ISSUE BRIEF Pandemic Flu Preparedness: LESSONS FROM THE FRONTLINES T he recent H1N1 (swine) flu outbreak demonstrated how rapidly a new strain of flu can emerge and spread around the world. As of June 1, 2009, the H1N1 virus was reported in 62 nations, with nearly 17,500 confirmed cases and more than 100 deaths. The sudden outbreak of this novel flu virus has tested the world’s public health preparedness. H1N1 provided a real-world test that showed the strengths and vulnerabilities in the abilities of the United States and the rest of the world to respond to a major infectious disease outbreak. This report examines early lessons learned more virulent strain, or if a different strain of from the response and ongoing concerns influenza, like the H5N1 (bird) flu, emerges. about overall U.S. preparedness for potential Overall, the H1N1 outbreak has shown that the pandemic flu outbreak. The first section re- investment the country has made in preparing views 10 key lessons based on the initial re- for a potential pandemic flu has significantly im- sponse to the H1N1 outbreak; and the second proved U.S. capabilities for a large scale infec- section discusses 10 underlying concerns and tious disease outbreak, but it has also revealed provides recommendations for addressing se- how quickly the nation’s core public health ca- rious continued vulnerabilities in the nation’s pacity would be overwhelmed if the outbreak preparedness in the event that H1N1 returns were more widespread and more severe. in the fall, either in its current form or as a JUNE 2009 PREVENTING EPIDEMICS. PROTECTING PEOPLE. SUMMARY OF TEN EARLY LESSONS LEARNED FROM THE 2009 H1N1 OUTBREAK 1. Investments in pandemic planning and stockpiling antiviral medications paid off; 2. Public health departments did not have enough resources to carry out plans; 3. Response plans must be adaptable and science-driven; 4. Providing clear, straightforward information to the public was essential for allaying fears and building trust; 5. School closings have major ramifications for students, parents, and employers; 6. Sick leave and policies for limiting mass gatherings were also problematic; 7. Even with a mild outbreak, the health care delivery system was overwhelmed; 8. Communication between the public health system and health providers was not well coordinated; 9. WHO pandemic alert phases caused confusion; and 10. International coordination was more complicated than expected. SUMMARY OF TEN RECOMMENDATIONS FOR ADDRESSING CORE VULNERABILITIES IN U.S. PANDEMIC FLU PREPAREDNESS In addition to the lessons learned from H1N1, there are a number of systemic gaps in the nation’s ability to respond to a pandemic flu outbreak. To further strengthen U.S. preparedness, the following core areas must be addressed: Strategic National Stockpile and Vaccine Development Recommendations: 1. Maintaining the Strategic National Stockpile -- making sure enough antiviral medications, vac- cinations, and equipment are available to protect Americans, which includes replenishing the stock- pile when medications and supplies are used; 2. Vaccine development and production -- enhancing the biomedical research and development abilities of the United States to rapidly develop and produce a vaccine; and 3. Vaccinating all Americans -- ensuring that all Americans would be able to be inoculated in a short pe- riod of time. Adaptable, Science-Based Planning and Coordination Recommendations: 4. Planning and coordination -- improving coordination among federal, state, and local govern- ments and the private sector preparedness and planning activities on an ongoing basis, including taking into account how the nature of flu threats change over time; 5. School closings, sick leave, and community mitigation strategies -- improving strategies to limit the spread of disease ensuring all working Americans have sick leave benefits and that com- munities are prepared to limit public gatherings and close schools as necessary; and 6. Global coordination -- building trust, technologies, and policies internationally to encourage sci- ence-based, consistent decision making across borders during an outbreak. Core Public Health Infrastructure Improvement Recommendations: 7. Resources -- providing enough funding for the on-the-ground response, which is currently under- funded and overextended; and 8. Workforce -- stopping layoffs at state and local health departments and recruiting the next genera- tion of public health professionals. Surge Capacity and Care Recommendations: 9. Surge capacity -- improving the ability for health providers to manage a massive influx of patients; and 10. Caring for the uninsured and underinsured -- ensuring that all Americans will receive care during an emergency, which limits the spread of the contagious disease to others, and making sure hospitals and health care providers are compensated for providing care. 2 TEN EARLY LESSONS LEARNED FROM THE 2009 H1N1 OUTBREAK 1. Investments in pandemic planning and stock- piling antiviral medications paid off. Federal, state, and local efforts to develop and exercise pandemic response plans over the last several years enabled public health officials to react to the outbreak effectively and keep the public in- of the spread of the virus into a community, which resulted in the need for different policies in different places. 4. Providing clear, straightforward information to the public was essential for allaying fears and 1 SECTION building trust. Informing the public about what formed. Investments in antiviral stockpiles and is known about an outbreak, acknowledging enhanced vaccine manufacturing capacity also that certain information is not yet known, and proved to be prudent. updating facts as they become available is para- 2. Public health departments did not have enough mount to help contain the spread of disease and resources to carry out plans. Federal, state, and also give people the facts they need to be pre- local health departments are stretched too thin pared, not scared. During the outbreak, the to adequately respond to emergencies after President and other leaders around the coun- decades of underfunding the public health in- try served as clear spokespeople, conveying con- frastructure. Capacity to track, investigate, and sistent, accurate information about good hand contain cases of H1N1 has been hampered due hygiene, cough/sneeze etiquette, and the need to lack of resources. For instance, CDC and for people to stay home if sick. Effective lead- state laboratory testing was days to more than a ership and communication helped dispel ru- week behind the on-the-ground reality. Also, mors and myths -- from allaying concerns about the country must make a sustained commit- the safety of imported Mexican foodstuffs to re- ment to pandemic preparedness by providing versing the unfair characterization of Spanish- consistent federal funding for stockpiling med- speaking people as carriers of the contagion. icines and medical supplies, training, and plan- Public health officials also encountered the ning activities. However, there have been no need to explain to members of the public that state and local pandemic preparedness funds different policies are not necessarily inconsis- appropriated since fiscal year (FY) 2006. If the tent, but tailored to local realities. current outbreak had been more severe, state and local health departments likely would have been even more overwhelmed. 3. Response plans must be adaptable and science- driven. For years, pandemic flu planning fo- cused on the potential threat of the H5N1 (bird) flu that has been circulating in Asia for the past 10 years. In addition, much of the planning anticipated that there would be a six- week lead time between the time a novel flu strain was detected before it reached the United States. H1N1 showed that a new flu strain can emerge quickly or go undetected for a period of time and rapidly spread throughout the world. As the epidemic unfolded, new knowledge required government officials to re- assess guidance offered to the public and the medical community. For example, as it became clearer that H1N1 was circulating widely in communities and largely causing mild cases, the U.S. Centers for Disease Control and Pre- vention (CDC) officials lifted their recommen- dations on school closures to match the changing circumstances. Different communi- ties faced different situations, such as the extent 3 “ COMMUNICATION WAS KEY, INCLUDING THE NEED FOR US TO BE CAREFUL TO SAY WHAT WE DID NOT KNOW, FORESHADOWING POSSIBLE CHANGES IN POLICY, AND BEING CLEAR AT THE OUTSET THAT WHAT WE LEARNED ABOUT BOTH SEVERITY AND TRANSMISSIBILITY WOULD DETERMINE OUR RESPONSE. ” 1 DAVID FLEMING, MD, DIRECTOR OF PUBLIC HEALTH, SEATTLE & KING COUNTY WASHINGTON 5. School closings have major ramifications for well” overwhelmed emergency departments.2 students, parents, and employers. In areas Also, concerns about health care costs were a where schools were closed due to H1N1, par- deterrent for many in seeking early medical at- ents had to scramble to find alternative child tention, especially among the uninsured and care arrangements, which were complicated underinsured. A further deterrent to seeking by the guidance that children home from prompt medical care was fear among undocu- school should stay separated. Many parents mented immigrants that making contact with had to face taking sick leave from work to stay health authorities could result in deportation. home to care for their children even if they 8. Communication between the public health sys- were not ill, or taking days off without pay if tem and health providers was not well coordi- they did not have sick leave. Many families nated. During the outbreak, many private also rely on the school meal programs and be- medical practitioners reported that they did fore and after school care, which were also not receive CDC guidance documents in a not available when schools were closed. In timely fashion. Other practitioners noted that the event that another outbreak occurs or the CDC guidance lacked clinically relevant infor- H1N1 returns in the fall and schools may have mation and was difficult to translate into prac- to close in more places and for longer dura- tical instructions. tions, these complications would become an even bigger concern. This is especially prob- 9. WHO pandemic alert phases caused confusion. lematic for jurisdictions that require a mini- The WHO pandemic alert phase system was not mum number of days attended to graduate. well matched with the realities of the H1N1 out- break, since most of the planning was built 6. Sick leave and policies for limiting mass gather- around concerns of a much more severe pan- ings were also problematic. There were nu- demic outbreak and focused on the geographic merous media reports of people with spread and transmission patterns, but not the influenza-like illness continuing to go to work severity of the disease. WHO is currently con- because they had no sick leave and feared los- sidering how to revise its pandemic alert phases ing their jobs, and some parents sent sick chil- to address both the geographic spread as well as dren to school because they could not stay the severity of the virus. home to care for them. In addition, while they were not instituted during the outbreak, it be- 10. International coordination was more com- came clear to officials how difficult it would be plicated than expected. Despite advice from to carry out plans to limit mass gatherings or the WHO, some countries chose to close cancel major events if that became necessary. In their borders to Mexican citizens or banned areas of Mexico, there were serious economic pork products from the