Preparing for Pandemic Influenza

In 2005, APHA adopted Resolution 2005-2 — Developing a Comprehensive Public Health Approach to Influenza¹.  That resolution dealt primarily with establishing a comprehensive approach to deal with annual epidemics of influenza.  Unlike annual epidemics, individuals have virtually no immunity against a pandemic flu strain, leading to widespread person-to-person transmission around the world, and higher rates of hospitalizations, illness and death.  The purpose of this paper is to serve as a policy supplement to 2005-2 and to identify the most important issues to be addressed in preparation for, and response to, an influenza pandemic. 

I.          Background and problem statement

There are three groups of influenza viruses — A, B, and C.  Each of these groups can cause illness in humans, but only group A viruses are associated with major epidemics or pandemics.² Influenza A viruses infect humans and other animals, notably birds and swine.^3,4 Influenza A viruses are continually undergoing evolutionary changes in their two major antigenic constituents – hemagglutinin (H) and neuraminidase (N).  There are 16 H strains and 9 N strains of influenza A viruses currently recognized.⁵ The viruses are named according to their H and N components, as well as the location where they were originally isolated.³ The evolutionary changes in H or N (drift) may result in sufficiently changed antigenic structure that immunity from prior infections may not protect all those who come in contact with it, contributing to annual epidemics.  In addition, simultaneous infection with two different influenza A viruses (in humans or other animals) may result in a reassortment of H and N components — antigenic shift — giving rise to a novel strain against which no one has immunity.  In this circumstance, pandemics of influenza may occur.³ In 2003-2006, an avian influenza strain (H5N1) has caused widespread disease among birds and occasional illness and death in humans.  Human infection with H5N1 has been associated with high case-fatality rates, and there is concern that the virus might acquire characteristics that make it easily transmissible among humans.⁵

For most people, infection with influenza virus causes an unpleasant but short-term illness from which they fully recover.  However, in certain people, including the very young, the very old, the immune compromised and those with many chronic illnesses, influenza can result in serious complications (e.g., pneumonia) or even death.  During an annual influenza season, an estimated 36,000 persons die as a result of having contracted influenza.⁶ Most people have some immunity to seasonal influenza strains. By contrast, during pandemics, since there is little natural immunity to the circulating strain, the disease can spread easily from person to person, and the number of excess deaths may be much higher.  During the 1918 influenza pandemic, it is estimated that more than 600,000 deaths occurred in the United States alone, with up to 50 million deaths occurring worldwide.  Subsequent pandemics, in 1957 and 1969, were associated with smaller numbers of excess deaths, but still numbering in the tens of thousands in the United States.⁷

Because of the continuous evolution of influenza viruses, influenza vaccines are reconstituted each year to include the most recently circulating strains.  To be protected, according to the Advisory Committee on Immunization Practices, certain individuals should receive the influenza vaccine annually. Influenza vaccines confer protection in 60-90 percent of recipients, depending on the degree of match between the antigens in the vaccine and those in the circulating viruses.² Approximately 200 million Americans are recommended to receive influenza vaccine each year — all those 6 months–59 months of age, all those 50 years of age and older, plus those with chronic illnesses, and close (household) contacts of such individuals.  Health care workers are also recommended for annual immunization.²

Mass immunization is the most important tool to try to mitigate the impact of an influenza pandemic, with antiviral medications playing an adjunctive role in prevention and, more importantly, treatment of influenza.  Unfortunately, as documented below, there are significant limitations on both the availability and use of each of these countermeasures.  Factors contributing to these limitations include production capacity of vaccines and antivirals as well as an inevitable delay between recognition of a pandemic strain of influenza and the first availability of a vaccine to prevent it.⁵

II.              Triggers for the transition of emergency phases

There is a global consensus on how to categorize phases of an influenza pandemic as well as the overarching public health priorities in each of the phases.  This categorization is included in the 2005 World Health Organization global influenza preparedness plan. Overall, there are six phases that occur during the interpandemic, pandemic alert and pandemic periods.  Phases 1 and 2 take place during the interpandemic period.  During phase 1, no new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease may or may not be present in animals. If present in animals, the risk of human infection or disease is considered to be low.  The goal of this phase is to strengthen pandemic influenza preparedness at the local, state, national and international levels.  Phase 2 is like phase 1 in that no new influenza subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease.  The goal of phase 2 is to minimize the risk of transmission to humans and, if such transmission occurs, to rapidly detect and report such transmission.⁸

Phases 3, 4 and 5 occur during the pandemic alert period. Phase 3 signifies that there are human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact. The goal of phase 3 is to ensure rapid characterization of the new virus subtype and early detection, notification and response to additional human cases.  During phase 4, there are small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.  The goal of this phase is contain the new virus or delay its spread in order to gain time to implement such preparedness measures as developing a vaccine.  Phase 5 is an intensification of phase 4, in that there are large cluster(s), but human-to-human spread is still localized.  This suggests that the virus is becoming increasingly better adapted to humans, but may not yet pose a substantial pandemic risk. Therefore, the goal of this phase is to maximize efforts to contain or delay spread of the virus to possibly avert a pandemic.  However, once there is increased and sustained transmission in the general population, the pandemic period (phase 6) has commenced.  The goal during the pandemic period is to minimize its impact. ⁸

The United States utilizes the WHO pandemic phases to gauge, plan for and implement the appropriate national response.  Nationally, operational phases can be divided into preparedness, response, recovery, and mitigation, based on the framework of the National Response Plan (NRP).  In November 2005, the U.S. Department of Health and Human Services issued a Pandemic Influenza Plan describing national as well as state and local responses to pandemic influenza.  Although many important facets are addressed, there are areas that APHA believes require additional attention, as described below.

III.       Roles and Responsibilities of Federal, State and Local Agencies and Health Care Delivery

The HHS Pandemic Influenza Plan states that the framework of the NRP would be followed in the multi-party response needed in the event of pandemic influenza, which includes all federal agencies.⁹ Responders would include a wide range of entities, such as federal, state and local governments and health agencies, hospitals, schools and businesses.  As an influenza pandemic would be deemed an Incident of National Significance, the NRP names the Department of Homeland Security (DHS) as the agency responsible for coordinating the overall federal response.  The NRP provides a mechanism to respond to a public health emergency such as pandemic flu in Emergency Support Function (ESF) #8 — Public Health and Medical Services.  In the implementation of this response effort, the HHS is named the primary federal agency.¹⁰ However, it is unclear how the relationship between HHS and DHS would be operationalized in the event of an influenza pandemic. 

The federal, state and local responses to the hurricanes of 2005 illustrated the problems that can arise during an emergency response when government agencies are unclear about and do not effectively implement their respective roles.  State and local governments were not familiar with the National Response Plan and the National Incident Management System, which resulted in these actors operating without an integrated response.¹¹ In preparing for pandemic flu, the HHS Pandemic Plan stresses the need for states and localities to have pandemic flu plans that have been tested.  Although most states have pandemic plans, many of these have not been tested.  Localities and communities are generally unprepared for pandemic flu in this regard.¹² Although state and local health departments will be at the forefront of the pandemic response and will need to have pandemic flu plans that have been vigorously tested, APHA believes that federal funding directed to state and local preparedness is insufficient to ensure our nation’s readiness and effective response to pandemic flu, including allowing states the opportunity to test their plans.

Therefore, APHA:

• Asserts that HHS, not DHS, should be the lead federal agency on issues related to domestic preparedness for and response to pandemic influenza, and should have wide authority to plan for a national response to the recurrent flu epidemics;
• Urges improved cooperation and coordination between HHS and DHS;
• Declares that the National Response Plan is an insufficient framework for pandemic influenza response efforts due to its lack of focus on public health leadership, preparedness and response;
• Urges federal agencies to rework the National Response Plan or formulate a different multi-party response framework to ensure that all actors at the federal, state and local levels are coordinated in their responses to pandemic influenza;
• Urges DHS and HHS to continue to provide training about the National Incident Management System to public health and response partners at the state and local levels to ensure familiarity with the system, as all emergencies involve the local level; 
• Calls upon Congress to appropriate new and additional resources to state and local levels to improve overall surveillance and response plans, including influenza preparedness efforts, including monies for states and localities to draft and vigorously test their systems and plans, including their pandemic influenza plans.

