President Bush is expected to approve soon a national pandemic influenza response plan that identifies more than 300 specific tasks for federal agencies, including determining which frontline workers should be the first vaccinated and expanding Internet capacity to handle what would probably be a flood of people working from their home computers.
The Treasury Department is poised to sign agreements with other nations to produce currency if U.S. mints cannot operate. The Pentagon, anticipating difficulties acquiring supplies from the Far East, is considering stockpiling millions of latex gloves. And the Department of Veterans Affairs has developed a drive-through medical exam to quickly assess patients who suspect they have been infected.
The document is the first attempt to spell out in some detail how the government would detect and respond to an outbreak, and continue functioning through what could be an 18-month crisis, which in a worst-case scenario could kill 1.9 million Americans. Bush was briefed on a draft of the implementation plan on March 17. He is expected to approve the plan within the week, but it continues to evolve, said several administration officials who have been working on it.
Still reeling from the ineffectual response to Hurricane Katrina, the White House is eager to show it could manage the medical, security and economic fallout of a major outbreak. In response to questions posed to several federal agencies, White House officials offered a briefing on the near-final version of its 240-page plan. When it is issued, officials intend to announce several vaccine manufacturing contracts to jump-start an industry that has declined in the past few decades.
Some agencies better prepared than others
The background briefing and on-the-record interviews with experts in and out of government reveal that some agencies are far along in preparing for a deadly outbreak. Others have yet to resolve basic questions, such as who is designated an essential employee and how the agency would cope if that person were out of commission.
"Most of the federal government right now is as ill-prepared as any part of society," said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Osterholm said the administration has made progress but is nowhere near prepared for what he compared to a worldwide "12- to 18-month blizzard."
Many critical decisions remain to be made. Administration scientists are debating how much vaccine would be needed to immunize against a new strain of avian influenza, and they are weighing data that may alter their strategy on who should have priority for antiviral drugs such as Tamiflu and Relenza.
The new analysis, published in Proceedings of the National Academy of Sciences, suggests that instead of giving medicine to first responders and health-care workers, as currently planned, it might be wiser to give the drugs to every person with symptoms and others in the same household, one senior administration official said.
The approach offers "some real hope for communities to put a dent in the amount of illness and death, if we go with that strategy," a White House official said.
Pandemics rare but deadly
Each year, about 36,000 Americans die from seasonal influenza. A worldwide outbreak, or pandemic, occurs when a potent new, highly contagious strain of the virus emerges. It is a far greater threat than annual flu because everyone is susceptible, and it would take as much as six months to develop a vaccine. The 1918 pandemic flu, the worst of the 20th century, is estimated to have killed more than 50 million people worldwide.
Alarm has risen because of the emergence of the most dangerous strain to appear in decades -- the H5N1 avian flu. It has primarily struck birds, but about 200 people worldwide have contracted the disease, and half have died. Experts project that the next pandemic -- depending on severity and countermeasures -- could kill 210,000 to 1.9 million Americans.
To keep the 1.8 million federal workers healthy and productive through a pandemic, the Bush administration would tap into its secure stash of medications, cancel large gatherings, encourage schools to close and shift air traffic controllers to the busier hubs -- probably where flu had not yet struck. Retired federal employees would be summoned back to work, and National Guard troops could be dispatched to cities facing possible "insurrection," said Jeffrey W. Runge, chief medical officer at the Department of Homeland Security.
The administration hopes to help contain the first cases overseas by rushing in medical teams and supplies. "If there is a small outbreak in a country, it may behoove us to introduce travel restrictions," Runge said, "to help stamp out that spark."
Question of authority
However, even an effective containment effort would merely postpone the inevitable, said Ellen P. Embrey, deputy assistant secretary for force health preparedness and readiness at the Pentagon. "Unfortunately, we believe the forest fire will burn before we are able to contain it overseas, and it will arrive on our shores in multiple locations," she said.
