States' flu plans vary widely
By Lauran Neergaard
Associated PressTrailers packed with cots and medical supplies are parked in secret locations around Colorado, ready for doctors to open makeshift hospitals in school gyms if a flu pandemic strikes.
Parts of southeastern Washington are considering drive-through flu shots during a pandemic -- although a practice run this fall showed they'd better hire traffic cops. If Alabama closes schools amid a super-flu, students may take classes via public television. In Dallas, city librarians may replace sick 911 operators.
States and communities are getting creative as they struggle to answer the Bush administration's call to prepare for the next influenza pandemic, whether the culprit is the much-feared Asian bird flu or some other super-strain.
The Associated Press took a closer look at those preparations and found wide differences in how far along states are -- and little consensus on the best policies, even among neighboring states, on such basic issues as who decides whether to close schools.
Almost half the states haven't spent any of their own money yet to gird against a super-flu, relying instead on grants from the federal government.
Ethical queries abound about how to ration scarce drugs and vaccine. As Oklahoma epidemiologist Dr. Brett Cauthen puts it, that's "the toughest question out there." Some states are debating whether to purchase the recommended anti-flu medications to store for their citizens, or to gamble that they'll receive enough from a federal stockpile.
And while some states proudly list other pandemic supplies they've stockpiled in guarded warehouses -- 4.5 million protective face masks, touts New York -- others, like West Virginia, still are putting final drafts of their plans to paper.
"How are states doing, and how do we know how states are doing?" asked Dr. Pascale Wortley of the Centers for Disease Control and Prevention. "There's a lot of important things that are very hard to measure. It's a real challenge."
Indeed, when the government's first official assessment of state readiness begins in a few weeks, officials expect few states will have tackled some of the toughest issues: How will you keep grocery stores stocked? Will you reserve enough anti-flu drugs for utility workers so the water and electricity stay on? If you close schools, will local businesses let parents stay home with their children, or fire them?
When the feds fly in your state's share of vaccine and medicine, can you store it properly and get it to patients without being mobbed?
"Nothing, we think, is better than having 5,000 communities right now wrestle with this," said Dr. William Raub, emergency planning chief at the Department of Health and Human Services. "What will seem to work happily in one community is probably not going to work in some others."
Super-strains of the easy-to-mutate influenza virus cause worldwide outbreaks every few decades or so, three in the last century. Worst was the 1918 pandemic that killed about 50 million people worldwide, 500,000 in the U.S. alone. If a 1918-style pandemic struck today, up to a third of the population could fall ill and 1.9 million Americans could die.
With another pandemic overdue, the CDC began telling states to prepare years ago, plans that have taken on greater urgency with the simmering H5N1 bird flu. In 2004, just 29 states had pandemic plans of some sort. Today, all have at least a draft on paper.
Next spring, federal health officials will have their first report card on the quality of those preparations, based on a questionnaire that Raub hopes to ship to the states by month's end -- questions that will go beyond health care to ask how communities would keep the economy and society in general running.
Raub said he's not playing "gotcha," but that the responses are key to helping less prepared states catch up, and identifying best practices that neighbors can copy.
"I feel pretty confident we will have covered far and away all the important things," he said.
It's an assessment that public health advocates, worried at varying state investments, call long due.
"Where you live shouldn't determine your level of preparedness," said Jeff Levi, executive director of the Trust for America's Health. "This is not a question of letting 51 flowers bloom. The federal government, as the primary payer and the entity that can see the biggest picture, needs to define a minimum standard of protection that every American can expect."
For now, hospital overflow, purchases of the anti-flu drug Tamiflu, plans for school closures, and how states are practicing for an outbreak are emerging as initial indicators of readiness.
A new study by Levi's group suggests half the states would run out of hospital beds within two weeks of a moderately severe pandemic outbreak, not even as bad as a 1918 outbreak.
In interviews conducted by the AP in every state, health chiefs repeatedly said they know their hospitals will be overrun -- but that having enough beds isn't the most critical issue.
"We don't have the health care workers to take care of all the patients," explained Alabama State Health Officer Don Williamson.
Indeed, nursing shortages and other issues mean that today, hospitals around the country may have staff available for just 60 percent or so of their beds. In a pandemic, some of those workers are going to be sick or caring for ill relatives, not at work.
That's where some states are getting creative.
Those trailers parked in strategic spots around Colorado hold a total of 6,500 beds that could be set up in school gyms or event halls, anywhere with power, water and bathrooms.
"Where we're best prepared is a place to put people," said Dr. Ned Calonge, chief medical officer of the Colorado Department of Public Health and Environment.
Now, the state is recruiting volunteers to take care of the people who will lie in those beds, creating a master list of health workers not usually involved in flu care, from pharmacists to physical therapists, who could be credentialed now and put on standby.
El Paso County, in addition, wants to set up a phone bank of retired doctors to advise people on when to go to crowded doctors' offices and when to just sneeze at home.
Louisiana has discussed expanding visiting hours so relatives can help with some patient care, or even giving recovering patients some light duty.
"There's no easy answer. You have to be thinking creatively with what you have, rather than thinking you'll be able to find accessory staff," said Dr. Frank Welch, the state's immunization director.