United States and ramifications when officials recommended peo- Mexico. These measures were not based on ple avoid shopping and public events. either science or reasonable public health practices and caused unnecessary economic 7. Even with a mild outbreak, the health care de- losses. Once a flu virus is circulating livery system was overwhelmed. Even this rel- throughout the population, containment atively mild outbreak proved to be a low-level strategies, like travel restrictions, generally “stress test” on the health system. It revealed will not work, given that it is possible to in- significant problems and lack of preparedness fect others before a person develops flu-like particularly for out-patient settings where there symptoms. Also, the effectiveness of some was inadequate personal protective equipment mitigation strategies implemented (face and a limited understanding of infection con- masks in Mexico) were overstated. trol measures. At many hospitals, the “worried 4 TEN RECOMMENDATIONS FOR ADDRESSING CORE VULNERABILITIES IN U.S. PANDEMIC FLU PREPAREDNESS T he investment in pandemic flu preparedness helped the country respond to the first round of the H1N1 outbreak much more effectively than could have been achieved a few years ago. However, the limits of the response underscored ongoing 2 SECTION gaps in the nation’s core capabilities and the need to build up and modernize the pub- lic health infrastructure, which has been underfunded and under resourced for decades. Unless these gaps are addressed, our ability to respond to emergencies will re- main inadequate. A. STRATEGIC NATIONAL STOCKPILE AND VACCINE DEVELOPMENT RECOMMENDATIONS The fact that the country had stockpiled a supply the clock to develop an H1N1 vaccine for the fall of antiviral medications made it possible to rap- of 2009 while continuing to develop vaccines for idly deploy medicine to treat flu patients around other flu viruses. the country, though ultimately large supplies The possible need to find ways to swiftly vacci- were not needed. The outbreak showed the lim- nate the entire U.S. population, however, also its of the current stockpile, which is currently shows that the country does not yet have an ad- based on a system that relies on states to pur- equate system in place to rapidly vaccinate all chase a portion of the medications, and does not Americans. Nor is there a registry in place to have mechanisms in place for constantly replen- track the two vaccinations per person. ishing and updating the supplies. The following recommendations relate to en- In addition, the importance of the investment suring systems and supplies to mass treat and the country has made in biomedical research, vaccinate the public during a flu outbreak: and in particular vaccine development and pro- duction, is underscored as scientists race against 1. MAINTAINING THE STRATEGIC NATIONAL STOCKPILE: Purchasing antiviral medications, vaccines, and equipment for the stockpile must be updated and restocked on an ongoing basis. I Purchasing antiviral medications, vaccines, and I HHS needs to develop a workable plan for both equipment for the stockpile should be a federal the use and stockpiling of antivirals. Currently, responsibility. states are expected to purchase a portion of the antiviral medications that would be needed to Combined, the federal and state antiviral pur- protect citizens in their states through a pro- chases are intended to treat 25 percent of the gram that included 25 percent subsidy from the U.S. population, or 75 million people. Prior federal government. HHS must develop a plan to the H1N1 outbreak, the U.S. Department for use and distribution of stockpiled antivirals of Health and Human Services (HHS) had during a pandemic. This plan should consider completed the purchase of 50 million treat- existing federal and state stockpiles, as well as ment courses of antiviral drugs for the federal how to address current shortfalls. HHS must portion of the antiviral stockpile goal. The recognize that while some states, have already federal government should replenish its share expended resources to develop their own stock- of the antiviral stockpile deployed to states piles, others have not, either as a result of lim- and localities intended for treatment during ited resources or operational constraints. the current H1N1 outbreak and purchase ad- ditional courses for prophylaxis. See Appendix B for a list of state purchases of antiviral medications as of October 2008. 5 In addition to antivirals and vaccines, even be- During the H1N1 outbreak, HHS released a fore the H1N1 outbreak, the stockpile had ex- total of 11 million treatment courses to help isting shortfalls in the number of masks, states, in addition to moving 400,000 treatment respirators, and medications needed to respond courses to Mexico to help stop the spread of the to this and other possible pandemics, which virus. In order to replenish the Strategic Na- must be completed to be prepared for the pos- tional Stockpile, HHS announced at the end of sibility of other strains of flu. As of 2008, HHS April 2009 that it would purchase an additional had purchased 105.8 million N95 respirators; 13 million antiviral treatment courses.5 States 51.7 million surgical masks; 20 million syringes have purchased 23 million courses of antivirals, for pre-pandemic vaccine; and 4,000 ventila- as of January 2009 with the help of a federal sub- tors.3,4 It is important to continue to evaluate sidy. (The goal is for states to purchase 31 mil- medical supply needs for the stockpile and re- lion courses).6 plenish supplies as they are used. 2. VACCINE DEVELOPMENT AND PRODUCTION: A vaccine is the most effective way to protect the public from an infectious disease outbreak, but current vaccine development and production capacity is severely lacking. I U.S. vaccine development and production ca- HHS is supporting a multi-pronged approach pabilities must be enhanced. The National for boosting U.S. domestic production capacity Strategy for Pandemic Influenza sets out two goals by subsidizing the construction of new manu- related to vaccine stockpiling: To stockpile facturing plants and the renovation of existing enough H5N1 (bird flu) pre-pandemic vac- ones; funding research and development of cine to inoculate 20 million people at the cell-based manufacturing technology, while se- onset of a pandemic influenza, and to be able curing an egg supply for egg-based production; to vaccinate the entire U.S. population of and advancing the research and development some 300 million within six months from the of adjuvants, substances that can be added to a onset of a pandemic influenza. In light of the vaccine to boost its ability to produce an im- H1N1 (swine flu) outbreak, the federal gov- mune system response. However, a September ernment is embarking on a similar course of 2008 report by the Congressional Budget Office action with respect to the first goal. HHS has (CBO) has raised serious concerns about the issued contracts to manufacture and test pre- ability of HHS to meet these goals.10 pandemic vaccines against the newly-emerg- Other factors that might impede the nation’s ing 2009-H1N1 virus for the Strategic ability to inoculate the entire population in- National Stockpile. The goal is to build a clude cost and the public’s reaction to the vac- stockpile of at least 40 million doses of 2009- cine. According to a CDC estimate, it may cost H1N1 vaccine to inoculate 20 million people up to $8 billion to procure 600 million doses (this assumes two doses of vaccine will be nec- of the 2009 A-H1N1 vaccine for 300 million essary). Laboratories are already working on people (two doses per person). This figure generating the seed viruses needed for vac- does not include needles, syringes, distribu- cine production. Once the manufacturers tion, and the like. have completed their seasonal influenza vac- cine production, they will start production of Whether or not the public would be willing to the 2009-H1N1 vaccine.7 line up for three flu shots -- one to combat sea- sonal flu and two to prevent the novel H1N1 However, with respect to the goal of vaccinating flu virus -- remains to be seen. Seasonal in- the entire U.S. population within six months of fluenza vaccine uptake, even among health an influenza pandemic, challenges remain due care workers, has yet to meet public health to still-limited U.S. vaccine production capabil- goals. In the fall of 2008, more than half of ities. U.S. production capacity is “completely in- Americans in a national survey said that they adequate,” according to a report from the did not intend to be vaccinated against flu that Congressional Budget Office (CBO).8 Former season. Among the reasons cited were the HHS Secretary Leavitt urged his successor to thought that the vaccine was unnecessary, ensure completion of manufacturing facilities, worry that the vaccine causes illness, and dis- so that in the event of a worldwide pandemic, belief in the vaccine itself.11 U.S. citizens are not dependent on foreign gov- ernments to provide a vaccine.9 6 I Adequate and sustained funding is needed for tools of public health must be modernized to biomedical research and development to keep adequately protect the American people. This pace with new technologies. includes research and development of vac- The federal government should enhance re- cines and new technologies; and improved search and development of vaccines and pub- chemical laboratory testing capabilities. lic health technologies. Basic technology and BIOMEDICAL ADVANCED RESEARCH AND DEVELOPMENT AUTHORITY (BARDA) The Biomedical Advanced Research and Development Authority (BARDA) was established to encour- age and facilitate research and development (R&D) of new biomedical countermeasures, diagnostics, and related technologies; however, the intentions of the Congress and the administration in creating BARDA are far from being realized. The small amount of funding provided to BARDA to date only has allowed HHS to establish an infrastructure to support a yet-to-be-seen robust advanced R&D portfo- lio for many innovative biomedical products. To achieve the goals identified in HHS’ Public Health Emergency Medical Countermeasures Enterprise Implementation Plan, BARDA would need $3.39 bil- lion in FY 2009 to have a 90 percent chance of developing successful medical countermeasures for each biodefense requirement set forth in the plan. Congress should increase the level of BARDA funding to at least $850 million as advised by 14 sena- tors who signed a letter to the Appropriations Committee on this issue on May 7, 2009 and as re- quested in last year’s Presidential FY 2009 Amended Budget request.12 FLU VACCINE CAPACITY WORLDWIDE IS LIMITED Worldwide, the five egg-based flu vaccine manufacturers include the following: I CSL Limited (Australia) which makes Afluria; I GlaxoSmithKline Biologicals (Belgium) which makes Fluarix; I ID Biomedical (Canada), which makes FluLaval; I Novartis Vaccine (UK), which makes Fluvirin; and I Sanofi Pasteur (Pennsylvania, USA), which makes Fluzone. In addition, MedImmune makes FluMist, which is a live attenuated nasal spray vaccine. On May 6, 2009, the U.S. Food and Drug Administration (FDA) approved a new egg-based influenza vaccine facility in Swiftwater, Pennsylvania, which will produce 100 million doses of Fluzone when operating at full capacity. This brings the total domestic production from Sanofi Pasteur's two-approved facilities to 150 million doses. GSK is building a manufacturing facility in the United States, but it is not yet operational or approved by the FDA. The lack of U.S. manufacturing capacity means the country will be dependent on imported vaccines, which will become more difficult to obtain in the event of a pandemic. 