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Preparing for the Next Pandemic

Audio

Aired 6/2/09

The swine flu outbreak has reached 64 countries, infecting more than 17,500 people worldwide and causing at least 115 deaths. We'll look at how public health officials responded to swine flu and how they're preparing for the upcoming flu season.

MAUREEN CAVANAUGH (Host): I’m Maureen Cavanaugh. You’re listening to These Days in San Diego. Back in April, it seemed as if our concerns about the economy and Iraq and a number of other pressing issues took a backseat for a couple of weeks while the world waited and wondered what the new swine flu virus would do. We heard frightening reports from Mexico, which turned out to be exaggerated about the lethality of the new virus. And before you knew it, schools were closing around the country, and the vice president talked about not flying on airplanes. Now that we’ve got some distance from the initial hubbub about the H1N1 virus, it’s a good time to assess what was done right and what was done wrong and what we’ve learned from the reaction from the outbreak. We do this while acknowledging that the swine flu outbreak is not over. The disease has been found in 64 countries and has killed over 115 people including, recently, a twelfth U.S. fatality. As part of our monthly series on ethics in science and technology, we’ll examine the reaction by the public health community to the outbreak of swine flu and what preparations are underway to deal with the upcoming flu season. My guests are Phillip Van Saun, Director of Continuity and Emergency Services at UC San Diego. Phillip, welcome.

PHILLIP VAN SAUN (Director of Continuity and Emergency Services, University of California at San Diego): Good morning.

CAVANAUGH: And Dr. Francesca Torriani from the Infectious Diseases Division of the UCSD School of Medicine. Dr. Torriani, welcome.

DR. FRANCESCA TORRIANI (Physician, Infectious Diseases Division, UCSD School of Medicine): Good morning. Great to be here.

CAVANAUGH: But first, we’ll get an update on swine flu right here in San Diego, and we’re joined by a woman we spoke to frequently during the initial outbreak of the virus. Dr. Wilma Wooten is San Diego County public health officer. Dr. Wooten, thank you for joining us this morning.

DR. WILMA WOOTEN (Physician, San Diego County Public Health): Thank you for having me.

CAVANAUGH: Now according to the CDC, there are over 800 confirmed or probable cases of swine flu documented in California. How many confirmed cases have there been in San Diego?

WOOTEN: As of yesterday afternoon, we have a total of 212 confirmed cases.

CAVANAUGH: And what is the status of the outbreak here in the county? Is it over? Are people still reporting flu-like symptoms?

WOOTEN: I wouldn’t say that it’s over. It’s definitely on the decline. So – And keep in mind that regular seasonal influenza, actually we have surveillance that goes on year round and we do have a few viral detections that occur between the peak periods of November to – or the regular flu season which is, in San Diego, November to March.

CAVANAUGH: I see, so this is rather late, though, for people to be reporting flu symptoms, isn’t it?

WOOTEN: Not at all. There are flu symptoms but it’s just not as profound as it is during the regular flu season. Again, influenza does occur year round and we do have the rare cases that are reported in terms of viral detections. Influenza in itself is not a reportable disease but we have sentinel sites throughout San Diego and we do, between the regular seasonal flu period, do have some viral detections that are reported to – or, sent to our public health laboratory.

CAVANAUGH: And just so we are all on the same page about this, Dr. Wooten, if you could remind us what those symptoms are for the flu and the H1N1 virus because I believe they’re similar.

WOOTEN: They are very – they are very similar. Usually with influenza you will get a fever greater than 100.4 degrees Fahrenheit, can be associated with a cough, sore throat, malaise, which basically means you’re just tired, and you can have diarrhea and nausea in some cases, as well.

CAVANAUGH: Now what is the county doing to prepare for the next flu season? Dr. Wooten?

WOOTEN: Yes, in – the first that we want to do is to debrief from the H1N1 situation that we had in April. So on June eighteenth, we will be conducting – which would have been a statewide pan flu exercise but because San Diego and many other counties throughout the state have gone through the exercise with the real life experience, we will conduct debriefings with our community stakeholders, so that’s going to be our first step. And then we’re looking at all of the components of our pan flu response plan and seeing how – looking for gaps and as we get the information and feedback from our community stakeholders and we conduct our own internal assessments, we will develop an after action report and make improvements that will help us if we have a bad flu season and if we have a recurrence of the novel H1N1.

