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TMCNet:  When virus arrived, Tarrant County health officials were ready

[May 09, 2009]

When virus arrived, Tarrant County health officials were ready

May 09, 2009 (Fort Worth Star-Telegram - McClatchy-Tribune Information Services via COMTEX) -- Public health officials have been saying for years that it was not a question of if, but when, a new, virulent virus would strike the United States.


Two weeks ago, when the first signs of a pandemic surfaced, Tarrant County Medical Director Lou Brewer had one of those "aha" moments.

"We did say, 'This is it,'" Brewer said, adding that the health department knew what to do next. "This is what we trained for." Overall, public health officials have been praised for their quick response to the swine flu outbreak.

But there were shortcomings -- such as a lack of lab equipment in Austin -- and with so many people weighing in, communication sometimes got scrambled. Canceling Mayfest while keeping the Fort Worth Zoo and Rangers Ballpark at Arlington open sent contradictory messages.

None of the decisions surrounding the flu were made off the cuff, said Rep. Mark Shelton, R-Fort Worth. At the federal, state and local level, decisions were based on the information available to officials about an unknown virus.

"It is really difficult for public health, because they have to make decisions before they really know what has happened," said Shelton, who is a physician and infectious-disease specialist.

Those unknowns make for tough calls.

"When faced with large amounts of uncertainty, yes, officials overreacted, but they appropriately overreacted," said Dr. Edward J. Sherwood, chairman of the Texas Medical Association's infectious-diseases committee. "It is a lot better than underreacting and then having an event get out of hand because you didn't respond." Lab results When the flu cultures started pouring in toward the end of April, Tarrant County was ready.

Its North Texas Regional Laboratory was equipped to handle 30 tests over six to eight hours. Staff members worked round the clock, completing three batches of tests over 24 hours. By May 3, they were caught up.

Although it was taking the Centers for Disease Control and Prevention up to five days to confirm test results, local health officials recognized early on that most probables would come back confirmed. That knowledge played a part in their recommendations.

It was a different story at the state level, where the only machine for testing could not handle the volume of samples. Early in the outbreak only 181 of the 2,492 samples received had been tested, said Department of State Health Services spokesman Doug McBride.

The state responded by adding four machines, including a model that could handle more samples in less time. To improve efficiency, more people were trained. Since April 24, the lab has received 6,677 samples for testing; 864 have been completed.

"We haven't caught up, but we are taking some steps," McBride said.

Observers said the state addressed the backlog as much as possible.

"They did learn a situation like this can overwhelm their diagnostic capabilities," Sherwood said. "The lesson learned is they didn't have equipment in place but they moved quickly to get it, which will be a benefit in future events." Confusing messages Some school districts shut down; others closed only the campus where a probable case had occurred.

Different decisions in similar circumstances made for confusing messages. School districts received advice from their local health authorities, but the decision to close schools or cancel events rested with school district and city leaders. Experts said that system is best in a pandemic because emergencies should be handled by experts on the ground.

Jason Lamers, city spokesman, said Fort Worth worked with Tarrant County Public Health to figure out what facilities needed to be closed and what events canceled.

But canceling Mayfest and other events appeared perplexing.

Moving the Bike MS ride's finish line two days before the event was tough, said Kristen Stubbs with the North Texas Region Lone Star Chapter National MS Society.

"We had to scramble and reroute our second day ride, find a new finish line and alert our participants and vendors," she said. "It was a huge problem for us." From health officials' perspective, logistics complicated tracking cases and recommending school closures.

The Northwest school district, which is in Denton, Wise and Tarrant counties, got public health advice from different localities, spokeswoman Lesley Weaver said.

"We have students who live in different counties and go to doctors in different counties," she said.

When a probable case arose, the district conferred with Tarrant and Denton county health officials, Wise County doctors and state health officials in Arlington.Before closing schools, local health officials and superintendents talked extensively about what was best for the community.

When Dr. Sandra Parker of Tarrant County Public Health recommended closing the Fort Worth school district, it drew criticism. But it was the right thing to do, Tarrant County Commissioner Gary Fickes said.

"I'd rather her being up here last week telling us we should close the schools than being up here this week telling us that we have 600 cases because we didn't close the schools," he said.

Communication State and federal health officials, school superintendents, the Texas Education Agency, municipal leaders, infectious-disease nurses and others were communicating behind the scenes.

But the situation changed quickly, and people became impatient waiting for some facts to be released.

"We totally understand that people want to know," Brewer said. "But the information comes to us raw, and we need time to make sure it is as accurate as possible." In the health department's zest to make sure everything was accurate, some people inevitably fell through the cracks.

Amy Capps of Crowley was desperate to find out whether her 6-year-old son, Ethan, had swine flu. But she didn't learn test results for four days, when the call came from the school nurse.

Capps said that she understands that the health department has been overwhelmed but that the testing could be done faster and the communication could be better.

