Notes on online learning and pandemic flu.

1. Online Learning

Consideration #1: A member called the other day to ask my opinion about an online (Ph.D.) degree program that she was thinking about signing up for. In what seemed like two seconds later, I received an e-mail from a staff member who asked me for a reference letter for an online master's-degree program that she wanted to take.

Consideration #2: Various members of the NEHA Board of Directors have been encouraging us to move more deeply into online learning because it represents a way of keeping our profession current--and at less expense than a typical conference.

Consideration #3: The quality of online learning has improved vastly since its early days, when it functioned primarily to automatically turn the pages of electronic books.

Consideration #4: If the threat of a serious flu pandemic ever becomes the real thing, all businesses--NEHA included--may well find themselves trying to provide their services in a much more difficult business environment. For example, many experts predict that if a serious pandemic were to develop, travel would be significantly cut back. Most associations (NEHA included) depend on their annual conference for a major part of their income. If travel is restricted, or if people are too afraid to travel, NEHA will suffer the financial consequences. Accordingly, we have to look now for other ways of delivering continuing education. Online learning gives us that opportunity.

When these considerations are taken together, it becomes clear that online learning is big and is here to stay. NEHA is now incorporating online learning into the fabric of our operation.

In March, we launched our brand-new online university. Our first offering, not surprisingly, was on pandemic flu. We are pleased with how many students have signed on for this important two-course program. In addition, we aim to make available an online-learning opportunity that substitutes for in-class training for our credentials. In other words, any professional seeking to become credentialed with NEHA will soon be able to prepare for the exams through this helpful online-learning experience.

We are now on track to grow and expand our online learning program. We will be developing courses on a wide variety of environmental health concerns and offering appropriate continuing-education credit for them. Between our existing conference offerings and what is becoming available through our online-learning program, NEHA is taking significant steps to remain your source for high-quality, affordable, contemporary, and accessible continuing education for the world of environmental health practice.

2. From What I Hear--More Concerns About Pandemic Flu

I recently had the opportunity to personally hear Department of Health and Human Services Secretary Leavitt speak on the topic of pandemic flu. Among the points he made, one clearly stood out--at least to me.

He emphasized that pandemics are a part of life itself. They happen (10 have occurred in the last 300 years), and they will continue to happen. He spoke of the need to appreciate their inevitability. He went on to say, however, that our calling is to integrate the planning we do for pandemics with the planning we do for other catastrophes (such as incidents of terrorism). His "punch line" was that we need a cultural change in our country so that preparedness becomes a part of our value system and how we think. When that day happens, he said, "we will indeed be prepared."

I wish other comments that I have been hearing as of late were as enlightening as the Secretary's.

For example,

* I was recently listening to a governor who was urging the citizens of his state to build personal stockpiles (which I agree with) to enable them to get by until the feds could come in to help. In virtually every assessment that I have heard or studied of how a serious pandemic flu would play out, it is emphasized over and again that there will be no federal cavalry to come in to save the day. It just isn't possible. Across the nation, the response to a serious pandemic will be a state and local affair.

* I was recently speaking with a doctor who is also the medical reporter for a TV station. She advised me that if a serious pandemic flu were to hit, we would need to be concerned about obese people. When I explained to her that 95 percent of the victims of H5N1 were under 39 years of age and that most of the victims were strong and healthy people, she continued, "yes, I know, but obese people are going to have a really difficult time with such a virus"!

* For months, I've been listening to health officials and reading state pandemic-flu plans. It would seem that the central feature of our overall response (to a serious pandemic) is the quick creation of mass-vaccination centers all across the nation. That sounds fine--except for one thing. There is no vaccine to dispense! Moreover, there won't be an effective vaccine until the virus mutates and becomes transmissible between people. And even then, the supply of the vaccine will be limited.

Dr. Robert Webster of St. Jude Children's Research Hospital in Memphis, one of the world's foremost authorities on the flu, has warned that it takes up to eight months to produce, test, and distribute a new flu vaccine and so "it's virtually impossible to produce an adequate amount of vaccine during a pandemic" (see "Influenza," in American Scientist, Volume 91, Number 2, page 122).

