ISSUE BRIEF H1N1 Challenges Ahead “ ALTHOUGH WE WERE FORTUNATE NOT TO SEE A MORE SERIOUS SITUATION IN THE SPRING WHEN WE FIRST GOT NEWS OF THIS OUTBREAK... THE POTENTIAL FOR A SIGNIFICANT [H1N1] OUTBREAK IN THE FALL IS LOOMING. WE WANT TO MAKE SURE THAT WE ARE NOT PROMOTING PANIC, BUT WE ARE PROMOTING VIGILANCE AND PREPARATION. ” -- PRESIDENT BARACK OBAMA AT THE FLU SUMMIT1 I In June 2009 the World Health Organization (WHO) raised the pandemic flu alert to six, the highest level, which indicates a global pandemic is underway. This is the world’s first in- fluenza pandemic since 1968.2 I H1N1 has spread to all states and D.C., hospitalizing almost 10,000 people and killing close to 600 people as of September 2009. I Twenty-six states were reporting widespread influenza activity as of September 19, includ- ing: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Delaware, Florida, Georgia, Illinois, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Nevada, New Mexico, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and OCTOBER 2009 Washington. Any reports of widespread influenza activity in September are very unusual. I Monitoring has shown that the virus remains virtually identical to initial outbreaks and it has PREVENTING EPIDEMICS. not mutated to a more virulent or lethal form.4 PROTECTING PEOPLE. Introduction A s the United States gets ready for an increase in H1N1 flu virus activity this fall, there are a number of challenges the country faces. Federal, state, and local governments, health care $1.9 billion in emergency supplemental funding providers, businesses, schools, and communities and an additional $5.8 billion in contingency fund- around the country are taking extraordinary meas- ing, some of which has already been tapped by the ures to respond to the second wave of H1N1, when Obama Administration, to enhance vaccine pro- a significant percentage of Americans could be- duction, help bolster state and local health de- come sick from the H1N1 virus. According to a partment capacity, upgrade surveillance planning scenario developed by the President’s capabilities, and meet other needs. In the last few Council of Advisors on Science and Technology months, $1.4 billion has been drawn from the (PCAST), if 30 percent of the U.S. population con- available funds to assist states in their pandemic re- tracted H1N1, it could mean around 90 million sponse and vaccination implementation programs. Americans could get ill, 1.8 million could need to This fall and winter, federal, state, and local health be hospitalized, and around 30,000 could die.5 departments will undertake the most ambitious The country is much better prepared to face a vaccination plan in U.S. history, by making the pandemic than it was just a few short years ago. H1N1 vaccine available to all Americans and par- The investments that have been made to im- ticularly targeting high-risk groups as soon as it is prove pandemic preparedness have resulted in ready. The U.S. Food and Drug Administration significantly enhancing the country’s ability to (FDA) has approved vaccines for H1N1 and a vac- respond to an influenza pandemic. These in- cine distribution policy was created in so far as the vestments have increased the country’s vaccine U.S. Centers for Disease Control and Prevention manufacturing capacity, provided helpful aware- (CDC) has set up a system to process orders and ness and education campaigns, contributed to a deliver vaccine when it is available to locations more robust federal stockpile of antiviral med- identified by each state. HHS has also worked ications, improved many core facets of the na- with health departments, hospitals, and other tion’s public health system, and assisted in the providers to rapidly improve surveillance capabil- development of federal, state, local, community, ities to be able to track and monitor the spread of business, and school pandemic plans. Since the virus. Federal, state, and local officials have 2005, a strong National Strategy for Pandemic In- been also working hard to educate the public fluenza has been developed, and every state has about H1N1 issues and ways to best prepare for a pandemic plan, which are constantly being re- and protect themselves during the outbreak. vised and refined. But many challenges still remain: However, there were also many concerns that I Vaccine Issues: One major challenge the were identified, but were not adequately ad- country faces is that only a limited amount of dressed or funded in prior planning efforts. the vaccine will be available by October, when Some very large underlying issues, including how the flu is expected to become more wide- to manage surge capacity during a mass event, de- spread. Communities and health care systems veloping a reimbursement system for uncompen- will therefore have to prepare for how to man- sated care during an emergency, and the need to age until a vaccine is widely available, by an- modernize and strengthen, in a sustained way, ticipating high levels of needed care and much of the public health infrastructure, are still finding ways to limit the spread of disease by major challenges. In addition, before this year, encouraging people to practice good hygiene policies called for many preparedness functions habits and for those who are sick to limit con- to be state and local responsibilities and did not tact with others. Communities will have to provide federal support for these needs, includ- plan how to reach high-risk groups early, ing vaccine distribution and the expectation that when supplies are low, and the rest of the pop- states should purchase a significant portion of an- ulation as more vaccine becomes available. tiviral medications to protect their own citizens. Since the vaccine may not be made widely Since the emergence of H1N1 this spring, officials available until later in the outbreak, it may have been racing against the clock to address many deter many individuals from seeking out the of the remaining issues. Congress appropriated vaccine, since they may feel the risk has di- 2 minished. However, experts recommend mild strain of flu, and the plans and capacities everyone still get vaccinated because a third to deal with this influx are limited. Federal, wave of the disease could emerge next year. state, local, and health system officials will have to continue to clearly communicate with the L Once a vaccine is available, an additional public as to which groups are urged to seek challenge will be to get it to young adults, rapid care and who should practice sound self- who are considered to be at particularly high- care measures and stay home when ill. risk for contracting H1N1, and to minority populations, who have high rates of underly- I Eroding Public Health Infrastructure: One of ing health conditions which make them the biggest ongoing challenges health officials more vulnerable to H1N1. Historically, low face is that preparations are taking place in the levels of young adults and minority commu- context of a public health system that has been nities receive seasonal flu vaccinations. chronically underfunded for decades. Many core systems and capabilities are lagging be- I Competing Seasonal Flu: Another challenge hind where they should be or could be, which is that the seasonal flu will also be circulating leaves the nation unnecessarily vulnerable dur- at the same time as H1N1. Typically, the sea- ing times of emergency. The concurrence of sonal flu sickens between five and 20 percent lost workforce due to the economic recession, of the U.S. population, leads to an average of the continuing need to address other pressing more than 200,000 hospitalizations, and re- public health issues simultaneously with a pan- sults in about 36,000 deaths from flu-related demic, and the diversion of health department causes.6 This may create added confusion employees to the H1N1 response have placed around who has which kind of flu and put in- a severe strain on the public health system. creased strain on the health system. There are some reports that H1N1 could be “crowd- This report examines the series of challenges the ing out” the regular seasonal flu and may re- country faces in preparing to deal with the com- sult in reducing cases of the seasonal flu. plications that an H1N1 outbreak adds to this flu season related to medical care capacity, antiviral I Strain on Medical System: Surge capacity, medications, disease surveillance, vaccinations, which is the ability of the medical system to budget cuts at public health departments, and care for a massive influx of additional patients, caring for people in communities, particularly is one of the most serious remaining chal- meeting the special needs of at-risk populations, lenges for emergency health preparedness. and provides a series of recommendations for Health care providers and hospitals could be how to address preparedness gaps. quickly overrun or overextended during the H1N1 outbreak, even though it is currently a Pandemic Influenza Preparedness and Response: 2009 HHS Funds for H1N1 (dollars in millions) HHS Original Contingent Total Funds Appropriations Release* Vaccine Production and Ancillary Supplies Includes bulk vaccine antigen and 1,117 2,485 3,602 adjuvant manufacturing, fill finish, and syringes and needles Ongoing Pandemic Influenza Activities with H1N1 Impacts Includes manufacturer retrofits, clinical trials, antiviral procurements, diagnostic test 179 232 411 development, and PPE Vaccination Campaign Planning and Implementation: Upgrading State and 350 -- 350 Local Capacity Includes Cooperative Agreements for Hospitals and State/Locals Vaccination Campaign Planning and Implementation: Vaccine Distribution 30 213 243 Distribution of vaccines and ancillary supplies to receiving sites within the States Vaccination Campaign Planning and Implementation: State and Local Vaccine Implementation/Administration Includes funding to plan and execute a -- 1,094 1,094 mass vaccination campaign through the Public Health Emergency Response Grants Vaccination Campaign Planning and Implementation: CDC Vaccination -- 112 112 Campaign Activities Includes vaccination monitoring and communications Federal, State and Int’l Surveillance & Preparedness – CDC 170 154 324 Compensation, ASPR, and FDA 4 11 15 Total 1,850 4,300 6,150 *A total of $5.8 billion in contingency funds are available at the Administration’s discretion. These numbers represent the latest release of funds as of press time. 3 I. PREPARING FOR SURGE IN MEDICAL CARE With limited vaccine expected to be available at cantly stretched beyond normal capabilities. the start of the outbreak and significant numbers Figuring out how to plan for a massive influx of of Americans becoming ill, the health care system patients is one of the hardest parts of preparing could be quickly overwhelmed by a major influx for health emergencies, and it has yet to be ad- of patients seeking medical care. Health depart- equately dealt with. “Surge capacity” manage- ments, health care providers, and hospitals are ment is one of our biggest public health preparing for how to manage a surge of poten- emergency preparedness weaknesses. Many of tial patients. Patients could rapidly fill existing the surge capacity problems have been identi- hospital beds and cause a surge in demand for fied -- including having enough supplies, staff, critical medicines and equipment, such as antivi- and space to treat patients -- but solutions to ral medications, ventilators, and protective masks. these problems are often lacking. During a major emergency like a pandemic out- break, the health care system could be signifi- A. AMBULATORY CARE AND EMERGENCY DEPARTMENTS In the spring, doctors’ offices and hospitals were pact on the country’s public health and health overrun by patients who had the flu or were con- care systems could be disastrous if hospitals, com- cerned they had the flu. During disasters, health munity health centers, and primary care facili- providers have to adapt their regular practices to ties treat large numbers of uninsured.9 Young treat a large number of patients very quickly. In adults between 19 and 29 years old are consid- an effort to manage the number of patients seek- ered to be at high-risk for developing more se- ing care, the government is working with physi- vere cases of H1N1, and they represent one of cians in states and local communities to develop the largest and fastest growing segments of the telephone hotlines and interactive websites to population without health insurance.10 In addi- prevent patients with less severe symptoms from tion, individuals without insurance often end up going to the hospital.7 The U.S. Centers for Dis- going to the emergency room when they need ease Control and Prevention (CDC) has provided medical care, which results in higher cost care. information and guidance to states and health fa- Some experts have recommended an emer- cilities on how to set up the call centers, based on gency health benefit be enacted to ensure care models similar to poison control centers. for all Americans during emergencies and to en- Surge capacity issues are particularly acute in sure that health care providers receive compen- emergency rooms, where in the best of times, sation. Other experts have suggested that they already face capacity shortages and staffing Medicaid, Medicare, and private insurers should issues. For instance in New York City, one of the extend out-of-network benefits during times of places hardest hit by the spring wave of H1N1, emergencies, like a pandemic, so that patients hospital and city health officials reported that have access to a wider community of doctors and 44,678 people visited emergency rooms in with so that hospitals and other facilities can more flu-like symptoms from May 15 to June 15, com- easily seek compensation if they provide care for pared to just 4,267 the previous year.8 out-of-network patients. Expedited enrollment for Medicaid can also be deployed in a crisis, as With more than 15 percent of Americans lack- it was after the September 11th tragedy. ing health insurance coverage, the financial im- 4 B. HOSPITAL BED CAPACITY Emergency care centers and doctors’ offices are ing its peak at five weeks. Based on the FluSurge expected to see an influx of patients during the estimates, 15 states would exceed their current initial phase of the outbreak. But as the pan- available hospital bed capacity during the fifth demic progresses, there will likely be growing week of the outbreak. In addition, 22 states need to hospitalize large number of patients would reach or exceed 80 percent of their hos- who will be in need of more significant care. pital bed capacity and 26 states would exceed 75 This becomes even more of an imperative percent of their hospital bed capacity. should the severity of the pandemic increase. North Dakota (32 percent), Mississippi (35 per- In order to illustrate the number of people who cent), and South Dakota (37 percent) would could become hospitalized and the capacity of have the highest amount of available bed ca- hospitals to meet the potential influx of patients, pacity at peak of the pandemic during week five. Trust for America’s Health (TFAH) used CDC’s Delaware (203 percent) and Connecticut (148 FluSurge modeling program to estimate the percent) would have the highest overload rates. number of hospitalizations that could occur per These estimates do not take into account Army state and how quickly this would fill the number mobile hospitals or other emergency mobile of available hospital beds in that state. hospital bed capacity. It is also important to The estimates are based on expert predictions note that the H1N1 pandemic appears to follow that the H1N1 virus is a relatively mild strain of a slightly different pattern. Instead of an eight- flu, similar to the severity of the 1968 pandemic week wave with the peak of the pandemic oc- flu outbreak, and that up to 35 percent of Amer- curring during the fifth week, H1N1 appears to icans could potentially become sick with H1N1. have a much earlier, rapid onset reaching its Based on these assumptions, the