A decade before COVID-19 emerged as a pandemic, emergency preparedness, response, and resilience professionals were focused on infectious diseases. The H1N1 (swine flu), H5N1 (avian flu), and SARS (Severe Acute Respiratory Syndrome) outbreaks were real, and lessons needed to be learned in preparation for something bigger. So, in April 2010, DomPrep polled the experts (i.e., DomPrep advisors and readers) to gather their thoughts on pandemic preparedness and response. A decade later, their responses are haunting.
The respondents’ answers to seven simple questions in 2010 revealed the strengths, weaknesses, and gaps in Pandemic Preparedness & Response. Resources, roles and responsibilities, and messaging were identified as preparedness gaps. These same gaps proved to be ongoing challenges ten years later as COVID-19 swiftly traveled around the world.
In modern times, the 2009 H1N1 pandemic could be considered a practice run for the COVID-19 response. However, even the processes that worked well in 2009-2010 were not handled as well in 2020. For example, designed to supplement local and state resources, the Strategic National Stockpile (SNS) was able to pre-position personal protective equipment (PPE) like masks, gloves, and gowns before H1N1 infection rates accelerated. After H1N1, though, funding and congressional action were not sufficient to replenish those supplies and meet the needs that would arise in 2020. According to Greg Burel, former director of the SNS, in March 2020,
Although funding provided for the current response is important, the nation would have been in a better posture had the funding provided for pandemic influenza response been continued as part of SNS appropriations so the investment made would have been sustained.
Respondents to the 2010 survey were almost evenly divided as to whether the SNS resources should include all pandemic response needs or only the items that are not easily accessible through commercial supply chains. In light of the nationwide PPE shortages, agencies discovered that even the commercial supply chains were not prepared to handle the surge as demand rapidly increased. In April 2020, a personal call to one local Maryland supplier revealed that, even companies that had large supplies of PPE on hand would only distribute them to preexisting customers.
In 2010, experts mostly agreed that local and state governments did not have sufficient resources for all the tasks required for an emerging infectious disease. Despite that assessment, the emergence of COVID-19 seemed to catch many of these agencies underprepared and under-resourced.
Roles & Responsibilities
There is no doubt that all levels of government hold some responsibility for pandemic planning and response. However, in 2010, the survey found that almost half of the experts leaned toward the federal government as having primary responsibility for such efforts, with state and local governments sharing the rest of the burden. During the COVID-19 response, the main responsibility to develop and implement response plans was put on states and counties. However, funding still remained a critical role of the federal government, upon which state and local agencies depended. A May 2020 article published in the National League of Cities pointed out a cascading effect that may hinder a bottom-up approach for disasters when they cross state borders:
With states likely to cut aid to local governments to help alleviate their own budget pressures, federal support for cities, towns and villages is more critical than ever.
Without adequate funding or guaranteed funding streams, it is challenging to develop realistic plans and implementable actions. Under non-pandemic conditions, local governments lack the funds needed to manage many disasters that occur on a much smaller scale. However, when states are facing the same disaster and seeking federal financial assistance to supplement their resources, the downstream funding becomes even more difficult to secure.
With regard to funding, about three-quarters of the 2010 respondents believed that the federal government should broaden its public health funding to cover all-hazards rather than specific threats like pandemic influenza. Over the past decade, many agencies have adopted an all-hazards approach to disaster preparedness and response. With the scale and scope of COVID-19, though, the question now is whether that transition has helped or hindered the pandemic response.
Perhaps one of the most interesting questions from the 2010 survey was whether “the federal government [should] provide more standardized prescriptive guidance to states for their pandemic planning and response.” About two-thirds of respondents said “yes.” Unfortunately, standardized guidance from the federal government was either lacking or confusing in 2020. Federal guidance did not provide definitive statistics and facts required to make informed decisions regarding mask usage, social distancing, reopening schedules, travel restrictions, vaccine distribution, etc.
Without standardized guidance at the federal level, public health agencies across the country implemented their own guidance. As a result, data collection and reporting varied, making it difficult to compare and analyze statistics from jurisdiction to jurisdiction. Compounding the messaging concerns, some leaders cherrypicked or altered these findings to enhance their successes and downplay their failures. Subsequently, leadership credibility was often questioned and community buy-in suffered. This has left community stakeholders severely divided on PPE use and other safe practices during a pandemic.
Vaccine use and distribution have also received mixed reactions. The efficacy and safety of the various vaccinations have been questioned due to mixed messaging. In 2010, most of the respondents believed that the successes and lessons learned from the H1N1 vaccination campaign would have a long-term impact on future vaccination efforts. Unfortunately, the vaccine rollout for COVID-19 has had many reported challenges. The timeline and messaging for H1N1 demonstrates the stark difference between past and current federal messaging efforts. The first H1N1 influenza case was detected in the United States on 15 April 2009. After interagency coordination efforts to develop a vaccine, on 10 September, “HHS secretary and CDC Director joined the National Foundation for Infectious Diseases (NFID) in a news conference to stress the importance of getting vaccinated for the upcoming influenza season.” Similar joint messaging efforts during COVID-19 have been lacking.
Lessons to Be Learned – Past, Present & Future
The 1918 flu pandemic infected an estimated 500 million and led to about 50 million deaths, of which 675,000 were in the United States. The World Health Organization, currently reports COVID-19 statistics at more than 110 million confirmed cases and almost 2.5 million deaths, of which more than half million have been in the United States. With modern medicine and communications, hopefully COVID-19 will not meet or exceed the fatalities reached in 1918-1919. However, the instantaneous ability to share information around the world is still a wild card. False information that could lead to increased infections and death is just as easy to spread as life-saving information.
False information, poor messaging, and lack of buy-in are factors that will be studied for years to come as researchers examine how the United States jumped from less than 1.5% of the total deaths reported for the 1918 flu to 20% of the total deaths reported for COVID-19. Many important issues will be identified for improvement, including those identified during the H1N1 pandemic in 2009 (albeit, probably not in the same order of importance): clarity of responses, communities, competing direction from federal partners, common terminology/data elements.
As the pandemic has demonstrated, a public health emergency is not solely a public health problem. A multi-discipline, multi-jurisdictional effort is needed to overcome the numerous challenges that communities face. It is not good enough to create lessons learned and best practices if no subsequent actions are taken. Here are just a few ways DomPrep readers can take action to help communities respond better in the future:
- Revisit the National Planning Scenarios – in particular, Scenario 3: Biological Disease Outbreak – Pandemic Influenza
- Share lessons learned and best practices – both the good and the bad
- Examine and implement lessons learned and best practices from other agencies and jurisdictions
- Participate in local, regional, and national level exercises
- Take the Pandemic Planning 2021 survey