3. VACCINATING ALL AMERICANS -- the country has not developed or adequately tested a system that will ensure that all Americans would be able to be inoculated in a short period of time. I A robust public system is needed to be able to rected program will be necessary to oversee vaccinate all Americans for H1N1 over a short vaccinations and coordinate delivery through period of time. Currently, only a fraction of a combination of public and private settings. Americans are vaccinated each year for the This will require an infusion of major re- seasonal flu and they typically receive shots sources to state and local health departments through their doctors or private clinics. If the responsible for creating this system. Estimates country is going to be successful in creating a by state and local health officials suggest that program that can vaccinate all Americans for between $15 and $20 per person may be H1N1 rapidly in the fall of 2009, a publicly-di- needed for administration and follow up. 7 THE CASE FOR A PUBLIC SECTOR APPROACH TO DISTRIBUTION OF A PANDEMIC VACCINE The HHS Pandemic Influenza Plan states that after a pandemic vaccine becomes available, state and local health departments will be expected to: I Work with health care partners and other stakeholders to distribute, deliver, and administer pan- demic vaccines to priority groups; I Monitor vaccine supplies, distribution, and use; I Monitor and investigate adverse events; I Phase-in vaccination of the rest of the population after priority groups have been vaccinated; I Provide updated information to the public via the news media; and I Work with federal partners to evaluate vaccine-related response activities when the pandemic is over.13 While actual delivery of vaccines may occur in both public and private settings, it is vital for the public sector to be in charge of the overall system of delivery to assure that key public health challenges unique to a pandemic vaccine are addressed. These challenges include: I A pandemic vaccine must be delivered to individuals as rapidly as possible. Americans re- ceive their seasonal influenza vaccine over a period of many months and only a fraction of the U.S. population receives a flu vaccine annually. Health departments will need to organize (often in con- cert with the private sector) mass immunization clinics that can speed delivery -- possibly as many as 100-150 million doses in a month’s time. I A pandemic vaccine will be rationed at the beginning of the production cycle, targeted at critical infrastructure workers and high-risk individuals. Unlike seasonal influenza vaccines, which are manufactured over a long period of time but essentially distributed at one time, a pandemic vaccine will be distributed as it comes off the production line. This will require targeting of initial doses to those key personnel (such as health care workers) who will be central to a pandemic re- sponse, followed by those at highest risk for influenza complications. This kind of rationing re- quires careful oversight. During the 2007 seasonal flu vaccine shortage it became clear that the private distribution and delivery system was not able to systematically follow recommendations for priority populations, and health departments were forced to intervene. I A pandemic vaccine may require two doses. Assuring that all individuals who receive a first dose return for a second dose will require a centrally organized system of monitoring and re- minders. It may well be that private sector entities (e.g., pharmacies) have systems in place to ad- minister such call-backs, but they must all be organized and structured in a similar manner, which can only be coordinated by a public health agency to ensure consistency with federal guidelines. I A pandemic vaccine will require careful monitoring and reporting of adverse reactions. Because the pandemic vaccine will be one with which there is far less experience than a seasonal vaccine, it will be critical to assure that all adverse events are investigated. This is a public health responsibility and the system of vaccine distribution and delivery must be designed to assure rapid communication of this information to health departments and then to the FDA. I A pandemic vaccine must be distributed equitably, and should not be available based on ability to pay. With nearly 50 million Americans uninsured, and with broad-scale vaccination critical to protecting not just individuals but the entire population from a pandemic, it is essential that the vac- cine delivery and distribution system not depend on private insurance and reimbursement systems. It would be tragic if vaccines were more likely to be available based on insurance status or ability to pay. I A pandemic vaccine distribution program will require communication and outreach to the public. This is traditionally a public health function; public health agencies have unique levels of trust with the public, especially vulnerable populations. That trust will be needed to ensure compliance with a complicated system of vaccine distribution. 8 B. ADAPTABLE, SCIENCE-DRIVEN PLANNING RECOMMENDATIONS During the H1N1 outbreak, it was clear that top H1N1 also showed the challenges that commu- government officials were following the guid- nities face around decisions to close schools or ance of public health experts and science was work places or limit public gatherings. There driving policies. Government officials provided are numerous ramifications for all of these ac- clear and consistence guidance to individuals tions that affect families and the economy. It is about the best ways to protect themselves. In ad- essential to consider the impact of these types of dition, the response continued to appropriately community mitigation strategies, and plan for adapt to changing circumstances as more infor- ways to make them easier to implement, for in- mation became known about the virus and how stance, by ensuring sick leave benefits to work- it was evolving, such as the timely decisions ers, so they do not face the tough decision of about when to close schools or limit gatherings. foregoing a paycheck against staying home to care for their children during an outbreak. The outbreak underscored the need for ongoing planning and coordination among all levels of gov- The following are recommendations for ensuring ernment and between the government and private that planning and coordination are ongoing ac- sector. It also reinforced the difficulties of inter- tivities and that community mitigation strategies national coordination and planning. Without clear are updated and realistic: lines of communication and careful planning, it is difficult to maintain an effective response strategy. 4. PLANNING AND COORDINATION: Federal, state, local, and private planning and coordination must be consistent and ongoing -- reflecting the constantly changing nature of the influenza threat. I Federal, state, local and private sector pan- just when one becomes imminent. Further- demic influenza plans should be systematically more, bringing together the creative ideas and reviewed in light of the experience with the collective expertise of diverse leaders and or- outbreak and response to H1N1. It is critical to ganizations will help build community resilience ensure that the plans build in flexibility in re- to a public health emergency. It is also impor- sponse, given that the H1N1 virus did not be- tant for local communities and health depart- have as many planners had anticipated -- it did ments to coordinate based on the circumstances not originate overseas and our global surveil- they face during an outbreak and issues that are lance system did not give us the level of warn- specific to their communities. ing desired. It is also important to review I Government at all levels should work to engage various guidances, in particular the school clo- the private health care system and communities sure guidance, in light of the real world expe- in their plans and exercises. Sufficient resources rience over the last two months. must be devoted to preparing for possible dis- I The federal government should take the lead in ease threats and the government should be increasing and better coordinating federal, state, transparent about its actions and held account- local, and private planning and preparedness, able for protecting the public. Initial planning and all jurisdictions should work together to cre- by HHS and other federal agencies failed to ad- ate policies that follow best infection-control equately involve states and localities in national practices. Often there is a flurry of planning ac- preparations for a pandemic, even though the tivities when a potential health threat is identi- national plan relies on these efforts.14,15 HHS fied and communication about preparation and and the White House should engage partners response is strong. However, over time, while in updating the National Strategy and Imple- the threat remains dormant, private-public com- mentation Plan. The federal government, in munication may decline. There should be on- collaboration with the states, should share states’ going and evergreen communication among pandemic preparedness plans and performance public and private partners as to roles and re- grades with the public to increase transparency sponsibilities during a major health crisis, not and build community resiliency.16 9 CUYAHOGA COUNTY, OHIO: COMMUNICATION KEY TO EFFECTIVE H1N1 RESPONSE The Cuyahoga County health department was formally alerted universities, daycares, and businesses. They also established a about the H1N1 outbreak late on Friday, April 24, 2009. The regular email briefing for local elected officials. next day, the county activated its Northeast Ohio Health Alert Although Cuyahoga County has only had two confirmed cases Network to communicate with other local emergency pre- of H1N1, some local schools began unilaterally closing be- paredness partners. By Sunday, April 26th, the state of Ohio cause of fears about ill students or faculty. The county health had its first confirmed case of H1N1 in a suburb of Cleveland. department was able to correct the false information that was That same day the U.S. government declared a public health circulating and work with schools so that they were following emergency and Cuyahoga County readied guidance and infor- CDC school closure guidance. The public soon came to trust mation to be disseminated to the public. these local public health officials, which had the important ef- On Monday, April 27th, the local preparedness working group fect of reducing panic and anxiety in the community. met and the 24/7 City of Cleveland/Cuyahoga County com- Cuyahoga County Health Commissioner Allan attributes the rapid bined Emergency Operations Center was up and running to response and mobilization, the ability to continue normal daily op- begin issuing clear and unified messaging on the H1N1 out- erations, and the establishment of a link to the media and public, break and to track the progress of and response to the out- to the fact that “public health had formally integrated as an essen- break. The county public information officers developed fact tial partner in our community emergency response system.”17 sheets and updated the county website with links to the CDC. The county health commissioner, Terry Allan, and Commis- Mr. Allan warned Congress in a recent hearing, that cuts to sioner of the Cleveland Department of Public Health, Matt state and local preparedness dollars could seriously affect the Carroll, began holding twice daily conference calls with part- ability of local health departments to respond effectively to fu- ners from hospitals, nursing homes, safety forces, schools and ture public health emergencies. 