number of peo- peak at week two or three. Therefore, hospitals ple who might need to be hospitalized could and health care providers need to be prepared range from a high of 168,025 in California to a for a crush of patients as soon as H1N1 becomes low of 2,485 in Wyoming. widespread in their communities. Models for a pandemic outbreak anticipate the pandemic to last for at least eight weeks, reach- 5 Potential Pandemic Influenza Cases, Hospitalizations and Bed Capacity From a 35 Percent Attack Rate Pandemic Flu* State Cases Hospital Admissions Bed Capacity at Week 5 Alabama 1,631,665 22,525 55% Alaska 240,203 2,848 58% Arizona 2,275,063 29,363 117% Arkansas 999,387 13,839 50% California 12,864,833 168,025 125% Colorado 1,728,810 21,927 88% Connecticut 1,225,438 17,305 148% Delaware 305,582 4,197 203% D.C. 207,142 2,904 47% Florida 6,414,919 95,064 80% Georgia 3,390,010 42,348 78% Hawaii 450,869 6,410 143% Idaho 533,336 6,803 66% Illinois 4,515,547 60,934 73% Indiana 2,231,877 30,234 57% Iowa 1,050,894 14,951 51% Kansas 980,747 13,331 43% Kentucky 1,494,236 20,475 52% Louisiana 1,543,779 20,381 48% Maine 460,760 6,762 83% Maryland 1,971,759 26,691 143% Massachusetts 2,274,288 31,942 110% Michigan 3,501,198 48,584 79% Minnesota 1,827,138 24,768 68% Mississippi 1,028,516 13,810 35% Missouri 2,069,062 28,587 60% Montana 338,604 4,706 48% Nebraska 624,201 8,576 44% Nevada 910,058 11,639 137% New Hampshire 460,533 6,419 84% New Jersey 3,038,931 42,510 101% New Mexico 694,525 9,273 93% New York 6,821,604 94,740 108% North Carolina 3,227,845 42,464 95% North Dakota 224,518 3,215 32% Ohio 4,020,069 56,228 70% Oklahoma 1,274,826 17,375 57% Oregon 1,326,521 18,155 107% Pennsylvania 4,356,898 63,573 77% Rhode Island 367,776 5,358 143% South Carolina 1,567,930 20,994 93% South Dakota 281,468 3,861 37% Tennessee 2,175,211 29,347 61% Texas 8,514,441 105,287 66% Utah 957,748 10,839 83% Vermont 217,445 3,125 108% Virginia 2,719,181 36,530 100% Washington 2,292,228 30,474 107% West Virginia 635,064 9,404 48% Wisconsin 1,969,788 27,196 75% Wyoming 186,434 2,485 40% *Based on the CDC’s FluSurge model program. Estimates rely on FluSurge 2.0 Beta Test Software, created by the CDC. More infor- mation about the model is available at http://www.cdc.gov/flu/flusurge.htm. This scenario examines what would happen during a mild pandemic outbreak. The severity for this type of outbreak is based on the 1968 flu pandemic, which is considered relatively mild. The factors in the FluSurge model are set to assumptions based on the 1968 pandemic. These default settings assume an outbreak would be eight weeks in duration and 35 percent of the population would become ill. The data for the age demographics are from the Census Bureau’s Current Population Survey, 2006, available at http://www.census.gov/. The bed statistics are based on the total number of licensed 2006 hospital beds (B) (which is available through Kaiser Family Foundation’s State Health Facts, available at http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi) and the typical hospital bed occupancy rates (R) (available for 2006 from CDC data and are available in the chart book, Health, United States, 2008). To determine the usual number of usual available beds, TFAH used the following formula – ((StatePop/1000) * B) * (1-R). 6 WAVES OF INFLUENZA AND THE IMPORTANCE OF VACCINES: 1957 PANDEMIC In February 1957, the Asian influenza pandemic -- A/H2N2— was first identified in the Far East. In preparation, vaccine production began in late May 1957, and health officials increased surveillance for flu outbreaks. Vaccine was available in limited supply by August 1957. The virus first appeared in the United States in the summer of 1957 through a series of small outbreaks.11 The 1957 pandemic had three winter waves during the first five years. There were significant mortalities from the same influenza strain during the 1957/58, 1959/60, and 1962/63 winters.12 The first wave accounted for 43 percent, the second for 28 percent, and the final wave, five years after the pandemic began, amounted to 29 percent of deaths. The 1957 pandemic highlights the importance of a well-designed mass vaccination campaign and of remaining vigilant in preparedness efforts. In the present situation, vaccine manufacturers should continue to produce vaccines doses, and countries need to continue encouraging citizens to be vaccinated, even after it appears that the worst has passed. The World Health Organization (WHO) has discussed plans to incorporate H1N1 into seasonal flu vaccines next year as part of ongoing vigilance. C. ANTIVIRALS Two antiviral medications, Tamiflu® (os- I 5.9 percent of adults are “extremely” obese eltamivir) and Relenza® (zanamivir), have been (BMI ≥ 40); shown to be generally effective for treating peo- I 952,221 Americans aged 13 and older have ple with the H1N1 virus. There have been some AIDS; and cases where the antivirals may not have been ef- fective, and there are some fears that the virus I 1,437,180 new cases of cancer were diagnosed could become resistant to antivirals as the season in the past year. progresses. In addition, there are reports that a During the past several years, the country has pur- new drug, Fludase®, may also prove to be effec- chased a stockpile of antiviral medications to use tive against both the seasonal and H1N1 flu. during a flu pandemic. The medications have a In September 2009, CDC issued guidelines sug- shelf-life of seven years. National pandemic plan- gesting antivirals should be reserved for patients ning called for purchasing enough antivirals to be with more severe cases of the flu or who are in a able to treat 25 percent of the U.S. population, or high-risk group for developing complications. In 75 million people. The current federal policy particular, experts emphasize the importance of calls for the purchasing of antivirals to be a shared its prudent use and being able to rapidly provide federal-state responsibility. The federal govern- antivirals to individuals with underlying risks. ment has purchased 44 million treatment courses for the states, and set a requirement for state gov- According to Flu.gov, “people with certain ernments to purchase the remaining 31 million health conditions, such as asthma, diabetes, can- treatment courses in proportion to the popula- cer, HIV/AIDS, and heart or kidney disease, tion of their states with the federal government may face special needs during flu season.” providing a subsidy for 25 percent of the cost. Currently in the United States:13 The federal government has another six million treatment courses in the stockpile for use in out- I 13.6 percent of adults have asthma; break control. In the spring, CDC pushed out 25 I 8.3 percent of adults have diabetes; percent of the federal stockpile to states. As of September 18, 2009, CDC’s Strategic National I 4.2 percent of adults have had a heart attack; Stockpile (SNS) contains approximately: 39.7 mil- I 4.3 percent of adults have been told they have lion regimens of oseltamivir capsules (Tamiflu), coronary heart disease; 9,279 regimens of oral suspension oseltamivir, and 10.3 million regimens of zanamivir (Relenza). I 2.6 percent of adults have had a stroke; In addition to the antivirals received from the fed- I 27.8 percent of adults have high blood pressure; eral portion of the stockpile, according to HHS, I 18.4 percent of adults currently smoke; as of September 10, 2009, state and local juris- dictions have stockpiled over 25 million treat- I 13.1 percent of adults have chronic kidney ment courses of antivirals, which is about five disease; million short of the national goal. Twenty-four 7 states and D.C. have purchased 100 percent or many states say they simply do not have the more of their federally-subsidized antivirals; 30 funds available. With deep budget cuts, states states and D.C. have purchased 75 percent or are reluctant to spend scarce resources on pur- more; 37 states and D.C have purchased 50 per- chasing and stockpiling antivirals, particularly cent or more; and 44 states and D.C. have pur- since they have a limited shelf-life (at the com- chased 25 percent or more. mencement of this program it was five years but was recently changed to seven years). In addi- Combining the federal allocations received by tion, according to the National Governor’s As- states with states’ purchases, 13 states do not cur- sociation (NGA) a number of states have rently have enough antivirals to cover 20 percent “…expressed concerns about the reliance on an- of their population: Arizona (16.1 percent); Col- tivirals given that their effectiveness in treatment orado (14.9 percent); Connecticut (15.6 per- may be compromised by the development of re- cent); Florida (17.6 percent); Idaho (15.5 sistance by the pathogen.”14 States also have percent); Massachusetts (17.7 percent); Mon- questioned the effectiveness of antivirals, par- tana (15.8 percent); Nebraska (19.0 percent); ticularly “…if they are used more than 48 hours New Mexico (19.0 percent); Oklahoma (17.6 after the onset of symptoms in an infected indi- percent); Oregon (15.9 percent); Rhode Island vidual” and others have expressed concern over (18.3 percent); and Utah (17.9 percent). potential side effects.15 So far, antiviral medica- And another 12 states have only enough antivirals tions have proven to be effective for H1N1. Fi- to cover between 20 and 25 percent of their popu- nally, states have questioned the management of lation (combining their federal allocation and state antiviral stockpiles. A position statement from purchases): Georgia (20.4 percent); Illinois (22.6 the Association of State and Territorial Health percent); Kentucky (20.2 percent); Maryland (24.7 Officials (ASTHO) notes that “Efficient man- percent); Minnesota (21.7 percent); Nevada (21.2 agement of antiviral stockpiles is essential to re- percent); New Hampshire (20.2 percent); North duce waste and ensure that maximum benefit is Carolina (23.0 percent); North Dakota (23.9 per- derived from this countermeasure.”16 As part of cent); Texas (23.2 percent); Washington (23.1 per- the efficient management of the states’ antiviral cent); and Wisconsin (21.5 percent). stockpile, ASTHO recommends that states be given the ability to rotate stocks of antivirals pur- This could present a problem if significant por- chased with the federal subsidy with stocks used tions of people with underlying conditions that for annual seasonal flu response. This way, the put people at risk, including asthma, diabetes, antivirals are more likely to be used before they cancer, HIV/AIDS, and heart or kidney disease, reach their shelf-life expiration date. This will become sick in states with limited antivirals avail- help preserve the states’ investments in antivi- able. Ensuring enough antivirals to care for at-risk rals and limit the need to repurchase antivirals patients is essential. Antiviral medications may that have passed their expiration date. also become needed if there is a third wave of H1N1, especially in the event the virus becomes Nationally, there are also many questions about more virulent over time as was the case with the the availability of medications suitable for chil- 1957 pandemic. Currently, there is no system in dren. As of November 2008, there were just over place to ensure that either federal or state stock- 3.8 million regimens of pediatric antiviral for- piles of antivirals are replenished if used. mulations in the federal stockpile to treat a po- tential pandemic flu for the nation’s 73.6 million States that have not purchased their entire al- children.17 The government has not set any tar- lotment of federally-subsidized antivirals have get for stockpiling pediatric antivirals, even expressed concerns about different barriers, in- though children and adolescents are known to cluding funding, shelf-life of the drugs, antiviral often be disproportionately affected by conta- resistance, and stockpile management. Funding gious respiratory illnesses, and have been espe- for antiviral purchases has been a major barrier, cially affected by the current H1N1 outbreak. even before the current economic recession and 8 Antivirals: Federal Stockpile Allocation for States and States’ Purchases State Population Federal Initial State All Antivirals Percent of Percent of Stockpile Subsidy Purchased by Allocation Population Allocation Allocation* State (09/10/09) Purchased Covered by (06/30/06) Antivirals Alabama 4,503,726 671,156 472,860 533,553 112.8% 26.7% Alaska 648,280 96,608 68,065 77,030 113.2% 26.8% Arizona 5,579,222 831,429 585,780 67,717 11.6% 16.1% Arkansas 2,727,774 406,500 286,397 382,398 133.5% 28.9% California (including LA County) 35,462,712 5,284,740 3,723,339 3,809,362 102.3% 25.6% Colorado 4,547,633 677,699 477,470 215 0.0% 14.9% Connecticut 3,486,960 519,635 366,107 22,829 6.2% 15.6% Delaware 818,166 121,925 85,902 180,095 209.7% 36.9% District of Columbia 557,620 83,098 58,546 90,926 155.3% 31.2% Florida 16,999,181 2,533,259 1,784,796 461,238 25.8% 17.6% Georgia 8,676,460 1,292,987 910,968 474,022 52.0% 20.4% Hawaii 1,248,755 186,093 131,111 172,487 131.6% 28.7% Idaho 1,367,034 203,719 143,529 8,567 6.0% 15.5% Illinois (including Chicago) 12,649,087 1,884,997 1,328,067 978,370 73.7% 22.6% Indiana 6,199,571 923,875 650,912 650,912 100.0% 25.4% Iowa 2,941,976 438,420 308,887 312,631 101.2% 25.5% Kansas 2,724,786 406,054 286,084 286,084 100.0% 25.4% Kentucky 4,118,189 613,703 432,381 216,224 50.0% 20.2% Louisiana 4,493,665 669,657 471,804 478,734 101.5% 25.6% Maine 1,309,205 195,101 137,457 164,659 119.8% 27.5% Maryland 5,512,310 821,458 578,754 541,429 93.6% 24.7% Massachusetts 6,420,357 956,777 674,093 179,862 26.7% 17.7% Michigan 10,082,364 1,502,498 1,058,578 1,079,450 102.0% 25.6% Minnesota 5,064,172 754,675 531,703 346,013 65.1% 21.7% Mississippi 2,882,594 429,571 302,652 338,648 111.9% 26.7% Missouri 5,719,204 852,290 600,477 600,477 100.0% 25.4% Montana 918,157 136,826 96,400 8,174 8.5% 15.8% Nebraska 1,737,475 258,923 182,423 71,952 39.4% 19.0% Nevada 2,242,207 334,139 235,416 141,673 60.2% 21.2% New Hampshire 1,288,705 192,046 135,305 68,000 50.3% 20.2% New Jersey 8,642,412 1,287,913 907,393 880,293 97.0% 25.1% New Mexico 1,878,562 279,948 197,236 77,409 39.2% 19.0% New York (including NYC) 19,212,425 2,863,082 2,017,172 2,444,836 121.2% 27.6% North Carolina 8,421,190 1,254,946 884,167 677,882 76.7% 23.0% North Dakota 633,400 94,391 66,503 57,000 85.7% 23.9% Ohio 11,437,680 1,704,471 1,200,877 1,388,858 115.7% 27.0% Oklahoma 3,506,469 522,543 368,155 93,765 25.5% 17.6% Oregon 3,564,330 531,165 374,230 36,668 9.8% 15.9% Pennsylvania 12,370,761 1,843,521 1,298,844 1,313,517 101.1% 25.5% Rhode Island 1,076,084 160,361 112,981 36,625 32.4% 18.3% South Carolina 4,148,744 618,256 435,589 459,960 105.6% 26.0% South Dakota 764,905 113,988 80,310 80,310 100.0% 25.4% Tennessee 5,845,208 871,067 613,706 613,706 100.0% 25.4% Texas 22,103,374 3,293,899 2,320,701 1,827,986 78.8% 23.2% Utah 2,352,119 350,518 246,956 71,591 29.0% 17.9% Vermont 619,343 92,296 65,027 71,036 109.2% 26.4% Virginia 7,365,284 1,097,593 773,304 828,445 107.1% 26.2% Washington 6,131,298 913,701 643,744 501,206 77.9% 23.1% West Virginia 1,811,440 269,945 190,189 248,462 130.6% 28.6% Wisconsin 5,474,290 815,792 574,763 363,729 63.3% 21.5% Wyoming 502,111 74,826 52,718 74,826 141.9% 29.8% Total: 290,788,976 43,334,080 30,530,828 24,891,841 81.5% 23.5% Source: http://www.pandemicflu.gov/plan/states/antivirals.html (accessed September 23, 2009). * “Initial allocation” is for subsidized treatment courses only; 25% federal subsidy per treatment course. Many states have purchased additional antivirals at unsubsidized prices. 