CAVANAUGH: Do you have any preview on that assessment for us? I mean, is there anything that was a sort of a glaring thing that came up again and again in the county’s response to the swine flu outbreak?

WOOTEN: No, I think overall we did very well. It – I just think there’s always room for improvement, and communication is an essential feature of acting promptly and swiftly. So we are identifying community stakeholders that we – additional community stakeholders that we need to have contact with if situations were worse. This was a mild situation and we had communications with the necessary stakeholders but if things are moderate or severe, there are other strategies or tactics that we need to take. So planning in advance for that is also on our table as well.

CAVANAUGH: And, Dr. Wooten, just for my edification, when you mention stakeholders, what kinds of organizations do you mean when you refer to stakeholders?

WOOTEN: Well, in this mild situation we were primarily concerned with our hospitals, our community clinics, our physician providers, our first responders, in the form of our EMT and paramedics transporting patients to the hospitals, as well as our schools, our colleges and universities. Those are – were some of the primary stakeholders that were involved with responding to this situation.

CAVANAUGH: And as you assess and prepare and get in the information from all those various organizations and devise a strategy for next fall, do you think you’ll be preparing a public outreach campaign for flu inoculations?

WOOTEN: Well, we are always doing that in terms of outreaching to the public to encourage them to get the seasonal flu shot so that’s a mainstay of public health and we do that every year in collaboration with CHIP, the Community Health Improvement Partners, and the San Diego Black Nurses and community clinics. So that is an ongoing effort that we implement and conduct every year.

CAVANAUGH: And I’m wondering, I know that you’re busy and I know you have to leave us but what do you have for the public in terms of staying alert to the dangers of this swine flu. As you say, it is…

WOOTEN: Umm-hmm.

CAVANAUGH: …it’s a year round thing. You can get it at any time. So what should the public do to stay alert?

WOOTEN: I think the first thing for them to – for the public to be informed is to go to the County’s website, www.sdcounty.ca.gov, and keep updated on the information that’s also provided on CDC’s website. So that’s the first and foremost important thing that they can do, and know what they should do if they become sick, whether it’s the flu or seasonal flu or any other type of infection. The main thing is that you don’t want to go to work or to school or be out in public so that you can transmit or spread an infectious type disease or respiratory, particularly, infectious disease. And if symptoms, however, do not resolve and particularly with influenza—seven days is the period of time that we have told people they should stay home, seven days or until their symptoms resolve, plus one day. If they have risk factors that would place them at greater risk for complications due to influenza, they need to let their doctor know so that they can develop a strategy or plan. If they have respiratory problems as a result of the infection, then they also definitely need to call their doctor and be evaluated. So all of that information, again, is on the County’s website. And just being educated and knowing what to do when you become infected and knowing that washing your hands and covering your cough are key tools that we all can do to help prevent the spread of influenza.

CAVANAUGH: Well, Dr. Wilma Wooten, thanks so much.

WOOTEN: Thank you for having…

CAVANAUGH: That’s Dr. Wooten, the San Diego County Public Health Officer. And for the rest of the hour I’m going to be speaking with my two guests who are in the studio with me: Phillip Van Saun from the Community and Emergency Services at UC San Diego, and Dr. Francesca Torriani from the Infectious Diseases Division of the UCSD School of Medicine. And we’re also inviting you to join the conversation if you would – if you think the information you received about the swine flu outbreak from both public health officials and from the media, we’re wondering if you thought that information was useful. Did the precautions go overboard or did most organizations hit the right balance? Give us a call. Our number is 1-888-895-5727, that’s 1-888-895-KPBS. And Dr. Torriani, as I said in the opening, you know, this is an outbreak that the headlines are not – you know, that is not in the headlines anymore but is still taking place. The disease is in 64 countries and killed 115 people. And I wonder if you can tell us where this stands in terms of outbreak, epidemic, pandemic, all those terms that we heard so much in April.

