The State of my State - Pandemic Preparedness in Connecticut - Special Guest Blog by Pixie
Since the country is about to embark on a new course with a new administration, it might be a good time to reflect on where our present leadership has led us with regard to pandemic flu preparation.
One measure of the efficacy of that leadership might be the level of pandemic preparedness that has filtered down to the state and local level. With that in mind, here’s a snapshot of my own state’s level of preparedness. It does look like we have a very long way yet to go.
The “DRAFT” status of the CT Pandemic Response Plan
A cursory look at the State of CT Pandemic Response Plan makes it immediately clear that there’s a problem. Why? The cover sheet notes that it was “Last Revised February, 2006.” The CT pandemic response plan is also still stamped with the word “DRAFT.” So, nearly three years on, Connecticut’s official pandemic plan is frozen just exactly where it was when it was ponied out for HHS Secretary Leavitt’s February, 2006, state pandemic flu summit.
If anyone at the CT State Department of Public Health thought that pandemic planning was any kind of priority, surely someone would have been tasked with the job of updating the State of CT Pandemic Response Plan in the intervening almost three years. Instead, this official CT Pandemic Response Plan languishes in endless "draft" status, indicating clearly that state pandemic planning and preparation languish as well. There’s a vacuum of leadership, and it starts right here, with the most basic official state pandemic planning document inexcusably having been left quite intentionally in “Draft” form for nearly three years.
The document explains that:
This is a working draft document and, as sucha(sic) is subject to revision. The plan will be reviewed periodically to ensure that the plan’s provisions are up to date with current public health knowledge.
That hasn’t happened.
No one political party can be blamed for this failure. CT is a state whose legislature and Congressional leadership is typically dominated by Democrats, but we are also led by a Republican Governor, Jody Rell. Ironically, some of the most well known figures in the panflu world are here in CT such as Matt Cartter, MD, MPH (creator of the pandemic severity index) and Dr. Greg Dworkin, also known as DemFromCT, editor of Fluwiki, so failure to perform cannot be attributed to a lack of local knowledge and understanding.
Yale University has also been active in the pandemic planning sphere on subjects such as the ethics of pandemic allocation and the preparation of universities for a pandemic. Yet there seems to be little political will to even do the most basic work here, which would seem to imply bringing the state’s major pandemic planning document out of mothballs and out of woefully outdated draft status after three years of ignoring it.
Projection of CFR and the level of pandemic strain virulence
The CT Pandemic Response Plan is, in fact, in great need of this updating. Work began on this document in 2001, and it was put in its final form during 2005. At that time, public health officials believed with unshakable certainty that any pandemic influenza would arrive here in the United States with a very low CFR. They believed that in order to become efficiently transmissible to humans, any influenza virus circulating, such as the present H5N1 “bird flu” as they term it, would have to drop in virulence. Since that time, respected scientists such as Dr. Webster from St. Jude have suggested that a virus such as H5N1, now circulating in Indonesia with a CFR of 80%+ and a global cumulative CFR of 60%+, would in fact not have to drop in virulence should it become easily transmissible H2H.
The CT Pandemic Response Plan makes no acknowledgement of this unfortunate scientific fact, however, and instead uses a CFR of .35% for planning purposes - quite a statistical reach away from H5N1’s current 60%-80% CFR, or even from 1918’s H1N1 pandemic CFR of 2.5%. Unfortunately, this .35% CFR number is the one which has been used to make the balance of the calculations regarding any practical impact of a pandemic and therefore the types of interventions which will be required on the part of the State and its public health officials. That they are perhaps ridiculously off the mark considering the virulence levels of the 1918 pandemic and H5N1 currently is not considered within the CT Pandemic Response Plan, nor are the implications for such miscalculations alluded to.
Projecting a possible attack rate of 25%, our CT Pandemic Response Plan assumes that only 2,844 will die out of 850,000 infected. They assume that only half of those infected will be ill enough to seek out medical care and that only 2.2% of those seeking care will be sick enough to need hospitalization (or 9,978 people). The percentages used are exactly the same when they make the assumption that 35% of our public will be infected by a new pandemic strain to which no one will have any immunity. One might reasonably expect that such a mild pandemic, if that's what's truly expected, it is not worth revising the state pandemic flu response plan, and maybe that is in fact what's happened.
Duty to Care
CT’s Pandemic Response Plan does pause to remind our health care workers that they have a “Duty to Care” during a pandemic.
Duty to Provide Care. Health care workers have an ethical duty to provide care and respond to suffering. During a pandemic, demands for care may overwhelm health care workers and their institutions, and create challenges related to resources, practice, liability and workplace safety. Health care workers may have to weigh their duty to provide care against competing obligations (i.e., to their own health, family and friends). When providers cannot provide appropriate care because of constraints caused by the pandemic, they may be faced with moral dilemmas.
No suggestion is made within the CT Pandemic Response Plan as to how, exactly, those “moral dilemmas” and apparently legal obligations will be reconciled. They recommend further discussion of the issue, an issue and a conflict which I doubt most of our health care providers have even been made aware of.
The issue of the State having an obligation to protect these same health care workers who have a “duty to care” is not mentioned in the CT Pandemic Response Plan. Unfortunately, in any public health meeting I have attended, no one has been able to report that the State of CT has made any efforts to acquire sufficient PPE in order to protect its health care workers and first responders. Queries about this are answered with the reply that the National Strategic Stockpile push-packs will arrive in CT within 48 hours of the declared outbreak of any pandemic, and that the contents of those federally supplied push-packs will be more than adequate to meet the needs of everyone for the duration. This seems fanciful in the extreme, and a bold failure of both logic and ethical responsibility. Faced with a virulent pandemic, our health care workers deserve better treatment than to be reminded that they have a “duty to care” even as the State of CT Pandemic Response Plan makes not a single mention of having any reasonable strategy to protect them.