5. SCHOOL CLOSINGS, SICK LEAVE, AND COMMUNITY MITIGATION STRATEGIES: Strategies to mitigate a major infectious disease outbreak include ensuring that all working Americans have sick leave benefits available and that communities are prepared to limit public gatherings and close schools as necessary. Clear, consistent, culturally-competent commu- policies should be clarified. The federal gov- nication with the public is essential during a dis- ernment, in coordination with the states, ease outbreak, so that health departments and must establish clear legal authority and guid- providers can let people know about latest de- ance for the use of such measures to effec- velopments, how to best protect themselves, tively limit the spread of disease.19 when they should limit their public activities and I One of the most difficult challenges during an avoid going to work or school, and when and outbreak is managing sick leave concerns, since where they should go for medications or vacci- currently 48 percent of private sector workers nations.18 This includes letting people know the have no paid sick days. That means during an prioritization plans for vaccinations when limited infectious disease outbreak, like a pandemic, amounts of vaccine may be available or when it is they may be forced to choose between a pay- more important to vaccinate a target population check and their own health. During the recent in advance of the rest of a community. H1N1 outbreak, anecdotal stories emerged of I Continued work is needed in communities workers threatened with termination if they around the country to develop and test effec- stayed home, despite being sick. Forcing sick tive policies for slowing the spread of infec- people to go to work or school during a pan- tion that also minimize the known social and demic not only threatens their own well-being, economic consequences associated with these but the health of coworkers, customers, and measures. Such measures need to be based on schoolmates and undermines efforts to limit sensible and practical policies that are in line the spread of disease. The “Healthy Families with the science available at any given time of Act” was introduced in Congress in response to an outbreak rather than responding to panic the H1N1 outbreak to facilitate the ability of or complacency. Current state and federal workers to stay home when they or their family roles in invoking quarantine and isolation members are ill, but it has not been acted upon. 10 6. GLOBAL COORDINATION – Efforts must be made to increase coordination across borders to build trust, improve surveillance technologies and treatment capabilities, and encourage science-based policies and decision making internationally. I The United States should work closely with I The United States should also take the lead on the World Health Organization to revise the improving global disease surveillance. The pandemic phase system and to encourage President’s 2009 pandemic flu emergency fund- countries around the world to base policies ing request includes $220 million for enhanced for detection and control on sound science. global disease detection and Congress should provide these funds. C. CORE PUBLIC HEALTH INFRASTRUCTURE IMPROVEMENT RECOMMENDATIONS The H1N1 outbreak highlighted many of the on- outbreak or other major disaster occurs, the going vulnerabilities in the nation’s public health health departments do not have the resources or infrastructure. The system has been under-re- personnel in place to adequately protect the sourced for decades, and now with the economic health of their communities. recession leading to budget cuts in many states, The following are recommendations for provid- most public health departments are laying off ing the resources and capabilities needed to workers. The result is that health departments are maintain public health preparedness and for already stretched too thin to maintain their day-to- bolstering the public health workforce: day responsibilities. When an event like the H1N1 7. RESOURCES: Adequate funding must be provided for on-the-ground response. Right now, state and local health departments do not currently have enough resources to respond to a severe outbreak. I Congress should assure a reliable funding stream ing to the Center on Budget and Policy Prior- for all core public health activities as part of ities (CBPP), at least 46 states face shortfalls to health reform -- both to prevent and address the their 2009 and/or 2010 budgets. CBPP esti- on-going public health responsibilities of state mates that combined budget gaps for states in and local government and to ensure back up ca- the remainder of 2009, 2010, and 2011 could pacity is available to respond to a major public total more than $350 billion.22 health emergency. Sustained funding to ensure a I To adequately support public health prepared- fully operational and fully staffed public health ness needs, Congress should: system is critical to emergency response. During an emergency such as a flu pandemic, all public L Complete the funding to implement the National health workers will be needed to mount a the re- Strategy for Pandemic Influenza. The President sponse. Frequent budget cuts to non-prepared- originally requested $7.1 billion to carry out re- ness programs undercut the capacity of state and search and development for vaccinations, phar- local health departments to gear up in response maceuticals, and medical devices needed to to the H1N1 outbreak. respond to a pandemic. $870 million of this has never been funded. This money is needed to I The federal government should update as continue pandemic R&D. This funding was orig- needed, fully fund, and promptly carry out the inally included in the proposed 2009 stimulus President’s National Strategy for Pandemic In- bill, but it was removed before the bill’s passage. fluenza Implementation Plan.20,21 The National Subsequently, in April 2009 President Obama Strategy and Implementation Plan should be submitted a request for $1.5 billion in emergency evergreen documents, updated as the science funding for pandemic preparedness. Congress evolves and the White House assesses the effec- should approve this supplemental funding. tiveness of implementation on an ongoing basis. L Provide resources for state and local health de- At present, public health departments around partments to adequately prepare for outbreaks. the country are under-funded and over-ex- State and local officials are the front line re- tended to manage the demands of their ongo- sponders to outbreaks, yet they have not re- ing responsibilities. In the current economic ceived any new federal funding for pandemic climate, public health departments are facing flu preparedness since 2006. $350 million is severe cutbacks around the country. Accord- 11 needed annually to adequately maintain state Preparedness cooperative agreements, which and local pandemic preparedness activities. have been cut 25 percent over the last five years. The President’s FY 2009 pandemic flu emer- L The federal government should modernize and gency supplemental includes $350 million for provide sustained support of disease surveil- state and local pandemic preparedness, which lance systems, public health laboratories, com- should be enacted. munications systems, and other core public L Maintain investments in state and local pre- health capabilities needed for rapid detection paredness efforts through federal grant pro- and response to public health threats. grams such as the Public Health Emergency CURRENT STATUS OF STATE PREPAREDNESS A Government Accountability Office (GAO) report published According to federal guidelines, state plans are required to demon- in September 2008, found that the HHS-led review of state strate the state’s ability to accomplish a range of expectations, but pandemic influenza response plans found “many major gaps” in states have not been adequately funded to meet these demands:26 state pandemic planning in 16 out of 22 priority areas.23 The I Ensure public health continuity of operations during each GAO concluded that “while the federal government has pro- phase of a pandemic; vided some support to states in their planning efforts, states and localities have had little involvement in national planning for I Ensure surveillance and laboratory capability during each an influenza pandemic….even though the National Pandemic phase of a pandemic; Implementation Plan relies on these stakeholders efforts.”24 I Implement community mitigation interventions, e.g., school clos- A January 2009 “Assessment of States’ Operating Plans to ings or cancelation of large public events; Combat Pandemic Influenza” report from HHS to the White I Acquire and distribute medical countermeasures, like Tamiflu® House Homeland Security Council found that many states or Relenza®; scored well in areas such as protecting citizens and administer- ing mass vaccinations, but found major gaps in such areas sus- I Ensure mass vaccination capability during each phase of a taining state operations, developing community mitigation pandemic; and plans, and maintaining key infrastructure.25 I Ensure communication capability during each phase of a pandemic. SEATTLE & KING COUNTY, WASHINGTON: RESPONSE TO SWINE FLU AMID BUDGET CUTS AND EVOLVING POLICIES A month into the outbreak, Seattle & King County had more daycares, were slated, as a result of previous budget reduc- than 160 cases of H1N1 and several schools were closed to tions, to receive their lay-off notices two weeks later.28 prevent the further spread of the novel flu virus. The local re- The budget cuts also are likely to severely strain local and state sponse to the H1N1 outbreak was undertaken amidst con- laboratory testing capability. According to Dr. Fleming, “Limita- cerns about steep cuts in local public health funding. In fact, tions in testing capability in our local laboratory, at the state lab- the last day of the 2009 Washington state legislative session -- oratory, and at CDC led to a national picture of the outbreak as in which Seattle & King County’s public health funding was cut reported in the national media that was a week to 10-days-old by $14.4 million from $201.6 million to $187.2 million -- was from the front line reality. We had widespread community ill- the same day as cases were first identified in the United States. ness before CDC posted a single confirmed case in Seattle.” According to the Seattle Post Intelligencer, the King County op- erating budget deficit for 2010 could be $50 million and the Dr. Fleming believes the key to Seattle & King County’s success to 2009 budget may have to be further revised downward.27 date in containing the H1N1 outbreak is attributable to communi- cation, and local health officials being careful to say what they A major concern is that two programs which helped in the re- didn’t know, foreshadowing possible changes in policy, and being cent response face an uncertain future without additional fund- clear at the outset that what they learned about both severity and ing: the childcare health program, which allowed nurses to transmissibility would determine their response. “In that context work with schools to screen for possible cases, and the com- the community work that had been done on pandemic prepared- municable disease program. According to Dr. David Fleming, ness, while key, was a barrier,” Dr. Fleming says. “Changing poli- Director of Public Health for Seattle & King County, at the cies to match those indicated by a less severe strain was difficult height of concern the public health nurses who were