Preparing for emergencies is nothing new for Patricia Bean, Hillsborough County, Fla., administrator. After all, hurricanes are a way of life in the Southeast, and readiness for the next storm is at the top of every official's list of essential tasks.

But, anticipating an influenza pandemic is different. “We're used to dealing with a situation that we see coming and then passes,” she says about hurricanes. “But this situation is very different. We may have 30 to 40 percent of our staff out of work. How can we cover that?”

Bean is most concerned about a warning from the federal government that local officials are generally on their own if a pandemic strikes. “The federal government is not equipped to handle a pandemic all over the country,” she says. “Local governments will have to step up and be responsible.”

The threat of a flu pandemic lurking just over the horizon has Bean and many other local officials questioning how their communities will respond. In fact, a recent call-in/Web program produced by the Washington-based International City/County Management Association on avian flu outbreak preparation drew more than 1,700 officials, who flooded the contributors with questions.

If the avian flu makes it to the United States, the consequences could be truly catastrophic, starting with an expected death toll of 2 million Americans, according to the Department of Health and Human Services. “Governments have to start preparing now,” says David Heyman, director and senior fellow for the Center for Strategic and International Studies, a Washington-based think tank, who has been working and writing on the avian flu issue. “The worst time to prepare is at a time of crisis. What do you tell the public when you don't have vaccines once the flu hits?”

History's dire lessons

Given the nature of previous pandemics, the forecast is grim. There were three pandemics in the 20th century: in 1918, 1957 and 1968. The 1918 influenza was the worst, killing more than 675,000 Americans and more than 50 million worldwide, according to the Centers for Disease Control and Prevention (CDC) statistics. The disease spread quickly throughout cities, escalating in severity over a six- to eight-week period before diminishing.

Some cities, like Philadelphia, were devastated, while neighboring cities were hardly touched. Some of the differences were luck, but some could be attributed to certain steps that cities took to prevent widespread infection and significantly reduce the severity of the outbreak. The consequences of inaction are so catastrophic that communities that defer planning are doing so at their own peril, Heyman says.

“Education is our best tool to put people in the right place,” says Jacquelyn Polder, a public health specialist for the National Center for Infectious Diseases at the Centers for Disease Control in Atlanta. “Lots of people don't think it's an issue. There are a lot of skeptics. We have to build a measure of trust with community leaders.”

Heyman understands the skepticism, but thinks people are asking the wrong question about a pandemic. “If you ask me, ‘What is the probability that a pandemic will happen tomorrow?’ the probability is zero,” he says. “But it's 100 percent if you ask me whether it will happen within the next 50 or 60 years. Figuring out where we are in that curve is the great challenge.”

A dangerous evolution

The avian flu has several characteristics that make disease prevention officials particularly fearful. The H5N1 strain of the virus that is currently being watched is considered especially virulent, killing more than half of the few people who have been infected. Migratory birds transport it, so though steps can be taken to slow it down, the virus cannot be stopped. And, H5N1 continues to evolve, changing form. Currently, the disease is only passed from wild birds to domestic poultry. But, in a few rare cases, humans have been infected from close contact with poultry.

Because there is little or no immunity to the virus, what would be most dire is for the virus to evolve so it could pass from human to human. The government would need at least six to nine months to identify the strain, create a vaccine and then distribute it. Depending on such a solution falls short, Heyman says.

Heyman and Polder say that, in the interim, cities should plan to implement “non-pharmaceutical intervention” to limit people's exposure to the disease. Because the flu would pass from human to human, keeping people apart would prevent the illness from spreading. Heyman proposes that governments close locations for large public gatherings, isolate and quarantine the infected individuals and take steps for infection control.

There is evidence that St. Louis, which had a relatively light bout with the 1918 influenza, was successful by using such techniques. However, Philadelphia, which had a citywide parade in the midst of the pandemic, was devastated.

Expecting the unexpected

As Bean found out in a recent Hillsborough County exercise, pandemics raise many issues that county officials never anticipate or address in typical emergency plans. For example, pandemics hit an area and peak over time. At a pandemic's peak, hospitals would be over capacity, and a large number of emergency medical service personnel might be home themselves with the flu. “We have to think, ‘How are we going to cover that?’” she says. “It's a huge problem.”

For their exercise, county officials brought in leaders from all of the cities in the county as well as local hospitals, health agencies and nonprofit groups. By state law, the county has primary responsibility for disasters, but “we need all the help we can get,” she says.

By walking through how local officials would deal with potentially 1.2 million people sick with the flu, they now have an idea of what needs to be done. A major piece of the county's program is to ensure that employees understand how to respond and that county administrators know the capabilities of each employee. The county has developed a databank with information on each employee, such as if they have a chauffeur's license, so they could step in and drive different types of vehicles.

In Vestavia Hills, Ala., Mayor Charles McCallum is taking a slightly different approach for his suburban Birmingham community. With only 31,000 residents, he is trying to engage people to accept some of the planning burden. “We are trying to get the community interested,” he says. “We want them to be informed, be responsible and prepare their family.”