As Katrina illustrated, a central issue would be "who is ultimately in charge and how the agencies will be coordinated," said former assistant surgeon general Susan Blumenthal. The Department of Health and Human Services would take the lead on medical aspects, but Homeland Security would have overall authority, she noted. "How are those authorities going to come together?"
Essentially, the president would be in charge, the White House official replied. Bush is expected to adopt post-Katrina recommendations that a new interagency task force coordinate the federal response and a high-level Disaster Response Group resolve disputes among agencies or states. Neither entity has been created.
Analysts at the Government Accountability Office found that earlier efforts by the administration to plan for disasters were overly broad or simply sat on a shelf.
"Our biggest concern is whether an agency has a clear idea of what it absolutely has to do, no matter what," said Linda Koontz, director of information management issues at the GAO. "Some had three and some had 400 essential functions. We raised questions about whether 400 were really essential."
In several cases, agencies never trained for or rehearsed emergency plans, she said, causing concern that when disaster strikes, "people will be sitting there with a 500-page book in front of them."
A gutted workforce
The federal government -- as well as private businesses -- should expect as much as 40 percent of its workforce to be out during a pandemic, said Bruce Gellin, director of the National Vaccine Program Office at HHS. Some will be sick or dead; others could be depressed, or caring for a loved one or staying at home to prevent spread of the virus. "The problem is, you never know which 40 percent will be out," he said.
The Agriculture Department, with 4 million square feet of office space in metropolitan Washington alone, would likely stagger shifts, close cafeterias and cancel face-to-face meetings, said Peter Thomas, the acting assistant secretary for administration.
The department has bought masks, gloves and hand sanitizers, and has hired extra nurses and compiled a list of retired employees who could be temporarily rehired, he said. A 24-hour employee hotline would provide medical advice and work updates. And as it did during Katrina, Agriculture has contingency plans for meeting the payrolls of several federal departments totaling 600,000 people.
Similarly, the Commerce Department has identified its eight priority functions, including the ability to assign emergency communication frequencies, and how those could be run with 60 percent of its normal staff.
Parking-lot triage plan
Operating the largest health-care organization in the nation, the VA has directed its 153 hospitals to stock up on other medications, equipment, food and water, said chief public health officer Lawrence Deyton. "But it's a few days' worth, not enough to last months," he added.
Anticipating that some nurses may be home caring for family members -- and to reduce the number of patients descending on its hospitals -- the VA intends to put nurses on its toll-free hotline to help veterans decide whether they need professional medical care. At many VA hospitals, nurses and doctors would stand in the parking lots armed with thermometers and laptop computers to do drive-through exams. Modeled after its successful drive-through vaccination program last fall, the parking-lot triage is intended to keep the flow of patients moving rapidly, Deyton said.
Much of the federal government's plan relies on quick distribution of medications and vaccine. The Strategic National Stockpile has 5.1 million courses of Tamiflu on hand. The goal is to secure 21 million doses of Tamiflu and 4 million doses of Relenza by the end of this year, and a total of 51 million by late 2008.
In addition, the administration will pay one-quarter of the cost of antivirals bought by states. The Pentagon, VA, USDA and Transportation Department have their own stockpiles -- and most intend to buy more as it becomes available.
Blumenthal, the former assistant surgeon general, questioned why two years after Congress approved a $5.6 billion BioShield program to develop new drugs and vaccines, so little progress has been made.
Homeland Security's Runge has a different concern: "One of the scariest thoughts is, if this country has successfully developed a vaccine within six months of an outbreak or our supply of antivirals is greater, there may be a rush into the United States for those things."
And even if those fears do not materialize, officials have warned that the federal preparations go only so far. Much is left to the states, communities and even individuals.
"Any community that fails to prepare -- with the expectation that the federal government can come to the rescue -- will be tragically wrong," HHS Secretary Mike Leavitt said in a speech April 10. The administration is posting information on the Internet at http://www.pandemicflu.gov.