Connecticut to Revamp Pandemic Flu Strategy
WASHINGTON, Dec. 16– Scientists everywhere are breathing a sigh of relief: Pandemic flu is finally on the global agenda. But the task ahead is just as daunting, as health professionals and government officials prepare for an eventual outbreak. The states carry a particular burden, faced with a logistical nightmare and limited resources.
In the United States, state and local health departments are considered the nucleus for protecting and responding to a health crisis like a flu pandemic== an outbreak of the disease that affects large numbers of people simultaneously and is geographically widespread.
Their responsibilities range from monitoring for unusual sickness to creating emergency response plans to help treat sick residents and stop the spread of a disease outbreak. Leaders and health workers are expected to coordinate an efficient and effective plan to protect their community.
Connecticut health officials agree the main challenges they face are logistical – things like personnel shortages and being able to mass-distribute whatever treatments are available at the onset of a major health crisis.
The federal government, in the November release of its National Pandemic Influenza Preparedness Plan, acknowledged this weighty but essential state role.
Earlier this month, U.S. Health and Human Resources Secretary Mike Leavitt convened a meeting of senior state and homeland security officials to address pandemic planning. Leavitt chose strong language to underline the seriousness of the threat and noted that no one can predict when the next massive outbreak will strike.
The immediate fear concerns a deadly avian – or bird – virus, called H5N1, that continues to affect mostly birds but has also shown a rare capacity to kill people and other animals. Experts worry that the virus may acquire the ability, through genetic mutation, to pass easily from person to person.
“The reality is–and you know it – pandemics happen,” said Leavitt, who began a 50-state tour to meet with health and government officials after the meeting in Washington. “When it comes to a pandemic, we are overdue and we are under-prepared.”
While the federal move to action on planning for a health crisis of this magnitude is generally commended, some advocacy groups, including Trust for America’s Health, a nonprofit group that advocates for disease prevention, expressed concern about some aspects of the national plan that relate to state responsibilities.
“The Bush plan calls for states to spend $510 million for anti-flu drugs, which can reduce the severity of the flu,” read a statement released by the group. “However, earlier this year, the administration proposed a cut of $130 million in state and local public health preparedness.” While the national plan calls for $100 million to states to ramp up pandemic planning, the group said that “this sum does not even offset the previous proposed cut in funding.”
A recent report by the trust gave the federal government a grade of D+ on public health emergency preparedness. Many states did not fare much better in their evaluations. The study looked at such things as “capabilities to test for chemical and biological threats and hospital surge capacity to care for patients in a mass emergency.” Connecticut earned a score of 5 out of 10.
Connecticut has a pandemic action plan to guide emergency responders and other relevant groups, but it was created before Washington announced its national strategy. Most states, including Connecticut, are working to update their plans. Gov. M. Jodi Rell established a joint committee, drawing upon the efforts of four state agencies, to address this need. She asked the four agency heads to complete the State Plan for Influenza Preparedness and Response by next month.
The Connecticut plan is more strategic than operational, said Dr. James Hadler, the state epidemiologist and director of the infectious disease section of the Department of Public Health. “It outlines issues, responsibilities and methods we’d consider,” he wrote in an e-mail message. “We will be developing operational plans in the future – for example, how we’ll actually distribute vaccine and antivirals to healthcare providers who aren’t part of a larger healthcare system such as a hospital or community health center.”
One important update to the state plan, Hadler said, will identify priority groups that comply with federal recommendations to receive antiviral medications and vaccines. The national plan calls on states to first vaccinate health care workers who are directly exposed to patients.
Because of the uncertainties inherent in a flu pandemic, he emphasized that any emergency response plan must be flexible.
“For example, we don’t know if a pandemic strain will spread as quickly as regular influenza,” he said. “We don’t know how virulent it will be; we don’t know if it will preferentially affect one age group or another; and we don’t know how fast it will get to the U.S.”
He added: “All of these are relevant factors in determining an appropriate response at the time.”
One of the most outspoken congressional advocates for pandemic planning, Sen. Tom Harkin, D-Iowa, said that while the administration’s plan embraces the major components of a national strategy, its “greatest weakness is helping improve state and local health infrastructure.” He said states need to hire more epidemiologists, lab workers and emergency responders.