California budgeted $18 million this year to buy three 200-bed mobile hospitals, and $78 million more to buy equipment -- including 20,000 beds -- for what officials call "alternate care sites."
The idea: The very sickest get hospitalized; the moderately ill stay home; those in between get care on cots at schools or fairgrounds.
Adds Dr. Bob England, health director for Maricopa County, Ariz., "We have to set up some kind of system for checking on folks (at home) and weeding out the people who really need to come in."
Inside hospitals, shortfalls will go beyond beds. For example, Georgia predicts 20,000 of its citizens would need ventilators over the months of a severe pandemic. In the entire state, there are 1,500. Officials just bought 2,000 portable versions to truck to different hospitals as needed, but worry they won't be durable enough.
Because it will take months to custom-brew a vaccine once a pandemic begins, flu-treating medicines, mostly Tamiflu, form the backbone of the nation's preparations. World flu authorities recommend stockpiling enough for a quarter of the population, or 75 million Americans.
The Bush administration is in the process of buying enough to treat 44 million people, and will hold each state's share in a national stockpile.
States are supposed to buy enough to treat the remaining 31 million people, doses they would store. The federal government negotiated a cheap price and offered to chip in 25 percent of the cost, but told states "we need you to come the rest of the way," Raub said.
Most states say they do plan to buy at least some of those outstanding doses, although at least nine still are awaiting money for the purchases from their state legislatures.
And at least four states don't know if they'll spend their own scarce dollars for the extra purchases, saying the drugs might not work against a super-flu -- or expire before they're needed.
"There's a chance that it might be useful, but there's also a chance that it might not be useful at all," frets Arizona assist health director Will Humble. The state used a $1 million federal grant to purchase enough medicine for 66,000 people; he isn't sure if it will buy more.
Nevada spent a $2 million federal grant on anti-flu drugs, but none of its health districts was interested in buying more.
"There are always competing uses for the money," said state health officer Dr. Bradford Lee. "We're trying to balance what may be needed for a disease that doesn't exist with needs that are immediate."
Whether they buy their own stocks or not, many states don't yet know how they'll successfully dispense their share of the nationally stockpiled Tamiflu and other supplies once federal workers deliver it. A new requirement heading for the states: Figure out exactly how they'll handle the supplies so they get to doctors or pharmacies for proper dispersal.
"Some of these pallets weigh more than 350 pounds," noted Raub. "We think it (the plan) ought to be something more than 'Stick it in the back of the state police car and drive it somewhere.'"
The way to know if all these preparations have a shot at working is to practice them, Raub said -- and there have been few statewide drills yet. But some communities are trying innovative dry runs.
In Hawaii, volunteers pretended to be sick during a mock drive-thru clinic on the island of Maui, letting health workers practice how fast they could decide who to pull out their cars and hospitalize -- and who to send back home.
In Minnesota and Idaho, health workers handed out M&Ms to rehearse how they'd dispense anti-flu drugs.
Communities in at least 15 states have practiced mass vaccination, most by testing how fast they could give people the regular winter flu shot. Billings, Mont., vaccinated more than 6,300 people in a day.
In Washington, Benton and Franklin counties held drive-thru flu shots. They underestimated the demand, and the traffic.
Here's the rub: CDC's Wortley doesn't think super-fast vaccination is the best to practice. The first scarce doses of vaccine to arrive in each state will be reserved for high-risk groups, such as health care workers and those most at risk of death. The federal government currently is debating if other people needed to keep key industries going, such as grocery truck drivers and power-company workers, should be added to that list. But it won't be first-come, first-served.
"You're potentially talking about a vaccination campaign that draws out over more than a year," Wortley warned. "Really the issue isn't how many people can you vaccinate in a day. The issue is how do you pull off this type of campaign where people are going to be wanting vaccine and there's not enough?"
As for drive-thru flu shots, she jokes that it's "the American way," but doubts it will work because of traffic jams.
With scarce vaccine and still unclear drug stocks, strategies to slow the next pandemic "will be primarily classical public health measures that go back to the Victorian era or before," Raub warns -- such measures as staying home when sick and avoiding crowded places.
That's where school closings come in. Children are prime spreaders of the flu, but it's unclear whether closing schools will really help -- and if so, when they should shut. Still, most states told the AP they'd probably leave that decision to local school officials.
"If we just close the schools and everyone goes to the mall, we haven't gained anything," pointed out Jay Butler, Alaska's deputy health director.
Wyoming hopes schools can stay open, so parents don't have to leave their jobs to care for young children.
"Think how that will impact all the doctor's offices, hospitals, grocery stores," said state epidemiologist Tracy Douglas Murphy.
What if states do all this planning and the next pandemic never arrives? Much of the work is applicable to other disasters, too, from earthquakes to bioterrorism.
"People forget that you're supposed to be doing all-hazards preparedness," said Washington Secretary of Health Mary C. Selecky.
"We're trying to be prepared for a range of events," agreed Alabama emergency planner Kent Speigner, his voice echoing in a cavernous warehouse where the state stores flu supplies right next to smallpox supplies. "We really don't know what's coming next."
