US and international preparedness evaluated

Feds detail progress on pandemic preparedness

Lisa Schnirring and Robert Roos Staff Writers

Dec 29, 2006 (CIDRAP News) – In a recent update on pandemic influenza preparedness planning, the US government reported meeting more than 90% of a long list of objectives it set for itself about 6 months ago.

The report charts progress on a wide range of preparedness measures, from shoring up laboratory capabilities to planning for distribution of critical medical supplies and preparing checklists for various sectors of the economy.

In May, federal officials released the National Strategy for Pandemic Influenza: Implementation Plan, a 228-page document describing how the government will cope with an influenza pandemic. The statement was a follow-up to the HHS Pandemic Influenza Plan, released by the Department of Health and Human Services (HHS) in November 2005.

The status report, released Dec 18, covers 104 tasks that were to be completed within 6 months of release of the implementation plan. The tasks fall into 6 categories: international efforts, transportation and borders, protecting human health, protecting animal health, law enforcement and public safety, and institutions.

Of the 104 tasks addressed, 96 have been completed, and 8 are in progress, the report says. The introduction notes that even though most of the 6-month goals have been met, work on many of the tasks is continuing.

Jeff Levi, PhD, executive director of Trust for America's Health (TFAH), a Washington, DC-based nonprofit public health advocacy group, commended federal officials for meeting most of the 6-month benchmarks in the pandemic plan.

"This first phase of the federal pandemic preparedness plan moved at full speed ahead," he said in a Dec 18 TFAH press release. "It has been an historic government-wide effort, and the release of the results demonstrates a serious commitment to transparency and accountability, allowing Americans to see how well their tax dollars are being spent to improve preparedness for a major health emergency."

The status report shows that overall progress is being made, even though media reports on pandemic flu have waned, Chris Logan, a senior policy analyst with the National Governors' Association, told CIDRAP News. The status report is useful for state officials because it raises questions they need to be thinking about. "It's not just the obvious stuff, it's the implications of decisions that people need to be aware of and thinking through," he said. "To the extent these documents help people think through the potential second- and third-order effects, they're helpful."

Michael T. Osterholm, PhD, MPH, director of the University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP), publisher of the CIDRAP Web site, said he applauds the Bush administration for issuing a progress report on pandemic preparedness. "But we really have to ask ourselves the hard question 'What does it mean to be prepared?', and right now, I don't think we have a clue," he said.

It's difficult to determine if the country is better prepared now than it was 6 months ago, Osterholm told CIDRAP News. He said officials need to start the difficult task of prioritizing preparation measures. "We've got to do a better job of understanding the key factors that will get us through a pandemic," he said. "If there are 10 major factors and 100 little ones, you can get 90 done, but if you don't get the 10 major ones done, you're not prepared."

Osterholm said one problem with the status report is that it reflects a US-centered view of pandemic planning. "What happens to the world will happen to the United States because of the global just-in-time economy," he said.

A number of the activities discussed in the report are summarized below.

International efforts
The federal government has informed 2 million US citizens living abroad about the latest developments in avian and pandemic flu, mainly through the US government's main pandemic flu site, and has provided additional information through US consulates and warden networks.

Also, federal officials have developed a policy for contributing to international medication stockpiles and deploying antiviral medications. The government reviewed whether or not US stockpile contributions should require liability limits, but officials found that there's not an urgent need to propose such arrangements.

The US Agency for International Development (AID) and the US Department of Agriculture (USDA) developed a model compensation program for farmers affected by animal influenza outbreaks, which will be launched in early 2007 with partners at the World Bank, United Nations Food and Agriculture Organization (FAO), and the Indonesian government.

Work is continuing on an international strategy to contain pandemic influenza outbreaks, and the US has provided $400,000 to the World Health Organization to host workshops on proper transport of influenza samples to reference laboratories.

The US State Department, along with the Department of Commerce and the Centers for Disease Control and Prevention (CDC), drafted a pandemic preparedness checklist for US companies that have overseas operations. Three major business organizations are reviewing the checklist, and once completed, the document will be posted on the government's pandemic flu Web site.

Transportation and borders
HHS and the departments of Homeland security (DHS), Transportation, and Labor (DOL) developed a pandemic planning checklist for the travel industry and workforce protection guidelines for airline crew members and other people who may come in contact with people and cargo from pandemic-affected areas.

To ensure that all border and transportation stakeholders receive accurate and current information about quarantinable diseases, HHS, USDA, and other departments reviewed the current protocol and added several groups to the notification chain.

Policy recommendations for air, land, and maritime entries and exits, including response plans and screening, were developed by HHS with assistance from 5 other federal departments.

Federal security forces have been briefed by the Department of Justice and DHS about protecting shipments of critical supplies and facilities and are developing contingency plans to carry out the security responsibilities.

Protecting human health
HHS, with the Department of Defense (DOD), the Veterans Administration, and medical specialty societies, developed a guide to help community planners address mass-casualty care with scarce resources. The document was released in November and is posted on the Web site of the Agency for Healthcare Research and Quality.