IV.           Local and State Preparedness and Response

Current Capacity

Federal, state, and local governments are responsible for assuring that the capacity of State Health Departments (SHDs) and Local Health Departments (LHDs) is sufficiently robust to respond to pandemic influenza once it affects a community.  LHDs, which have always formed the basis of the public health emergency response system, have been vigorously working to improve their capacity to respond to a global emergency since September 11, 2001.^13,14,15 The capacity of SHDs and LHDs to respond to emergencies differs among and within states. Such capacity depends on the public health training of their respective public health workforces and is presently in jeopardy as a result of a long under-funded public health system, an aging work force, low salaries that impede recruitment, and inconsistencies in preparation in public health.

The Health Resources and Services Administration (HRSA) Public Health Workforce Study explored the capacity of the public health system in this country.¹⁶ The study found that lack of funding is the biggest challenge facing public health departments seeking to assure adequate staffing levels. This is consistent with the National Association of City and County Health Officials statement that state and local agencies are not adequately funded to address pandemic influenza.¹³ While recruitment of qualified public health practitioners is a challenge across all public health fields due to work force shortages, the HRSA work force study identified nurses, epidemiologists and laboratory personnel as being especially difficult to recruit into public health departments.  As minority health professionals are more likely to serve minority and under-served communities, the shortage of minority health professionals has led to poorer health outcomes for minorities due to a lack of health literacy and access to health care.¹⁷ Therefore, recruitment efforts need to specifically target diverse populations.

The ability to respond effectively to a pandemic is further compromised by a system that does not foster ongoing collaboration and communication among partners at national, state and local levels.  Current local public health efforts in preparedness have already strained an over-burdened work force that must balance the day-to-day needs of communities with the labor-intensive activities of pandemic flu planning. Planning efforts need to include the collaboration of administrators, information technology and health educators amongst other professionals. The realities of local public health activities include using the same staff for all of the demands of public health. Cross-training of existing staff in issues related to planning, training and evaluation for pandemic flu as well as other possible epidemics is necessary, but will not adequately cover the anticipated surge in demands during a pandemic. Federal funding restrictions that prohibit states and localities from using federal dollars to supplant other state and local funds, as is the case with the Preventive Health and Health Services Block Grant and bioterrorism funding, do not take into consideration that it is the traditional public health functions (such as disease surveillance and vaccination) in addition to antiviral therapy and other public health activities that hold the key to adequately responding to a flu pandemic. Additionally, HRSA programs that fall under Titles VII and VIII of the Public Health Service Act — aimed at diversifying the physician, public health and nursing workforces — are being targeted for funding cuts.  During this time of state and local budgetary restraint, positions may be lost, seriously compromising local ability to meet these demands. Without an adequate, well-prepared work force, our hopes of reducing the impact of a pandemic are severely impaired. In addition, projections estimate that 30 percent of the active work force may be seriously ill and therefore unable to work during some portion of a pandemic. Therefore, if staffing levels remain stagnant, expectations of adequate staffing during the response phase are unrealistic. Lastly, while multiple attempts have been made to enumerate the public health work force, we do not have a national standard for defining what constitutes an adequate work force in non-pandemic times.  Pandemic times will require more personnel, but there will be a drop-off in the personnel due to illness and fears.

Further, supporting SHD and local HD programs such as those which train physicians in preventive medicine, epidemiology, and public health to serve in leadership positions,¹⁸ train and mentor epidemiologists such as California’s Epidemiologic Investigative Service (Cal-EIS),¹⁹ and distance learning programs in schools of public health, medical schools, universities, and SHDs that provide ongoing distance learning programs for public health staff at the state and local level, including community-based organizations, will also serve to support the capacity of the public health system to respond in the case of pandemic influenza or any other public health emergency. 

In order to support the federally stated goal that preparation for a potential influenza pandemic is essential to protect the public’s health, significant financial investment should be offered to facilitate training in containment strategies and other relevant skills to minimize the consequences of an influenza pandemic.²⁰

Therefore, APHA:

• Urges Congress to enact legislation to provide incentives, including scholarship or loan repayment support in return for a commitment to public health service, to attract and retain public health students and professionals, especially racial and ethnic minorities, to work in SHDS and LHDs;
• Calls upon Congress to increase funding directed towards HRSA health professions programs that fall under Titles VII and VIII of the Public Health Service Act, including public health traineeships and preventive medicine residencies;
• Calls on national, state and local public health partners to develop public health staffing standards and work to ensure adequate funding for a standards-based public health work force capacity at the local level;
• Urges the continued and consistent funding of state and local pandemic flu training that brings together all partners, including partners at all levels of government, across different government agencies, and from the non-profit and private sectors;
• Stresses the need for all fifty states, the District of Columbia, Puerto Rico and the U.S. territories to create, test and update annually a pandemic plan that identifies resource and work force gaps and supports efforts to fill those gaps;
• Encourages federal, state and local governments to fund efforts to support volunteer training and the development of plans and strategies to integrate volunteer health professionals into emergency response efforts;
• Recommends the adoption of planning checklists by families, communities and other entities, including businesses and schools, such as those supplied by the United States Department of Health and Human Services²¹ for use in preparing to respond to a public health emergency; 
• Supports the development of a continuity of operations plan for essential health department services, including contingency planning for increasing the public health workforce in response to absenteeism among health department staff and stakeholder groups that have key responsibilities under a community’s response plan²¹ as an essential part of preparedness planning;
• Encourages efforts to foster cooperation between a) different levels of government and different government agencies, and b) the public, private, and non-profit sectors. Strong relationships, ongoing communication and effective coordination between all of these entities and institutions as well as with the media are important to providing an effective pandemic response.

Preparing for State-Level Public Health Laboratory Network Response During Pandemic Influenza Outbreak

Because the antigenic properties of influenza viruses are constantly changing, strong laboratory-based surveillance will be critical through all stages of the pandemic to monitor both for disease activity and changes in virus strain. Timely identification of viral strains is equally important for pandemic detection and vaccine preparation. During the earliest stages of the pandemic, public health and hospital laboratories are likely to receive a large number of specimens for testing. Planning for laboratory surge capacity and the availability of diagnostic reagents will be essential for timely and effective testing.

State health departments should provide financial, human and material resources, and necessary leadership and guidance to state and local public health laboratories. It is essential to build strong, statewide laboratory-based surveillance capacity in the interpandemic phase, including strengthening partnerships between state laboratories and local public health laboratories to enhance the ability to monitor for disease activity and strengthening control measures.  Furthermore, university and private or other public laboratories may have the requisite facilities and expertise to be of assistance, especially at times when surge capacity is needed, so that relationships with these non-governmental institutions should be expanded and strengthened.  Ultimately, state-level public health laboratory networks should be able to:

• Characterize and monitor interpandemic influenza activity year-round with continuous surveillance for the introduction of novel influenza strains.
• Once a novel virus has been detected in the United States, monitor the level of novel influenza virus activity statewide.
• Support special epidemiologic and clinical studies needed to evaluate phase-specific clinical interventions and containment measures.
• Support development and implementation of individual case decision scenarios surrounding case management, including antiviral treatment and prophylaxis and isolation and quarantine.

Therefore, APHA stresses the need for CDC laboratories to collaborate with state-level public health laboratory networks, to:

• Develop standard diagnostic tests for influenza and novel influenza viruses (e.g., virus isolation, direct antigen testing by rapid antigen tests and PCR, and serologic testing);
• Develop and distribute recommended laboratory diagnostic guidelines for both interpandemic influenza and novel influenza virus;
• Establish criteria for confirmation of laboratory diagnosis of interpandemic influenza and novel influenza virus and distribute sample specimen collection and transport protocols;
• Provide needed education and training for state and local public health laboratory employees addressing sample specimen collection, transport protocols, laboratory diagnostic guidelines and diagnostic testing; and
• Increase local capacity to perform diagnostic testing for interpandemic influenza and novel influenza virus by transferring new technologies for influenza rapid testing (e.g., PCR) to interested state and local public health and university laboratories, as appropriate. 