TORRIANI: Yes. So from a pandemic WHO, so World Health Organization, standpoint, we’re still in phase 5, which is basically a pandemic poised to start, so it’s not the ultimate phase 6, pandemic phase. That doesn’t tell us – that tells us about where the virus – the viral illness is, so it’s widespread and it’s spreading from person to person. How easily it’s spreading, however, is still unclear and how virulent or how bad this disease is, we think that it’s not as bad – even as bad as a bad flu season. So I think that in those pandemic phases, really, those pandemic phases don’t take into account the severity of the disease, which we think is relatively mild for now, and it takes into account the spreadability but we’re not in phase 6, which would be basically pandemic. I think that we are lucky enough that we’re getting on to the summer and, therefore, in the western hemisphere we will have the summer to buffer us and to prepare us for the fall, which might be much more severe.

CAVANAUGH: Part of this show, as we’ve been – as I’ve been saying, is looking back and sort of assessing what went on just a couple of months ago, and I’m wondering as you look at the World Health Organization list of levels, should they include severity in those levels considering how quickly it went up from one to five, and really how relatively—I hate to say minor because people have died from this flu but it’s not a terribly lethal flu and yet you’re up to level five of a six level world pandemic scale from WHO. And I’m wondering if people are sort of looking at that and assessing that at this point.

TORRIANI: Yes, I think several organizations want to add in that scale severity, but you always have to consider what the purpose of this pandemic scale is and then how it fits with countries’ priorities and the country function. And I think that, as I view it, the WHO really serves worldwide and is kind of the watchdog telling us, you know, this could happen. We’re in phase 5, which means that a pandemic is imminent but we’re not in phase 6, which means the pandemic is here and so, basically, there’s nothing that countries can do. So I think that for that purpose the phases of – the pandemic phases serve that purpose well. Then it’s up to, really, other organizations such as the CDC—and they’re actually discussing about that—to take into consideration severity and then to plan for the future.

CAVANAUGH: You know, we’re up against a break here. It came rather quickly because I was speaking with Dr. Wooten. Let me take this break and then go back and start to talk to Paul Van Saun about the emergency services at UC San Diego when we were dealing with the outbreak in April. You’re listening to These Days right here on KPBS.

[ break ]

CAVANAUGH: Welcome back. I’m Maureen Cavanaugh. You’re listening to These Days in San Diego and we’re talking about what we are learning or have learned from the reaction to the swine flu outbreak back in April. And my guests are Dr. Francesca Torriani from the Infectious Diseases Division of UCSD School of Medicine, and Phillip Van Saun is Director of Continuity and Emergency Services at UC San Diego. And we’re taking your calls at 1-888-895-5727. So I’m wondering, Phillip, you head the Emergency Services at UC San Diego and I’m wondering when you heard the World Health Organization declaring this H1N1 outbreak up to Level 4 and Level 5, what did you get ready for at UCSD?

VAN SAUN: Well, the two years prior to this, really, the entire nation was preparing for bird flu and the assumptions were that the flu would move from Asia into North America. So, you know, in the twenty-four months prior to this, we had been exercising around that type of an event. And it’s important to think about this in terms of all hazards so our approach was really, regardless of what information we receive, we want to be prepared for any type of an event. So we participated in a number of scenarios. We gamed out what we would do should there be bird flu on campus or in California or somewhere else in the nation. And, really, our concern is for the health of our students, the staff and the faculty, that’s number one. So part of that is working with a county public health officer, Dr. Wooten, and the state to decide what’s in the best interest of the students, that’s our prime mission, education. So the best thing we can do is follow the best guidance based on science, and that is the challenge, it’s really to discern what is the appropriate action at that step.

CAVANAUGH: Right.

VAN SAUN: So regardless of what the WHO declared, we then brought together our local staff and decided for our university and for the local community what’s best for these students. And, really, we were very blessed to have the two medical centers, Thornton and Hillcrest, because we have research scientists there who can give us great guidance on the specific strain and what they know about flu, and that really guides our decision so we can make an informed decision.

