic we had in the 20th

century in 1957 and 1968 were much much milder. They were only

moderately more severe than our normal annual up tick of influenza. It was -

you know 2 million deaths versus you know 1 million deaths in 1957, 1968

compared to 50 million in 1918.

So quite a bit different. So even if we have a pandemic we don’t have any

priority reason to think its going to be like the 1918 epidemic which is

historically unprecedented.

And finally press enter again and I think this is worth remembering we at

public health have been working hard to improve our ability to respond to the



attacks and control and slow down recover from large infectious disease

outbreaks for some years now.

And there has been a systematic worldwide effort to work on this and a very

intense effort here in the United States. So I think we’re in a better position

than we were last year, much better position than five years ago in terms of

our lab systems and communication and emergency response capacity in a lot

of different ways.

I’m not saying we don’t have a long way to go. But we can focus on this for a

number of years. And I think we’re better off then we were. And we’ll

continue to work on this to get more and more prepared.

Press enter again and it goes to slide with a little background and context for

human avian influenza. Press enter again and we’ll get as part of the talk - get

to another blank slide and says background and context human influenza.

Press enter and we’ll just step through these bullets. Again this bug this

human infectious disease agent has been with us for a very long time. There

are clear records of 11,000 of disease that must be human influenza. So there

has been human - humanity has been living with this for a very long time.

Press enter - annually we get about 36,000 deaths from regular old seasonal

influenza. And that’s why every year as ask people to make sure they’re

getting their shots. And all of you dealing with young populations that often

do carry infectious disease it would be very wise for you to get your flu shots

every year. Because apart from the deaths we also have hundreds of thousands

of hospitalizations from influenza.



Press the enter key some of this is just background but it helps I think to help

demystify some of what you may be reading in the papers. First of all there

are various types of influenza - virus types. A and B types are the kinds that

cause human epidemics. There is influenza C you don’t need to worry abut it.

But influenza types A and B typically cause these outbreaks we get every

winter.

And enter - among the influenza A types there are surface proteins called

antigens. Those are the ones our immune system reacts to. And there are two

kinds that they characterize the virus by. One is called hemogluten and

another is proteins floating on the surface of the virus - influenza A virus is

neuromunidases.

And scientists just refer to these two proteins as H and N as a short cut. And

then there are 15 shapes for hemogluten and 9 shapes for neuromunidases

these little proteins. And again their shorthand for describing which influenza

A bug they’re talking about which virus they’re talking about.

It’s indicated - well its hemogluten 1 and neuromunidases 9 or something like

that. And so you have influenza A H1N1 is their shorthand for that in 1918.

One of the bugs circulated this year is influenza A H3N2. So that’s what those

code words refer to. They’re just talking about the kinds of proteins that are

on the virus.

Press enter again and we make the distinction between antigenic drift versus

antigenic shift again the antigen is the proteins. These proteins tend to change

in small ways all the time. So year to year the hemogluten is a little different

than it was maybe last year.



And we’re therefore - if we had the flu preceding year we’re a little bit

immune to the new flu but not completely because it’s changed enough that

our antibodies aren’t completely efficient at eliminating it.

So this kind of drift happens all the time. And then we have - that’s why we

need a new flu shot every year because the drift is enough that without that

new flu shot we may still get sick from the flu although probably we won’t die

from it inmost cases.

Now antigenic shift although it sounds like drift just to confuse everybody, an

antigenic shift is like a virus we’ve never been exposed to before. It’s like

we’re all brand new infants who’ve never had a bug like it. And so it’s when

you’re having an antigenic shift that we see a pandemic.

Because once again it spreads through the world and it’s a very severe disease

because none of us have any immunity to anything even like it. And that’s the

thing that we’ve seen in the avian flue this year is antigenic shift this H5N1.

That’s what’s got everybody worried.

Press enter again and just talks you through what I just said which is that a

worldwide epidemic or pandemic occurs after a shift. There is quite a range

there. I’ve got it that it infects 15 to 40% of the population. And there is no

magic right number there. It kind of depends on how closely people associate

the level of nutrition the population and so forth.

So but even in an antigenic shift not everyone in the populations gets the

disease. Although I will say that it probably sweeps through every human

habitation. That’s a remarkably efficient infectious disease.



Okay going to the next slide what changes are needed for A H5N1 to become

a pandemic virus. Press enter as I’ve said just one increase transmissibility

among humans. Now even here I want to give a distinction.

Press enter again and point out that increased transmissibility - that if

increased efficiency of going from person to person can happen through two

mechanisms. One is reassortment.

