Preparing for a pandemic: concern over a possible avian flu pandemic is moving states, communities and the federal government to action.

Pandemic. It's a word of horrific implications. In the past, millions of people have died from flu viruses that swept through a less populated, less well-traveled world than the one we know today. So the idea that the avian flu, a bird virus that has killed some 100 people in Asia, may be the precursor of the next pandemic has started a national dialogue about how prepared we are and where responsibility lies.

And much of it lies with the states.

"It is states and communities that will be on the front lines," says Health and Human Services Secretary Mike Leavitt. "While the federal government is stockpiling antivirals, success will be determined by whether state and local officials can put pills in people's hands everywhere they are needed within a short time.

"Actions at the state and local level will define victory."

Preparation seems wise. The H5N1 strain of the avian flu virus has infected 173 people in Asia, including the Near East. As of mid-March, 98 of them have died, according to the World Health Organization.

In poultry or wild birds, the virus has spread into Europe and Africa. Human-to-human transmission of the virus is rare--but there are a handful of cases, the result, apparently, of close and prolonged contact. Most infections in humans are believed to occur from direct contact with infected poultry or contaminated surfaces.

But fears that the virus could eventually mutate and be easily passed between humans, as viruses have in the last hundred years, make avian flu big news.

THE FACTS

Avian flu is an infection caused by a bird virus. All avian flu strains originate in migratory waterfowl, which carry the virus in their intestines usually without becoming sick. The virus is very contagious and can sicken domesticated birds, including chickens, ducks and turkeys, and kill them in large numbers.

The flu strain that's concerning health officials today is the Avian influenza A (H5N1) virus. In late 2003 and early 2004, outbreaks in poultry resulted in the death or destruction of more than 100 million birds in eight Asian countries (Cambodia, China, Indonesia, Japan, Laos, South Korea, Thailand and Vietnam).

In 2005, the H5N1 strain was detected in domestic poultry in Turkey and Romania and in wild birds in Croatia. Active outbreaks have continued in 2006, mostly following wild bird migratory routes into Europe. In early March a dead cat in Germany tested positive for H5N1, probably the result of eating infected birds.

THE FEARS

A flu pandemic occurs when a new type of virus emerges for which there is little or no immunity in humans. It causes serious illness and spreads easily person to person worldwide.

At least three human influenza pandemics have occurred in the 20th century. In the most deadly of these, the 1918 Spanish Flu, a virus that probably began in the United States killed an estimated 20 million to 50 million people worldwide. The virus evolved into a virulent form easily transmitted between humans and circulated on the crowded battlefields of World War I. In 1957, a flu strain from China caused 70,000 deaths in the United States. The most recent influenza pandemic occurred in 1968 with the Hong Kong flu outbreak, which resulted in nearly 34,000 U.S. deaths.

"It will happen again," says John Barry, distinguished visiting scholar at the Center for Bioenvironmental Research at Tulane and Xavier Universities and author of a book on the 1918 Spanish Flu. He points out that the longest gap between human influenza pandemics was 42 years and "right now we're at 37 years and counting."

"I am not alone in saying that another pandemic is going to happen," Barry says. "Everybody, the WHO, CDC, says this is going to happen. It may not be H5N1. It may not come for 30 years." But, he says, "when there's enough exposure, it's going to jump species. We must prepare and we are not yet adequately prepared."

Today, unlike 1918, people frequently travel around the world in packed airplanes. An easily transmittable avian flu virus will inevitably spread around the globe. The entire world will be susceptible.

THE CHALLENGES

The challenges of a pandemic are enormous. A rapidly spreading virus, an overloaded health care system, a need for vaccine that is likely to outstrip the supply, a shortage of antiviral drugs that will force decisions about who will receive them. Travel bans, school closings and cancellation of public events might help slow the spread of the virus. Widespread economic and social disruptions--affecting everything from grocery stores to gas stations to transportation--will snowball as workers succumb to the flu or stay home to care for others or because they are afraid of catching the disease.

Barry says that governments "should be thinking hard about how they sustain the society during an enormous outbreak of disease and what that does to the economy. How to keep people and government supplied with things like water. Most treatment facilities don't have more than a few days of chlorine. We've gone to a 'just-in-time' society."

PREVENTION AND RESPONSE

Are we prepared? Many people cite the lack of a coordinated federal response to Hurricane Katrina as proof we're not.

