States have their own ideas for dealing with an outbreak of bird flu or other super-flu strain — readying possible quarantine sites and talking about closing schools and businesses.
State officials may tell hospitals they may have to evict all but the most critically ill. Several states will ask residents to stay home and take a "snow day" if a pandemic strikes.
The stakes are enormous.
Texas, alone, estimates as many as a quarter-million of its people might die.
These details and more are spelled out in the pandemic preparedness plans that state governments have prepared in recent years. The Bush administration updated the federal blueprint for a pandemic response just this week.
Many states aren't sure yet how their plan would mesh with what the federal government expects of them. However, they already have concerns about whether state and local governments have the resources to meet the Bush administration's goals.
For example, the Bush plan calls for states to spend $510 million for anti-flu drugs, which can reduce the severity of the flu.
"The plan is useful, and the planning process is useful, but what isn't occurring is any analysis to see whether the staffing required to do the plans is actually there," said Dr. Rex Archer, president of the National Association of County and City Health Officials. "That's the weakness with all of this. I'm afraid that probably 90 percent of the staffing at the state and local level is not there to carry out the plans."
The Bush plan does call for $100 million for state preparedness and planning, but Sen. Tom Harkin, D-Iowa, complained that the president's budget for this fiscal year proposed to cut $120 million from state public health agencies.
Texas' draft plan, released last week, assumes at least two waves of pandemic influenza will occur. It tells health care officials they may have to consider "non-standard approaches" to meet demand, including:
- Discharge of all but critically ill hospital patients.
- Using all available space and "less than code-compliance beds."
- Recruiting volunteers to serve as custodians.
- Relax the licensure requirements of health practitioners as necessary.
Dr. Tom Betz, acting state epidemiologist for Texas, said the national plan validated much of the work his state has done over the past three years.
"Our approach just mirrors what's in the national plan," Betz said. "To me, what was nice about the national plan was that it was not a sky-is-falling approach. It really stressed the need for vaccine as one our primary tools in fighting any strain of influenza."
The completion of 50 state plans for a flu pandemic is a top priority of the federal government, because as one top Bush administration official said, a battle against a pandemic will be fought on 5,000 different fronts.
"The federal government can deliver stockpiles of medication and supplies to a city in the U.S. in a matter of hours, but it is distribution at the state and local level that defines victory," said Health and Human Services Secretary Mike Leavitt.
A review of several state plans shows they have taken stock of the potential toll. The projections for some of the worst-case scenarios are ominous. Texas cites the potential for up to 250,000 deaths if 25 percent of the population were infected. Georgia says up to 6,210 people could die. Kansas predicts the potential for up to 2,500 deaths.
Bird flu has killed at least 62 people since it surfaced in 2003, all in Southeast Asia, according to the World Health Organization. Most had contact with sick poultry. But health experts have warned that the virus could mutate into a form that can be easily transmitted between humans and trigger a global pandemic.
States have planned for a potential pandemic for several years, and they've taken cues from the Centers for Disease Control and Prevention and the World Health Organization in forming those plans. However, their work has taken on greater urgency in recent months, said Patrick McConnon, executive director of the Council of State and Territorial Epidemiologists. Several states have submitted new plans to his association in recent weeks. Most plans are labeled as drafts.
In June 2004, 29 of 50 states had plans in place for a potential pandemic. Since then, the remaining states have at least completed drafts of a plan, he said.
Most states plan for shortages of medicine, and they realize they will have to make some tough decisions. Most also have been inexact when saying who would be the first in line to get medicine. For example, Kansas states that it will listen to recommendations made at the national level. Its current priority list starts with hospital and health department staff, as well as their family members. Next in line are emergency medical workers, police officers and firefighters. Last on the list are members of the "general public."
Georgia says the state's health director may choose a committee to help decide who would get drugs first. The committee would include health officials as well as experts on ethics. Some protest from the public should be expected, it hints.
"Educating the public on these priority groups will be key," said the Georgia plan.
The Bush plan says the first to be treated for pandemic flu should be patients admitted to the hospital and the highest-risk outpatients, including pregnant women and people whose immune systems have been compromised, such as cancer patients undergoing chemotherapy, as well as health workers sickened by caring for them. It says the first who should be given medicine to prevent contracting the disease are health workers.
Another key aspect of the state plans is surveillance. North Carolina said that in the case of a novel virus alert, officials should monitor persons traveling from geographic areas where the strain has been isolated, they should monitor poultry and swine workers, and military personnel.
In the event of a pandemic alert, officials should consider monitoring schools and daycare centers as a means of measuring the community's overall health.
Kansas addresses the issue of quarantines by stating that the governor may choose to utilize snow days as a way to encourage non-emergency workers to stay home.
McConnon said states will adjust their plans once the Bush administration has finalized details on the amount of vaccine and antivirals that would be available.
"I would not be surprised if most of the states pull their plan down as soon as the federal plan comes out, so that they can revise it," McConnon said. "We know, for example, there will be some new details related to drug distribution. They'll also need to look at the issue of quarantine and how they're handling it."
William Raub, who oversees health emergency preparedness at HHS, said the agency will work with state and local officials in coming months to incorporate the federal government's advice into their own plans. He described state plans as "uneven" in places, such as when to close schools or to discourage public gatherings.
"Some have addressed it quite thoroughly," he said. "Others have more work to do."