How Maui will deal, and not deal, with an Avian Influenza pandemic
April 26, 2007
On a Saturday afternoon in March, I spent a few hours with 23 Maui
residents listening to Dr. Skip Hofstrand speak about what could become
the 21st century's first global health catastrophe: pandemic influenza.
"We need to be proactive, not reactive," he told the small audience
in the Cameron Center Auditorium in Kahului. Wearing a bright aloha
shirt over slight shoulders and Midwest pale coloring, this Northern
Minnesota emergency room physician and author of Expedition Home: Journey to Safety from Pandemic Influenza, A Preventive Quarantine Solution somehow managed to smile periodically while calmly telling the audience on how to deal with a flu pandemic.
"The American public has a dangerous and inordinate faith in
science, technology and the 'powers-that-be' to protect us in a major
catastrophe," he said. "Neither our government nor our health care
system will be able to adequately protect and care for all Americans
when the pandemic hits."
Current projections for the next pandemic estimate that a
substantial percentage of the world's population will require some form
of medical care. Few countries have the staff, facilities, equipment or
hospital beds needed to cope with the huge numbers of people who will
suddenly fall ill. Surprise—this includes Maui.
Hofstrand's advice: voluntary isolation. "No exposure equals no illness," he said.
During an influenza pandemic, Hofstrand believes the best barrier
device available is complete social distancing. He said isolation will
not only save you from being exposed to a deadly virus, but will also
slow its course. He further advises families to stockpile an eight to
12-month supply of food and hide out from others until a vaccine is
Vaccines are considered the first line of defense for protecting
populations. But here's the kicker: no human vaccine will be developed,
produced or administered until scientists identify and isolate the
exact pandemic strain. Recently the Food and Drug Administration
approved the use of the Sanofi Aventis SA vaccine in the event that
Avian Influenza becomes transmissible from person to person, but it
requires two 90-microgram doses taken a month apart—hardly a quick
response to an outbreak. In any case, a proper vaccine will take at
least six to eight months to develop once an outbreak occurs.
But even when pandemic influenza vaccine supplies finally become
available, high demand nationwide means Hawai`i will not receive
sufficient doses to vaccinate the entire population. Faced with this
limited supply of available vaccine and antiviral medication, the
federal government advises isolation, quarantine and general public
health containment as options for slowing the spread of pandemic
What is Pandemic Influenza?
Avian Influenza refers to a large group of different influenza
viruses that primarily affect birds. Avian H5N1 is a strain with
pandemic potential since it might ultimately adapt into a strain that
is contagious among humans. Once this adaptation occurs, it will no
longer be a bird virus—it will be a human influenza virus. Like a
seasonal flu, influenza viruses are commonly spread from
person-to-person through respiratory droplets in coughs and sneezes.
Scientists say the Avian Influenza Type A H5N1 virus, currently
found in parts of Asia, Africa, the Middle East and Europe, may mutate
into a form that spreads quickly among people, possibly killing
millions worldwide. When the virus changes, few (if any) people will
We can expect an influenza pandemic to occur every few decades.
Three occurred in the previous century: "Spanish influenza" in 1918,
"Asian influenza" in 1957 and "Hong Kong influenza" in 1968. The 1918
pandemic killed an estimated 40–50 million people worldwide and is
considered one of the deadliest disease events in human history,
killing more people than World War I. The subsequent pandemics were
milder, with an estimated two million deaths in 1957 and another
million in 1968.
Spreading from person-to-person, the virus will quickly travel
around the world and cause increased levels of serious illness and
death. A recent World Bank report estimates the worldwide human death
toll from a virulent and communicable H5N1 pandemic at 71 million
(low-end) to as high as 180-260 million.
The World Health Organization (WHO) uses a series of six phases of
pandemic alert. The world is presently in the third phase: a new
influenza virus subtype is causing disease in humans, but is not yet
spreading from human to human contact.
Experts at the WHO say the world is now closer to another influenza
pandemic than at any time since 1968. People can be contagious one day
before developing symptoms and are most contagious earlier in the
illness. The sheer numbers of airline passengers circling the globe
every hour of every day will spread the disease like wildfire on a
Hawai`i's popularity as a tourist destination will put the state's
residents at great risk early on. Local experts believe our
travelers—visitors and residents returning home—will quickly
disseminate the virus throughout the state.
Response and Treatment
The lead state agency coordinating the preparedness and the medical
and public health response for an influenza pandemic is the Hawai`i
Department of Health. On Maui, that responsibility falls on Dr. Lorrin
Pang, Maui's District Health Officer. Having worked controlling
communicable diseases in Southeast Asia, South America and most
recently in Louisiana, Pang carries a wealth of experience in his
While not familiar with Hofstrand's book, Pang supports any strategy
that slows the virus from barreling through and crushing the community.
As a port-of-entry, Pang believes Hawai`i will be at the front end of
the pandemic influenza wave. If so, Pang predicts Hawai`i will
experience a high mortality rate—perhaps 15 to 20 percent of those
infected will die.
