A Few Questions

Tracy Rowlett chats with Dallas County medical director John T. Carlo, M.D.

It is inevitable: bird flu will hit the United States, according to the Office of Homeland Security. It won¹t be a critical threat until the virus is consistently spread between people, which has happened only in a few isolated cases overseas. But, with history as our guide, the outlook grows dire. Killer flu outbreaks have spread through unprepared populations several times in the last century, killing millions worldwide. That¹s why the Bush administration has proposed spending $7.1 billion to get Americans ready for a bird flu pandemic. Here, that responsibility falls on 33-year-old John T. Carlo, M.D., Dallas County¹s medical director.

ROWLETT: Is such a pandemic a real possibility?
CARLO:
Absolutely. It’s happened before. In fact, three have occurred in the last century. The most famous one was in 1918 and it killed over 500,000 Americans and 50 million people worldwide. So, the likelihood of it happening again is there.
 
We have a flu season every year. Why are we so concerned now?
Well, the specific threat we’re concerned about right now is a strain called H5N1 that’s occurring overseas in the bird population in epidemic proportions. It has been so deadly among birds that if it becomes person to person, we’re going to have a real problem.
 
Yet, I understand it isn’t easily spread person to person, so why such great concern?
They’ve taken this strain into the lab and determined that there are only about five mutations that it has to take before being spread person to person. We’ve seen this virus around, circulating in birds, since 1996. We don’t know for certain why it hasn’t made that jump to people yet. It’s possible it hasn’t reached that correct combination yet.
 
Well, since we don’t quite know what we’re dealing with, is it possible that Dallas County can really be prepared?
Yes. I think it is possible. We can be prepared using our existing infrastructure. For example, we have emergency management structure where we deal with tornadoes and other natural disasters. If we use this infrastructure on top of our good health care system, we do have a chance. But we have to coordinate all our efforts. We can’t have every hospital off on its own making its own disaster plans. 
 
So what is your office doing to get the County prepared?
We are educating the community and informing them that everyone is a key stakeholder. Everyone—from health care to law enforcement, government, even business—has a role in this. And it has been our responsibility to convey that message. Everybody has to get involved. The entire population is susceptible.  
 
Some statistics I’ve seen say one out of every three Americans could catch bird flu if there is a pandemic.
That’s entirely possible. We have no vaccine available to us. This is a novel strain that has never circulated in recorded human history. Therefore, if it got released, everybody would be susceptible, and depending on how crowded your population is, you can estimate that 30 to 50 percent would get sick.
 
So we could have 150 million Americans sick with bird flu?
Yes. Absolutely. It’s entirely possible. Now, we’ve had other emerging threats in the past. You remember we had SARS (Severe Acute Respiratory Syndrome) that came and went, another novel virus to which we all would have been susceptible. We also had hantavirus that came and went recently. We had lasa fever and ebola virus. So it’s happened before but it didn’t spread across the entire population. But it is certainly entirely possible.
 
Are you getting the federal resources you need to fight a bird flu outbreak?
The major point that the federal government needs to concentrate on is the development and distribution of a vaccine. There is no way that my agency can do that. So we really need the federal government to be pushing industry to develop and manufacture a successful vaccine. We’ve been manufacturing influenza vaccine in the same way for over 30 years. There has really been no change in the technology of how these vaccines are made, and that is going to hinder us. We are behind the curve in manufacturing and that is going to hurt us if a pandemic happens soon.
 
Would the influenza vaccines we have now be of any help?
No. The H5N1 virus is so different that the vaccines we have now would be of no help at all. But I do still think there is some benefit to getting that seasonal vaccine because it better prepares your body to develop antibodies. You certainly want every ounce of help possible to fight this deadly disease.
 
Should people be concerned about buying birds as pets?
Well, right now in North and South America, there are no diseased birds with the H5N1 virus. So there really is no significant threat to being around birds in this community. But we are hearing that we can expect migratory birds with H5N1 by next year. So, there is no danger right now, but he have to be aware of what’s on the horizon.
 