working because that’s not what people had been trained to do.” overtime conducting education and outreach to schools and 12 8. WORKFORCE: The public health workforce is seriously strained, and budget cuts are re- sulting in additional layoffs. I Federal, state, and local governments must I Despite tough economic times, it is important take action to recruit, train, and retain the to sustain the public health workforces to pro- next generation of public health profession- tect America’s health. In the past year, public als in public health. From first responders to health departments around the country are scientists who detect and contain diseases, the being forced to layoff experts and professionals nation’s public health workforce is vital to needed to protect communities from threats protecting the nation’s health. There is a like pandemic flu. A preliminary survey of shortage of public health workers in the local health departments by the National As- United States, and as Baby Boomers retire, sociation of County and City Health Officials there is not a new generation of workers (NACCHO) has found both budget cuts and being trained to fill the void of expertly workforce reductions to health departments. A trained public health workers. The country survey of 2,422 local health departments na- has an estimated 50,000 fewer public health tionally in November-December 2008 found workers than it did 20 years ago, and one- that more than half of local health depart- third of the public health workforce in states ments have either laid off employees or lost is eligible to retire within five years, and 20 them through attrition. Because of the current percent of the local public health workforce is budget limitations, health departments have eligible to retire within two years. been unable to replace the lost workers, and they anticipate more cuts in 2009 and 2010.29 These cutbacks have serious consequences for responding to a health emergency. SACRAMENTO COUNTY: H1N1 CRISIS RESPONSE IN THE FACE OF BUDGET CUTS AND LAYOFFS On Friday, April 24, 2009 Dr. Glennah Trochet, Sacramento County’s chief public health officer as- sembled her staff to deliver some bad news: job cuts were a near certainty due to severe budget cri- sis facing California and the weak national economy. That same day health officials were warned about a novel influenza virus that was killing otherwise healthy young adults in Mexico. When the first case was diagnosed in Sacramento County on April 26, a panicky public jammed telephone lines with questions and “worried well” descended on local health care facilities, while lab technicians labored to diagnose and differentiate H1N1 flu cases from seasonal flu. Dr. Trochet sounded the alarm and her local public health workforce jumped into action. A squad of 50 Sacramento County health workers began putting in 12-hour shifts and logged more than 1,200 hours over the first five days of the outbreak. That kind of dedication in the face of looming budget cuts and layoffs is emblematic of the U.S. public health workforce. Across the country, the economic recession is leading to severe cuts in public health budgets. In 2008, local health departments across the country lost $300 million and 7,000 staffers to budget cuts and could lose an equal number of workers this year, according to NACCHO. In Sacramento County, over the past two years the Division of Public Health has seen its budget slashed in half -- dropping from $9.8 million to $5.1 million. The department has been forced to let go more than a quarter of its staff. According to the Sacramento Bee, in 2008, 57.4 full-time positions were shed; an additional 31 or more could be lost in 2009, bringing staffing below 228 full-time-equiv- alent positions. “I hope the public realizes how much work is going on to keep them safe and to keep them well,” said Dr. Trochet. “It’s only when we fail that the public notices that there is a public health disaster.”30 13 D. SURGE CAPACITY AND CARE RECOMMENDATIONS While the H1N1 outbreak was relatively mild and return of H1N1 in the fall and/or the potential of limited in duration in the United States in early other outbreaks, caring for a major surge of pa- 2009, hospitals and clinicians across the country re- tients remains one of the most difficult challenges ported major surges in patients, including individ- for the public health and health care systems. uals with the flu, flu-like symptoms, or the “worried The following are recommendations for ways to well.” As health providers prepare for a potential better prepare for a massive influx of patients: 9. SURGE CAPACITY: The ability for health providers to manage a massive influx of patients during an emergency remains a major challenge for emergency public health preparedness. During a major emergency like a pandemic out- out of supplies very quickly if they have to treat break, the health care system will be significantly a major surge of patients. In addition, hospi- stretched beyond normal capabilities. In the best tals are likely to run short of ventilators and de- of times, most emergency rooms already face bed contamination units very quickly. shortages and staffing issues. During disasters, I Staff: Workforce shortages plague hospitals and health providers have to adapt their regular prac- health care facilities even in the best of times. tices to treat a large number of patients very According to a June 2008 report from the Cen- quickly. Many of the surge capacity problems ter for Studying Health System Change, “the have been identified -- including having enough day-to-day shortages of key health personnel -- stuff, staff, and space to treat patients -- but solu- such as nurses, physicians, pharmacists, labora- tions to these problems are often lacking. tory technicians, and respiratory therapists -- ex- The HHS Pandemic Influenza Plan projects that acerbate the challenge of having sufficient a pandemic could result in 45 million additional numbers of health workers in an emergency.”32 outpatient visits, with 865,000–9,900,000 indi- One way to increase workforce capacity is to pro- viduals requiring hospitalization, depending on vide incentives to medical providers, such as pri- the severity of the pandemic. Such a major dis- ority status for receiving medications or aster would cross state lines and quickly over- vaccinations. Another is to recruit health care whelm health care systems. providers outside of the emergency systems to serve as volunteers during disasters. Liability I The federal government must take a lead in protection concerns for volunteers must be ad- providing guidelines to states on surge capacity dressed as part of the planning process. An planning. Currently, definitions of appropri- analysis in 2008 found that eight states have low ate “disaster standards of care” are lacking, ac- levels of protections for health care volunteers cording to the New England Journal of Medicine.31 during times of emergencies, meaning that Although various federal agencies have pub- states have only Good Samaritan or similar laws lished surge guidance, there have been few in- under which volunteers may be provided with centives or unified directions to enable states an affirmative defense, but not necessarily im- to implement surge planning. During mass munity from liability. In addition, 26 states did emergencies, measures must be put in place to not have statutes that extended some level of li- care for a potential surge of patients, including ability immunity to groups and/or organizations creating alternative care sites and recruiting providing charitable, emergency, or disaster re- additional health care personnel. Surge plan- lief services.33 ning includes planning for altered standards of care and addressing legal and ethical concerns I Space: Hospitals and other facilities will have before an emergency occurs. Hospitals must to address limited numbers of hospital beds also consider how to provide continued care and space to care for sick individuals. They for daily emergencies and chronic care when will have to manage issues like rapid dis- they are also responding to a major outbreak. charging of patients, canceling elective sur- geries and procedures, reducing the use of I Stuff: Today’s hospitals and health care facili- tests and ancillary services, converting single ties operate using a “just-in-time supply chain,” rooms to accommodate more people, using which means very limited supplies are stored cots and portable beds, and finding unused on-site and instead are replenished on an as space to treat or triage patients. needed basis, so many health providers will run 14 MEDICAL RESERVE CORPS: VOLUNTEER HEALTH CARE PROFESSIONALS RESPOND TO H1N1 OUTBREAK The Medical Reserve Corps (MRC) is a national network of community-based volunteer units that support local public health and provide for an adequate supply of volunteers in the case of a public health emer- gency. During the H1N1 outbreak, MRC units across the nation were activated to assist in the response. Arizona I The Navajo County MRC volunteers dispatched four members to help the Navajo County Public Health Department in the receiving, inventorying, and sorting of Strategic National Stockpile (SNS) pharmaceuti- cals. Six MRC volunteers from this unit later assisted in the distribution of SNS supplies to local hospitals. Florida I The Sarasota County MRC sent three MRC nurses to staff a H1N1 triage phone line. Over six days they worked a total of 27 hours at two community health department sites. These volunteers were also trained in personal protective equipment (PPE) protocols to conduct physical assessments of walk in patients who possibly were ill with H1N1 flu. Louisiana I Calcasieu Parish MRC helped the Regional Office of Public Health in Lake Charles, Louisiana, with calls to hospitals, doctors’ offices and other health care facilities to check on their needs and current avail- ability of supplies. They also delivered test kits to health care facilities. Approximately 22 volunteers also were involved in community mitigation efforts, teaching proper hand washing at local schools. New York I New York City MRC physician volunteers assigned to the NYC Department of Health and Mental Hygiene helped to staff the Provider Access Line call center to answer questions related to H1N1. Utah I Davis County MRC conducted a point-of-dispensing (POD) training course in anticipation of future mass vaccinations. Washington I Whatcom County MRC volunteers were involved in respirator fit testing for the local hospital. They ran four fit test stations over one weekend. Their goal was to perform fit testing on 1,000 people over 20 days. They also staffed a telephone triage call line. Whatcom County MRC also developed a potential Alternate Care Facility for surge capacity in event of hospital overflow. Whatcom County MRC staffed a phone bank in conjunction with Peace Health St. Joseph’s Hospital. Wisconsin I Southeast Wisconsin MRC volunteers staffed call centers, and clinics where they performed diag- nostic testing on patients. Source: All information provided to TFAH by the Office of the Civilian Volunteer Medical Reserve Corps. 