"If we get it quick—say 50 percent of us get it in four months,
that's a hell of a lot of deaths," he said. "If we can drag it out—say
over a year, I can take that kind of infection rate. We won't be
swamped. The vaccine could be developed; we'll have a fighting chance."
Pang wants three gray areas cleared before a pandemic strikes Maui:
sequestration plans, the role of Maui's hospital and the distribution
of the vaccine and antiviral medication.
Running one of the largest shelters in Louisiana after Hurricane
Katrina, Pang witnessed first-hand the ineptness and inefficiencies of
the Federal Government during major catastrophes. "The feds were the
weakest link during Katrina," he said.
Pang also doesn't feel Federal Disaster Planner's blanket
recommendation of sequestering the sick has been thought out. For
travelers coming into Hawai`i from infected areas, there are no
quarantine plans in place for the airports. And for residents, Dr. Pang
doesn't feel voluntary isolation is realistic.
"Families will need to decide now what they will do when faced with
different scenarios: if the whole family is sick, if no one is sick, if
some of the family gets sick, if some get exposed but are not yet
sick," he said. "People need to ask themselves, 'Who's going to go?'
Then, 'Where are they going to go?'"
Pang wants people to understand that if some of the family gets the
virus, people cannot send the rest of the siblings to auntie's house.
They will already be infected and will spread the virus.
Following steps taken in the 1918 pandemic, Dr. Pang's plan is to
set up eight designated care areas around Maui County. He loosely
refers to these areas as "tent cities."
"The pandemic can only managed if the sick are gathered in one
location and given basic services like water, sanitation, food and
primary care," he added.
The virus is transmittable within a three to seven-foot radius, but
not through tent walls. Considering this, Pang has developed two
designs for his external medical centers: small partitioned areas under
one large tent, or if there is no partition, spreading patients out
seven feet from each other.
"With Hawai`i's warm weather, tent cities will work," he said. "The
feds said it was a stupid idea, but they haven't come back with a
better one. When their voluntary isolation plans break down, when our
streets began to be filled with sick individuals trying to isolate
themselves from their family, what's the fed's contingency plan?"
'The Sick Will Storm the Hospital'
Pang believes external units will need to be set up because the
231-bed Maui Memorial Medical Center will not be able to handle
thousands of sick people. Rod Bjordahl, D.O.—the Chief Medical Director
at Maui Memorial, said the hospital will not treat patients suspected
of having pandemic flu.
"The hospital's primary function will be to continue caring for
trauma, deliveries, surgeries, heart attack and strokes and other
conditions," he said. "We cannot risk infecting the entire hospital. If
pandemic influenza enters the hospital, the hospital will have to be
quarantined and essentially shutdown."
But Pang needs an agreement with Maui Memorial. He says they have to
take his seriously ill, infectious patients. At the end-stage of the
pandemic flu, all patients are in need of care.
"If someone is dying, I need to be able to send them to the
hospital," Pang said. "I can't tell people I tried to send their loved
ones to the hospital but they wouldn't take them."
Pang worries that if that happens, his external units will lose
credibility. "We don't want the reputation that we can't do our job,"
he said. "If they lose faith in us, they will stop coming to the
external medical facilities. Then, the sick will storm the hospital."
Pang is currently trying to recruit a volunteer workforce to help
run his tent cities. Asking people to risk their lives and their
families by possibly exposing them to the virus to help others will be
difficult, and for that reason, Pang said he needs incentives.
Federal disaster planners told Pang that volunteers and their
families will be vaccinated. But these guidelines are mutating like the
flu virus itself. Since then, Pang has been told that vaccinating
volunteers' families is now out of the question.
Supplies of vaccines and antiviral drugs—the two most important
medical interventions for reducing illness and deaths—will be
inadequate during a pandemic. Once the vaccine is developed in the
first year of the outbreak, there will only be enough for 15 percent of
the American population. Antiviral medication—which is given if someone
already has the virus—will be doled out in limited amounts, as well.
Adhering to federal government recommendations, Hawai`i is
stockpiling anti-viral medication to cover 25 percent of the state's
population—including tourists. As of March 2007, the Department of
Health on Oahu holds approximately 367,000 doses of the antiviral drug
Tamiflu. Of those, 48,000 regimens are set for Maui.
Running large shelters with only limited medication will be
challenging at best, Pang admits. "Giving out medication to only
limited individuals among thousands will be a curse, like throwing a
bone to starving dogs," he said.
Residents need to understand that high-priority persons will get the
initial doses of pandemic influenza vaccine. Those essential to running
our community and those with lots of contact with others will be Pang's
Pang says even though the vaccine is not guaranteed and the Tamiflu
carries only a 60 percent success rate, he needs these "carrots" to get
people to volunteer for his workforce in order to help the large
numbers of sick people. He also needs a rapid test to check if someone
has pandemic flu. That hasn't been developed, either.
"If we don't [do these things], who will show up to help?" Pang
asked. "If we don't protect our workforce, they will possibly die. But
before they die, they will disseminate it to everyone they've
When the time comes, Pang says he will be too busy caring for Maui's sick to waste time arguing over these issues.
"I want this dialogue now," Pang said. "I need these issues resolved now, before it's too late." MTW
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