9 D. OTHER MEDICAL EQUIPMENT AND THE STRATEGIC NATIONAL STOCKPILE The Strategic National Stockpile (SNS) consists ventilators, personal protective equipment such of medicine and medical supplies to provide as N-95 respirator masks, syringes, sterile gloves support during public health emergencies when and other life-saving medical materiel. state and local resources are overwhelmed and With the H1N1 outbreak, the availability of med- exhausted. Each state has plans to quickly re- ical equipment is likely to be limited, and states ceive and distribute SNS medicine and medical may seek help from the SNS to meet their needs. supplies to local communities.18 A 2008 U.S. The quantity of non-pharmaceutical interven- government review of state pandemic plans, tions for pandemic influenza in the SNS, such as found that 34 states and D.C. were adequately N-95 respirator masks and surgical masks, falls prepared to acquire and distribute medical far short of what may be needed. As of the spring countermeasures during a pandemic, including: of 2009, the U.S. stockpile contained 105.8 mil- Alabama, Arizona, Arkansas, California, Col- lion N-95 respirators and 51.7 million surgical orado, Connecticut, Delaware, District of Co- masks.20 CDC reports that 25 million N-95 res- lumbia, Florida, Illinois, Indiana, Iowa, pirator masks were distributed from the SNS dur- Louisiana, Maryland, Massachusetts, Michigan, ing the spring, reducing the nationally-available Minnesota, Mississippi, Missouri, Montana, Ne- number of N-95s to 79.7 million. The SNS also braska, New Jersey, New Mexico, New York, contains 37.7 million surgical masks, which are Ohio, Oklahoma, Oregon, Rhode Island, South not considered effective protection against Carolina, South Dakota, Texas, Vermont, Vir- H1N1. This is short of the number that many ex- ginia, Washington, and Wisconsin.19 perts believe would be adequate, but no action The federal portion of the flu antiviral medica- has been taken to replenish this supply and there tion stockpile is part of the SNS. The SNS also are some questions if additional respirator masks contains back up stores of equipment, such as are available due to limited availability. E. TRACKING THE DISEASE Surveillance issues are also a major concern. The and deaths, rather than reporting all probable flu has traditionally been tracked through a sur- and confirmed cases of H1N1. veillance system through a partnership among In order to respond to the pandemic, the Presi- CDC, state, and local health departments, public dent’s Council of Advisors on Science and Tech- health and private clinical laboratories, vital statis- nology (PCAST) developed six surveillance tics offices, health care providers, clinics, and questions that must be asked in order for federal emergency departments. The system offers output decision makers to have the data necessary to measures including number of outpatient consul- make informed policies and recommendations:23 tations for influenza-like illnesses, hospitalization rates for influenza, pediatric deaths from in- 1. About how many people are becoming in- fluenza, population-wide deaths from pneumonia fected, getting sick, seeking medical care, and influenza, and virus characteristics.21 How- being hospitalized, requiring intensive care, ever, the system does not report data in real time, and dying from H1N1? which is particularly important for tracking a 2. How are the numbers changing over time? major outbreak to identify clusters where the out- break is heaviest or to monitor the severity of the 3. Who is at greatest risk of becoming infected virus to see if it might be getting more dangerous. and most susceptible to severe outcomes? Prior to the onset of H1N1, CDC’s National In- 4. How is the virus changing? fluenza Surveillance System consisted of nine sys- 5. Are the medical and public health systems tems to monitor flu viruses and follow the flu’s able to respond adequately? geographic spread. In response to the rapid spread of H1N1, CDC and the states imple- 6. How well do medical and public health re- mented line-listing reporting for cases of H1N1 sponses work? beginning in April 2009.22 As cases continued to To respond quickly and appropriately to the fall grow, the system was adapted to include total resurgence of H1N1 there must be an even more counts of H1N1 cases, hospitalizations, and efficient and all-encompassing surveillance sys- deaths. By August, the updated surveillance sys- tem in place to track the numbers of people in- tem transitioned to include only hospitalizations 10 fected, seeking medical treatment, being hospi- experts question whether there are sufficient re- talized, and dying. The recently released PCAST sources to improve the system on such a short report outlines an ambitious surveillance system timetable. Also, it is important to consider that upgrades the current national surveillance whether the PCAST recommendations are a systems in time for fall 2009 by integrating and one-time emergency system to respond to expanding existing systems. H1N1, or whether this will change the surveil- lance system for future outbreaks. Carrying out the PCAST recommendations will require significant time and resources. Some II. VACCINE ISSUES Vaccination is the best defense against an infec- I Persons aged 25 through 64 years who have tious disease epidemic, but in order to maximize health conditions associated with higher risk its utility, implementation must be timely and of medical complications from influenza.26 cover the most at-risk segments of the population. Every state has created a vaccination plan, which After the initial H1N1 outbreak, the United includes identifying locations where the public States immediately started preparing for H1N1 will be directed to receive vaccinations. These vaccinations. In mid-September, the U.S. FDA locations will vary by state and may include cleared vaccines from CSL Limited, MedIm- health care providers, community health centers, mune LLC, Novartis Vaccines and Diagnostics and pharmacies, and/or state and local health Limited, and sanofi pasteur Inc to help prevent departments may set up special vaccination cen- H1N1. The U.S. FDA approved the vaccine ters in places like shopping malls or even drive- more rapidly than the European consortium. thru stations. States are providing CDC with CDC has reported that somewhere between 45 vaccine ordering information, and CDC has con- million and 52 million doses should be available tracted with the McKesson Corporation to dis- by mid-October and to be followed by weekly in- tribute vaccine directly to approximately 90,000 stallments of vaccine totaling about 195 million locations the states have identified. The vaccines doses by the end of the year.24 Vaccinations are will be distributed along with ancillary equip- starting immediately in some other countries, ment items like syringes and sterilization swabs with many other nations planning to begin im- in accordance with state plans. munization efforts in October.25 The states’ mass vaccination plans also include Once the vaccine begins to be available, the U.S. plans for how to transport vaccines safely, re-dis- strategy is to heavily target at-risk individuals and tribute vaccines if some locations require more then as the vaccine is more widely available, to or fewer supplies than planned, track vaccina- offer it to all Americans. CDC does not antici- tions, and monitor potential adverse effects that pate any vaccine shortages. people may have to the vaccine. In 2008, HHS conducted a review of state pandemic plans and Based on what is currently known about the found that 29 states and D.C. were adequately H1N1 virus, the federal Advisory Committee on prepared to meet mass vaccination capabilities Immunization Practices (ACIP) issued a list of based on their plans, including Alabama, priority groups for the H1N1 vaccine including: Arkansas, California, Connecticut, Delaware, I Pregnant women; D.C., Georgia, Hawaii, Idaho, Illinois, Kansas, Louisiana, Maine, Massachusetts, Mississippi, I Household contacts and caregivers for chil- Nevada, New Hampshire, North Carolina, dren younger than six months of age; North Dakota, Oklahoma, Oregon, Rhode Is- I Health care and emergency medical services land, South Carolina, Tennessee, Texas, Utah, personnel; Vermont, Virginia, Washington, and Wiscon- sin.27 The additional states were determined to I All people from six months through 24 years have some gaps in preparations. of age; and 11 A. CHALLENGES FOR MASS VACCINATIONS Vaccinating millions of Americans presents a se- Unlike the typical seasonal flu, the H1N1 virus is ries of challenges. Traditionally, the United proving to be more dangerous for young adults States does not have strong mechanisms in place than it is for seniors. Historically, very low rates for providing mass vaccinations. of young adults get an annual flu shot, the rate is 24.1 percent for 18 to 49 year olds. The rate for The annual vaccine for seasonal flu is the largest this age group is highest in South Dakota at 37.8 existing program for adult vaccinations in the percent and is as low as 15.4 percent in Nevada. United States. However, only a fraction of adults This means the group that will be most at risk for receive this vaccine. In some states, the rates of more severe cases H1N1 is less informed and the adult vaccinations for the flu is as low as 25.5 least accustomed to getting vaccinations. One percent (Nevada), and even the state with the reason for the low vaccination rates for young highest vaccination rate, 49.2 percent in South adults is that individuals between 19 and 29 years Dakota, is less than half of the state’s population. old represent one of the largest and fastest grow- Seasonal flu shots have been largely recom- ing segments of the population without health mended for seniors above the age of 65, since insurance and often do not have a regular doctor they are most at risk for health complications re- or do not seek regularized or preventive care.28 lated to the flu. Even with targeted efforts to Reasons for being uninsured include that many vaccinate seniors, the rates of annual flu vacci- low-income young adults are ineligible for public nations for seniors is as low as 61.3 percent in programs, move between schools and jobs, have D.C. and no state exceeds 80 percent. The high- shorter job tenure, and work at entry-level tem- est rate is 78.1 percent in New Hampshire. porary jobs that do not provide health insurance. 12 SEASONAL FLU VACCINATION RATES FOR ADULTS, 2008 State 18-49 Year Olds 50-64 Year Olds 65 Years and Over Total Alabama 26.3% (+/- 2.8) 41.8% (+/- 2.8) 68.7% (+/- 2.7) 37.9% (+/- 1.9) Alaska 26.7% (+/- 3.5) 43.0% (+/- 4.9) 68.5% (+/- 6.3) 35.2% (+/- 2.8) Arizona 22.2% (+/- 3.6) 39.4% (+/- 4.6) 71.4% (+/- 3.2) 34.8% (+/- 2.6) Arkansas 27.7% (+/- 2.7) 44.9% (+/- 2.8) 70.5% (+/- 2.5) 40.1% (+/- 1.8) California 18.4% (+/- 1.5) 39.5% (+/- 2.2) 70.0% (+/- 2.2) 30.8% (+/- 1.1) Colorado 28.9% (+/- 1.6) 48.6% (+/- 1.9) 77.9% (+/- 1.7) 40.4% (+/- 1.2) Connecticut 28.3% (+/- 2.6) 45.7% (+/- 3.0) 74.6% (+/- 2.4) 41.1% (+/- 1.8) Delaware 26.1% (+/- 3.0) 46.7% (+/- 3.9) 69.6% (+/- 3.5) 38.8% (+/- 2.2) D.C. 30.3% (+/- 2.8) 44.2% (+/- 3.3) 61.3% (+/- 3.5) 38.2% (+/- 2.0) Florida 17.7% (+/- 2.5) 32.4% (+/- 2.8) 63.5% (+/- 2.5) 31.4% (+/- 1.7) Georgia 21.8% (+/- 2.3) 38.6% (+/- 2.8) 65.2% (+/- 2.9) 31.8% (+/- 1.7) Hawaii 31.9% (+/- 2.5) 47.4% (+/- 2.8) 77.1% (+/- 2.5) 44.2% (+/- 1.7) Idaho 20.8% (+/- 2.3) 39.5% (+/- 2.8) 68.4% (+/- 2.9) 33.0% (+/- 1.7) Illinois 20.8% (+/- 2.2) 38.6% (+/- 3.0) 63.2% (+/- 2.9) 31.9% (+/- 1.7) Indiana 21.5% (+/- 2.6) 39.9% (+/- 3.1) 68.6% (+/- 3.1) 34.1% (+/- 1.9) Iowa 32.7% (+/- 2.4) 48.2% (+/- 2.7) 76.5% (+/- 2.2) 44.8% (+/- 1.7) Kansas 26.9% (+/- 2.0) 43.5% (+/- 2.1) 72.0% (+/- 1.9) 38.9% (+/- 1.4) Kentucky 25.8% (+/-2.5) 43.6% (+/- 2.6) 73.6% (+/- 2.3) 38.6% (+/- 1.7) Louisiana 27.5% (+/- 2.3) 43.6% (+/- 2.6) 68.0% (+/- 2.8) 38.2% (+/- 1.6) Maine 25.0% (+/- 2.1) 47.3% (+/- 2.3) 74.6% (+/- 2.2) 40.6% (+/- 1.5) Maryland 26.8% (+/- 2.0) 46.3% (+/- 2.4) 69.8% (+/- 2.5) 38.5% (+/- 1.4) Massachusetts 28.5% (+/- 1.6) 45.8% (+/- 1.8) 72.0% (+/- 1.7) 40.5% (+/- 1.1) Michigan 23.0% (+/- 1.8) 41.8% (+/- 2.1) 70.0% (+/- 2.0) 35.7% (+/- 1.3) Minnesota 36.8% (+/- 2.9) 50.4% (+/- 2.9) 76.4% (+/- 2.6) 46.6% (+/- 2.0) Mississippi 24.7% (+/- 2.2) 38.4% (+/- 2.3) 67.5% (+/- 2.2) 35.5% (+/- 1.5) Missouri 26.5% (+/- 2.8) 45.1% (+/- 3.3) 71.3% (+/- 2.8) 39.2% (+/- 2.0) Montana 25.3% (+/- 2.6) 40.9% (+/- 2.5) 69.3% (+/- 2.4) 37.8% (+/- 1.7) Nebraska 33.0% (+/- 2.4) 51.3% (+/- 2.3) 75.7% (+/- 1.8) 45.2% (+/- 1.6) Nevada 15.4% (+/- 2.3) 29.6% (+/- 3.5) 57.1% (+/- 3.9) 25.5% (+/- 1.8) New Hampshire 28.9% (+/- 2.2) 49.4% (+/- 2.5) 78.1% (+/- 2.1) 42.6% (+/- 1.6) New Jersey 22.9% (+/- 1.9) 39.9% (+/- 2.2) 65.9% (+/- 2.2) 34.8% (+/- 1.3) New Mexico 28.0% (+/- 2.6) 42.3% (+/- 2.8) 69.7% (+/- 2.6) 38.6% (+/- 1.8) New York 24.8% (+/- 2.1) 43.9% (+/- 2.6) 70.9% (+/- 2.4) 37.6% (+/- 1.5) North Carolina 28.4% (+/- 1.7) 47.3% (+/- 1.9) 73.0% (+/- 1.6) 40.4% (+/- 1.2) North Dakota 30.0% (+/- 2.8) 45.4% (+/- 2.7) 73.2% (+/- 2.4) 42.1% (+/- 1.9) Ohio 24.2% (+/- 1.9) 42.0% (+/- 2.0) 70.3% (+/- 1.8) 37.1% (+/- 1.3) Oklahoma 27.8% (+/- 2.0) 51.3% (+/- 2.4) 73.2% (+/- 2.1) 41.8% (+/- 1.4) Oregon 20.7% (+/- 2.3) 43.2% (+/- 2.7) 70.1% (+/- 2.6) 35.3% (+/- 1.7) Pennsylvania 23.7% (+/- 2.0) 43.2% (+/- 2.3) 71.7% (+/- 2.0) 38.3% (+/- 1.4) Rhode Island 28.1% (+/- 2.8) 49.9% (+/- 3.0) 74.0% (+/- 2.6) 42.0% (+/- 2.0) South Carolina 23.6% (+/- 2.3) 42.9% (+/- 2.7) 68.0% (+/- 2.4) 36.3% (+/- 1.6) South Dakota 37.8% (+/- 2.7) 53.6% (+/- 2.6) 76.3% (+/- 2.1) 49.2% (+/- 1.8) Tennessee 29.0% (+/- 3.2) 42.7% (+/- 3.1) 70.8% (+/- 2.8) 39.5% (+/- 2.1) Texas 24.8% (+/- 1.9) 42.1% (+/- 2.5) 71.1% (+/- 2.2) 35.4% (+/- 1.5) Utah 30.7% (+/- 2.4) 48.6% (+/- 3.2) 73.3% (+/- 3.0) 39.8% (+/- 1.8) Vermont 26.1% (+/- 2.1) 46.9% (+/- 2.2) 73.4% (+/- 2.2) 40.2% (+/- 1.5) Virginia 29.3% (+/- 3.3) 48.0% (+/- 3.6) 73.1% (+/- 3.1) 40.7% (+/- 2.4) Washington 26.3% (+/- 1.3) 44.2% (+/- 1.4) 71.4% (+/- 1.4) 38.0% (+/- 0.9) West Virginia 23.5% (+/- 2.4) 46.5% (+/- 2.9) 71.1% (+/- 2.8) 39.1% (+/- 1.8) Wisconsin 28.9% (+/- 2.8) 44.4% (+/- 3.2) 73.0% (+/- 3.0) 40.5% (+/- 2.0) Wyoming 27.7% (+/- 2.0) 44.8% (+/- 2.1) 70.7% (+/- 2.1) 39.5% (+/- 1.4) National Totals 24.1% (+/- 0.5 ) 42.0% (+/- 0.5 ) 69.5% (+/- 0.5 ) 36.1% (+/- 0.7) Source: Behavioral Risk Factor Surveillance System. For more information on the methodology, see Appendix A. 13 Also, experts believe children may be at in- retary of Education Arne Duncan believes “to creased risk for contracting H1N1. Typically, open our doors [at schools] and be part of the children receive some required vaccinations be- solution really makes sense.”29 In fact, hundreds fore starting school through their health care of schools across the country are participating provider or sometimes through public health in what could be the most widespread vaccina- departments, but few children regularly get flu tion effort since polio.30 A survey by the National shots, which are available later in the fall and are School Boards Association found that approxi- not required for school entry. Officials around mately three-quarters of school districts plan to the country are exploring ways to quickly try to allow vaccinations to be distributed in school reach children when an H1N1 vaccine becomes buildings.31 In New York City, all primary school widely available, including the possibility of mak- aged children will be offered both the H1N1 ing vaccines available through schools. U.S. Sec- and seasonal flu vaccination at no cost.32 MONITORING VACCINE SAFETY As with any immunization or medication, receiving a flu shot has the potential to cause various side ef- fects. Generally, reported side effects for influenza vaccines include post vaccination fever, soreness at the vaccination site, runny nose, headache, vomiting, and abdominal pain. The symptoms are typi- cally mild, and rarely interfere with the recipient’s daily routine.33 HHS created the Vaccine Adverse Event Reporting System (VAERS). VAERS is a cooperative program for vaccine safety between CDC and FDA. The system collects information about adverse events and possible side effects that occur after the administration of U.S. vaccines. Vaccines and Payment Issues The hybrid public-private vaccine delivery sys- I If a person gets vaccinated through a public tem in the United States makes the distribution health department mass vaccination location and administration of vaccines complicated. or through