And Texas is in the migratory path, isn’t it?
Yes. Texas has a big migratory fly away pattern. Now, there are some good things that we do here in terms of our poultry industry. We have very large poultry farms that are regulated and most of the birds stay indoors all of their lives. So, already, it is almost a quarantine measure in the way that they manage the animals.
 
Have we seen any of the other strains of bird flu in Texas?
Yes. Bird flu or avian influenza outbreaks have occurred recently in the United States and they have managed them appropriately.   In fact, in 2004, there was an H5N2 outbreak that occurred in Gonzales County, Texas, and that was managed by Texas Parks and Wildlife and the Animal Health Commission.
 
Bird smuggling is big in this country. Is it a major threat?
Yes. You have to anticipate that if things are occurring elsewhere, that they will arrive here no matter what you do.   So, it’s possible that smugglers will be a major threat because compliance must be 100 percent if you are going to try to prevent the entry. Smuggling clearly limits that factor.
 
What would happen if we had a full-blown bird flu outbreak in Dallas County?
That’s what we have to plan for, a worse case scenario, with no vaccine available and no anti-viral therapy. The only thing in our pockets would be public health control measures. So what we would do is called “social distancing,” where we would have to tell everyone in Dallas County to maintain a distance of three feet from each other. With that would come school closures. And we know for any of these measures to be effective, they’d have to be done early. So, in that case, we are going to have to go out there and make these control measures preemptively. But I don’t think we could do these things—for instance, close our schools indefinitely—without it having a very significant effect on our community. Many of our school children get most of their food through the school lunch programs, and after a while you have to worry about what the children are eating. So many of the things that we depend upon would be disrupted, but it would be with the knowledge that it would only be for a week or something like that.
 
That would be hard to pull off with public transportation, grocery shopping, and other venues where people come together.
You realize there are many essential services in our community and you couldn’t simply lock the doors and expect everything to function. Dallas County has enough food only for about 48 hours without new supplies. So we have to develop contingency plans for these essential services. In Dallas County, we’ve been educating the leaders of these types of industries, and we are charging them to go out and develop their own contingency plans in case of a pandemic. They have to maintain their businesses with perhaps 40 percent of their people unable to work.
 
Are you asking Dallas physicians to report unusual flu cases?
Yes. Physicians will be our first line of defense. I think the big message right now is for physicians to ask about travel history. The big threat right now is that someone will visit some place where it exists and bring it back.
 
Should folks rethink their travel plans to such places?
Right now, no. The CDC for Global Restrictions says there is really no need for global travel restrictions at this time. They say that may be an issue in the future. But they’re also advising people to use precautions when they travel and be careful of eating poultry that may be contaminated. Make sure you are eating safe food.
 
What will it cost to ensure an effective protection against bird flu?
That certainly is an issue. The federal program will only give the State of Texas about $6 million this year. We don’t get much out of that once you divide that up between the major urban centers. So there is an issue of funding. We have been a part of the bioterrorism funding, which we have used for this effort, but this threat encompasses a lot more. We’ve been looking at the private sector, showing them this is an issue, and we’ve been receiving some support. The Meadows Foundation has been a significant contributor, and we’ve also been working with Perot Systems. They’ve had a keen interest in how they can help. That’s what it’s going to take. It has to be a combination of a lot of different funding sources. We really need everybody to step up to do this.  
 
So, are we just blowing this whole thing out of proportion and scaring folks needlessly?
I get that a lot. And there is an element of politics. But I think the threat is there. And even if this H5N1 does not become a person to person transmission, and I hope it does not, but we invest our time in community preparedness, we will be that much better off if anything else were to happen.

Photos: Rowlett: Tom Hussey; Carlo: Dan Sellers


D Magazine contributing editor Tracy Rowlett is a news anchor and managing editor at CBS Channel 11.

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