Reassortment is where two viruses in the same person - two influenza viruses

maybe I have human influenza virus and I get the avian flu at the same time.

And these viruses can exchange their DNA. And then they essentially create a

new virus that has characteristics of each.

When that happens you get a sudden new virus. I mean the creation in that

individual created a new virus that can be very infectious and have

characteristics of both. That’s what everybody is really worried about. But it

also - this increased transmissibility could happen very gradually.

I mean the bug may adaptively change over time and become more - gradually

more transmissible over time. And if that happens - even if we get increased

transmissibility if it’s through that route we’ll have plenty of time to respond

to that. We’ll see it coming and we’ll have time to generate vaccines and we’ll

be able to deal with that. It’s really the reassortments that we’re concerned

about.

Next page press enter you get to - some background and context on the bird

influenza avian influenza. We’ll talk about influenza in birds now. This by the

way like you I learned most of this - I should say like most of you learned all

about this just this year having never studied bird flu in my life.



Press enter - it defines what bird flu is which is a very contagious disease of

animals - a viral disease. Typically infects birds less commonly pigs.

Influenza viruses have been with birds for a very very long time too. It seems

to be natural reservoir in Mother Nature that influenza can live in birds. On

rare infections it does cross the species barrier to infect humans and that’s

happened throughout the centuries.

Next - enter it says in domestic poultry two main forms of avian flu exist - so

called pathogenic and non-pathogenic or highly pathogenic and low

pathogenic. What we’re seeing - what you’re hearing about is bird flu

sweeping though Asia and having to destroy large flocks.

This is the highly pathogenic avian flu. And the big words highly pathogenic

just means real serious. If a bird gets this up to 100% of birds infected will die

from it. So it’s a very serious disease if you’re a bird.

Only viruses of the H - hit enter again only virus of the H5 and H7 sub types

are known to cause this high path avian flu. And of course H5N1 is one of

those types.

Enter again - mild waters - like ducks - like swans seem to be this natural

reservoir for the influenza A viruses. Hit enter one last time. And this is new it

appears and the science is not solid on this it is a debate. But it appears that

some migratory birds are now directly spreading the highly pathogenic H5N1

as they travel.

That’s really new. The way this has spread in the past seems to have been the

low path avian flu would infect migratory birds. And they might then infect

domestic flocks low path flu. So the birds got a cold. And that was it.



And then occasionally having received low path flu it would mutate in a flock

and become high path. Now that’s how it happened in the past and that’s why

when we’ve seen high pathogenic avian flu its been very limited to the flock

that its infected or to that particular part of the world.

And it was controllable. And what it seems like now is that these migratory

birds are taking - are actually spreading the high path form - or some of them

can. Now I said this is controversial because from month to month you may

have seen this even in the newspapers you’re hearing epidemiologists

differing about whether in fact migratory birds have had anything to do with

introduction of avian flu into Africa for example.

The theory they believe right now seems to be that maybe they didn’t. It might

have been smuggled birds that brought infection in rather than migrating

birds.

Okay another enter should take you to the next slide - some more background

and context of avian flu. Press enter - current outbreaks now that we’re seeing

around the world of this high pathogenic avian flu have never been before

seen in history.

I mean at least those who’ve followed this have nothing on record to indicate

that we could have so many countries simultaneously effected resulting in the

loss of so many birds wild and domestic. So this is really historically

unprecedented.

And this is one of those kinds of scary realities that we have to deal with.

Even if we never see pandemic flu in humans in our life time and I’ve got my

fingers crossed that we don’t there is no getting around the fact that this is



historically unprecedented - spreading around the world this way. And it’s

worrisome for reasons I’ll explain in a few minutes.

Next enter key should give you the second bullet talking about the fact that we

destroyed 150 million birds in an effort to control this. And some countries

like Viet Nam seem to have done a thorough job of eradicating this from their

borders although it could be back tomorrow we have no evidence that it’s

going on there now. The same thing in Thailand.

But in other countries like Cambodia and China it appears - and in Indonesia -

parts of Indonesia it appears that this bird flu may still be endemic - still

actively going on there.

Another enter key we talk about the fact that we’ve got this in poultry all over

the world in Asia, in Europe and in Africa now. And no we don’t have it in

North America but a lot of folks are saying it’s just a matter of time.

Enter key again - control of disease it says here in poultry is going to take

several years. That’s probably a minimum estimate 2 to 3 years would be

really good news. Why is this a time of great concern?

If you hit the enter key it shows you a lot of nasty photographs of a bird - to

people holding it. If you’re trying to catch up to where I’m you can just flip

around until you get there. There are two scientists in gear - protective gear

holding a dead bird.