Tamiflu and antiviral purchases (or not)
Connecticut is one of the states cited by the Trust for America’s Health as having failed to fulfill the quota of Tamiflu purchases set by the federal government and partly funded by them with 25% subsidies afforded for such purchases. http://healthyamericans.org/states/states.php?measure=bt2
While it is true that we do not know if a pandemic strain will be sensitive to Tamiflu, and we are seeing increasing evidence of Tamiflu resistance in flu strains worldwide, should Mr. Durrani’s appearance (straight from the hottest H2H2H H5N2 cluster in the world in Pakistan) at nearby JFK Airport have launched a pandemic last year, CT would have had almost no Tamiflu with which to treat a still Tamiflu-sensitive strain. I’m really not at all sure how CT state health official would have, or potentially will, explain such a startling lack of basic preparation should pandemic arrive and our antiviral cupboards are found empty.
Vaccine
Much of the CT Pandemic Response Plan not surprisingly involves the distribution of a pandemic vaccine. With little else in the way of material preparation hopes rest, I guess, on a viable pandemic vaccine appearing on the horizon on the back of a white horse in time to rescue our political and public health leadership from the hole they have dug themselves into as a result of their failure to plan for a pandemic in any other meaningful way.
Yes, our towns have exercised, as they have been mandated and well funded to do by CDC, the mass dispensing of a pandemic vax. Yet this has had the effect of lulling our local public health officials into believing that vax will solve all their pandemic problems. Several of them have told me that they have absolute confidence that the pandemic vaccine will arrive via CDC on their doorstep within 48 hours of a pandemic outbreak. That they’ve been misled seems obvious to anyone with a modicum of knowledge about pandemics and the status of vaccine manufacture, yet arguing with a local public health official on this count does not lessen their beatific faith in CDC and a magical vax. One can only assume, at this point, that they’ve all been told, and firmly, that vax is their answer. That instruction can only have come from CDC. Yet, even the dusty CT Pandemic Response plan notes some of the limitations of this 48-hour scheme; limitations that they’ve presumably been convinced by CDC have now been overcome:
In a pandemic, the current aim is to vaccinate the whole population over a period of four months on a continuous prioritized basis.
My local public health officials have complete confidence that a vax will be on their doorstep within two days of pandemic outbreak and that their diligent practice in mass dispensing has equipped them to vaccinate entire towns within a day. I’m not sure what these public health officials will be thinking or doing in the months of waiting for that vax to be manufactured. I’m not sure how they’ll feel about being so misled by CDC or how they’ll answer the questions they receive from our physicians and public, or whether they’ll even feel like answering the phone.
Only one sentence is devoted to the availability of any pandemic vaccine:
Vaccine shortages will likely exist, especially during the early stages of the pandemic.
The CT Pandemic Response Plan makes no mention any strategies whatsoever for keeping our public safe – fed, warm, disease free – between the outbreak of the pandemic and the time (likely six months or more later) when a vaccine becomes available to the general public.
There is no discussion of NPI measures. There is no acknowledgement of the possibility of our JIT supply system breaking down and the interruptions in delivery of basic necessities that this may imply.
A member here at PFI received a written response to her query to the Stop & Shop supermarket chain management about what would happen to their operations during a pandemic outbreak. They replied that they’d outfit their employees with PPE, they’d reduce hours of operation, and that they expect that inevitably they would close. Surely if a PFI member can receive a clear response to such a question the State of CT Department of Public Health officials can query and learn the same. There is no plan to address any potential interruptions in the food supply, nor any power generation interruptions that may be caused by grid worker absenteeism. While the health of our citizens requires food, water, and power, and it is widely acknowledged that a pandemic can interfere with the delivery of them all, the State of Connecticut has officially chosen to ignore this reality, thereby making a truism of the phrase “failing to plan is planning to fail.”
Ironically, Dr. Bruce Gellin, a Connecticut native, is Director of the National Vaccine Program Office (NVPO) and the Chair of the Secretary’s Task Force on Influenza Preparedness at HHS does not see vaccine as the panacea for pandemic’s ills. I encountered him at the Keystone/ASTHO Syracuse meeting where he was spending his valuable time that day not on vaccines, but on helping to strategize non-pharmaceutical measures that would keep our citizens safe until his organization could produce a vaccine. At this meeting in the fall of ’06, Dr. Gellin’s response to my complaint that CT was doing little to nothing in this area was met by Dr. Gellin speed dialing Matt Cartter, MD, MPH (who is now the CT DPH Epidemiology Program Coordinator) on his Blackberry to ask what in the world was up with that.
Dr. Greg Dworkin, writing as DemFromCT at Fluwiki, and a very active participant in CT at the state, regional, and local level in pandemic preparedness in CT, is very familiar with Dr. Michael Osterholm, (director of CIDRAP, director of the NIH-supported Center of Excellence for Influenza Research and Surveillance within CIDRAP, and an HHS appointee to the National Science Advisory Board on Biosecurity) Osterholm has repeatedly warned that essential services will be interrupted during a pandemic.
Our State of CT Public Health officials are well tied-in, have personal relationships with these experts, and have had the advantage of having this level of expertise shared with them by these top-level contacts (who are intimately familiar with the true dangers of pandemic) and yet they ignore the realities shared with them and fail utterly to incorporate them into their pandemic planning. There is a true failure of honesty and leadership from the top to the bottom in those tasked with Connecticut’s public health pandemic planning and CT residents are being placed at risk because of it. That failure of overall leadership begins in Julie Gerberding’s office at CDC because regardless of the other voices chanting “beware and prepare,” the CDC and Gerberding is the authority who, ultimately, my local and state public health officials listen to. If she will not lead, they will not follow.
