ISSUE BRIEF Fighting Flu Fatigue INTRODUCTION Last year, the H1N1 pandemic thrust the flu We continue to face a serious threat each flu into headlines around the globe. season. Seasonal flu is preventable with a vac- cine, yet millions of Americans still needlessly Even though it was viewed as a relatively mod- get the flu each year. The flu is often seen as erate pandemic, the novel H1N1 Influenza a nuisance, but it is actually very serious. Ac- (A) virus still had a serious impact on the cording to CDC, between 1976 and 2007, flu- United States -- infecting around 20 percent of related deaths in the United States have Americans (approximately 60 million individ- ranged from a low of around 3,000 to a high uals), and resulting in approximately 274,000 of 49,000 Americans each year.6 Even for hospitalizations and 12,000 deaths.1 More people who get sick, they need to take sick people were hospitalized from H1N1 than are leave from work, possibly costing their pay typically hospitalized from the seasonal flu. and costing employers in lost productivity About 90 percent of the Americans who died and the economy as a whole. In fact, the flu from H1N1 were under the age of 65, and at contributes to more than $10 billion in lost least 340 children died from H1N1.2 However, productivity and direct medical expenses in according to the U.S. Centers for Disease Con- the United States each year and another $16 trol and Prevention (CDC) the actual number billion in lost potential earnings.7 of deaths in children could be as high as be- tween 910 and 1,880. This year, following the H1N1 pandemic, the country could take two different paths: we The H1N1 outbreak dramatically raised could go back to a national complacency awareness about the threat that the flu poses, around the flu or we could build on the mo- but now that a vaccine is widely available for mentum of response efforts and work toward H1N1 as part of the seasonal vaccine and increasing the number of Americans who are concerns about the severity of the new strain vaccinated to spare millions from suffering of the virus have diminished, there is a real yearly from the seasonal flu and to better pre- likelihood that the country will return to pare the country for future health emergen- complacency in its attitude toward the flu. cies and disease outbreaks. Nevertheless, there remains a significant risk In this issue brief, the Trust for America’s that a more serious new “pandemic” strain of Health (TFAH) examines recommendations to the flu could still emerge. If a new flu virus build on the momentum created by the invest- emerged that was as severe as the 1918 pan- ments over the past several years, prepare for a demic, it could lead to 90 million Americans potential flu pandemic, enhance seasonal flu becoming sick, 2.2 million deaths, and major prevention and response efforts, and improve economic losses.3 According to Carolyn B. how the country routinely deals with the flu. Bridges, M.D., of CDC, “just because we’ve just had a pandemic does not mean we’ve de- The first section reviews ways to protect more creased our chances of having another. We Americans from the flu by increasing vacci- have to stay vigilant.”4 For instance, as one nation rates, and the second section exam- potential concern, as of August 2010, there ines issues that must be addressed to NOVEMBER 2010 have been 500 total cases – including 300 continue to prepare the country for future deaths – from the H5N1 “bird” flu that pub- pandemics and other health emergencies. PREVENTING EPIDEMICS. lic health officials and researchers around the PROTECTING PEOPLE. globe have been tracking.5 I. INCREASING FLU VACCINATION RATES FOR THE SEASONAL FLU AND FUTURE PANDEMIC FLU OUTBREAKS This year, for the first time, the Advisory Com- During H1N1, young children, young adults, mittee on Immunization Practices (ACIP), which and pregnant women were generally the top pri- advises CDC on vaccine issues, has recom- ority groups for vaccination. Since only a lim- mended that all Americans -- ages six months ited amount of vaccine was available at the start and older -- should be vaccinated this flu season. of the fall 2009 flu season, vaccination efforts A single vaccine will protect people against the first targeted the highest risk groups. As vac- seasonal viruses, which now includes H1N1. cines became more available, efforts expanded to vaccinate the general population. Since flu is highly preventable, encouraging all Americans to get vaccinated could greatly re- By the end of June 2010, around 27 percent of duce the number of people who get sick and die Americans -- more than 80 million individuals -- from flu complications -- and cut down on were vaccinated against H1N1.13 By the time vac- missed school days and lost productivity from cinations were opened up to the general popu- people who are out sick from the flu. lation, the virus had proven to be relatively moderate, which decreased much of the interest This recommendation is a dramatic shift in our and incentive for the rest of public to seek vacci- national approach to the flu and presents a major nation. The H1N1 vaccination rate for children challenge to implement. In an October 2010 was nearly double that of adults, with more than public opinion survey conducted by Consumer 40 percent of children receiving vaccinations, Reports, only 37 percent of respondents said they compared to fewer than 23 percent for adults.14 would definitely get this season’s flu vaccine.8 Seasonal flu vaccination rates reached histori- Traditionally, flu vaccination rates for adults (ages cally high levels -- with 40 percent of adults ages 18 and older) have been low. Only around 30 per- 18 and older and 44 percent of children ages six cent of American adults have routinely been vac- months to 17 years old receiving the seasonal flu cinated.9 One reason for these low rates is vaccination during the 2009-10 flu season.15 because there has been a long standing focus on vaccinating seniors (ages 65 and older), who are The following chart includes H1N1 vaccinations seen as one of the highest-risk groups for compli- by state for the initial period of the outbreak -- end- cations from the seasonal flu, and other high-risk ing in January 2010. During this time, many loca- groups, including young children and individuals tions initially had limited supplies of vaccine, with underlying chronic health conditions. For which they targeted toward the most high-risk the 2010-11 flu season a new high dose vaccine is groups. Nationally, including the time period available for those 65 and older.10 According to when the vaccine was widely available to the entire Dr. Greg Poland of the Mayo Clinic, the new vac- population and disease transmission had largely cine has four times the concentration of the ma- ended, overall vaccination rates only grew by two terial that stimulates the body to make antibodies, percent -- from nearly 25 to 27 percent -- from the causing greater protection for older adults.11 end of January to the end of the flu season. ACIP has not yet recommended a preference for Adult H1N1 vaccination rates were the highest the normal or high-dose vaccine for seniors. in South Dakota (34.4 percent), Maine (32.0 Focusing on vaccinating seniors has helped con- percent), and Minnesota (28.5 percent) and tribute to an imbalance in vaccination rates based lowest in Mississippi (8.7 percent) and Alabama on age. For instance, nearly 70 percent of seniors (10.7 percent). were vaccinated in 2008, while only 24.1 percent Childhood H1N1 vaccination rates were the of adults under the age of 50 were vaccinated. highest in Rhode Island (84.7 percent) and Ver- Child flu vaccination rates have also historically mont (72.3 percent) and lowest in Georgia (21.3 been low. During the 2008-09 flu season, only percent) and Louisiana (24.1 percent). 24 percent of children, ages 6 months to 17 years, received a seasonal flu vaccination.12 2 Estimated influenza A (H1N1) 2009 monovalent vaccination coverage among children and adults, by state -- United States, BRFSS and National 2009 H1N1 Flu Survey (NHFS), end of January 2010. State Children aged 6 mos to 17 yrs Persons aged ≥18 yrs % (95% CI) % (95% CI) Alabama 29.2 (+/-6.4) 10.7 (+/-1.9) Alaska 26.6 (+/-5.6) 24.5 (+/-8.8) Arizona 40.3 (+/-10.2)** 20.1 (+/-5.1) Arkansas 50.0 (+/-19.7)§§ ** 15.7 (+/-2.8) California 31.2 (+/-5.5) 17.7 (+/-2.9) Colorado 35.2 (+/-11.2)§§ ** 20.4 (+/-3.0) Connecticut 43.2 (+/-6.6) 15.2 (+/-3.8) Delaware 45.4 (+/-8.7) 18.8 (+/-4.6) DC 38.7 (+/-13.3) 14.6 (+/-4.5) Florida 32.3 (+/-6.1) 16.1 (+/-2.1) Georgia 21.3 (+/-5.0) 15.3 (+/-3.6) Hawaii 55.4 (+/-10.9)** 23.4 (+/-3.7) Idaho 29.5 (+/-5.6) 17.8 (+/-3.2) Illinois 37.5 (+/-5.9) 21.6 (+/-3.7) Indiana 46.7 (+/-7.7) 19.7 (+/-2.6) Iowa 47.7 (+/-6.7) 27.4 (+/-3.4) Kansas 39.4 (+/-6.5) 21.0 (+/-2.7) Kentucky 31.8 (+/-5.3) 17.1 (+/-2.6) Louisiana 24.1 (+/-4.3) 11.9 (+/-2.2) Maine 60.2 (+/-9.4) 32.0 (+/-5.1) Maryland 41.3 (+/-7.1) 21.4 (+/-2.8) Massachusetts 60.3 (+/-8.8) 27.8 (+/-3.3) Michigan 31.2 (+/-7.4) 15.3 (+/-2.6) Minnesota 44.2 (+/-5.8) 28.5 (+/-4.3) Mississippi 28.2 (+/-5.6) 8.7 (+/-1.9) Missouri 27.5 (+/-6.2) 12.7 (+/-2.7) Montana 33.6 (+/-5.6) 20.2 (+/-2.9) Nebraska 40.8 (+/-6.3) 24.0 (+/-3.1) Nevada 25.2 (+/-6.0) 15.8 (+/-3.5) New Hampshire 45.5 (+/-7.5) 22.9 (+/-3.9) New Jersey 32.7 (+/-4.6) 13.1 (+/-2.0) New Mexico 39.3 (+/-12.1) 23.7 (+/-6.2) New York 34.0 (+/-5.6) 18.3 (+/-3.8) North Carolina 44.7 (+/-17.4)§§ 21.4 (+/-3.5) North Dakota 42.1 (+/-6.3) 25.6 (+/-4.6) Ohio 33.5 (+/-5.4) 18.0 (+/-2.3) Oklahoma 25.2 (+/-5.4) 18.0 (+/-3.2) Oregon 35.3 (+/-6.3) 20.9 (+/-3.3) Pennsylvania 36.8 (+/-4.4) 14.5 (+/-2.2) Rhode Island 84.7 (+/-6.6) 26.6 (+/-5.2) South Carolina 37.6 (+/-5.8) 14.6 (+/-2.5) South Dakota 45.8 (+/-8.0) 34.4 (+/-4.8) Tennessee 34.5 (+/-10.0) 19.5 (+/-3.2) Texas 24.9 (+/-4.7) 13.7 (+/-2.1) Utah 31.0 (+/-6.1) 21.4 (+/-7.5) Vermont§§ 72.3 (+/-6.3) 25.9 (+/-7.1) Virginia 39.9 (+/-5.4) 22.6 (+/-3.6) Washington 36.6 (+/-6.5) 23.4 (+/-3.1) West Virginia 47.3 (+/-7.7) 18.2 (+/-2.7) Wisconsin 30.6 (+/-7.8) 21.2 (+/-4.0) Wyoming 32.6 (+/-6.0) 21.0 (+/-3.4) §§ Estimates are based on NHFS only. ** Estimates might be unreliable because confidence interval half-width is >10. Source: Centers for Disease Control and Prevention. “Interim Results: State-Specific Seasonal Influenza Vaccination Coverage —- United States, August 2009—January 2010” MMWR, 59(12);363-368, 2010. 