V.             Public health interventions

Surveillance

APHA agrees with the HHS plan on the need to implement enhanced surveillance activities at the local, state and federal levels during a pandemic to accurately monitor disease spread, which will complement the activities occurring at the international level by the International Partnership on Avian and Pandemic Influenza.  Monitoring disease spread among vulnerable populations, including pregnant women, children, the elderly, individuals in under-served areas, persons with chronic conditions and those who are immune-compromised is essential.⁹ However, resources requested and appropriated to surveillance activities domestically and internationally are not sufficient to build a strong national surveillance infrastructure, and to assist in containing the spread internationally.  A stronger focus on international surveillance and containment could assist in delaying the entry of a pandemic virus into the United States.  This investment internationally is especially vital as most developing countries have minimal public health resources and, in the event of a pandemic, do not have the ability to increase their efforts to mount a significant response.  At the same time, an investment in determining the environmental linkages to avian influenza spread is key in order to accurate assess risks of transmission and identify optimal mitigation measures.

When human-to-human transmission of pandemic influenza occurs in the United States, new cases must be reported to the CDC as frequently as it recommends.   However, before this occurs, there is a need to clarify which types of influenza illness will be officially reportable.  In addition, further clarification is needed about which and what proportion of viral isolates at different pandemic stages will be sent to public health laboratories for confirmation. 

Therefore, APHA:

• Stresses the need for HHS to develop and issue guidelines in consultation with state epidemiologists concerning which types of influenza illness should be officially reportable;
• Urges Congress to provide new and additional resources towards improvement of surveillance efforts at the national and international levels;
• Requests that Congress provide funding to efforts that explore the environmental linkages to the spread of avian influenza.

Clarifying local, state and federal roles

Both the HHS plan and the State and Local Pandemic Influenza Planning Checklist appear to leave all decisions about public containment efforts (e.g., school closings, limiting public transportation, and other movement restrictions within, to, and from the jurisdiction) to state and local authorities.  It is inappropriate to suggest that local authorities should make the decisions about closure of airports or other large transportation hubs independently.  Clear federal guidance is needed on issues that have implications for other parts of the nation.

Therefore, APHA:

• Urges the U.S. Department of Transportation (DOT), in collaboration with HHS, to provide clear guidance addressing interstate transportation issues, ranging from airport closures to limiting public transportation;
• Stresses the need for DOT and HHS to develop draft national guidelines for limiting local public transportation to ensure that communities have a clear set of procedures to follow;
• Encourages HHS, DOT and the Department of Commerce to lead efforts engaging federal, state, local, and tribal governments to develop relationships to enable multiple jurisdictions to work together to limit transportation if necessary during a pandemic.

Utilization of containment measures

Public health laws and triggers for utilizing containment measures

A variety of methods may be utilized to contain the spread of disease, including reducing animal to human interchange rates, implementing community hygiene and hospital infection control, and encouraging social separation through “snow days,” border controls, isolation, quarantine, closing public places, and canceling public events.²² Efforts to achieve “social distancing” — reduce personal interactions — are assumed, but not proven, to slow the spread of respiratory disease.²³

Powers to implement containment measures are found predominantly in state (and to a limited extent federal) emergency powers laws, but many containment measures can be achieved without an emergency declaration. Voluntary containment measures can be quite effective, especially in smaller towns and rural areas where group contacts are less numerous.^23,24,25 Similarly, public health officials may have powers under their normal authority to conduct a range of containment activities. However, the onset of an influenza pandemic may necessitate the invocation of extraordinary legal powers. State emergency powers laws often provide these exceptional powers once an emergency has been declared, which may include the ability to more rapidly implement containment measures, control the movement of people, and seize or destroy property to facilitate a public health response. Many states have updated their public health emergency power based on the Model State Emergency Health Powers Act.²⁶ The federal government may also declare an emergency, but federal public health powers are more limited.

Community restrictions raise profound questions of faith (religious worship), family (funeral attendance), and protection of the vulnerable (food, water, clothing, medical care). The constitutional questions are equally complex, as the Supreme Court finds travel and free association to be fundamental rights.²⁷ In the event of an influenza pandemic, the use of community restrictions will have to be balanced against upholding civil liberties. The courts would uphold reasonable community restrictions.

Therefore, APHA:

• Urges public health officials to incorporate into their containment plans the strategies recommended by the WHO Pandemic Influenza Protocol for Rapid Response and Containment;
• Urges state and local health officials to clarify who possesses the legal authority to sanction the utilization and enforcement of containment measures. This may require government officials to reconsider and/or revise their public health emergency powers laws;
• Urges HHS, in consultation with state and local health officials, to develop national standards for sheltering in place (“snow days”);
• Encourages public health officials to plan to implement a range of containment efforts, including reducing animal to human interchange rates, implementing community hygiene and hospital infection control, and encouraging social separation through “snow days,” border controls, isolation, quarantine, closing public places, and canceling public events;
• Urges public health officials to develop pandemic containment strategies that permit explicit cooperation between 1) different levels of government, 2) different government agencies, and 2) the public, private, and non-profit sectors;
• Urges Congress to provide sufficient resources to state and local governments and health departments, hospitals, community health centers, other health care delivery entities and laboratories to build their capacity to rapidly respond to and contain an influenza pandemic;
• Encourages HHS, in collaboration with state and local health departments, to develop public education and risk communication plans related to containment, including the need for continuing and increasing mental health services.

Border Control

Approximately 120 million individuals pass through the nation’s 474 airports, seaports and border crossing stations every year.²⁸ CDC operates quarantine stations that are responsible for preventing the introduction of infectious diseases of public health importance — including pandemic flu — into the United States.⁹ In response to an influenza pandemic, it may be necessary to restrict movement at international borders and international travel to contain and minimize the spread of disease. Although the HHS Pandemic Influenza Plan calls for the continuation of activities to enhance detection of U.S. cases of influenza at our country’s borders and ports of entry, there is insufficient attention paid to the fact that there are not enough quarantine personnel or dedicated resources to counter the challenges posed by international travel and trade.  In fact, the Institute of Medicine Committee on Measures to Enhance the Effectiveness of the CDC Quarantine Station Expansion Plan for U.S. Ports of Entry found that there were gaps in the current quarantine system, the most severe being the inability of personnel to identify persons carrying a virus but who are asymptomatic, and the difficulty in quickly locating airline passengers who may have been exposed to a high-risk infectious agent.²⁹ In November 2005, the CDC proposed quarantine regulations that will increase the powers of federal agents at these quarantine stations and require airlines to retain passenger information.³⁰

Therefore, APHA:

• Urges Congress to provide additional resources for quarantine activities at ports of entry to identify persons with pandemic flu symptoms;
• Stresses the need for international collaboration in surveillance and international travel activities to minimize the spread of disease over international borders;
• Supports the implementation of the CDC quarantine regulations.