Schools and Universities
The CT Pandemic Response Plan makes no mention of school closures to prevent the spread of a pandemic influenza. As a representative to my local Board of Education, I can testify that there has been no emphasis on extending planning for pandemic to the schools and their administrations or boards of education. Since we are a state with 169 very independent-minded towns and no county organizational structure, most assume that school closures for a pandemic will be decided on an ad-hoc basis, or that if the situation gets severe enough (far beyond, then, any hope of mitigation, by definition) that the governor will eventually order the schools closed. There’s been no effort beyond one or two tabletops (which provided no answers, but just raised questions) to educate our educational leadership about what pandemic means. They will be ignorant of the risks, and have little understanding of when to close schools when pandemic strikes or when to reopen them once again as the first wave lessens because no one has thought it prudent to get instruction to them. Our school officials will be caught completely by surprise and in great disarray when pandemic begins. That sort of inherent disorder will sadly ensure that schools are not closed before the necessary threshold for effective mitigation via school closure is reached. The Center for Law & the Public Interest seems to indicate that in Connecticut, it’s only the local education departments (rather than the state) who have the power to close schools during non-emergencies (i.e. before pandemic is circulating, and while mitigation is still possible - page 18). Our local school administrators and boards of education who must make such decisions remain woefully uninformed and uneducated on the critical topic of pandemic flu.
This is true regardless of the fact that school administrators and boards of education face potential legal liability exposure on the grounds of negligence. Further, the confusion generated by an imminent pandemic may result in a flurry of legal challenges. From the same report:
In absence of clear legal authority, their potential reliance on broad authority to operate schools or protect the public’s health, respectively, may not wholly support school closure. Departments of education or health that seek to close schools in the face of such competing concerns or amidst legal confusion or generalities may have to withstand legal challenges.
Yet our school authorities remain wholly uneducated.
Yale University has held a meeting on pandemic planning for universities but unfortunately the wording of the program seems to suggest their emphasis has mostly been on strategies to continue operations during a pandemic.
Balance of the CT Pandemic Response
The balance of the CT Pandemic Response Plan covers two additional topics. They discuss what they term “ethical considerations” and muse about the fact that they will have to think about balancing the public’s liberty with public health concerns but offer no practical solutions for that dilemma (one which will be exacerbated by their failure to purchase sufficient antivirals or communicate about personal preparation to the public).
They also spend considerable time reviewing mechanisms for disease surveillance, which everyone at every public health meeting I have attended has assumed they’ll be able to do. Once their systems inform them that they are at pandemic peak, however, the CT Pandemic Response Plan has no more to say about what to do next about that but plan to vaccinate.
Disappearance of the CT Pandemic Response Plan
Curiously, although the federal government has mandated that the states develop a pandemic plan, and those plans are linked to for the benefit of the state’s citizens at www.pandemicflu.gov, if a Connecticut citizen clicks on the link there that is supposed to lead them to their state pandemic plan, it does not. In fact, clicking on the link for the CT Pandemic Response Plan leads instead to http://www.ct.gov/dph/site/default.asp , the cover page of the State of CT Dept. of Public Health website where the reader is asked, in a rather Orwellian tone considering the disappearance of the CT Pandemic Response Plan: “How May We Help You Today?” No links on the CT DPH website link to that plan.
It is nearly impossible to reach the CT Pandemic Response Plan from the CT Dept. of Public Health website. The Plan (and its embarrassing state) has been very effectively buried.
The Influence of Yale and Sandman/Lanard on CT Pandemic Planning
A symposium held at Yale University in the fall of ’05 has had a great deal of influence on the path that pandemic planning has taken in Connecticut. The symposium: Ethical Aspects of Avian Influenza Pandemic Preparedness took place at Yale on October 21, 2005. A key address was given there by Jody Lanard, (Senior Advisor for Pandemic Communications, World Health Organization, Geneva, Switzerland; Risk Communication Consultant, The Peter Sandman Risk Communication Website, reprinted in the Yale Journal of Biology and Medicine ). Her talk was entitled: Talking to the Public about a Pandemic: Some Applications of the WHO Outbreak Communication Guidelines (which Dr. Lanard helped WHO to produce as a consultant). It’s worth examining what happened at that Yale symposium since it’s often been cited to me as having provided the “ethical” reasoning behind pandemic elements such as making the decision to not talk frankly - or not in fact ever – to our public.
In her remarks, Dr. Lanard maintained a rather elitist view that members of the public were incapable, apparently, of understanding the dualistic risks and reality of pandemic:
It is very hard to help people hold this two-by-two table of ideas in mind at the same time — soon/distant, mild/catastrophic.
Dr. Lanard also has some odd views of how honest or transparent our public officials should be expected to be:
Trust, transparency, and candor are aspirational goals—we do not expect complete let-it-all-hang-out transparency from officials….
Really?
With this in mind, Lanard had two major recommendations for her audience:
I will leave you with two recommendations for involving the public now, in advance of a pandemic.
CHANGE PUBLIC WASHROOM FAUCETS AND DOORKNOBS!
(no, really…)
And
INVOLVE THE PUBLIC REALLY EARLY — BRAINSTORM ABOUT VOLUNTEERS DURING A PANDEMIC
But what does Dr. Lanard mean by that? Is she referring to actually creating local Pandemic Flu Coordinating Committees involving all stakeholders in the pandemic planning process? Is that what this high-profile opportunity to speak on the ethics of pandemic was used for?
Not a chance.
She’s recommending the creation of a (what may be oxymoronic) “Flu Survivors Corps.”
(no, really…)
Picture it: What happens early on in a pandemic? Lots of people get sick. And then what happens? Most of them get better. And then what? Presumably, they are immune — at least for that wave of the pandemic (but no guarantees). And they can do high-risk jobs — like delivering food to home-bound sick people or answering phones at the hospital or covering for a fellow worker if they have crosstrained for the job.And they can volunteer.
The best time to help people understand that they will likely be immune (for at least awhile) after surviving the Great Pandemic of 2___ is now, before it happens….
This suggestion — planning in advance for a Flu Survivors Corps — always gets people’s heads shaking or nodding, sometimes simultaneously. This wonderful suggestion is actually in the WHO Checklist for Influenza Pandemic.