3 In 2009-2010, seasonal flu vaccination rates for of 32.4 percent in Nevada. Seasonal flu vaccination adults ranged from a high of 52.5 percent in Min- rates for children ranged from a high of 67.2 per- nesota and 52.3 percent in South Dakota to a low cent in Hawaii to a low of 23.6 percent in Nevada. Estimated seasonal influenza vaccination coverage among children and adults, by state -- United States, BRFSS and National 2009 Flu Survey (NHFS), end of January 2010. State Children aged 6 mos to 17 yrs Persons aged ≥18 yrs % (95% CI) % (95% CI) Alabama 33.5 (+/-6.3) 36.4 (+/-2.9) Alaska 35.0 (+/-8.4) 37.2 (+/-5.8) Arizona 41.3 (+/-12.0)§ 40.4 (+/-4.8) Arkansas*^ 65.3 (+/-15.8)§ 41.0 (+/-3.7) California 33.7 (+/-4.8) 37.5 (+/-3.5) Colorado^ 42.9 (+/-11.3)§ 42.4 (+/-2.7) Connecticut 46.2 (+/-5.7) 41.3 (+/-4.1) Delaware^ 42.9 (+/-6.6) 42.2 (+/-3.8) DC^ 34.8 (+/-15.5)§ 41.4 (+/-5.0) Florida* 26.4 (+/-4.3) 33.0 (+/-2.2) Georgia 30.8 (+/-7.1) 35.4 (+/-4.0) Hawaii* 67.2 (+/-8.3) 47.6 (+/-3.0) Idaho 30.5 (+/-6.0) 35.1 (+/-2.8) Illinois 39.1 (+/-6.9) 39.0 (+/-3.1) Indiana 46.2 (+/-9.7) 39.2 (+/-2.5) Iowa 44.1 (+/-5.8) 50.2 (+/-3.1) Kansas* 38.3 (+/-3.8) 43.5 (+/-2.4) Kentucky 37.1 (+/-5.6) 42.3 (+/-3.1) Louisiana 42.2 (+/-5.2) 40.1 (+/-3.1) Maine* 57.2 (+/-7.5) 46.2 (+/-2.7) Maryland* 51.0 (+/-6.9) 42.3 (+/-2.7) § Estimates might be un- Massachusetts*^ 61.6 (+/-9.4) 47.5 (+/-3.0) reliable because confi- Michigan 32.4 (+/-5.9) 37.2 (+/-2.8) dence interval half-width is >10. Minnesota 49.2 (+/-5.5) 52.5 (+/-3.9) Mississippi 31.7 (+/-10.4)§ 36.0 (+/-2.6) * Child estimates were significantly different from Missouri 34.4 (+/-6.8) 39.7 (+/-3.4) adult estimates in the fol- Montana* 31.6 (+/-5.3) 39.4 (+/-2.8) lowing states: Maine, Nebraska 42.9 (+/-7.7) 49.7 (+/-3.1) Massachusetts, Maryland, Nevada* 23.6 (+/-5.2) 32.4 (+/-3.6) Pennsylvania, Florida, New Hampshire 49.7 (+/-6.9) 46.2 (+/-3.6) North Carolina, Arkansas, New Jersey^ 42.7 (+/-7.5) 36.1 (+/-2.4) Kansas, Montana, Hawaii, New Mexico 49.9 (+/-8.1) 44.3 (+/-3.5) and Nevada. New York 40.6 (+/-7.1) 39.8 (+/-2.8) ^ BRFSS data were not North Carolina*^ 59.8 (+/-14.9)§ 40.9 (+/-2.9) collected for children in North Dakota 45.5 (+/-7.4) 44.0 (+/-3.2) Massachusetts, Vermont, Ohio 35.3 (+/-6.1) 38.8 (+/-2.4) New Jersey, District of Oklahoma 37.2 (+/-6.8) 41.6 (+/-3.3) Columbia, Virginia, North Carolina, Arkansas, and Oregon 34.7 (+/-6.7) 39.2 (+/-3.0) Colorado. BRFSS data Pennsylvania* 47.8 (+/-6.5) 40.6 (+/-2.3) were not collected for Rhode Island 57.0 (+/-10.8)§ 48.5 (+/-4.0) adults aged 18-49 years South Carolina 32.6 (+/-6.0) 38.8 (+/-2.9) not at high risk in Ver- South Dakota 54.0 (+/-8.2) 52.3 (+/-3.9) mont and Delaware. Tennessee 44.5 (+/-8.9) 41.5 (+/-3.2) Source: Centers for Dis- Texas 40.5 (+/-4.7) 39.1 (+/-2.5) ease Control and Preven- Utah 36.5 (+/-8.6) 39.7 (+/-3.0) tion. “Interim Results: Vermont^ 46.8 (+/-7.4) 39.8 (+/-4.0) State-Specific Seasonal In- Virginia^ 40.8 (+/-6.0) 43.5 (+/-2.7) fluenza Vaccination Cov- Washington 43.9 (+/-7.4) 38.9 (+/-1.9) erage —- United States, West Virginia 41.2 (+/-9.8) 43.8 (+/-2.4) August 2009—January 2010” MMWR, Wisconsin 37.0 (+/-7.6) 40.6 (+/-3.3) 59(16);477-484, 2010. Wyoming 39.6 (+/-6.0) 39.7 (+/-2.5) 4 The H1N1 vaccination efforts revealed the need n Education about the need for a yearly seasonal to improve tracking systems of people who re- flu shot, focused on why everyone should get ceived vaccinations. Tracking systems are partic- immunized, and the safety of the shots; and ularly important for monitoring vaccine adverse n Increased easy access to flu shots, even to peo- events, adequate coverage of target populations, ple who are uninsured or do not receive reg- and any inequities in access to the vaccine. ular medical care. Encouraging more Americans to get vaccinated One strategy to begin increasing vaccination will be a challenge and require a significant edu- rates involves targeting high priority areas or cation effort to ensure Americans know the ben- areas that need special focus, including: efits and safety of the vaccine. An October 2010 public opinion survey from the National Foun- A. Increasing Education about the Need and dation for Infectious Diseases (NFID) found that Safety of Flu Vaccines, Especially to Minor- 43 percent of Americans do not plan to get a flu ity Groups: Even though flu vaccinations are shot this year.16 (The vaccine is available in both considered very safe and effective, many a shot and nasal spray form). Americans still harbor concerns about the safety of vaccines or believe myths that the Moving forward, in order to significantly in- vaccine can cause a person to get the flu. crease vaccination rates, a major campaign will be needed to provide: VACCINES ARE SAFE AND PROTECT THE COMMUNITY At the peak of fears over H1N1 flu, some groups worried seasons. It found that the vaccine was safe and offered clinical about vaccines perpetuated a myth that it was safer to get benefit that exceeded the risk.19 H1N1 than to be inoculated against it. But data from Califor- Severe adverse reactions to the flu vaccination are rare. nia show that getting the flu was much more dangerous. Ac- Other reactions are generally mild and self-limited, such as cording to statistics from the California State Department of soreness at the vaccination site, and seldom interfere with the Health, one in every 10,000 Californians who contracted recipient’s daily routine.20 H1N1 died.17 Out of 13 million Californians who were vacci- nated for H1N1, three people died, and it was not confirmed Officials also carefully examined the evidence before recom- that the deaths were necessarily linked to the vaccination.18 mending flu vaccines for all children six months and older. A number of studies found a low risk of minor adverse events in Flu vaccines are considered to be safe. They are monitored by vaccinated children, such as local skin reaction to injected vac- several systems, including the Vaccine Adverse Event Reporting cine, and wheezing or irritability after a nasal dose of vaccine. System (VAERS), a national voluntary reporting system jointly Serious adverse events, including hospitalization or death, operated by CDC and the U.S. Food and Drug Administration were rare and not necessarily caused by the vaccine.21,22,23 (FDA). The system collects information about adverse events and and it can potentially detect safety concerns, such as possi- In addition, a recent study of 49 Hutterite farming colonies in ble side effects that occur after the administration of vaccines. western Canada showed how giving flu shots to schoolchild- Another major safety monitoring system is the Vaccine Safety ren protects a whole community from the flu -- creating what Datlink (VSD), a collaboration between CDC and eight large is called “herd immunity.”24 Doctors gave flu shots to half the medical care organizations that conduct rapid population-based communities and placebos to the other half, and more than 10 monitoring of the safety of flu vaccines as well as other vaccines. percent of the adults and children in the placebo colony had confirmed seasonal flu, compared to less than five percent of A recent study of a seasonal influenza vaccine investigated the those in the flu shots colonies.25 effectiveness as well as the safety of the vaccine over two flu Clear, consistent education campaigns must be and to teach providers that vaccines are not risky developed about the safety and effectiveness of for most patients. The federal government the vaccine -- and local efforts must be made to should consider leveraging a small portion of ensure individuals know when to get shots and the Prevention and Public Health Fund -- which where they are available, including alternatives was created by health reform -- for an ongoing, to going to their doctors’ offices. nationwide vaccine acceptance campaign to in- form Americans of the need for everyone to be Health reform presents an opportunity for a vaccinated against seasonal influenza. wide-scale campaign to teach the public that flu vaccines are a normal, safe part of a healthy life 5 Special, concerted outreach to minority groups higher rates of underlying chronic conditions is particularly important, since minority groups such as diabetes may make African-Americans have much lower vaccination rates compared and Latinos at a greater risk of complications with Whites -- but have higher rates of mortality of influenza. and pneumonia associated with the seasonal H1N1 hospitalization rates for African-Americans, flu.26 H1N1 also had a disproportionate impact Hispanics, and American Indian/Alaska Natives on racial and ethnic minorities. Disease experts were nearly twice as high rates for Whites. suggest that overcrowding in urban areas and H1N1 Hospitalization Rates by Race and Ethnicity in the United States 2009-201027 Race/Ethnicity Hospitalizations Per 100,000 White, non-Hispanic 16.3 Black, non-Hispanic 29.7 Hispanic 30.7 Asian/Pacific Islander 12.5 American Indian/Alaska Native 32.7 n According to the Illinois Department of Pub- In order to increase minority vaccination rates, lic Health, African-Americans and Latinos campaigns must address negative beliefs and were hospitalized at a rate of 23 per 100,000 misinformation. Individualized, culturally ap- compared to Whites at a rate of seven per propriate, evidence-based information was 100,000 from April 2009 to December 2009. found to be effective in increasing vaccination They also found that the mortality rate was six rates among disadvantaged, racially diverse, per 100,000 for Latinos, and seven per inner-city populations.32 To be effective in 100,000 for African-Americans, versus three reaching diverse audiences, information must per 100,000 for Whites.28 be provided in channels beyond the Internet, such as radio and racial and ethnic publications n In Boston, 71 city residents were hospitalized and television, and in languages other than Eng- with H1N1 -- 49 percent of whom were lish. Materials must be tailored to specific cul- African-American and 28 percent who were tural perspectives. Communications should be Latino, double each minority group’s pres- from a trusted source, such as religious and ence in the city. African-Americans and Lati- community leaders. Translations also need to nos also account for a disproportionate share be idiomatic rather than word-for-word.33 of the 477 laboratory confirmed cases of H1N1 in Boston.29 During the H1N1 outbreak, CDC conducted a series of focus groups to learn effective ways to n H1N1-related deaths among American Indi- communicate about the flu. Some key findings ans and Alaska Natives were four times higher included the following: than rates for all other groups according to data from 12 states across the nation.30 n The message “Every flu season is different, and influenza can affect people differently. Even While racial and ethnic minorities were at higher healthy children and adults can get very sick risk for complications from H1N1, vaccination from the flu and spread it to others” was a con- rates were often lower.31 As of March 2010, vac- cept that resonated with people who perceived cination rates were 9.8 percent lower for African- themselves to be at low risk from the flu; American adults than for Whites and 4.2 percent lower for African-American children. Rates were n Using data and statistics makes messages more 11.5 percent lower for Hispanic adults, although credible and relevant. The more tailored the rates were 5.5 percent higher for Hispanic chil- data for specific audiences, the more motivat- dren. For seasonal flu in 2009-2010, vaccination ing the message; rates were 16.5 percent lower for African-Ameri- n African-American focus group participants can adults and 5.6 percent lower for African- particularly responded positively to images of American children than for Whites, and 21.7 families and images that portrayed the older percent lower for Hispanic adults and 2.6 percent protecting the younger and serving as a role- lower for Hispanic children than for Whites. model for positive health behaviors.34 6 B. Making Flu Vaccinations Easy, Accessible, and s Pharmacies: Many pharmacies provide flu Affordable for All Americans -- With Special shots for a fee. Many pharmacies also have Emphasis on Providing Shots for the Unin- systems where they can bill a person’s in- sured and Underinsured: Every American surance for payment. should have access to an affordable or free flu s Schools: Shots can be provided to students, shot. Many doctors prefer and encourage pa- but efforts should be made to provide infor- tients to get vaccinated through their “medical mation about the vaccination to students’ pe- home” -- by their primary care physician or pe- diatricians. Shots can also be provided to diatrician when possible -- or through other teachers and other staff. In addition, schools doctors who provide them with regular care. are a good location to provide vaccinations However, many insured Americans do not re- to parents and to members of the surround- ceive regular well care or regularly see doctors. ing communities. s Child care facilities: In addition to chil- And millions of uninsured or underinsured Amer- dren, shots can be provided to all teachers icans also go without regular care and also do not and day care providers, which help protect have insurance to help pay for vaccination costs. the student community. Caregiver protec- Making shots easily accessible and affordable tion is particularly important for infants can greatly increase the chances that more under six months of age, who are not able