CAVANAUGH: I’m wondering kind of specifically what did the university do when – during this outbreak? What did you – what kind of level were you guys at, let’s put it that way.

VAN SAUN: So the first thing we did was we brought all of our leadership together. We have what’s called an Emergency Operations Center, very similar to what the county and the state and the federal government have, and we also have an Epidemic and Pandemic Response Committee. So we brought both of those groups together and our decision was what can we do now for the university? And, again, we contacted the County and the State and we looked at what WHO said but we took that in counsel with all of the other guidance, and the guidance was unless we had a case on campus and it fit certain parameters, that we were good to continue to provide instruction.

CAVANAUGH: Okay, so…

VAN SAUN: So that was our – that was our decision but it was based on all of these other factors.

CAVANAUGH: So classes went on.

VAN SAUN: Correct.

CAVANAUGH: And everything, you basically – operations normal. And it turned out you didn’t have any swine flu cases on campus.

VAN SAUN: Correct.

CAVANAUGH: Let’s take a caller. Chris is in San Diego. Good morning, Chris and welcome to These Days.

CHRIS (Caller, San Diego): Good morning. Thanks for taking my call. I’m an emergency room physician here in San Diego and one of the aspects of the pandemic that I find myself most frequently treating or addressing is not as much the medical complications of the disease clinically, but the fear that people have. And in the media, regarding your question has the media adequately addressed the needs of the people and the various aspects of the disease, one of the best ways that I’ve always found to mitigate the fears that people bring, at least to me in the emergency room, people always want to know what can I do? What can -- You know, how can I protect myself, you know. Yes, cover your cough, wash your hands, all of these things are very good guidelines but, above all, something that we still do not address enough is the emphasis on prevention, on maximizing your own wellbeing, you know, stopping smoking, exercise, proper nutrition. And that I’ve found to be a mainstay of my treatment of the psychologic aspects of the disease, which is fear, and, of course, that can have a devastating effect on the economy, on people’s behavior, and that’s really all I had to say about it. I think, otherwise, the media has done a very good job of informing people, and influenza is a very dangerous disease in any of its varieties, whether it’s swine flu or something else and so I think all the precautions that have been advised have been very reasonable.

CAVANAUGH: Well, thank you for that comment. That was Chris. He works as an emergency room doctor. And we’re inviting your calls, listener calls, at 1-888-895-5727, 1-888-895-KPBS. And Chris, I think, makes a very good point, Dr. Torriani, about fear, fear that was – I don’t know, I think fear and panic, perhaps, is a little too extreme. I don’t think we actually had much panic involving this outbreak but I think people were definitely concerned, especially when you saw all those pictures of people in Mexico City wearing face masks and all of that. What do you think of Chris’s idea of emphasizing just good total, overall health as a way to counteract that fear of disease?

TORRIANI: I definitely think that this is a very good idea because getting any – I mean, being fit and having a good natural immunity to any viral disease is a good idea, and that clearly involves being fit, having good nutrition, and having also a good morale. And so I think that has to be – well, another thing is really talking through things which I can do because of my university appointment. Maybe I have a little bit more time on my hands than, clearly, an emergency physician who sees patients very quickly and in a completely different setting. But I think that talking to people and kind of taking away the myths and the fears really helps because then it helps them explain to others who then explain to others and it puts people more at ease. And it’s – it’s a very long process, it’s not just a one stop shot. But, clearly, talking with people and saying why would you be so afraid with this and you’ve already gone through how many flu seasons, right?

CAVANAUGH: Right.

TORRIANI: And you’ve survived. So let’s talk it through, let’s think about it and think how you can prevent and keep healthy.

CAVANAUGH: And, Phillip, you were going to comment about the power of talking?

VAN SAUN: Well, the idea that the communication that we receive and we process and we give out, as long as it’s coming from a scientific basis and we can qualify that, I think that really takes away the panic. In fact, we know that panic is really not that – doesn’t occur that often. Look, when you have good scientific data that you provide people, I think it gives them a better frame of reference in order to make an informed decision and I think we saw that from the County and both from the State here in the local community.

