If and When the Time Comes (Fall 2006 Trust Magazine article)

A flu pandemic will affect all sectors of society. Will they be ready to deal with it? The Pandemic Preparedness Initiative helps them plan. It saves time and resources—and quite possibly its work will save lives.

In the spring of 1918, as the First World War was drawing to a close, a strange disease began spreading through the trenches of Belgium and France. On both sides of the front, soldiers fell ill by the thousands, their heads and joints aching, their bodies burning with fever. One in 20 of the afflicted died, usually within the week, their faces turning blue as they drowned in their own body fluids.

Many months later, this disease would be identified as the “killer flu,” and its first appearance, according to many historians, would eventually be traced to an army barracks in Kansas. At the time, however, it was spreading like wildfire, passing through the air from person to person, unit to unit, army to army and, by the middle of August, among the third-class passengers crowded aboard a Norwegian steamship bound for New York City. By September, the city was seeing hundreds of new cases every day.

The disease spared no country, and mortality was shocking. In Philadelphia, one of the hardest-hit U.S. cities, 752 people died in a single day and more than 12,000 in the month of October alone. By the time the flu ran its course, 500,000 Americans had died—more than five times the number killed in the war. The worldwide death toll is estimated at between 20 million and 50 million.

Doctors, accustomed to dealing with the common flu, were flabbergasted at the death toll. The seasonal flu virus changes from year to year, mutating as it courses through the human population, but usually remains similar enough for a healthy person's immune system to recognize and combat it. The common flu can be deadly—even today it kills 36,000 Americans each year—but its victims are usually people weakened by age or illness. But of the millions the 1918 virus swept away, many were young and healthy, yet unable to resist it.

Only in recent years have scientists begun to figure out why the 1918 flu virus was so deadly. In the process, they have realized how easily it could happen again.

By examining tissue samples taken from victims of the 1918 virus, geneticists have figured out why people had so little resistance. The virus, named H1N1 (the letters refer to its protein structure), had jumped to humans from infected poultry that had been imported, possibly from China. All human viruses derive initially from birds, but with this flu, humans had no resistance because nobody alive had ever encountered anything like it before. That's why it rolled on with such virulence.

“What makes a pandemic virus different from the seasonal flu is that there hasn't been prior exposure,” says Jeffrey Levi, Ph.D., director of Trust for America's Health, a Washingtonbased health advocacy organization established by the Trusts and other funders in 2001. “What has everyone on high alert today is a new form of avian flu, which appears to have jumped to people and could mutate into something that is readily transmitted from human to human.”

The current avian flu variant, H5N1, has been a pandemic in birds for more than a decade, and, by June 2006, it infected birds in 53 nations, with hundreds of millions of them dying. It was first identified in humans in 1997, when it killed a boy in Hong Kong, prompting authorities there to order a mass slaughter of poultry that temporarily halted the spread to people. But the disease did not go away, and scientists are now growing concerned that this flu contains worrying parallels to the deadly 1918 flu variant.

Most bird flu strains aren't equipped to invade human cells, and until recently scientists believed the only way they could develop the capability was by first jumping to an intermediate host species. Pigs were considered the most likely candidate, as they are capable of catching both avian and human influenza. A virus jumped from birds to pigs, the theory went, and, on further mutation, became capable of infecting humans.

The theories weren't wrong: This appears to be exactly how two of the 20th century's pandemics happened. In 1957 and 1968, strains of bird flu infected pigs and were passed on to humans. A total of two million people worldwide died in the two outbreaks, a tiny fraction of the 1918 deaths, presumably because bird viruses that had made an intermediate stop in swine were more familiar to human immune systems, thus easier to combat.

Today's epidemiologists are nervous that the current H5N1 avian flu may mutate to share the rare quality that 1918's H1N1 virus had: the ability to move directly from birds to humans and, subsequently, from human to human. It has already shown at least one similarity: Because H5N1 is so unlike anything people have been exposed to before, it has proved lethal. As of July 2006, the virus had infected more than 231 people and killed more than half of them, an astonishingly high fatality rate. Among the dead is an Indonesian man who caught it from his infected 10-year-old son, confirming fears that the virus may be capable of moving from human to human. If H5N1 mutates into a more infectious form, a 1918-style pandemic could be in the making.

Even if H5N1 fails to achieve a highly contagious form, public health experts say it's only a matter of time before another strain does. After all, pandemics occur three or four times every 100 years—in that respect, there was nothing exceptional about the 20th century. “It's not a matter of if a pandemic flu will happen, but when,” says Georges Benjamin, M.D., executive director of the American Public Health Association. “In this country we've never really done a good job dealing with seasonal flu, so the concept of a worldwide pandemic event—that's something society is totally unprepared for.”