Americans will get vaccinated. This requires to get the vaccine yet. providing flu shots where it is convenient -- and s Recreation centers and community centers. covering the cost of vaccines and the associated s Faith-based organizations, such as administration fees through insurance or mak- churches and synagogues. ing free shots available. s Community health centers and other n Making access to flu shots as convenient as safety net providers. possible: Strategies that focus on making vac- s Health fairs. cinations more convenient by “going where the people are” to provide vaccines can dra- s College campuses, at health centers and matically help to increase vaccination rates. It in other locations. is important to be sure that vaccines are ad- s Senior centers. ministered by trained health care professionals s Nursing homes. in any location. Active immunization registries s Shopping malls. would be particularly helpful for being able to track individual vaccinations to share infor- s Voting locations. mation with medical providers and population s Airports. vaccination trends. Local health departments n Making sure uninsured and underinsured can will need additional support in order to be afford shots: Lack of insurance should not put able to offer clinics in a variety of sites and ven- any Americans at increased risk of getting sick ues. It is also important to provide individuals from the flu. The recent health reform bill will with a record of their vaccination so they can greatly expand the number of Americans with share it with their doctors. This will help build access to health insurance in the coming years -- a better system where the information can be which will help provide insurance coverage for directly provided to doctors, pediatricians, and more people to receive more vaccinations. The other health care professionals when individ- flu vaccine will also be a required benefit with- uals receive a shot. Public health officials out cost sharing in the “new” plans. However, should work with groups and venues around even as the different aspects of the new health the community to offer easy locations to pro- reform take effect, many will remain uninsured vide vaccinations, particularly large institutions or underinsured. A lack of insurance may deter or places where people congregate. Visiting many Americans -- particularly young adults and nurses can also come to locations, such as lower-income individuals -- from getting vacci- workplaces, to provide shots. Insurance plans nated. For instance, right now, many young must also be willing and able to pay for vacci- adults are ineligible for public programs, move nations given outside of the traditional med- between schools and jobs, have shorter tenure ical home. Some venues that have been used jobs, or work at entry-level jobs without benefits, or could be considered to be used to offer flu so they go without health insurance. shots include: 7 C. Encouraging Seasonal Flu Vaccinations for personnel. For measurable progress to occur, All Health Care Workers: Even though policymakers, employers, and the health care health care workers typically work around sick workers themselves must commit to achieving as patients, their vaccination rates are often low. close to universal seasonal flu vaccine coverage As of January 2010, only 62 percent of health of health care personnel as possible. To be suc- care workers had been vaccinated against sea- cessful, executive and senior staff in health care sonal flu, and only 37 percent received an facilities must be involved in ensuring wide- H1N1 flu shot.35 In typical years, the rates of spread vaccine acceptance and vaccination. health care worker vaccinations are around 50 Proponents of mandatory vaccination policies be- percent. According to a survey of nurses, the lieve the public health benefits of protecting pa- most common reason for not receiving a vac- tients and reducing worker absenteeism, as well as cine was concern about adverse reactions.36 the historically low rates under voluntary programs All health care personnel should receive the sea- and the mandate for health care workers to “do no sonal influenza vaccine. The ACIP has recom- harm,” justify requiring vaccination as a condition mended this policy since 1986.37 Studies have of employment. Proponents of voluntary policies repeatedly shown that Americans have great argue that mandatory programs violate the civil trust in the advice of their health care providers. liberties of healthcare personnel, who should be Health care providers are role models as well as able to opt out of vaccination programs. trusted sources of information. Americans are Health facilities can incentivize workers to get vac- less likely to trust the safety of vaccines if their cinated, including providing the vaccine for free, providers are not vaccinated, and no one should comprehensive education for employees, and ever get the flu from their doctor, nurse, or med- publicly reporting vaccination rates. States and ical technician. Influenza can be fatal for already the Centers for Medicare and Medicaid Services sick or immunocompromised patients. Health (CMS) could incentivize higher rates through care professionals must themselves serve as role public reporting and/or lower reimbursement for models and stress the importance of the yearly facilities that fail to meet certain standards, as it flu vaccination to patients. The U.S. Department will soon be doing with other quality measures. of Health and Human Services (HHS) is plan- The Joint Commission, which provides evalua- ning to include a section about flu vaccination tions and accreditation of hospitals and other of health care workers in its revised action plan health care facilities, could strengthen its accred- to prevent health care-associated infections.38 itation requirements related to facilities’ health There is currently a debate around whether care worker vaccination programs by expanding health care worker vaccination should be manda- the flu vaccine standard to all accredited settings; tory or voluntary. In the meantime, the goal requiring public reporting of vaccination rates; should be 100 percent vaccination of health care and setting a benchmark that facilities must meet. EXAMPLES OF WAYS TO HELP INCREASE HEALTH CARE WORKER VACCINATION RATES Some hospitals and health care settings are trying new policies to help encourage health care workers to get vaccinated. For example, at the Children’s Hospital and Medical Center in Omaha, Nebraska, employee vaccina- tion rates climbed from around 50 percent to around 97 after some new policies were instituted, in- cluding requiring staff to sign an explicit form if they decline vaccination that acknowledges the possibility that not getting immunized could spread the virus to children and requiring workers who did not get vaccinated to wear surgical masks through the flu season.39 8 II. PREPARING FOR A POSSIBLE FUTURE PANDEMIC AND OTHER HEALTH EMERGENCIES The response to the H1N1 outbreak showed the partment of Health and Human Services (HHS) country was much better prepared to respond to a and included steps for how to set up mass vacci- pandemic than it would have been a few short years nation campaigns. Many communities, busi- ago. There was an unprecedented large-scale na- nesses, schools, and other organizations around tionwide public health response including surveil- the country also created pandemic plans. lance, laboratory testing, public and practitioner When H1N1 emerged in the spring of 2009, gov- education, medical countermeasure management, ernment officials acted quickly to respond. Con- and the distribution and launch of a national vac- gress appropriated $1.9 billion in emergency cination campaign, all in a very short period of supplemental funding and an additional $5.8 time. However, the outbreak also revealed major billion in contingency funding. These funds ongoing gaps in America’s readiness for future helped enhance vaccine production capacity, pandemics and other health emergencies. purchase and distribute vaccines, upgrade sur- Since the National Strategy for Pandemic In- veillance capabilities, and meet other needs. fluenza was issued in 2005 and building on the However, the emergency funding could not efforts that came about after the September 11, backfill long-existing gaps in the nation’s public 2001 tragedies and Hurricane Katrina, the coun- health infrastructure. try is significantly better prepared for pandemic and other health emergencies. As a result, the The outbreak not only provided a real-world sce- country created a strong, in-depth national re- nario that tested pandemic plans, but also tested sponse plan, which included defined and dele- the fundamentals of the overall public health gated roles and responsibilities for every federal system, and showed that while plans and emer- agency and grants to support preparedness in gency resources are important, plans can only states. In addition, every state had a plan in be effective if there is a strong enough public place that had been reviewed by the U.S. De- health infrastructure to carry them out. EVENTS OF H1N1 On April 26, 2009 a public health emergency was declared in the United States as cases of H1N1 began to spread across the country. More than a year later, the emergency declaration expired on June 23, 2010. Approximately 60 million Americans had H1N1 during this time. According to CDC, around 274,000 people were hospitalized and 12,000 individuals in the United States may have died from H1N1.40 Traditionally, about 90 percent of individuals who die due to complications from the flu are over the age of 65, but in 2009, 90 percent of those Americans who died from H1N1 were under 65.41 In a typical year, about 100 flu-related deaths of children under the age of 18 are reported to CDC, but during the pandemic, more than 300 flu-related deaths among children were reported to CDC.42 Between April 2009 and January 2010, there were approximately 19 million cases among those younger than 18, 33 million cases for those 18 to 64 and just five million for those 65 and over.43 “ WE ARE GRATEFUL FOR THE MODERATE IMPACT (OF H1N1). HAD THE VIRUS TURNED MORE LETHAL, WE WOULD BE UNDER SCRUTINY FOR HAVING FAILED TO PROTECT LARGE NUMBERS OF PEOPLE. ” 44 -- MARGARET CHAN, MD, WORLD HEALTH ORGANIZATION (WHO) DIRECTOR-GENERAL 9 “ EVERY INFLUENZA PANDEMIC IS DIFFERENT. PLANNING AND INVESTING IN KEY RESOURCES AHEAD OF TIME, AND BEING ABLE TO NIMBLY ADJUST TO CHANGING CIRCUMSTANCES ARE TWO KEY LESSONS LEARNED SO FAR FROM THIS H1N1 PANDEMIC. THEY ARE ALSO LESSONS LEARNED THAT WILL HELP US CONTINUE RESPONDING TO THIS EVENT AS WELL AS THE NEXT ONE. ” 45 -- MARK HORTON, DIRECTOR OF THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH ACCREDITATION AND PREPAREDNESS In order to improve the health of the public, the national Public Health Accreditation Board (PHAB) developed a national voluntary accreditation program for state, local, territorial and tribal public health departments that will launch in 2011. The goal of the accreditation program is to improve and protect the health of every community by advancing the quality and performance of public health departments. A study conducted by the North Carolina Preparedness and Emergency Response Research Center found that public health agencies accredited by the state of North Carolina performed a significantly larger scope of activities in response to the H1N1 outbreak compared to non-accredited agencies, and that these differences were “apparent in all domains of activity including planning, incident com- mand, investigation, communication, and response and mitigation activities.”46 The findings suggest that participating in and meeting accreditation standards can help public health departments effectively meet and demonstrate preparedness capabilities. A. Addressing Real-World Lessons The H1N1 outbreak showed that transferring ommendations. This is particularly challeng- plans from paper to action can be more