Erie County this week stretched its resources to inject 10,153 people over five days in a hepatitis A scare that offered a real-world test of the community's readiness for a far more serious disaster.
It left an uncomfortable illustration of the nightmarish scenario confronting even the best-run health department if pandemic flu strikes, and many scientists believe it is only a matter of time before that happens.
The county pandemic flu plan, put together under federal guidelines, calls for vaccinating 950,000 people in less than a week if a new, deadly strain of influenza spreads around the globe.
The goal is overwhelming.
"We've been sending messages back up the chain to the federal government that the plan is not realistic. What we just experienced proves our point," said Dr. Anthony Billittier IV, the county health commissioner.
Hundreds of county and state workers, backed up by volunteers, pitched in at the mass vaccination clinics for hepatitis A at Erie Community College North. By most accounts, they coped well with the challenge.
Their training and preparations paid off. As a result of lessons learned, officials already see potential improvements to avoid problems that did arise. But the response raised a larger question that isn't easily answered. What price are residents here and elsewhere across the nation willing to pay for greater disaster preparedness?
It's roughly estimated the hepatitis A clinic cost more than $500,000, yet risk of exposure to the disease was considered low, and it generally causes only flulike symptoms that clear up. So far, there is just one reported case.
The dilemma for public health officials is that they can't afford to wait to see if the one case is the first of hundreds more, with some causing potentially fatal liver failure. In 2003, the largest hepatitis A outbreak recorded in the United States sickened about 660 people and killed four others who ate contaminated green onions at a restaurant near Pittsburgh.
"We asked ourselves what was the right thing to do. We asked the state and the CDC. All three levels decided to do what science says we should do," said Billittier.
"We've had doctors come through with their children who felt the benefit of the shots was worth it," he said. "Other doctors have asked me why we are doing this. My position is that the role of public health is to keep this at one case, to be proactive instead of reactive."
An employee at the Wegmans store at 5275 Sheridan Drive in Amherst was diagnosed last Friday with hepatitis A, a liver disease caused by a virus. In food-related outbreaks, the illness is spread primarily by eating raw produce handled by an infected person who didn't wash his or her hands adequately after using the bathroom. Within 24 hours, the county was offering hepatitis A vaccine or immune globulin for protection. The first few hours proved chaotic when more than 1,000 people showed up Saturday in a freezing rain and were forced to wait more than three hours in line.
"It was frustrating, especially with the weather the way it was, but they did a good job," said Joseph Zdarsky, a Buffalo attorney who arrived with his wife shortly after the clinic opened. "What are you going to do in a situation like that?"
Officials retooled on the fly, bringing in more workers and a fleet of buses to "stage" the overflow patients in a warm, safe place.
"It's difficult to gauge public reaction. But one thing we now know is that it's better to plan big and then scale back, instead of starting too small and having to play catchup," said Billittier.
The event taught other lessons.
Information about hepatitis A from the county, state and Wegmans wasn't entirely consistent, leading to some confusion about who was a candidate for treatment. The county Health Department learned that there was no one on duty over the weekend to update its Web site, and the state Health Department telephone hotline was so swamped that callers initially could not get through.
Officials also may have gotten a more accurate estimate of how many people would seek injections by looking more closely at Wegmans data. Based on its Shoppers Club card use, the company learned that 13,000 households bought produce during the time frame when shoppers could have been exposed to hepatitis A.
"If I were to list the three top problems we experienced, they are communication, communication and communication," said Billittier. "The challenge is coordinating the message."
Staffing also proved a challenge. Officials needed doctors, nurses, security, paramedics, administrators, epidemiologists and an assortment of helpers, especially with patients divided into five different treatment groups, depending on their age-related dose and choice of drug, and needing privacy if they received an injection in the buttocks.
Among the hitches along the way: Union contracts prevented the county from mandating overtime for its nurses. Moreover, New York remains one of a handful of states that forbids anyone but nurses and physicians from giving injections. Officials said the state should allow pharmacists and emergency medical technicians to administer shots in public health emergencies.
"The laws about who can do what have outlived their usefulness," said County Executive Chris Collins.
The price of the injections mounted quickly as the crowds showed up and the clinic days expanded.
The immune globulin costs $30 a dose, and 4,716 people received it, for instance.
It's likely the state, which provided the 5,437 doses of vaccine, as well as critically needed nurses and other personnel, will provide more financial help.
"I can't say with precision what we will do. But we will be responsive and sympathetic," said Gov. Eliot L. Spitzer, who visited the vaccination site Wednesday.
Talk also has begun about what more Wegmans might do, although officials praised the company's actions.
The Rochester-based supermarket chain notified thousands of customers by telephone the Saturday morning of the first clinic. It supplied food and refreshments at the clinic. When the county exhausted its supply of immune globulin Saturday night, Wegmans arranged for an airplane to pick up additional medication in Nashville, Tenn., and return to Buffalo by the time the next clinic opened Sunday. It also operated a telephone center that took thousands of hepatitis-related calls.
"We can have a conversation about what would be an appropriate role for us when the county is ready," said Wegmans spokeswoman Ann McCarthy.
The county can't file a claim to recoup the costs because no insurance exists for food-borne illness outbreaks, according to Collins.
Overall, Collins and others expressed satisfaction with how the county responded.
"I can't believe how well this went. I'm extremely comforted with how we pulled this off in real life," Billittier said.