Maryland Flu Plan Needs Update, Officials Say

By Jacqueline Ruttimann
Capital News Service
Friday, Oct. 21, 2005

WASHINGTON - Maryland has had a plan for dealing with a widespread outbreak of disease since 1999, but it's not specific enough and must be updated to deal with the growing threat of avian flu, both its authors and critics say.

"I feel confident that Maryland is preparing," said Maryland Department of Health and Mental Hygiene epidemiologist Dr. David Blythe, one of the co-authors of the plan.

Yet he and other DHMH officials say the response plan will be updated after the Bush administration releases its strategy, expected later this month.

Originally detected in migratory waterfowl in Southeast Asia, the deadly H5N1 avian influenza virus has spread across Russia and most recently into parts of Europe. Researchers suspect it could reach pandemic proportions if it manages to become transmittable from human to human.

Medical officials also say another pandemic is imminent, whether caused by this particular virus or a similar one. The last three major pandemics that occurred -- the Spanish flu in 1918, the Asian flu in 1957 and the Hong Kong flu in 1968 -- were caused by an avian flu virus.

A "medium-level" U.S. pandemic would affect 15 percent to 35 percent of the population, cause 89,000 to 207,000 deaths and 314,000 and 734,000 hospitalizations, according to the Centers for Disease Control and Prevention Web site.

If the virus crosses into the United States, Maryland might be in particular danger because of its large poultry industry.

Maryland's current plan is in its fifth version and was last updated in April 2002.

The plan, developed by about 150 individuals representing 90 state, local, private and volunteer organizations, outlines six phases of the pandemic and how local health departments, three state agencies -- DHMH, Maryland Emergency Management Agency and Maryland Institute for Emergency Medical Services Systems -- and the federal government should act.

The plan sees the pandemic in six phases:

•  identification of the virus in a small number of people;
• identification of multiple cases in the same area;
• high mortality rates in multiple areas;
• virus and deaths in multiple countries;
• a second wave of multiple infections; and
• an end phase, in which the virus is under control.

An additional six "essential components" are discussed in the plan: command and control procedures, surveillance, vaccine delivery, anti-viral medication delivery, emergency medical services and communications.

All government agencies involved are to collaborate. Each agency also has its own role, such as the federal government's responsibility for anti-viral and vaccine stockpile development and distribution. The local health departments would provide normal influenza and pneumococcal vaccines for those at high risk and health care workers; survey available hospital bed space; and create additional treatment centers such as schools and gymnasiums. They also would create temporary morgues, if warranted.

The head state agency is the Department of Health and Mental Hygiene, would be responsible for monitoring and distributing information from the Centers for Disease Control and Prevention and the World Health Organization, as well as surveillance testing of viral strains.

It is also responsible for creating a reporting system on any adverse effects from the administration of antivirals such as Tamiflu.

Media communications and the declaration of a public health emergency will be handled under MEMA.

The third state agency, MIEMSS, would be responsible for the monitoring of available hospital bed space and medical supplies. To track that, it has established a database, which runs in all regional hospitals, county health departments, 911 centers and lead law enforcement agencies, as well as neighboring states, such as Pennsylvania.

"We can inventory in a matter of minutes where in the past it took days to do," said State Emergency Medical Services Director Dr. Richard Alcorta.

Critics say the plan is outdated.

"It's a sketch not a plan," said Dr. Jeffrey Levi, senior policy adviser of Trust for America's Health. "It needs to be updated on what we know now."

Recently, the Association of State and Territorial Health Officials posted guidelines for state preparedness plans. While Maryland's plan covers most points, it fails to address key issues, such as liability laws for volunteer health care workers who will replace those who fall sick, interstate and intrastate transportation circumvention and arrangements for hospital overflow of patients.

Others, such as former Baltimore Health Commissioner Dr. Peter Beilenson, said the current plan is too generalized.

"It's relatively generic to any biological infectious disease plan," said Beilenson. It needs to consider a ring vaccination for those far enough from the start of infection, but close enough to be exposed; cancellation of all public outings, such as schools and theaters; and use of hospitals for supportive care, since past pandemics have spread the fastest within hospitals, he said.

Health officials further recommend the public employ respiratory hygiene measures such as sneezing and coughing into the crook of the elbow and hand washing.

They also suggest stockpiling several days worth of water, food and toilet paper, and keeping flashlights and batteries handy.

"While they seem simplistic and mundane, they really are important," said Blythe.

Health officials caution the Maryland plan is an overarching schematic for many plans that focus on the avian flu.

"There are a series of embedded plans," said Alcorta. "To the question of 'Is this all we have?' I'd say no. We have a system, and it works."

Dr. Michael Sauri, medical director of Rockville-based Occupational Health Consultants, said Maryland is at the forefront of pandemic planning.

"Maryland is by far the most organized of states because of ... fear of being in the ground zero of things," said Sauri, who just returned from helping hurricane survivors in Louisiana and Texas. "The purpose of the plan is one of coordination. I think it's achieving that."

However, he said, "You never know how good a plan is until there is an accident."

Hurricanes Katrina and Rita provided valuable lessons, Sauri said.

"The kind of plan that Houston had and the lack of one that Louisiana had was an eye-opener," he said.