Isolation and Quarantine

Isolation of infected persons, quarantine of exposed persons, and quarantine of a geographic area (cordon sanitaire) are the most complex and legally/ethically controversial public health powers.³¹ Although widely used in Asia and Canada during the SARS outbreaks, they are likely to play a limited role in the early stages of pandemic influenza and are not considered effective or practical during later stages.²³ The transmission characteristics of influenza allow little time for isolation and quarantine, and consequently the infection is difficult to detect before the onset of symptoms and highly contagious spread.²³

Legal authority for isolation and quarantine must be clear and constitutionally acceptable, with criteria based on risk and fair procedures. Containment powers principally are exercised at the state level. While some state isolation and quarantine powers derive from old and outdated statutes, at least 27 states have modernized their laws based on the Model State Emergency Health Powers Act.²⁶ Federal containment powers are reserved for interventions at U.S. borders and to mitigate interstate spread of infection. In 2005, novel influenza viruses with pandemic potential were added as a quarantinable federal disease.³² CDC’s proposed rule permits provisional quarantine for three business days³⁰ and full quarantine not to exceed the period of incubation and communicability of the disease.³⁰ Provisional quarantine can generally be ordered without a hearing, but full quarantine requires due process.³⁰

Federal and state statutes rarely specify where quarantine should take place, and there are myriad options, as evidenced by the SARS outbreaks: home, hospital, school, workplace, or other institutional setting (such as a military base, prison, nursing home, or stadium). Perimeter quarantines may restrict movement to and from designated geographic areas, sometimes coupled with medical prophylaxis. Modern conceptions often do not envisage formal confinement, but rather “sheltering in place” (“snow days”), protective cloistering, or voluntary sequestering. Public concerns with quarantine include overcrowding, exposure to infection, and inability to work, shop, or contact family.³³ These concerns may represent accurate logistical problems of large-scale quarantines: assuring safe and hygienic locations, medical and nursing care, necessities of life (food, water, clothing), and communications.³⁴ Monitoring and enforcement of quarantines could also be problematic. Authorities often enforced SARS quarantines by intrusive surveillance such as thermal scanners, electronic bracelets, web cameras, or placards.³⁵ Military enforcement has been proposed, although the Posse Comitatus Act prohibits the military acting as a domestic police force unless authorized by the Constitution or statute.³⁶

Isolation and quarantine are extreme measures that require rigorous safeguards: scientific assessment of risk and effectiveness, safe and habitable environment, procedural due process, and the least restrictive alternative to other forms of containing an outbreak. Such safeguards should take the health needs of certain populations into consideration, such as mothers who are breastfeeding and their babies. Above all, state power must be exercised fairly, and never as a subterfuge for discrimination. Containment, as with all public health interventions, requires public trust and acceptance in accordance with the principles of justice.³⁷

Therefore, APHA:

• Supports laws and policies that grant federal, state and local health officers the authority to make decisions about quarantine and isolation orders. These decisions should be made on the basis of scientific risk and use the least restrictive alternative.
• Urges state and local health officials to clarify who has the power to impose quarantine and isolation orders in their jurisdiction and who does not.
• Supports the imposition of informal or voluntary isolation or quarantine whenever possible. Compulsory isolation and quarantine powers should only be used when necessary. People subject to quarantine and isolation orders should have the ability to appeal these orders.
• Urges state and local government to plan for the types of isolation and quarantine that will likely be used during an influenza pandemic and make provisions to support the logistics of this plan. Food, water, medications, mental health services and other necessities may need to be delivered to people under quarantine.
• Declares that people placed under quarantine orders in institutional settings should not be confined to the same space as people subject to isolation orders.
• Urges state and local government to support public education campaigns communicating the importance of isolation and quarantine orders and the need to prepare to shelter at home for a length of time of at least two weeks.

School health issues

Schools and school systems are critical to improving our nation’s readiness for and response to pandemic influenza, as planning efforts anticipate that illness rates will be highest among school-aged children (about 40 percent).⁹ As such, the HHS Pandemic Influenza Plan stresses the need for school systems to develop pandemic influenza plans that deal with such issues as school closings and keeping sick students, faculty, and workers at home while they are infectious.  This recommendation for children to stay at home can also be applied to children in day care.  Schools also must work with public health officials, community leaders and partners to determine whether school facilities will be used as alternative sites of care.⁹ Pandemic influenza preparation guidance from the World Health Organization stresses that hand washing and respiratory hygiene/cough etiquette should be routinely encouraged in public health messages, and that such practices should be facilitated by making hand-hygiene facilities available in schools, workplaces, and other settings where amplification of transmission would be expected.23 The HHS and CDC recommend that, in advance of a pandemic of influenza, schools implement effective infection prevention policies and procedures that help limit the spread of influenza including providing sufficient and accessible infection prevention supplies such as soap, alcohol-based/waterless hand hygiene products, and receptacles for their disposal.³⁸

Therefore, APHA:

• Urges the HHS and the U.S. Department of Education, in consultation with state and local health and education officials, to develop and disseminate national criteria for school closings so state education agencies, school districts, and public and private schools are aware of the triggers for this containment measure;
• Encourages state legislatures or education agencies to adopt and enforce standards for the provision of adequate hand washing facilities and supplies in preK-12 school restrooms, classrooms, cafeterias, gymnasiums and sport facilities;
• Encourages state education agencies, school districts, and public and private schools to actively participate in coalitions and activities at the state and local levels that focus on pandemic influenza preparedness, prevention and response;
• Recognizes the need for education curricula at all levels to teach students, caregivers, faculty and staff about preventing the transmission of influenza, including hand hygiene knowledge, skills, and behaviors in a culturally and linguistically appropriate manner.

Business and occupational health issues

Most businesses do not have pandemic preparedness plans in place.³⁹ Business plans need to cover issues including: absenteeism policies for pandemic-related situations (like closed schools, ill family); social distancing policies; remote work opportunities; reinforced work force availability and trained flexibility, for supply sources, production, and distribution; and communication plans, for pandemic response and public health advisories. Although HHS has released a Business Pandemic Influenza Planning Checklist to provide guidance to businesses in preparing for pandemic influenza, more education is needed at the state and local levels to ensure that businesses understand the threat to the public’s health and the economy posed by pandemic flu and are ready to respond.

There are no federal legal requirements for paid sick leave. Although companies subject to the Family and Medical Leave Act are required to offer unpaid sick leave,⁴⁰ most employees without a paid sick leave benefit do not have the financial security necessary to stay home from work when they are sick. This problem could be especially problematic in the event of pandemic flu.

Over 15 million first responder personnel, including health care and law enforcement workers, may be required to protect the public from and manage a pandemic outbreak in the United States.  Other workers will be occupationally exposed prior to awareness of an epidemic, including poultry and agricultural workers, laboratory workers, and transportation workers.  Finally, workers who provide essential services will be needed to continue working throughout an epidemic, including those in health care, laboratories, transportation, public infrastructure, institutions such as prisons and group homes, child and elder care professionals, and mortuary workers.  These workers will face enormous risks and make great sacrifices on the public’s behalf.  Protecting them goes beyond a moral obligation; the U.S. public depends on these workers. 

Several applicable workplace safety standards describe minimum governmental expectations.  The Occupational Safety and Health Administration (OSHA) Personal Protective Equipment Standard includes sections on Respiratory Protection and Eye and Face Protection,⁴¹ and the General Duty Clause fills in the gaps between other standards, requiring employers to maintain safe workplaces.⁴² Well-developed government policy documents for Poultry Workers provide further guidance.⁴³ Despite this established obligation to safeguard these workers, existing guidance documents fail to cover the majority of those at risk.  Further, in past times of crisis, OSHA has sometimes suspended enforcement of regulations, leaving exposed workers even more vulnerable.⁴⁴

There is no program in place assuring governmental resources to address increased workplace expenses for pandemic preparedness and for providing exposure controls, mental health support, and assistance with family and outside commitments. There are no clear job or workers’ compensation protections for ill workers, increasing the likelihood that individuals might continue to work while contagious.  In addition, many health care workers tend to continue to come to work, especially in prodromal phases of illness.

Although OSHA has issued “Guidance for Protecting Workers Against Avian Flu,” which focuses primarily on H5N1 avian influenza,⁴⁵ it lacks a standard specifically relevant to infection control in a flu pandemic. A coalition of labor organizations petitioned OSHA to issue an Emergency Temporary Standard applying to health care workers, emergency responders, essential personnel, and those having close contact with birds and other potentially contagious animals.⁴⁶ Mandatory provisions in an emergency standard are needed because of the urgency to protect workers and remove barriers to their participating in response efforts.

