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Public health's main fear over bioterrorism: surge capacity

Health departments are concerned they may not have the facilities, tools and personnel to carry out smallpox plans.

By Victoria Stagg Elliott, AMNews staff. Feb. 24, 2003. Additional information

Are we ready for a bioterrorist attack? The answer is an unsettling maybe -- or even no.

In recent months, significant resources have been focused on bioterrorism planning, steps that have improved dramatically the nation's ability to confront an attack involving smallpox or some other insidious agent. But holes in the long-neglected public health sector still exist, triggering uncomfortable doubts about the health care system's so-called surge capacity if such a worst-case scenario were to occur.

Take the Kansas City (Mo.) Health Dept. as an example. It developed a plan to respond to smallpox or other possible pathogens that would likely sicken thousands and require mass vaccinations. But Rex Archer, MD, MPH, the health department director, is not sure he could pull it off.

"We don't have the capacity to do either ring vaccination if there are very many cases or mass immunizations," Dr. Archer said. "It doesn't do any good to put plans in place if you actually don't have the capacity to do what the plan says."

In Kansas City, he said, a mass smallpox vaccination effort would take 10 days and require 4,000 volunteers, most of them rapidly trained lay people, scattered at eight locations.

"No way, no how," he said. "I don't have enough nurses to supervise at each of those sites for the 24 hours a day for those 10 days, and I don't have enough epidemiologists to do contact tracing if a case shows up."

His concerns are very real, echoed across the country -- from cities with varying populations and levels of awareness. According to a survey by the National Assn. of Counties and the National Assn. of County and City Health Officials, most local health departments are better prepared for a bioterrorist attack than a year ago, but only 3% would be ready if it happened tomorrow. Another 18% said they were nearly ready. The largest group -- 47% -- said they were about halfway there. Thirty-two percent said they were in the very early stages of planning or were not ready at all.

Although these data were not analyzed for patterns according to communities' sizes, experts suspect that the smallest health departments are less prepared than metropolitan ones, such as New York or the District of Columbia, where the concept of the threat has been more front-and-center for a longer period. But in today's society, the impact of bioterrorism could be felt anywhere.

"Many large public health departments can demonstrate progress in preparation, but there's an awful lot of scenarios in a relatively mobile society," said Patrick Libbey, NACCHO executive director. "How many people from different types of communities pass through an airport or in a large congregated area? These are prime targets for the distribution of an agent."

So far, a great deal of money has been spent on planning. Less, however, has gone into ensuring adequate staff levels, bed space and the means to deliver the shots.

Even the efforts to vaccinate first responders against smallpox, seemingly minor compared with handling a full-blown incident, are adding to the public health burden. "If diversion of general public health resources to smallpox vaccination continues, our communities will become more vulnerable to ongoing public health threats," said Libby, who testified in the U.S. Senate last month.

There is also evidence that the hospitals, already stretched thin, would not be able to cope with a true mass casualty event.

A report published last summer in the Centers for Disease Control and Prevention's Emerging Infectious Diseases examined the impact of a 1997 influenza outbreak in Los Angeles. It found that leading up to the outbreak, the city's population had increased while the number of hospital beds had decreased. As a result, during the outbreak, the number of hours during which hospital emergency departments were diverting patients increased from an average of 3,715 hours a month to more than 11,000. Experts say this situation has not improved since -- a fact that doesn't bode well in the event of a crisis.

"Every day, in the hospital emergency departments around this country, we face a smoldering mass-casualty scenario," said Georges Benjamin, MD, executive director of the American Public Health Assn.

Many of those working on the issue concede that having empty beds and additional supplies is not economically viable for most hospitals. "An unused hospital bed is a very expensive luxury for a community," said Kristine Gebbie, RN, DrPH, director of the health policy center at Columbia University School of Nursing, New York. Still, in some instances, health care facilities have taken unusual steps toward a solution, trying to build links with hotels and other community businesses that would do in a pinch.

The silver lining?

Those involved in preparing for major infectious outbreaks, however, say all the work done in recent months has had some benefit.

Lab capacity has improved and surveillance systems are better. The planning work has resulted in better communication links with other stakeholders. And some public health officials even say that, as a result, they could now deal reasonably well with a flu pandemic. In a smallpox attack, they would figure out a way to get everyone a shot. They believe they would rise to the occasion.

"The challenge would be tremendous. We could mobilize our workforce, and, if we could mobilize our volunteers quickly enough, we could do it," said Gary Cox, director of the Tulsa Health Dept. in Oklahoma. "But we're working with a bare-bones crew to get the job done, and we still have a lot of work to do."

Public health officials also would like more guidance on the capacity required. How much surge capacity does America want, and how much is it willing to pay for? How much disruption to normal activities during an outbreak is acceptable? What is not?

"We have not, as a nation, sat back and defined what level of protection we want to assure that our citizens have from biological agents, whether they be natural outbreaks or intentional use," Dr. Archer said. "We're losing the war against regular infectious diseases. We really need to up our capacity."

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 ADDITIONAL INFORMATION: 

Copyright 2003 American Medical Association. All rights reserved.