a private pharmacy, the payment The health insurance system is comprised of for the administration of the shot may be cov- thousands of separate coverage arrangements ered by the government in some places or the governed by multiple laws that lack common state may charge people for their shot or the content or coverage and payment requirements. state may try to bill the person’s insurance, de- Some issues presented by this system, in the con- pending on the state’s plan. text of H1N1 mass vaccination include: L There are no systematic policies for assuring I The federal government will pay for the actual third party reimbursement for administra- vaccine, but not the administration of the vac- tion of vaccines in emergency situations, cine. Instead, the federal government will work even when an individual has insurance. with states and localities to determine how and Some private insurance companies have vol- where to distribute the shots effectively. untarily indicated they will pay, but how broad that coverage will be remains to be de- I The shots will be made available in varied ways termined. America’s Health Insurance in every state and locality in the country based Plans (AHIP) has stated that, “Every year on the plans that each state has in place to health plans contribute to the seasonal flu best meet local need. vaccination campaign in several ways: a) I Vaccinations will be available through a num- Health plans communicate directly with ber of different places, including through plan sponsors and members on the current doctors’ offices, through public health de- ACIP recommendations and encourage im- partment distribution locations, and likely munization; they also provide information through private pharmacies in stores. on where to get vaccinations, and who to contact with any questions. b) Just as health I Payment methods for the administration of plans have provided extensive coverage for the vaccines could vary depending on where the administration of seasonal flu vaccines a person gets a shot. in the past, public health planners can make I Some insurance companies will cover admin- the assumption that health plans will provide istration of the shots, while others may not. reimbursement for the administration of a 14 novel (A) H1N1 vaccine to their members Department of Labor (DOL) also oversee the by private sector providers in both tradi- state regulated insurance market for both small tional settings e.g., doctor’s office, ambula- group and individual coverage as a result of the tory clinics, health care facilities, and in Health Insurance Portability and Accountability non-traditional settings, where contracts with Act (HIPAA). Finally, DOL oversees the admin- insurers have been established.” [sic.]34 istration of health benefit plans offered by private employers. As of 2009, around 60 percent of pri- L According to CDC, providers may charge vate employers sponsored health benefit plans for patients if they are uninsured. The admin- their employees.39 Virtually all of these plans op- istration fee cannot exceed the regional erate under the authority of the Employee Re- Medicare vaccine administration fee. How- tirement Income Security Act (ERISA). Finally, ever, there will be no administration fee for the Internal Revenue Service (IRS) oversees the vaccination in public-health organized awarding to tax-free status to the 2,900 non-gov- large scale vaccination clinics.35 ernmental, nonprofit hospitals in the United L Medicare will reimburse for their beneficiar- States, which includes requiring these hospitals ies. Medicaid coverage is determined by the meet defined “community benefit” standards. states, and, according to the U.S. Govern- Sara Rosenbaum, JD, Chair of the Department ment Accountability Office (GAO), in four of Health Policy at The George Washington Uni- states, Medicaid does not even cover regular versity School of Public Health and Health Serv- flu vaccinations for adults.36 ices, conducted an analysis for TFAH to I For the uninsured or in places where individ- determine what actions federal agencies could uals are expected to pay for shots, the cost may take to help improve vaccine administration is- deter many individuals from seeking vaccines. sues, which found that as of mid-September: One in seven Americans lack health insur- I Medicare has updated and clarified their poli- ance.37 The Seasonal Influenza and Pandemic cies to make sure the administration of shots Preparation Act of 2009, introduced by Sen. are covered for their beneficiaries at no cost, Tom Harkin in May, would establish a nation- including no deductibles or coinsurance pay- wide voluntary influenza vaccination program ments, and to permit roster billing. Medicare under which any individual may receive an an- has not clarified their policies around out-of- nual influenza vaccine, free of charge.38 network coverage for beneficiaries or Three major insurance issues surround H1N1 im- Medicare Advantage patients.40 munizations. These issues may create barriers that I Medicaid should update their policies around deter low-income families and individuals from co-pays, roster billing, or out-of-network is- seeking immunizations. The concerns include: sues. They should clarify that their polices I Determining whether an insurance provider should provide coverage for administration of will require a co-pay or deductable for receiv- the vaccine and out-of-network medical care ing an H1N1 immunization; related to H1N1 and allow for roster billing. The program covers 60 million individuals in- I Making it easy for providers to bulk bill insur- cluding the nation’s most vulnerable low-in- ance companies or government insurance come and medically high-risk individuals. providers for payment though a method called H1N1 vaccine administration is covered for roster billing, instead of filling out individual children enrolled in Medicaid through the paperwork claims for every single patient; and early and periodic screening, diagnostic and I Allowing for out-of-network coverage, so that treatment benefit (EPSDT). patients can go to available locations adminis- I DOL has the ability to communicate with tering vaccines without concern for whether ERISA-governed health benefit plans offered they are part of their official insurance network. by private employers to encourage them to The federal government has direct oversight re- provide information to all of their beneficiaries sponsibilities for certain health insurance arrange- about the importance of getting vaccinated; ments and can set policies for these programs, waive co-pay requirements for vaccinations; including Medicare, Medicaid, and the Children’s and waive out-of-network restrictions for vacci- Health Insurance Program (CHIP). In addition, nations; and provide state and local public the federal government plays a key oversight role health departments with information about in the case of health benefit plans covering the vaccination rates and progress to the extent federal civilian and military workforce (Office of covered by law (ERISA does not pre-empt pub- Personnel Management (OPM) and the U.S. De- lic health reporting requirements). partment of Defense (DOD)). HHS and the U.S. 15 I OPM and DOD can also communicate with the Another challenge is that many individuals may contractors that manage their health plans to need two vaccines during the upcoming flu sea- encourage that they provide information to all son, one for the seasonal flu and one for of their beneficiaries about the importance of H1N1.42 Health officials have expressed con- getting vaccinated; waive co-pay requirements cerns that many individuals could become con- for vaccinations; and waive out-of-network re- fused and only try to get one of the two shots, strictions for vaccinations; and provide state or that some individuals who are at high risk for and local public health departments with in- seasonal flu may put off getting their seasonal formation about vaccination rates and progress flu shot until both shots are available and they to the extent covered by law. can try to get the shots at the same time. I The U.S. Treasury Department, of which the Health officials advise that people should get IRS is one of the divisions, could remind non- their seasonal flu shot as soon as possible, and profit hospitals that immunization is a key then get an H1N1 shot as soon as they can once community benefit and encourage that they it is available. actively work to provide vaccines to the com- In order to get as many people vaccinated as pos- munity and extend hours and their workforce sible, CDC has recommended extending the tra- to help state and local health departments ditional flu vaccination period, normally October with community vaccination efforts. The IRS through January, to September through May.43 found has found that in the past, nearly one in two nonprofit hospitals spent nothing on immunizations, and for those who did, many may have charged for the care.41 UPGRADING FLU VACCINE DEVELOPMENT AND PRODUCTION IN THE UNITED STATES In an effort to increase the availability of vaccines for infectious diseases and potential bioterrorism threats, Congress created the Biomedical Advanced Research and Development Authority (BARDA). BARDA awarded a $487 million multiple year contract in January 2009 to Novartis Vaccines and Diagnostics, Inc. to build the first United States facility to manufacture cell-based vaccine for seasonal and pandemic influenza.44 GLOBAL DISPARITIES OF VACCINES The manufacturing capacity for influenza vaccines is very large globally, yet even if all companies worked on producing only a vaccine for H1N1 there would still not be enough for everyone in the world.45 During a global health crisis it is imperative that all countries, rich or poor, have equal access to vaccines. For the H1N1 vaccine, three major manufacturers -- GlaxoSmithKline, Sanofi-Aventis, and Novartis -- have all indicated the possibility of offering tiered pricing, as well as donating up to 100 million doses to a stockpile for poor countries.46 In addition, the United States has announced that it will donate 10 percent of its H1N1 vaccine supply to the World Health Organization for use in low- income countries. The other countries making donations are Australia, Brazil, Britain, France, Italy, New Zealand, Norway and Switzerland.47 Poor countries face issues with acquiring adequate amounts of vaccines, but fortunately they have an advantage in mass distributions. Many poor countries have had recent experience with mass vaccinations against diseases such as polio, measles, and hepatitis B.48 Wealthy countries, manufacturers, and regulatory agencies all have a responsibility to continue to make sure vaccinations are distributed quickly and fairly to all countries. 16 III. BUDGET CUTS AND HEALTH DEPARTMENT WORKFORCE SHORTAGES Public health departments around the country icant cuts during economic downturns. While are understaffed and underfunded, which few states allocate funds directly for public health makes it challenging to carry out pandemic preparedness, state and local funding is essential plans. The current economic crisis makes the for supporting public health infrastructure and problem even worse, as many state and local core capacities of health departments. health departments are facing budget cuts. Health departments around the country are also Historically, funding for public health emer- facing severe workforce shortages. Around one- gency preparedness has focused on responding fourth of public health workers are eligible for re- to the crisis of the moment. This has lead to a tirement.50 That problem is worsening as state pattern where new funds are appropriated to re- and local governments cut their budgets. The spond to a new threat, but these funds are typi- National Association of County and City Health cally a one-time allocation or erode over time, Officials (NACCHO) found that local health de- and do not address many of the underlying partments eliminated 8,000 staff positions in the problems in the system. first half of 2009, which adds to the 7,000 local public health jobs lost in 2008.51 According to After September 11, 2001 and the anthrax at- NACCHO, local health department staffing lev- tacks, Congress made a major investment aimed els this coming fall and winter are less than they at upgrading America’s public health system. were this past spring, even though demands are However, the funding was only a fraction of what greater as the H1N1 outbreak is expected to be would be needed to truly modernize public much more widespread. The Association of State health systems across the country. Over the and Territorial Health Officials (ASTHO) reports years, this funding for state and local public similar problems at state health departments. health preparedness has eroded. In FY 2009, funding for state and local public health pre- States are further hampered by current restric- paredness was down 25 percent from FY 2005 tions which do not allow employees who are sup- levels. Although the current Administration ported by federal dollars to be reassigned or proposed restoring $15 million in state and local “loaned” from their categorically defined and preparedness dollars in the FY 2010 budget, that funded programs to help with the H1N1 re- does not undo the damage the cuts in previous sponse at the discretion of local health depart- years had on public health preparedness. ments. For instance, without new direction from the federal government, an employee sup- During the spring outbreak, the capacity of ported by federal dollars in the environmental health departments to track, investigate, and con- health division may not be temporarily reas- tain cases of H1N1 was pushed to the limit due to signed to work on the H1N1 response. CDC has lack of resources. In addition to the 25 percent recently issued guidance to states to allow for cut of federal funds to support state and local pre- greater flexibility on the use of categorical funds paredness from FY 2005 to FY2009, 48 states are and assets to respond to H1N1, but other fed- experiencing shortfalls in their budgets for FY eral agencies, including the Substance Abuse 2010. The shortfalls total $168 billion, which is and Mental Health Services Administration one-quarter of state budgets, according to the (SAMSHA), the Health Resources and Services Center on Budget and Policy Priorities.49 Public Administration (HRSA), and the Women, In- health funding is typically discretionary spending fants, and Children (WIC) Program, have not. in states and therefore, often experiences signif- 17 STAFFORD DISASTER RELIEF AND EMERGENCY ASSISTANCE ACT The Stafford Act is a federal law that provides statutory authority for a Presidential declaration of an emergency or a declaration of a major disaster.52 The Act helps quickly disperse federal funds to state and local governments, families, individuals, and certain nonprofit organizations. Actions the Act authorizes include setting up temporary housing, dispersing grants for immediate needs of families and individuals, the repair of public infrastructure, and organizing emergency communications systems. Generally, in order for assistance to be granted, the President must receive a request from the Governor of an affected state, unless the incident involves primarily Federal interests. When considering whether to grant relief for the request the President evaluates a number of factors, including the cause of the catastrophe, damages, needs, certification by state officials that state and local governments will comply with cost sharing and other requirements, and official requests for assistance. The Federal Emergency Management Agency (FEMA) has established thresholds which are evaluated by the President and Department of Homeland Security (DHS) officials in determining whether to declare a disaster or emergency. By way of executive orders, the President has delegated the responsibility of administering the provisions of the Stafford act to FEMA.53 Funding for the Stafford Act is appropriated to the Disaster Relief Fund (DRF), which is overseen by DHS. Money in the DRF is a “no-year” appropriation and remains in the fund until it is used in full. The Stafford Act authorities were designed to address localized natural disasters. Some experts suggest revisions may be needed to facilitate appropriate federal support in response to an emergency, such as a pandemic. 