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  • State preparations for pandemic vary widely

    State preparations for pandemic vary widely
    Saturday December 16, 2006
    AP Medical Writer

    Trailers 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-thru 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.''

  • #2
    Re: State preparations for pandemic vary widely

    Pandemic preparations, state-by-state

    <table cellpadding="0" cellspacing="0" border="0" width="428"> <tbody><tr valign="bottom"> <td class="byln" width="328">12/16/2006, 12:36 p.m. ET
    The Associated Press
    </td><td width="3"> </td><td width="97"></td> </tr> </tbody> </table>

    (AP) ? Some steps that states have taken to prepare for a flu pandemic:

    State purchased 900 cots, with plans for 250 more, that could be set up in churches or school gyms. Education officials working with Alabama Public Television to try to show classes on television if schools are closed.

    In Ketchikan, health workers rehearsed how to set up an alternative care site when hospitals overflow. Other drills assume the state will hear there is a pandemic on the TV news, amid a panicked public, before getting official word from the government.

    State urging counties to work with schools and churches on plans to minimize public gatherings during a pandemic, such as holding small worship services several times a week instead of a big one on Sunday.

    Considering drive-through vaccination clinics.

    State has budgeted nearly $70 million to purchase supplies for alternative-care sites and $18 million for three 200-bed mobile field hospitals. Held a first-of-its-kind pandemic drill bringing health care, business, community and religious-based organizations together.

    Trailers parked around the state hold 6,500 extra beds for creating emergency clinics. Next year's focus will be on recruiting health volunteers who would come staff them.

    Hospitals would become intensive care units for the flu, moving other patients out and canceling elective surgeries. Airport and health officials joined in a drill last summer to practice how they would react if a plane landed carrying the first U.S. cases of pandemic flu.

    Nation's capital is piloting a program to mine the Medicaid database to locate vulnerable citizens, such as the homebound elderly, who might need special attention during a pandemic.

    State has set up a medical reserve corps. Drills have pointed to such issues as quarantine laws and whether funeral homes have enough storage capacity for the dead that still need addressing.

    State is working on where and how to store supplies such as protective masks before beginning stockpile purchases and soon will begin public education campaign on how consumers can prepare.

    State is working on uniformity of communities' "social distancing" plans, worried that one city might close theaters only to see consumers head for the movies in the suburbs.

    Maui held a mock drive-thru clinic, to let health workers practice triaging "sick" volunteers. State is planning on a shelter specifically for people with special health-care needs and trying to develop a buddy system to ensure someone checks on those with developmental disabilities.

    Drills where workers handed out M&Ms in place of Tamiflu and practiced mass vaccination pointed out both a shortage of nurses and the need for bathrooms for the waiting crowds.

    Statewide drills identified planning gaps, now being addressed, that include how to get prompt and accurate information to an anxious public.

    Advisory groups that include not just health officials but lawyers from the American Civil Liberties Union and parents are helping inform policies on how the state would ration scarce drugs and vaccine. Nearly 10,000 people have attended town-hall meetings on pandemic preparedness this year.

    State has distributed nearly 150,000 guidebooks with consumer-friendly preparation information.

    A weeklong drill allowed 30 counties, plus businesses, schools, state agencies and charities, to practice mass vaccination and other steps.

    State health office created a grassroots network for contacting contact the disabled and other particularly vulnerable populations during a pandemic or other emergency. It was recognized by federal health officials as a model program.

    Hospital crowding will be worsened given the hospital closures in wake of Hurricane Katrina. State considering expanded visiting hours so relatives can pitch in with some patient care, bringing in retired health workers.

    State assembled a task force to bring businesses into pandemic planning, including how the state will keep critical infrastructure such as water, power and transportation available.

    State would use schools, armories and motels for overflow hospital patients. The state's health chief met with the two largest supermarket chains to discuss how to make sure food supplies are not choked off.

    State would set up "influenza specialty care units" to handle about 5,000 patients once regular hospitals are full.