difficult ing when the situation is unfolding at the same than is often anticipated. All local, state, federal, time when there is a need to communicate and private pandemic plans should be evaluated with the public. Messages must strike a bal- and revised based on lessons learned from the ance between building trust and communi- H1N1 outbreak. The challenges experienced cating that the guidance will change. from the real-world implementation of pan- Acknowledging uncertainty can be an impor- demic plans revealed a number of lessons for fu- tant component of building trust. The H1N1 ture planning, including that: pandemic also showed the challenge and frus- trations of communicating about priority n Plans must be adaptable and science-driven. groups for vaccination and treatment, partic- Even if preparations are based on past expe- ularly when the groups were not consistent for riences, each disease outbreak is unique and every community. Since there could also be unpredictable, and requires constant re- limited early availability of vaccine in future assessment of priorities and guidance for the potential pandemic outbreaks of new strains public and medical community. For instance, of the flu, it is important to create clear and at the start of the H1N1 outbreak, no one consistent priority group recommendations -- knew how severe the virus would be. Officials as well as clear mechanisms for communicat- had to constantly reevaluate issues like school ing who the priority groups are and how they closure recommendations to match changing change as circumstances unfold. The lack of circumstances. Some aspects of plans must be an immediate widely available vaccine also un- flexible enough to adapt to changing circum- derscored the importance of having a strong, stances as well as differing resources and situ- clear message about basic hygiene and social ations across locations. distancing, which are important to help slow n Establishing trust with the public through the spread of seasonal flu, and may also be par- clear and honest communication is impera- ticularly important in the early stages of out- tive. If the public does not receive timely in- breaks before a vaccine is available. Some formation or trust the information they special communications concerns that arose receive, they are unlikely to comply with rec- during the outbreak included: 10 s Declaring “emergency” messages and pan- measures, such as social distancing, are partic- demic level alerts: According to an after ac- ularly important before a vaccine is available, tion report from the Association of State the H1N1 outbreak demonstrated the chal- and Territorial Health Officials (ASTHO), lenges with implementing these measures. At a one unintended consequence that arose news conference in late April 2009 President from official public health emergency dec- Obama emphasized this: “If you are sick, stay larations, which are often required to make home. If your child is sick, keep them out of resources available, was that declarations school.”48 These seemingly simple measures often “made the situation sound much more proved to be more complicated in reality. severe and threatening than it actually s Sick leave: Health officials encouraged was.”47 One potential challenge for the fu- people who were sick to stay home. This ture is to find ways to legally declare emer- guidance can be hard to follow, particularly gencies in ways that are consistent with for around 40 percent of American workers messages that officials want to convey to the in the private sector who do not have any public. Another problem was that it was not paid sick leave available. This amounts to clear what impact the declaration of a na- approximately 40 million people, and dis- tional health emergency was supposed to proportionately includes women, lower- have. In the years of planning, it was as- wage workers, and part-time workers.49 In sumed that such a declaration would mean addition to those lacking personal sick leave, enhanced powers for health authorities, but millions more do not have sick leave that en- this did not happen. In some states, a state ables them to take time off to care for an ill declaration of an emergency seemed to be child, spouse, or parent. Congressional leg- necessary even though there was a national islation has been introduced -- but not declaration. In addition, ASTHO reports passed -- to require employers with 15 or that members of the public were often con- more employees to offer a minimum of fused by the difference between the World seven paid sick days each year, which could Health Organization (WHO) pandemic rat- be used for individual health needs or to ing announcements and statements from care for sick family members. HHS about the severity of the pandemic. A report “Sick at Work: Infected Employ- s Reaching the highest risk populations who ees in the Workplace During the H1N1 often have the lowest trust levels: The Pandemic” released by the Institute for H1N1 outbreak disproportionately impacted Women’s Policy Research found that, al- racial and ethnic minorities -- at the same though almost 26 million employed Amer- time, these communities are often the most icans adults may have been infected with reticent to trust government recommenda- H1N1 in 2009, nearly eight million em- tions and messages. To earn the trust of ployees took no time off work while in- these communities, special efforts must be fected. “Employees who attended work made to target racial and ethnic minorities while infected with H1N1 are estimated to with communications that are tailored to res- have caused the infection of as many as 7 onate with these communities and are as million co-workers.”50 This could mean transparent and straightforward as possible. that restaurants, child care centers, nurs- It is essential that these relationships are es- ing homes, hotels, public transit systems, tablished and maintained on an ongoing schools, businesses, and health care basis. It is too late to try to establish this type providers across the country may have of trust during an emergency. The ongoing been operated and run by individuals in- work of public health departments -- such as fected with the flu who lack the ability to reaching out to high risk communities take sick leave.51 around the seasonal flu and working with these communities on chronic disease pre- s School closings: Hundreds of schools across vention -- provide numerous opportunities the United States closed in the initial weeks for building and strengthening these ties. of the H1N1 outbreak. Officials were not These pre-established relationships could sure how severe the outbreak would be, and lead to increased trust and hopefully in- often chose to be cautious. HHS Secretary creased vaccination in a pandemic situation. Kathleen Sebelius noted that with school closings, “there is a large ripple effect. n Recommendations for sick leave, school clos- What happens to the parents? Where do ings, and limiting community gatherings have those children go? Do you close the day major ramifications that must be taken into care center if a younger sibling is there? account. Although community mitigation 11 Many schools’ and communities’ emer- The H1N1 outbreak also showed how chal- gency plans will be put to the test during lenging it is to coordinate among countries, the weeks and months to come.”52 During particularly when they may have competing in- the outbreak, public health officials re- terests when there is low availability of vaccines ported that implementation of school clos- or medicines. For instance, when the out- ings was difficult, and many parents ended break was initially identified in Mexico, many up dropping their children off at libraries, countries quickly tried to close borders and re- community centers or other locations.53 A strict travel despite recommendations from public opinion survey by the Harvard public health experts, and different countries School of Public Health found that 43 per- around the globe had vastly differing levels of cent of respondents said school or daycare investments and guidance around vaccines closures would likely cause a loss of income and medicines. Greater effort must go into and money problems, and over a quarter of fostering international communications and parents responded that having to stay home collaboration in responses to outbreaks. with children would cause them to lose n Limited legal authorities and competing their job or business. 54 emergency declarations must be better co- In the event of a future pandemic, if ordinated to avoid confusion and provide schools need to be closed for a significant protection to volunteers. Thirty-three states period of time, issues of handling parental and D.C. had statutes that extended some level sick leave and ways to limit interaction of at- of immunity to business and non-profit or- risk children must be addressed. In addi- ganizations providing charitable, emergency, tion, many families rely on food assistance or disaster relief services, although these laws programs, particularly the National School varied greatly among states, according to a Lunch and Breakfast program, and before study by the Public/Private Legal Prepared- and after school care, which could all be ness Initiative, North Carolina Institute for disrupted during school closures. Public Health. In addition, according to the Office of the General Counsel at HHS, volun- n Coordination across communities, states, and teer health professionals and some paid health countries is extremely complicated, but must personnel may or may not be covered under a be a high priority. The H1N1 outbreak “patchwork” of federal liability protections.59 showed how difficult it can be to coordinate An H1N1 after action report conducted by across borders and even within local commu- ASTHO found that legal authorities were an nities. One challenge, according to the after issue in some states. Lack of defined emer- action report by ASTHO, was that states and lo- gency declaration or specific liability coverage calities were receiving guidance documents for medical volunteers during the H1N1 out- and updates so frequently that they found it break hindered the response and limited the hard to keep up with the information and ability to provide care in some states.60 The make timely decisions about the appropriate Medical Reserve Corps reported that in some next steps or what to communicate to their places, “the lack of state provisions ensuring li- stakeholders.55 For instance, according to an ability protections for health care and other after action report in California, “One rural volunteers inhibited recruitment and made community stated that they would sometimes some reluctant to volunteer initially to help have two or three versions of the same guid- with H1N1 response activities.”61 ance document and didn’t know which was the most recent.”56 Some local health departments In addition, multiple federal emergency dec- have suggested centralizing how and where in- larations, including the National Emergency formation comes from into a single, accessible Act and the Stafford Act, created confusion area to minimize the amount of time each during the H1N1 pandemic.62 Follow-up community had to spend synthesizing infor- should be conducted to understand what was mation.57 Many local health departments also effective in areas where existing laws worked reported that they relied on the routine sum- and what issues should be addressed to im- maries of the CDC conference calls since it was prove the laws that did not work as well in other hard to keep pace with and synthesize the in- places. Before the next emergency, HHS and formation provided on the numerous calls that states should also clarify what liability protec- were being held. In addition, health care tions are in place for volunteer health profes- providers reported that communication be- sionals and attempt to translate the current tween providers and the public health system patchwork of federal and state protections into was often slow and uncoordinated.58 coherent, defined liability coverage. 