The Next Pandemic: Understanding the Public Health Role

In coping with pandemics, public health authorities play one of the most important roles in the overall process of planning, preparedness, response, and recovery. Although the term “pandemic” refers to a wide range of infectious diseases – e.g., human immunodeficiency virus (HIV), plague, smallpox, and tuberculosis – the current focus of public health preparedness planning is on influenza (flu) pandemics. Examining some pandemics of the past – as well as more recent events such as the severe acute respiratory syndrome (SARS) and influenza A (H1N1) virus pandemics – will assist in shedding light on what has been and what still needs to be learned from them, as well as the specific roles and responsibilities of public health in understanding the last pandemic better and preparing more effectively for the next one.

Almost a century ago, in 1918, the “Spanish flu” killed tens of millions of people worldwide, including an estimated 675,000 in the United States. It was an unusually severe and deadly pandemic that spread around the world – the fatality rate for diagnosed cases was estimated to be about 10 to 20 percent of those who had been infected. Unfortunately, historical and epidemiological data are inadequate for identifying the specific geographic origin of the disease, but it is known that most of the victims were healthy young adults. Even at that time, the improvement of modern transportation systems had made it easier for soldiers, sailors, and civilian travelers to spread the disease, and that capability was considered to be a major factor in the worldwide occurrence of the disease.

More recently, in 1957, the “Asian flu” killed nearly two million people worldwide, including an estimated 70,000 in the United States. A World Health Organization (WHO) expert panel found that, in some countries, the disease spread more rapidly in the wake of public gatherings such as conferences and festivals, and in many cases broke out first in camps, army units, and schools. The WHO findings suggested that the avoidance of crowding – and the implementation of social-distancing, quarantine, and/or isolation measures – might play an important role in reducing the peak incidence of an epidemic. In early 1958, though, as the previous year’s pandemic seemed to be dying down, another wave of illness, this time among the elderly, became a prime example of the “second wave” that can develop during a pandemic – i.e., the disease infects one group of people, seems to decrease (at least temporarily), but then infects a growing number of victims in a different segment of the population.

Ten years later, in 1968, the “Hong Kong” flu killed about 700,000 people worldwide (about 34,000 in the United States). Fewer people died during that pandemic than in the two previous pandemics cited above – and for various reasons, including the following: (a) the earlier pandemics left some population groups with a certain degree of immunity against the flu virus; (b) in some countries, the 1968 pandemic did not gain full momentum until the start of the winter school holidays, thus limiting the spread of infection (through what was de facto social distancing); (c) there was greater access to improved medical care (which translated into earlier and more effective support available to the very ill); and (d) a broader range of antibiotics were available that proved to be more effective against secondary bacterial infections.

Current Events & a Long List of Lessons Learned

More recently, the world coped with the Severe Acute Respiratory Syndrome epidemic in 2003 and the H1N1 flu outbreak in 2009-2010. Although SARS has been termed a “near pandemic,” the lessons learned from it also are worth noting – within a matter of weeks in early 2003, SARS spread from Hong Kong and rapidly infected individuals in some 37 countries around the world. Each nation affected reacted differently, though, and collectively utilized a relatively broad range of public health strategies, including the following:

• The prompt isolation of infected individuals after they started to show initial signs and symptoms of infection;
• The quarantine of those who might have been exposed to already infected or potentially infected individuals;
• The heightened monitoring and active surveillance of asymptomatic contacts – usually through contact tracing;
• The implementation of improved community-control measures such as the closing of schools and the use of voluntary limitations on public gatherings;
• The rapid and more effective dissemination of educational information – through travel alerts and advisories, press releases, and interagency partner notifications; and
• The implementation of mandatory limits on public interactions and curfews, as well as the total cancellation of some public events.