15 10. CARING FOR THE UNINSURED AND UNDERINSURED: A “State of Emergency” health benefit should be created to ensure that all Americans will be cared for during emergen- cies. Providing care is not only important for the individual patient, but since individuals are contagious, it also helps limit the spread of disease to others. With more than 15 percent of Americans lack- and treatment and not be delayed due to con- ing health insurance coverage, the financial im- cerns about their inability to pay for services. pact on the country’s public health and health Delayed diagnosis may complicate public care systems could be disastrous if hospitals, health officials’ abilities to control the spread community health centers, and primary care fa- of infection. Similarly, delayed diagnosis cilities treat large numbers of uninsured.34 Like- might render useless potential treatment with wise, if uninsured or underinsured patients antivirals, since such treatment is most effec- hesitate to seek treatment because of fears of tive when begun early after infection. out-of-pocket costs, treating and containing the I The Public Health Emergency Response Act further spread of a pandemic would be nearly (PHERA) is an example of legislation that would impossible. According to the Center for Biose- address this concern. The act calls for bolster- curity, U.S. hospitals could lose as much as $3.9 ing public health preparedness as part of a re- billion in uncompensated care and cash flow formed health system. It would address losses in a severe pandemic.35 payment streams for hospitals and health care Health reform offers the opportunity to find providers during emergencies, and it supports ways to ensure all Americans would be covered major equipment upgrades and maintenance of during an infectious disease outbreak and that capacity for hospitals and health care facilities.36 health providers would be compensated for pro- Currently, hospital preparedness is financed viding care. through the Hospital Preparedness Program I However, if universal health insurance cover- (HPP), which focuses on improving the clini- age is not achieved, the federal government cal response to a large-scale health emergency. should act now to create emergency health Initially run by the Health Resources and coverage and reimbursement. It would have Services Administration (HRSA), HPP is now to guarantee providers some level of com- run by the Office of the Assistant Secretary for pensation for the services they provide during Preparedness and Response (ASPR) as man- a pandemic, while encouraging individuals to dated by the 2006 Pandemic and All-Hazards come forward for diagnosis or treatment. Preparedness Act. ASPR awards one-year funding grants to hospitals and other health For the health care system, the emergency ben- care facilities to improve surge capacity and efit would mitigate the economic impact of pro- enhance community and hospital prepared- viding such a high level of emergency care, much ness for all-hazards, including bioterrorism of which may be uncompensated, while also for- and pandemic influenza. The funding system going revenue generating activities, such as elec- is viewed as unpredictable and insuffi- tive surgeries, which could place hospitals and cient.37,38,39 Hospitals only receive an average other health care providers in financial jeopardy. of $82,500 a year per hospital. The benefit would also encourage the unin- Appendix C examines options for funding an sured or underinsured who fall ill to access emergency health benefit. primary care services for prompt diagnosis 16 LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH: KEEPING MESSAGES SIMPLE AND FOCUSED Even though the events are still unfolding, the significant steps that of the next public health crisis, and that instead, overall respira- the Los Angeles County Department of Public Health (LACDPH) tory disease and emergency preparedness should be the core enacted in their emergency response provide important lessons focus. LACDPH also continued to hold a balanced view of the learned and guidance for future actions and policies -- not just for role of antivirals during a pandemic not promoting a strategy that H1N1 or flu pandemics, but for most public health events. antivirals can be used for community-wide prophylaxis. Instead of assuming they could affect a pharmaceutical response to preven- Be quick to respond, but keep messages measured. tion during a pandemic, they stressed a behavioral response Upon first confirmation of person-to-person spread in Mexico, (washing hands, staying home when sick, etc.). A lesson learned LACDPH’s emergency command operations were activated. from the current H1N1 situation is that novelty and transmissibil- This occurred weeks before the first confirmed case in Los An- ity does not necessarily equate to severity. The core pubic mes- geles and well before there were any notable changes in our sage was to communicate the particular severity profile of this seasonal flu disease surveillance. Activating the emergency pandemic in the United States (like seasonal flu), and frame the command was not meant as a declaration of alarm, but recog- prevention messages in reference to seasonal flu. Flu is always a nition that an effective response would require increased inter- serious disease and every season is the opportunity and the rea- action among the multiple units within Public Health as well as son to prepare. And now that H1N1 has morphed into seasonal a close collaboration with many of our communities’ agencies circulation, this emphasis is especially relevant. in the 88 cities in Los Angeles County. Public Health officials were aware they would need to serve as the primary emer- While the message focus was generally successful, an area where gency response entity. Bringing key internal and external officials felt they could be better prepared for was the great de- groups together from the very beginning of the response mand for tailored information and guidance to many different helped them develop cohesive message, shared goals, and plan groups and populations. They rapidly developed many guidances, coordinated action from the onset. In addition, because the in- complied information and documents in multiple languages and cident command structure is not a method of operations most pushed out information through their Web site and other channels. are familiar with, and is certainly not how Public Health rou- However, it continues to be an ongoing challenge to effectively tinely conducts business, this early activation allowed for clarifi- reach and reframe the guidance for the great diversity of the popu- cation of the flow of information and the process of assigning lations that comprise the 10 million persons in Los Angeles County. tasks before tensions increased and in advance of any crisis. Every crisis is a potential opportunity. Similarly, very early into their response, LACDPH enacted Pandemic and emergency planners cannot overlook the many several other steps -- steps that typically only occur after an “silver linings” to these events. Officials feel they have been fortu- emergency has had local impact, but their early initiation nate that, at least to date, the overall severity of this disease has greatly improved our preparations and set the stage for our been relatively mild; and yet it has heightened awareness in the ongoing operations. This included hosting an early joint press general public of the need to prepare for a pandemic and also conference with Public Health and several of our core com- forced some quick resolution to some policy issues that needed munity partners; this helped to solidify the collaboration and attention, but were resolved until the emergency arose. For in- further emphasized the roles, messages, and basic recommen- stance, school settings have always been recognized as an envi- dations. Very early into the response they also initiated the ronment for the potential spread of disease; but closing schools process to declare a local emergency and to present key infor- has to be considered very carefully as an approach to prevent dis- mation to our Board of Supervisors; this allowed for arranging ease transmission, and this practice can have serious unintended supportive fiscal and functional options in anticipation of the impact on the function of our communities. As a result of the as- challenges they would face in the response. The presentation sessments during the local response they developed a decision to the Board further clarified Public Health’s role in this type framework for school closing and did not close any schools. of event and helped to amplify public educational messages. LACDPH has been developing innovative modeling projects de- signed to provide a range of hypothetical scenarios and alterna- Keep the message simple: focus on facts and promote tive solutions during a pandemic. The H1N1 events provided a protective actions. valuable opportunity to test their model and to enact and refine Because LACDPH held a pragmatic view of pandemic planning, an actual response to what was previous a hypothetical solution. an area where they excelled was in their educational messages. The core messages were of value before H1N1 events occurred, The events also allowed officials to put their pandemic flu plan into applicable during, and still ring true today. For instance, they al- action: to identify its strengths and begin to consider improvements ways stressed that it is wrong to assume that birds are the sole where it is lacking. The events significantly strengthened existing source of a novel virus -- agencies that incorrectly used the term partnerships and provided a valuable opportunity to develop new “bird flu” as a synonym for “pandemic flu” in their educational partnerships that had been overlooked. Planning is essential to ef- materials and planning documents were caught unprepared when fective emergency response and officials learned that the many the swine-based H1N1 virus emerged. The importance of this hours spent on pandemic flu exercises and community collabora- distinction was to emphasize that they cannot predict the cause tions could be successfully transferred into a real-life application. 17 AAPPENDIX PANDEMIC FLU PLANNING BACKGROUND HOW IS PANDEMIC FLU DIFFERENT THAN SEASONAL FLU? Most Americans are familiar with seasonal flu, a respiratory illness that strikes annually. Seasonal flu kills approximately 36,000 people in the United States every year and hospitalizes more than 200,000, but experts generally consider it a predictable public health problem, since many peo- ple have some form of immunity to it and a yearly vaccine is available.40 A pandemic (from Greek, meaning “of all the people”) influenza is a new strain of the flu that is capable of sustained transmission among humans and, as a result, causes a global outbreak. Because there is little natural immunity, pandemic influenza will affect significantly more people than seasonal flu and like seasonal flu, is easily spread from person to person. There have been at least 10 recorded flu pandemics during the past 300 years.41 PANDEMIC FLU IS EVERYONE’S PROBLEM If a severe pandemic occurs, it is likely to be a prolonged and widespread outbreak that could require major changes in many sectors of society, such as schools, work, transportation, business, health care, and government. The public can greatly reduce their risk during a pandemic by being informed and prepared before the emergency. To be prepared for an outbreak, HHS encourages individuals, businesses, and communities to: I Talk with your local public health officials and health care providers, who can supply information about the signs and symptoms of a specific disease outbreak and recommend prevention and con- trol actions; I Adopt business/school practices that encourage sick employees/students to stay home and antici- pate how to function with a significant portion of the workforce/school population absent due to ill- ness or caring for ill family members; I Practice good health habits, including eating a balanced diet, exercising daily, and getting sufficient rest. In addition, take common-sense steps to stop the spread of germs including frequent hand washing, covering coughs and sneezes and staying away from others as much as possible when you are sick; and I Stay informed about pandemic influenza and be prepared to respond.42 18 STATE PURCHASES OF ANTIVIRAL MEDICATIONS As of June 1, 2009, 37 states and D.C. had purchased 50 percent or more of their federally-subsi- dized antivirals to stockpile for use during a pandemic influenza. 