A young man, just returned home from a trip to Hong Kong, shows up at his doctor's office in Vancouver, complaining of flu-like symptoms. As the physician begins cataloguing them–fever, cough, aches, pinkish eyes–she senses there may be more here than a run-of-the-mill flu bug. Her hunch will turn out to be correct: the patient is the first Canadian carrier of the deadly avian flu virus. But even before that diagnosis becomes official, what steps the doctor takes in the next few hours could be critical–not only for the young traveller and his family, but for the entire nation.
If or when that scenario plays out–as for any highly contagious and potentially lethal disease–keeping an initial incident from sparking a countrywide pandemic could save the lives of millions. Epidemiologists predict that if the H5N1 avian flu virus–which has begun jumping from birds to humans in several Asian countries–ends up mutating to a virulent human strain, the death toll could rival that of the 1918 Spanish flu epidemic, which killed between 20 million and 40 million worldwide, including 30,000 to 50,000 people in Canada. “We at the World Health Organization believe that the world is now in the gravest possible danger of a pandemic,” Dr. Shigeru Omi, WHO's Western Pacific regional director, warned at a global health conference in Ho Chi Minh City in February. Every 20 to 30 years, pandemics have occurred, said Omi, and with nearly 40 years elapsed since the last one–1968's Hong Kong flu, which killed about 700,000 globally–we are “now overdue.”
A few days earlier, at a national meeting of the American Association for the Advancement of Science, Dr. Julie L. Gerberding, head of America's Centers for Disease Control and Prevention, warned that H5N1 is showing signs of becoming a global killer. “We are seeing a highly pathogenic strain of influenza virus emerge to an extraordinary proportion across the entire western component of Asia,” Gerberding said. “You may see the emergence of a new strain to which the human population has no immunity.”
According to WHO, as of Aug. 5 the avian flu virus has infected 112 humans and killed 57–a 50% mortality rate. So far, the extent of spread to humans has been relatively minor. But if the disease ever reaches its tipping point, some pessimistic observers predict that as many as a billion people could die worldwide.
If such a scenario ends up realized, the death toll in Canada may reach five million. The best defence, says Lloyd Osler, president and CEO of Ovistech Corp., is an aggressive containment strategy. Osler has spent the past three years trying to convince Canadian health officials that whether it's avian flu, SARS, the Marburg virus that killed more than 300 people in Africa over the past year, bioterrorism or any number of other disease emergencies, Canada is ill-prepared for the contagion age. Where cures aren't available, he argues, those countries that use computers to execute rapid quarantine strategies are the only ones that will keep their populations from perishing en masse. To be effective, Canada's response time, says Osler, will have to be measured in “minutes or hours,” not days or weeks. “If you can detect the early cases and identify those early on, then you can provide that alert to the people with responsibility for dealing with it, and they can do some things very rapidly.”
Based on the experience of the SARS crisis that hit Ontario in 2003, Osler says that reducing the potential for physician oversight and tightening the response time of public health resources will be critical in preventing pandemics in the future. And he claims his Edmonton-based company's EpiTrack Sentinel software can do both. Too bad Canadian officials aren't buying.
As it stands, Canada's health-care system marches to a slower pace. Today, when a patient shows up at his doctor's office with flu-like symptoms, the physician fills out a form to be faxed–at some point–by an assistant to the local health authority (all potential flu diagnoses must be reported), while the patient is sent for blood tests. With normal flu strains, that pace isn't a problem. But if the doctor doesn't immediately recognize that she's looking at H5N1 or another fast-spreading, dangerous virus, it could be hours before the patient is alerted and quarantined. By then, the infected individual could have exposed enough people to make containment strategies impossible.
Instead of filling out forms, doctors using Ovistech's EpiTrack system enter symptoms on their computers or Palm devices (EpiTrack is designed to sit atop any existing software the physician already uses) and immediately red-flag symptoms that fit the profile of the dozens of bugs on the WHO's or Health Canada's watch list. EpiTrack alerts public health officials, who can immediately order a quarantine of the patient, the doctor or anyone else who may have been exposed to the virus. With a rapidly spreading lethal illness, Osler says, “we can't take the chance to wait for lab results. If we wait eight hours and it's a fast-spreading disease, it's too late.”
EpiTrack catalogues the names and locations of anyone who may have been exposed to the first patient and, as more cases are diagnosed, monitors the geographic spread of infection, lighting up germ hot spots on computer-generated maps. That, says Osler, not only gives health officials the information they need to strategically deploy limited resources–medicine, doctors, antiviral drugs and so on; it also allows health workers to rapidly quarantine office buildings, schools or any other potential outbreak site, long before the people who may have been infected begin to show symptoms. For a virus such as H5N1, that's critical, says Osler. Unlike the SARS virus, avian flu has a roughly three-day incubation period–SARS incubated for 10. Typically, someone with the flu is contagious before they even have symptoms; with SARS, it's the other way around.