Complicating matters still further are the trial results that are now in for the experimental H5N1 vaccine. In an article just published in the New England Journal of Medicine ("Safety and Immunogenicity of an Inactivated Subviron Influenza A [H5N1] Vaccine"), results were reported from a trial involving 451 people who were subjected to a vaccine derived from an H5N1 strain from Vietnam isolated in 2004. (There is some thought that we can get a leg up on the vaccine challenge by producing a vaccine today that can deal with today's version of the H5N1 virus and that can possibly confer some protection against the yet-to-exist mutated virus that would actually trigger the pandemic.) The vaccine provided only partial protection and only if administered at high doses, of 45 or 90 micrograms. (A normal vaccine dose for a specific flu virus is 15 micrograms.) In this case, "partial protection" was defined as a little over 50 percent for the 90-microgram dose and around 45 percent for the 45-microgram dose. It should also be noted that the doses were administered twice, 28 days apart. In other words, a lot of vaccine will have to be produced to protect about half of our population--which is highly unlikely to happen, given that the world's vaccine-manufacturing capacity isn't great enough to produce that much vaccine. Also, we just don't know how protective--if at all--this vaccine would be for a mutated virus.

Even Dr. Fauci, Director of the National Institute of Allergy and Infectious Diseases, recognized these disappointing results, saying: "We have a vaccine that can spur an immune response, albeit at very high doses. We're going in the right direction. The sobering news is that we have a long way to go. So it's muted good news" (see Peter Gorner, "Small dose of hope in bird flu fight," Chicago Tribune, March 30, 2006).

The bottom line is simply this: If a serious pandemic develops and if it hits in waves (as many experts expect it to), our defense for the duration of at least the first wave is going to be basic public health practices, ranging from promoting proper cough etiquette to encouraging lots of handwashing to (possibly) implementing some degree of social distancing, closing places of congregation, and so forth. It seems to me that the sooner we can get the word out on these kinds of responses, the sooner we can achieve a base level of preparedness. We will never get to this point if we continue to imply that "the answer" lies in the creation of a large network of mass-vaccination centers. Such a message engenders a false sense of security and tempts much of the public to believe that they don't have to do anything now. Instead, the mindset we're encouraging is that if something bad happens, people will just have to walk down to their health department to get a vaccination shot.

On a personal level, I'm trying to get the word out on public health practices by even encouraging my homeowner's association to include in its newsletter information about stockpiling and basic public health practices.

Finally, I should share that upon a recent visit to Kentucky, I had the pleasure of an inspired conversation with a couple of local health officers. They made it clear to me that if a serious pandemic were to break loose, their health departments would quickly become all-hands-on-deck operations. Employees (including those working in environmental health) might find themselves doing work that they had never done before, including, if necessary, distributing medicines such as antivirals and, at some point, possibly even vaccines.

Hearing these comments was encouraging. Not so encouraging have been a few stray comments that my ears have picked up from elements within our profession who prefer not to step outside the bounds of traditional environmental health work.

While I respect what attracts and excites people to this wonderful profession of ours, we are all first and foremost public health professionals. If our communities need us to take on roles unfamiliar to us but necessary to see a community through the challenge of a serious pandemic, we need to be there, ready to serve.

This is a confusing issue and a confusing time. I continue to take heart from those in public health who maintain that a serious pandemic anytime soon is unlikely. I hope they're right. The truth, however, is that no one really knows what is going to happen. Secretary Leavitt has sounded the bell: We need to be prepared. Preparedness is not going to be as easy as a vaccine that will be available at the corner drugstore. As more and more public health officials seem to be now saying, we will need to ride out at least the first wave of a pandemic on our own.

That means that the public health profession needs to be spreading the word now on basic public health principles. It means spreading the word at every opportunity and as widely and frequently as possible. And isn't being involved in such an effort interesting?--not exactly traditional environmental health work, is it?!

Nelson Fabian, M.S.

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