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How Oklahoma might respond to the worst disaster it might ever face

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Authorities now say the 2008 flu may have been the worst epidemic to hit humanity. Yes, more than the black death of Europe or smallpox in the New World. The World Health Organization now admits its original prediction — 7.4 million deaths globally, estimated in its 2006 report — was short of the mark.1

But how would anyone believe that as many as 150 million2 worldwide — and still counting — would meet the grim reaper in those few months? In the face of such casualties, efforts by local, state and national government officials in the face of the 2008 pandemic would look like a sandbag dike before a tsunami.

In Oklahoma, the deaths were unimaginable, like losing a city greater than the size of McAlester.3 Even so, these factors still do not take into account the economic impact of months of lost production, the shutdown of stores, industries and facilities across the state, or the rash of business failures that followed, washed like jetsam before the tide of the plague.

The economic losses alone are expected to take a decade from which to recover. The deaths can’t be measured beyond counting them, although communities know too well the loss of their police chief, their town’s banker and the guy from the mailroom who made everybody laugh. And everyone remembers that photo of the refrigerated morgue trucks lined up outside the office of the state medical examiner.

“First of all, every flu season is bad,” said Oklahoma State Department of Health epidemiologist Dr. Brett Cauthen in a 2007 interview. “We have 36,000 Americans die every year from the flu. That translates into 400 (to) 600 Oklahomans who die every year just from the seasonal flu. There are over 200,000 hospitalizations during the flu season, so our hospitals are pushed to the limit every year, just for seasonal flu. … You put a pandemic on top of it, even a moderate pandemic like the 1957 or the 1968 pandemics, and they are pretty bad. You get an especially virulent virus like the 1918 virus and the numbers are much bigger.”4

Such a devastating loss felt ironic to Oklahomans who remembered their state being declared the “most prepared” for any disaster in 2006, according to one national organization.5

The cruel irony of being “most prepared” is that, indeed, Oklahoma was.

Warning shot

We now know the 2008 pandemic began in the summer in Vietnam, from there spreading to mainland China, Singapore and Thailand. It was clear from the earliest tests that the H5N1 avian flu virus, first discovered in 1997, broke out in virulent human-to-human transmission in 2008, leading to the Ho Chi Minh City epidemic.

Officials had been tracking H5N1 more than a decade. Science saw it coming. By 2007, many knew it was probably a matter of time.

“There are big differences between the virus first found in 1997 and the virus we see now,” said one scientist in 2006. “We are watching this virus turn itself into a human pathogen.”6

Thousands sickened in the Ho Chi Minh City outbreak, and the high morbidity — or number of sick — gave the alarm. The city ground to a halt and the economic heartbeat of Vietnam fell to its knees, poleaxed by the virus. More than 6,700 died and more than 220,000 were struck ill for a week to two weeks. There were food riots when those aboard ships in port refused to unload their stocks for fear they would contract the virus.

In the weeks that followed, other Asian countries immediately quarantined ties with Vietnam, but with little avail. China shared a border with the country, as did Laos and Cambodia, two countries which also suffered loss as yet uncounted. Strictest in applying quarantine was Singapore, whose navy that September fired on the crew of a container ship that tried to make port flying a Vietnam flag. Four crew members died. It was later determined that none harbored the virus.

Even as such panic mounted, it all seemed so far away from Oklahoma, but the state’s health authorities immediately instituted measures put in place in 2006.7 With the World Health Organization’s declaration of pandemic alert Phase 4, the Oklahoma State Department of Health activated its Situation Room, staffed it and reviewed plans. The health officials identified early school closures. They requested money from the Legislature. They reviewed their stocks of antivirals and vaccines, and compiled a priority list of individuals deemed necessary for the continuation of government, utilities and emergency services.

While the country had been preparing flu vaccine for the H5N1 for some time, the virus was always a moving target. Conventional flu vaccines had been produced by injecting the live virus into chicken eggs. The immune response of the eggs would produce antibodies that rendered immunity into humans when those antibodies were injected. But in the case of the H5N1, the eggs just died, so virulent was this strain.8 Other methods were problematic and costly. Even vaccines that showed promise were created by such time-consuming methods that enough quantity to protect everyone had not been produced. By the time the virus reached U.S. shores in late fall, it became clear that no vaccine would be forthcoming. The country would face the pandemic alone, with no shield against the onslaught.

Then came more bad news.

For several years, beginning with a $2 billion stockpile started by act of U.S. Congress and the George W. Bush administration, the country had been hoarding new antiviral medications on the possibility that such medicines could combat the flu. Called Oseltamivir, the medicine was held in doubt, as some initial tests of Oseltamivir in Vietnam proved of no avail. Further suspicion about the efficacy of the treatment was aroused when it was revealed that a former member of the outgoing Bush administration held stock in a company that produced the drug.9

Still, officials held out hope that the new drugs would effectively counter the virus. In 2006, Oklahoma had enough of the drugs stockpiled to give 119,000 people a 10-day preventative treatment course, far short of Oklahoma’s 3.5 million population.10 By the time the 2008 pandemic struck, Oklahoma had little more than enough to treat its medical responders with preventative doses.