The reason this is worrisome is as long as there are birds with this high

pathogenic flu and as long a humans are in contact with those birds then we

have an opportunity for that reassortment that I talked about. There is an



opportunity for some child to mix human influenza to be co infected with

avian influenza.

And then genetic reassortment could occur and we could be off to the races.

So eradicating this in birds is critically important. And to the extent that we do

we reduce the chances of us seeing a novel influenza virus that could sweep

around the world in a pandemic.

Next Slide - a picture of lovely spring flowers here in May and talk about

where we are in our current situation. Hit enter again and we get to our current

phase of the alert. There are the six phases of a pandemic influenza alert. And

we’re in phase three which means that there is either no human to human

transition or there is very limited human to human transmission.

And that’s where we are now and we’ve been there for quite some time and

I’m hoping that’s where we stay until I can get to retirement and this is

somebody else’s problem. But we’re solidly at the place where if there has

been human to human transmission it is very rare.

And it may not even have occurred. And maybe this in fact that there were the

same people living in the family exposed to the same infected flock. And

sometimes it’s hard to tease that out.

If you go to the next Slide it’s a map. And the next few maps that I’m going to

show you - for these of you looking that is. Indicates how the bird flu spread.

And we’re first going to look at bird flu outbreaks not human cases.

You should be looking at a map that is essentially China, Laos, Indonesia,

Cambodia and Viet Nam are infected. I mean the light gray colors mean that

there is less than 100 cases. And the yellow dots mean new cases. So January



to June in 2004 you can see from largely in Eastern Asia and in China and

various parts of China though and throughout the Southeast Asia as well.

Press the enter key it fades to another map. The next six months July to

December 2004. And now you see a number of yellow cases again are new -

the red dots now represent the cases from the proceeding slides. And you see

that throughout Indonesia there is a tremendous spread of bird flu and also in

Cambodia.

Press enter again and you see it hasn’t changed much from January to June

2005. So during this whole 18 month period it’s kind of confined to the same

parts of the world. But the next six months you press enter again you get into

July to December 2005 and that’s where you see this rather frightening spread

of the bird flu into Russia and into Ukraine and Romania and into Turkey and

Croatia into Europe.

So this is rather surprising that so many countries were infected so quickly.

Finally if you press enter one more time you get to the current situation

January to May 2006. And now you see where you are with bird flu - it’s gone

completely through Europe.

It spits out in the UK in France, Austria, Italy, you’re also seeing it now in

Africa both northeast Africa on Egypt and Sudan in (Jabuti) on the horn of

Africa and in western Africa in the Niger and the Nigeria and Cameroon.

So its spread to Africa is particularly worrisome because the public health

systems there for surveillance are really quite underdeveloped. And so the

concern was of controlling it, it would be very difficult. Even monitoring what

was happening is very difficult.



Now if you press enter one more time it fades to another slide that now we’re

going to focus on human cases. Not the bird flu. And each of these little boxes

you’ll notice Thailand and Viet Nam - those show you the number of cases of

bird flu confirmed by WHO.

And the number of deaths. And the parenthetical numbers next to it will be the

accumulative account. So they’re the same the initial count for January to

June 2004, 12 cases and 8 deaths in Thailand, 20 cases and 16 in Viet Nam.

So press enter again and we get to July to December of 2004. That the

epidemic is still - human cases are still only in Thailand and Viet Nam. Hit

enter again January to June 2005 we now have 4 cases and 4 deaths in

Cambodia.

Moving now to the first - second half of 2005 and we see deaths in Indonesia

and now deaths in China as well. The first half of 2006 we now see deaths in

Turkey, Egypt, Iraq and (Jabuti). And so - and the death in (Jabuti) just

occurred - 1 case and 1 death just very very recently also deaths and cases in

(unintelligible).

So again worrisome but not surprising as you saw that follows very much the

spread of avian flu. And all of these cases with perhaps rare exceptions - 1 to

2 rare exceptions maybe were directly caused from humans exposed to

infected birds. So it mapped very nicely to where you saw the proceeding

infected birds.

So if you press enter and then I’ll pause for a moment to see if there are any

questions. This is the -a table of the accumulative number of confirmed

human cases. Not bird cases now human cases avian flu. And if you’re just

interested in the totals it’s the last column - cases of deaths.



All the way at the bottom you see 208 cases 115 death. Now a couple of

interesting things to note here. If you look at Thailand and Viet Nam over

time for 2003 you see - let’s take Thailand for example. You see 17 cases and

12 deaths in 2004, 5 cases and two deaths in 2005. So far no cases in 2006.