12 n Building a Stronger Foundation health infrastructure and core capacities of Notwithstanding the strong federal, state, and local health departments. Everyday programs, serv- response, the H1N1 outbreak highlighted gaps in ices, and resources must be maintained and re- U.S. preparedness to face not just future health main strong and scalable to serve as a solid emergencies, but also to satisfy ongoing responsi- foundation to more effectively respond to large- bilities required to respond to the seasonal flu. scale public health events. Numerous after action reports, including those While there was the quick release of emergency from ASTHO and the National Association of supplemental funding for the H1N1 response, County and City Health Officials (NACCHO), public health departments were also experienc- called for a more consistent and robust invest- ing budget and staffing cutbacks, making these ment in the underlying core infrastructure that new and one-time funds not necessarily additive. supports the response to any and all health Because they were short-term funds, states often emergencies as well as regular activities.63, 64 could not rehire lost personnel or require work during state-mandated furlough days. Much of During the H1N1 outbreak, the capacity of the success experienced by state and local health health departments to track, investigate, and departments in responding to the H1N1 pan- contain cases of H1N1 was pushed to the limit demic was attributable to the years of planning, due to lack of resources. However, instead of training, and relationship-building that emer- new investments to help replenish and fill gaps gency preparedness funding had made possible in the public health system, departments around over the previous decade. Budget cuts were the country are experiencing major cuts. overcome by the flow of Public Health Emer- Prior to the H1N1 outbreak, public health de- gency Response (PHER) funds from the federal partments’ resources, funding, and personnel government. These were one-time only funds, were already stretched thin from budget reduc- which helped the response but will not help tions that were measured beginning in 2008, mak- build a lasting and effective infrastructure.68 ing it challenging to conduct effective seasonal flu Over the years, federal funding for state and vaccination public education campaigns, track the local public health preparedness has also spread and severity of the seasonal flu virus strain, eroded. In fiscal year (FY) 2009, the funds for and hold vaccination clinics with trained staff. the federal cooperative agreement grants that During the second half of 2009, almost half of support state and local public health prepared- local health departments lost necessary work- ness was down approximately 25 percent from force, adding up to 8,000 lost jobs. Layoffs and at- FY 2005 levels. A portion of these remaining trition to the local health department workforce funds were also in jeopardy when the Adminis- in the last six months of 2009 combined with the tration had also proposed cutting $184 million 15,000 jobs already lost from 2008-2009 resulted from the Public Health Emergency Program in a cumulative loss of 23,000 jobs. In addition to (PHEP) cooperative agreements for FY 2011, lost jobs, during the latter half of 2009, 13,000 but Congress did not end up making these cuts. local health department employees were affected by shortened work weeks and mandatory fur- Some key areas that need to be at the ready for any potential emergency and to respond to the loughs because of budget cuts.65 seasonal flu, but are often lacking due to limited The current economic climate means states and resources include: localities are facing budget shortfalls and many n Up-to-date and available pharmaceuticals, vac- have cut funding and staff for public health de- cines, and medical equipment; partments. According to the Center on Budget and Policy Priorities, 48 states are experiencing n Surge capacity to provide mass care to pa- shortfalls in their budgets for FY2010 that total tients; and $168 billion, which is one-quarter of state budg- n Core public health infrastructure, such as sur- ets.66 Future predictions are that the situation will veillance, laboratory capacity and workforce. get worse in FY 2011.67 Public health funding is Without increased and sustained investments in discretionary spending in most states and, there- core public health functions, the country will al- fore, is at high risk for significant cuts during eco- ways be less than optimally ready for health nomic downturns. While few states allocate funds emergencies -- leaving Americans open to un- directly for public health preparedness, state and necessary risks. local funding is essential for supporting public 13 1. Ensuring Up-to-Date And Available Pharmaceuticals, Vaccines, and Medical Equipment The H1N1 outbreak showed how important it is During this period, issues related to vaccines, an- to maintain the research and development of tivirals, and medical equipment that should be up-to-date countermeasures, including vaccines addressed came to light, including: and antiviral medications, and to keep enough n Improving Vaccine Research and Develop- pharmaceuticals and medical equipment stock- ment: An August 2010 report released by the piled for emergencies. Having the ability to re- President’s Council of Advisors on Science spond quickly is essential during an outbreak or and Technology (PCAST) highlighted five key emergency, but requires an ongoing investment points necessary to improve vaccine capabili- in pharmaceutical research and development ties in the United States to prepare for possi- and stockpiling of medicines and equipment. ble future pandemics, including:72 Last year, scientists raced against the clock to de- 1) Surveillance: Accelerate identification of velop a vaccine to protect against the H1N1 flu newly emerging pandemic viruses, so vaccine strain, yet they were operating with an outdated vac- production can start sooner; cine research capacity and technology. Despite these challenges, vaccine manufacturers were able 2) Seed viruses: Develop a collection of stock to produce limited quantities of vaccine by mid-fall, viral “backbones” to allow faster production which public health officials directed to the high- of specific vaccine strains; est-risk populations. However, it took until later in 3) Sterility tests: Develop better and faster tests the year before enough vaccine was available for the to ensure sterility during vaccine production; entire U.S. population. This delay in the supply fur- ther discouraged people from getting vaccinated. 4) Potency-test reagents: Develop faster and more reliable tests to document vaccine potency; and In addition to vaccine development, within one week of the outbreak, the Strategic National 5) Fill-and-finish: Enlarge capacity and mod- Stockpile (SNS) delivered more than 11 million ernize machinery used in final stages of vac- courses of antiviral drugs, 12.5 million face- cine production, including vial-filling. masks, and 25 million N-95 respirators to 62 pre- In addition, a number of promising studies are un- determined areas in states and localities around derway to find a “universal” flu vaccine, which the country. These materials included 25 per- would have the potential to provide protection to cent of the states’ fixed pandemic influenza al- individuals from all flu strains for decades. How- locations and was the first large scale distribution ever, this vaccine may still be years away from being of its kind.69 In the fall, an additional 535,000 available to medical and public health officials. courses of antiviral drugs and 59.7 million N-95 respirators were also deployed from the SNS in n Replenishing and Coordinating the Antiviral response to the pandemic emergency. Stockpile: Overall, according to after action re- ports, the deployment and distribution of ma- The rapid development of a vaccine despite lim- terials from the SNS went according to plan.73, ited production capabilities and the quick dis- 74 However, there was not a clear mechanism tribution of antivirals and other equipment were for tracking how antivirals from the SNS were only possible due to prior investments in re- used and there is uncertainty of how many SNS search and development, stockpiling, and prac- supplies states have left. Antivirals deployed tice in drills and tabletop exercises. from the SNS were replenished in summer In late August 2010, the Obama administration 2009. In addition, other issues related to an- announced a plan to build the medical counter- tiviral distribution and guidance include: measure capacity to respond to future pandemic s Many states reported that they were unsure and bioterrorism threats, including plans to use about administering countermeasures, fees $1.9 billion, most of which would come from the for dispensing, and costs of recovering and H1N1 response.70 A large portion of these funds disposing of expired countermeasures. In would be devoted to improving the capability to the ASTHO after action report, one state quickly develop drugs and vaccines in the case of replied that, “guidance from CDC for treat- a pandemic -- including $822 million for pan- ment was excellent; however, guidance on demic influenza vaccine development, $200 mil- how and when to use the stockpile was ab- lion to create a government sponsored firm to sent;” lack of guidance on triggers and create innovation in the pharmaceutical indus- strategies for antiviral also made it difficult try, and $170 million to improve FDA regulation for local health departments to manage an- of the drug-development process.71 tivirals they received from the state. 14 s Some local health departments lacked stor- n Ensuring Adequate Availability of Appropriate age or cold chain management (climate- Emergency Medical Equipment: There were controlled storage) capabilities for SNS conflicting opinions during the H1N1 outbreak supplies. A number of localities returned on what type of facemasks or respirators should unused supplies to the states or distributed be used by medical professionals. In Septem- them to hospitals instead;75 ber 2009, the Institute of Medicine (IOM) ad- vised physicians and other health care s According to an upcoming, not-yet- published professionals to use fitted N-95 respirators, report from a think tank NACCHO con- while CDC recommended N-95 use for health vened, local health departments experienced care workers, but recommended against their a range of additional challenges related to an- use in community and home settings except po- tiviral use and distribution, including that: tentially for people at increased risk for severe • While local health departments had pre- illness from the flu. Meanwhile, the Occupa- paredness plans that outlined strategies tional Safety and Health Administration for receiving, storing, distributing, dis- (OSHA) supported the use of facemasks and N- pensing, and tracking antivirals, plans 95 respirators in the workplace and suggested often lacked the level of detail, infra- employers should stockpile facemasks and res- structure, and formalized agreements re- pirators in case of a pandemic.77, 78, 79, 80 More quired to operationalize those strategies. research will help lead to consensus about how to best protect health care workers during a • As CDC antiviral guidance evolved to re- pandemic. In September 2010, CDC released flect the epidemiology and practices dur- new guidance for preventing flu in health care ing H1N1, it was challenging for local settings recommending the use of surgical health departments to similarly modify masks instead of N-95s, based on information their plans and communicate these gathered during the 2009-2010 season.81 The changes to stakeholders. For example, impact of this guidance, including acceptance local health departments