So, as you can see, much Mickey-Mouse shenanigans goes on here in CT under the guise of “pandemic planning and preparedness.” High-profile people like Jody Lanard speaking at high-profile events sponsored by high-profile institutions such as Yale University have led to mis-direction of both our public health officials and thereby our public. Intentional misdirection? At this point, it is hard to argue otherwise. I know of several local public health officials who’ve been through the Sandman/Lanard training and their first impulse is NOT to provide the public with transparent and meaningful information regarding pandemic. In fact, it’s as if it’s been suggested that any means possible be used instead used to minimize the true potential risks which pandemic poses to our citizens, to shield them from the truth, and to do anything possible to deflect attention form the very real need to prepare in very practical ways for interruptions in the supply chain. The severity of a possible pandemic and any attempts to and mitigate its effects in the months before an efficacious vaccine can be produced are steered clear of, and this on the basis (if you can believe it) of “ethics.”
The takeaway of that Yale symposium overall by attendees seemed to be that since not everyone is able to prepare equally, it’s not “fair” to speak of the necessity of preparation to anyone. My own very prominent and influential pediatrician (Yale degree) attended this conference on the ethical considerations in a pandemic and related to me that she would not be prescribing prophylactic Tamiflu to any of her patients because of the ethical considerations involved – it was not fair, she thought, to allow some to have it when others could not afford it. The same tone has been taken by many other physicians and public health professionals here (many of whom attended that Yale meeting or who heard about it later). They state that, time and again, that it’s just not “fair” to tell people to prepare if not all can. I can unfortunately date these sentiments to this very influential Yale symposium on the “ethics” of pandemic. While the thinking in many other states has moved well beyond this, the thinking in on the part of my state and local officials has decidedly not. When New Canaan wanted to purchase Tamiflu as a town, using their own funds, the State of CT Department of Public Health just out and out lied to them, telling them that they could not as a local entity ride on the federal subsidy program. Of course they could. That’s what the program was for. But our official State of Connecticut Public Health Department’s stance was that it was not “ethical” for a very rich town like New Canaan to purchase these critical supplies (that the State itself refused to purchase as advised) because poorer towns and cities would not be able to do the same. That they had to lie outright to New Canaan to achieve this “ethical” goal did not enter into their “ethical” considerations.
Public Involvement in Pandemic Flu Planning
While we’ve heard over and over that both media and the public have tired of the subject of pandemic flu, there are those of us here who have worked on the issue tirelessly day after day, for years now. Some of us live here in Connecticut.
Has our interest in and knowledge of this subject been welcomed by our state and local public health officials?
No.
Have our repeated attempts to remain informed of, and in fact become part of, the pandemic planning and mitigation process been embraced by public health officials happy to learn that the public IS, in fact, an interested party?
No.
Repeatedly, any efforts most of the local in-the-know panflu netziens have made to be incorporated into the pandemic planning process here in this state, or to at least be allowed to be informed of and be allowed to observe such processes as members of the public (as is allowed under FOI law for any non-exempt meeting of public officials here in CT) have been met with obfuscation and avoidance. If we’ve been alerted to meetings at all, it’s been at the penultimate 11th hour (if at all and usually we are not informed as we have so collegially requested to be).
My own experience with this tight and exclusive control of the pandemic planning process in this state is indicated by the fact that I have repeatedly requested to be informed of any and all pandemic related events or communications by my local public health district official and I have been met with great resistance on this count. For two years she has completely and utterly ignored this request. Finally, I had to FOI her officially (and will go to the media if needed in the future) to receive even a modicum of pandemic-related material. The cordial and casual approach I had been using was obviously not working, and the law had to be implemented.
Further, I have expressly requested – in my role as an elected Board of Education member - of this same public health official that she inform me of any pandemic activities related to our schools or the educational sphere. As a result of my FOI request, I now realize that she failed to meet this very reasonable request also. Two items I would have been very interested in learning about as a Board of Education member:
- Legal Preparedness for School Closures in Response to Pandemic Influenza and Other Emergencies (a document circulated to our local public health officials by Matt Carter, MD, MPH, at the CT State Dept. of Public Health
- Notice of a conference held in July, funded by CDC, sponsored by the CT. Dept. of Public Health on “Communicating During Pandemic Influenza,” a training and tabletop exercise on risk communications during a a flu pandemic. Mention of that this event was for people who will be responsible for “the development and dissemination of messages in the event of a pandemic influenza to include those in….school systems.” Since my local public health official is very much aware that I sought Board of Education post in part in order to do just this, her failure to notify me of this event seems volitional.
To get a realistic overview of the level of my local Director of Public Health official’s involvement in pandemic planning and preparedness efforts, it might be educational to examine what I did receive as a result of my FOI request. I requested any and all materials that she had read or sent out between the months of July and October, 2008 that had anything to do with pandemic. What I received in total were copies of:
- the notice of the “Communicating During a Pandemic” meeting (as noted above) months too late for me to attend
- the email from Matt Cartter on “Legal Preparedness for School Closures”
- a press release from Yale on how to write news releases
- an advertising piece from Channing Bete (provider of public health educational materials)
- copies of four emails I had sent to her copying articles on the recent Idaho and Wyoming panflu simulations
- a copy of a UK news story on pandemic flu posing a greater threat than terrorism which was sent to her by a local newspaper reporter
- the monthly CT Dept. of Emergency. Management & Homeland Security newsletter which contained a few short paragraphs describing the H5N1 Alternate Care Full Scale Exercise which took place in June in Manchester noting: “On the whole, the exercise was a huge success.”
- an email from someone at the State Dept. of PH notifying her of the HHS PlanFirst Webcast in September
- an email from someone at the CT Dept. of Emerg. Mgmt. & Homeland Security notifying her in July that “HHS and DHS have released guidance on allocating and targeting pandemic influenza vaccine.”
- an email she sent out notifying the regional Dept. of Emerg. Mgmt. & Homeland Security that the Ct. Dept. of PH would be hosting “a risk communication training and tabletop exercise on pandemic influenza” with a note to: “Please also share this information with local law enforcement, fire, EMS, and school officials in your area.” This is the same workshop that she, as the Director of Health for my own local Health District failed to inform me, a BOE member, about in spite of my repeated requests that she do so.