37 states and D.C. have purchased have purchased 50 percent or more of their federally-subsidized antivirals drugs to stockpile for use during an influenza pandemic State All Antivirals Percent of 13 states have purchased LESS than 50 percent of their share of federally-subsidized antiviral drugs to stockpile for use during an influenza pandemic State All Antivirals Percent of B APPENDIX Purchased by Allocation Purchased by Allocation Entity as of Purchased* Entity as of Purchased** 06/01/2009 06/01/2009 Alabama 533,553 112.8% Arizona 67,717 11.6% Alaska 77,030 113.2% Colorado 215 0.0% Arkansas 382,398 133.5% Connecticut 22,829 6.2% California** 2,772,922 103.2% Florida 277,798 15.6% Delaware 121,164 141.0% Idaho 8,567 6.0% D.C. 90,926 155.3% Massachusetts 50,662 7.5% Georgia 474,022 52.0% Montana 8,174 8.5% Hawaii 172,487 131.6% Nebraska 71,952 39.4% Illinois** 516,018 50.3% New Mexico 77,409 39.2% Indiana 650,912 100.00% Oklahoma 93,765 25.5% Iowa 312,631 101.2% Oregon 26,523 7.1% Kansas 286,084 100.0% Rhode Island 11,900 10.5% Kentucky 216,224 50.0% Utah 52,033 21.1% Louisiana 478,734 101.5% Maine 164,659 119.8% Maryland 481,886 83.3% Michigan 1,079,450 102.0% Minnesota 340,900 64.1% Mississippi 338,648 111.9% Missouri 600,477 100.0% Nevada 135,514 57.6% New Hampshire 68,000 50.3% New Jersey 880,293 97.0% New York*** 2,444,836 121.2% North Carolina 677,882 76.7% North Dakota 57,000 85.7% Ohio 1,388,858 115.7% Pennsylvania 1,298,792 100.0% South Carolina 459,960 105.6% South Dakota 80,310 100.0% Tennessee 613,706 100.0% Texas 1,662,241 71.6% Vermont 71,036 109.2% Virginia 828,445 107.1% Washington 438,253 68.1% West Virginia 248,462 130.6% Wisconsin 363,729 63.3% Wyoming 74,826 141.9% Notes: *The percent reflects total state antiviral purchases and may include unsubsidized state purchases, which is why some states exceed 100% of their federally-subsidized allocation. **The population count for California and Illinois does not include residents of Los Angeles County or Chicago, respectively. These two localities, along with D.C., received their own allocation of federally-subsidized antivirals based on their populations. ***New York State antiviral purchases include those made by New York City. Source: http://www.pandemicflu.gov/plan/states/antivirals.html 19 CE APPENDIX FINANCING OPTIONS FOR CREATING SURGE CAPACITY ven in a system with universal health insurance coverage, the costs of creating surge capacity in the medical care system will be above and beyond the usual system of reimbursement to providers. Therefore, an additional system to finance the creation of surge capacity will be in needed and can be addressed during the health reform debate. OPTION 1: Establish a Preparedness Program under Medicare and Medicaid. A Preparedness Program through Medicare and The HIT funding formula is based on hospitals’ Medicaid could be created to help hospitals and Medicare share and Medicare bed days. The for- health providers upgrade equipment needed for mula calculation produces a dollar amount that emergencies, and to provide a billing mecha- an individual hospital is able to access if it can nism for care during emergencies. prove that it meets certain thresholds for mean- ingful electronic health record use. The thresh- Medicare olds would be defined by the HHS Secretary. There is precedence for using Medicare Part A In the proposed Medicare Preparedness Pro- (hospital insurance) to compensate hospitals for gram, preparedness accreditation standards and higher operating costs they incur in providing Medicare’s hospital codes of participation would services to low-income patients, and even using be reviewed and updated by the HHS Secretary Medicare Part A to preserve access to care for to strengthen the preparedness requirements. Medicare and low-income populations.43 The Dis- First year funding would be available to individual proportionate Share Hospital (DSH) Payments hospitals on a formula-basis if they produced an are used to mitigate the financial distress that action plan for their preparedness planning, the some hospitals experience in serving large num- scope of which would be defined by the HHS Sec- bers of low-income, uninsured or underinsured retary. In subsequent years, formula-based fund- patients and Medicare and Medicaid recipients. ing would be available if individual hospitals met Medicare Part A has also been used to compensate preparedness structure and process benchmark teaching hospitals for the higher costs associated measures defined by the HHS Secretary. The for- with running graduate medical education pro- mula would be based on hospitals’ Medicare grams and training medical residents. The Direct share and Medicare bed days. The HHS Secre- Graduate Medical Education (DGME) provides tary would be required to report to Congress an- payments to hospitals for the costs of approved nually on the use of preparedness program graduate medical education programs.44 Mean- dollars, and in year five make recommendations while, the Indirect Medical Education (IME) pro- for improvements in the program including ad- vides an additional payment to hospitals that have dressing any need for variations in the funding residents enrolled in GME programs, to reflect the formula based on geography, risk-assessment, etc. higher cost of patient care costs of teaching hos- pitals relative to non-teaching hospitals. Medicaid In order to reach children’s hospitals not reim- A newly formed Preparedness Program would bursed by Medicare, hospital preparedness pay- allow hospitals to meet and maintain enhanced ments would need to include a parallel funding preparedness accreditation standards and stream in Medicaid. Medicare codes of participation. The program would link payment to a process involving the Medicaid is a jointly funded, federal-state health HHS Secretary defining the scope of allowable insurance program for low-income children, the preparedness costs. Overall, this approach would aged, blind, and/or disabled, and other people be similar to the Health IT (HIT) incentive model who are eligible to receive federally assisted in- included in the American Recovery and Rein- come maintenance payments. Medicaid is a state vestment Act of 2009. The HIT program is not a administered program and each state sets its own traditional grant program where hospitals apply guidelines regarding eligibility and services, how- for money to do certain things and compete for ever, the federal government sets a minimum el- dollars, etc. It is, instead, like a lot of things igibility floor ensuring a certain level of coverage funded on the mandatory side, formula-based. to select populations. 20 In the past, Medicaid has been used to reimburse The proposed hospital preparedness program providers of medical assistance, including hospi- would involve a 100 percent federal match so tals, for infrastructure upgrades. For example, in there would be no reason for states to opt out of October 1972, Congress passed a law (P.L. 92-603) the program. The legislation could also include that provided for a 90 percent federal (10 percent creation of a Medicaid reimbursement for the state) financial participation for the design, devel- state health department’s role in administering opment, or installation of the Medicaid Manage- and coordinating the new program, as described ment Information System (MMIS), a mechanized later in the Eligibility for Reimbursement and claims processing and information retrieval system Standards for Surge Capacity section. approved by HHS. The law also provided a 75 per- cent federal (25 percent state) financial participa- tion for the operation of the MMIS. OPTION 2: Use Direct and Indirect Payments to Reimburse Hospitals for Surge Costs. The Graduate Medical Education (GME) pro- surge capacity, including hiring and retaining per- gram currently uses both direct and indirect pay- sonnel and recruiting a surge workforce. ments to reimburse teaching hospitals for the Centers for Medicare and Medicaid Services cost of educating medical students. Direct Grad- (CMS) could set up a new Medicare billing code uate Medical Education (DGME) provides pay- or a Diagnosis Related Group (DRG) add-on that ments to hospitals for the costs of approved could be used to reimburse hospitals for capital ex- graduate medical education programs. Mean- penditures and staffing for hospital preparedness. while, Indirect Medical Education (IME) pro- This approach would face some challenges to im- vides an additional payment to hospitals that have plement because Medicare currently does not re- residents enrolled in GME programs, to reflect imburse through DRG unrelated to direct patient the higher cost of patient care costs of teaching care and the process would require ongoing au- hospitals relative to non-teaching hospitals.45 diting of hospitals. CMS could determine whether The creation of a Direct Preparedness Payments having preparedness training curriculum in place (DPP) and Indirect Preparedness Payments (IPP) could be reimbursed and perhaps whether hospi- could help reimburse hospitals for the direct costs tals could receive an additional payment to cover of preparedness, such as the purchase of extra sup- the higher costs of training staff in emergency pre- plies and beds, and provide hospitals with a mod- paredness and surge capacity techniques. est enhancement for the ongoing costs of building Eligibility for Reimbursement and Standards for Surge Capacity CMS, in conjunction with the Assistant Secretary I ASPR would need to develop guidance to for Preparedness and Response (ASPR) and states for coordination of a state program, in- other appropriate partners, could develop stan- cluding communication between hospitals, dards and guidelines for determining both if a triggering of surge protocols, deployment of hospital should be eligible for (and is capable assets, and other issues. of) developing surge and what surge capacity I In order to receive reimbursement, hospitals entails. Although CMS would provide the reim- would need to meet preparedness standards bursement mechanism, ASPR, with input from as determined by the federal rulemaking Coordinating Office for Terrorism Prepared- process. Examples include having a hospital ness and Emergency Response (COTPER), preparedness coordinator, a hospital-specific should oversee the program and provide over- plan that is approved by the state, an interop- sight and technical assistance to state and hos- erable communications system, and a conti- pitals to ensure efficacy. A number of issues that nuity of operations plan. would need to be addressed include: I By agreeing to participate, hospitals would have I Through the rulemaking process, a certification to agree to participate in a state surge program, process would need to be developed so state to be coordinated by the state health department health departments could determine if a hospi- with guidance and technical assistance from HHS. tal is eligible to participate in the program. The state would take into account the regional need I Prior to creating the hospital preparedness billing for surge and the capacity of individual hospi- code, CMS would have to determine for what tals to participate, based on a state-wide plan. items it would be willing to reimburse hospitals. 