18 IV. PREPAREDNESS IN COMMUNITIES Clear, consistent, culturally-competent commu- more important to vaccinate a target population nication with the public is essential during a dis- in advance of the rest of a community. ease outbreak so that health departments and Health officials will rely on communicating the providers can let people know about latest de- importance of non-pharmaceutical interventions velopments, how to best protect themselves, (NPIs) to reduce people’s exposure to the virus. when they should limit their public activities and As noted by GAO, some health officials hope that avoid going to work or school, and when and spreading out the number of people who become where they should go for medications or vacci- ill at any given time, “can help the health care sys- nations. This includes letting people know the tem by reducing the anticipated influx of patients prioritization plans for vaccinations when limited by limiting the rate of disease transmission.”54 amounts of vaccine may be available or when it is Types of Non-Pharmaceutical Interventions Type of NPI Definition Isolation The separation or restriction of movement of individuals ill with an infectious disease to prevent transmission to others. Quarantine The separation or restriction of movement of individuals exposed to an infectious disease, but not yet ill, who may become infectious to others. Social distancing Measures taken to decrease the frequency of contact among people, such as the closing of schools, shopping malls, or movie theaters, or the cancellation of large public events. Infection control Hygiene measures to reduce the risk of transmission from infected individuals to uninfected individuals, including hand washing, cough etiquette, use of masks, and disinfection. Source: CDC Sick Leave One proven non-pharmaceutical intervention leave, another 100 million workers do not have to slow or curb the spread of a pandemic is to sick leave that enables them to take time off to stay home if you are sick, or keep your child care for an ill child, spouse, or parent. home if they are sick. At a news conference in In new guidance issued on August 19, 2009, late April President Obama emphasized this: “If CDC recommends actions businesses should you are sick, stay home. If your child is sick, take to decrease the spread of influenza in the keep them out of school.”55 workplace during the 2009 flu season.59 One This advice presents special challenges for the recommendation is to keep sick workers home nearly half of American workers in the private sec- and not let them return to work until 24 hours tor who do not have any paid sick leave available. after their fever is gone. The guidance stresses This amounts to more than 59 million people.56 the importance of allowing sick workers to stay This statistic also disproportionately includes home without fear of losing their job. women, low-wage, and part-time workers. Draft guidance by the U.S. Office of Personnel In an already unstable economic situation, indi- Management (OPM) suggests that the govern- viduals who are sick and should stay home may ment may extend new leave policies to federal em- still go to work for fear of lost wages or losing ployees providing care to family members with the their job. According to Debra L. Ness, the pres- H1N1 flu.60 Federal employees would be able to ident of the National Partnership for Women use accrued or accumulated sick leave to stay and Families, “This could be the beginning of a home to care for a family member if a doctor or spiral into economic disaster. People can’t just other health official determines that their pres- cavalierly put their jobs or paychecks at risk.”57 ence in the workplace might jeopardize the health of co-workers and to use advanced sick leave if they This could mean that restaurants, child care have exhausted their annual allotment. The pro- centers, nursing homes, hotels, public transit sys- posal is not likely to go into effect until well into tems, schools, and offices across the country the H1N1 outbreak, however, and the proposed could be operated and run by individuals in- rules would not affect government contractors, fected with the flu who should be at home, not who often do not have any sick leave available. at work.58 In addition to lacking personal sick 19 A. CHILDREN’S ISSUES How to treat and care for the nation’s 73.6 mil- ease. Children gather in groups -- in school, in lion children and adolescents during an in- childcare settings, on playgrounds, in households, fluenza pandemic raises unique concerns.61 An and elsewhere -- and often are careless when it estimated 67 million of these children and youth comes to their personal hygiene. They cough and are in schools or childcare facilities at any given sneeze, not always taking care to do so into a tis- point during the week.62 With so many children sue, or into their sleeves, which many pediatri- spending a large percentage of their time at cians consider the next best alternative. Instead, school it is important to consider what will hap- they cough into their hands, and then touch other pen in the fall and winter of the H1N1 pandemic. objects -- a door knob, a computer mouse or key- board, toys -- or other people, including other Children are not “small adults” and special con- children. Moreover, it is challenging to try to sideration needs to be given to complicated is- teach very young children “cough etiquette,” or sues ranging from child-appropriate doses of to get them to wash their hands frequently. medications and vaccines to caring for children if schools and childcare facilities are closed for Three federal agencies (HHS, Department of extended periods. Parents and other caregivers Homeland Security, Department of Education), may also become sick during a pandemic, com- and Sesame Workshop, the nonprofit educational plicating their ability to care for children. organization behind the television show Sesame Street, have gotten together to launch a public Children are at disproportionate risk for spread- service advertising (PSA) campaign. The PSA ing virus (and have been disproportionately af- uses Sesame Street’s Elmo and Gordon to en- fected by H1N1 so far). According to findings courage children and families to practice healthy reported by CDC, children ages five to 14 be- habits including washing hands, sneezing into the came ill with H1N1 at a rate of 147 per 100,000 bend of your arm, and avoiding contact with your people in Chicago from April to July— a rate 14 eyes, nose and mouth to minimize the spread of times higher than that of the elderly.63 H1N1. The PSAs can be found at www.flu.gov and Public health experts agree that children infected will also be distributed nationwide and aired on with influenza are major transmitters of the dis- airtime donated by television stations.64 Vaccinating Young Children Currently, ACIP recommends that all children The decision to recommend flu vaccinations for aged six months to 18 years should be vaccinated all children six month and older weighs the ben- against the flu every year. In 2004, ACIP expanded efits and risks associated with vaccinating chil- the age range for routine vaccination to include dren. A number of studies found a low risk of children aged six to 23 months, and finally in 2006, minor adverse events in vaccinated children, such they further expanded the recommendation to in- as local skin reaction to injected vaccine, and clude all children aged 24 to 59 months.65 wheeze or irritability after nasal dose of vaccine, and serious adverse affects, including hospital- CDC explains the expansion to a greater num- ization or death, were almost negligible.67,68,69 ber of children because of the following: Although recommended for children under I Growing evidence that the flu vaccine is ef- two, other issues exist when it comes to vacci- fective and safe for children; nating very young children. The current flu vac- I Accumulated evidence that the flu has sub- cine is given annually, and young children are stantial adverse impacts among children and recommended to get two doses the first year for their contacts such as school absenteeism, in- optimal results.70 It is important to note that creased antibiotic use, medical care visits, and children are recommended to receive up to 16 parental work loss; and different immunizations before turning two, and adding two more injections to an already I The expectation that an age-based flu vaccine crowded schedule can be difficult for parents. recommendation for all children and adoles- Traditionally in the United States, there has cents will improve vaccination rates among been a gap in vaccination rates for preschool children who already should be receiving the aged children. Around 20 percent of preschool- vaccination due to another factor putting ers have gone without recommended vaccinates them at heightened risk.66 every year for the past three decades, leaving ap- 20 proximately two million children at increased Some reasons that contribute to this vaccination risk of preventable diseases.71 Rates of low vac- gap include: an underfunded and underutilized cination are particularly a concern in minority immunization registry system; public misper- and low-income communities, where it is often ceptions about the importance of vaccines and difficult to reach and communicate with parents their safety; and systemic issues, such as vaccine before children enter a formal school system. supply, distribution, and inadequate funding. School-Based Actions to Reduce Exposure CDC issued new guidance on school responses in pandemics with a high proportion of disease to influenza just before the start of the 2009- among school-age children. Given the high at- 2010 school year.72 CDC includes two action tack rate among children in this pandemic and plans, the first is to be followed if the fall out- the frequent clusters and outbreaks reported in break has similar severity as in the spring 2009, schools both in the spring and since schools and a second set of guidance in the case that the started reopening in the late summer and early fall outbreak is more severe than the spring 2009 fall, school dismissals in this pandemic might be outbreak. In each set of guidance, CDC recom- useful under conditions of increased severity. mends a series of activities to reduce exposure After the initial outbreak, on May 1, 2009 CDC of students, faculty and staff to the flu viruses issued guidance recommending school dismissal within the school setting. when H1N1 infection was detected in any stu- The actions recommended for the current level of dent.73 Shortly after, as more information about severity of influenza disease include ensuring that: H1N1 was collected and the virus was found to be less harmful than anticipated, on May 4 CDC I Ill students stay home released updated guidance recommending I Students who fall ill during the school day be school closings only if the absenteeism of faculty promptly isolated while awaiting parents to or students became so large that it interfered take them home with the school’s ability to function.74 I All students are able to perform adequate In the weeks following the first cases of H1N1 hand hygiene hundreds of schools closed across the United States. In response to school closings Kathleen I Students are encouraged to practice respira- Sebelius, the health secretary acknowledged tory etiquette that, “There is a large ripple effect. What hap- I Facility staff perform routine cleaning of fre- pens to the parents? Where do those children quently touched surfaces go? Do you close the day care center if a younger sibling is there? Many schools’ and communi- I Students at high risk for complications seek ties’ emergency plans will be put to the test dur- early treatment if they have symptoms of flu ing the weeks and months to come.”75 I Specialized schools serving students at high Closing schools for up to two weeks triggers a risk of complications consider selective school number of social corollaries. Seeking alternative dismissals if flu is prevalent in the community. child care arrangements is especially compli- Under conditions of greater severity, more dis- cated when the intent is to keep children sepa- ruptive non-pharmaceutical interventions might rated from one another. Workplace absenteeism be recommended. These include active screen- increases as parents need to stay home with chil- ing of students upon arrival, allowing high risk dren, who may or may not be ill. It is important students or staff to stay home, household quar- to remember that U.S. schools provide more antine of well siblings of ill students, increasing than educational services -- including subsidized the physical distance of students within the meals and before and after school care -- which school, extending the isolation period for sick also are disrupted when a school closes. A large students, or school dismissals. percentage of low-income families rely on food assistance programs like the National School The most disruptive intervention to reduce Lunch and Breakfast program, and in the case school-based exposure to flu is school dismissal. of school closures many children could go hun- The effect of school dismissal on reducing trans- gry. The U.S. Department of Agriculture mission in the school or in the community is dif- (USDA) is exploring contingency plans for al- ficult to measure. While observational studies ternative delivery of meals to students in the and models have shown mixed results, the bene- event of school closings. ficial effect of school dismissal is most apparent 21 In just the few days that schools were closed parents polled said that school or daycare clo- across the country, many state and local public sures would cause them or someone in their health officials found the implementation of household to miss work.77 Forty-three percent school closures to be difficult and burdensome said this kind of closure would likely cause a loss on communities.76 Children were being of income and money problems, and over a dropped off at libraries and community centers quarter of parents responded that having to stay because so many parents lacked the sick leave to home with children would cause them to lose stay home with their children. their job or business. The poll also showed that school closures would have a disproportionate In a public opinion survey conducted by the impact on minorities. Harvard School of Public Health, over half of B. AT-RISK COMMUNITY ISSUES Many of those who are likely to be affected most mented individuals may not seek medical care due by a resurgence of H1N1 are vulnerable popu- to lack of coverage and fear of potential legal reper- lations such as pregnant women, uninsured, and cussions.78 This presented an issue in a number of minorities. The elderly are not considered high- communities during the spring outbreak of H1N1, risk for H1N1, but they are a high-risk category and can be particularly problematic during an in- for the seasonal flu and they often also have un- fectious disease outbreak, when the individual may derlying medical conditions. be putting others in the community at risk by not seeking care.79 ASTHO has developed an At-Risk Individuals with mental illnesses, the homeless, and Populations and Pandemic Influenza: Planning Guid- undocumented immigrants are also categories of ance for State, Territorial, Tribal, and Local Health De- special concern, as they are often underserved or partments to assist states in planning.80 un-served by the medical community. Undocu- 1. Minority Populations Multiple reports reveal that H1N1 has had a dis- Health workers in the city of Boston are pledg- proportionate effect on racial and ethnic mi- ing to improve outreach to the more vulnerable norities. communities for the fall flu season. The Mayor of Boston, Thomas M. Menino, also promised I In Chicago, a study found that from April that he would make it possible for all city em- through late July African-Americans were hos- ployees to take two hours of paid work time to pitalized at a rate of nine per 100,000, Hispanics get flu shots when they become available. at a rate of eight per 100,000 and whites at a rate of two per 100,000. Health officials say that the Racial and ethnic minority communities tend to difference is most likely not genetic, but rather experience higher rates of injury, disease, trau- because some minorities suffer from more matic stress, death and loss in public health chronic conditions like asthma and diabetes emergencies. According to Drexel University’s that make them more vulnerable to the flu. Center for Health Equality, the reasons behind these disparities include:82 I African-American and Hispanic residents in Boston account for more than three of every I Historic societal patterns of neglect; four residents who have visited the hospital in I Lower socioeconomic status; the recent months because of H1N1.81 In Boston, 71 city residents were hospitalized I Culture and language barriers; with swine flu -- 49 percent of whom were I Distrust of service providers; African-American and 28 percent were His- panic, double each minority group’s presence I Lower perceived risk from disasters and lim- in the city. The two groups also account for a ited preparation; and disproportionate share of the 477 laboratory I Reliance on informal channels of information. confirmed cases of H1N1 in Boston. A literature review of studies on the prepared- Disease specialists suggest that overcrowding in ness of racially and ethnically diverse communi- urban areas and underlying chronic conditions ties found limited information regarding such as diabetes make African-Americans and emergency preparedness and minorities.83 Hispanics more prone to the complications of Many studies that exist highlight problems with influenza. information, communication, and education. 