And as I said great success in eradicating this in domestic poultry.

Viet Nam similar story we have 29 cases in 2004, 61 cases in 2005 and so far

no cases in 2006. Once again they’ve done a thorough job in their case of

vaccinating their poultry to eliminate avian flu.

So it does seem to indicate that if we can do a good job of handling the bird

flu we can have the expected decreased in human cases as well and therefore

decrease our chance of never seeing a pandemic from this bug. Let me stop

for a moment to see if there are any questions.

(Roger Slater): This is (Roger Slater) at OESD 114

Patrick O’Carroll: Yes go ahead (Roger).

(Roger Slater): Based on what I’ve read in the past the number of deaths in 1917 and 1918 the

cause of the factor is not really the flu itself but pneumococcal (numinitis).

And of course that time we didn’t have any antibiotics. Is this the - your sense

as well?

Patrick O’Carroll: Certainly many of the deaths - I think it’s hard for people to get accurate about

what percentage of deaths were from pneumonias - secondary pneumonias

and what were due to influenza. In fact for most of my career public health

they’ve counted seasonal influenza by counting deaths from pneumonias and

influenza because it’s very hard to tease that out.



Having said that there is no question that a numbers of people who died from

influenza large proportion whether its 20% or 70% I couldn’t tell you but a

large proportion died from secondary infections due to the fact that their lungs

were all torn up from the influenza. And it’s like a mild field for

pneumococcal infection as well.

This is one of the reasons why particularly for people that are - that may be at

high risk we strongly recommend that you consider getting the pneumococcal

vaccine because it’s actually a vaccine against pneumococcal pneumonias.

And if one did come down with avian flu H5N1 that the human infection and

one had been immunized against pandemic - or against pneumococcal

pneumonias you’re that much better off.

Your chances of survival are that much better. So I strongly encourage folks

particularly folks that have any other coincidental medical conditions, heart

disease, COPD or what ever it might be to strongly consider getting a

pneumococcal vaccination.

(Roger Slater): Thank you.

Patrick O’Carroll: Sure. You know its 11:35 now so you’ve got the slides in front of you. I’m

just going to - maybe if you just skip ahead I’m not going to be going through

every single one. If you skip ahead to a slide called US strategy for pandemic

influenza it’s got a graphic of three pillars in the right hand corner.

I just kind of want to mention this is what we’re doing in the country. We’re

working very hard in preparedness and increasing our capacity to

communicate. Not just from federal to state to local communities but federal

agency to federal agency.



I mean this is a new thing for CDC to be talking to the department of

agriculture and the department of state to find out what surveillance they’re

doing in birds in Alaska.

So we’re working really hard to make sure we’re getting communication

across government levels and up and down through our various levels of

government.

The other thing we’re working very hard on is surveillance and protection. A

lot of effort to get out there into Asia and into Europe and into North Africa

and sniff out what’s really going on. Huge amounts of energy going into

surveillance which I think is really important because it will give us an early

warning if we’re seeing trouble - or the disease is beginning.

And the last effort of course is response containment. We’re not doing that yet

because there is nothing to respond to but we’re building our capacity to do it.

Now containment is an important word there because I think some people

imagine that we can sort of just stop this at the borders.

And there really is no reason to believe that’s true. Influenza despite our, you

know, good nutrition and our efforts to you know cover our mouth when we

cough that sort of thing pretty much rolls right through every country on earth

every year.

It’s a highly infectious disease and we humans have learned to tolerate it. But

we never learn to completely stamp it out. Even our influenza vaccine isn’t

100%. However the vaccine I want to hasten to say and then I’ll stop on this

the vaccine is far and away our best instrument.



It is the best for what we have. You’ll hear a lot of talk about anti-viral drugs

and how much we stock pile them. But that in my judgment is an argument we

should spend only a certain amount of our energy on.

Because what really matters is getting that vaccine built, identifying the virus

early getting it to the vaccine manufacturers and getting them to produce an

effective vaccine and then mass creating it. And they do this every year for

influenza.

That’s their business and every year they are able to detect the virus from the

year before and within six months crank out an approved vaccine to give for

next year’s virus. So that’s what we need to do if we start seeing avian flu

jumping to humans.

And that’s how we’re ultimately going to control this thing. In the mean time

all of our other efforts including (unintelligible) virus will be to slow the

epidemic to give us time to develop a vaccine and to avoid getting it in our

particular institutions as long as we can.

And then to treat take care of people as they get sick with the modern health

resources that we have at hand. But I want to stress that that’s the key to all of

this is getting influenza vaccine developed.

