The schools could be closed. The Dane County Farmers' Market, Mallards baseball games and other large public gatherings could be canceled. Local hospitals might convert entire floors into isolation wards. And the Dane County coroner might bring in refrigerated semis to store all the bodies.
It's a nightmare scenario of what could happen if avian flu were to strike Dane County. Right now, the flu has been transmitted only to humans who have handled infected birds. But it has been lethal, killing 109 people worldwide. If the virus mutates so that it can pass from person to person, it could cause a pandemic.
"I think it's a potential threat," says Dr. William Scheckler, an epidemiologist at St. Marys. But knowing when - and if - bird flu might appear is "less predictable than the weather."
If a pandemic does sweep the globe, the state Department of Health and Family Services estimates 1.9 million people in Wisconsin would get sick. Of those, an estimated 8,000 would die. That's 10 times as many people as were killed in car crashes in Wisconsin last year.
"Pandemic flu would be unlike other disasters in that it would last a long time," says Dr. Thomas Schlenker, the new director of the Madison-Dane County Health Department. "It wouldn't be like a tornado that comes in and causes a lot of damage and then leaves."
Avian flu would last for two to three years, striking in waves that would each last for up to eight weeks. During each wave in Dane County, according to numbers generated by Schlenker using software developed by the Centers for Disease Control, more than 1,400 people would be sent to the hospital and 260 would die - about 32 fatalities a week. Thousands more would be too ill to come in to work. The grim predictions have spurred Dane County and the city of Madison to begin preparing for a potential outbreak.
"How would we function if 25% of the staff didn't show up at businesses, hospitals, government entities?" asks Schlenker. "That's a real complicated problem."
Next week, the local Health Department will host a forum to help businesses and government agencies begin planning. Managers will be challenged to answer questions like, What happens if a worker uses up all his sick leave benefits? Are employees cross-trained to fill in for each other? Who is an essential employee?
"It turns out some basic maintenance is really essential," says Schlenker. "What if no one knows how to unlock the building? What if you have a fleet of vehicles that need to be maintained? It's not necessarily the company's director who is the most important person."
The Health Department has also spent months planning how the government will respond to such an emergency. The first goal, says Schlenker, would be to contain the spread of the virus: "We'd be trying to minimize the chance for transmission by various kinds of actions."
The Health Department has the authority to shut down everything from schools to private businesses, including nightclubs and restaurants, if necessary. Reflects Schlenker, "We'd have to balance the desire to limit transmissions with the fact that people have to go on living."
During the 1918 influenza outbreak that killed between 20 million and 40 million people worldwide, Wisconsin officials closed public institutions and quarantined sick individuals in their homes. The state also distributed free vaccines, which were ultimately ineffective.
Obviously, modern medicine is more advanced. But a vaccine for bird flu would likely not be available until six months after the virus first appears to be spreading in humans. Once it is ready, however, Schlenker says the Health Department would try to vaccinate 5,000 individuals a day.
To this end, the department would set up two dozen vaccination sites around the county. Local hospitals would send personnel, and police would provide security and monitor traffic. "It would be a fairly big operation," says Schlenker. The Health Department plans to hold a couple of practice runs of large-scale vaccinations this fall.
The local Health Department would also, with the assistance of state officials, decide which patients get anti-viral medications.
"There wouldn't be enough anti-virals for everybody," says Schlenker. "We'd have to have some system of prioritizing and rationing."
Deciding who would get the potentially life-saving drugs wouldn't happen until the outbreak occurs and doctors see who is most affected by the disease. Elderly patients are usually more susceptible to developing deadly complications from the flu, but the 1918 pandemic was actually more lethal to young adults.
One group who would definitely get vaccinations and anti-viral medication would be health-care workers. This is because they are, says Schlenker, "an essential part of the emergency response system."
Local hospitals have full-time staff dedicated to planning for potential outbreaks. Dr. Scheckler of St. Marys says the hospital began building "negative pressure" rooms in the 1970s to deal with tuberculosis cases. The rooms vent air outside, instead of back into the hospital.
"Because of a concern about bioterrorism, we've been using federal grant money to expand our capacity to deal with isolation cases," says Scheckler. When St. Marys built a new seventh and eighth floor, it made all the rooms convertible to negative pressure if necessary. "I think the hospitals are well prepared. We want to be ready for the next big bad thing that comes along."
Of course, there is a catch. "No matter what we plan," says Madison Fire Marshal Ed Ruckriegel, "if people don't follow directions, it won't work."
Citizens would have to heed recommendations to get vaccinated, stay home if they're sick, and minimize contact with others, he says. "The most important thing is that people also plan at home."
Parents should discuss who will stay home with sick children or what they'll do if schools and daycare centers close. Individuals should also take steps to minimize their chances of becoming ill by getting yearly vaccinations not just for the flu, but for pneumococcal pneumonia, a secondary infection that often kills those weakened by the flu.
And people need to be prepared for a disruption of their daily life. "If we did have this epidemic rolling across the country, a large number of people would get sick, and the entire economy would suffer," says Dr. Schlenker. Grocery stores might miss shipments because truckers fall ill, and shops might not have enough healthy workers to keep their regular business hours. "Everything would be slower. It might be a good idea to have a little nonperishable food stocked."
Schlenker adds that the biggest health crisis might not come from avian flu but from something as yet unforeseen. "There are so many different threats that can arise that we might have no expectation of," he says. "HIV came out of nowhere. So did SARS. There are always surprises."