This insight into a local public health official’s pandemic “inbox,” one who has been tasked by CDC for pandemic planning and preparedness for several CT towns, should give some indication of the seriousness – or lack thereof - with which such efforts are held. That list of documents encompasses the sum total of my local Director of Public Health’s pandemic activities from July through October (and both DemFromCT – Dr. Greg Dworkin – and I share this same Director of Public Health and the same local public health district). There’s not much meat there, and one would have to ask why pandemic planning and preparedness is almost completely off the radar of a District Public Health official.
Additionally, I would not be at all surprised to learn that the “risk communications” workshops and tabletops which have taken place here recently have been generated by the Sandman/Lanard panflu industry. It’s all a bit circular and insulated here, more like inbred and dysfunctional family members reinforcing each other than a prudent, scientific, and logical approach to either state or public pandemic preparedness, a level of serious preparedness and public education that other entities which are more independent (of Gerberding/Sandman-Lanard influence) and able-to-think-for-themselves such as the Idaho and Wyoming public health departments seem to be able to manage. http://www.panfluidaho.org/index.html http://www.health.wyo.gov/phsd/epiid/pandemic.html
The CT. Dept. of Public Health long ago put up this generic flu/pandemic flu website, but it has not been updated in years. It is the most logical place which our citizens would go to for answers on pandemic influenza. It asks and answers these sorts of questions:
How likely is a flu pandemic?
Three pandemics have occurred in the last 90 years, in 1918, 1957 and 1968. Scientists predict that another pandemic will happen, although they cannot say exactly when.
How likely is it that pandemic flu will spread to the U.S.?
The World Health Organization, CDC, and the Connecticut Department of Public Health are watching for the first signs of an emerging pandemic.
Does the State of CT website and the Pandemic Taskforce advise that its citizens prepare for a pandemic in any material way? Does it advise that they do anything?
Only that they should check back in to their website when pandemic begins and then our officials will clue everybody in as to what they should do:
If it looks like a pandemic is going to reach the U.S., the government will issue warnings and work with the media to advise people on the best course of action. If it looks likely that a pandemic will reach Connecticut, health officials will use the media and this website to advise people on what they should do.
Gee, thanks.
Meanwhile….nothing.
Nothing beyond “cover your cough, wash your hands often, and stay home when you are sick.” It also admonishes: “Get Healthy & Stay Healthy” (with no nod to the deadly cytokine storms encountered both in 1918’s Great Influenza and in today’s H5N1 patients who had young, vibrant, immune systems).
On the questions of Tamiflu:
Should I buy my own supply of Tamiflu, or some other antiviral medication?
We are urging people not to do that…
In fact, a letter was issued to all CT physicians by the State DPH lead physician very unequivocally instructing them not to prescribe Tamiflu prophylactic ally to their patients who request it, making Tamiflu very difficult indeed to obtain here.
On the other hand, if you happen to work at one of this state’s many Fortune 100 corporate headquarters (companies like GE are headquartered here) you’ll no doubt have the privilege of being enrolled in the company’s (Osterholm/Sandman-approved) private corporate Tamiflu distribution scheme. Everyone else is still very much out of luck.
Meanwhile, as GE survives, so will the WHO, who has also advised stockpiling of Tamiflu for its own employees:
If a pandemic is declared it is very likely that all stocks of medicine useful against influenza, particularly Oseltamivir, will be in very high demand and rapidly exhausted. Therefore UN offices must be prepared and stockpile some Oseltamivir…
UN offices each should stockpile enough oseltamivir to provide for a 5-day course of treatment for approximately 30% or more of all their staff and their dependants. The stockpile amounts can be increased as resources allow and based upon specific Organizational considerations.
In addition, stockpile enough oseltamivir to provide prophylaxis for 6 weeks for all persons who are needed to maintain all functions identified as “essential” by the specific UN Organization. (p. 16-17)
It’s “One World, One Health” unless you are part of the elite WHO world apparatus. In that case you get inequitable and very privileged exceptions to the usual rules.
To underline once again, because of the very close ties that many involved in the CT pandemic planning community have to the luminaries in the panflu world, including opinion leaders, CDC officials, HHS officials, WHO officials, it is not from lack of knowledge or awareness that CT has chosen to disregard the obvious need for a vigorous pandemic preparation program for our citizens. It is apparent that our own CT leadership has been very much aware of the intense levels of preparation for some time within many entities and the seriousness with which they regard a potential pandemic outbreak. Our own response here in CT is not at all commensurate with that knowledge or level of information.
Particularly, no efforts have been made beyond the Roche-sponsored (Osterholm/Sandman-approved & promoted) corporate Tamiflu program in an effort to extend to ordinary citizens the same protection that our officials and workers at the most rarefied corporate levels will enjoy. Ethical considerations with regard to these glaring inequalities have been completely ignored by our public health and political leadership, who continue to refuse to allow the public to stockpile Tamiflu, even as they themselves refuse to stockpile it FOR the public. But some – the well connected tip of the pyramid – are protected. At the very least, our CT State Department of Public Health should rescind its terse directive that physicians here not prescribe Tamiflu to their patients requesting it, and it should do so on the grounds of equity.
Returning to the CT Flu Watch website, a general Q & A is offered, but the answers are far from thoughtful. One generic example:
How are we preparing for outbreaks of avian influenza or a potential human pandemic?
The Connecticut Department of Agriculture and the United States Department of Agriculture has prevention and preparedness programs in place to deal with any outbreak of avian influenza in poultry including the Asian H5N1 AI. Because scientists cannot predict if Asian H5N1 AI virus will cause a pandemic, federal, state and local government and others are focusing on comprehensive public health efforts – increased monitoring for outbreaks, international cooperation, antiviral and vaccine stockpiles, and building capacity for vaccine production – that will help protect us no matter what pandemic strain emerges or where.
The CT Flu Watch website, in short, is not worth the price of the electronic ink used to manufacture it. Not a word is said about personal preparedness for a pandemic event.