CAVANAUGH: And I think a very important point was that people kept saying don’t panic but, again, I don’t think that there was a lot of panic around this particular outbreak. Would you agree, Phillip?

VAN SAUN: Yeah, I would. And you had Amanda Ripley on your program and she’s done really great research in this area. You know, it’s not panic to be concerned. But to take some kind of an action that’s inappropriate, that would be, you know, what we would be concerned with, and we didn’t see that on the campus. The students reacted in an informed way. We communicated with them, and that’s probably the most important aspect of this, is to provide good, solid information in a timely basis and that’s difficult to do in a breaking situation.

CAVANAUGH: It is difficult to do, and that’s part of this assessment. I invite our listeners to get involved and tell us whether or not you think you got timely information, whether you think it helped you, and what you’d like to hear about if there are future outbreaks—and we imagine there will be—of different diseases. The number to assess the swine flu information cycle, 1-888-895-5727, 1-888-895-KPBS. Dr. Torriani, I’m going back to those face masks because those images were a little startling, I must admit. Should people wear face masks if there is another outbreak of swine flu?

TORRIANI: If you’re in a confined, non-ventilated place with people who are coughing and sneezing, then I think that there might be a use, and that specifically would be in a healthcare environment where you really are trying both to protect yourself as a provider but yourself from being sick and spreading disease to others. So I think in very confined quarters, it may probably make sense whether the level of protection, you know, from an N95, which is kind of a more – a mask that filters more, or a simple surgical mask, that’s still a discussion or debate.

CAVANAUGH: Well, say that again because I think that’s important. There are two different kinds of masks, right?

TORRIANI: Yes. Well, there’s simply – so, for the person who’s coughing, clearly, what you want to do is stop the cough, the spit, from aerosolizing, right. And so for that, you can use a tissue, you can use whatever. So anything that is in front of the mouth and basically stops that spray of droplets is fine. For the person who is avoiding to get sick, there are different types of masks and those are based on how the virus or the bacteria aerosolizes, so how little of particulates are ejected when the person coughs and how much they stay in the air. And so a surgical mask basically protects from anything that is what we call a droplet, so three feet, six feet. An N95 respirator protects from tuberculosis, from diseases like SARS, tuberculosis, and other diseases. And for now, the flu has always been a droplet, so surgical mask, but in this situation, because there was some concern of transmission to healthcare workers, the CDC initially put it up to an N95 for healthcare workers working in close contact with a patient with the swine flu.

CAVANAUGH: We have a caller on the line with more questions about this. Michael is in North Park, and good morning, Michael. Welcome to These Days.

MICHAEL (Caller, North Park): Good morning. I was – I traveled to Washington on a plane and, curiously enough, I was with a physician because we were going to a conference, and he put on a mask. I think it was an N95, if I recall, from what he told me. I did not put on any mask but what I’m wondering about is at what point in one’s – I’m talking about in the public response, I’m talking about governmental response and so forth, would they urge airlines to hand out masks?

CAVANAUGH: Okay. Under what conditions would it be a good idea to start handing out those masks on an airplane and other enclosed odd places you find yourself, like in this studio.

TORRIANI: So, I think ideally what you would want to happen is that you would want a very strict screening process to occur before anybody who’s sick walks on a plane, right. And actually the CDC and other organizations put out recommendations on how to screen, A. B, on what to do if a passenger were to fall sick during a flight or whether a flight attendant or flight person, flight personnel, were to fall sick. So I think that the mask is – is the second step but – and, clearly, I mean, if I were to fly on a very long flight, you know, to Europe or to somewhere else, maybe I – I am better off, you know, just for my comfort in – in wearing a mask. Whether that will really help me in that confined of a space if I’m, you know, three feet – just sitting near somebody coughing, I – I’m not sure.

CAVANAUGH: You bring up a very interesting point, too, considering that we are assessing the outbreak of flu in April and looking ahead to a possible reassertion of this swine flu during the flu season that will come up for us from November through March. And I’m wondering what is it that we don’t know about the H1N1 virus or we didn’t know enough about it to know which kind of mask to use back in April, so what is it that researchers are still trying to learn about this new strain of flu?

