The following is an edited excerpt from and interview with Dr. Allison McGeer, conducted in late 2005...

If there were human-to-human transmission in Thailand, how would you as a doctor first hear about that in Toronto?

I’d likely first hear about it through a national notification plan that was developed post SARS called KIOSK but it would come simultaneously through that system through PROMED, probably on CNN, and through a variety of other public health notification systems that are active. I’d probably hear it simultaneously on the news, from PROMED and from all three levels of government in Canada.

The key question is when we move into World Health Organization Pandemic Level Six, which is a little beyond human-to-human transmission. The key timing issue is when we move from some limited human-to-human transmission to “we think the pandemic is starting.”

That’s not likely to be a single on/off switch. I think there’s likely to be a period of weeks, maybe months, of increased anxiety, of not being absolutely certain what has happened. I think there is likely to be a prolonged period of time where we’re starting to move into the pandemic mode and we’re not really sure it’s going to happen.

For that period of time there will be a lot of confusion, there will be a lot of disagreement about exactly how far we ought to be going. At the moment, at the ground level where I work, there’s also not really clear decisions made yet about what we’re doing at different stages.

The first thing that will happen when this notification comes is that there will be an immediate diversion of resources into working on the plan and trying to make it better and functional. And the important pieces of that plan are obviously how we’re going to manage patients who do have influenza, and how we’re going to manage patients who don’t have influenza.

Will every hospital in the country have its own pandemic plan?

Every hospital in the country has to have its own pandemic plan. Every hospital has a different population of patients, a different physical structure, a different management structure, and a different number of entrances to the building. We have templates for pandemic planning, but exactly how things are going to function is very hospital-specific.

Across the country, what’s the range for preparedness in healthcare institutions for a pandemic?

At this instant, most healthcare institutions have recognized the need for a pandemic plan; many have a pandemic plan in some stage of development. Very few have a pandemic plan that has been practiced at any level, and even fewer have a pandemic plan that they would say they were happy with, or that really makes them prepared for the pandemic.

Let’s say a pandemic has begun – what sort of things should governments be doing at that point to prepare people here or to prevent it from coming here?

We’re not preventing the influenza pandemic. There is no opportunity to prevent the influenza pandemic. We will attempt to do things that will slow the spread from country to country and prevent it from spreading. But what evidence we have is that none of those efforts will work, particularly if it’s a severe pandemic and people are very ill, we will close borders, we will attempt to stop movement.

But we know that those attempts will not be successful. Really, it’s about preparing for when it’s going to come and trying to minimize the damage when it arrives. The most important thing we’ll be doing is trying to make the decision at the right time to go for maximal vaccine production and hopefully we’ll have some more information about how to make vaccines and how much vaccine we can make.

If we’re talking about H5N1 as the next pandemic, those efforts will not get us anything like sufficient vaccine in time to protect even essential workers or very high risk patients.

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Once there’s sustained human-human transmission, how quickly might you expect it to make it to North America?

The situation could in some ways be similar to SARS where it was approximately two weeks from the time that people recognized that there was a significant problem to the time that we had sustained transmission in Toronto.

And it is not impossible – it’s unlikely, but not impossible – that the very earliest piece of sustained transmission would involve travelers to Canada, because you’re not going to detect sustained transmission at the moment of it happening.

How long would it take us to get vaccine ready to use or to manufacture?

Realistically, to have any amount of vaccine supply, we’re probably talking about a good deal longer than six months.

If the first wave of the pandemic happens in early 2006 and if it’s avian influenza, we will not have vaccine in Canada for the first wave.

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How on would you handle 1,000 people lining up to see a doctor the first day of the pandemic – perhaps even 10,000 the next day?

It’s not going to be easy, unless we do a lot of planning between now and then. It’s not going to be smooth; it’s probably not going to be particularly efficient unless we accomplish a great deal before the pandemic arrives.

But we have survived through previous pandemics; we will survive through this one. It requires as much organization as we can get to create efficient triage systems for identifying who the seriously ill people are, who the people are who need to be admitted to the hospital, and who the people are who can be sent home with instructions.

Would you set up tents outside the hospital?

Tents are probably pretty effective for a lot of hospitals as long as the weather’s good enough. If it’s a mild enough pandemic, some of us may be able to divert resources from other ambulatory care clinics so that we don’t need tents. If it’s a severe enough pandemic then we’ll be co-opting arenas, the Air Canada Centre, hotels…

Part of pandemic preparedness in that this is the kind of information that people will be supplied with is very specific about what to do with different types of symptoms, when you need to report to a doctor, where you need to go to do that.

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What is the basic message to give people in the early stages to a population?

The important thing is to be clear to people about when it’s safe for them to stay home and when they need to come into a hospital, when they need to see a physician. For example, children under six months of age need to be seen very quickly, no matter how ill they are because they can be very unstable very quickly.