"I tend to think back to Katrina and what didn't happen," says Iowa Representative Linda Upmeyer, a nurse practitioner. "The bottom line is that you have to be prepared at the local level." She and her staff have organized local preparedness meetings in every legislative district after hearing from U.S. Department of Health and Human Services Secretary Mike Leavitt who is going state to state urging local readiness.

State and local governments are scheduled to receive $100 million through HHS to strengthen preparedness efforts. The allocation is a portion of a $350 million emergency appropriations package passed by Congress in December and intended to supplement state activities. The remaining $250 million will be allocated sometime before August and will focus on specific objectives, which are being developed.

Each state will initially get $500,000, plus more based on population. New York City, Chicago and Los Angeles County will get separate grants. Money is to be used for practical, community-based procedures that could prevent or delay the spread of influenza, and help reduce the burden of illness during an outbreak.

So far, there is no vaccine to protect humans from a potential pandemic, but researchers are working on it. The National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, has been conducting a clinical trial for nearly a year on an experimental vaccine based on the H5N1 virus. While there is no way for scientists to know exactly what a pandemic virus will look like, research focuses on the bird flu virus that has infected people in Asia.

There is $3 billion in the Department of Defense Appropriations Act for the development of vaccines, antivirals and other necessary supplies to respond to a possible outbreak as well as for the improvement of current laboratories, and for more research at the Centers for Disease Control.

State officials are still concerned about being able to afford vaccines and antivirals if there should be a pandemic. In late February they didn't yet know how the purchase arrangements would be set up. All state officials do know at this point is that the federal government will pay 25 percent of the cost of antivirals, whatever that is. They also know there will be a limited number of doses available for all the states and territories. The federal government only plans for 20 million doses as recommended by WHO. States may purchase antivirals outside of the negotiated agreement with the feds but they are taking a risk of paying a great deal more.

THINKING AHEAD

Being ready for any kind of catastrophe requires a public health infrastructure that is equipped to survey and quickly assess the magnitude of the event, effectively communicate risk and response through government agencies to the public. This, according to Leavitt, is the state and local role.

"I've had people say, it will never happen," says Representative Upmeyer. "But if we do nothing to be prepared, how will we look to the world? We don't need to panic. We just need to think ahead."

Preparing for infectious diseases or deliberate bioterrorism requires a public health system that supports vaccine development and production, stockpiles of antiviral medications, encourages research and has distribution systems in place. This is the federal role.

"A pandemic, unlike other disasters, can happen in a thousand different places all at the same time," Secretary Leavitt says. "States and communities will be the ones making decisions about whether to close schools or cancel public events. They will also be deciding how to handle the influx of patients at local hospitals and how to distribute medicines."

The states are key in the fight against a pandemic. But avian flu is just one example of an outbreak that poses a statewide health hazard. Preparing for a pandemic now will help state public health officials respond to other emergencies that may occur as well.

MORE RESOURCES

NCSL on public health preparedness: www.ncsl.org/statefed/health/PubPrep.htm

World Health Organization up-to-date information: www.who.int/csr/disease/avian_influenza/en/

Centers for Disease Control: www.cdc.gov/flu/avian/index.htm

State and Local Planning Checklist: www.pandemicflu.gov/plan/pdf/Checklist.pdf

State plans currently online: www.pandemicflu.gov/plan/stateplans.html

Health and Human Services: www.hhs.gov/news/press/2006pres/20060112.html

RELATED ARTICLE: States in motion.

California legislators are acutely aware of the potential impact of an avian-borne illness. In 2002-03, the Exotic Newcastle Disease forced the slaughter of more than 3 million birds in Southern California. It cost the federal government more than $160 million to purchase and destroy the birds to prevent a national outbreak. In 2005, the Legislature directed the state's Department of Food and Agriculture to cooperate with other states and the U.S. Department of Agriculture in planning a program to protect poultry from an avian influenza outbreak, and in turn to keep the flu from spreading to humans.

More legislation is planned this year. Assemblywoman Lois Wolk wants to establish a task force in consultation with the University of California that would develop a plan for surveillance, monitoring, sampling, diagnostic testing and reporting of avian influenza in wild birds and animals.

Other legislation is being developed by Assembly Member Lori Saldana who worries about agricultural workers handling infected poultry. "Doctors and nurses are on the front line of treating people who are sick," she says. "Agricultural workers are on the front line of dealing with infected birds."