had difficulty ex- and compliance, should be monitored. plaining to first responders why national guidance no longer prioritized them over other groups for antiviral treatment. • During H1N1, local health departments needed to communicate how antivirals should be used, where antivirals were avail- able, and what groups were prioritized to receive them. This information was both difficult to obtain from state health depart- ments and communicate with the public, which led to delays in messaging and hin- dered the ability of local health depart- ments to be in front of the situation early. This impacted the ability of local health de- partments to ensure timely access to antivi- rals. Communication was especially difficult in jurisdictions where providers and other antiviral prescribers did not per- ceive the local health department as the opinion leader in the community. s Many people received commercially-sup- plied antivirals through the private phar- macy system, which complicated plans for decisions around the government release of the federal stockpile; and s States and localities noted the need for more guidance about the use and dosing of oseltamivir (Tamiflu) for children.76 There are still no stockpile goals for antivi- rals suitable for children in the SNS. 15 2. Upgrading Surge Capacity to Be Able to Provide Mass Care to Patients While the H1N1 flu pandemic turned out to be n Extending the Hospital Preparedness Pro- relatively mild, future pandemics could be much gram to include the ambulatory care system: worse. Preparing for the outbreak showed how During the H1N1 outbreak, doctors’ offices quickly overwhelmed the medical system could and ambulatory care centers were over- have been if the pandemic had been more severe. whelmed with patients, yet there is no system in place to provide support for these During the initial phases of H1N1, outpatient providers. The current HPP grants could be clinics and doctors’ offices were overwhelmed expanded to include these providers. and many did not have any system for triage, separating infectious patients, or protecting n Expanding the Hospital Preparedness Pro- workers and their families. Emergency rooms gram to include coordination with state and were overrun in spring. In New York City alone, local health departments: Hospital plans need 44,678 people visited emergency rooms with flu to be coordinated with state and local health like symptoms from May 15 to June 15, com- department efforts to assure appropriate first pared to just 4,267 the previous year.82 responder, treatment and triage resources in the community or the region being served. In the event of a severe outbreak or health emer- gency, the health care system would be stretched n Improving crisis standards of care planning and beyond normal capabilities. Patients would development: The federal government should quickly fill emergency rooms and doctors’ offices, take a more active role in the planning and de- exceed the existing number of available hospital velopment of crisis of care standards and take beds, and cause a surge in demand for critical steps to address the legal issues created when the medicines and equipment, including antiviral need for care overwhelms available resources medications, ventilators, and protective masks. (staff, supplies, and space) in an emergency. Surge capacity, the ability of the medical system n Improving regional coordination of health to care for a massive influx of patients, remains care facilities, including alternative care one of the most serious challenges for emer- sites: Better coordination among hospitals, gency health preparedness. Improving health state and local health departments, and emer- care system preparedness means having enough gency management agencies to build and supplies, staff, and space available to treat an in- strengthen regional consortiums would lead flux of patients. to more efficient use of resources. This in- cludes regional coordination with local health TFAH recommended a series of ways to bolster departments and with state health depart- health care system emergency preparedness in ment resources and plans. the Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism 2009 report, n Addressing issues that create barriers to suc- including: cessful alternative care sites: Alternative care sites are often one of the most efficient and ef- n Full funding of the Hospital Preparedness fective ways to provide care in mass emergen- Program (HPP) and developing a long-term cies, but issues related to facilities planning, solution to funding hospital preparedness: coordination among health agencies and HPP is a federal grant program intended to providers, licensing and liability concerns, and enhance the ability of hospitals and health resources to support the sites have meant only care systems to prepare for and respond to limited numbers of communities have strong bioterrorism and other health emergencies. alternative care plans and capabilities. The funding for the HPP program is limited and does not cover large-scale emergency ca- n Creating incentives and limiting obstacles to pabilities. Hospitals receive an average of recruiting a surge workforce: It is essential to $80,000 annually, but some receive as little as set up surge workforce plans so providers are $10,000. To be as effective as possible in the ready for times of emergency, including creat- current form, the HPP program must be fully ing incentives for private and public health funded, but policymakers should also exam- workers to participate, and reaching out to a ine if HPP is the best model for preparing the range of staff, including administrative staff, health system for a disaster. HPP is a relatively medical technicians, EMS, public safety work- unstable (discretionary) funding stream, and ers, and medical and nursing students in ad- health facilities may not be motivated to meet dition to doctors and nurses. Issues of liability, HPP grant requirements for a relatively small licensing, and accreditation should all be ad- sum of money. dressed ahead of an emergency. 16 3. Modernizing and Fully Funding Core Public Health Infrastructure The capacity to track, investigate, contain and Two core areas that proved particularly prob- prevent cases of H1N1 was hampered by a lack lematic during the outbreak included: of resources. The public health system has been s Disease Surveillance: Disease surveillance underfunded for decades, which makes carry- systems in the United States have been out- ing out day-to-day functions a challenge. When of-date and under-resourced for decades -- an emergency arises, it typically stretches public and it hurt the ability of health depart- health departments beyond their limits. And ments to track and respond to the H1N1 public health departments often do not even outbreak. H1N1 surveillance was not uni- have the resources they need to meet the re- form -- including having two options for re- sponsibilities required to carry out an effective porting hospitalizations and deaths and seasonal flu response. inconsistent utilization of confirmatory lab- Unlike having a standing fire department or po- oratory testing -- so data could not be com- lice capability, public health often only receives pared across states.84 States are currently supplemental “crisis funding” support to respond given the autonomy to report in the way to an emergency after it has already started. they like. Many local health departments reported difficulty collecting data, and According to a range of studies, from the IOM many reported that they were strained to to CDC, many core public health functions are even collect the minimum level of data.85 antiquated or do not have enough resources -- State or regional data often obscures local leaving the nation unnecessarily vulnerable in and neighborhood-level differences. Some times of emergencies. The H1N1 outbreak states reported that they were unable to strained and diverted funds that were typically keep up with processing laboratory infor- used for other public health functions from the mation, causing a backlog of information already-struggling system. and ultimately hindering their ability to de- A post-H1N1 assessment by HHS found the fol- scribe the extent of the situation in their lowing major needs and gaps in sustaining state community or state.86 and local operations and maintaining key infra- PCAST has provided recommendations for ways structure:83 to improve the systems so data is rapid and eas- n A reliable, sustained funding stream is needed ily accessible to allow experts to track the course for all core public health activities -- such as and severity of disease outbreaks. This would disease surveillance, public health laborato- help identify how to target vaccination cam- ries, and communications systems -- to ad- paigns, where and when additional antiviral dress on-going public health responsibilities medications and medical equipment may be and to ensure back-up capacity is available to needed, and if and when a disease is becoming respond to major public health emergencies. resistant to medication. ELECTRONIC HEALTH RECORDS Electronic Health Records (EHRs) hold the promise for improving many aspects of emergency health preparedness. Health care providers, insurance companies, and the public health system should work together to ensure that the development of EHRs are compatible and include the ability to: n Incorporate full and updated vaccination records for patients; n Provide patients and their doctors with easy access to vaccine histories and reminders of needed vaccines. In addition, this system should provide information to non-primary care doc- tors, so patients can receive information about needed vaccines when they visit specialists, such as obstetrician/gynecologists or cardiologists. An integrated system would also make it easier for doctors to track and reach out to patients at high-risk to remind them to get vaccinated; n Allow health departments to track vaccination rates, surges in disease outbreaks and let people living in communities know when there is increased risk; and n Let first responders know where to send patients faster and track availability of hospital beds in real time. 17 s Public Health Laboratory Surge Capacity: local public health workforce has been cut due Within two weeks from the first recognition to financial cutbacks in government budgets. of H1N1, CDC was able to develop and val- During the H1N1 outbreak, this meant that idate the new polymerase chain reaction many health departments were significantly un- (PCR) assay, manufacture the reagents, ob- derstaffed.87 In addition, the federal govern- tain FDA Emergency use Authorization for ment had restrictions on categorically-funded use, and begin distributing the kits to qual- programs that meant that state and local gov- ified laboratories. ernments often could not reassign employees working in other areas of public health to help Much of this was possible because of delib- with the outbreak response. Many state and erate and coordinated pre-pandemic ef- local governments also had hiring freezes so forts to expand the use of standardized many health departments could not hire addi- molecular tests for seasonal influenza sur- tional staff to help with the response. veillance in public health laboratories. Currently, public health departments around the Although most public health laboratories country are facing major workforce shortages, in- were able to quickly implement the new cluding lost jobs. For example about 25,000 health assay and provide surge level confirmatory workers faced reduced hours and required fur- testing for the pandemic H1N1 virus, test- loughs in 2009. In addition, local health depart- ing demand quickly exceeded federal and ments have been forced to cut various programs. state laboratory capacity in some jurisdic- Most notably, 13 percent of local health depart- tions, which slowed states’ ability to cor- ments have made cuts to immunization programs, rectly