Germ Warfare

Posted January 16, 2009 by Julie Walsh

Health Command Center.

Dinner Hour (circa 1915) on the docks in Jacksonville, Florida. Unsanitary conditions and a lack of understanding of how the disease was transmitted contributed to the spread of influenza.

Courtesy of the Library of Congress.

We’re overdue for a deadly flu pandemic. But are we prepared?

It sounds like something from a horror movie.

If a flu pandemic hits, 50,000 people could die statewide, and millions would fall sick across New Jersey. Businesses and schools might close, and utilities could shut down, as the invisible contagion rages across our state. Even the Internet might succumb—cutting off a vital lifeline for survivors seeking safety in their homes.

But state officials are taking this plotline seriously—and they’ve launched several innovative measures in response.

“We have a tremendous amount of tools available,” says Dave Gruber, senior assistant commissioner for preparedness at the state’s health department. “We have actions to take, and actions to take if those actions don’t work.”

Still, some experts question whether New Jersey would have enough resources—like ventilators, medicines, and even healthcare workers—to treat an estimated 2.5 million ill citizens. And even state officials note any response will rely heavily on people taking care of themselves.

“Pandemic flu really is different than other emergencies,” says Dr. George DiFerdinando Jr., a health-disaster expert at the University of Medicine and Dentistry of New Jersey. “Everyone has the disaster at the same time. There’s no cavalry to call in.”

Unlike other potential crises, experts say a flu pandemic isn’t a matter of if but of when. “We’re way overdue,” says Tom Slater, a spokesman for the state Department of Health and Senior Services. “Historically they occur every 30 or so years,” he explains, noting that the last global flu struck in 1968.

The 1968 pandemic was relatively mild compared to the catastrophic 1918 outbreak that  wiped out tens of millions worldwide. And the flu could spread like wildfire through New Jersey—the country’s most densely populated state and one of the most heavily traveled.

While no one knows whether the state’s measures will be sufficient—“You can always overwhelm the system,” says Gruber—some experts praise New Jersey’s efforts at preparedness. These include a groundbreaking health command center—the only state facility of its kind—and the health department’s newly updated pandemic flu plan.

This latest plan compares “very favorably” with other states’ preparations, says DiFerdinando. “It’s a lot more detailed than the previous one,” notes the epidemiologist, who heads UMDNJ’s Center for Public Health Preparedness.

And the $1.8 million command center “is as good as we’ve seen,” says Dr. W. Craig Vanderwagen, a rear admiral in the U.S. Public Health Service.

“New Jersey has been preparing [its] medical and public-health systems well,” adds Vanderwagen, the U.S. Department of Health and Human Services’ assistant secretary for preparedness and response.

In the classroom-size command center—a room on the sixth floor of Trenton’s Health and Agriculture Building—a ten-screen video display covers most of one wall.

The video unit allows officials to monitor a health-care arsenal, tracking dozens of ambulances at any given moment or the availability of hospital beds across the state.

In a flu pandemic, officials could see which hospitals were overburdened, and call for the opening of additional facilities, says Slater.

“We could keep up with staffing issues with the [state] hospital association,” he explains.  “We can make the most of assets like masks [and] move them from one county to another, if one area is being hit harder.”

The video wall also can display TV news and Internet sites, and provide videoconferencing with the 21 county health agencies, among others.

Plus, the display can split into many smaller monitors to show multiple images simultaneously, including any of the computer screens that dot twenty or so work centers spread around the room.

Such comprehensive information would better enable officials to make decisions—like whether to shut down schools, cancel public events, and even isolate flu patients in special facilities.

“The theory of this room is that we have everything we need should we be faced with an event,” says Gruber—from a flood to an earthquake to a terrorist attack. “There’s the potential to have a more effective response…to save lives and prevent illness.”

In fact, the center was activated in 2007 during the forest fires in southern Ocean County. It enabled health officials to monitor the blazes, and helped them evacuate two long-term care facilities that were threatened.

A state-developed software system—called Hippocrates—makes much of the information-gathering possible. It even allows officials to access the command center’s data from their home computers—and thereby protect their own health during a pandemic.

“Hippocrates is exemplary,” says Vanderwagen, noting that the software is being considered as a nationwide standard for states. New Jersey has “exceptional capability to monitor a situation and understand what’s happening in the state at any given moment.”

