Jun 28, 2011 (CIDRAP News) – A report released yesterday by the Government Accountability Office (GAO) offers yet another review of lessons from the federal government's response to the H1N1 influenza pandemic while detailing how the government spent, and is still spending, $6.15 billion that was appropriated for the response.
The 67-page document from Congress's investigative arm says the Department of Health and Human Services (HHS) had spent $4.17 billion on the pandemic by December 2010. The remaining $1.98 billion was earmarked for continuing pandemic preparedness efforts, including attempts to speed up the production of pandemic vaccines.
The report sounds generally familiar themes about lessons from the federal response, saying that pandemic planning paid off but the overly optimistic early forecast of vaccine supplies hurt the government's credibility. It says the use of the Strategic National Stockpile (SNS) of medical supplies met its major goal but caused some headaches for state and local health agencies.
The stated aims of the report were to examine how HHS used the supplemental appropriation for the pandemic, identify issues raised by the government's response, and look at what federal agencies are doing to identify and implement lessons learned from the episode.
Of the $4.17 billion that HHS had spent on the pandemic by last December, 41%, or $1.72 billion, went for vaccines, adjuvants, and ancillary supplies, including needles and syringes, according to the report. The government bought 190 million doses of pandemic vaccine from five manufacturers as well as 200 million ancillary supply kits.
Another 36% of the money, or $1.49 billion, was spent to support state and local responses to the pandemic, mostly through the Public Health Emergency Response grant program, the report says. The funds were distributed in four phases starting in August 2009, with each phase targeting a focus area, such as communication or vulnerable populations.
The federal grants were critical for state and local responses to the pandemic, but state and local agencies had some problems with the administrative rules that came with the money, the GAO says. For example, the requirements focused mainly on vaccination, leaving too little flexibility to use the money on epidemiology and lab expenses.
The remaining 23% of the money, about $1 billion, was spent on various other activities, including (but not limited to):
- Centers for Disease Control and Prevention (CDC) components of the pandemic vaccination program, $340 million
- Antiviral drugs, $231 million
- CDC domestic response, including outbreak investigations and production of a diagnostic test kit, $199 million
- Hospital preparedness grants, $90 million
The GAO also outlines how HHS plans to spend the remaining $1.98 billion of the pandemic appropriation. Plans call for spending $758 million on influenza vaccine production, with $458 million of that designated for new technologies designed to shorten production time. Another $108 million is intended for HHS's new Centers for Innovation in Advanced Development and Manufacturing program, involving "multiuse facilities" that could be used to expand vaccine production during a pandemic.
Another $435 million of the remaining money is intended for advanced development of antiviral drugs, including peramivir, an intravenous drug that was used on an emergency basis during the pandemic. Other spending plans include $257 million for replenishing the SNS and $225 million for the CDC's "base influenza activities."
Reviewing pandemic lessons
As for lessons learned, the GAO said a key one is that previous pandemic planning and federal funding paid off, even though some recommendations, shaped by the H5N1 avian flu threat, weren't followed because the pandemic didn't match what was expected. In particular, interagency meetings and exercises built relationships that were valuable during the response, and prior funding built capacity in vaccine production and other areas, the report says.
On the other hand, it observes, "The credibility of all levels of government was diminished when the amount of vaccine available to the public in October 2009 did not meet expectations set by federal officials."
The GAO says further that state and local agencies appreciated the flexibility they enjoyed in deciding their vaccine distribution methods and that the use of a central distributor for the vaccines was generally seen as effective. However, the 100-dose minimum order for vaccines was a problem for some.
Concerning the SNS deployment, the GAO found that it achieved its major goal, including distributing 11 million courses of antiviral drugs and millions of face masks, respirators, gowns, and gloves by early May of 2009. But CDC and state officials identified some communication problems regarding timing of deliveries and various mismatches between the materials expected and those delivered.
Citing other problems with the SNS deployment, the GAO said:
- N-95 respirators provided from the SNS in some cases were not the type normally used by hospitals, so hospitals had to do additional fit-testing.
- State and local health officials were confused by conflicting federal and nonfederal guidance concerning the need for healthcare workers to wear respirators.
- Some states didn't use all of their SNS supplies and incurred resulting storage costs, and the CDC acknowledged that there was no federal plan for dealing with these unused materials.
The GAO report does not address certain other pandemic topics, such as the effectiveness of the vaccines and antiviral drugs used and the impact of nonpharmaceutical interventions such as school closings.
The report says the National Security Staff of the federal Homeland Security Council has asked federal agencies to prepare after-action reports based on their involvement in the pandemic response, but the NSS has not determined if those reports will be shared with key stakeholders.
HHS's assistant secretary for legislation reviewed a draft of the report and expressed general agreement with its findings, according to the GAO. The HHS official also said an upcoming HHS after-action report will highlight several of the key themes in the GAO document.
Full text of GAO report
Oct 29, 2010, CIDRAP News story on Institute of Medicine workshop summary on pandemic vaccination efforts