Local response key to pandemic preparedness

Washington -- In the event of a public health emergency, such as an outbreak of pandemic flu, physicians could find themselves caring for patients in convention centers and hotel ballrooms while also advising others on isolation and disinfection.

A plan developed by a local California health department includes these scenarios and is being praised as a model for others to follow.

The necessity of connecting local public health systems to medical communities and area businesses became apparent in the fall of 2001 and received added momentum after Hurricane Katrina struck. It also became obvious that in a widespread disaster, federal help was not assured.

In response to this new level of awareness, the National Assn. of County and City Health Officials and the Centers for Disease Control and Prevention designated seven local health departments as Advanced Practice Centers. The centers now have developed plans that address local aspects of pandemic preparedness.

These plans are intended to serve as models for other local health departments to save them the expense and effort of designing their own approaches from scratch.

The Santa Clara (Calif.) County Public Health Dept. is one such center. Its pandemic influenza plan calls for establishing levels of patient care that could spare county hospitals from being overwhelmed in a disease outbreak that would likely hit 25% to 30% of the population.

According to the blueprint, only the sickest of the sick would be sent to hospitals, explained Marty Fenstersheib, MD, MPH, the county's health officer, while speaking at a May 22 Capitol Hill briefing.

People less than critically ill would be cared for by physicians and nurses in alternate facilities, probably convention centers or hotel ballrooms. Those only mildly affected would be cared for at home by family.

"Whether we have a pandemic today, next week or in five years, we still have to be prepared," Dr. Fenstersheib said. "Our challenge is to provide a response that is local because all responses to this pandemic will be local. And the preparedness we do will save lives."

A system of self-reliance

Part of the reason why this planning is so critical is the message from the federal government that local governments should not count on aid coming from the top. Health and Human Services Secretary Michael Leavitt has been spreading the word that responses will take place in and by the community, noted Patrick Libbey, NACCHO's executive director.

Therefore, the Santa Clara plan involves a triage system for care that was drawn up combining the expertise of local physicians and infectious disease specialists, health plans and hospitals. As a result, "If you go to the doctor's office or to the hospital or if the 911 system picks you up. they will refer you to the right level of care," Dr. Fenstersheib said.

When home care is indicated, families must be educated on how best to provide this care, Dr. Fenstersheib said. "They need to isolate sick family members, they need to know how to disinfect and when to wear gloves and masks. We know that even opening the windows can go a long way to decrease the burden of the virus that is floating around." Keeping people hydrated is another important consideration, he said.

Ensuring that individuals have sufficient medications on hand is a key lesson learned from Hurricane Katrina, Dr. Fenstersheib said. Many diabetics, for example, were caught without sufficient supplies.

Patients sent to large facilities such as convention centers and hotel ballrooms -- sites that allow for large numbers of people to be fed and have sufficient bathroom facilities -- would be cared for by physicians and nurses and could receive more intensive care than they could at home, such as intravenous hydration, Dr. Fenstersheib noted.

The plan also includes a system of alerts to keep physicians' apprised of new clinical information. "Novel influenza infections may appear in any season, may produce clinical syndromes that differ significantly from the seasonal influenza to which providers are accustomed and may disproportionately affect unexpected populations -- as did the 1918 Spanish flu, which most severely affected young adults who were otherwise healthy," according to the plan.

Police departments are also involved in the plan and charged with, among other duties, ensuring that quarantines are followed. Public offices could be called upon to prohibit large gatherings or to close schools.

Dorothy Teeter, interim director and health officer for Seattle and King County (Wash.), noted that the impact on businesses, including those that provide vital public services, could be severe. In the event of a pandemic, 25% to 35% of the work force could be affected at any given time, she said.

Her public health department was also designated an Advanced Practice Center. Not only was minimizing death and illness a goal, but minimizing social disruption and economic losses also was considered.

And despite the go-it-alone challenge faced by local health departments, a stronger federal role in preparatory efforts is "worthy of debate," Teeter said.

The extra federal dollars to help stockpile needed supplies would be welcome, she said. "It isn't that we aren't willing to take on the responsibility, but a huge amount of money is needed. We don't have the $15 [million] to $20 million to get ready."

The other APCs with model preparedness plans are the Cambridge (Mass.) Public Health Dept., DeKalb County (Ga.) Board of Health, Montgomery County (Md.) Dept. of Health and Human Services, Tarrant County (Texas) Public Health Dept. and Twin Cities (Minn.) Metro, a partnership of Hennepin County Public Health Protection and the St. Paul-Ramsey County Dept. Of Public Health.

Each plan includes a particular set of responses that best meet the needs of their populations, NACCHO said.