McCallum, a physician, wants every family to have two weeks' supply of food and water, which would keep them away from public places as much as possible. The city also has established a Health and Emergency Committee to take the lead in case the pandemic strikes.

The mayor anticipates closing schools and public areas, and restricting access to hospitals. “Once a person with the flu gets to a hospital, it would have to be shut down,” he says. “It's contaminated.”

Those are really the easy parts. Harder still would be taking actions against individuals, so an attorney is included on the Health and Emergency Committee. “We would have to deal with isolation and quarantine,” he says. “People today would ask, ‘Can you do that to me?’ We want an attorney to advise us on what steps we can take.”

The response from the community has been positive, McCallum says. “People have been attending meetings. At least, they have knowledge. That's the important thing. People have to be made aware.”

Robert Barkin is a Bethesda, Md.-based freelance writer.

How are cities and counties preparing?

Baltimore has a bio-monitoring system that tracks the number of sick children out of school each day and patients with viruses that are treated in city ambulances and hospitals. The University of Maryland Medical Center has stocked up on bio-hazard suits for medical staff and opened 10 new isolation rooms for contagious patients.

Guilford County, N.C., developed RapidResponse, in which, following natural disasters, disease outbreaks, or other public health problems, field data is collected on hand-held computers running GIS mapping software. The information can then be uploaded to state public health databases.

Kansas City, Mo., implemented a program to improve preparedness collaboration between local public health agencies, private health insurance plans and employers in a large, multi-jurisdictional community that crosses state boundaries. Health insurance plans are joining with public health agencies to provide surge capacity in areas such as contact tracing, home health monitoring for isolation and quarantine, and staffing phone banks with medical personnel to answer questions from residents.

Milwaukee health workers met with church and business leaders to gain their cooperation in handling a pandemic outbreak. The city also tested its pandemic flu plan on a mumps outbreak that swept through the mid-west in early 2006.

Pittsburgh held a seminar at the University of Pittsburgh Medical Center titled “Risky Business: Planning for Pandemic Flu,” which brought together local government disaster agencies and local business leaders to share plans for recovery after a pandemic flu and to begin forming a long-term health care plan for the city.

San Francisco is coordinating planning through an avian/Pandemic Influenza Task Force. The health department is reaching out to hospitals, clinicians, front-line workers, businesses, and organizations that meet the needs of special populations. San Francisco is part of the Bay Area Regional Emergency Planning Project, which brings together 10 counties and three major cities to coordinate planning and response efforts for a variety of hazards.

Santa Clara County, Calif., has drafted a plan that includes an effort to mobilize a volunteer disaster response team that would help health care professionals. It also would create “temporary influenza care centers,” away from overburdened hospitals and clinics.

Springfield, Ore., has created “Team Springfield,” a collaboration between all local government agencies, to facilitate the Springfield Pandemic Influenza Plan. In addition, “FireMed,” the ambulance membership program, runs a “Get Prepared, Not Scared” public information campaign.

Vancouver, British Columbia, and Seattle share one of the busiest border crossings and are designing pandemic flu operational plans to encompass the region. The efforts have created the “Security and Prosperity” summit and the signing of an expansion of the 1996 Pacific Northwest emergency management compact, agreeing to provide mutual aid in cases of disaster.

SOURCE: The Washington-based National League of Cities Municipal Action Guide “Preparing for Pandemic Influenza,” August 2006. To view NLC's Web site about pandemic preparations, visit www.nlc.org/resources_for_cities/publications/11403.cfm.

Avian flu: The basics

What is a pandemic?

A global disease outbreak.

What is the avian flu?

The H5N1 strain of avian flu is considered especially virulent. It is carried in migratory wild birds but does not harm them. However, domestic birds almost always die after infection.

Have there been any human deaths?

There have been 265 human cases of avian flu, and 159 of those have died. Almost all of the cases involved very close human contact with infected birds. There have been a few cases of human-to-human infection, but there has been no sustained outbreak.

What are scientists worried about?

Public health officials are watching for a genetic reassortment in the virus that would make the bird flu transmissible from human to human.

Why is that such a problem?

Humans have no natural immunity to the H5N1 strain. Typical seasonal influenza is a variation from year to year of basically the same virus. Scientists can identify the most common strain and create a vaccine that usually is effective.

Why won't they do the same with the avian flu?

Scientists will not know the type of flu virus until it strikes, and it would take six to eight months to develop, produce and distribute the vaccine. That would be too late in most cases. And, most likely, the first vaccine would go to health workers.

How many people could be affected?

Based on the 1918 experience, without effective counter measures, more than 90 million Americans could get sick (30 percent of the population). Almost 10 million could be hospitalized, and almost 2 million could die.

What about the economic effects?

The Congressional Budget Office estimates the Gross National Product would drop by 4.25 percent, and absenteeism would rise to 40 percent of the workforce during the peak.

Visit www.pandemicflu.gov for more information.