Another snag: While flu statistics were kept up to date in Tarrant County, there was a lag between the state and the CDC's reporting. As a result, data on local, state and federal Web sites didn't match.

Meanwhile, the county health department scrambled to inform the public. A phone bank was created. Health officials briefed city, county and school leaders. Updates went on the health department's Web site. And on May 1, at the end of the outbreak's first week, regular news conferences with Tarrant County Public Health officials began.

"We are a very data-driven society, and we're information-hungry," Brewer said.

Public information officers in Fort Worth's community relations department were busy composing public service messages. The information was distributed under the Tarrant County Public Health logo so the public wouldn't be confused by different messengers.

A dozen community outreach workers distributed the information at malls, day-care centers, bus stops and businesses. City consumer health inspectors educated restaurants about the virus threat.

Monitoring of outbreaks is taking place much faster than in years past, with the help of the Internet and the federal Health Alert Network, which has been better developed and implemented after the 9-11 and anthrax attacks, said Dan Reimer, public health official for Fort Worth.

"It really got tested during this outbreak," said Reimer, who took part in daily meetings where public health leaders managed the outbreak. "It was essential. It was the vehicle of our culture of learning." Lessons learned James Sims, safety officer for the UNT Health Science Center, said it is only in hindsight that communities determine pandemic missteps. During the 1918 Spanish influenza pandemic, doctors downplayed the disease; Boy Scouts went door-to-door to check whether people had bought Liberty bonds.

Early lessons during this outbreak indicate that more public education and improved lab testing capacity will help during a future crisis.

"Every influenza virus is a little different. Since no one has ever seen this before, we are all learning together," Sims said.

The health department will examine whether additional funding for equipment and personnel is needed in Tarrant County. Since 2006, when federal funding for preparedness peaked, money to Tarrant County has been reduced by 40 percent.

Despite any problems that arose, public health authorities moved fast to respond to an unknown threat, experts said.

In Texas, there was extraordinary mobilization, said Scott Lillibridge, assistant dean of the Texas A&M Health Science Center School of Rural Public Health.

The World Health Organization and the CDC also mobilized.

"The information coming from Mexico suggested that this strain of influenza carried a very high mortality rate, possibly as deadly as the 1918aEUR"1919 pandemic," Lillibridge said.

A week later, when it was determined the virus was relatively mild, schools reopened.

Now the nation stands ready if the virus turns severe. It has better disease tracking, more antivirals and a new vaccine on the fast track.

"Our pandemic influenza plan has been well-rehearsed. It worked dramatically better than expected," Lillibridge said.

Staff writer Anthony Spangler contributed to this report.

Tracking swine flu Public health authorities said they are still learning about the swine flu, which stirred global concerns when Mexico City reported an outbreak. Events have unfolded quickly since the American public began paying attention.

April 24 Two cases of swine flu reported in Guadalupe County near San Antonio. Dallas County public health officials tell people who have respiratory illnesses to be tested for swine flu. Tarrant County public health officials tell the medical community to be on the lookout for people with flulike symptoms.

April 25 Mexico City closes museums, libraries and schools. World health officials worry about a global pandemic flu. Eight New York City teens are reported to have the swine flu. Officials announce that Bryon Steel High School in Cibolo will close because of swine flu cases.

April 26 Three probable cases emerge in Dallas County. None are reported in Tarrant County. Mexico City closes down because of swine flu fears. Canada becomes the third country to confirm human cases of swine flu.

April 27 A 12-year-old Fort Worth girl is the first probable swine flu case in Tarrant County. The World Health Organization raises the alert level to Phase 4.

April 28 Five probable cases in Tarrant County.

April 29 First confirmed case in Tarrant County; five probable. Cleburne and Fort Worth schools close. The WHO raises influenza pandemic alert to Phase 5.

April 30 Four confirmed cases in Tarrant County; nine probable.

May 1 Sixteen probable cases in Tarrant County.

May 2 Ten probable cases; three confirmed in Tarrant County.

Sunday Twelve probable cases in Tarrant County.

Monday Eight new probable cases in Tarrant County; affected area schools continue closing.

Tuesday The CDC says campuses with confirmed or probable cases can reopen. Texas health officials announce the first death of a U.S. resident with swine flu. The total of confirmed cases in Tarrant County is 22. Mexico reopens businesses.

Wednesday Tarrant County Public Health officials liken the swine flu outbreak to a mild influenza season. Many schools reopen.

Friday Fort Worth students go back to school.

Sources: World Health Organization and Centers for Disease Control and Prevention, wire reports, Star-Telegram archives Jan Jarvis, 817-390-7664 Diane Smith, 817-390-7675 To see more of the Fort Worth Star-Telegram, or to subscribe to the newspaper, go to http://www.dfw.com. Copyright (c) 2009, Fort Worth Star-Telegram, Texas Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

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