A year or two ago, avian flu was an item on the world news report, a problem occurring in far-off places in Asia. Now, it has become a looming health emergency, with many experts convinced that chances for a widespread outbreak of influenza – in a form that has not been seen since 1918 – are increasingly likely.
“The Army Corps of Engineers thought that the chances of a hurricane like Katrina devastating New Orleans was about 5 percent,” said Dora Anne Mills, the head of Maine CDC (formerly the Bureau of Health.) “We don’t really know the odds on a flu pandemic, but they’re probably a lot greater than 5 percent.”
As most readers know by now, the big question is whether the most famous strain of bird flu – known as H5N1 – will ultimately be transmitted from human to human. It has so far caused millions of bird deaths and mandatory slaughter of infected flocks, and over 200 human fatalities – so far all from close contact with birds. While no cases have been reported in the U.S., health officials believe it is just a matter of time before infected birds show up here as well. A mutating strain of the virus could result in human-to-human transmission, and since there is no immunity to this influenza strain, the toll could be catastrophic.
The numbers from the 1918 pandemic, known in the United States as “Spanish flu” even though it probably started here, are sobering. Perhaps 20 million people died worldwide, more than perished in World War I. There were 675,000 American deaths, and 5,000 in Maine. As a rural state, where people congregated less, transmission was less than in the big cities, yet there were few communities that escaped entirely. There were smaller, though deadly, outbreaks of swine flu in the 1960s and 1970s, but nothing like the 1918 virus is known to have occurred before or since. At least until now.
Nearly a century after the pandemic, public officials are very much engaged in planning for a similar situation, with some federal assistance and a lot of intense discussion at forums, planning sessions, and across institutional boundaries.
How is the effort going? “We’re a lot readier than we were a year ago, that’s for sure,” said Mike Russell, epidemiology manager for Portland. “But ready? I wouldn’t think so. Not yet”
The Maine plan
Maine, like other states, has received a federal grant for pandemic flu planning, based on population, in this case totaling $97 million nationally and $819,000 for Maine. That sounds like a lot, but as Dora Mills points out, it is less than 75 cents per person.
The state has chosen to push most of the money through to the local level, in large part because Maine lacks any kind of institutional public health infrastructure at the county or municipal level.
The county health department has been a routine part of life in most of the nation for more than a century, but not in New England. The lack of strong county governments has meant the job has fallen to municipalities where they are large – as in Massachusetts and Connecticut – and has largely gone unfilled in the rural states of northern New England.
“ Vermont has tried to set up a regional public health network,” with some success, Mills said. In New Hampshire and Maine, however, public health awareness falls by statute to local health officers, a 19 th century system that has since fallen into disuse. (See “Role of Local Health Officer” article in this issue)
While there is no regional public health system, the state has encouraged Maine’s largest cities to help fill that role. Portland has the largest such effort, and has spearheaded flu planning for Cumberland and York counties, plus adjacent coastal counties. There’s less staffing in Bangor, but that office has the widest geographic area to cover. A parallel effort among health care providers called the Northeast Regional Resource Center includes a third planning area around Lewiston.
Both Portland and Bangor rely primarily on grants and federal funding for their work, although the services offered are fairly extensive. In Bangor, Patricia Hamilton, the public health nursing director, said that the office oversees the public assistance program, WIC, public health nursing, sexually transmitted disease testing, women’s health, dental clinics, and a regional epidemiologist. Overall there are six nurse-epidemiologists funded through the state, though Mills admits they are “stretched thin.” [Epidemiology is defined as the study of the outbreak and transmission of communicable diseases, with emphasis on detection and investigation.]
The state itself is forced to redeploy resources to try to get ahead of the possibility of a flu pandemic. Maine CDC (which, following the national model, stands for Center for Disease Control and Prevention) recently designated its first full-time employee for pandemic flu, but did so by vacating the rural health program office. “Most of us are working on this part-time in addition to our regular responsibilities, including me,” Mills said.
So when considering the lack of public infrastructure needed to carry operations down to a regional, let alone the local level, the state decided to begin with a county planning process. Maine produced its first state draft pandemic influenza plan in July 2005, and has since been laboring to fill it out. There are now 16 county planning directors, who vary in their background experience.
The existing county emergency management agency (EMA) is a key, though sometimes a thin-staffed link in the chain of command for responding to natural disasters like hurricanes, the ice storm of 1998, and, most recently, extensive flooding in York County. Many county EMA directors, however, lack any public health background, so other officials have taken on the job. In Cumberland County, Julie Sullivan, Portland’s public health director, is the county director, and Mike Russell also serves on the Cumberland County Leadership Team.
In many counties, though, “They’re essentially volunteers,” Mills said. “They’re all good people, but in terms of dealing with an actual crisis, it’s a little frightening.”
Thinking the unthinkable
Influenza, in a population that has never been exposed to a particular strain, can have devastating consequences. Mortality rates can be high, and no age group is immune. Many of those who died in 1918, were young, healthy adults.
Surveying the situation nearly a century later, Mills says there are clear advantages – and disadvantages – for Maine today. On one hand, “we have anti-viral drugs, and ventilators, and effective germ barriers,” she said. “We have a lot of technology that they couldn’t have even imagined back then.” On the other hand, “We’re a lot less self-sufficient than we were back then.” Most people still lived on farms, and were used to getting by on their own for weeks at a time, she said. “Now, we rarely even have enough food in the house for a week, and many people rely on daily medical care.”