Concerned about the potential consequences of a pandemic flu event, The Pew Charitable Trusts, in December 2005, invested $1.5 million in an initiative to hold accountable federal, state and local officials to do all they can to prepare for a possible flu pandemic. “One of the most effective tools in policy-making is sunlight,” says Jim O'Hara, the Trusts' managing director of Policy Initiatives and the Health and Human Services program. “If you want an effective plan, it's important to have someone asking questions, making sure deadlines are being met, and that the media are aware of what is happening.”

The vehicle for those efforts is the Pandemic Preparedness Initiative, a project overseen by Trust for America's Health (TFAH). As part of the initiative, TFAH's staff has been assessing the federal government's pandemic response plan and implementation of recommendations the organization has compiled. They have found some significant progress, but overall the results have been slow in coming.

The Bush administration's government- wide pandemic plan, released last May, recognized the scope of the threat and many critical response measures, but failed to address how those measures would be paid for. The plan invests $3.5 billion in helping pharmaceutical companies expand their vaccine-production capacity, “but not one penny to pay for the purchase of those vaccines in the event of a pandemic,” says TFAH Director Levi. “There's additional money to expand the ability of state and local health departments to prepare for a pandemic, but not one penny to pay for the care that people will need.”

Assuming that the federal government will purchase all of the vaccine, some cash-strapped jurisdictions may not be able to afford to buy enough necessary antiviral treatment medications, and millions of uninsured people may be reluctant to seek care— circumstances that could cripple efforts to contain the spread of the disease.

“Unfortunately, the federal government has said that states and localities are on their own,” Levi says. “We saw with Hurricane Katrina what happens when the federal government doesn't play a major role, and by definition, a pandemic will be much bigger than Katrina, since it will hit almost every U.S. jurisdiction simultaneously.

“Where you live,” he adds, “shouldn't determine whether you survive the pandemic.”

TFAH has identified another worrisome shortcoming: a failure to adequately communicate the risks and implications of a pandemic to various sectors of society or to provide technical assistance to state and local health departments, which are being left to devise their own flu plans. The United States has more than 3,500 such departments, and every one of them is trying to reinvent the wheel.

Manchester, N.H., is a case in point. Today, Manchester is merely the state's largest city, with 110,000 residents, but it was once an industrial powerhouse of national importance. A century ago, the long, red-brick buildings lining the Merrimack River housed the Amoskeag Mills, the world's largest textile manufacturer, which kept the United States clothed for nearly a century. They also put Manchester on the front lines of applied epidemiology.

The mills attracted tens of thousands of poor Irish, French and Italian immigrants who worked amid great heaps of raw wool and animal hides in the hot, poorly ventilated mills. Disease outbreaks were so common that Manchester became one of the first cities in New England to create a public health department. Good thing, too, because, in 1957, Manchester's Arms Textile Mill was the site of the only accidental outbreak of anthrax in U.S. history; four workers died before it was contained.

In a low-slung building just up the hill from where the Arms Mill once stood, Frederick A. Rusczek, M.P.H., heads the city's venerable public health department. Rusczek says the past five years have kept him on his toes. In the aftermath of the September 11 terrorist attacks, someone started mailing weaponized anthrax to people in other states, and suddenly the people of Manchester were reporting suspicious white powders in letters, sugar bowls and vacuum cleaners. In 2003, there were both the SARS scare, which had public officials meeting flights at Toronto's airport, and the invasion of Iraq, when President Bush issued an abortive order for public health departments to inoculate millions of Americans against smallpox.

None of those threats reached the city, which has made it all the more difficult for Rusczek to get Manchesterians, from the mayor on down, to take the pandemic flu threat seriously. “The biggest challenge is that most people just don't believe it,” he says. “They haven't experienced it in their own lives, so they figure that they'll think about it if and when the time comes. Then, of course, it's too late.”

But in August 2005, Rusczek received a parcel of full-color brochures prepared by TFAH's Pandemic Preparedness Initiative. The materials were the first in a series targeted at specific sectors—business leaders (in this first case), health care professionals, the media, community groups, and individuals and families—explaining what pandemic flu was and the issues each sector needed to think about in preparing for an outbreak. Rusczek and his colleagues began handing them out at meetings and soon were even receiving requests for them.

“These were wonderful,” he says, “because they were something we were able to pass out that came from outside government,” a particularly important consideration in New Hampshire, with its long tradition of skepticism toward public officials. “It really adds to the credibility of our message, both with the public and other parts of city government.”

The brochures engaged local business leaders, agrees Timothy Soucy, M.P.H., the city's chief of environmental health. “We could have tried to get people to pay attention until we were blue in the face,” he says. “When there's a recognized, reliable, non-governmental source that's coming out with the same message, it backs up what we are saying and has really helped get people's attention.”