The National Pandemic Influenza Plan⁹ does not provide adequate worker protection, as noted by the labor organizations.⁴⁶ The plan does not recommend respiratory protection at the level required in the OSHA Respiratory Protection Standard,⁴¹ including NIOSH-certified respirators provided with training and fit-testing.⁷⁶ The plan instead recommends surgical masks, which are not actually intended to protect the wearer from a virus.  The plan does not recommend comprehensive infection control plans, as have been required for other agents. For example, OSHA’s Bloodborne Pathogens standard includes requirements on exposure control plans, exposure assessment, industrial hygiene controls, housekeeping, training, communication, surveillance, and record-keeping.⁴⁷ Further, the plan relies only on voluntary compliance.  CDC has issued guidance on mask use by healthcare workers.⁷⁷  HHS has developed a checklist for pandemic planning for businesses.⁷⁸

Therefore, APHA:

• Encourages OSHA to issue the proposed Emergency Temporary Standard for protecting first responders and healthcare workers in the event of pandemic flu;
• In the absence of such a standard, urges OSHA to increase enforcement of the Personal Protective Equipment Standard and General Duty Clause in affected workplaces during a pandemic situation;
• Calls for the strengthening of the National Pandemic Influenza Plan in response to the critique provided in the Emergency Temporary Standard petition by:
  • Requiring employers to develop pandemic preparedness plans similar to those in OSHA’s Bloodborne Pathogens standard,
  • Requiring employee training in prevention and exposures control,
  • Requiring appropriate respiratory protection as provided in the OSHA Respiratory Protection Standard, and
  • Require employers to provide Medical Removal Protection (MRP) policies such that workers who are removed from work due to symptomatic flu are paid to remain off work until cleared to return;
• Stresses the need for the incorporation of the following additional amendments in the National Pandemic Influenza Plan:
  • Develop guidelines about establishing work-relatedness of influenza cases, for use in workers’ compensation cases.
  • Provide governmental support for: essential employers who must hire or replace workers on MRP; laboratory surveillance; worker mental health services; emergency assistance to enable workers to stay at work while managing outside commitments; and extreme business expenses for worker protection.
  • Develop and maintain a list of key occupations and workplaces at risk, to aid in assuring workers are protected, including prioritization for distribution of limited vaccine or prophylaxis.
  • Require employers of first responders and healthcare workers (often local government) to stockpile respirators and other protective equipment.
  • Urges businesses to establish policies for employee compensation and sick leave that would be used during a pandemic that are not punitive and provide employees with adequate financial security to enable them to stay home from work when they or a family member are sick; 
  • Affirms that businesses need to be intimately involved in planning efforts for pandemic flu on the local and state level, in collaboration with state and local health departments, schools and government;
  • Stresses the need for businesses to conduct education programs related to pandemic influenza to ensure that employees are aware of how to prevent transmission of the flu, signs and symptoms of the virus, and the need to stay home from work when they are sick.

  Public Health Education and Communications

  The HHS Pandemic Influenza Plan stresses that the success of containment measures, ranging from isolation to hand washing, depends on the level of understanding of the community of the importance of such measures.  Such education must begin before a pandemic influenza outbreak or other public health emergency.  Ultimately, public information and key messages must work to garner public cooperation, help multiple populations understand federal, state and local response efforts, educate and motivate vigilant adherence to self-protective prevention behaviors, and prepare communities for lifestyle, mental, and emotional issues related to response and containment measures.  To this end, the media must be included in creating national, state and local education campaigns to ensure that accurate messages get consistently communicated.

  The field of risk communication focuses on how to communicate with the public during an emergency.  Significant questions will be raised by the public with the arrival of both avian influenza (food safety, water safety, handling and disposal of dead birds, need for environmental safeguards, etc) as well as in response to the emergence of a pandemic (need for increased protective hygiene measures, use of gloves and masks, utilization of public health containment measures such as “snow days” and where and when the public can access vaccinations and/or antivirals).  However, there is a need to communicate effective messages to the public before a pandemic occurs so that they are ready and have accurate expectations.  

  Communication challenges are frequently the greatest issue faced in any emergency response.⁴⁸ Accurate, consistent information and language understood by all community members is the backbone of a coordinated effort with local, state and federal government and allied response partners.  In the pre-pandemic, pandemic alert and pandemic states, there must be consistent messages from local, state and federal public health partners. 

  The HHS Pandemic Influenza Plan, in annex 10, provides guidance regarding public health communications and contains recommendations for communications during the interpandemic, pandemic alert and pandemic stages.  For the interpandemic and pandemic alert phases, the report recommends that pandemic flu preparedness efforts should include:  assessing communications capacity and needs; conducting collaborative planning; developing and testing standard procedures for disseminating information; and developing, testing, and disseminating locally tailored messages and materials.  During a pandemic, the plan outlines steps that need to be taken to provide timely, accurate information; coordinate communications leadership across all tiers of jurisdiction and promptly address rumors, misperceptions, stigmatization, and any unrealistic expectations about public and private health provider response capacity.9

  Therefore, APHA:

  • Urges that communication systems, such as the national Health Alert Network, must be put in place and regularly tested to build rapid response capability as well as participating in drills and exercises with other response partners;
  • Urges CDC and state and local governments to provide funding to immediately plan and disseminate public health education campaigns urging individual and community readiness for an outbreak.  Such efforts should include organizing community coalitions including local public health agencies, schools, churches, businesses and other key community stakeholders in order to create and disseminate effective disease containment messages;
  • Urges CDC and state and local health departments, in partnership with the media, schools, business and faith- and community-based organizations conduct a public education campaign addressing the utilization of containment measures ranging from restriction of public events to isolation to quarantine before a pandemic occurs so the public is aware of their use and importance;
  • Calls for HHS to develop templates for ads, fliers, radio ads and speeches that focus on different disease containment measures that local public health agencies, community leaders and multimedia outlets can use in order to ensure that public health education and communications are consistent across community and state lines;
  • Urges the development of public education campaigns for those on continuing medication to stockpile medication and medical supplies in case of an emergency;
  • Urges further research on the role of stockpiling other supplies;
  • Urges the development of public education campaigns in access to vaccines and other countermeasures, their administration and risks and benefits.

  VI.           Medical Countermeasures

  Vaccine Manufacturing, Distribution, Tracking and Administration

  Improving the nation’s readiness for pandemic influenza must be led by an effort to prevent transmission of the virus. As such, our national strategy must not be dominated by or solely rely on antivirals.  Vaccine development, research and purchase should be priority activities in planning for pandemic influenza on the federal level, as pandemic viruses might be resistant to antivirals or develop drug resistance due to widespread use.49^,50 The goal of developing and utilizing a pandemic influenza vaccine will differ from the seasonal flu vaccine, as mild illness will likely not be prevented.  Ultimately, vaccine use should prevent mortality and severe morbidity associated with pandemic influenza.⁵¹ Vaccine administration may also be different if two doses of vaccine are required to achieve a protective level of immunity.  If two doses of vaccine are required, then the education of the public will be a key component, as they are accustomed to the one-dose seasonal influenza vaccine.⁹

  Scientists face several challenges in developing a pandemic flu vaccine especially since the exact viral strain that will result in an outbreak will be unknown until the incident begins unfolding. If the pandemic influenza strain is avian, mechanisms other than requiring two doses of vaccine may need to be developed to enhance the immunogenicity of the avian hemagglutinin (HA) to achieve a protective level of immunity.  Also, researchers will not know what level of cross-protection a vaccine matched to an earlier virus strain would provide to the pandemic strain in circulation.  Finally, considering there will not be enough vaccine supply in the early months to vaccinate the population at risk, researchers will have to explore different ways to maximize the number of doses available.  This would include reducing the amount of HA antigen required to reach a protective level of immunity; alternative means to administer the vaccine; and use of known and novel adjuvants to enhance immunogenicity.⁵¹

  Widespread vaccination of the population against the pandemic virus depends on the capacity to manufacture vaccines in an expedited and effective manner.  As the process of preparing high growth reassortant influenza viruses by infecting an embryonated hen’s egg does not yield an efficient vaccine production, APHA supports efforts to utilize plasmid-based reverse genetics or other techniques to generate pandemic influenza vaccine candidates.  

