TFAH says pandemic response shows strengths, weaknesses

Robert Roos

Dec 15, 2009 (CIDRAP News) In its seventh annual report card on the nation's public health preparedness, the advocacy group Trust for America's Health (TFAH) praised the US response to the H1N1 influenza pandemic but also said it has exposed serious gaps in the ability to deal with public health emergencies.

Releasing a "good news, bad news" report, the nonprofit group said preparedness investments in recent years "dramatically improved" the nation's readiness for the epidemic. But in the wake of decades of sparse funding, the pandemic also has revealed deficiencies in disease surveillance, laboratory testing capacity, vaccine production capability, hospital surge capacity, and the public health workforce.

The report, titled "Ready or Not? Protecting the Public's Health from Diseases, Disasters, and Bioterrorism," also notes that the economic recession has hurt preparedness by forcing public health layoffs, which have come amid declining federal preparedness grants to states. The federal grants have shrunk by 27% since 2005, it says.

At a press conference this morning, TFAH officials and others praised the response of public health personnel to the pandemic. "I think some short- and long-term fixes can be made, but overall, considering the resources, it was quite an impressive response so far," said Richard Hamburg, deputy director of TFAH.

Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University's Mailman School of Public Health, acknowledged there were "tremendous problems" with the pace of vaccine production, but added that the vaccine, once made, was distributed rapidly and that health officials worked very hard to administer it.

The report itself says the federal government has been "remarkably transparent" with the American people about the pandemic.

However, information about health emergency preparedness in general is scarce, which is part of the rationale for the report, according to TFAH. "This report aims to foster greater accountability for how effectively taxpayer dollars are used to improve the nation's readiness for health emergencies," the report says.

At the press conference, Redlener said there is no generally accepted definition of preparedness, and no one really knows exactly how much has been spent on it since Sep 11, 2001. "A lot of the preparedness efforts have been pretty random, disconnected, and not all that helpful," he said.

State ratings
Much of the 96-page report describes states' public health preparedness, rating each state on the basis of 10 indicators, as TFAH has done in past years. Saying that six of the indicators are the same as those used last year, Hamburg explained that some of the indicators are changed each year in an effort to spur progress. "We're always raising the bar," he said.

Nearly two thirds of the states satisfied 7 or fewer of the 10 indicators, and 20 scored 6 or fewer, officials said. Seven states tied for the highest score of 9 out of 10: Arkansas, Delaware, New York, North Carolina, Oklahoma, Texas, and Vermont. Montana had the lowest score with 3 out of 10.

The 10 indicators and some key findings on the states' performance follow:

Antiviral stockpiling: Thirteen states have bought less than half of their share of federally subsidized antiviral drugs for use in a flu pandemic. Hamburg commented that states haven't had to use their stockpiles in the pandemic so far. "I dont know if it caused any major problems, but certainly if it had been a more virulent strain, the fact some states didn't [buy their full share] could have had an effect on the response," he said.
Hospital preparednesshospital bed availability reporting: Ten states don't submit weekly data on bed availability for at least 50% of their hospitals, as required by the Department of Health and Human Services (HHS) during the pandemic.
Public health labspickup and delivery services: Thirteen states lack the capacity to ensure timely, 24/7 transportation of samples to an appropriate public health lab.
Public health labssurge workforce: Twelve states and Washington, DC, lack the staff to work five 12-hour days for 6 to 8 weeks during an infectious disease outbreak.
Biosurveillance: Six states don't have a surveillance system compatible with the Centers for Disease Control and Prevention's (CDC's) National Electronic Disease Surveillance System.
Food safetydetection and diagnosis: Fourteen states couldn't identify the pathogen involved in foodborne disease outbreaks often enough to match the national average of 46%.
Medical Reserve Corps (MRC) readiness: Nine states don't meet the MRC readiness criteria.
Community resiliencychildren and preparedness: Only 20 states and Washington, DC, require all licensed child care facilities to have a written evacuation and relocation plan.
Legal preparednessemergency liability protection: Nineteen states have not adopted entity emergency liability protection or have made no determination under existing law.
Public health funding commitment: Twenty-seven states cut funding for public health from fiscal year 2007-08 to 2008-09.

Redlener said the recession has led to roughly 15,000 public health job layoffs around the country and that 15% of state health departments expect to lose more staff in the months ahead.

Pandemic communication draws praise
In a summary of key findings, the report offers a mix of positive and negative comments about the H1N1 pandemic response and related issues.

It says the federal response appears well coordinated, adding, "Public health officials have leveled with the American peoplemaking appropriate adjustments to recommendations as our understanding of the nature of the pandemic has evolved. The same has held true as supply issues have arisen." Constantly updated information has caused some confusion, "but it has reflected an honest attempt to reflect the current state of knowledge."

The report also notes that all states and Washington, DC, have pandemic plans, which were reviewed and graded by HHS last January.

On the other hand, TFAH says there are no funds or plans to replenish recently deployed supplies from the Strategic National Stockpile in time for the potential third wave of the pandemic. The CDC has distributed most of the supply of N-95 respirators and children's oseltamivir (Tamiflu), along with some of its surgical masks, it says.

On the flu vaccine front, the report says the $487 million HHS contract awarded to Novartis last spring to help build a cell-based production facility represents progress. But despite the spending of about $1 billion to boost manufacturing capacity, "we are still reliant on old egg-based production lines, which contributed to delays in production and delivery of the H1N1 vaccine," the report asserts.

In other observations, the report says:

New technology supported by HHS helped identify the pandemic H1N1 virus quickly. But during the first wave of cases in the spring, lab testing capability was quickly overwhelmed in some states.
The CDC has made improvements in disease surveillance, but the nation still lacks an integrated national approach to surveillance.
Few states have developed crisis standards of care, and there is no federal clearinghouse to share information on best practices for developing such standards.
Low-income and minority communities continue to suffer disproportionately during health emergencies, as exemplified by higher H1N1 hospitalization rates in African-Americans and Hispanics in the spring wave.

TFAH published the report in collaboration with the Robert Wood Johnson Foundation.