And finally let me close - I really think it’s at the end of the slides - I’m

skipping way ahead. But you can go through the others as you like. We’re not

going to die. What you can do is protect yourself and your family and protect

your environment is really laid out on a Web site that I think is a very final

slide.



Or the second to the final slide which is pandemic flu dot gov. I actually used

to work at (informatics) and helped to design some Web sites. And I have to

say this is one of the most well laid out useful Web sites that I’ve seen. There

are particular check lists not only for families and businesses that should be

useful to us but the kinds of businesses including child care centers.

The specific check list to go through that you might want to look at. I want to

make sure we’re as prepared as we can be - let’s go through the check list. So

it’s a very practical site if you click on if you’re a school or a healthcare

provider or committee organization.

Click on that particular section and find the check list for that section and

work your way through it very practical very doable. And I think very

measured advice. It’s not extreme it not inappropriate it’s well thought

though. And I highly recommend that you guys take a close look at the check

list that’s relevant to you personally for your family and also to your business.

Allison Hertel: Patrick this is Allison just to let everyone know the child care and preschool

checklist should have been attached to the email you received today.

Patrick O’Carroll: Okay well let me stop there because I’ve talked an awful lot and I went

through a lot and skipped some. But you’ve got the slides there in front of

you. And a lot of it is kind of technical. But I just want to make sure that I’ve

demystified it a bit for you and gave you some sense of why folks are worried.

And why we shouldn’t panic. Why we should take this seriously. So let me

just stop with that and have a discussion so you guys can react to it or ask me

questions or whatever you like.



(Roger Slater): This is (Roger Slater) again. Last question checking with the health

department I was surprised to find out that Washington State influenza is not a

reportable disease. Now when you’re collecting data then incidence figures

first of all it’s my understanding about Washington State correct. And

secondly how do they acquire data when it’s not reportable.

Patrick O’Carroll: Good questions I believe you are correct that it’s not reportable. I’m not sure

it’s reportable anywhere. And the reason is that people typically don’t do lab

tests to confirm seasonal influenza. In fact most of us say we have the flu

which is short for influenza. But what we really mean is we have a cold - bad

cold.

And so when doctors see some body they make their best judgment whether

this is a bacterial infectious like pneumonias like pneumococcal pneumonias.

If they think it’s viral which includes influenza but has many other viruses

you know choice of official viruses and other things.

If they think it’s viral they just tell you what you’ve all heard which is not

much to be done you know take some Tylenol drink lots of fluids you know

make yourself as comfortable as you can be. And if you’re not better in you

know seven to ten days call me back.

And that’s because antibiotics for the most part don’t do anything against

viruses. And antiviral are really not called for unless somebody is very very

sick because they’re quite expensive and they really only really help if you

take them right out of the gate.

So most people don’t do a test for influenza. So there is nothing for them to

report. They would just be reporting colds if they reported colds. However

how do they know about it then? There are some sentinel clinics that people



set up that health department set up where certain physicians offices make it -

are specifically engaged to doing active surveillance.

And they do tests for influenza on behalf of the public health department

essentially. So these sentinel clinics are scattered throughout the country. And

these sentinel clinics that first detect influenza activity. And when CDC says

we’re seeing influenza in the northeast and we haven’t seen it yet in Texas or

in the west they’re really reporting what their finding from their sentinel

clinics which are specifically set up to detect influenza as it goes around the

country.

And so that’s probably a cost effective way of dealing with a problem given

that it rolls through every year and the difficulty of trying to count every case.

Now apart from sentinel cases which gives us our most current picture of

what’s going on in the community then we have what I alluded to earlier the

mortality statistics where they kind of lump deaths that a corner says were due

to pneumonias and influenza.

Even there they’re not testing for influenza many times they’re just saying the

person died from pneumonias it could have been bacterial it could have been

viral but they died from pneumonias or influenza. And that’s where we get a

crude measure.

But generally it tracks very carefully - that demonstrated it tracks influenza

quite nicely. But it’s a crude overstatement of how many deaths due to

influenza every year. So mortality gives us a sense as well. But for a current

sense it’s the sentinel clinics.

(Roger Slater): Thank you.



Patrick O’Carroll: Sure. Other questions.

Woman: Yes I was wondering if - can a vaccine not be developed then for human

beings until that point when virus does switch over from A B into human.

Patrick O’Carroll: That’s where we are right now. Now they are - for example the current H5N1

bird flu that has jumped to as you saw a number of individuals and hopefully

thankfully not gone further than that. There are in fact vaccines being

developed against that strain.

