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Responding to a Pandemic

City releases a preliminary plan on how it would respond to a pandemic flu outbreak.

It’s a difficult scenario to imagine: Alexandria is forced to grapple with complex decisions as a pandemic avian flu grips the city. Should those infected be quarantined? What could happen if a potential quarantine were legally challenged? How will city residents get services? When should schools be closed, and who should decide how long is too long to keep students out of their classrooms?

“I don’t know about you, but I don’t hear as much about avian flu as I used to,” said Dr. Charles Konigsberg, the city’s health director. “But this no reason for complacency.”

Konigsberg and a team of experts put their heads together recently to battle complacency on the issue of planning for a potential flu pandemic. Officially styled the “Mayor’s Pandemic Influenza Planning Working Group,” participants included everyone from representatives of the mortuary industry to the chief judge of Alexandria’s circuit court. They spent months studying what would happen if an influenza pandemic flu swept the globe, which happened three times during the 20th century. The result of their efforts is a wide-ranging document that considers everything from continuity of operations to fatality management. But the plan leaves many important questions unanswered.

“What if we don’t have enough respirators for everybody?” Konisgsberg asked while presenting the plan to City Council members earlier this month. “Nobody has come up with a good answer to that yet.”

OVER THE PAST SIX MONTHS, the working group has been meeting to try to answer some of these difficult questions. Participants included key city agencies, neighborhood associations, nonprofit organizations, hospital administrators and the medical examiner’s office. One of the major assumptions in the plan is that many patients will be able to be safely cared for at home, keeping the hospital open for those who require immediate care. To accomplish this, the plan calls for the institution of a series of “community care stations” throughout the city for assessment and triage.

“Individuals who think they have the flu can go to these stations for evaluation to determine whether hospitalization is needed,” the plan states. “These stations would keep the ‘worried well’ out of the hospital emergency department.”

The stations would provide residents with special health-care kits to help them battle the flu at home. According to the plan, the kits would include pain medication, a thermometer, hand sanitizer and masks for the sick. The plan also calls for a quarantine of those who are ill and those who have been exposed to an ill person — even if they are not yet ill themselves.

“Only the Commissioner of Public Health has the authority to issue such an order,” the plan admits. “But these procedures have rarely if ever been fully tested — especially under the new Virginia statues.”

TO TEST THE PLAN, the city participated in a statewide pandemic drill in October. The drill gave Circuit Court Chief Judge Donald Haddock an insight into the finer points that might be raised during a challenge to a city-ordered quarantine. And city officials worked through the motions of the plan, discovering which parts went smoothly and which parts ran into a snag.

“The attorneys were bringing up legal issues that we hadn’t anticipated,” said Konisgsberg. “And as we were going through the testimony, it actually began to feel real. This was the most interesting exercise of my career.”

After a pandemic has been announced, the role of the chief medical examiner would take the lead in dealing with death at any location under involuntary isolation. The city would expect families to make necessary arrangements for other pandemic-related deaths, although some city personnel would be dispatched to help determine a cause of death and assist with transportation of the corpse.

“We have to take an all-hazards approach,” said Konisgsberg. “And we need the whole community to take this seriously.”

THE EMERGENCY OPERATIONS part of the plan calls for the city’s Health Department to distribute vaccines and formulating containment strategies. Yet the city would have to deal with the likelihood of coping with significantly reduced staffing levels due to absenteeism associated with the flu. Much of the strategic planning has been left to the federal Centers for Disease Control and Prevention in Atlanta.

“If the vaccine is in short supply, which is likely during a pandemic, the CDC, in conjunction with advisory committees, will provide guidance for a rank order listing of priority groups for vaccination,” the plan states. “The amount received will depend on nationwide availability and is likely to start out being a percentage of what is ultimately needed — especially because two doses may be required.”

When Konisgsberg presented the plan to City Council, Councilwoman Del Pepper recalled that she almost had to drop out of college because she caught a particularly virulent form of the flu. Then she asked the health director how long a pandemic might last — a key consideration for city leaders who will have to answer questions about closed schools and undelivered services.

“We could expect it to last about 18 months,” Konisgsberg said.

The plan calls for six distinct phases, everything from pre-pandemic planning to alerting the public of an outbreak and coping with high rates of morbidity. It also accounts for a "second wave" of infections, in which the epidemic activity recurs within several months. Ultimately, many of the details concerning the difficulty of maintaining order and closing schools have yet to be made.

"Let's pray we'll never have to deal with this," said Mayor Bill Euille. "But we must be prepared for anything. That's what this exercise is all about."