There were no SARS-related deaths in the United States – but there were eight confirmed cases of persons who had contracted the virus overseas. However, the media and public attention on SARS in the United States led to several helpful lessons learned, such as the need to: (a) Develop more robust public health risk communications training and messaging (e.g., messaging should be standardized, current, and culturally sensitive); (b) Better understand the legal and political impact of various isolation, quarantine, and social-distancing measures – and how each would be implemented if needed; and (c) Coordinate across agencies and departments to ensure that public health was at the planning table alongside police, emergency medical services (EMS), fire, emergency management, hospitals, and other “stakeholders.”

Many countries, including the United States, that had been affected in various ways by the SARS outbreak implemented additional public health measures – including, but not limited to: the expanded use of disease surveillance systems; the implementation of heightened infection controls in hospitals and EMS units; intensive contact tracing (coupled with medical surveillance); and the formation of multidisciplinary investigation and response teams.

Among the more prominent public health control strategies used during the H1N1 pandemic of 2009-2010 were additional and more widespread school closures and the increased use of antiviral drugs. The same pandemic also saw a push-out, to various state health departments, of antiviral medications from the Strategic National Stockpile (SNS) that had been created by the U.S. Centers for Disease Control and Prevention (CDC). In addition, several other nations with confirmed H1N1 infections – Australia and Hong Kong, for example – used isolation, home quarantines, antiviral medications, and enhanced infection-control practices to reduce the spread of disease.

Although SARS was certainly a different virus strain, the lessons learned from 2003 might have significantly helped the preparedness for and response to H1N1. However, there seemed to be at least a few cases of “reinventing the wheel” in 2009 – and, for that reason, many of the same lessons learned during SARS also emerged during and after H1N1. After H1N1, there was a better planned, and more effective, push to develop not only Pandemic Influenza Plans but also some complementary Isolation and Quarantine Plans.

It is worth noting that this type of joint/complementary planning had already been emerging, in certain communities throughout the United States, but was not yet either widespread or mandatory. Most of the pre-2009 initiatives started earlier – usually to cope with the 2005-2007 SARS and H5N1 outbreaks (the latter, also referred to as the Bird Flu, never escalated into a pandemic).

How Prepared Is the United States Today?

Since 11 September 2001 and the anthrax attacks that followed in short order, the U.S. Congress has appropriated billions of dollars in federal funding to help CDC increase the public health sector’s preparedness and response capabilities. CDC does this primarily through the downstream dispersal of those same federal funds to: (a) create, expand, or otherwise improve such programs as the Public Health Emergency Preparedness (PHEP) Cooperative Agreements; (b) write and promulgate guidance documents (related, for example to the National Response Framework, Target Capabilities List, Presidential Policy Directive 8, National Incident Management System, and the Homeland Security Exercise and Evaluation Program); and (c) provide and upgrade technological systems and equipment. In 2002, the CDC also released the “Local Public Health Preparedness and Response Capacity Inventory” – a survey instrument that attempted to develop a quick but reliable assessment of the current preparedness of states and local health departments. (Although 22 states and 800 local health departments used the tool in some manner, it did not include measurable indicators, directions for how to answer the questions, or provide standardized questions and analyses relevant to the information collected.)

In 2006, the CDC’s SNS division started to develop more robust tools and resources to assist states and local health departments in increasing their capacity to receive, distribute, and dispense SNS assets in the event of an emergency/disaster. In 2007, the SNS Technical Assistance Review (TAR) Tool began collecting and reporting data, as viewed from the federal level, of state and local readiness to receive SNS materiel and to measure the plans of local Cities Readiness Initiative (CRI) Metro Statistical Areas in relation to their ability to ensure the prompt delivery of prophylaxis to their populations within 48 hours after the start of a significant public health emergency – another anthrax attack, for example.

In responding to the H1N1 outbreak, CDC administered $1.4 billion, between 2009 and 2010, in Public Health Emergency Response (PHER) grants awarded to participants in the PHEP cooperative-agreement program – 50 states, eight territories and freely associated states, and four major metropolitan areas (Chicago, Los Angeles County, New York City, and Washington, D.C.). The goal, of course, was to help ensure increased preparedness and response capacity, particularly during the pandemic. The PHER grants included guidelines for how the money should be spent (e.g., on vaccinations, dispensing, community mitigation, and epidemiological surveillance). The guidance for participants in the PHEP cooperative agreement program also became increasingly more robust each year, along with new or revised federal guidance for improving public health preparedness capabilities.