“Communicate openly that in the event of an influenza pandemic, critical decisions regarding who will receive vaccine or antivirals will be made wisely, ethically, and based upon the best available scientific information,” stated Oklahoma’s 2006 Pandemic Influenza Management Plan. “These decisions will not be based on fairness issues but rather on who must be protected to ensure essential services are maintained for society to function (vaccine to those in critical occupations vs. those most vulnerable). These decisions will likely be unpopular.”11

The plan recommended that priority doses be given first to “medical workers and public health workers who are involved in direct patient contact, other support services essential for direct patient contact, and vaccinators,” and as well to “immediate family members of those involved in direct patient care or supply and distribution of vaccine.”
“Health care workers are required for quality medical care,” the plan stated, noting that “studies show outcome is associated with staff-to-patient ratios. There is little surge capacity among health care sector personnel to meet increased demand. A sick family member may increase workforce absenteeism.”12

Against such perilous events, the drugs were distributed to the frontline health care workers in hospitals and health centers around the state. Many hospitals also beefed up security, expecting possible nefarious attempts by common citizens to seize antiviral stocks.13 While officials faced criticism from some groups, most Oklahomans, used to adherence to authority in disasters, complied.

Then came the news: Not only were the antivirals ineffective; they were dangerous. “Antigenic shift,”14 in which a virus mutates as it is passed from host to host, made the H5N1 stronger after the Vietnam outbreak. By the time it burned through China, it also was resistant to the antivirals.15

Now, the real killing began.

Echoes

China at first attempted to clamp down on reports of human-to-human transmission in the Xinjiang province. Soon, however, word came of desperate attempts to corral a massive outbreak. Reports of mass evacuations, whole villages being quarantined and travel restrictions soon reached the West. The Chinese government attempted strict quarantine measures — “flu camps” patrolled by People’s Liberation Army soldiers where infected peasants were held at gunpoint. These draconian measures slowed the flu’s spread but ultimately did not stop it. Indeed, the flu camps served to incubate the virus until it was fully adapted to human-to-human transmission. By the time the virus appeared in Hong Kong, the new variant of H5N1 was the pandemic everyone had feared.

Travel restrictions to and from China were immediately imposed despite an initial outcry of protest from Beijing. However, too many examples of airline-spread flu already existed, as well as the remedy: no flights to infected areas.16 Airline passengers deplaning in ports of entry all along the North American West Coast were subjected to more than the usual take-off-the-shoes, pass-through-the-detector examinations. They were monitored for fevers. Passengers with colds and sniffles were set aside and quarantined from Seattle, San Francisco, Los Angeles and other airports.

Soon the country reeled under reports of thousands sickened by the outbreak. By the time the disease was identified positively using genetic Reverse Transcriptase Polymerase Chain Reaction testing,17 Denver, Phoenix, Ariz., and Albuquerque, N.M., had reported outbreaks. Then, Miami-Dade, Newark, N.J., and Cleveland reported cases, areas with little to no direct links to the West Coast. Unlike the old days, however, global travel moved the virus everywhere.

In Oklahoma, health officials tensed. Oklahomans were told to ready themselves with two-week stockpiles of food, water and medicines.18

“Citizens need to be prepared to be in their homes for a week or two without going outside,” said Norman Regional Hospital Emergency Preparedness Coordinator Sharon Sanderson in 2007. “The majority of the population is not prepared to do this.”19
Travel was discouraged, especially to affected areas. Hospitals readied plans and brought extra ventilators out of storage as the first reports of Acute Respiratory Distress Syndrome, or ARDS,20 came out of West Coast hospitals. They confirmed Oklahoma’s worst fears.

ARDS is a particular aspect of avian flu that usually is not present in “normal” flu and strikes young people, ages 20 to 40, most severely. With ARDS, a person’s healthy immune system responds so dramatically to the virus entering the pathways into the lungs that it damages the linings of the lungs. A description of an attack of the 1918 flu on soldiers of the U.S. Army is hauntingly familiar to symptoms of the 2008 flu:
“The soldiers rapidly develop the most viscous type of pneumonia that has ever been seen. Two hours after admission they have the mahogany spots of the cheek bones, and a few hours later you can begin to see the cyanosis (turning a deep shade of blue) extending from their ears and spreading all over the face. … It is only a matter of a few hours, then until death comes, and it is simply a struggle for air until they suffocate.”21

Onslaught

The first Oklahoma victims of the 2008 flu were recorded in Tulsa, when the Tulsa Area Syndromic Surveillance System22 signaled an alarm. A 22-year-old Conestoga State University student, home from college for fall break, staggered into the St. John Medical Center emergency room with extreme difficulty breathing. As his symptoms quickly developed, the man was put on a respirator, but he died a short time later.