Kim Elliott, deputy director of TFAH, says the organization started developing pandemic brochures in 2005 when it realized that critical information wasn't being made available by anyone else. “We started with the business community,” she says, “so corporate executives could be aware of how to keep a workplace healthy and of the steps that they could be taking now in terms of ensuring business continuity during an outbreak.”

Most large businesses have plans to ensure that vital records and other critical business elements can survive a relatively localized event like a fire, hurricane or bomb. “But a pandemic is not a single event,” Elliott says. “It will last over a period of several months and affect society at large,” creating a situation few businesses have considered.

“The big culprit is sustained employee absenteeism, projected at 40 percent and affecting not just your business, but everyone else as well. We live in a just-in-time economy, so what happens when 40 percent of the air-traffic controllers, pilots, truck drivers, railroad engineers and factory workers are too sick to come to work? Business in the U.S. as we know it will cease to exist.”

“Few industries are going to be insulated from the pandemic,” says Ann Beauchesne, executive director of homeland security at the U.S. Chamber of Commerce, which collaborated on the business-sector brochures and distributed them to more than 3,000 state and local chapters. “Our message to our members is that the pandemic will happen, we're overdue for one, and it's not a waste of time and resources to prepare.”

Preparation is even more critical in the health-care industry, which, in a 1918-style scenario, would have to attend to more than 55 million extra patients, 10 million requiring hospitalization. But many doctors, absorbed with more immediate demands, know little about the pandemic flu.

That worried L.J. Tan, Ph.D., director of infectious diseases at the American Medical Association. “There really wasn't anything out there to prepare our physicians,” he recalls. “How do you distinguish between a seasonal and pandemic flu? What do you say to your patients? What are the critical things you will need to do to ensure that your practice will continue to function in the event of a pandemic? We were really at a loss.”

In July 2005, Tan met TFAH's Jeff Levi at a pandemic-planning conference and shared his concerns. Levi showed him the brochure they had prepared for business leaders. “I looked at it and said, hey, that's exactly what we need,” Tan says. A few months later, the two organizations had put together a carefully vetted brochure for health-care professionals, which has since been distributed to 380,000 physicians across the country.

Because it would take six months or more to develop and produce a vaccine capable of countering a novel flu strain, the brochures warn, hospitals will be quickly overrun. Ventilators and antiviral drugs capable of fighting the infection will likely be in short supply, and hospitals will be forced to ration care. Practices, clinics and hospitals should be developing plans now that will help them stay up and running during a pandemic event.

“The public expects the hospital is going to be there for the care that is needed,” says Sandra Demars, director of safety and emergency management at Manchester's Elliot Hospital, the city's largest, which has been preparing for a pandemic event for months. “We'll be there for people to the degree we possibly can, but there's a gap between what we have and what we would need in a serious event.”

Example: A ventilator for an intensive care unit costs around $30,000. Elliot has a dozen, more than enough to meet patients' needs in normal circumstances. In the event of a severe pandemic flu outbreak, says Demars, projections suggest the hospital would receive hundreds of patients in need of ventilator care. It is looking into acquiring large numbers of cheaper, less sophisticated ventilators, but inevitably not every patient would receive the standard of care a clinician would normally provide.

That led to another realization for Demars and her colleagues. In a desperate situation where care has to be rationed, securing the city's hospitals would be essential to their continued operation. They realized that pandemic planning needed to be coordinated with the police department, emergency medical technicians, the fire department and competing hospitals. “We may need the police to be on hand to lock down our campus because there are 500 people trying to force their way onto our property,” Demars says. “We said to the police: ‘We're good at health care, but you know how to control a riot.'”

Fortunately, Manchester is a small place where people know one another, so it was relatively easy to get decision- makers together, face-to-face, to work out a coordinated plan. Elliot and its rival hospital, Catholic Medical Center, have worked out what sort of cases each institution will handle during a pandemic. Emergency medical technicians and fire department rescue teams know which patients will go where, while the police have plans to secure facilities and re-route traffic. When the fire department was shopping for new respirator masks capable of protecting their personnel from infection, they worked with the police and public health department to buy models with interchangeable filters.

“This regional planning is essential,” Demars says, “and if you approach it in the right way, you can develop a modular plan that can be applied to a range of other emergencies” from smallpox and SARS to a chemical spill or an accident at a nuclear power station. “Then it's vital to hold drills for each of those plans, so that everybody knows what to do if it really happens.”

Manchester is well ahead of the game. In many other cities—particularly large metropolitan areas—there is often little coordination among institutions. Most emergency plans assume that help will arrive from the outside, but because a flu pandemic would, by definition, affect everyone at once, there would be no “outside” to draw help from.