Had his system been in place during Toronto's SARS emergency, Osler speculates, the damage might have been greatly reduced. For one thing, doctors fumbled the diagnosis of the first SARS cases, leaving patients to cough all over other patients in hospital waiting areas. Canada ended up being the only nation outside Asia that allowed SARS to spiral out of control. EpiTrack, says Osler, would automatically alert a doctor looking at SARS-like symptoms that the disease was on a WHO watch list and that extra precautions should be taken, specifically precautionary quarantine.
“The major public health tool that stopped SARS in its tracks was quarantine,” says Ted Darby, CEO of Northern Ontario's Mattawa General Hospital and an emergency planning consultant. How large-scale quarantines are executed in the future may depend very much on technological solutions. Even after the danger of the SARS outbreak had become apparent, for instance, health-care workers were forced to track the spread of the disease using outdated methods. Dr. Sheela Basrur, medical health officer for Toronto at the time, told a reporter that the crisis management team used “flip charts and colour-coded Post-its as one of the key ways in which we shared information….[As] issues would be dealt with, they would be literally struck off the list with a big Magic Marker.” Whenever the provincial ministry wanted an updated count of infection numbers, Basrur said, “it was practically a matter of counting stick men.”
If sorting through boxes full of paper to track an epidemic was hard on a local level, says Brian Hay, vice-president of Toronto-based consulting firm Crisis Management Specialists, it would be impossible in the case of a national epidemic. “They couldn't do it on a citywide basis,” Hay says of Toronto's SARS experience, noting there were half a dozen hospitals directly involved. These days, he notes, “we have the technology and we have the tools. We have the technology to track where you've been when you get sick. We have the computers that can do the calculations. We have various programs that can spot things ahead of time.” But as it stands, it seems no one in Canada is prepared to use those tools if–or when–the time comes that we need them.
Though it may not have seemed that way for those living through it, Canada's SARS crisis could go down as a footnote in the history of epidemics. Forty-four people died, but the disease proved far less infectious than a flu virus. Yet Toronto and the province of Ontario lost billions of dollars due to health-care costs and economic aftershocks, including the short-term collapse of Toronto's tourism and film industries. Imagine the fallout from a pandemic panic: tens of billions robbed from the economy in lost productivity, and billions more spent on vaccination programs and health-care costs. All on top of the cost in lives.
Osler thinks his EpiTrack software will help save Canada from that fate, but he has yet to get federal health officials to agree. Dr. Theresa Tam, Health Canada's associate director of immunization and respiratory infections, says that quarantine is not the priority for a pandemic outbreak. “Once a pandemic starts and the virus has acquired its ability to spread between humans, we're not going to be counting cases–it's just not going to happen,” says Tam. The infectiousness of the disease would make quarantine impractical, she says. Instead, Ottawa is committed to a mass vaccination strategy, which, as soon as the WHO declares a pandemic emergency, will see the production of nearly 32 million doses of vaccine–enough for every man, woman and child. “If it would happen, let's say tomorrow, it would take seven weeks to get the first vaccine, then we would continue to produce,” says Michele Roy, vice-president of corporate communications for ID Biomedical Corp. (TSX: IDB), a Vancouver-based firm that has the exclusive contract to manufacture the Canadian pandemic vaccines. “Within six to seven months, all the doses would be produced.” By 2007, Roy says, upgrades and renovations to current facilities will cut that production time to almost four months.
When the 1918 Spanish flu pandemic began, cases turned up in Madrid, Bombay and Philadelphia all in the same week–and that was before the advent of commercial air travel. No wonder some critics of Health Canada's plan believe that if an avian flu outbreak occurs, it will cut a swath through the population long before any vaccination strategy has time to get rolling. What's worse, says Hay, is that the people most likely to get the disease from the start are “those who are exposed first–namely, front-line health-care workers.” That would seriously impede the vaccination plan and hobble efforts to provide medical care to all the other Canadians who end up infected.
But even if Ottawa was willing to consider a containment strategy, Osler admits that Canadian doctors are just not equipped to exploit today's technology. Many private-practice physicians still prefer a Bic pen and clipboard to computer tablets or wireless devices. “One of the challenges in this country–in fact, all the developed countries–is that the newer generation of practitioners tend to use the tools, [but] the older generation tend not to,” says Osler. In Ovistech's home province, the Alberta government has earmarked more than $80 million to bring doctors' offices into the 21st century–something Osler hopes bodes well for his technology finally finding a market. Still, only half of GPs have taken the Klein government up on its offer.
Rather, the greatest interest in the technology that powers Ovistech's EpiTrack has come from the private health-care sector, and in particular from veterinary medicine. Osler says that he recently signed a deal (the details are still confidential) to develop livestock tracking technologies. Biometric computer chips attached to cows or sheep can measure the water each one is drinking or its body temperature, or can even detect abnormal motion in the animal. With real-time data at their fingertips, farmers can identify and isolate diseased animals before the herd becomes infected–not unlike the way EpiTrack might quarantine an infectious human before he or she sets off a national health emergency.
Call it a two-tier health policy, but if a viral pandemic ever does wash up on Canada's shores, at least we can rest easy knowing that livestock will be safe.