  The HHS Pandemic Influenza Plan and the National Strategy for Pandemic Influenza outline the role of the federal government in investing in cell-based vaccine technology, and to purchase 20 million doses of the current avian A/H5 N1 vaccine.  The plan also states that “at the onset of an influenza pandemic, HHS, in concert with federal partners, will work with the pharmaceutical industry to procure vaccine directed against the pandemic strain and to distribute vaccine to state and local public health departments for pre-determined priority groups based on pre-approved state plans.⁹

  APHA supports the significant investment in cell-based vaccine technology, which will not only facilitate mass, expedited manufacturing of millions of doses of influenza vaccine, but has the potential to create vaccines for other diseases and to make current vaccines more effective.  However, APHA is concerned that the HHS plan did not clearly outline whether federal purchase of influenza vaccine and centralized distribution will continue beyond the onset of a pandemic.  Our current system of private purchase, reliant on supply and demand, will not give vaccine manufacturers ample incentive to produce all the necessary pandemic influenza vaccine, as there is no guarantee that they will be left with leftover vaccine due to insufficient purchasing levels.   Also of concern is that the distribution of pandemic vaccine to health departments and providers may occur through private-sector vaccine distributors or directly from the manufacturer(s), without adequate federal oversight, and state and local public health input.  Thus, the vaccine may not be available to those at highest risk.

  The HHS plan also calls for the creation of a vaccine database by CDC, which should build on existing systems and be able to import relevant information from state immunization registries to help us more efficiently track the immunization of priority populations — including children, pregnant women, health care workers and the elderly — in an equitable fashion.  However, without federally led vaccine distribution efforts, this database will not provide timely information regarding vaccine distribution, as manufacturers and private vaccine distributors will be relied on to provide the necessary information.  This potential information gap on vaccine distribution and tracking of vaccines could be a significant obstacle in ensuring that priority individuals receive pandemic vaccine in proper order.  In addition, such tracking will assist in ensuring equitable vaccine use across racial and ethnic populations.  Existing immunization information systems (IIS, immunization registries) can be of great assistance in this tracking.  Also, the HHS plan does not outline a process for how the priority vaccination guidelines may be altered or reviewed at the time of the pandemic to adapt to the epidemiology of the disease. 

  However, regardless of the epidemiology of disease, it is imperative that health care workers and first responders, as priority populations, get vaccinated in the event of a flu pandemic. Vaccination of such populations will not only protect their colleagues, but their patients and communities as well. 

  Therefore, APHA:

  • Calls for a guaranteed, substantial, if not complete, federal purchase of pandemic influenza vaccine, with some buyback provision included, so there are a number of vaccine manufacturers committed to produce adequate amounts of the vaccine most effective against the pandemic influenza strain; 
  • Supports congressional efforts to appropriate additional resources to research activities targeted at manufacturing and utilizing cell-culture influenza vaccines;
  • Stresses the need for additional research targeted at pandemic vaccine development, including reducing the amount of HA antigen required to reach a protective level of immunity; alternative means to administer the vaccine; and use of known and novel adjuvants to enhance immunogenicity;
  • Urges that additional funds be made available to the CDC for developing and testing vaccine distribution and tracking systems; 
  • Stresses the need for HHS to formulate a process to amend and review priority vaccination guidelines to adapt to the epidemiology of the pandemic influenza virus;
  • Strongly encourages the use of a pandemic influenza vaccine among all health care personnel and first responders as early on as possible in a pandemic. 

  Antiviral Drug Distribution, Tracking and Use

  Antiviral medications such as oseltamivir and zanamivir have been shown to reduce the severity and duration of seasonal influenza, typically reducing the duration of illness by one or two days.^5,52 However, their efficacy in effectively treating many individuals during an influenza pandemic is uncertain at best.⁵ The problem is that influenza strains can become resistant to antivirals, antivirals need to be administered within the first two days of the onset of symptoms to be effective, and the supply will likely be dramatically less than the projected need.⁵²

  The HHS plan, considering that an effective pandemic vaccine will not be in general circulation during the first months of an influenza pandemic, calls for the purchase of enough antivirals — oseltamivir and zanamivir — to treat 25 percent of the population.  Efforts center on the federal purchase of 44 million courses of antiviral drugs for treatment, with another 6 million courses for containment. However, the federal plan contains a strategy to leverage state tax dollars to purchase the remaining 31 million courses of antiviral drugs with a 25 percent federal subsidy.  Public health officials must have the flexibility to provide the medication where outbreaks are most severe, as certain states and communities will likely be affected more than others.  Reliance on states to pay for a substantial portion of the cost of purchasing enough antiviral medication to cover their populations amounts to an unfunded mandate of approximately $510 million over a very short time.  If this holds, states will likely either raise taxes or find offsets from already under-funded health programs to address this mandate.  Also, the plan does not account for the fact that with current antiviral production capacity, there will likely be a shortage of antivirals at the advent of a flu pandemic as well. 

  The HHS plan again does not outline a process for how the priority guidelines for the distribution of antivirals may be altered or reviewed at the time of the pandemic to adapt to the epidemiology of the disease.  The plan’s guidance for the use of antivirals for post-exposure prophylaxis is not clear. The HHS plan’s antivirals annex states that “When a vaccine becomes available, post-exposure prophylaxis may also be used to protect key personnel during the period between vaccination and the development of immunity.  Strategies for antiviral prophylaxis may be revised as the pandemic progresses, depending on supplies, on what is learned about the pandemic strain and on when a vaccine becomes available.”  However, the plan does not define a process for the identification of these key groups; moreover, strategies and priority groups for both treatment and prophylaxis will need to be developed.  Once these key groups are identified, there is a need for accurate distribution and tracking systems to ensure that antivirals reach priority populations.

  Therefore, APHA:

  • Calls upon Congress to require the federal government to protect Americans by purchasing all of antiviral treatment courses deemed necessary, as the level of protection Americans receive should not be determined by where they live and the current fiscal position of their states;
  • Opposes the provision of the HHS Pandemic Influenza Plan which would require states to purchase antivirals with a federal subsidy, as such action would divert needed resources from core public health and preparedness programs;
  • Urges the U.S. government to examine the effects of and consider increasing incentives for pharmaceutical companies to invest in the research concerning new drug development, efficacy assessments, and production capacity of antivirals to determine the most effective drugs, doses, timing for administration, the best methods of administration, and its integration into plans for vaccination;
  • Encourages Congress to appropriate additional resources to bolster U.S. production capacity of antivirals to ensure that the supply of antivirals in the event of a flu pandemic is sufficient to meet national demand;
  • Urges Congress to appropriate additional funds to CDC to develop and test antiviral drug distribution and tracking systems;
  • Urges HHS to formulate guidelines that outline strategies and priority groups for both treatment and prophylaxis.

  Medical and Lab Supply Stockpiling and Use

  APHA is aware of the Strategic National Stockpile’s work in amassing medical material, but is concerned that there are still inadequate funds for critical medicines and supplies, such as ventilators, syringes, gloves and intravenous antibiotics that will be in high demand during a pandemic.  Equal priority should be given to assuring such material is available to permit a comprehensive response to a pandemic.  Without it, manufacturers of key medical and lab supplies will not have the incentive necessary, or be able to invest in increasing their capacity, to produce such a high quantity of goods.  Lessons learned from the Hurricane Katrina response include the need to stockpile response-related equipment and medication as well.¹¹ Such stockpiling needs to include durable medical equipment and assistive devices and medications for children with special health needs, immunizations, and equipment and medication needed to maintain the health status of those with chronic illness, HIV/AIDS and other health problems. 

  Therefore, APHA:

  • Urges Congress to appropriate new, additional and sufficient resources towards the stockpiling of critical medicines and supplies, such as ventilators, syringes, gloves, intravenous antibiotics, reagents and N95 respirators;
  • Stresses the need for funds to be dedicated towards the stockpiling of equipment and medication needed to maintain the health status of those with chronic illness, HIV/AIDS and other health problems during a pandemic, including insulin, dialysis machines and oxygen;
  • Encourages HHS to work in cooperation and coordination with state and local health departments to create guidelines for the public use of certain stockpiled supplies, such as surgical masks, which may be necessary to transport patients from one location to another;
  • Urges the Food and Drug Administration to review its guidelines that limit the supply of prescription medication to be dispensed per prescription, so that individuals with serious health problems can access the prescriptions they need in the event of isolation or quarantine orders during a pandemic.