Efforts to trace the specific contacts the man may have had were of no avail. Unable to speak by the time he’d come to the emergency room, he had previously told of a number of parties he’d attended. Other cases in Tulsa presented themselves, even as health authorities attempted to track the initial victim’s contacts. Their findings chilled them. The man had attended several off-campus parties in Norman. In one sense, Conestoga State University had stopped larger chances for outbreaks by declaring a dry campus years previously. Gone were the massive fraternity parties of days past. However, the partying carried on underground in area homes. Contacts with the infected individual could have happened in a number of places, or even in a ride shared with another victim. And other attendees would keep quiet about their speakeasy parties.

Inadequacy of preparation at Conestoga State soon was apparent. No written campus flu plan existed even as late as 2007,23 although other universities had such plans available online. One official said no written plan existed because the university wanted to remain flexible in the face of the pandemic — after referring questions to a government plan already online.24 It was later revealed that university officials, while claiming to have a committee “working on the problem,” never attended county flu planning meetings.25 University officials in the county did not even have credentialed medical officials able to receive government drug stockpiles specially set aside for pandemic use.26 Despite yearly mass casualty exercises conducted by county hospital officials, the university denied use of its Lawrence Virtue arena, requesting rental for such exercises.27

University students began showing up sick on the eve of the great college rivalry game with Nebraska. Warning calls came in from state officials. However, no official flu cases had yet been recorded in the county. With a lot of money at stake, the game was held. No figures for just how many were infected at the game are calculated, although infections in the county surged following the game. A crowd of 80,000 spectators is believed to have provided a large resource pool for the virus.28

The state officially declared the pandemic period following cases in Tulsa, Oklahoma City, Norman, Stillwater, Lawton and Claremore. The Oklahoma State Department of Health scrambled to ready hospitals with flu preparations that had been in place since 2006. Hospital rooms were quickly converted to non-private status, with two or more to a room as the hospitals filled with patients. While a normal flu season always caused an at-capacity surge, this one soon had hospitals converting hospitality rooms, assembly halls and other areas to medical use. A week (eight days after the big game with Nebraska) into Oklahoma’s outbreak, three area nursing homes, shut down years past for various code violations, were brought out of mothballs for emergency use as alternative care centers.29

Meanwhile, OSDH officials implemented “social distancing” outlined in the 2006 plan.30 These plans called for a voluntary ban of public meetings. A legal aid convention at the Ford Center, with expectation of more than 50,000 attendees from both in and out of state, was canceled over protests from event organizers. Concerts, games and other public events were canceled. Individuals were asked to stay home as much as possible. Businesses and other organizations were told to implement flu plans, such as they had. Personnel able to work from home were encouraged to do so in order to keep as many businesses as possible still functioning. Oklahoma Gas and Electric Co. implemented its flu preparedness plans, and the electricity kept flowing.31 So did water and the sewage system.

Untold businesses suffered a severe impact from the virus. With as much as 40 percent of their workforce home sick, many closed up shop. Restaurants, which depended on a constant flow of customers spending time together in a social setting, suffered a heavy blow. Movie theaters, clubs, department stores and countless mom-and-pop shops shuttered their doors, some permanently. Some stores, such as Wal-Mart,32 had flu plans in place and contingencies to keep food, medicine and services flowing despite the ravages of the epidemic. Some worked in tandem with state, county and city officials to keep towns supplied. But business was difficult.

By the time the 2008 pandemic peaked in Oklahoma, 1.1 million in the state had fallen ill. Even yearly flu illnesses pushed Oklahoma hospitals to the limit, but with more than 100,000 victims requiring hospitalization to survive, the virus crushed medical services under an avalanche of sickness.33

But not completely. Officials put into effect “alternative standards of care.” These plans upped the ante of what kinds of illnesses would require hospitalization. Do-not-resuscitate orders were implemented without hesitation.34 Soon, the unrelenting surge of desperate respiratory cases had all ventilators online, but those were drops of rain on a raging fire.

Alternative care centers set up in gymnasiums, schools, even churches, were filled with sick. All available medical personnel were brought to the front lines. The long-missing house call was again a valid mode of medical treatment.35 Those with any capacity to do so treated family members at home until hospital care became the only option. The state medical community rode the waves of the pandemic like sailors on a storm-tossed ship.
Eventually, the tide turned, but not before the state was beset with thousands of dead. It took weeks, with the help of the mobile refrigerator morgue trucks, to inter the large numbers of victims.

By the end, the 2008 pandemic had killed more than 23,000 Oklahomans and hospitalized nearly 120,000. More than half a million suffered through outpatient care. Almost 1.1 million Oklahomans contracted the virus. Medical costs alone exceeded $2 billion. Nationwide, 90 million fell ill and nearly 2 million died. Medical costs rose to $166 billion.

In the end, officials are still sifting through the wreckage for data. Could it have been worse? Yes. In the pandemic of 1918, 90 years before, there had been no drugs, not even penicillin, to combat the secondary infections that had caused many of the deaths of that era. Similarly, pneumonia vaccinations, routinely administered often as an afterthought, saved possibly hundreds of thousands more. Oklahoma, with its larger hospital capacity than other states, fared better than others.

It was a small consolation.

(EDITOR’S NOTE: The imagined narrative you’ve just read is not real. This futuristic fiction is based on facts referenced throughout the story in endnotes detailed on Page XX.)

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