    Ice storms have provided real-world practice of how to get care to vulnerable populations such as the homebound elderly. About 90 other pandemic drills over the past year and a half showed the importance of little things like using walkie-talkies in case phone service is cut.

    Three major drills, including one involving 10,000 people, gave M&Ms to volunteers as practice for dispensing Tamiflu. The entire state has just 700 ventilators, and while there are plans to buy 300 more, the health department has begun talking with doctors about how they would make the difficult choices of who will get that care.

    State has identified about 1,400 volunteers to help with mass vaccinations.

    Officials are discussing the appropriate chain of command for closing schools, malls or businesses, so there is statewide consistency.

    More than 6,300 people in Billings received flu shots in one day during a mass vaccination drill.

    State led efforts to form the Mid-America Alliance ? with Kansas, Iowa, Montana, Utah, North and South Dakota, Missouri, Colorado and Wyoming ? that will share resources and expertise during a public health emergency such as a pandemic.

    The state stockpiled a little Tamiflu using federal dollars, but its local health districts were not interested in buying more, saying the money was better spent on other supplies. Las Vegas poses a special challenge in predicting health needs, with such a large population of long-term hotel visitors.

    State will address legal authority surrounding quarantines in legislation next year and plans a full-scale drill with neighboring states and Canada in the next year.

    State is debating whether to expand on current federal guidelines about rationing scarce drugs not just to the sick but as protection for such essential workers as grocery truck drivers. State has put together a 211 phone system, similar to the 911 emergency number, that would have trained staff answering pandemic questions from the public.

    State is working closely with 22 American Indian tribes to integrate surrounding communities' plans.

    A pandemic drill involving 1,400 people from eight counties revealed some still unanswered questions, such as confusion over who closes schools. State stockpiles include 4.5 million protective masks.

    In addition to a statewide pandemic drill, health leaders called a summit with leading businesses to discuss meshing state and corporate plans ? including suggestions to keep certain employees at work for long stretches so they would have fewer off-hours opportunities to catch the flu.

    State's goal is to have "very robust plans" completed by August. Among the plans are alternate care facilities, a step below hospitalization, to basically keep the ill fed, clean and hydrated.

    State gives regional health authorities the ability to open MASH-style emergency clinics to handle hospital overflow.

    Mass vaccination drills have the goal of inoculating 400 people in an hour.

    State had a full-scale rehearsal of how to receive, store and dispense to far-flung rural areas drugs and other supplies flown in from the federal government's stockpile.

    State has begun talking to employers about sick policies so infectious workers stay home, and may enlist religious-based organizations to help care for such vulnerable populations as the homebound elderly during a pandemic.

    Each hospital has been asked to plan for up to three alternate care sites to handle patient overflow.

    State working with public television to hold a documentary on pandemic influenza, and produce pocket flu guides, to educate the public about individual preparedness.

    State has delivered protective equipment for health workers to hospitals.

    Pandemic drills are planned for next year. The state is among those still undecided on how much Tamiflu to try to stockpile.

    State operates a network to connect 13,000 doctors with public health announcements by e-mail, phone or fax. Dallas' plans to replace ill workers include the possibility of training librarians as temporary 911 operators.

    State is still finalizing its plan, with a governor's task force that began meeting monthly in September and full drill tentatively scheduled for next summer.

    Health officials in discussions with universities, other entities that have large kitchen facilities that might be used to help feed vulnerable populations.

    A statewide drill identified gaps including how to store bodies and when localities should close schools. State has established a call center where health workers would provide information to the public during a pandemic.

    State would reserve hospitals for the sickest, and treat others at schools and fairgrounds. Drive-thru flu shots showed if that were used during a pandemic, officials would need people to direct traffic.

    State still putting final draft of its plans to paper. Among the ideas is to enlist church nursing programs around the state to beef up supplies of health workers.

    First statewide drill exposed gaps ranging from businesses that haven't done any planning to the state's still evolving plans on how to ration scarce drugs and vaccine.

    State recently joined Colorado, Nebraska and Kansas in a regional drill. It is establishing a system to track school absenteeism, part of statewide monitoring for the first signs of flu outbreaks.