22 I Currently, emergency preparedness informa- tion does not correctly translate -- leading to mis- tion is disseminated primarily through the In- communication of the public health message. ternet, which is a problem because its use is I Communication messages to minority and im- often limited for minorities, particularly for migrant populations must be targeted specifi- people whose first language is not English. In cally to each group, according to a 2007 study fact, only one in three emergency preparedness published in the Journal of Health Care for the websites include content in foreign language. Poor and Underserved, because “cultural groups I One study also found that the mere translation respond to risk and crisis communication on of English-language material to other languages the basis of their perceptions and ways of think- is not enough -- often times the literal transla- ing, and these differ from group to group.”84 Mistrust of the Health System In order to help minority communities be re- rina through: mobilization of resources, providing silient, they must be provided with culturally ap- services to survivors, brokering relationships be- propriate information, resources, and training tween individuals and the larger disaster response for emergency preparedness. After Hurricane community, and acting as moral agents and social Katrina, one study found that “a majority of justice advocates on behalf of evacuees.87 African-Americans and Asians, and half of His- Communities that have limited numbers of pro- panics feel they can no longer rely on the Amer- ficient English speakers are at a disadvantage ican system and its institutions to protect their when it comes to preparing for a pandemic. Not family during a crisis.”85 Because of mistrust only does the language difference cause a bar- from minority populations toward the American rier, but also the cultural differences. A pilot health system, the best way to overcome cultural program in Seattle, Washington with medical in- barriers and spread public health messages is terpreters assessed limited English proficient through community based organizations. communities and found the following: Training community members as volunteer com- I Medical interpreters found a need for more munity health workers or health promoters is an disaster preparedness training and education important way to connect minority communities in order to adequately do their job; with the health care system and to ensure that im- portant public health messages are received and I Medical interpreters reported that limited understood.86 Churches are another under- English-proficient (LEP) communities are not tapped resource in disseminating emergency pre- prepared for disasters; and paredness information. Research shows that I Medical interpreters said there is a need for cul- African-American ministers and their religious in- turally appropriate information and education. stitutions played a huge role after Hurricane Kat- Vaccinations Although seasonal influenza vaccinations are I Mistrust toward the health care system.89 fairly safe and inexpensive, disparities in those Yet, even after accounting for provider visits, ac- who are vaccinated exist in the United States. cess to care, socioeconomic status, health insur- Minority groups have much lower rates of sea- ance, perceived health, chronic disease, and sonal influenza vaccination compared with demographics, racial/ethnic differences in in- whites.88 In 2004 and 2005, 66 percent to 69 per- fluenza vaccinations still exist.90 A study of cent of whites were vaccinated compared with Medicare beneficiaries found that African Amer- 48 percent to 55 percent for Hispanics and only icans were significantly less likely than whites to 45 percent to 50 percent for African Americans. report positive attitudes toward influenza vacci- Hispanics and African Americans also have nation. In order to increase minority vaccina- higher rates of mortality from seasonal influenza tion rates interventions must address negative and pneumonia compared with whites. beliefs and misinformation. Individualized, cul- Some explanations for disparities in influenza turally appropriate, evidence-based interven- vaccination include: tions were found to be effective in increasing vaccination rates among disadvantaged, racially I Barriers to access such as cost, insurance sta- diverse, inner-city populations. Prior to the tus, and language differences; health trial only 27.1 percent of participants had I Underestimation of personal risk and misun- received an influenza vaccination, and at year derstanding of vaccination risks; and four the rate had increased to 48.9 percent.91 23 2. Health Care Workers Another at-risk segment of society is health care Only 33 percent of respondents believed the ma- workers. In June 2009, CDC reported that 81 jority of their employee members would show up U.S. health care workers contracted the H1N1 to work during a pandemic.96 influenza virus, about half of whom caught it on Various studies show that health care workers the job.92 may not go to work during a pandemic for fear Health care workers must take extra care to not of becoming infected.97 A study in 2005 of al- spread the virus to their patients as well as pro- most 6,500 employees in long-term care facili- tect their own health, and one easy way is to get ties and outpatient centers found that less than the seasonal and H1N1 influenza vaccination. It two-third of employees reported an ability to go may be more of a challenge than expected to en- to work in the case of a severe acute respiratory courage health care workers to get vaccinated. syndrome outbreak.98 Another smaller study For instance, the seasonal flu vaccination rates found that just barely more than half of em- have typically been low for health care workers. ployees of county health departments would re- According to a study of a group of over 1,000 port to work during an influenza pandemic.99 registered nurses in four states, only 59 percent One way to decrease health care worker absen- reported receiving seasonal influenza vaccine teeism during a pandemic is to put measures in during the 2005-2006 flu season.93 The most place before the pandemic occurs. Protective common reason for not receiving a vaccine was measures will give employees confidence that concern about adverse reactions. Those most their employer will protect them during a pan- knowledgeable about the vaccine were more demic. Plans to protect employees include: per- likely to receive a vaccination. sonal protective equipment, identification and Advisory Committee on Immunization Practices isolation of infected patients, identification of (ACIP) recently released recommendations ad- health care workers who will provide care for in- vising which populations should be prioritized to fected cases, worker training, and securing ade- receive H1N1 vaccines in the fall.94 Health care quate supplies of safety equipment, antiviral workers and emergency medical responders can drugs, and vaccine.100 The Institute of Medicine be found at the top of the list. The list accounts (IOM) recently issued recommendations for for approximately 159 million people -- about half how to best protect workers when there may not the population -- yet by mid-October at most only be adequate supplies, which is particularly of po- 52 million doses are expected to be available. In tential concern for N-95 respirator masks.101 the case that the supply is not adequate, health Many health care workers visit their patients at care workers will be bumped from the highest home. Approximately 85 percent of the 1.5 mil- priority group, but certain eligible health care lion home health care workers are low-wage workers will still be among the first vaccinated. workers, represented mostly by women and mi- CDC and the Occupational Safety and Health norities.102 These home health care paraprofes- Administration (OSHA) recently provided guid- sionals provide personal assistance with activities ance for standards to protect health care work- such as bathing, toileting, and cooking. The ers in the case of a pandemic.95 A survey number of patients cared for at home generally developed by six trade unions representing is three times the number of patients cared for health care workers found that many workplaces in hospitals. Data from a 1997-1999 Current are not ready for pandemic influenza. More Population survey found that only half of home than one-third of respondents said that their care aides had some form of health insurance.103 workplace is at best “slightly ready” to address the During a pandemic, home health care workers needs of health care workers during a pandemic. will be very important because many unpaid care Worker training and communication scored very providers may become ill or unable to continue poorly. Less than half of facilities surveyed re- providing care. Also, in order to increase the ported they had been provided training on pan- number of beds available during a surge many demic flu, had been communicated their hospitalized patients will be discharged early and employer’s pandemic flu plan, had been taught home health care workers will be able to help by how to recognize flu symptoms in themselves, or offering their services during a pandemic. had conducted drills of their pandemic flu plan. 24 PROVIDING VACCINATIONS AND HEALTH CARE WORKERS On August 13, 2009 New York adopted a new regulation requiring health care workers in the state to be vaccinated for both seasonal and H1N1 influenza.104 The regulation affects workers at hospitals, in home health care agencies and hospice care, but because of a technicality in the language it does not include nursing homes. Until the new regulation, vaccinations for health care workers were only voluntary and fewer than half of health care workers were getting an annual flu shot. The regulation requires applicable workers to get the seasonal flu vaccine as well as the new H1N1 vaccine. Workers and volunteers who have any contact with patients will be required to get vaccinated -- including nurses, doctors, aides, and even nonmedical staff such as food service workers. Shortly after the New York regulation, Massachusetts enacted a measure that requires hospitals and clinics to make the H1N1 vaccine available to all workers and certain volunteers.105 Although most health care settings already have vaccines available, the measure “emphasizes the importance of being vaccinated to physicians, nurses and other health care workers.” The Massachusetts Public Health Council also voted to allow dentists, pharmacists and paramedics to administer flu vaccinations in an effort to supplement the opportunities for individuals to get vaccinated. 3. The Elderly Currently, there are an estimated 14 million people aged 65 or older, approximately 80 per- cent of whom live with some level of disability according to the 2000 U.S. Census.106 During seasonal influenza approximately 90 per- cent of severe and fatal cases occur in people 65 years of age or older, but in the current outbreak, the elderly are not at the top of the list of vulner- able populations -- children are 14 times more likely to be infected than the elderly.107 However, it is important that the elderly are highly encour- aged to get the seasonal flu vaccination. There are also ongoing concerns for vaccinat- ing and providing treatment for the elderly when they have limited mobility. In a public health emergency, “conditions such as stress, the lack of food or water, extremes of heat or cold, and exposure to infection can contribute to the rapid worsening of a chronic illness that was dition, many elderly have underlying health con- under control before the event,” according to ditions, which can make them susceptible for Preventing Chronic Disease.108 In addition to complications when they contract a disease. chronic conditions, older adults may suffer from impaired mobility or cognitive ability, poor vi- Significant numbers of seniors do not live in in- sion or hearing, and economic limitations. stitutionalized care settings, but still often have limited mobility. Ensuring care for seniors with Many elderly live in nursing homes or in retire- limited mobility and reaching them with vacci- ment communities, which are densely populated nations presents a series of challenges. Public communities where infectious diseases can spread health departments often include senior out- rapidly. Many facilities provide seasonal flu vac- reach plans, but these are difficult to implement cine, but since the elderly are not on the priority in regular times and will be even more difficult list for H1N1 vaccine, they will not receive the vac- during a widespread outbreak where officials cine early in season, so institutional care facilities will be dealing with numerous challenges across must work hard to promote non-pharmaceutical a range of populations. interventions to limit the spread of disease. In ad- 25 4. Pregnant Women Observations from H1N1, past pandemics, and The study acknowledges the short time frame seasonal influenza show that the flu can be more and small pool of subjects, but concludes that, severe for pregnant women. “Pregnant women might be at increased risk for complications from pandemic H1N1 virus in- According to a study conducted shortly after the fection. These data lend support to the present initial outbreak of H1N1, pregnant women in- recommendation to promptly treat pregnant fected with H1N1 were more likely to be hospi- women with H1N1 influenza virus infection with talized from the flu, and they also had a greater anti-influenza drugs.”111 chance of death.109 The findings come from data reported between April 15 and May 18, For years CDC and the American College of Ob- 2009, during which time there were 34 probable stetricians and Gynecologists have urged expec- cases of H1N1 in pregnant woman, 11 were ad- tant mothers to get the seasonal influenza mitted to the hospital and six of the cases re- vaccine, but