21 Endnotes 20 Trust for America’s Health. Blueprint for a Healthier America: Modernizing the Federal Public Health System to Focus on Prevention and Preparedness. Washington, 1 Personal correspondence with David Fleming, MD, D.C.: TFAH, 2008, p. 92. Director of Seattle & King County Public Health De- 21 U.S. House of Representatives, Committee on partment, May 21, 2009. Homeland Security, Report by the Majority Staff. 2 CNN.com. “‘Walking well’ Flood Hospitals with -- or Getting Beyond Getting Ready for Pandemic Influenza. without -- Flu Symptoms.” May 2, 2009. Washington, D.C.: U.S. Congress, January 2009. http://www.cnn.com/2009/HEALTH/05/02/wor- http://homeland.house.gov/SiteDocuments/20090 ried.well.hospitals/ (accessed May 18, 2009). 114124322-85263.pdf (accessed January 23, 2009). 3 Improving Pandemic Preparedness, 2008. 22 Johnson, N., E. Hudgins, and J. Koulish. Facing Deficits, 4 Trust for America’s Health. Ready or Not? 2008: Pro- Many States Are Imposing Cuts That Hurt Vulnerable Resi- tecting the Public’s Health from Diseases, Disasters, and dents. Washington, D.C.: Center on Budget and Policy Bioterrorism. Washington, D.C.: Trust for America’s Priorities, October 20, 2008. http://www.cbpp.org/3- Health, 2008, p.20 . 13-08sfp.htm (accessed May 20, 2009). 5 U.S. Department of Health and Human Services. 23 U.S. Government Accountability Office. Pandemic In- “Secretary Sebelius Takes Two Key Actions On Strate- fluenza: Federal Agencies should Continue to Assist States gic National Stockpile.” News Release, April 30, 2009. to Address Gaps in Pandemic Planning. Washington, http://www.hhs.gov/news/press/2009pres/04/20090 D.C.: U.S. Government Accountability Office, 2008. 430a.html (accessed May 11, 2009). 24 Ibid. 6 Pandemic Planning Update VI, 2009. 25 U.S. Department of Health and Human Services. 7 U.S. Department of Health and Human Services. “2009- “Federal Assessment Finds Progress, Gaps in State H1N1 Influenza Vaccine Development Next Steps: Plans for Pandemic Influenza.” News Release, January Questions and Answers.” Medical Countermeasures.gov 15, 2009. http://www.hhs.gov/news/press/2009pres/ https://www.medicalcountermeasures.gov/BARDA/M 01/20090115i.html (accessed May 6, 2009). CM/panflu/nextsteps.aspx (accessed May 29, 2009). 26 U.S. Centers for Disease Control and Prevention. “Eval- 8 Ibid, p. 5. uation Criteria for Key Supporting Activities Linked to PHEP Funding.” http://emergency.cdc.gov/cotper/ 9 Pandemic Planning Update VI, 2009. coopagreement/08/pdf/evaluation.pdf (accessed Sep- 10 Congressional Budget Office. U.S. Policy Regarding tember 25, 2008). Pandemic-Influenza Vaccines. Washington, D.C.: U.S. 27 Grygiel, C. “Swine Flu Return, Severe Flooding Big Congress, September 2008, p. 5. King County Concerns.” Seattle Post Intelligencer, May 11 Harris, KM, J Maurer, N Lurie. Midseason Influenza 18, 2009. http://www.seattlepi.com/local/406276_flu- Vaccine Use by Adults in the U.S. Santa Monica, CA: flood18.html?source=mypi (accessed May 21, 2009). RAND Corporation, 2008]. 28 Information provided to TFAH in private communi- 12 Letter to Senator Inouye, Chair, Senate Appropria- cation dated May 18, 2009. tions Committee and Senator Cochran, Ranking 29 National Association of County and City Health Offi- Member, Senate Appropriations Committee from cials (NACCHO). Preliminary Findings: NACCHO Sur- 14 U.S. Senators advocating for increased appropri- vey of Local Health Departments’ Budget Cuts and Workforce ations for the Biomedical Advanced Development Reductions. Washington, D.C.: NACCHO, 2008. Research Authority, May 7, 2009. 30 Calvan, B.C. “Cuts Add to Health Staffers’ Worry.” 13 http://www.hhs.gov/pandemicflu/plan/ The Sacramento Bee, May 3, 2009. sup6.html#summary http://www.sacbee.com/ourregion/story/1829626- 14 U.S. Government Accountability Office. Pandemic In- p2.html (accessed May 18, 2009). fluenza: Federal Agencies Should Continue to Assist States 31 Okie, S. “Dr. Pou and the Hurricane -- Implications to Address Gaps in Pandemic Planning. Washington, for Patient Care during Disasters.” The New England D.C.: U.S. Government Accountability Office, 2008. Journal of Medicine 358, no. 1 (January, 2008): 1-5. 15 Getting Beyond Getting Ready for Pandemic Influenza, 2009. 32 Felland, L. E., A. Katz, A. Liebhaber, and G. R. Cohen. 16 Ready or Not, 2008, p. 90. Developing Health System Surge Capacity: Community Ef- 17 Allan, T. M. Statement of the Cuyahoga County forts in Jeopardy. Research Brief no. 5. Washington, D.C.: Board of Health to the Committee on Oversight and Center for Studying Health System Change, 2008. Government Reform, U.S. House of Representa- 33 Trust for America’s Health. Ready or Not? Protecting tives. Washington, D.C.: Cuyahoga County Board of the Public’s Health from Diseases, Disasters, and Bioterror- Health, May 20, 2009. ism, 2008. Washington, D.C. , Trust for America’s 18 U.S. Government Accountability Office. Influenza Health, 2008. Pandemic: Challenges in Preparedness and Planning. 34 DeNavas-Walt, C., B.D. Proctor, and J.C. Smith. Income, Washington, D.C.: U.S. Government Accountability Poverty, and Health Insurance Coverage in the United States: Office, June 2008. http://www.gao.gov/new.items/ 2007, U.S. Census Bureau, Current Population Reports, d05863t.pdf (accessed January 23, 2009). P60-235. Washington, D.C.: U.S. Government Printing 19 Trust for America’s Health. Preventing and Control- Office, 2008. http://www.census.gov/prod/2008pubs/ ling Pandemic Flu and Other Infectious Diseases. Wash- p60-235.pdf (accessed September 26, 2008). ington, D.C.: Trust for America’s Health, March 35 J. Matheny, et al. “Financial Effects of an Influenza 2008. http://healthyamericans.org/assets/files/ Pandemic on U.S. Hospitals.” Journal of Health Care 10ThingsPanFlu.pdf (accessed December 4, 2008). Finance 31, no. 1 (Fall, 2007): 58-63. 22 36 There is precedence for using federal funding 41 CIDRAP. “Historical Perspective.” streams to compensate hospitals for their contribu- http://www.cidrap.umn.edu/cidrap/content/in- tion to public health. Medicare Part A has been fluenza/panflu/biofacts/panflu.html#_Historical_P used to compensate teaching hospitals for the erspective_1 (accessed April 27, 2009). higher costs associated with running graduate med- 42 Ready America. “Pandemic Influenza.” Department ical education programs and training medical resi- of Homeland Security. http://www.ready.gov/amer- dents. ica/beinformed/influenza.html (accessed October 37 Katz, R. and J. Levi. “Should a Reformed System Be 27, 2008). Prepared for Public Health Emergencies, and What 43 Association of American Medical Colleges. “Medicare Does that Mean Anyway?” Journal of Law, Medicine, Disproportionate Share (DSH) Payments.” and Ethics (Winter 2008):485-490. (In print.) http://www.aamc.org/advocacy/library/teachhosp/ 38 Toner, E., R. Waldhorn, B. Maldin, et al. “Hospital hosp0003.htm (accessed February 4, 2009). Preparedness for Pandemic Influenza.” Biosecurity 44 Centers for Medicare and Medicaid Services. “Di- and Bioterrorism: Biodefense Strategy, Practice and Science rect Graduate Medical Education (DGME).” 4, no. 2 (2006): 207-217. http://www.cms.hhs.gov/AcuteInpatientPPS/06_dg 39 De Lorenzo, R. A. “Financing Hospital Disaster Pre- me.asp#TopOfPage (accessed February 4, 2009). paredness.” Prehospital and Disaster Medicine 22, no. 5 45 Centers for Medicare and Medicaid Services. “Indi- (Sep-Oct, 2007): 436-439. rect Medical Education (IME).” 40 Trust for America’s Health. “A Killer Flu?’’ citing http://www.cms.hhs.gov/AcuteInpatientPPS/07_im “Questions and Answers: Seasonal Influenza,” Cen- e.asp#TopOfPage (accessed February 4, 2009). ters for Disease Control and Prevention, at URL http://www.cdc.gov/flu/about/qa/disease.htm (ac- cessed April 27, 2009). 23 ACKNOWLEDGEMENTS TFAH BOARD OF DIRECTORS Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by pro- tecting the health of every community and working to make disease prevention a national priority. Lowell Weicker, Jr. President The Center for Biosecurity is an independent, nonprofit organization of the University of Pittsburgh Former 3-term U.S. Senator Medical Center. The Center works to affect policy and practice in ways that lessen the illness, death, and and Governor of civil disruption that would follow large-scale epidemics, whether they occur naturally or result from the Connecticut use of a biological weapon. Cynthia M. Harris, The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our PhD, DABT country. As the nation’s largest philanthropy devoted exclusively to improving the quality of the health and Vice President health care of all Americans, the Foundation works with a diverse group of organizations and individuals to Director and Associate identify solutions and achieve comprehensive, meaningful, and timely change. For more than 35 years, the Professor Institute of Public Health, Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that Florida A&M University affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. Patricia Baumann, MS, JD Treasurer President and CEO Ann Norwood, MD, COL, USA, MC (Ret) Bauman Foundation REPORT AUTHORS Senior Associate Gail Christopher, DN Jeffrey Levi, PhD. Center for Biosecurity of the University of Pittsburgh Vice President for Health Executive Director Medical Center WK Kellogg Foundation Trust for America’s Health and Associate Professor in the Department of Health Policy Jennifer Nuzzo, SM John W. Everets The George Washington University Associate David Fleming, MD School of Public Health and Health Services Center for Biosecurity of the University of Pittsburgh Director of Public Health Medical Center Thomas V. Inglesby, MD Seattle King County, Chief Operating Officer and Deputy Director Monica Schoch-Spana, PhD Washington Center for Biosecurity of the University of Pittsburgh Senior Associate Arthur Garson, Jr., Medical Center Center for Biosecurity of the University of Pittsburgh MD, MPH Medical Center Laura M. Segal, MA Executive Vice President Director of Public Affairs Eric Toner, MD and Provost and the Trust for America’s Health Senior Associate Robert C. Taylor Professor Center for Biosecurity of the University of Pittsburgh of Health Science and Serena Vinter, MHS Medical Center Public Policy Senior Research Associate University of Virginia Trust for America’s Health PEER REVIEWERS Robert T. Harris, MD CONTRIBUTORS TFAH thanks the reviewers for their time, expertise, and Former Chief Medical insights. The opinions expressed in the report do not Officer and Senior Brooke Courtney, JD, MPH, necessarily represent the views of the individuals or the Vice President for Associate organization with which they are associated. Healthcare Center for Biosecurity of the University of Pittsburgh David Fleming, MD BlueCross BlueShield of Medical Center Director of Public Health North Carolina Kimberly Elliott, MA Seattle King County, Washington Alonzo Plough, MA, Deputy Director Robert Kadlec, MD MPH, PhD Trust for America’s Health Former Special Assistant to the President for Homeland Director, Emergency Crystal Franco Preparedness and Security and Senior Director for Biological Defense Policy Senior Analyst Response Program Center for Biosecurity of the University of Pittsburgh Los Angeles County This report is supported by a grant from the Robert Wood Medical Center Department of Public Health Johnson Foundation. The opinions expressed in this report Gigi Kwik Gronvall, PhD are those of the authors and do not necessary reflect the Theodore Spencer Senior Associate views of the foundation. Project Manager Center for Biosecurity of the University of Pittsburgh Natural Resources Medical Center Defense Council 1730 M Street, NW, Suite 900 • Washington, DC 20036 (t) 202-223-9870 • (f) 202-223-9871 24