TORRIANI: First of all, there are – they have pretty good knowledge of how the current virus that is causing the outbreak is, and what did it form by and what mutations and etcetera. And I thought that the information that I read indicated that actually this was a virus that was already circulating in the past fall in Mexico and that was a reassortment (sic) of an avian, swine and human strain that reassorted (sic) in the swine and then, again, reassorted. So that put it at the level of, basically, of a potential virus causing potentially a pandemic with high – because it was not known by humans. What they’re doing now is really figuring out and working on vaccine production so that this new – the new flu vaccine would be either added or added as a separate booster to the new season. And I think what they’re working at is really figuring out how infectious, how contagious, how readily it spreads from human to human and are these characteristics any different, and is the severity going to change. So, is this only in people who are at high risk for complications and who then die of complications of this infection, so bacterial or superinfection or other things. Or does this virus have another, you know, other characteristics?

CAVANAUGH: I – We want to talk more about vaccines and the future of the H1N1 virus but we do have to take another break right now. I’m going to come back with my guests and be taking your calls at 1-888-895-5727. You’re listening to These Days on KPBS.

[ break ]

CAVANAUGH: I’m Maureen Cavanaugh. You’re listening to These Days in San Diego. We’re assessing what we’ve learned from the reaction to the swine flu outbreak this spring. My guests are Phillip Van Saun, Director of Continuity and Emergency Services at UC San Diego, and Dr. Francesca Torriani from the Infectious Diseases Division of the UCSD School of Medicine, and taking your calls and comments at 1-888-895-5727. And, Phillip, as an emergency planner for UCSD, you found yourself, during this outbreak, trying to manage perceptions as much as you were trying to maintain the safety of the students on campus.

VAN SAUN: I think the entire community faced the same challenge. And the caller that talked about seeing someone on the flight wearing a mask and wondering whether that was good behavior or not really points to the challenge and it also points to the need to be flexible. We had, again, plans and thought about this but the event is not going to follow your plan, and no plan survives first contact with the enemy, in this case, the unknown. So our challenge, as a university and as a community, and to be a good member of the community, is to react to the events as they unfold with a foreknowledge based on some of our thinking and planning. And, you know, perception is one of those factors that you need to plan for because the reality is there probably wasn’t a need for a mask on that flight, perhaps, but the perception might’ve been that everyone ought to have a mask, or that the university should close at a certain level regardless. And so, again, that is really part of your communication strategy and working with the local healthcare providers.

CAVANAUGH: I’m wondering, did you – were there discussions about closing the university in April?

VAN SAUN: There were never discussions about closing for the event but we were always thinking about contingencies. And part of this, and the importance of doing this before the event, is to think through those possibilities before you face them. Really, now’s the time for any organization to think through those possibilities because in the event, with the press of time and incomplete information, that’s really not when you want to be making these decisions for the first time.

CAVANAUGH: And how severe would that H1N1 viral outbreak have to have been for you to have closed the university?

VAN SAUN: We had guidance from the state public health office based on the number of cases that presented and the severity, so we would have had to have a certain percentage of students that presented and had tested positive, and we didn’t have that threshold. So – But we could have made decisions just based on the community. There could have been decisions made by the public health officer that we would have used to guide our own decisions on campus.

CAVANAUGH: And I’m wondering, you say no plan survives the first contact with the enemy, the enemy being a flu outbreak, so what specifically are you reassessing now?

VAN SAUN: Well, we’re going back and looking at all of the World Health Organization triggers, we’re looking at the Center for Disease Control triggers. The state has reevaluated from a K-through-12 plus university standpoint what might be a new threshold based on not just the spread of the virus but how severe the virus is. And, again, you pointed that out, that might be a different trigger than we had in this case.

CAVANAUGH: Dr. Torriani, let’s move ahead and talk about a vaccine for this H1N1 virus. I saw a note from the CDC this week that they are not going to be able to have that vaccine before October but they will have one in October. The Obama administration is now talking about having two vaccines, one for the H1N1 and one for a more usual strain of flu. That opens up a lot of questions, doesn’t it?