less than 15 percent follow the rec- sulted in death.110 Pregnant women make up ommendation.112 Many women are hesitant to one percent of the U.S. population, but at the get the vaccine for fear of injury to the fetus. In time of the study they accounted for six percent new guidance, CDC recommends that women of all deaths from H1N1. exhibiting flu-like symptoms should be immedi- ately treated with antiviral medications.113 26 V. RECOMMENDATIONS “ THIS IS NOT ABOUT RAISING ALARMS OR STOKING FEARS, BUT ABOUT BEING PREPARED. KATHLEEN SEBELIUS, HHS SECRETARY114 ” During infectious disease outbreaks, public prehensive pandemic influenza plans over the last health departments serve as the front lines for several years. State and local emergency pre- identifying, monitoring, and developing strate- paredness planners had exercised these plans and gies for containing outbreaks. Federal, state, and learned from them, which helped them respond local health departments, health care providers, to the outbreak effectively. We also saw a willing- businesses, schools, and communities around ness on the part of both federal and state public the country are working tirelessly to prepare for health officials to adapt their pandemic response H1N1 and the seasonal flu this fall and winter. plans based on the real-life situation on the ground and on the science of the pandemic. For The investments made over the past several years example, CDC updated and revised its school clo- to bolster pandemic preparedness in the United sure guidance as it became apparent that H1N1 States have led to tremendous improvements in was circulating widely in communities and shut- federal, state, and local response capabilities, in- tering schools and sending school kids home was cluding greatly enhancing vaccine research and having no effect on containment. Federal and development and the stockpiling of antiviral state officials also were able to provide clear, medications. And the efforts since the spring straightforward information to the public, which H1N1 outbreak, including $1.9 billion in emer- was essential for allaying fears and building trust. gency supplemental funding and an additional $5.8 billion in contingency funds, have filled in At the state and local level, public health depart- gaps to support vaccine production, upgrading ments and medical systems developed innovative state and local capabilities, improving surveil- practices to deal with the H1N1 outbreak, in- lance systems, and federal preparedness. cluding the use of alternate care sites to screen, sort, diagnose, and treat patients complaining of Gaps remain, however, in some critical areas. flu-like symptoms. In some cases, these sites were Health officials inherited many legacy problems, tents set up outside hospitals, in other cases these including the need to address surge capacity were virtual sites or telephone call numbers, and weaknesses in the public health infrastruc- staffed by trained medical personnel, who could ture, which hinder their ability to do their jobs answer questions and ease the burden on hospi- as effectively as possible. tals. State governments also worked hard to Many public health preparedness experts believe reach out to vulnerable populations, including the best way to gauge how well communities are low-income residents and those with limited-Eng- prepared for emergencies is through drills or ex- lish proficiency. The Los Angeles County Health ercises. The H1N1 outbreak provides a real-life Department issued fact sheets in 11 languages. opportunity to assess and learn the strengths and We also saw local governments rely on volunteer vulnerabilities of preparedness capabilities all health care workers to staff some of these alter- around the country. As of now, the H1N1 virus nate care sites and call centers. Again, these suc- is considered relatively mild, so while the num- cesses highlight the importance of the investment ber of Americans who could become sick, hospi- in pandemic and all-hazards preparedness. talized, or even die will be significant, it provides The following are recommendations that ad- the chance to see how well-prepared communi- dress: some immediate concerns that must be ties are during a more controlled outbreak as op- considered for responding to the current H1N1 posed to a worse-case scenario. season and for a third wave of H1N1 that will In addition, federal, state, and local governments likely emerge next year; and longer term recom- and the health care community have already mendations that will help shore up core public learned a great deal from their experiences dur- health systems to better prepare the country for ing the Spring H1N1 outbreak. What the rapid future emergencies and disease outbreaks. In- response to the H1N1 crisis showed is that the vestments made in preparing for and responding large federal investment in pandemic planning to H1N1 will also have long-lasting impact in up- and stockpiling antiviral medications paid off. All grading the nation’s public health system. 50 states and many U.S. cities had developed com- 27 SHORT-TERM RECOMMENDATIONS: Vaccination Campaigns I Refine plans for rapid distribution and ad- I Payment systems for vaccine administration ministration of vaccinations: H1N1 will pres- must be improved: While the federal govern- ent the first mass vaccination effort to be ment will pay for the purchase and distribu- conducted in a short time frame in modern tion of vaccines, payment for the U.S. history. States and localities should con- administration of vaccines will be the respon- tinue to revise plans for the most effective sibility of insurance providers, state or local ways to provide vaccinations once they are health officials, or in some cases, it possibly available. Federal, state, and local officials will become an out-of-pocket cost for individ- need to identify if additional resources are uals. Clear policies and effective systems must needed to pay for administration of vaccines, be established as quickly as possible to ensure especially if third party payers do not provide that health departments, health care adequate coverage for the insured. providers, clinics, pharmacies, and other or- ganizations who will be administering the vac- I Special efforts must be made to reach out to en- cines to individuals will receive compensation. courage young adults, minorities, and other at- risk groups to get vaccinated: Health L Medicare and Medicaid should ensure their departments must intensify efforts to encourage policies cover the administration of H1N1 high-risk individuals to get H1N1 vaccinations. vaccines and out-of-network care for H1N1 Young adults, pregnant women, and minorities, related illnesses and to allow providers to in particular, traditionally have low flu vaccina- bulk bill for the administration of vaccines tion rates and often do not know where or how to their beneficiaries through roster billing. to get vaccinations. In addition, a significant L DOL should communicate with ERISA-gov- percentage of young adults do not have health erned health benefit plans offered by pri- insurance, which could deter them from going vate employers to encourage them to waive to get vaccinations. Outreach to minority pop- co-pay requirements for vaccines and out- ulations must reflect culturally-competent com- of-network restrictions and to provide in- munications and be delivered by respected, formation to state and local health trusted, and culturally-competent messengers. departments to help with their vaccination I Vaccination campaigns must continue past the campaigns in communities. fall to prepare for a potential third wave out- L OPM and DOD should work with their con- break: The fact that the H1N1 vaccine will tractors to waive co-pay requirements for likely not be available to the entire population vaccines and out-of-network restrictions in October and that the virus is proving to be and to provide information to state and mild so far could mean that efforts are not health departments to help with their vac- made to try to encourage the entire popula- cination campaigns in communities. tion to get vaccinations. It is likely, however, that a third wave outbreak of H1N1 will occur, L The Treasury Department and IRS should and it could become more virulent. Federal, remind nonprofit hospitals that immuniza- state, and local health departments should tions are a key community benefit, and the make plans to encourage all Americans to get importance of meeting community benefit vaccinated even past the height of the fall and standards as part of retaining tax-free sta- winter outbreak, in case there is a third wave tus. They should encourage nonprofit hos- H1N1 outbreak and to help people build im- pitals to be an active part of vaccination munity for potential future related flu strains. campaigns in communities, making their facilities and staff available to work with I Vaccine tracking systems must be enhanced to state and local health departments. monitor for adverse reactions: A better system is needed to track when vaccinations are adminis- tered. This is crucial for determining if anyone is having adverse effects related to the vaccine. 28 Stocking Medical Supplies and Antivirals I Replenish and update equipment in the SNS: less than half their share of federally-subsidized In the spring, 25 million N-95 respirator antiviral medications for use during a pan- masks were deployed from the SNS to states, demic outbreak. States that have not pur- but this inventory was never restocked, re- chased significant shares of their allotment of portedly due to lack of dedicated funding. antiviral should at least take action to purchase The current stockpile of 79.7 million N-95s is enough to be able to care for at-risk patients or considered to be severely lacking according to patients with severe cases of H1N1. It is un- a number of experts and now because of high clear how severe the H1N1 virus will prove to demand, the product is on back order. be with high-risk populations this fall and it will likely re-emerge in a third wave, so states I States should purchase enough antiviral med- should be prepared by having enough med- ications to care for at-risk patients in the im- ications to protect their citizens if needed. mediate term: CDC has recommended that Over the long-term, antiviral purchasing poli- antiviral medications be used only for people cies should be updated to make purchasing an- with severe cases of H1N1 or for people with tiviral, vaccines, and equipment for the SNS a underlying health conditions. Many states federal responsibility. Until that happens, have purchased their full share of antiviral states should take action to ensure they have medications, however 13 states have purchased enough medications to protect their citizens. Surveillance I The surveillance recommendations in the sistant to antivirals. HHS officials have been President’s Council of Advisors on Science working hard to improve systems so they can and Technology (PCAST) report should be monitor the spread of H1N1, and the PCAST fully-funded and implemented: Disease sur- report identifies specific ways to continue to veillance systems in the United States have upgrade H1N1 surveillance systems and capa- been out-of-date for decades. Having rapidly bilities to link systems among hospitals, health available data that is easily accessible is essen- departments, and other health providers, to tial to allow experts to track the course and compile real-time data. Enough resources severity of the disease, determine who is most should be devoted to ensuring these recom- at risk when, identify when additional antivi- mendations are carried out as swiftly as possi- rals or equipment are needed in a particular ble, and officials should find ways to leverage community, detect adverse reactions to the these capabilities and lessons to modernize all vaccine, or learn if the disease is becoming re- U.S. disease surveillance systems. Providing Care in Communities I States and localities should follow CDC guid- whether the Department of Labor’s Disaster ance for school and day care closures: Com- Unemployment Assistance Program would munities around the country should follow cover workers without sick leave who self-quar- the federal guidance on school closures and antine in the event of a pandemic flu. Con- find the balance between limiting the spread gress should pass legislation that would require of disease and causing social disruption by employers with 15 or more employees to offer closing schools. a minimum of seven paid sick days each year, to be used to deal with individual medical needs I An emergency health benefit should be es- or to care for sick family members. tablished: Congress should establish an emer- gency health benefit to ensure hospitals and I Health providers and health departments health care providers can function and get should develop and disseminate strong pub- compensated for providing care for the unin- lic messages about ways to practice good hy- sured and underinsured during a public giene and understand symptoms and health emergency, to maintain the solvency of remedies: Hospitals and health providers the healthcare system and ensure all patients should develop a public messaging system to receive needed care. give people information about symptoms and remedies to prevent unnecessary trips to the I Emergency sick leave should be made avail- emergency room and they should have pan- able: The federal government should clarify demic plans in place to protect employees. 29 I Federal, state, and local health departments I The federal government should lift restric- should share lessons, innovations, and re- tions to allow states to reassign employees sources: Better systems should be developed for supported by federal funds to be able to real-time sharing of approaches and innovations help with the H1N1 response: Federal across different states, communities, and juris- waivers should be granted to release federal dictions. In addition, neighboring communities categorically funded program staff to assist should share and coordinate to the extent pos- with response at the discretion of local sible plans for policies for providing care and in- health officials. formation, and if necessary, resources. I Health care personnel should follow the guid- I HHS and DHS should institute a policy that no ance from HHS and OSHA on the best way to one who contracts H1N1 should be denied care: protect health care personnel: Given there is HHS and DHS should issue a joint statement likely going to be a shortage of N-95 respirator outlining a policy that undocumented individu- masks in many communities, officials should als who receive care for H1N1 will not be sub- clearly communicate guidance to health fa- ject to enforcement action in order to ensure cilities on the best way to allocate personal that people who are sick will seek care, which protective equipment and reduce the need helps prevent the spread of the disease and also for respirators among health care workers. limits emergency room visits by patients who delay seeking care until they are severely sick. LONG-TERM RECOMMENDATIONS: The following are a series of recommendations sponse, these should be used to update federal, that would help shore up the nation’s core public state, and local preparedness planning. There is health system, which is essential for responding to still the threat of the H5N1 “bird” flu circulating future and ongoing health emergencies. In addi- and ongoing concerns about future infectious dis- tion, as lessons are learned from the H1N1 re- ease outbreaks, bioterrorism, and natural disasters. Surge Capacity I Disaster Standards of Care: The IOM re- health emergencies. Such regional collabora- cently issued guidance for establishing stan- tion can lead to more efficient use of resources dards of care for use in disaster situations. among hospitals and health departments, in- The guidance is a “preliminary framework” cluding personnel, and facilitate the sharing of that describes the key elements that should be promising