identify and describe the extent of nine percent have made cuts to epidemiology and the disease to the public.83 surveillance, and seven percent have made cuts to Laboratory capacity has greatly improved their emergency preparedness programs.88 Health since the anthrax attacks in 2001, but there departments around the country are also facing are still challenges in sustaining existing ca- an impending “brain drain” -- there are an esti- pacities, managing the surge in testing de- mated 50,000 fewer public health workers than mand during major emergencies, and there were 20 years ago and another one-quarter keeping the labs up-to-date with ever-chang- of current public health workers around the coun- ing technologies.84 try are eligible for retirement.89 From epidemiol- ogists to first responders who detect and contain n Even in difficult economic times, it is impor- diseases, the nation’s public health workforce is tant to sustain the public health workforce. vital to protecting the nation’s health. Efforts must Action must be taken to recruit, train, and re- be made to fill the void of expertly trained public tain the next generation of public health pro- health workers in the United States. fessionals. Approximately 15 percent of the 18 18 Weise E, “Swine Flu Vaccine Safe, California and Endnotes CDC Data Show.” USA Today, February 8, 2010. http://www.usatoday.com/news/health/2010-02-08- 1 U.S. Centers for Disease Control and Prevention. “Up- Swineflu08_ST_N.htm (accessed August 9, 2010). dated CDC Estimates of 2009 H1N1 Influenza Cases, 19 Jackson LA, Gaglani MJ, Keyserling HL, et al. “Safety, Hospitalizations and Deaths in the United States, April Efficacy, and Immunogenicity of an Inactivated In- 2009 -- April 10, 2010.” http://www.cdc.gov/h1n1flu/ fluenza Vaccine in Healthy Adults: A Randomized, estimates_2009_h1n1.htm#Table%20Cumulative (ac- Placebo-Controlled Trial Over Two Influenza Sea- cessed July 19, 2010). sons.” BMC Infectious Diseases, 10(71), 2010. 2 Norman J, “Public Health Emergency for H1N1 20 U.S. Centers for Disease Control and Prevention. Draws to an End.” CQ Healthbeat June 28, 2010. “2009-10 Influenza Prevention & Control Recom- 3 Trust for America’s Health. Pandemic Fu and the Po- mendations.” http://www.cdc.gov/flu/profession- tential for U.S. Economic Recession: A State-by-State Analy- als/acip/index.htm (accessed September 17, 2009). sis. Washington, D.C.: Trust for America’s Health, 21 Neuzil KM,, et al. “Influenza Vaccine: Issues and Op- 2007. http://healthyamericans.org/reports/flureces- portunities.” Infectious Disease Clinics of North sion/ (accessed October 18, 2010). America, 15(1), March 2001. 4 McNeil DG, “Study Criticizes Swine-Flu Follow-Up.” 22 Rosenberg M, et al. “Serious Adverse Events Rarely The New York Times, June 17, 2010. http://www.ny- Reported After Trivalent Inactivated Influenza Vac- times.com/2010/06/18/health/18flu.html (ac- cine (TIV) in Children 6-23 Months of Age.” Vaccine, cessed July 8, 2010). 27:4278-4283, 2009. 5 Santibanez S. “Pandemic Influenza and Diverse Popu- 23 Fleming DM and Elliot AJ. “Health Benefits, Risks, lations.” Office of Infectious Diseases. U.S. Centers and Cost-Effectiveness of Influenza Vaccination in for Disease Control and Prevention. Presentation Children.” The Pediatric Infectious Disease Journal, October 5, 2010. 27(11), November 2008. 6 U.S. Centers for Disease Control and Prevention. “Es- 24 McNeil DG, “Flu Shots in Children Can Help Com- timates of Deaths Associated with Seasonal Influenza -- munity.” New York Times March 9, 2010. United States, 1976—2007.” MMWR. August 27, 2010 http://www.nytimes.com/2010/03/10/health/10fl / 59(33);1057-1062. http://www.cdc.gov/mmwr/pre- u.html (accessed August 9, 2010). view/mmwrhtml/mm5933a1.htm?s_cid=mm5933a1_e %0d%0a (accessed August 31, 2010). 25 McNeil DG, “Flu Shots in Children Can Help Com- munity.” New York Times March 9, 2010. 7 Li C, and Freedman M. “Seasonal Influenza: An http://www.nytimes.com/2010/03/10/health/10fl Overview.” J Sch Nurs. 2009 Feb; 25 (suppl 1):4S-12S. u.html (accessed August 9, 2010). 8 “Fears About the Flu Shot Linger, Our Poll Finds.” Con- 26 Logan JL. “Disparities in Influenza Immunization sumer Reports. October 2010. http://www.consumerre- Among US Adults.” Journal of the National Medical ports.org/health/healthy-living/flu-vaccine/overview/i Association, 101(2): 161-166, February 2009. ndex.htm (accessed October 19, 2010). 27 Santibanez S. “Pandemic Influenza and Diverse Pop- 9 Trust for America’s Health. H1N1 Challenges Ahead. ulations.” Office of Infectious Diseases. U.S. Cen- Washington, D.C.: Trust for America’s Health, 2009. ters for Disease Control and Prevention. http://healthyamericans.org/reports/h1n1/TFAH20 Presentation October 5, 2010. 09challengesahead.pdf (accessed October 18, 2010). 28 FluTrackers. “Racial Disparities Seen in Illinois H1N1 10 Tessman, R. “New High Dose Flu Vaccine for Seniors.” Flu Deaths.” http://www.flutrackers.com/forum/show Minneapolis NBC News. http://www.kare11.com/news/ thread.php?p=327438 (accessed August 10, 2010). news_article.aspx?storyid=876981 (accessed October 14, 2010). 29 Smith S. “Cases of Swine Flu Higher Among City Blacks, Hispanics.” Boston Globe August 18, 2009. 11 Tessman, R. “New High Dose Flu Vaccine for Seniors.” Minneapolis NBC News. http://www.kare11.com/news/ 30 Graham G. “Getting Ahead of the Curve: Reaching news_article.aspx?storyid=876981 (accessed October Minority and Vulnerable Populations to Prevent 14, 2010). 2010-11 Seasonal Flu.” Presentation. Office of Mi- nority Health, U.S. Department of Health and 12 U.S. Centers for Disease Control and Prevention. Human Services. October 6, 2010. “Influenza Vaccination Coverage Among Children and Adults -- United States, 2008—09 Flu Season.” 31 Santibanez S. “Pandemic Influenza and Diverse Pop- MMWR, 2010. 58(39): 1091-1095. ulations.” Office of Infectious Diseases. U.S. Centers for Disease Control and Prevention. Presentation 13 Norman J, “Public Health Emergency for H1N1 October 5, 2010. Draws to an End.” CQ HealthBeat June 28, 2010. 32 Nowalk MP, et al. “Raising Adult Vaccination Rates 14 U.S. Centers for Disease Control and Prevention. Over 4 Years Among Racially Diverse Patients at “Final Estimates for 2009-10 Seasonal Influenza and Inner-City Health Centers.” Journal of American Geri- Influenza A (H1N1) 2009 Monovalent Vaccination atrics Society. 56: 1177-1182, 2008. Coverage—United States, August 2009 through May, 2010.” MMWR, 2010. 59(39). 33 Carter-Pokras O, Zambrana R, Mora S, Aaby K. “Emergency Preparedness: Knowledge and Percep- 15 U.S. Centers for Disease Control and Prevention. tions of Latin American Immigrants.” Journal of Health “Final Estimates for 2009-10 Seasonal Influenza and Care for the Poor and Underserved, 18: 465-81, 2007. Influenza A (H1N1) 2009 Monovalent Vaccination Coverage—United States, August 2009 through May, 34 Sheedy K. “CDC Influenza Vaccination Communica- 2010.” MMWR, 2010. 59(39). tion Activities and Resources for the 2010-11 Season.” Presentation. National Center for Immunization and 16 Reinberg S. “Many Americans Plan to Skip the Flu Respiratory Diseases. U.S. Centers for Disease Con- Shot This Year.” HealthDay. October 7, 2010. trol and Prevention. October 6, 2010. 17 Weise E, “Swine Flu Vaccine Safe, California and 35 Rabin RC, “Prevention: More Health Care Workers CDC Data Show.” USA Today, February 8, 2010. Got Flu Shots This Season.” The New York Times April 8, http://www.usatoday.com/news/health/2010-02-08- 2010. http://www.nytimes.com/2010/04/13/health/ Swineflu08_ST_N.htm (accessed August 9, 2010). research/13prev.html (accessed August 10, 2010). 19 36 Clark SJ, Cowan AE, and Wortley, PM. “Influenza February 2010. http://www.iwpr.org/pdf/B284sick- Vaccination Attitudes and Practices Among US Reg- atwork.pdf (accessed August 9, 2010). istered Nurses.” American Journal of Infection Control, 51Meric L. “Stay Home Sick? Not An Option for Many 1-6, 2009. Workers” Atlanta Journal Constitution May 14, 2009. 37 U.S. Centers for Disease Control and Prevention, http://www.ajc.com/health/content/opinion/sto- “Recommendations of the Immunization Practices ries/2009/05/14/mericed_0514.html%3Fcxntlid%3 Advisory Committee (ACIP) Prevention and Control Dinform_sr (accessed August 13, 2009). of Influenza.” MMWR Weekly. May 23, 1986 / 35(20); 52 Quaid L., and Zalazar C. “Closing Schools May Not 317-26, 331. http://www.cdc.gov/mmwr/preview/ Stop Flu Transmission.” The Associated Press April mmwrhtml/00022941.htm 30, 2009. http://www.google.com/hostednews/ 38 U.S. Department of Health and Human Services. ap/article/ALeqM5iu1XeOZnzPrr-dJpEm- “HHS Action Plan to Prevention Healthcare-Associ- cibGTDP9wAD97STRE00 (accessed April 30, 2009). ated Infections.” http://www.hhs.gov/ash/initia- 53 U.S. Centers for Disease Control and Prevention. tives/hai/actionplan/index.html “Analysis of Novel Influenza A (H1N1) and Implica- 39 Seppa, N. “Should Health Care Workers Be Required tions for School Dismissal Policy.” May 4, 2009. to Get Flu Vaccinations?” Science News. October 26, http://www.cdc.gov/h1n1flu/k12_dismissal.htm 2010. http://www.usnews.com/science/articles/2010/ (accessed May 7, 2009). 10/26/should-health-care-workers-be-required-to-get- 54 Harvard Public Health Press Release. “National Sur- flu-vaccinations.html (accessed October 28, 2010). vey Finds Six in Ten Americans Believe Serious Out- 40 Reinberg S. “57 Million Americans Sickened by break of Influenza A (H1N1) Likely in Fall/Winter.” H1N1 Flu: CDC Deaths Totaled Over 17,000, Still July 16, 2009. Fewer Than ‘Typical’ Flu Season.” Healthday Febru- 55 Association of State and Territorial Health Officials. ary 12, 2010. http://health.usnews.com/health- Assessing Policy Barriers to Effective Public Health Response news/managing-your-healthcare/infectious-diseases in the H1N1 Influenza Pandemic: Project Report to the Cen- /articles/2010/02/12/57-million-americans-sick- ters for Disease Control and Prevention. Arlington, VA: ened-by-h1n1-flu-cdc.html (accessed July 27, 2010). June 2010 http://www.astho.org/Programs/Infec- 41 Norman J, “Public Health Emergency for H1N1 tious-Disease/H1N1/ (accessed August 16, 2010). Draws to an End.” CQ Healthbeat June 28, 2010. 56 Dorian A, Rottman SJ, Shoaf K and Tharian B. “The 42 Allday E, “Health Officials Plan for Next Flu Season Novel Influenza A H1N1 Epidemic of Spring 2009: With H1N1 History.” San Francisco Chronicle August National After Action Workshop on a Federal Public 15, 2010. http://www.sfgate.com/cgi-bin/ Health Emergency: 21-22 Torrence, California.” Pre- article.cgi?f=/c/a/2010/08/14/BATL1ESLU4.DTL hospital and Disaster Medicine November 2009. (accessed August 17, 2010). http://pdm.medicine.wisc.edu/H1N1.pdf (accessed 43 Reinberg S. “57 Million Americans Sickened by August 18, 2010). H1N1 Flu: CDC Deaths Totaled Over 17,000, Still 57 Dorian A, Rottman SJ, Shoaf K and Tharian B. “The Fewer Than ‘Typical’ Flu Season.” Healthday, Febru- Novel Influenza A H1N1 Epidemic of Spring 2009: ary 12, 2010. http://health.usnews.com/health- National After Action Workshop on a Federal Public news/managing-your-healthcare/infectious-diseases Health Emergency: 21-22 Torrence, California.” Pre- /articles/2010/02/12/57-million-americans-sick- hospital and Disaster Medicine November 2009. ened-by-h1n1-flu-cdc.html (accessed July 27, 2010). http://pdm.medicine.wisc.edu/H1N1.pdf (ac- 44 “WHO Chief Defends Her Agency’s Pandemic Re- cessed August 18, 2010). sponse.” Reuters September 28, 2010. 58 Association of State and Territorial Health Officials. 45 The California Healthcare Foundation. “Lessons Assessing Policy Barriers to Effective Public Health Response Learned from California’s H1N1 Experience.” Cali- in the H1N1 Influenza Pandemic: Project Report to the Cen- fornia Healthline January 4, 2010. http://www.cali- ters for Disease Control and Prevention. Arlington, VA: forniahealthline.org/think-tank/2010/lessons-learn June 2010 http://www.astho.org/Programs/Infec- ed-from-californias-h1n1-experience.aspx (accessed tious-Disease/H1N1/ (accessed August 16, 2010). August 17, 2010). 