We are apparently just supposed to go about our business until pandemic strikes, and then, but not before then, they’ll think of something or other to tell us to do. Since they’ll be making that up as they go too, it’s hard to conceive of how they will be able to do much more than “risk communicate” and tell everyone not to “panic” while they wait for the vax. And wait…
Under the general preparedness section of the CT DPH website, they recommend storing “at least three days” worth of water and food to our citizens in case of emergency: There is no mention of the possibility of our citizens ever encountering a lengthy public health emergency, or one which would endanger the functioning of our supply chains.
The Idaho Department of Public Health’s website links to the panflu.gov recommendations: A Guide for Individuals and Families where “two weeks” of food storage are recommended. Connecticut’s Department of Public Health and its Pandemic Taskforce don’t even make the basic, minimal, effort to mirror that federal recommendation. Wyoming’s website advises its citizens to “store an ample supply of food” in advance of a pandemic.
While I have been told (usually in a whisper, for some reason) that CT public health officials are loathe to tell our citizens to prepare in a practical way because of their fear of “panic,” I’ve yet to hear of one story of a citizen from Idaho or Wyoming that has run down the street in “panic” as a result of the attention their public health officials have brought, rather vigorously, to the topic of pandemic or as a result of their attempts to get their citizens to prepare.
On the other hand, every individual I have spoken with here in the state has, after being educated briefly on the risks, understood the logical need for stockpiling basic necessities in advance of a pandemic. They understand the JIT inventory system. They invariably ask why our public health officials are not saying anything about this. Some of them then prepare on their own, some of them decide that they’ll wait till the outbreak is imminent (somehow, usually assuming they’ll get advice from me or our panflu boards in time) and (perhaps very mistakenly make the assumption) they will prepare then. No guidance is readily available to them, however, from our public health officials on just how to do this.
Exercises and Simulations
Connecticut officials like to do these exercises. They are funded. (One public health department – Wilton - even ran a vax exercise on a holiday, whereby they were no doubt entitled to extra pay for their time). They seem to be fond of them too because they reinforce that officials are doing things well – these exercises are always and invariably declared “a success.”
One hospital surge exercise I attended which took place in Bethel, CT, in May I have already commented on at length here:
I have also attended the follow-up meetings for this event, which of course was declared a “success” by all involved. I would have to take issue with that on any number of levels. The emphasis was on our officials “being ready” for a pandemic. If anything, this exercise richly demonstrated that they were very far indeed from that goal. While the medical surge facility was helpful, and would indeed be helpful during a low-level epidemic or localized outbreak, it was abundantly clear that it will be of little or at least of limited, use during a pandemic outbreak. If I had any hope that we could ever mount an effective medical response to a pandemic, those thoughts were put to bed for good on the day that I witnessed that panflu hospital surge drill. We will not be able to cope with thousands sick at one time. We are not ready for a virulent pandemic strain and cannot meet that challenge with effective medical response. We will be inundated, and we have insufficient medical tools with which to counter that reality. We need to re-think our priorities for action going forward, and move away from the medical model and medical/vax simulations and exercises and begin to emphasize the community protection and the prevention of illness in our population. And no, I don’t mean “just in time” community preparation and education because every expert has stated that if we start then, it will be too late.
Again, this hospital surge exercise demonstrated that our public health officials believe that the SNS is the source of all goodness. It was assumed that SNS stockpiles will be the source of this field hospital’s supplies, just as it is assumed that those stockpiles will be sufficient to supply our standing hospitals, our private physicians’ and clinc offices, our long-term and elder care facilities, etc., etc. They will not be sufficient to run either this field hospital nor any other care facility 24/7 for months at a time. There is no acknowledgement of that, as these exercises are declared a “success,” just as there is no acknowledgement at vaccine distribution exercises that there will be no vaccine for months (they are also invariably declared a “success”).
I mentioned in my review of that hospital surge drill that PPE protocols on the part of public health officials and other participants were lax. If they are exercising for a real event (one they really believe will happen, one they thus take seriously), the proper use of PPE should properly be a major priority. Otherwise, these medical care centers staffed with many unfamiliar with infectious disease protocols may become the loci of mass infection, rather than a source of cure. The more recent mass vax dispensing exercise I attended in Danbury was supposed to use that opportunity to train its vax administrators in the use of and underline the need for proper PPE, but no one we had contact with while my daughter received her immunization wore a mask. I realize that the wearing PPE in a realistic manner during a drill may not be the preference of those participating, but it’s a critical element in authentic PPE drill and preparation and one that does not seem to be emphasized here in CT.
Vaccine exercises I have already mentioned and they may have done far more harm than good here in their “success.” Most public health officials believe their primary role will be that of a case counter and vax distributor. While they do plan to count cases, few of them believe that they’ll potentially be enduring a first wave of an influenza pandemic and counting cases for months without the relief of any vax at all. No local public health official I have discussed this with has any reasonable answer to this dilemma, nor any suggestion as to how the public might be effectively protected from the serious medical and collateral dangers engendered by a pandemic in the meantime. The lack of creative thinking on this count I really do find to be startling. I can only assume that someone, somewhere, has told them that they have no need to worry about such things.
Much of what the local emergency and public health officials focus on has to do with communications. There is no question that our officials’ efforts to ensure they can communicate effectively have been impressive. They have double checked their equipment for agency interoperability and have even sought to create an operational glossary to overcome acronym confusion across disciplines. There are now extensive communications protocols – email and telephone ladders, explanations of chains of command and responsibility. There are many procedures now in place to allow local officials in emergency management or public health to request aid from one another. However, at one meeting I did ask whether any procedures had been put in place to describe how one entity was supposed to give aid in a situation where all resources will be stretched, and if they aren’t on the first day of the pandemic, everyone will be very aware that they will be the next. I was told they had not really addressed that subject yet. While these people are ready in the terms that are meaningful to them under traditional rubrics, I really don’t feel that the reality of a pandemic situation has been fully explained to them. If it had been, they would themselves be asking the question “what will we be saying, what will we be able to ask for?” when pandemic brings shortages of staff, shortages of critical medical goods, power outages, supply chain interruptions for water and foodstuffs. They’ll be able to talk to each other, but I ‘m not at all sure what they’ll be able to productively say.