To coordinate and communicate effective messages to the public about pandemic flu, HHS and several other federal agencies and local officials enlisted and trained a wide range of influential community spokespeople who will be available to speak on the pandemic crisis. Risk communication strategies are also planned for local public health, community, and tribal leaders. Several government agencies have also help develop risk communication strategies ("message maps") on avian flu, pandemic flu, antiviral medications, and vaccines.

One topic of interest to state officials is the possibility of broadening the Food and Drug Administration's Shelf Life Extension Program to state stockpiles of antiviral medications. The program allows the federal government to keep medications beyond the expiration date under certain conditions. However, federal officials determined that including state stockpiles in the program is not currently feasible.

Logan said that decision is a concern for states. The federal government is providing a 25% subsidy to help states build their own antiviral stockpiles, but the drugs have a listed shelf-life of 5 years and can be used only for pandemic flu, not for seasonal flu, he said. "If a pandemic doesn't happen before the end of the shelf-life, you have to throw the antivirals out. . . . And then states will have to go out and buy replacement antivirals for their stockpiles. That's obviously an issue of concern for the states."

To boost vaccine production in the event of an influenza pandemic, HHS explored current production capacities of US vaccine producers and in June issued a request for proposals to retrofit their facilities to produce pandemic vaccines in an emergency.

Smooth, efficient allocation of medical equipment such as ventilators and gloves is a key part of a pandemic response, and HHS and other government agencies have developed and tested a plan to distribute critical materials. The plan was tested in October, and will undergo further trials through March 2007.

To speed the genetic sequencing of viral isolates during a pandemic, HHS set a goal of releasing the findings to GenBank within 1 week of diagnosis confirmation at the Institute for Genomic Research. Complete viral genome sequences can now be obtained from a clinical sample in 3 days, and HHS, with the Association of Public Health Laboratories, can publish sequence data on a human H5N1 isolate within 1 week.

There were other accomplishments on the laboratory front. HHS improved access to standardized influenza reagents for use in tests and research; it can now distribute the reagents within 3 business days of a request. HHS, along with other government agencies and partners, has supplied all members of the US Laboratory Response Network with reagents and protocols to conduct tests using real-time reverse-transcriptase polymerase chain reaction (RT-PCR). These labs are prepared to use RT-PCR to identify and confirm pandemic flu strains within 24 hours.

HHS, using DOD threat-reduction modeling tools and software from other agencies, has developed a real-time epidemic analysis and modeling system for public health use and emergency preparedness.

The National Disaster Medical System has developed a strategy for deploying medical assets, such as materials and mobile medical units, held by DHS and HHS. Several federal agencies also developed a "Pandemic Influenza Playbook" that describes what public health and medical capabilities the federal government has available to support state responses to pandemic influenza.

Protecting animal health
Federal agencies, with the assistance of states, launched a wild-bird testing program for H5N1 avian flu in August along with an electronic reporting system, and is working on a response strategy if such an outbreak occurs.

In assessing the abilities and needs of federal animal research facilities, the USDA and DHS identified problems at a key animal influenza research facility. The departments completed a study of the facility's deficiencies, along with plans to address its needs.

Because of the risk of an avian flu outbreak in birds, several government agencies have prepared three messages based on three scenarios that can be used to deliver clear, coordinated information to the public. Federal departments, with the assistance of industry groups, have also developed food safety messages that can be customized and distributed if an avian influenza outbreak occurs.

Law enforcement and public safety
The Department of Justice, along with HHS, DHS, DOL, sponsored a forum in May for criminal justice officials on best practices to meet the challenges they may face in a pandemic outbreak. Information from the forum is available on the Web site of the Bureau of Justice Assistance. In addition, a consortium of criminal experts was convened in conjunction with the forum to guide ongoing criminal justice planning efforts.

To address emergency response issues, DHS and several other government agencies will host a forum in February for selected federal, state, local, and tribal officials. The group will review interim guidance and adopt a national pandemic flu planning model.

Checklists for law enforcement personnel and emergency responders on issues such as prepandemic vaccination have been developed by HHS and DOL. The documents, which were reviewed by police unions and other professional organizations, also include planning checklists for correctional facilities.

Institutions
Government officials have developed preparedness exercises with private-sector partners, and templates of the exercises are available for use by other interested groups. Business continuity guidance was developed and published on the government's pandemic flu Web site.

Interim guidance on environmental management and cleaning practices, including the handling of potentially contaminated waste materials, has been developed. The guidelines are intended for healthcare facilities, homes, schools, and businesses.

Unfinished tasks
Eight of the tasks were not completed by the 6-month deadline, and the report notes that work on each is continuing. They include measures to:

• Draft a report analyzing the pros and cons of invoking the Defense Production Act to procure medical countermeasures during a pandemic
• Improve the speed of mortality surveillance through the 122 Cities Mortality Reporting System
• Establish a protocol for state governments on how to request federal military assistance under the Insurrection Act
• Adopt and test a planning and preparation model for emergency response systems
• Publish interim guidance on environmental management of pandemic flu viruses
• Publish final pandemic planning guidelines for critical infrastructure owners and operators
• Help critical infrastructure entities conduct collaborative exercises to test essential functions and identify critical planning, response, and mitigation needs.