TORRIANI: Well, yes, but probably cannot be – it cannot be avoided in the sense that what we have to do is cover for the seasonal flu and so you cannot jam in too many different viral particles because your body simply will not get the message and so will not produce enough antibodies to protect you, right. So it seems now that probably we will have a seasonal flu vaccine and a novel H1N1 vaccine and that will take, because of the methods that we have right now for producing vaccines, will take probably the whole summer to develop and that’s why it will be available only in October.

CAVANAUGH: And as far as – if you know, let us know, are there going to be different guidelines for who should get these different strains of flu inoculations?

TORRIANI: I think that will all depend on how much vaccine is available, how much can we produce, right. We know that the production for the seasonal flu will cover a lot of the population and will clearly – one thing, some of us in epidemiology are clearly wanting to widen that group of – of people be – getting vaccinated so that we get more coverage of a larger segment of the population, not only the very, very young and the elderly and then the healthcare group but also the people who are at risk, when in contact with the virus, more easily and then get sick and spread it to others, right. So there’s two different thoughts. One is vaccinate who will have complications from the infection and so is at higher risk to die of complications. The other one is, well, vaccinate universities so that you decrease the spread of the disease and then those people who are at high risk of complication won’t get sick and won’t die. So I’m – I happen to be in the second…

CAVANAUGH: Vaccinate everybody.

TORRIANI: Yeah, vaccinate the most we have but there, too, there might be vaccine shortages and so we will have to carefully look at what vaccine we have available and then prioritize.

CAVANAUGH: Well, I’m going to ask you two procedural questions here. Who makes those kinds of decisions? And why, since we have such advance knowledge of this now, would there be a vaccine shortage? I mean, why can’t they make enough vaccine?

TORRIANI: Because they are production limitations. I mean, I think that the firms who can – there are definitely less production limitations than there were even ten years ago but, really, what we’re limited here is that these viruses have to basically be injected in an egg for now. We’re still tied to not an engineered vaccine but a vaccine that is produced from viral particles and so injected in an egg and then grows in a chicken egg basically, and that’s our limitation right now for the production of widespread vaccine. If we were to go down the route which we’re going of an engineered vaccine that only has a few important antigens and cannot clearly cause disease, then I think that could be jacked up and go very fast.

CAVANAUGH: Interesting. Let’s take a call. Rob from Riverside is calling us. Good morning, Rob, and welcome to These Days.

ROB (Caller, Riverside): Well, thank you so much. I’m – First, I want to say I’m not an alarmist but I ran a biotech lab for five years, and good practice says you contain an unknown until you know what it is. I think Joe Biden’s been proven right. There was – the containment wasn’t there early on and, generally, our policy puts commerce ahead of safety in that respect so now we have it spread worldwide. If it was really serious, consequences would be really serious at this time because of the lack of action in the front end. So I was wondering, are there any changes in national or international policy about early containment of unknown pathogens?

CAVANAUGH: Well, we’ll see if anyone here knows that, Rob. Thank you so much. What have you heard, Phillip?

VAN SAUN: I haven’t heard directly to his question but I know that after this event, just like any event, there are a number of different after action reports and groups that get together and I know the CDC is getting together and looking at how this virus moved and as well as the state health officer and the county and the city as well as the university, so there are certainly a number of different levels of government that are looking at how this moved and how that might be different in another event. And we can always…

CAVANAUGH: Yeah.

VAN SAUN: …learn from each one of these cases.

CAVANAUGH: And since we are talking about the ethics of the reaction to the swine flu outbreak, Dr. Torriani, I’m wondering about – you had something to say about the hoarding of antivirals. Now who was doing that? Was that a national thing or was that something that happened across – internationally?