They, like everyone else I have encountered in officialdom, are convinced that the SNS will provide all they need. I doubt they have this firm impression because Gerberding’s CDC and her mouthpieces have told them so. Of course they believe them. . They can’t seem to imagine that their requests for aid may be met with “we can’t – we don’t’ have any of that left.” There seems to be no “Plan B” for what to do when the “stuff” and the “staff” run out, nor it seems has anyone made any serious calculations as to just when during the pandemic wave that might be. And nobody seems to be planning for Wave 2.
Communications are great, I thoroughly endorse them. But if I call my local pizza place on a Monday it means little that my phone works. They aren’t open on Monday – no “staff” and “stuff” are available to make my pizza. They’re closed on Mondays, and I’m just out of luck. When we are talking about something more serious than pizza, there should be back-up plans. There aren’t any.
The reach and scale of what our pubic health and emergency officials can do is limited, by definition, by a pandemic. Failing to ready the public itself to cope with a pandemic in a practical way and by retaining all power on this matter unto itself, our State has failed its citizens. It’s failed them long before pandemic has even begun.
The Only Bright Spot
During a recent pandemic flu vax drill, the volunteers handed out a new pandemic flu brochure with the usual assortment of other paperwork. I’m not sure how many participants actually read the brochure, but I did, and I was pleasantly surprised. The brochure, available here is actually pretty good. Surprisingly good, considering.
It does make one claim that is complete balderdash:
The State of Connecticut has created a website, CT Flu Watch, at www.ct.gov/ctfluwatch/ to provide you with up-to-date information about avian and pandemic influenza. It includes what is going on around the world..
No it does not.
It does tell the truth here, however, and it’s a major truth that needs to be told:
Vaccines for pandemic flu will be in short supply during the pandemic and may still be limited even after the pandemic.
Less frank is this:
Antiviral medications may make the flu less serious, but there are not a lot available and no one can be sure how well they will work.
True, but the CT Department of Public Health does not pause to explain that the reason WHY they expect “there are not a lot available” for our citizens is because the CT Department of Public Health has chosen to not buy any. Roche has plenty to sell, it’s just that CT isn’t buying.
The really positive aspect of this pamphlet for the public is that they do, finally, make the huge recommendation that people put together a “Pandmeic Kit” and that it include “at least two weeks” worth of foodstuffs:
Your pandemic flu preparedness kit should have enough food and personal items to last you at least two weeks.
In a world of pandemic preparedness starvation, we’ll take those crumbs. While a recommendation for “two weeks” is not nearly enough for an event that could last for weeks, maybe months, I don’t expect that any state officials will be addressing the reality of JIT supply chain breakdown and the very real distress that such a potentiality can cause to our citizens. They feel they’ve got it covered now with the “at least” two weeks recommendation. I don’t expect they’ll be motivated to move that recommendation forward further.
Overall, the brochure is an improvement over the prevailing situation and the materials that have heretofore been available to our public, but still, few will see this brochure and only the most interested will both find it and read it. There is still no active outreach, no efforts planned on the part of most public health officials I know to directly communicate with their public in a meaningful and direct manner and get them prepared, on a personal and family level, in a practical way. Gerberding and CDC haven’t asked them to do that, so they won’t be doing that. It’s as simple as that, really.
Is Connecticut Ready?
In short, no.
Considering the elitist and insulated world that is Connecticut pandemic planning, I don’t think that will be changing anytime soon. The public has been shut out. In spite of having some of the best data from the world’s best experts available to them on the potential impact of a pandemic, our state continues to plan and operate as if the mildest pandemic (that .35%cfr level, Category 2) is the worst we will have to face. No plans address - realistically - any level of virulence beyond this. This knowledge - that a potentially virulent pandemic flu is possible and that our state is woefully unprepared for it - is kept from our public (whom they are supposed to be serving). Who does this massive effort at obfuscation and control help then? Possibly only the careerists, who as usual don’t want any complications interfering with their rise in the bureaucracy or with the power they wield there in their limited personal fiefdoms. I can think of no other reason for the lack of progress on pandemic flu preparation and education of our public on this critical subject here in this state. It’s not funding that is an issue. The meetings are held – the staff is there, salaried, in place. It’s just that the wrong questions are asked, and the needed answers are never attained.
Exercises are run, but they are exercises that point out our weaknesses even as those who run them declare them to be successes – weaknesses in medical surge and mass vax dispensing that cannot be addressed by anything other than a full-on effort to prepare our communities in a practical way in order to prevent infection in the first place. The mass mass distribution exercises presume vax that won’t be available to the general public until months into a pandemic. The surge drills only serve to point out, if we look at them realistically, that we cannot hope to cope with the medical demands of a virulent pandemic in anything approaching a humane manner.
The State of Connecticut is ready for exactly the kind of pandemic that the State of CT Department of Public Health has planned for in their CT Pandemic Response Plan. They’re ready – ready only for a mild pandemic, in which fewer than 3,000 of our citizens die, in which the CFR is .3%, in which hospitals will not be overwhelmed, in which the four-unit state medical field hospital can be of some reasonable use, in which the SNS stockpiles are sufficient, in which mutual aid protocols can be fulfilled, in which everyone’s water taps stay on, and beef from Iowa and lettuce from California keeps arriving at our supermarkets, gasoline keeps being delivered, and the lights keep burning at our hospitals, care facilities, and homes. Maybe or maybe not schools will need to be closed in such a mild pandemic, but likely not, since a mild pandemic is all that’s anticipated (and so that’s all the schools are planning for). “Wash your hands, stay home if you’re sick, and cover your cough” are all that they advise and all that the public really needs to know, along with the prescient advice to have three days of food and water handy in the pantry (which most here reasonably do).
