The federal government unveiled a massive pandemic influenza plan yesterday that would fight an outbreak with tools including surveillance of air travelers, rationing antiviral drugs, imposing community-wide "snow days" to keep people at home and aggressively controlling rumors to prevent panic.
Mixing detail and generalities, the 396-page document lays out a wide array of suggestions of how state and local health departments can marshal scarce resources and manpower. It declines, in most cases, to tell them exactly what to do.
Overall, the plan counts heavily on the public's cooperation and good sense. It mentions only briefly the option of forcibly detaining infected people during a flu pandemic, arguing that voluntary quarantines, often at home, are preferable -- and usually adequate. It outlines no role for the military, a possibility President Bush raised several weeks ago.
The document lays out the public-health piece of the flu preparations the president called for Tuesday in a speech at the National Institutes of Health. Other aspects of the national response -- the effect on transportation, for example -- are still in the works.
"It is clear that pandemic influenza has the potential to pose disease control challenges unmatched by any other natural or intentional disease event," the authors of the plan wrote.
In prose, charts and tables, the plan suggests what doctors should do if they think a patient has a novel form of influenza; how hospitals can limit the spread of infection in their emergency rooms; and what caregivers at home can do to protect themselves. It addresses how to sustain the morale of health care workers in a crisis that might last a year; who should get pandemic flu vaccine in the months before there is enough for everyone; and suggests that individuals stockpile supplies.
The plan took more than a decade to develop and was still being revised two weeks ago.
Some have criticized the Bush administration for not delivering it sooner, especially as the Asian strain of bird flu, H5N1, has claimed about 60 lives over the past two years and recently spread into Europe. Yesterday, however, there were few specific criticisms of the document itself. Most experts and interest groups were trying to absorb its contents.
"It certainly is much better than the earlier draft we'd seen," said Georges Benjamin, executive director of the American Public Health Association. "There is much more detail." But he and others noted there are many details to be worked out.
"The big battle is going to be over money," he said, adding that local health departments are already saddled with responsibilities they can barely afford.
The plan calls for substantial planning and investment by nearly every sector of the health care system: nursing homes, hospital intensive care units, the Centers for Disease Control and Prevention, the vaccine industry. In his speech this week, Bush said he would ask Congress for $7.1 billion in new funding for pandemic planning.
Health and Human Services Secretary Mike Leavitt defended that investment in a telephone briefing yesterday with reporters.
"Some will say this is an overreaction. Some may say, 'Did we cry wolf?' The reality is that if the H5N1 virus doesn't trigger pandemic flu, there will be another virus that will," he said.
There have been three influenza pandemics in the past 100 years. One in 1918-19 killed as many as 50 million people worldwide, including about 500,000 Americans. The new document describes two possible scenarios.
One is a "moderate" pandemic comparable to those in 1957 and 1968. It would cause illness in one-third of the population, hospitalize 865,000 and kill 209,000.
The other is a "severe" pandemic comparable to that in 1918. It, too, would sicken about one-third of the population. But about 9.9 million people would need to be hospitalized, and 1.9 million would die unless optimal preventive or treatment measures are in place.
In either case, a flu pandemic would typically afflict a community for six to eight weeks, and in many places would strike twice. The plan says officials must prepare for the worst case -- and with it shortages of such things as hospital beds, mechanical ventilators and possibly even antibiotics.
The global health costs of a moderate pandemic -- not including disruptions to trade and economic production -- would be about $181 billion. No estimates were made of the costs of a severe pandemic.
The plan suggests who should have priority for limited supplies of a pandemic vaccine, based on the recommendations of two independent expert panels. The government is stockpiling experimental H5N1 vaccine to immunize 20 million people.
At the top of the list are workers in vaccine and antiviral-drug plants (40,000 people), followed by medical practitioners and public health workers (8 million to 9 million), people older than 65 with chronic illnesses other than high blood pressure (18 million), and people between 6 months and 65 years at high risk of complications (7 million).
State plans could adjust this list. For example, some public health experts in farm states believe poultry and swine workers should be given experimental pandemic flu vaccines because they are potential links in the transfer of flu viruses from those animals to man.
"What is critical in Minnesota may not be what is critical in Manhattan," said Bruce G. Gellin, the head of the National Vaccine Program Office, who oversaw writing of the document.
Children are not a high priority, because they are generally healthy and unlikely to die from flu. Although residents of nursing homes are at high risk of death, they also would not have priority because vaccination often does not work well in them. However, they should get preventive treatment with antiviral drugs if pandemic flu breaks out, according to the plan.
The document says that ideally the country should have on hand 75 million "treatment courses" of antiviral medicine. The federal government would pay entirely for 44 million courses, enough to cover patients hospitalized with flu, health care workers, some high-risk patients, public health workers and first-responders. It would pay for 25 percent of the cost of the remaining 31 million courses; state and local governments would pay 75 percent.
The plan suggests that hospitals consider stockpiling an eight-week supply of masks, gowns, gloves, "morgue packs" and other items.
It also suggests that citizens consider having enough food to stay at home for 10 days. That is because local authorities might invoke a "snow days" option to keep people apart for the full incubation period of flu should an epidemic begin.