April 27, 2009 - Health

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This EarthSky interview with Dr. Grattan Woodson medical director of the Atlanta Research Center and an expert on pandemic preparedness, originally ran in 2005. Marc Airhart of EarthSky conducted the interview. Dr. Woodson released a pandemic preparedness manual around that time, which contains much good advice for treating flu patients at home. A PDF version is still available here.

EarthSky: What might happen once a pandemic starts?

Woodson: First, pandemics come in two forms – major and minor. Minor pandemics are serious – many people get sick – a whole lot more die than normally die from the flu. In the United States normally about 35,000 people die from the flu each year. During a minor pandemic, that number may increase by two or three times, which is a tremendous number – 100,000 people or more die. That’s a lot of people. But that typically can be handled very well by our medical system, by our hospitals. We have enough beds. We have enough ICUs. We’re pretty stressed out by that, but we can handle it.

But there’s a once in a hundred year pandemic that’s a whole different animal than a normal pandemic. And it’s 50 times worse than the regular flu season, both in terms of the number of people who die and how sick they become. And probably 10 times as many people get sick as during a regular flu season.

And this once in a hundred year pandemic is what’s been called the Killer Flu. It was called the Spanish Flu in 1918. That was the last time we had one. And I don’t believe anyone can say that’s what’s going to happen – but that’s what I’m concerned about and that’s what the medical community and frankly our political authorities are concerned about. And the chances of us having that are about one in three for this next pandemic.

The death rate will be significantly greater than what we would have with a minor pandemic. And so, many people would be sick that the hospitals would be simply overwhelmed. There wouldn’t be any beds left. There wouldn’t be ventilators left. The hospitals would probably run out of supplies. If enough workers in the economy get sick, if they can’t deliver coal to the power plants and so forth, you could even have brown outs in certain areas of the country or even black outs. And these could last for extended periods. There could be problems in deliveries of other essential items like food. Food processing could be interfered with. There could be places in the country that didn’t have water service, electric service. And this could go on a long time, long enough to make a difference in people’s lives.

If we had that kind of event, it would really be difficult to expect the health care system to be functional at all. And it’s my assessment that we would lose our hospital service and lose our organized medical care system which is now quite concentrated around the hospital that’s very high technology oriented. Under these circumstances, our best bet would be to take care of our sick family members and loved ones and friends at home rather than try line up outside the hospital and hope that a bed will come available sometime. It probably won’t. In 1918, they had to create temporary hospitals in fields, they had big tent hospitals or used closed factories. They put cots all over the floor. And at any rate, it turns out that the flu can be taken care of at home for most people.

EarthSky: So how should you treat a sick family member or yourself at home?

Woodson: The most important thing is to avoid dehydration, which can be done by using a simple oral rehydration solution, which is a quarter teaspoon of salt and three tablespoons of sugar mixed into a quart of a clean water. And this is essentially IV fluids given by mouth. This rehydration solution is what we use for treatment of diarrhea or anybody who’s dehydrated. Normally at the hospital we give it to people by vein but at home we can’t do that. We can do it by mouth by simply feeding this fluid when they’re sick, when they have high fever, this will prevent them from getting dehydrated. Because that’s going to be the main killer in patients who don’t actually succumb to the flu itself. They’ll actually succumb to dehydration.

EarthSky: Why is dehydration so dangerous?

Woodson: We’re 70 percent water. And there’s water in our blood system and in the vascular system, the arteries and the veins. And there’s also a lot of water in our muscles, even in the fat tissue and in the bones. And when we lose water because of a fever, actually most of it is lost through the skin. When the temperature is high, the vessels dilate on the surface of the skin and water actually comes out rapidly in the form of a vapor to try to cool us. And also we lose water through breathing more rapidly than normal. If you have any doubt about that, just simply breathe on a mirror or a piece of glass and you’ll see lots of water vapor will just condense there in front of your eyes.

The loss of water will come first from the vascular tree, some from the muscles, but as that happens our blood pressure begins to fall because the water pressure inside the vascular system drops and pretty soon it can drop so much that we don’t get enough blood flow to our brains and our organs, especially our kidney and our liver. When this happens we can lose consciousness, our kidneys stop functioning, our liver stops functioning. And ultimately we die due to a cardiac arrhythmia or an irregular heart rate because the body becomes so acidic internally that the electrical activity of the heart becomes so erratic.

And this can happen quite quickly. It’s especially quick in children – they can become dehydrated much faster than adults because they don’t have as much water that they can afford to lose. Adults can lose a couple of quarts of water and still be okay. They’ll be sluggish and they’ll feel sick, but they’ll be okay. But a child who loses that much water – well that will be it. They’re dead.

So, this water needs to be replaced. Normally a person needs to drink a gallon of water or maybe five quarts a day. But if you have a high fever, it could be a lot more than that. And so, it’s very, very important that patients who are sick with influenza where fever is a major feature have plenty of water to drink. And it needs to be a slightly salty, a little bit sweet fluid solution to replace the water that is lost from dehydration.

EarthSky: Apart from avoiding dehydration, what are some other general strategies people should use during a pandemic?

Woodson: First of all, don’t worry about eating. You’re not going to be hungry when you have the flu.

Most people haven not had the flu. If you’ve had the flu, you know what I mean, it’s not just like a bad cold. It’s serious stuff. You are so sick. You are too sick to go to the doctor first of all. You’re vomiting your head off, you’ve got diarrhea, you have a terrible headache, you have a high fever, a terrible cough. You can hardly breathe, your throat is so sore. It’s not just a cold. A lot of people say, oh, I had the flu. They didn’t have the flu. The flu in an adult is often very serious. Patients are often quite ill for a few weeks and maybe it will be a month until they will recover sufficiently to resume normal activities.