In addition to the preceding, some states have imposed additional requirements for their local health departments when providing them with funding. In 2004, the National Association of County and City Health Officials (NACCHO) developed the Project Public Health Ready (PPHR) program, which helps local health departments build and/or improve their preparedness capacities and capabilities by using locally developed public health preparedness standards. In March 2011, CDC released the Public Health Preparedness Capabilities: National Standards for State and Local Planning, which includes 15 capabilities – designed to serve as national standards, and aimed at ensuring that federal funds are directed to specific priority areas (which the awardees can use to demonstrate measurable and sustainable progress toward the capabilities desired).

In addition to the aforementioned efforts, there has also been significant progress in building public health preparedness capabilities and capacities through the additional funding of programs, research, and development of tools and resources by and within national associations and organizations, community-based organizations, private-sector businesses, universities, regional coalitions, and other groups. In short, it is undeniable that, over the past 10 years, public health has become a major player in responding to emergencies/disasters alongside traditional first responders, and that the overall public health community is much better equipped to do so.

Several questions remain, however, including the following: (a) How truly ready is public health for the next pandemic or disaster? (b) Have enough and/or the right types of lessons been learned and implemented from past events – or will additional time, effort, and money have to be invested into reinventing the wheel when the next pandemic hits? (c) Is the dwindling funding still available being properly used, in innovative ways, to push efforts forward – or are boxes being merely checked off and the minimum being done to continue receiving the funds still available?

How Prepared Should the United States Be?

So the question that must now be answered is this: What is the current preparedness level of the United States and where should it be? The answer depends to a large extent on the specific jurisdiction(s) involved – and raises several additional questions, including the following: (a) How much is public health preparedness supported by the leadership and partners of the specific jurisdictions involved? (b) How much time and effort are being put into the search for better and/or more innovative ways to make money and other resources last longer? (c) How much more willing are the health departments of those jurisdictions to invest in future preparedness efforts (with or without money)?

Over the years, the following messages have been emphasized the most to public health preparedness planners and staff across the country, and at all levels of government: It is important to change the public health culture to include preparedness as a cross-cutting and overarching concept that affects all other public health services; and, among other things, it is important to continue: Writing and maintaining plans; Training staff (all staff, not only newcomers and those who work on preparedness daily);  Exercising plans (with partners, not just internally); Determining where the gaps and lessons learned are; And, most important of all, actually implementing the improvements/corrective action plans developed so that the same deficiencies do not show up over and over again during each and every training exercise or “real-life” event.

Another important question: Have jurisdictions taken these messages seriously?  If they have, and have actually taken the steps needed to implement the changes required, then they are (or at least should be) much better prepared for the next pandemic or major public health event than in the past. The bottom line is that nobody knows when the next pandemic or major public health emergency is coming, where it will originate, and what is likely to be its overall impact on the general population. What is known, though, is that there has been a tremendous push from all levels of government – as well as from the private sector and academia – to develop and improve public health preparedness measures, create a more robust public health preparedness infrastructure and workforce, and provide more useful and practical resources and tools than were ever before available. Fortunately – and perhaps, at least in part, because of the H1N1 and SARS outbreaks – there has been an increased awareness of pandemics in general by public health authorities, government officials, and the American people. For that reason alone, there will probably be no better time than the present to take advantage of this opportunity before the next pandemic erupts.

Even if another pandemic is years in the future, and federal as well as state funding for preparedness efforts continues to drop, it is important not only to remain vigilant but also to continue to “do more with less” – if only to ensure the rapid response to, and recovery from, whatever the next event may be.

When – not if – the next worldwide pandemic or major public health emergency strikes, the worst-case scenario for public health is to believe in the spurious and totally unacceptable reason that “We didn’t think we were going to get hit with another major pandemic so soon,” and to not have updated preparedness plans, to not have trained staff, and/or to not have established partners.