  VII.         Liability/Compensation Issues

  Medical countermeasures administered in advance of or in response to an influenza pandemic may pose health risks to individuals receiving prophylaxis or treatment. Vaccines, antiviral medications, and other medical countermeasures are necessary tools to slow or halt the spread of the pandemic and to treat affected, or infected, individuals. However, all medical countermeasures carry some risk of adverse effects. Individuals who experience illness, disability, or death as a result of the administration of a medical countermeasure to combat pandemic influenza should have some method to receive compensation for their losses.

  Since some adverse events are statistically inevitable, a compensation program should be set up prior to the pandemic, include clear criteria for qualifying for compensation, incorporate a claims system that provides for due process and equal protection, provide adequate resources to compensate affected parties, and appoint an independent adjudicatory body to administer the claims. 

  Immunity from tort liability for industry and fair compensation for patients offers a sound dual approach to vaccine policy. The national Vaccine Injury Compensation Program (VICP) has created a no-fault system that pays for injuries caused by specific immunizations.⁵³ To recover compensation from the VICP, claimants must show that a listed vaccine caused their injury. Compensation comes from a Compensation Trust Fund financed by a tax on each administered dose.⁵³ Congress added influenza to VICP in 2004.⁵³ However, the VICP only covers trivalent (annual) influenza vaccine. Experimental influenza vaccines currently are not covered under VICP, so these new types of vaccine would need to be added. Patients can opt-out of VICP and bring a lawsuit in court, which has led to the critique that legal liability represents a major disincentive for the industry. Nevertheless, influenza vaccine litigation has been rare, with only 10 reported cases during the past 20 years and most with small verdicts.⁵⁴

  Mass use of an untried vaccine during a public health emergency would temporally coincide with the occurrence of numerous conditions.  There is some likelihood that the vaccine might be causally associated with adverse events, some severe. Health care workers and patients would be less likely to volunteer without a fair compensation system, as the failed smallpox vaccination campaign demonstrated.⁵⁵ A no-fault system, like VICP, would provide relief for injured patients and greater certainty for industry. A reformed VICP system would have to take account of important issues: an overwhelmed program, resulting in delays; assuring there is sufficient money in the compensation trust fund; and injustices caused by excessive burdens placed on patients injured by a new vaccine. In return, the industry should be spared lawsuits based on strict liability, but should answer to claims of recklessness or gross negligence.

  Therefore, APHA:

  • Recommends that a federally funded compensation program be established for those who become ill or are injured, disabled or die as a result of receiving the pandemic or experimental influenza vaccine.

  VIII.       Ensuring access to preventive care and treatment for pandemic influenza

  Preventing the transmission of and limiting morbidity and mortality related to pandemic influenza will ultimately depend on the access of Americans to the vaccine, and care and treatment should they become ill.  The health care utilization patterns of the uninsured need to be factored into pandemic influenza preparedness and response efforts. In general, studies have shown that being uninsured or underinsured leads to a decreased utilization of preventive care, as affected individuals only seek necessary health care in urgent situations. This is shown in the reality that the uninsured tend to have diagnoses of malignancies at more advanced stages,56 and have higher mortality rates resulting from hospitalizations when compared to insured individuals.57  This is especially troubling in the event of pandemic influenza, as the uninsured would be less likely to seek health care quickly if they developed symptoms of influenza.  And, when they seek care in later stages, it will be uncompensated care provided in hospitals.

  Therefore, APHA:

  • Calls for the federal purchase of vaccines and antivirals at least for uninsured individuals and children eligible for the Vaccines for Children (VFC) program;
  • Calls upon Congress and HHS to establish an emergency Medicaid designation for uninsured individuals during an influenza pandemic that would require states to provide medical assistance to these individuals under state Medicaid plans, but increase the federal medical assistance percentage for providing medical assistance to these individuals.

  IX.           Surge capacity

  Surge capacity is defined as “the number of critical casualties arriving per unit of time that can be managed without compromising the level of care.⁵⁸ The core components to increasing surge capacity during an influenza pandemic are the availability of: 1) skilled health professionals to supplement the existing health work force, 2) sufficient space and resources within health care and public health facilities to coordinate and handle the influx of patients, 3) adequate stockpiles of consumable and durable medical goods, including vaccines, antiviral medications, ventilators, and other necessary supplies, and 4) appropriate laws and policies to allow for the effective continuation of essential medical and public health services.

  The ability of the public health system to handle an influenza pandemic will require an unprecedented allocation of resources to both treat the victims and stem the tide of the pandemic. The current health care work force cannot be depended on in event of a flu pandemic, due to expected high absentee rates due to illness or fear of becoming ill.  It is important to recognize that local providers in many cases do not have the resources to provide basic primary health care under normal circumstances, much less to provide surge capacity.  Volunteers during Hurricane Katrina observed that chronic health conditions were as significant a concern as acute problems in the affected populations.⁵⁹ Populations that are already vulnerable will become much more so in a pandemic situation.⁷⁹ Hospital bed capacity is lacking in many areas, even those that are not under-served, due to cost cutting initiatives that reduce the availability of inpatient beds.  Therefore, the availability of adequate resources to provide surge capacity is imperative. Distribution of resources equitably to areas of the country based on need must be guaranteed.  Public health professionals should help to gauge the needs of each community. Resource allocation should be determined based upon need rather than other priorities.

  Efforts to increase surge capacity also need to include how to care for individuals who are in need of medical care not related to the prevention and treatment of pandemic influenza.  For example, as pregnancy and childbirth account for almost one out of four hospital stays for women,⁶⁰ measures must be taken to ensure that there are separate medical facilities to specifically cater to women in labor and delivery and pregnant women with complications.  Persons with other health problems ranging from broken bones to heart conditions need to be able to access medical care in alternate facilities.

  The HHS Pandemic Influenza Plan identifies multiple steps that may be taken to increase surge capacity during a pandemic, but most of these recommendations focus on the availability of clinical medical care. While this capacity is indeed vital to an effective pandemic response, pandemic planners should also consider and account for meeting surge capacity needs within the public health system. This can be accomplished by planning to expand the public health work force during an emergency, identifying and training public health professionals in disciplines relevant to pandemic response, and bolstering laboratory and epidemiological capacity to help track the disease. This planning should be done at all levels of government, but is particularly important for state and local health departments to have their own plans to meet surge capacity in case of a widespread pandemic.⁶¹

  Therefore, APHA:

  • Urges public health officials to follow the steps recommended by the HHS Pandemic Influenza Plan to improve surge capacity during a pandemic in the areas of staffing, bed supply, consumable and durable goods, and continuation of essential medical services;
  • Stresses the need for populations in need of medical care not related to pandemic influenza, ranging from women in labor and delivery to individuals with severe heart conditions, to be able to access such care in separate facilities from those treating individuals infected with pandemic influenza;
  • Encourages public health officials to plan for improving surge capacity of the public health work force to engage in core public health activities during a pandemic. Advance registry systems should be developed to coordinate volunteer health professionals, as these are preferable to relying on ad hoc or spontaneous volunteers;
  • Encourages the utilization of already existing voluntary agencies such as the Medical Reserve Corps to facilitate health care workforce surge in the event of a flu pandemic;
  • Stresses the need for training programs to be developed for volunteers listed on registry systems;
  • Encourages public health officials to plan for increasing laboratory and epidemiological capacity to assist in efforts to track the spread of pandemic influenza;
  • Supports the enactment of federal and state legal protections for health professionals responding to meet surge capacity during a pandemic, including licensure reciprocity, protections from legal liability, workers’ compensation coverage, and employment protection;
  • Urges public health officials to develop pandemic response plans and systems that permit explicit cooperation between 1) different levels of government, 2) different government agencies, and 3) the public, private, and non-profit sectors. Fostering strong relationships and effective coordination among all of these entities and institutions is important to providing effective surge capacity during a pandemic;
  • Urges Congress to provide sufficient resources to state and local governments and health departments, hospitals and laboratories to prepare for influenza epidemics and pandemic. Resources should be targeted to areas most in need of assistance as determined by public health experts.