Children do a lot better – they can recover so much faster. But at any rate, the flu is very serious. But it is an infection that the body is able to cope with in most cases. Even under the worst predictions that I’m aware of for the flu pandemic for instance, the number of people that are expected to die will be 1 in 20 of those who get the flu. Now that’s a lot of people. But that means that 19 in 20 are going to survive. But that assumes that they keep well hydrated.

Besides hydration, they need to be kept clean, they need to be kept dry, they need to be told they’re going to be okay. They need to be told they’re not alone. They need to be kept safe. Things we all do at home normally. Home is a great place to have the flu.

Now, are people going to die at home that would ordinarily have survived in the hospital? Sure. But on the other hand, a lot of the other people who die at home would have died in a hospital too. This flu is not like a normal flu. During the Spanish Flu in 1918, people would go home with a sore throat and a little sniffle and would be dead in bed the next morning. And no hospital in the United States would have saved those people – even today.

This flu can be so overwhelming especially in adults between age 20 and 30, ironically, that they can actually become entirely overwhelmed in as little as 24 to 48 hours. And in these people it causes a complete failure of their respiratory system. And they actually turn blue. There are many case descriptions of patients who looked completely dark blue from the lack of oxygen due to the flu.

Others develop a clotting disorder because of a massive number of viral particles in the blood that causes massive clotting throughout the body that leads to hemorrhaging. And all these patients routinely die. And they would die now. All these patients I’m describing would not survive under the best conditions in the United States today in the best ICU – say, at Columbia University’s College of Physicians and Surgeons.

The ones that would survive would be the patients who could be maintained on a ventilator until they could recover. But there are only 100,000 ventilators in the United States. And if between 35 and 50 percent of the population become sick with this influenza in a major pandemic, you’re talking about 150 million sick people.

EarthSky: What can we do to prevent the spread of the disease?

Woodson: A lot of people are interested in this and we do have some answers for them. And the most important thing is that the person should cover their mouth when they cough, using a handkerchief. You should not drink after them. When you are taking care of them, you should wash your hands, and so forth. And you should clean their bed linen and bed clothes with hot water and bleach.

But the truth is this: influenza is so contagious that none of us, nowhere, are going to escape it. You cannot avoid it. There’s all this business on the internet today about getting masks and all this other stuff. Well, you know if you wore a mask 24/7, and you didn’t come near anybody with the flu, OK, possibly you could avoid it until you took off your mask. Once you took off your mask, you’re going to get it, because it’s in the air. Just a few virus particles are probably enough to infect people.

We are so susceptible to this bug. This is our bug. This bug has been with humans for thousands of years. We’re only aware of the 12 pandemics that have occurred since the 1600s. That’s just because that’s as sophisticated as our medical history is. But this thing has been with us for centuries, and it never has wiped us out. It always takes its toll, but it has a certain balance with us. It becomes highly adapted to us and everybody gets it.

It’s very interesting, in 1958, 35 percent of the U.S. population got the flu. But someone did an antibody study and found that virtually 100 percent of the population had flu antibodies. What that tells you is that at least twice as many people get the flu as actually have the symptoms of the flu. Now some of them may have had mild, cold-like symptoms, but everybody gets it. You can’t avoid it. It’s everywhere. And unless you are living by yourself in the mountains some place and nobody else is around and no one comes around you – but as soon as you go down to the city to pick up your chewing tobacco, you’re going to get exposed.

EarthSky: Is there anything that people can do today, before a pandemic starts?

Woodson: Well, of course you want to try to be as healthy as you can, try to use good health practices.

Quit smoking. If you smoke, certainly you’ll be a lot worse off if you’re a smoker and you get the flu. Here’s another good reason to quit smoking. I hope my daughter is listening to this.

It’s difficult to give anybody any advice about how to prepare for this. The (pdf) manual that I’ve written does have some information about how to prepare, some things to obtain to have around the house, such as salt and sugar and sodium bicarbonate, some over-the-counter medications. And there are some prescription medications that you might be able to talk your doctor into giving you to have in reserve in case the flu happens.

I think that you need to be thinking about the possibility that if it gets really bad, that the power might turn off and there could be some food shortages and so forth, and how would you cope with that? I think that you need to be aware of the fact that there probably won’t be hospital service available and your doctor’s office is likely to be closed as well if it gets really really bad. For example, my office is totally dependent on electricity- you have elevators and air conditioners and so forth. We can’t stay open if there’s no power, and most doctors offices are the same way.

EarthSky: Do we know when this pandemic could happen? This year…next year….. the year after?

Woodson: Well, again, the chances of a major pandemic are really only 1 in 3. In medicine, that’s a big risk. I don’t know about in other fields, but if something has a 1 in 3 possibility of happening, that’s a really major chance, and we want to do everything we possibly can to reduce the risk or the impact of the event if it happens. And that’s why I wrote the manual on the preparation for the coming pandemic. I wish I could be more definite about the timing. It’s just not possible to say when it will happen. There are only probabilities and it may be this year or it may not. But it will happen. It’s not a matter of if, it’s a matter of when.

Dr. Grattan Woodson is medical director of the Atlanta Research Center and a faculty member at Emory University School of Medicine. He’s treated many patients with flu-like illnesses in over 25 years of medical practice. His book, “Preparing for the Coming Influenza Pandemic,” was first published by Health Communications Inc. in October, 2005. A PDF version is available.

Written by Deborah Byrd

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