The reason why a certain amount of self-sufficiency is vital to containing a flu outbreak is that quarantines are the first and perhaps most important line of defense. If flu were detected in a particular place, the best way to avoid transmission is to stay away from the people who are infected or are carrying the disease.
The essence of rescuing people from natural disasters is usually concentrating them in one place until they can be relocated to a safer area. In a flu outbreak, it would be the opposite – keeping the population as dispersed as possible.
The draft flu plan is pretty clear on this point. Public gatherings would be forbidden. People might not be able to go to work, or take their children to school. Churches couldn’t have services. Transportation networks might have to be shut down. In 1918, the disease was so little known that there were essentially no defensive measures taken. Now, we know a lot more about influenza but the steps that would be necessary have never been tried on a comparable scale.
Adding to the challenge, Mike Russell said, is the fact that most flu strains have only a two-day incubation period, one of the shortest of any communicable disease. The period from exposure to signs of infection is as little as 48 hours.
“Another issue is that we really don’t know how an actual outbreak would occur,” he said. “Would it be in a single location in a state like Maine, or would there be multiple occurrences all at once?” And while all populations could be vulnerable, those with compromised immune systems would be particularly at risk, Patricia Hamilton said. Those suffering from kidney disease, HIV/AIDs and other diseases would have a hard time fighting off the infection.
While Portland has the largest public health infrastructure of any region in the state, Hamilton said that the Bangor area has the advantage that its smaller numbers of professionals are already used to regular communication, something that can be important in responding to an emergency. “We know each other well, because we depend on each other to do our jobs on a daily basis,” she said. While devising strategies for a potential pandemic can be daunting, “You start with what you always have to do in any emergency.”
Hamilton says she’s often asked whether it’s a good idea to stock up on food. “You absolutely should. That’s helpful whether there’s a hurricane and power failures, flooding, or an ice storm.” But she also observes that, “There are people who really can’t afford to do that,” and are already dependent on assistance to make ends meet.
Portland, with a denser population to go along with its more developed health infrastructure, would face some special challenges, Russell acknowledges. A flu outbreak in a large apartment building, an office building, or a college dormitory could involve quarantining hundreds of people, rather than just a family or two. That’s why Cumberland County is already bringing institutions such as USM into its pandemic planning. “Getting everyone to the table now is a really important part of preparedness,” he said.
While the 1918 outbreak is too distant to be of much use in contemporary planning, there may be points to be learned from attempts to contain polio, before that once-feared disease was controlled by vaccines in the 1950s. “We’re looking into whether there were any techniques used then that would be helpful to us today,” Russell said.
Naturally, hospitals and physicians would be key to treatment and quarantines in an actual emergency, and in Bangor the Primary Care Physicians Association is participating in planning. The role for municipal officials is not as obvious, but first responders such as EMTs would definitely be involved, and law enforcement would be a high priority if it became necessary to shut down traffic links and maintain order among a fearful public.
As the county planning gears up – a draft plan for each of the 16 counties is due by August – municipal employees will increasingly become involved. Once the plan is approved, training can begin, and the state expects that it will become a significant part of emergency preparedness, just as hazardous materials (Hazmat) and even weapons of mass destruction (WMD) are now part of the municipal vocabulary.
Municipal emergency management officials, health officers and first responders should take a hard look at the local emergency management plans already in place and evaluate how those plans will mesh with the county plans. The county plans will not establish detailed chains of command or communication mechanisms at the local level, so it will be up to the municipalities to develop their own strategies.
The key to avoiding panic during a widespread outbreak, Dora Mills said, is to have a response plan that extends from federal to state and then to local levels, and then to educate the public about what would need to be done.
People may need to be kept at home or, in some cases, at work if that’s where exposure occurs. “If people are assured that they will get the food and medicine they need, they’ll be more comfortable about quarantines and other steps to arrest the outbreak,” she said.
State and local plans will include hotlines for delivery of such essentials, and, unlike other natural disasters, phone and electric lines would likely remain intact.
No plan will be able to anticipate everything that could happen simply because disasters unfold differently than any plan can encompass. “There’s no doubt that we’ll have to get used to doing things differently,” Mills said. Flexible thinking and knowing when to disregard regulations designed for institutional routines will be important.
For instance, “We’d have to know quickly how much mortality there is, and where.” Right now, with just six nurse-epidemiologists to investigate outbreaks, there are only enough personnel to do a weekly statewide survey, she said. “When that came up at meetings, I said we’d have to do it daily. You can’t respond effectively if you have to wait.” How can a daily survey happen, then? “You just figure out how to get it done. That’s the nature of a crisis,” she said.
Similarly, she studied a rural hospital’s plan to increase the number of ventilators that would be needed to keep severely ill flu victims alive. The hospital figured out how to increase its usual total of four ventilators to 20 during an emergency – but still had only enough nursing staff to use four. “You can’t keep a 4-1 patient-nurse ratio in a situation like that,” said Mills. “You have to know when the rules aren’t going to allow you to respond effectively.”