For people who are older, it’s about understanding that if you develop acute shortness of breath or your fever’s not resolving after a period of time, that’s when there’s likely to be a complication that may become serious.

Some of those messages will change a little bit depending on the pandemic, because the pandemic may vary in severity, and because who gets sick quickly and who gets sick severely may be different.

When it comes to the media, what’s irresponsible and what’s responsible, in terms of reporting?

I’m hoping before the pandemic that we have a discussion in Canada about media response and government messaging. What we saw during SARS, in general, the media were incredibly helpful. Partly because, media are organizations that are trained to move large amounts of information in very effective summary forms and get them to lots of people.

I think the danger Americans worry about more than Canadians is that in order to make a good story, the media will attempt to show kind of conflicting opinions and conflicting evidence. I am frankly not worried about that in Canada. We did not see that at all during SARS. It seems to me the media understands like everybody else that what we’re out there to do is to get the right information to the largest number of people

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I get sick, and I come to the hospital, isn’t that making the hospital a really dangerous place to be during a pandemic?

The risk of being infected during a pandemic is being alive. It doesn’t seem to matter a where you are. Attempts for people to isolate themselves and stay protected have historically not worked. They may work to some degree, but they don’t work very well.

One of the interesting things about influenza, unlike SARS, is that you’re most infectious with influenza just before you get sick or when you’re coming down with it. By the time you come to the hospital, which is likely to be three or four days later, you’re probably not very infectious any more. So, in fact, hospitals may be somewhat safer than other places.

If I try to protect myself by leaving town and going to a small town am I going to be safer?

We don’t know whether attempts at social isolation are effective. We do know that in previous epidemics they were not very effective. Everybody’s attempts to isolate their communities did not work. However, it’s reasonable to believe that basic precautions like hand hygiene and maintaining social distance will reduce your risk.

Unfortunately what we can’t tell you is how much it’ll reduce your risk. We don’t know how effective it is. We do know that in a setting of fear and uncertainty, with people getting sick, that people will not always believe even when there are things with solid evidence. Things like airport screening or closing the borders.

We know that airport screening will not be effective. We know that by the time we close the borders it’s not going to work. I think, have reasonable data about closing schools once a pandemic has established does not help. But we will almost certainly use a number of those interventions because we will be justifiably afraid and we will feel that we have to do everything we can.

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What can I do to protect myself once a pandemic has started?

I think the best that can be done at an individual level for protection from a pandemic is good hand hygiene – washing your hands, or using an alcohol hand wash at least five times a day, more often in a pandemic. Maintaining social distance from people – staying more than three feet away. Protecting other people if you get sick – making sure that you stay away from other people if you’re sick. And conversely, making sure that if you’re at work that people who are ill exclude themselves.

What sort of garb would you wear in a hospital to protect yourself from a pandemic?

In general, the two things that we know are effective and substantially infective are very good hand hygiene and wearing masks.

Why shouldn't I wear a mask?

There are a few difficulties with wearing a mask during a pandemic. The first is that we’re going to be short of supplies so it may be nice to say that you should wear a mask, but there probably aren’t going to be enough masks. And the difficulty with most masks is that after you’ve worn them for a while, they get moist they don’t work nearly so well anymore.

The second problem with mask use is that the circumstances where you most need it – close contacts with your kids, with your family members, with other friends – are the times when you’re least likely to wear it. If you’re going to wear a mask, it’s probably important that you wear a mask all of the time and that’s going to be very difficult for people to do, but maybe needed for effectiveness.

The third thing that some makes people a little nervous about masks is that when one of the consequences of wearing a mask – particularly for those of us who don’t usually wear masks – is that it draws your hands to the face. If your hands are not clean, and you keep putting your hands up around your face, you may actually increase the risk that you might get influenza despite the fact that you’re wearing a mask.

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What can I do now for myself to prepare for this pandemic?

The things that will protect you going into the next pandemic are getting your pneumonia shot if you’re at potential risk of pneumonia, stopping smoking if you smoke – because smoking presents a very clear increased risk for the setting of influenza or other pneumonias. Maintain a healthy lifestyle. The more physically fit you are going into any kind of illness, the better off you’ll be when you get there.

Training yourself and the people around you to wash your hands, or clean your hands with the waterless hand rinse, at least five times a day so you don’t have to re-train yourself during a pandemic.

Making sure that if you require regular medication that you have a set up with your physician that you know how that’s going to happen during a pandemic. Stock up on the kinds of supplies you need to have in your house for an influenza illness, so that even during the regular season if you get it you’ll have enough things to get through and manage appropriately. Things like having a thermometer at home at home and medication for fever. If you have small children you care for, make sure that if you get sick somebody you know is going to care for them while you’re sick.

It’s a short list, a perhaps somewhat irritating list, because in public health we’re always telling you to do those things anyway, but those are the things that will make significant differences to whether you get ill and how ill you get during a pandemic.

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