practices. This should include all fed- included in disaster standards of care proto- eral resources active in each region. cols and a template matrix for state and local I Surge Workforce: Hospitals, health care health departments for developing specific providers, and public health departments guidance for health providers to use when should redouble efforts to recruit additional there is a major influx of patients. Major dis- medically-trained staff for times of emergency. aster standards of care issues include surge ca- This includes creating incentive systems for pacity planning for when health providers are employees to work overtime and to find overtaxed, space is limited, and equipment is trained volunteers who can be screened and scarce and issues of alternate care sites (such would be ready and reachable during times of as public arenas or malls), as well as legal and emergency. Issues of liability protection must ethical issues, which should be carefully con- also be addressed. Many volunteers and pri- sidered in advance instead of during the time vate entities have expressed reluctance to par- of a crisis. The H1N1 outbreak provides a ticipate in emergency health response efforts mass test of the health care system, however, due to concerns about liability. A number of because the virus is currently mild, it will allow states have passed legislation to protect vol- for adjustments and modifications, including unteer health professionals. The federal gov- learning how to adapt the system for more se- ernment could also take measures to extend vere emergencies. liability protections if Congress amended the I Regional Coordination: Hospitals, local health Public Health Service Act to provide Federal departments, and emergency management Tort Claims Act protection to qualified health agencies should work to establish more regional professionals when they are activated during consortiums to organize and plan for public emergencies, and Congress could also con- 30 sider a minimum protection to address liabil- influx of patients. Planning must include how ity issues for businesses and non-profit organ- to provide continued care for daily emergen- izations who work with government officials cies and chronic care during emergencies, responding to emergencies. separating infectious patients from others in intake and emergency departments, and dis- I Hospital Plans: Hospitals and health care couraging the “worried well” from over- providers must have clear and practiced plans crowding emergency rooms. in place to respond to emergencies or a major Fund and Modernize Core Public Health I A fully-funded and reliable funding stream is out-of-date and do not provide real-time or needed to support public health prepared- easily accessible data. The upgrades to sur- ness: Public health infrastructure has been veillance during the H1N1 should be used to underfunded for decades, according to as- leverage upgrading the rest of U.S. disease sessments from CDC, IOM, and other experts. surveillance capabilities. The nationwide im- Federal funding for core state public health plementation of health information technol- preparedness was cut 25 percent between FY ogy systems through the American Recovery 2005 and 2009. It is important that states have and Reinvestment Act and health reform pro- a reliable, dedicated, and sustained level of posals must take into account the need for funding that is adequate to meet core capa- public health data accessibility. bilities and to continue to keep pace with new I Additional core public health infrastructure technologies that can help them better meet capabilities must be modernized: There is no the needs of communities. Congress should system in place to ensure that the basic public assure a robust, reliable funding stream health systems and equipment keep pace with through health reform legislation for all core advances in science and technology. There public health activities. needs to be a systematic way to ensure that the I A mechanism should be created to ensure that technology and equipment that support core vaccines, medications, and equipment in the functions, like laboratory testing and com- SNS are replenished and upgraded as needed: munications, are routinely updated. Right now, there is no systematic way to en- I Pandemic plans must be continually revised: sure that new supplies are purchased to re- As the emergence of H1N1 demonstrated, place used items so the country will be new strains of flu can emerge quickly and rap- prepared for the next emergency. After the idly. In addition, experts are still concerned H1N1 outbreak, it will also be essential that that the H5N1 “bird” flu could potentially be- the SNS and states replenish the supply of an- come a human pandemic. It is essential that tiviral medications to prepare for the poten- the National Strategy for Pandemic Influenza tial threat of future outbreaks. and state plans be continually revised. Plans I All U.S. disease surveillance systems must be should particularly be updated to incorporate modernized: The nation’s disease surveil- the lessons learned during the H1N1 out- lance and health tracking systems are severely break and response. MAJOR FLU OUTBREAKS OF THE 20TH CENTURY115 1918 -- The “Spanish” flu pandemic killed 500,000 in the United States, 50 million worldwide. 1957-58 -- An outbreak spread from China across the globe, killing approximately 70,000 in the United States. In April 2005, a company testing laboratory proficiency mistakenly distributed samples of this pandemic strain to laboratories worldwide, triggering worldwide concern until all samples were accounted for and destroyed.116 1968-69 – The “Hong Kong” flu, the most recent pandemic, affected millions worldwide and dis- rupted world economies. 1997 – The first identification of the avian “bird” flu H5N1, which remains active in Asia.117 2009 – As of August 13, 2009, the H1N1 virus was reported in over 175 countries, with nearly 5,000 hospitalizations and more than 475 deaths in the United States. 31 APPENDIX A: METHODOLOGY FOR SEASONAL FLU VACCINATIONS Data for this analysis was obtained from the Be- swered, “don’t know” or refused to answer. These havioral Risk Factor Surveillance System accounted for less than 0.5 percent of all obser- (BRFSS) dataset (publicly available on the web vations. Researchers then calculated flu vaccina- at cdc.gov/brfss).118 To conduct the analyses, tion rates for three different population samples TFAH contracted with Edward N. Okeke, MBBS, – individuals aged 18-49, individuals aged 50-64, MPH at the Department of Health Management and individuals 65 and older – for each state. and Policy at the University of Michigan School The research team reported 2008 flu vaccination of Public Health. The variable of interest was the rates for each sub-sample, along with standard FLUSHOT variable.119 Researchers weighted errors and 95 percent confidence intervals. Re- data from 2008 using sample weights provided spective sample sizes for each sub-sample were by the CDC in the dataset and dropped observa- 151,903, 130,713, and 121,459. tions where either the survey participant an- 32 APPENDIX B: POTENTIAL PANDEMIC INFLUENZA CASES, HOSPITALIZATIONS AND BED CAPACITY Potential Pandemic Influenza Cases, Hospitalizations and Bed Capacity Pandemic at a 15% Attack Rate Pandemic at a 25% Attack Rate State Cases Hospital Bed Capacity Cases Hospital Bed Capacity Admissions at Week 5 Admissions at Week 5 Alabama 689,855 9,654 23% 1,149,758 16,089 39% Alaska 100,508 1,220 25% 167,513 2,034 41% Arizona 924,948 12,584 50% 1,541,580 20,973 84% Arkansas 421,631 5,931 22% 702,718 9,885 36% California 5,468,632 72,011 54% 9,114,387 120,018 89% Colorado 713,007 9,397 38% 1,188,344 15,662 63% Connecticut 525,721 7,416 63% 876,202 15,430 132% Delaware 128,021 1,799 87% 213,369 2,998 145% D.C. 87,230 1,244 20% 145,383 2,074 33% Florida 2,713,483 40,742 34% 4,522,472 67,903 57% Georgia 1,404,591 18,149 33% 2,340,985 30,249 56% Hawaii 192,825 2,747 61% 321,375 4,579 102% Idaho 219,970 2,915 28% 366,616 4,859 47% Illinois 1,924,796 26,114 31% 3,207,993 43,524 52% Indiana 947,028 12,957 24% 1,578,380 21,595 41% Iowa 447,313 6,408 22% 745,521 10,679 36% Kansas 414,611 5,713 18% 691,019 9,522 31% Kentucky 630,911 8,775 22% 1,051,519 14,625 37% Louisiana 643,165 8,735 20% 1,071,942 14,558 34% Maine 198,236 2,898 36% 330,394 4,830 59% Maryland 842,359 11,439 61% 1,403,932 19,065 102% Massachusetts 965,579 13,689 47% 1,609,298 22,816 79% Michigan 1,514,346 20,822 34% 2,523,911 34,703 56% Minnesota 775,065 10,615 29% 1,291,775 17,691 48% Mississippi 436,581 5,919 15% 727,635 9,864 25% Missouri 876,407 12,252 26% 1,460,678 20,419 43% Montana 141,695 2,017 21% 236,158 3,361 34% Nebraska 265,250 3,675 19% 442,083 6,126 31% Nevada 374,329 4,988 59% 623,882 8,314 98% New Hampshire 197,234 2,751 36% 328,724 4,585 60% New Jersey 1,308,684 18,219 43% 2,181,140 30,365 72% New Mexico 293,190 3,974 40% 488,650 6,624 66% New York 2,895,927 40,603 46% 4,826,546 67,671 77% North Carolina 1,328,476 18,199 41% 2,214,126 30,331 68% North Dakota 95,380 1,378 14% 158,967 2,296 23% Ohio 1,721,701 24,098 30% 2,869,502 40,163 50% Oklahoma 536,882 7,446 24% 894,803 12,410 41% Oregon 555,114 7,781 46% 925,190 12,968 76% Pennsylvania 1,866,093 27,245 33% 3,110,155 45,409 55% Rhode Island 160,142 2,296 61% 266,903 3,827 102% South Carolina 648,187 8,997 40% 1,080,312 14,995 66% South Dakota 117,288 1,655 16% 195,480 2,758 26% Tennessee 905,820 12,577 26% 1,509,701 20,962 43% Texas 3,526,167 45,123 28% 5,876,946 75,205 47% Utah 382,509 4,645 36% 637,516 7,742 59% Vermont 93,586 1,339 46% 155,977 2,232 77% Virginia 1,146,433 15,656 43% 1,910,721 26,093 72% Washington 959,370 13,060 46% 1,598,950 21,767 76% West Virginia 272,771 4,030 21% 454,618 6,717 34% Wisconsin 833,476 11,655 32% 1,389,127 19,426 53% Wyoming 77,251 1,065 17% 128,751 1,775 28% *Based on the CDC’s FluSurge model program. Estimates rely on FluSurge 2.0 Beta Test Software, created by the CDC. More information about the model is available at http://www.cdc.gov/flu/flusurge.htm. This scenario examines what would happen during a mild pandemic outbreak. The severity for this type of outbreak is based on the 1968 flu pandemic, which is considered relatively mild. The factors in the FluSurge model are set to assumptions based on the 1968 pandemic. The above assumes an outbreak would be 8 weeks in duration and that either 15 or 25 percent of the population would become ill. The data for the age demograhics are from the Census Bureau’s Current Population Survey, 2006, available at http://www.census.gov/. The bed statistics are based on the total number of licensed 2006 hospital beds (B) (which is available through Kaiser Family Foundation’s State Health Facts, available at http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi) and the typical hospital bed occupancy rates (R) (available for 2006 from CDC data and are available in the chart book, Health, United States, 2008). To determine the usual number of usual available beds, TFAH used the following formula – ((StatePop/1000) * B) x (1-R). 33 Endnotes Cancer Society’s Cancer Facts and Figures. http://www.cancer.org/downloads/STT/2008CAFF finalsecured.pdf. 1 President Barack Obama. Remarks by the President to 14 National Governors Association, Center for Best Practices. the H1N1 Preparedness Summit Via Telephone. July Pandemic Preparedness in the States: An Assessment of 9, 2009. http://www.whitehouse.gov/the_press_of- Progress and Opportunity. 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(accessed September 24, 2009). for Laboratory Workers and the Public.” (12 April 102 Baron, S, et. al. “Protecting Home Health Care 2005) http://www.who.int/csr/disease/influenza/ Workers: A Challenge to Pandemic Influenza Pre- h2n2 _2005_04_12/en/. (accessed 23 May 2005). paredness Planning.” American Journal of Public 117 World Health Organization. “Fact Sheet: Avian In- Health 99;S2: S1-SS7; 2009. fluenza.” (5 February 2004) http://www.who.int/ 103 Yamada, Y. “Profile of Home Care Aides, Nursing csr/don/2004_01_15/en/.6(accessed May 16, 2005). Home Aides, and Hospital Aides: Historical Changes 118 BRFSS is an annual cross-sectional survey designed and Data Recommendations.” Gerontologist. to measure behavioral risk factors in the adult 42;2:199-206; 2002. population (18 years of age or older) living in 104 Hartocollis, A. “State Requires Flu Vaccination for households. Caregivers.” New York Times. August 19, 2009. 119 The specific question asked by the CDC was “Dur- 105 Smith, A. “Massachusetts Enacts Measure Requir- ing the past 12 months, have you had a flu shot?” ing H1N1 Vaccination for Health Workers, Givers Other Clinicians Approval to Administer Vaccines.” Boston Globe, August 13, 2009. 106 He, W., et. al. 65+ in the United States: 2005. Wash- ington, D.C.: U.S. Department of Health and Human Services, National Institutes of Health, Na- tional Institute on Aging, and U.S. Department of Commerce, Economics and Statistics Administra- tion, U.S. Census Bureau, 2005. 37 ACKNOWLEDGEMENTS TFAH BOARD OF DIRECTORS Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. Lowell Weicker, Jr. President The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our Former 3-term U.S. Senator country. As the nation’s largest philanthropy devoted exclusively to improving the quality of the health and and Governor of health care of all Americans, the Foundation works with a diverse group of organizations and individuals to Connecticut identify solutions and achieve comprehensive, meaningful, and timely change. For more than 35 years, the Cynthia M. Harris, Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that PhD, DABT affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives Vice President and get the care they need, the Foundation expects to make a difference in your lifetime. Director and Associate Professor Institute of Public Health, REPORT AUTHORS PEER REVIEWERS Florida A&M University Jeffrey Levi, PhD. TFAH thanks the reviewers for their time, expertise, and Patricia Baumann, MS, JD Executive Director insights. The opinions expressed in the report do not Treasurer Trust for America’s Health and necessarily represent the views of the individuals or the President and CEO Associate Professor in the Department of Health Policy organization with which they are associated. Bauman Foundation The George Washington University James S. Blumenstock, MA Gail Christopher, DN School of Public Health and Health Services Chief Program Officer, Public Health Practice Vice President for Health Serena Vinter, MHS Association of State and Territorial Health Officials WK Kellogg Foundation Senior Research Associate David Fleming, MD John W. Everets Trust for America’s Health Director of Public Health David Fleming, MD Laura M. Segal, MA Seattle King County, Washington Director of Public Health Director of Public Affairs Crystal Franco Seattle King County, Trust for America’s Health Senior Analyst Washington Rebecca St. Laurent, JD Center for Biosecurity of the University of Arthur Garson, Jr., Health Policy Research Assistant Pittsburgh Medical Center MD, MPH Trust for America’s Health Jennifer Nuzzo, SM Executive Vice President Associate and Provost and the Center for Biosecurity of the University of Robert C. Taylor Professor Pittsburgh Medical Center of Health Science and Public Policy Eric Toner, MD University of Virginia Senior Associate Center for Biosecurity of the University of Robert T. Harris, MD Pittsburgh Medical Center Former Chief Medical Officer and Senior This report is supported by a grant from the Robert Wood Vice President for Johnson Foundation. The opinions expressed in this report Healthcare are those of the authors and do not necessary reflect the BlueCross BlueShield of views of the foundation. North Carolina Alonzo Plough, MA, MPH, PhD Director, Emergency Preparedness and Response Program Los Angeles County Department of Public Health Theodore Spencer Project Manager Natural Resources Defense Council 1730 M Street, NW, Suite 900 • Washington, DC 20036 (t) 202-223-9870 • (f) 202-223-9871 38