TORRIANI: Yes, so it clearly happens so if you know that a disease is going on and is spreading and, you know, you might have the thought of saying, well, I know that the viral characteristics are these and this is the antiviral we’ll use, so since I’m going to Mexico tomorrow and I’m getting on a plane full of people and then I’m going to be there in close quarters, well, I might, you know, take a little bit of Tamiflu just in case. And that, for us as a university, was not acceptable so what we did when this outbreak was kind of brewing and hadn’t been declared yet, we got together and set up clear guidelines on the use of antivirals, who should be receiving these antivirals and with the proviso that nobody would be given antivirals because there was shortage of antivirals just for the purpose of prophylaxis, just in case.

CAVANAUGH: I see. And is there – Tell us what you know about discussions going on internationally about the response to this swine flu outbreak because, you know, we’ve been talking largely about San Diego and the United States but, you know, in less developed countries you have whole – many, many people who are unvaccinated, many, many people who may need antiviral medication. Aren’t there discussions underway now as to how to handle that if this strain of flu should resurface next flu season?

TORRIANI: There are definitely discussion going on worldwide on the use of antivirals and the proper use of antivirals, and what antivirals should be used. As you know, while the swine flu is one hundred percent sensitive to Oseltamivir, which is an – Oseltamivir, which is a neuraminidase inhibitor, the seasonal flu issue is resistant, one hundred percent – basically ninety-eight percent resistant, and so that poses a problem to what antivirals should we be using because the key to the use of an antiviral is to use it very, very early when the symptoms arise, not when you have a diagnosis. You know, seven days…

CAVANAUGH: Yeah.

TORRIANI: …later there’s absolutely no point to use an antiviral.

CAVANAUGH: And, Phillip, Dr. Torriani brings up a very good point because during this outbreak of swine flu we were told again and again, you know, oh, by the way, regular seasonal flu kills thousands of people each flu season. Has this made the university and your emergency services preparedness rethink how important maybe access to inoculations are on campus?

VAN SAUN: Absolutely. And one of the callers mentioned wellness. We have a campaign on campus to promote wellness in the students and the staff and the faculty there and in the local community. So, again, in all of these situations, they make you reevaluate because you learn. One thing that we have learned is that we shouldn’t expect for the WHO and the CDC and the state and even the nation necessarily to be in lockstep initially because of all the differences in their perspectives. And we shouldn’t be surprised at that; that’s really predictable. It’s not to say that anyone is wrong, it’s just they’re looking at a situation from a completely different perspective and it takes time to discern what you need to do at the ground level. So at the university, our goal is to be a good member of the community so we’re promoting people to get the seasonal flu shot, to be members of the community and be well, and participate in the wellness campaign on the campus.

CAVANAUGH: And I wonder, Dr. Torriani, briefly because we’re running out of time, what do you think people need to know so that they don’t sort of get overly—I hate to use the word—panicky, overly concerned during – when they’re going to go for their flu shots next fall? That there will be enough flu shots, that this is going to take care of them, what should be their mindset when they approach that?

TORRIANI: I think, first of all, getting a flu shot for seasonal flu is very important, that’s the first step. Second step is really the respiratory ticket and that has varied for any respiratory virus. And the third point is to really think of how you can spread if you get sick. Even though it may not appear a bad disease to you, you can get other people sick and so how to protect other people if you get sick, and so consider staying home from work. I think that that’s one thing that we will have to look, as organizations, very carefully.

CAVANAUGH: It’s a very good point to end on. Thank you very much. I want to thank Dr. Francesca Torriani from the Infectious Diseases Division of the UCSD School of Medicine. Thanks again for being here. And Dr. Phillip Van Saun – I’m sorry, Phillip Van Saun, not a doctor but a director, of Continuity and Emergency Services at UC San Diego. Thank you so much, Phillip.

VAN SAUN: Thank you very much.

TORRIANI: A pleasure to be here.

CAVANAUGH: You can hear more about this topic at the Ethics Center monthly forum, “Facing Pandemics: Science, Ethics and Uncertainty”, that’s tomorrow, 5:30 in the afternoon at the Reuben H. Fleet Science Center. The event is free and open to the public. You can go to kpbs.org/thesedays for more information. Thanks for listening. Join us again tomorrow. This is These Days on KPBS.

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