Harkin added that states could look into mobilizing nurses and other health care workers who are not currently active in the workforce.
He also reiterated a common theme among experts: It’s likely the public health system in its current state will be overwhelmed during a pandemic.
“This is not Chicken Little alarmism,” he said.
The flu presents a unique set of challenges. Each year around 36,000 Americans die from seasonal human flu, with children and elderly populations disproportionately affected. A pandemic flu is different from the seasonal flu in one critical way: it is a brand new virus to which humans have no prior immunity. This would probably enable the pandemic virus to affect a cross-section of the population, regardless of age or health.
Because a pandemic virus would spread quickly and incapacitate scores of people, emergency responders woulod be first in line to receive vaccinations and other treatments, according to the national plan.
That plan lays out a worst-case scenario, in which by week six of a pandemic, 722,000 Americans could be infected. The hypothetical outbreak would begin in a small Thai village, and by the 16 th week, 92 million Americans would be infected with the H5N1 bird flu.
According to health officials, vaccination is the bedrock for averting or at least minimizing the impact of a pandemic. President Bush in the national plan calls for $7.1 billion, in part to improve vaccine production. The current systems in place are riddled with obstacles that make development and production a slower process than necessary.
Doctors have advice for the general public too. They say to practice good hygiene – like washing hands and covering mouths when sneezing or coughing – and avoid putting others at risk if flu symptoms are present.
The states monitor flu activity, observing trends in patient reports and looking for atypical health threats. One primary way states conducts what is broadly called biosurveillance is by collecting regular reports from labs, hospitals and physicians on incidents of flu. The states, in turn, contribute to a national tracking system.
The federal Centers for Disease Control and Prevention calls on states in the event of a pandemic to establish a network of clinics to each treat several thousand patients for a limited number of days. According to Connecticut’s pandemic plan, 70 clinics are necessary to serve the entire population.
State health officials are also concerned about the process proposed in the national plan for states to obtain antiviral drugs, which help lessen symptoms after infection.
” I think most people in [the] states believe we shouldn’t be competing with each other to buy antivirals and have some states that are ‘haves’ and others that are ‘have nots,’ ” Hadler said. A fairer and more effective route, he said, would rely on a central federal purchaser. But he added, “It would make sense to have much of the stockpile pre-positioned in states.”
“Requiring each state to purchase antivirals separately does not make sense from a health perspective,” Trust for America’s Health said. “Germs don’t respect jurisdictional boundaries, and we must have the flexibility to provide the medication where outbreaks are most severe.”
Flu pandemics are recurring events. Past outbreaks have led to soaring levels of illness and death, and great social and economic disarray. The pandemic flu virus of 1918 killed 20 million to 50 million – possibly more – people worldwide. Two other pandemics struck later in the 20 th century. Furthermore, a second, though usually less severe, wave of infection usually follows after a lull in the first outbreak. Pandemic readiness plans typically take this into account.
There are three conditions a flu virus must meet to be defined as a pandemic. The H5N1 strain has met two: it is a novel virus and it causes severe illness. The third condition – ease of transmission between people – has not been achieved, and there is no way to know if it will. However, as long as it continues to infect people and birds it threatens to initiate a pandemic.
Experts expect H5N1 to spread to all corners of the world via migratory flocks and interstate trade. The United States, they say, is no exception.
Human cases are still rare, and attributed in almost all cases to direct contact with sick birds. The World Health Organization maintains an official Web site that tracks the number of human infections and deaths. As of Dec. 9, 137 cases of human infection were reported since the onset, with 70 cases ending fatally. Health officials are particularly worried about the high death rate and the types of people – a number of them young and healthy – attacked by the virus.
In more-acute cases, bird flu in people has caused symptoms like “acute respiratory distress, viral pneumonia and other severe and life-threatening complications,” according to the Centers for Disease Control and Prevention.
Scientists in Hong Kong said that H5N1 bird flu can cause “a ‘storm’ of immune system chemicals that overwhelms the patient,” Reuters reported. The chemicals can suddenly engulf infected lung tissue to the point where it can prove fatal for the patient.
It is this potential menace that prompted Secretary Leavitt to warn the 50 governors that “we are facing one of our most serious public health challenges. The threat of an outbreak of pandemic influenza is real.”