Vanderwagen also lauds the state’s structure of regional medical coordination centers, located within nine hospitals from north to south. “If the state [command] center went down, other sites can take on the load of managing these events.”

“Most of the response to any disaster is more about the human systems than it is about a magic bullet,” he notes. “New Jersey has created a very strong human system.”

Still, the government hasn’t addressed one of the most critical concerns, says DiFerdinando: What if we run out of medical supplies and workers?

“The issues that remain vexing are the issues of allocation of scarce resources,” says the former acting state health commissioner. “If you have 20 patients and ten ventilators [breathing machines], what do you do? We’re not going to see that [answer] until the epidemic comes,” he predicts.

Whether we have enough antiviral drugs (Tamiflu or Relenza) is also uncertain. New Jersey’s stockpile can treat 25 percent of the population—the amount advised by the federal government. The stockpile, developed over a three-year period, cost the state about $1 million. The antivirals are expected to have a shelf life of five years or more.

But if a highly aggressive strain takes hold—like the “Spanish flu” of 1918—the state will run short of both antivirals and respirators (high-tech face masks), says DiFerdinando, who sits on several advisory committees to the state.

The state plan itself predicts shortages of health workers, as they are at higher risk than the general population. In fact, absenteeism could reach “30 percent to 50 percent in all sectors of the work force,” says the current plan, as millions of New Jerseyans would be sickened in a 1918-like outbreak.

Worldwide, that pandemic killed between 30 million and 50 million, researchers estimate. Yet even “mild” pandemics cause great suffering, authorities emphasize. In 1957, for instance, 80,000 Americans died—double the number normally killed by the flu each year.

And while seasonal flu typically strikes from November to March, a flu pandemic could hit at any time, experts say.

That’s because such a bug would develop from a different type of flu virus—one not originally found in humans. Currently, an existing strain that started in birds is the most likely breeding ground. As the virus mutates frequently, scientists think it’s only a matter of time before a form evolves that can spread easily from person to person.

Avian flu has already passed from poultry and other birds to people in Asia, Africa, Europe, and the Pacific, although it is difficult to spread between humans. But the disease is particularly worrisome because it’s so lethal. 

“The death rate of current bird flu is close to 60 percent,” says DiFerdinando.

That doesn’t mean a pandemic strain would be as devastating – experts predict a 2-percent death rate among those who become ill—but no one knows for sure. And unlike seasonal flu, to which people develop some resistance over time, humans have no immunity to the new types of flu viruses that can cause pandemics.

A vaccine would likely be developed once the disease strikes, but that would take six to eight months. “Vaccine may not be available in time for the first wave of illness,” reports the state plan. And an immunization program would be effective only if the virus does not mutate again.

“Once it starts coming, you can’t stop it,” says Slater. “You hope you can slow it down and contain it, to minimize the impact on society.”

Accordingly, the state’s plan stresses the need for public education, both before and during a pandemic. 

“We need to make sure people know what it is, how bad it is… what people could do to protect themselves,” Slater says. The plan calls for the promotion of basic precautions: Wash your hands frequently, avoid crowds, cover coughs and sneezes, and stay home if you are sick.

“Unless everyone does it, it won’t work,” Slater warns. “Getting the right message out is as important as any medication.”

The plan also advises New Jerseyans to prepare for the worst. For instance, store several weeks’ worth of food (especially non-perishables), water, medications, batteries and flashlights. Such supplies may be needed during shortages or utility interruptions, or to remain home to recover or avoid flu exposure.

Self-reliance is vital on a state level, too, according to the U.S. Centers for Disease Control and Prevention (CDC).

“States would be largely on their own in taking care of people, because the entire country will be affected,” says Dr. Richard Besser,  who oversees health-emergency activities at the CDC. (For their part, CDC and other federal agencies would focus on vaccine development, drug-related research, tracking the virus, and advising the states.)

New Jersey is preparing to release a more comprehensive plan in February—one that would address non-medical concerns like maintaining social order and infrastructure. Still, even that document “won’t have every answer to every question,” says Slater. “It’s almost like a Y2K issue—a pandemic will touch every aspect of our lives.”

For more information, visit njflupandemic.gov and pandemicflu.gov 

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