59 U.S. Department of Health and Human Services, Of- 46 Davis M, Mays, et al. “H1N1 After Action Review: fice of the General Counsel. Public Health Emergencies Local Health Departments in North Carolina.” North and Federal Health Law. Presentation to the Public Carolina Preparedness and Emergency Response Re- Health Preparedness Summit, Atlanta, February 2010. search Center. June 2010. http://www.phprep.org/2010/Agenda/upload/Inter- active-145.pdf (Accessed October 18, 2010). 47 Association of State and Territorial Health Officials. Assessing Policy Barriers to Effective Public Health Response 60 The National Association of County and City Health in the H1N1 Influenza Pandemic: Project Report to the Cen- Officials. NACCHO H1N1 Policy Workshop Report. Wash- ters for Disease Control and Prevention. Arlington, VA: ington, D.C.: June 2010. http://www.naccho.org/top- June 2010 http://www.astho.org/Programs/Infec- ics/H1N1/upload/NACCHO-Policy-Workshop-Repor tious-Disease/H1N1/ (accessed August 16, 2010). t-2.pdf (accessed August 16, 2010). 48 Warner J. “A Sick Situation.” The New York Times April 61 Association of State and Territorial Health Officials. 30, 2009. http://warner.blogs.nytimes.com/2009/ Assessing Policy Barriers to Effective Public Health Response 04/30/sick-leave/ (accessed July 16, 2009). in the H1N1 Influenza Pandemic: Project Report to the Cen- ters for Disease Control and Prevention. Arlington, VA: 49 The Joint Economic Committee. Expanding Access to June 2010 http://www.astho.org/Programs/Infec- Paid Sick Leave: The Impact of the Healthy Families Act on tious-Disease/H1N1/ (accessed August 16, 2010). America’s Workers. Washington, D.C.: March 2010. http://jec.senate.gov/public/index.cfm?a=Files.Serve 62 Association of State and Territorial Health Officials. &File_id=abf8aca7-6b94-4152-b720-2d8d04b81ed6 Assessing Policy Barriers to Effective Public Health Response (accessed November 4, 2010). in the H1N1 Influenza Pandemic: Project Report to the Cen- ters for Disease Control and Prevention. June 2010. Arling- 50 Drago R and Miller K. “Sick at Work: Infected Em- ton, VA. http://www.astho.org/Programs/Infectious- ployees in the Workplace During the H1N1 Pan- Disease/H1N1/ (accessed August 16, 2010). demic.” Institute for Women’s Policy Research, 20 63 The National Association of County and City Health 76 Dorian A, Rottman SJ, Shoaf K and Tharian B. “The Officials. NACCHO H1N1 Policy Workshop Report. Wash- Novel Influenza A H1N1 Epidemic of Spring 2009: ington, D.C.: June 2010. http://www.naccho.org/top- National After Action Workshop on a Federal Public ics/H1N1/upload/NACCHO-Policy-Workshop-Repor Health Emergency: 21-22 Torrence, California.” Pre- t-2.pdf (accessed August 16, 2010). hospital and Disaster Medicine November 2009. 64 Association of State and Territorial Health Officials. http://pdm.medicine.wisc.edu/H1N1.pdf (accessed Assessing Policy Barriers to Effective Public Health Response August 18, 2010). in the H1N1 Influenza Pandemic: Project Report to the Cen- 77 U.S. Centers for Disease Control and Prevention. “In- ters for Disease Control and Prevention. Arlington, VA: terim Recommendations for Facemask and Respira- June 2010 http://www.astho.org/Programs/Infec- tor Use to Reduce 2009 Influenza A (H1N1) Virus tious-Disease/H1N1/ (accessed August 16, 2010). Transmission.” http://www.cdc.gov/h1n1flu/ 65 National Association of County & City Health Offi- masks.htm (accessed August 16, 2010). cials. Local Health Department Job Losses and Program 78 Landers SJ, “N95 Respirators—Not Surgical Masks— Cuts: Findings from January/February 2010. Washing- Recommended for H1N1 Protection.” American ton, D.C., 2010. http://www.naccho.org/topics/in- Medical News September 14, 2009. http://www.ama- frastructure/lhdbudget/upload/Job-Losses-and-Pro assn.org/amednews/2009/09/14/prsa0914.htm gram-Cuts-5-10.pdf (accessed October 28, 2010). (accessed August 16, 2010). 66 Lav I. and McNichol E. “Fiscal Year Brings No Relief 79 Gever J, “Hospital Confirms Masks Help in H1N1 From Unprecedented State Budget Problems.” Cen- Control.” MedPage Today March 26, 2010. ter on Budget and Policy Priorities, September 2009. http://www.medpagetoday.com/InfectiousDis- http://www.cbpp.org/cms/index.cfm?fa=view&id=7 ease/SwineFlu/19250 (accessed August 16, 2010). 11. (accessed September 14, 2009). 80 The Occupational Safety and Health Administration. 67 Johnson N, Oliff P, and Williams E. “An Update on Proposed Guidance on Workplace Stockpiling of Respirators and State Budget Cuts: At Least 46 States Have Imposed Facemasks for Pandemic Influenza. http://www.osha.gov/ Cuts That Hurt Vulnerable Residents and the Econ- dsg/guidance/proposedGuidanceStockpilingRespira- omy.” Center on Budget and Policy Priorities, August tor.pdf (accessed August 16, 2010). 4, 2010. http://www.cbpp.org/files/3-13-08sfp.pdf 81 Schnirring, L. “CDC Finalizes Flu Prevention Guid- (accessed August 10, 2010). ance for Health Settings.” CIDRAP News. Septem- 68 Chandler S, Etkind P and Willman A. “Public ber 20, 2010. http://www.cidrap.umn.edu/cidrap/ Health Emergency Response Funding: The Ecstasy content/influenza/panflu/news/sep2010guid- and the Agony.” Journal of Public Health Management ance.html (accessed November 1, 2010). & Practice, 16(6):577-580, 2010. 82 Hartocollis A. “Lessons Learned: New York Braces 69 U.S. Department of Health and Human Services. for Swine Flu’s Return.” New York Times July 21, 2009. Statement by Michael R. Milner, Regional Health Ad- 83 U.S. Department of Health and Human Services. As- ministrator for Region 1 (New England) U.S. Public sessment of States’ Operating Plans to Combat Pandemic In- Health Service and the Health and Human Services fluenza: Report to Homeland Security Council. January on H1N1 Flu: Protecting Our Communities before 2009. http://www.flu.gov/professional/states/ The Committee on Homeland Security and Govern- state_assessment.pdf (accessed August 16, 2010). mental Affairs United States Senate, September 21, 84 Association of State and Territorial Health Officials. 2009. http://www.hhs.gov/asl/testify/2009/09/ Assessing Policy Barriers to Effective Public Health Response t20090921a.html (accessed August 17, 2010). in the H1N1 Influenza Pandemic: Project Report to the Cen- 70 Korade M, “$1.9 Billion Put Toward Countermeasures ters for Disease Control and Prevention. Arlington, VA: for Bioterrorism, Pandemics.” CQ Today August 19, June 2010 http://www.astho.org/Programs/Infec- 2010. tious-Disease/H1N1/ (accessed August 16, 2010). 71 Korade M, “$1.9 Billion Put Toward Countermeasures 85 The National Association of County and City Health for Bioterrorism, Pandemics.” CQ Today August 19, Officials. NACCHO H1N1 Policy Workshop Report. Wash- 2010. ington, D.C.: June 2010. http://www.naccho.org/top- 72 The President’s Council of Advisors on Science and ics/H1N1/upload/NACCHO-Policy-Workshop-Repor Technology. Report to the President on Reengineering the t-2.pdf (accessed August 16, 2010). Influenza Vaccine Production Enterprise to Meet the Chal- 86 Association of State and Territorial Health Officials. lenges of Pandemic Influenza. Washington, D.C.: Au- Assessing Policy Barriers to Effective Public Health Response gust 2010. in the H1N1 Influenza Pandemic: Project Report to the Cen- 73 The National Association of County and City Health ters for Disease Control and Prevention. Arlington, VA: Officials. NACCHO H1N1 Policy Workshop Report. Wash- June 2010 http://www.astho.org/Programs/Infec- ington, D.C.: June 2010. http://www.naccho.org/top- tious-Disease/H1N1/ (accessed August 16, 2010). ics/H1N1/upload/NACCHO-Policy-Workshop-Repor 87 National Association of County and City Health Of- t-2.pdf (accessed August 16, 2010). ficials. “Local Public Health Jobs Down 15% in 2 74 Association of State and Territorial Health Officials. Years.” April 6, 2010. http://www.cidrap.umn.edu/ Assessing Policy Barriers to Effective Public Health Response cidrap/content/influenza/panflu/news/apr0610lo- in the H1N1 Influenza Pandemic: Project Report to the Cen- calph.html (accessed August 10, 2010). ters for Disease Control and Prevention. Arlington, VA: 88 National Association of County and City Health Offi- June 2010 http://www.astho.org/Programs/Infec- cials. “Local Public Health Jobs Down 15% in 2 tious-Disease/H1N1/ (accessed August 16, 2010). Years.” April 6, 2010. http://www.cidrap.umn.edu/ 75 Dorian A, Rottman SJ, Shoaf K and Tharian B. “The cidrap/content/influenza/panflu/news/apr0610lo- Novel Influenza A H1N1 Epidemic of Spring 2009: calph.html (accessed August 10, 2010). National After Action Workshop on a Federal Public 89 Landers S. “H1N1 Put Further Strain on Public Health Emergency: 21-22 Torrence, California.” Pre- Health Work Force: The virus Outbreak Taxed Public hospital and Disaster Medicine November 2009. Health Departments’ Resources and Necessitated Plac- http://pdm.medicine.wisc.edu/H1N1.pdf (accessed ing a Hold on Routine Tasks.” AMANews June 8, 2009. August 18, 2010). http://www.ama-assn.org/amednews/2009/06/08/ prsa0608.htm (accessed September 3, 2009). 21 ACKNOWLEDGEMENTS TRUST FOR AMERICA’S HEALTH (TFAH) IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES AND MAKING DISEASE PREVENTION A NATIONAL PRIORITY. This report is supported by a grant from the Robert Wood Johnson Foundation (RWJF). The opinions expressed in this report are those of the authors and do not necessary reflect the views of the foundation. TFAH thanks RWJF for their generous support. The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need—the Foundation expects to make a difference in our lifetime. For more information, visit www.rwjf.org. TFAH BOARD OF DIRECTORS REPORT AUTHORS Lowell Weicker, Jr. Jeffrey Levi, PhD. President Executive Director Former three-term U.S. Senator and Governor of Connecticut Trust for America’s Health and Cynthia M. Harris, PhD, DABT Professor of Health Policy Vice President The George Washington University School of Public Director and Associate Professor Health and Health Services Institute of Public Health, Florida A & M University Laura M. Segal, MA Robert T. Harris, MD Director of Public Affairs Secretary Trust for America’s Health Former Chief Medical Officer and Senior Vice President for Rebecca St. Laurent, JD Healthcare Health Policy Research Associate BlueCross BlueShield of North Carolina Trust for America’s Health John W. Everets Dara Alpert Lieberman, MPP Treasurer Government Relations Manager Gail Christopher, DN Trust for America’s Health Vice President for Health WK Kellogg Foundation PEER REVIEWERS AND EXPERTS David Fleming, MD CONSULTED Director of Public Health TFAH thanks the reviewers for their time, expertise, and in- Seattle King County, Washington sights. The opinions expressed in this report do not necessarily Arthur Garson, Jr., MD, MPH represent the views of these individuals or their organizations. Executive Vice President and Provost and the Robert C. Abby Berns Taylor Professor of Health Science and Public Policy Program Associate, Community Health University of Virginia National Association of County and City Health Officials Alonzo Plough, MA, MPH, PhD James S. Blumenstock Director, Emergency Preparedness and Response Program Chief Program Officer, Public Health Practice Los Angeles County Department of Public Health Association of State and Territorial Health Officials Jane Silver, MPH Anna M. Buchanan, MPH President Senior Director, Immunization and Infectious Disease Irene Diamond Fund Association of State and Territorial Health Officials Theodore Spencer Paul Etkind, DrPH, MPH Senior Advocate, Climate Center Senior Analyst, Community Health Team / Immunizations Natural Resources Defense Council National Association of County and City Health Officials Lilly Kan, MPH Senior Analyst - Community Health National Association of County and City Health Officials 1730 M Street, NW, Suite 900 • Washington, DC 20036 • (t) 202-223-9870 • (f) 202-223-9871 22