In fact even there the strains have been different. They’re just - so there’s

several vaccines tentatively being developed in case that makes the jump to

highly transmissible bug.

So they sort of put their toe in the water and they’re ready to rock should that

become necessary. But they really won’t go to full capacity and develop

millions of vaccines until there is a reason for it because they go bankrupt

doing that because nobody would buy the vaccine because it’s not needed.

So the answer is until we see the bug that we’re worried about we can’t really

move forward. They are as they say in the emergency response field they are

leading forward in the sense of grabbing the one that we’re worried about and

beginning the process of developing a vaccine for it. But won’t go to

production unless that’s the virus that jumps and so far it hasn’t.

Woman: Is this usually done in the private sector?

Patrick O’Carroll: It is it’s an interesting reality of our world that vaccine industry is the private

sector industry. And it works for a profit. There have been interesting

discussions that I’ve been involved with saying if this is a national security



issue you know we don’t contract out our army. We figure it’s a national

security issues so we pay for the army out of our taxes.

And if this is a national security issues why don’t we pay for the vaccine out

of our taxes. And the answer is well maybe someday but that’s not how we do

business now. And we are in fact able to get insulin vaccine for this every year

via the private sector. Sometimes it takes arm twisting and it takes a lot of

cajoling and a lot of meetings.

But so far the private sector has been able to do that for us. There have been

some hiccups as you have seen in recent years where (Chiron) for example

was decertified and couldn’t produce vaccine.

But apart from some of those anomalies on the private sector has been able to

produce the vaccine in quantity and good quality and with a good safety

record. And so that is the model they’re continuing to use for the foreseeable

future.

(Chris Borchards):This is (Chris Borchards) with (Oly Cap) Head Start and I’m wondering how

are the local health departments communicating with Head Start or preschools

to help them report any unusual illness.

Patrick O’Carroll: Well that’s a great question and I don’t know the answer to that. That is really

a great question and my suggestion is probably the suggestion you’re making

via the question is that it makes a lot of sense for Head Start folks in a given

community to make sure that they have a working relationship with the lead

infectious disease person at their community health department.

(Chris Borchards):Right.



Patrick O’Carroll: And I think that’s a terrific idea.

(Chris Borchards):Yes I’ve contacted both Jefferson County and (Crown) County and they don’t

seem to have anything clearly written or identified as kind of indicators so far

that they’ve been able to give me. So that’s kind of the issues that I’m kind of

wrestling with right now. When do we call them - the Ghostbusters?

Patrick O’Carroll: Well I’ll tell you this many people don’t realize this because we’ve been

collecting you know so called notifiable disease data for years and its

published every week in the CDC MMWR journal. And I think even I through

most of my career figure that epidemic were discovered as epidemiologists

poured over their weekly data.

You’re laughing because you know better. In fact what happens is somebody

in the community - often it’s some other clinician calls the state

epidemiologists and says I think you’ve got an outbreak of E coli because I’ve

seen three cases this week. And I’ve seen you know about one a year for the

last five years.

Then they go look at their data and they say oh my goodness he may be right

or she may be right. So I think it’s going to happen when you see unusual

numbers and unusual severity of upper respiratory you guys should not

hesitate to call the local health department and tell them that.

There won’t be a magic number it won’t be - you know at least three a day or

people with fever over X. I mean if you try to get that accurate you’re going to

spend all your time measuring and trying to figure out if you’ve met the

criteria.



But seat of the pants experience that says there are more kids sick out there

then usual. And the ones that are sick are sicker than usual that should set off

alarm bells. You really don’t need to be more sophisticated than that.

And I wouldn’t hesitate to call and if it’s a false alarm no harm done. I mean

that’s what heath departments are for. Those would be the criteria serious and

numbers ill.

Allison Hertel: I just want to point out to everyone that what I gave you was a list of Web

sites the title of the page is pandemic and avian flu web resources. And every

state received funding to do pandemic flue summit. And at the bottom of the

page are the state plans for pandemic flu.

So to some extent each state has a plan. And it probably was in the plan talked

about where needed efforts at the local level. And there are opportunities for

community agencies to get involved.

And that’s probably where Head Start would fall into and then if you also

looked at the child care check list it talks about coordinating with your local

health department. So I would definitely encourage you to start to build some

unique partnerships with those agencies and try to get yourself into any of the

planning efforts.

Patrick O’Carroll: By the way let me also add because we’re talking about pandemic flu but this

is just one of any number of infectious diseases. So one of the things that

everyone in public health is trying to do is take this focus on pandemic flu and

make sure that the connections we make and the relationship we build the lab

systems we strengthen will serve for any kind of infectious disease that

threatens our population.