In Illinois, proposed legislation would use federal funding to help local health departments prepare. Hawaii legislators, noting that about half of U.S. deaths in the 1918 pandemic were due to secondary pneumonia infections, are considering a $1 million appropriation for free vaccinations for people over 65 and those with weakened immune systems.

Washington state lawmakers are proposing a surcharge of $2 per homeowner's policy and $4 for every commercial and business policy to pay for strengthening coordination between local and state emergency management. Other proposed legislation would require local public health officials to develop pandemic flu preparedness plans that include public information in various languages, responder training drills, disease surveillance, and coordination and communications systems for responding agencies.

At least 10 other states (Georgia, Illinois, Indiana, Massachusetts, Michigan, New Hampshire, Oklahoma, Pennsylvania, Rhode Island and Tennessee) are also considering avian flu legislation.

Amy Winterfeld tracks avian flu for states. Rachel Morgan, who follows the issue in NCSL's D.C., office also contributed to this piece.

TRACKING AVIAN FLU

Nations with confirmed cases of H5N1 avian
flu in poultry or wild birds from 2003
through mid-March include:

  Austria                       Japan
  Azerbaijan                    Kazakhstan
  Bulgaria                      Laos
  Bosnia and                    Malaysia
    Herzegovina                 Mongolia
  Cambodia *                    Myanmar
  Cameroon                      Niger
  China *                       Nigeria
  Croatia                       Poland
  Denmark                       Romania
  Egypt                         Russia
  France                        Serbia and
  Georgia                         Montenegro
  Germany                       Slovenia
  Greece                        Slovakia
  Hungary                       South Korea
  Hong Kong                     Sweden
  Italy                         Switzerland
  India                         Thailand *
  Indonesia *                   Turkey *
  Iran                          Ukraine
  Iraq *                        Vietnam *

* Countries with confirmed human cases.

The United States bans poultry and bird imports
from countries with confirmed avian flu.

FEDERAL FUNDS FOR STATE
AND LOCAL PANDEMIC
PLANNING

Money is to be used for practical, community-based
procedures that could prevent or delay
the spread of influenza, and help reduce the
burden of illness during an outbreak.

  Alabama                         $1,595,205
  Alaska                             657,647
  Arizona                          1,856,742
  Arkansas                         1,163,333
  California                       6,723,207
  LA County                        2,900,529
  Colorado                         1,605,882
  Connecticut                      1,347,950
  Delaware                           698,960
  D.C. Region                        635,601
  Florida                          4,633,819
  Georgia                          2,609,920
  Hawaii                             803,669
  Idaho                              832,432
  Illinois                         2,878,268
  Chicago                          1,197,706
  Indiana                          2,007,596
  Iowa                             1,215,422
  Kansas                           1,162,607
  Kentucky                         1,501,451
  Louisiana                        1,592,758
  Maine                              818,369
  Maryland                         1,840,470
  Massachusetts                    2,061,287
  Michigan                         2,951,805
  Minnesota                        1,731,493
  Mississippi                      1,200,982
  Missouri                         1,890,782
  Montana                            723,275
  Nebraska                           922,515
  Nevada                           1,045,254
  New Hampshire                      813,384
  New Jersey                       2,601,641
  New Mexico                         956,824
  New York                         3,205,759
  New York City                    2,466,271
  North Carolina                   2,547,844
  North Dakota                       654,029
  Ohio                             3,281,387
  Oklahoma                         1,352,695
  Oregon                           1,366,765
  Pennsylvania                     3,508,291
  Rhode Island                       761,679
  South Carolina                   1,508,881
  South Dakota                       686,008
  Tennessee                        1,921,423
  Texas                            5,875,044
  Utah                             1,071,983
  Vermont                            650,610
  Virginia                         2,291,072
  Washington                       1,990,994
  West Virginia                      940,502
  Wisconsin                        1,831,224
  Wyoming                            622,102
  Total                          $97,713,349

  Puerto Rico                      1,443,014
  American Samoa                     114,066
  Guam                               139,782
  N. Marianas Islands                118,513
  Virgin Islands                     126,461
  Micronesia                         126.298
  Marshall Islands                   113,722
  Palau                              104,795
  Total                           $2,286,651

  Grand Total                   $100,000,000