  X.            Mental health issues

  Attention to mental and behavioral health issues should be part of the integrated response to a pandemic.  While researchers have studied human behavior and human reaction following disasters for decades, it has only recently been recognized that mental health preparedness is central within every community. Previously, concerns related to immediate physical health and community infrastructure risks in the aftermath of disasters such as storms, earthquakes, or floods had overwhelmed considerations of the short- and long-term mental health consequences of disasters, or the extent to which mental health played a role in the impact of a disaster.⁶² Mental health needs in this section refer to the reactions of the public to the specter of pandemic influenza.

  In the arena of the health impact of natural disasters, the majority of data available relate to weather or geologic events.⁶² For example, there are some data on the long-term mental health impacts of such disasters as the Gujurat and Turkey earthquakes;⁶³ the 2004 Asian tsunami;64 a number of large impact disasters in South America and Asia; and Hurricanes Katrina and Rita.^65,66 We know that severe stress reactions are common; that front-line health and human services workers are at high risk for Post-Traumatic Stress Disorder; and that in general, even in relatively developed countries, there is very little existing infrastructure in place that can adequately address the mental health needs of victims.⁶⁶

  Furthermore, as a pandemic unfolds, emotional reactions can color the response to the factual situation.  Distrust of information can further foster extreme responses.  At the societal or community level, group reactions can occur, such as panic.  Panic and crisis reactions may become disproportionate to the actual threat, compromising effective action.  Enlisting cooperation with directives may prove problematic, further straining multiple institutional structures beyond the health and mental care institutions such as the police, and so on.  Some limited lessons may be learned from the study of populations under siege or at war.  Monitoring for the development of panic-like reactions may provide an opportunity for earlier intervention; plans for these contingencies need to be developed that integrally involve health and public health professionals. The failure to plan may have adverse sequelae; for example, driven by panic, the urge to contain the infected can lead to bizarre quarantine practices.^{70, 71, 72}   It is hoped that honesty in information flowing to the public about outbreaks may help limit panic.⁷³ During recent SARS outbreaks, lack of adequate disclosure may have contributed to panic.^74,75

  There are almost no data on the mental health impacts of outbreaks of acute pandemic disease.  This is largely because there have been few pandemic health threats in the last century.  Since the highly lethal pandemic outbreak of influenza in 1918, there have been few global threats from infectious agents.  The recent outbreaks of SARS in Asia and Canada, which caused global concern but fortunately did not result in large-scale outbreaks nor a global pandemic, provide the most recent data on the mental health concerns that are relevant to a pandemic flu outbreak situation.

  The data from the SARS outbreaks indicated that upwards of 40 percent of the community population experienced increased stress in family and work settings during the outbreak; 16 percent showed signs of traumatic stress levels; and high percentages of the population felt helpless, apprehensive, and horrified by the outbreak.⁶⁷ In another community survey, 30 percent of those surveyed thought they would contract SARS, while only a quarter believed they would survive if they contracted the disease, despite an actual survival rate of 80 percent or more, indicating a fairly high rate of perceived risk that might have preceded widespread panic had the outbreak been either more widespread or more lethal.68  Community residents were diligent about adopting appropriate person-to-person transmission precautions; however, precautions were adopted differentially based upon anxiety levels and perceived risk of contracting the disease, indicating the importance of stress and anxiety levels, as well as baseline mental health, on a public response to taking necessary precautions. 

  Decision-makers will be concerned with many issues beyond health per se, including feared and real economic impacts, and may feel pressured to take unduly hasty actions (such as relaxation of an imposed quarantine; for example, in Quebec data on the incubation period of SARS were ignored, and the lifting of quarantine was associated with a secondary outbreak).  There is a likelihood that uncertainties in data will occur, further complicating decisions about whether and how to react.

  We also know from the SARS outbreak that front-line health workers may be particularly vulnerable to negative mental health sequelae of treating outbreak victims.  Studies of the nurses who treated SARS patients indicated high levels of stress and about 11 percent rates of traumatic stress reactions, including depression, anxiety, hostility and somatization symptoms.⁶⁹

  While there have been relatively few large outbreaks to inform an appropriate response to a potential pandemic flu, the existing data on infectious disease outbreaks, data from natural disasters, and public mental health principles can be brought to bear on the development of such a response.  Public mental health measures must address numerous areas of potential distress, health risk behaviors, and psychiatric disease.  In anticipation of significant disruption and loss, promoting health protective behaviors and health response behaviors will be imperative.  Areas of special attention include: (1) the role of risk communication; (2) the role of safety communication through public/private collaboration; (3) psychological, emotional, and behavioral responses to public education, public health surveillance and early detection efforts; (4) preventing and responding to panic (5) psychological responses to community containment strategies (quarantine, movement restrictions, school/work/other community closures); (6) health care service surge and continuity; and (7) responses to mass prophylaxis strategies using vaccines and antiviral medication.  Attention needs to be focused both on global-level and community issues, such as the possibility of panic and other crowd or mob mentalities and reactions, and personal health related issues that focus on individuals.

  Therefore, APHA:

  • Reiterates the need for leadership preparation, including ensuring that public officials understand which members of the population will be most vulnerable and who will need the highest level of health services, including mental health services;
  • Calls for the identification of community leaders, spokespersons, and natural emergent leaders who can affect community and individual behaviors and who can endorse and model protective health behaviors;
  • Recommends the widespread dissemination of uncomplicated, empathically informed information on normal stress reactions, which can serve to normalize reactions and emphasize hope, resilience, and natural recovery;
  • Stresses the need to inform the public about the rationale and mechanism for distribution of limited supplies (e.g., Tamiflu);
  • Reiterates the importance of community rituals (e.g. speeches, memorial services, funerals, collection campaigns, television specials) as important tools for managing the community wide distress and loss and coping with such situations as deaths of important or particularly vulnerable individuals (e.g., children), new unexpected and unknown risk factors, and shortages of treatments;
  • Urges federal, state and local public health partners to plan at societal, local and individual levels for the psychological and behavioral responses of the health demand surge, the community responses to shortages, and the early behavioral interventions after identification of the pandemic, and especially during the time frame prior to availability of vaccines;
  • Stresses the importance of the maintenance of community, to manage community and organizational distress and untoward behaviors, especially as in-person social supports may be hampered by the need to limit movement or contact due to concerns of contagion.  Virtual contact — via web, telephone, television, and radio — will be particularly important at these times;
  • Declares that under conditions of continuing threat, the management of ongoing racial and social conflicts in the immediate response period and during recovery takes on added significance, as stigma and discrimination may marginalize and isolate certain groups, thereby impeding recovery;
  • Reiterates the need to plan for mass fatality and management of bodies, as well as the community responses to such situations and activities, including taking into consideration various religious rituals of burial and disseminating public health announcements addressing (if known) how long the virus remains in the corpse and what should be done with the bodies;
  • Supports efforts to increase health protective behaviors and response behaviors, including reminding individuals to take care of their own health and limit potentially harmful behaviors; 
  • Encourages the dissemination of good safety communication, as promoting clear, simple, and easy-to-do measures can be effective in helping individuals protect themselves and their families;
  • Calls for the utilization of evidence-informed principles of psychological first aid;
  • Stresses the need to provide care for first responders to maintain their function and workplace presence, including providing assistance to ensure the safety and care of their families;
  • Urges that mental health surveillance, at both the societal and individual level, be conducted in tandem with disease surveillance. Such surveillance should address PTSD, depression and altered substance use, psychosocial needs (e.g. housing, transportation, schools, employment), and loss of critical infrastructure necessary to sustaining community function or which might foster panic. 

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