So the advise I just gave your for pandemic flu is exactly the same advice for

anything. If your kids in your centers have more diarrhea than usual and they

seem sicker than usual once again that’s all that it take for you to make a

phone call if you’ve developed a working relationship with your local health

officials.

So you don’t need to say oh my goodness is this pandemic flu. You just need

to think - is this unusual are the kids unusually sick or more of them out than I

would expect this time of year. The parents seem you know unusually harried

because other kids are out of school as well. That’s the time to call the health

department.

Because it’s those calls that alert health authorities that something is going on.

And maybe an epidemic of well any number of different things. It may not be

pan flu but that does not mean it’s not important.

Woman: My question is, is this kind of practical for those of us in Alaska? There’s

been a lot of publicity around migratory birds coming this spring.

Patrick O’Carroll: Right.

Woman: Possibly they are carriers. So and a lot of our Head Start communities families

traditionally collect eggs and (unintelligible) spring time hunting.

Patrick O’Carroll: Right.

Woman: So what is the practical advice around handling birds? And I know each of the

tribal groups up here have done a lot of education and adversity around it. But

I’m just kind of curious what you would recommend for folks.



Patrick O’Carroll: Well its interesting the recommendation will be the same before and after we

discover that first bird that’s migrated over if it’s got A H5N1. But people will

take them a lot more seriously after we find the bird. But the

recommendations would be the same which is that you know the meat and the

eggs should be thoroughly cooked before they’re consumed.

And if they’re not you’re at risk of infectious disease that’s true right now

long before this H5N1 we all know we should thoroughly cook our food. And

if you don’t you’re more susceptible to infection.

When they’re defeathering the birds and there is blood products it makes very

good sense to protect yourself from being exposed to the blood product from

animals that may or may not carry infectious diseases. H5N1 included but not

exclusively to that disease.

So I realize that - I mean I fully realize that the community - the idea that

everyone is going to put on protective gear and wear rubber gloves when

they’re working with birds is ridiculous. But at the same time you have to let

people know there is a risk when you’re working with blood products and you

know doing hunting of birds and dealing with blood that comes from hunting.

They’ve got to do what they can to prevent from ingesting it and letting it into

open wounds. They’ve got to wash their hands thoroughly afterwards and

they’ve got to make sure that the meat is thoroughly cooked. All the things

we’ve been doing for centuries to protect our selves we need to do.

Now I would hasten to stress though that there is no evidence of any case -

accumulative case of H5N1 from ingesting food. The evidence appears to be

from being exposed to the infected and sick birds and their blood and feces.

But not from eating chicken from a restaurant that may have had H5N1.



Not to say that it isn’t something you want to be thoroughly careful about and

make sure that the food is cooked. But people aren’t typically getting sick

from eating infected poultry. So it’s a question of avoiding the feces and the

blood exposures to wild animals is always a good idea to minimize and

prevent if you can. And then of course as I say people will take that a lot more

seriously when we tell them we now know there is H5N1 in birds.

People ask a lot of hard questions when I was up at the pan flu summit you

may have been there. Someone in the community said you know this virus is

pretty hardy it can live in you know the lakes for some time which is true.

And our kids play in the lakes you know is there a danger they may get

infected that way.

You know our dogs will find these birds and eat them when their dead and we

won’t even know it. And you know then the dog is infected. There are lots of

sort of theoretical things to be concerned about. But again the reality is just to

look at the epidemiology and few people have been infected have been

infected through close sustained exposure to sick animals - to sick birds.

And not from their dog that ate one of the birds for example. So not to

minimize it but just to say please follow good hygiene and we’re testing like

made to see if this Minnesota and Alaska and so far it has not. I hope that’s

helpful.

Other questions?

Allison Hertel: I just wanted to make another comment that after looking through the child

care planning check list I think some of the basic hygiene practices that we



start to promote such as good hand washing, if the kids are sick having your

policies on when to exclude kids due to illnesses.

Finding alternatives for staff so that staff can stay home when they’re sick.

Just to present all sorts of illnesses and encouraging staff you know to get

their annual flu shots. But they state hygiene principles that in general we

should be promoting.

(Linda): I was looking through this communication plans for the child care. And it

recommends teaching families natural hand washing and covering your mouth

when you’re sneezing and all of that. And I’m just wondering if there is some

kind of resource that we can use.

I’ve been looking for a while for something that we can use as handouts for

parents or do parent training with. That would be real - a lot of wipes instead

of a lot of reading.