It’ll be barely a blip on our screen, this pandemic, from the way they describe things, from what we can read from their efforts to get our public prepared. That’s a good thing, I guess, because the State of Connecticut is ready, but only for the mildest of public health events, for a pandemic flu with a virulence of not much more than .3% CFR. How they’re going to ensure that it happens according to their script I would really like to know.
That H5N1 is the reason for our preparedness efforts as a nation, that it’s virulence is 60% cumulatively, that it’s CFR has risen rather than lowering, in contradiction to the hopes of those in the public health community (but not particularly surprising the virologists) and is now running at 80%+ in recent months (even as Tamiflu resistance sharply grows in flu strains globally, threatening lack of sensitivity on the part of H5N1 to our best weapon against it should it become pandemic) – all that is ignored by our state’s official planning and preparedness efforts, the level of which bear no relation to such a threat. We can meet a .3% CFR pandemic strain with confidence. I am sure of that.
I am equally sure that a pandemic strain with a virulence of. anything over 2% - a level we will be fortunate indeed not to exceed – will bury us here in CT.
This need not be the case. A virulence of greater than 2% CFR is officially described according to the Pandemic Severity Index as a “Category 5” pandemic.
But we are not planning for this eventuality. Why? Perhaps because Matt Cartter, a key pandemic planner at the CT Department of Public Health, was the key creator of the Pandemic Severity Index in the first place – he set the pandemic virulence levels and our mitigation efforts are now tied to those levels, as fanciful and as misleading as they might be.
Matt Cartter’s “Pandemic Severity Index” maxes pit at Category 5 – a 2%+ CFR pandemic. It cannot imagine a virulence of 3.5% or 6% or 11% or 22% or anything between those 2% and the reality of today’s H5N1 80% virulence. If we cannot conceive of it, or rather if we cannot allow ourselves to conceive of it, we cannot plan for it. So CT blithely plans for a .35% CFR pandemic – a Category 2 pandemic storm, according to Cartter’s scale. With Category 5 literally “off the chart,” no one plans for it. Why should they? They are bureaucrats and it’s not on the chart.
What about the problem that leading scientists such as Webster have clearly stated that H5N1 need not attenuate its virulence before becoming pandemic? What about the studies on this subject that have been published in respected scientific journals? Well, the problem may be that now that Connecticut’s own Matt Cartter has received much acclaim for the creation of this Pandemic Severity Index, it seems to be chisled in stone. It was featured on the front page of October’s CDC Pandemic Update. The Index is defended vociferously as being reasonable in the face of science and the evidence of the virulence of presently circulating H5N1 influenza strains. That CT cannot now back down from the impressions left by this Pandemic Severity Index seems to have something to do with the fact that the Index’s creator is a decision maker of major importance at our State Department of Public Health. But this lauded Pandemic Severity Index is inordinately misleading for pandemic planners. Sticking with its presumptions is perhaps just wrongheaded – the graphic appearance it gives of a reasonable expectation of a pandemic contained well below the 2% CFR threshold is not useful for getting our public health officials to seriously engage in creative thinking with which to meet a virulent pandemic. No change in thinking is going to be forthcoming about this in Connecticut – it’s just not going to be generated by our State of CT Department of Public Health under Matt Cartter, the Index’s creator. Unfortunately, the H5N1 virus has little regard for insular political and personal concerns, and only evidences increasing abilities of its own to confound all our expectations. The Index has has been designed to ghettoize mitigation strategies in pandemic response for Category 1 through 4 and it’s been effective in doing so. Here in CT, they’ve planned for a Level 2 pandemic event. Period.
Sure the Bethel MFH surge exercise used a 7% CFR (on paper), but that was immaterial. They exercised the first hours of the first days of a pandemic – not day 10. Nobody died. There wasn’t time. The numbers didn’t add up. Instead, in spite of the perfunctory (on paper) nod to greater virulence the public, the volunteers, and the public health officials and emergency responders involved got to see more magical thinking at work. A 7% CFR and nobody died out of 100+ victims. Remarkable. (And there were no staff illnesses or infections during this drill either!) I have asked, but there do not seem to be any plans afoot to exercise a pandemic surge at day 10 or day 21 or day 32 or day 43. Why? I imagine such exercises might not come off as so “successful.” They do love to say that to the newspapers.
The tragic lack of preparedness, the outcome we will suffer as a result of planning for only the most fairy tale-like pandemic, is assured only because of the intentionally misguided and misleading efforts to date to fail to “prepare” our public in any meaningful way. It would seem, that many of our public health officials themselves have been hoodwinked by false reassurances and repeated proclamations that “there will be a vax for that” and “the SNS stockpile is sufficient.” It will all end in tragedy, and tragically it’s a tragedy that could have been avoided with prudent and logical public health and education efforts that match the level of threat we may face. Instead, our state officials are preparing for something that has been “canned” for them in a palatable manner by CDC and WHO in order to ensure easy digestibility for highly political (and quite profitable for some of those involved) purposes that are beyond the means of most of our local public health officials, politicians, and citizens to even imagine.
One town “gets it,” though. Greenwich. This town, I believe will function more like a small nation-state during a pandemic outbreak. (I would not be at all surprised should they make the decision to close their town borders to all but those bringing necessary supplies, and quarantining everyone else away from the community before allowing entry, during a virulent pandemic).
Their town pandemic plan, I have heard, is more than 6 inches thick. They have not waited for the state to lead, but instead have engaged in several workshops to educate their own public health and emergency professionals – private efforts, not open to others in the state. They’ve most interestingly created an extensive plan for quarantine and isolation, something they’ve also held workshops on to train their locals, and again workshops that have been closed to the broader community. I don’t blame them. The public health community in Connecticut and our state officials have failed us. Greenwich’s extensive independent actions seem to be a reasonable counter effort to this. Maybe it’s time that all of us moved to the southwest corner. We’d better do it before the pandemic arrives, though.
Wednesday, November 5, 2008