“Any community that fails to prepare and expects the federal government will come to the rescue is tragically wrong,” U.S. Health and Human Services Secretary Michael O. Leavitt has told audiences across the country. “It's not because we don't care, don't want to, or don't have the money, but because it's logistically impossible.”

Because each community may face a pandemic on its own, it's essential that they all do what Manchester has done, says Levi of TFAH. “Governments— local, state and federal—need to coordinate and communicate with one another, and that's something that's not often the focus of exercises,” he says.

To raise awareness of this point, in October TFAH is organizing a daylong simulation of a pandemic flu outbreak in Los Angeles. The drill, co-sponsored by the Robert Wood Johnson Foundation and The California Endowment, will be attended by the directors of both the California and Los Angeles County public-health departments, who, along with 15 to 25 other leading officials, will play themselves in the simulation. The participants will represent a range of sectors and institutions, including city and other government agencies, hospitals and school boards.

In the first phase, these decision makers are informed that the World Health Organization has raised the worldwide threat level: A flu pandemic has started. “They learn that there's a woman who had been traveling in Vietnam and developed acute respiratory distress while flying to Los Angeles,” explains TFAH's Kim Elliott. Audience members begin the day by withdrawing to breakout sections by sector, where they will address possible issues and consider how they would be resolved.

Later, when the “real-time” scenario begins to unfold, the participants are shown professionally-produced, of-the-moment news reports, some accurate, some not. They hear government announcements and are handed various sorts of documents.

And they are openly observed: An audience of 200 people—reporters, business leaders, educators and others— watch the events unfold, occasionally participating in electronic votes on what they think should be done: Should the schools be closed now? shopping malls? the airport?

In the second phase of the exercise, the participants are thrown two weeks ahead: Hospitals are being overwhelmed, and thousands are sick. “Can you set up field hospitals?” Elliott continues. “Does anyone know how to operate them besides the military? Where is the military? Can the governor call the National Guard out?”

In the third phase, the action has moved forward by four more weeks, when participants must confront the more lasting societal effects. Food is in short supply, the transportation system is impaired, and people are unable to fill prescriptions for preexisting ailments, creating a whole new set of crises.

The drill should make decision makers in Los Angeles and throughout California more aware of what they need to be preparing for, but TFAH hopes to bring some of those lessons to a wider audience. “We're looking into turning the exercise into a documentary which we hope to be able to air on a cable outlet and turn into a training tool for other public-health agencies,” says Levi, who hopes not everyone will have to reinvent the wheel. “There's an enormous opportunity for replication and a sharing of experience.”

Meanwhile, TFAH continues to keep the issue on decision-makers' agendas. In addition to holding regular briefings for federal policy makers, it leads the public-policy and advocacy activities of the broad-based Working Group on Pandemic Flu Preparedness, which it has convened to share and disseminate information about government pandemic-preparedness initiatives. TFAH also posts updated information and issue briefs to its comprehensive pandemic-preparedness Web site, www.pandemicfluandyou.org.

And now TFAH's work is being augmented by a new Trusts project called Strengthening State and Local Public Health Preparedness, which hopes to address that “wheel-reinvention” problem facing state and local governments by helping them translate public-health policies into effective action steps. The project is being carried out by the Center for Infectious Disease Research and Policy at the University of Minnesota, under the direction of Michael T. Osterholm, Ph.D., M.P.H., one of the country's foremost experts in public-health preparedness.

In the first part of this project, expected to be completed by next February, project participants will determine the aspects of a public-health response that are the most troublesome for state and local governments, and then collect and analyze alternatives; the second phase, from March through June 2007, involves dissemination and outreach. The Pew Center on the States is collaborating on the entire project but will play a particularly important role in the latter efforts. “With the center's expertise both in gathering state-based information and circulating best practices, it makes sense to partner,” says the Trusts' O'Hara.

“It's very easy for policy makers to start off with great intentions but to be taken off track by new issues that come up, so helping keep them focused is very important,” he points out. “Being prepared for a pandemic is really being ready for anything.”

Pew is no longer active in this line of work, but for more information visit the Pandemic Planning Project on PewHealth.orgTrust for America's Health is located at 1707 H Street, NW, 7th Floor, Washington, D.C. 20006, and its phone is 202.223.9870. Its Web site is http://healthyamericans.org, and its pandemic flu Web site is http://pandemicfluandyou.org.

Information on the flu is also available at www.cidrap.umn.edu, the Web site of the Center for Infectious Disease Research and Policy at the University of Minnesota.

A Mainer, Colin Woodard is an award-winning journalist and the author of Ocean's End: Travels Through Endangered Seas and The Lobster Coast: Rebels, Rusticators, and the Struggle for a Forgotten Frontier. For more, see www.colinwoodard.com.