Patrick O’Carroll: Yes that’s a really good question. I know - I’m confident that there is but I

couldn’t tell you exactly where to go for it. What I would do personally is I’ve

been impressed that the health department here in the state of Washington has

produced a awful lot of pamphlets and things.

And I know they would be real eager to share it with you. I would probably

contact (Joe Hoffman) at the state of epidemiology infectious diseases -

epidemiologist to see what she would recommend. She may have to refer you

to the communications people. But I’m afraid I don’t have a ready resource

for that. CDC also may put out some nice material but I haven’t looked for it

so I couldn’t be sure.



Allison Hertel: (Linda) this is Allison I was at the Washington state flu summit and they gave

illustrations on hand washing for low literacy. And they also came in different

languages. I will try and find that and send it out to all of the health

coordinators so you can have that resources.

(Pam): This is (Pam).

(Linda): Is there something that has like when not to send children to school that might

have symptoms.

Allison Hertel: Yes there are some resources on that too that I can send you.

(Pam): This is (Pam) in Washington Early Head Start. I found - I don’t have the Web

site at my - here in this office at the moment. But if you look - a search for

Mr. hand. There is some very interesting coloring pictures - coloring book

pictures and children’s education on hand washing and covering with sneezing

that I find very appealing with kids and parents.

You might try doing a search for that - Mr. Hand. (Website is: It is "Henry the

Hand." Here's the website. < http://www.henrythehand.com/default.html >)

Woman: I noticed on our handout sheet it says communication and planning to make

sure the staff family understand your flu pandemic plan and explain why you

need to have this plan. And one of our staff asked that - why do we need - you

know how are we going to explain why we need a plan.

Does this plan have to be over and above our normal - you know policies and

procedures for keeping the children home.

http://www.henrythehand.com/default.html



Patrick O’Carroll: Well I think it does and a couple of important respects. Again the pandemic

plan is in many ways a plan for disaster. It’s a plan for a serious pandemic of

the 1918 nature. It’s a plan to keep your business working under those kinds

of conditions. And remember those things don’t just pop up and rage for a

week.

It’s a slow moving over multiple months kind of things that will cross the

country and it will come into a community for six to eight weeks you’ll be

dealing with it as it works it way through the community and people develop

immunity to it.

During that period you can expect a lot of fear a lot of disruptions of services -

for example bussing and things like that there maybe as many as 30% of their

employees not showing up for work. And it’s a bus route making a cut back

and nobody getting to work.

A lot of your normal workers may not show up because they are either

carrying for sick kids of their own or they themselves are sick. Or they may

just be afraid to come into work with (unintelligible). So during the period -

again this has not happened in our lifetime.

But planning for the worst during such a period you need to have a plan in

place for how you would continue to function with 30 to 40% of your staff

missing. What would your procedures be and how would you protect your

staff for example.

And that’s the second piece is there may be some extraordinary protection that

you want your staff to use in the event that there was a serious pandemic the

influenza bug is circulating where you might want to use gloves or you could



decide if you wanted to use masks or to put masks on kids for example while

they are there.

Those are discussions that you need to have now and have kind of thought

through before the event occurs. So that’s why a pandemic flu plan is needed

more than just normal planning for how to deal with sick kids.

Woman: Okay.

Allison Hertel: This is another good opportunity and way that your health services advisory

committee can be supportive for your program. And working in partnership

with other child care other community agencies, your public health

department to see if you can incorporate it into some of their planning efforts.

Because it can be overwhelming to think of a flu plan. And I know some

people get overwhelmed with emergency planning. And it’s all really within

the context of just being prepared. We have about a minute left and I just

wanted to wrap up.

If you’re interested in some additional training and technical assistance

support it’s definitely something that we can be creative in how we provide

support. And help with some of the planning efforts. And then I just wanted to

say a huge thank you to you Patrick for taking the time to…

Patrick O’Carroll: Sure.

Allison Hertel: …do this and support Head Start. I really appreciate it and I speak for

everyone on the phone also.



Patrick O’Carroll: You are all very welcome and I appreciate you setting this up Allison so

thanks.

Allison Hertel: So thanks everyone for participating and Ill send out an email with some of

these resources. And then also with a reference to the Web site once the call

information gets posted. So thanks everyone and enjoy this beautiful day - I

think it beautiful down there - its beautiful up here.

Patrick O’Carroll: It’s beautiful here too.

Allison Hertel: Enjoy your day and thank you.

Patrick O’Carroll: All right good bye.

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2001499 health and human services transcript pandemic flu call 05-17-2006

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