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