Our meetings provide a national forum for leaders in the field to explore and discuss priorities, challenges, and policy implications in health security.
The 2009 H1N1 Experience: Policy Implications
for Future Infectious Disease Emergencies
On March 5, 2010, the Center for Biosecurity of UPMC convened an invitational conference in Washington, DC, to review the most significant lessons learned from the response to the 2009 H1N1 influenza pandemic and to consider policy implications for future infectious disease emergencies. More than 140 participants attended, including federal and state government officials, congressional staff, policy analysts, academics, members of the media, and experienced practitioners from medicine, public health, and emergency management. The conference included speeches by:
- Dr. Nicole Lurie, Assistant Secretary for Preparedness and Response, Department of Health and Human Services
- Dr. Thomas Frieden, Director, Centers for Disease Control and Prevention
- Dr. Richard Besser, Senior Health and Medical Editor, ABC News
- Col. Randall Larsen, Executive Director, Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism
In addition, 3 panels of distinguished experts explored some of the most challenging questions that arose over the past year and their implications for future public health and medical responses.
This conference was sponsored through the generous support of the Alfred P. Sloan Foundation.
Major Themes and Conclusions
The prioritization and distribution of vaccine in future influenza pandemics should be reexamined.
In the event that a future infectious disease emergency requires the mass vaccination of the American people, immunization programs should have an explicitly stated goal (eg, the reduction of morbidity and mortality in vulnerable populations vs. the reduction of viral transmission). The supply of initially available vaccine should be a primary consideration in determining this goal of the vaccination program and in the formulation of priority groups. As a pandemic progresses, the supply of available vaccine and the emerging epidemiologic data may necessitate changes in the priority groups. Guidance from the federal government and plans for communication with the public should reflect this reality. As Dr. Besser noted, honest, prompt communication with the public is an essential function in the response to a public health emergency. Finally, as Dr. Lurie emphasized, the systems in place to distribute the vaccine to the public should take advantage of all possible outlets, including hospitals, school-based clinics, healthcare providers, and pharmacies.
Improvements are needed in the healthcare response to a large-scale bioterrorism attack.
While the 2009 pandemic was a significant health event-as Dr. Frieden pointed out, it sickened millions of Americans and caused tens of thousands of deaths-it was not a true test of our healthcare system's ability to respond to a catastrophic event, because it did not cause a level of systemic stress sufficient to overwhelm our ability to respond. It did, however, significantly increase the workload in emergency departments and intensive care units, which already operate near capacity. Even a slight increase in the severity of the disease caused by the 2009 H1N1 influenza virus could have proved disastrous. In this sense, the pandemic can be thought of as a large-scale drill and can be used to evaluate and improve the nation's medical response capacity.
In the event of a large-scale bioterrorism attack, similar issues would likely emerge: many thousands of victims would need hospital care, and many times that number would seek screening or preventive countermeasures. However, the ability to quickly ramp up the nation's medical response capability remains severely limited. State and federal governments have neither the capability of sending in sufficient medical resources for such an event nor the capacity for transporting a large number of patients to other parts of the country for medical care. The mismatch between patient needs and medical capacity in such an event requires the further development of crisis standards of care. Likewise, the need exists for increased coordination of the medical and public health response at the local, state, and federal levels. To address these needs, the further development of local or regional healthcare coalitions should be fostered by the federal government and improved systems for healthcare situational awareness should be developed.
The role of disease containment measures in the response to a SARS-like emerging infectious disease should be reconsidered.
In response to a contagious infectious disease emergency, government leaders and health officials should anticipate public and political pressure to take actions intended to prevent the further spread of disease, such as the implementation of travel restrictions or screenings, quarantine, and isolation of cases. During the 2009 H1N1 pandemic, some nations did implement such restrictive actions, contrary to the recommendations of WHO.
The decisions as to which measures to employ will depend largely on the disease's epidemiology, especially its mortality, which may be difficult to determine accurately in the early days of the outbreak. Because every infectious disease is unique, the methods used in one outbreak may not be effective in another. Yet, for the actions to be effective, the decisions must be made early on with incomplete information. It is likely that as the situation evolves and more data are gathered, the actions and policy will need to be adjusted.
These measures have historical precedent and in some cases may theoretically be beneficial, but many may not be operationally feasible. For example, in planning to respond to pandemic influenza, the Canadian government considered quarantining passengers arriving on planes from Asia but realized that they would run out of room to put the quarantined passengers before the end of the first day. Public health and political leadership should recognize that the unintended consequences of these actions, including economic disruption, might outweigh any public health benefit.
With the benefit of the recent pandemic experience, both the scientific and practical bases for these interventions should be reconsidered. Political realities and the difficulty of communicating complex messages laced with uncertainty must be considered as well. Because these issues are so difficult, state and local public health officials expressed the need for more specific guidance from the federal government during the 2009 H1N1 pandemic.
While much progress has been made, much remains to be done.
Drs. Lurie, Frieden, and Besser all made the point that the response to the 2009 pandemic benefited greatly from the years of work on pandemic and all-hazards healthcare preparedness that preceded it. This progress notwithstanding, each of the panels highlighted a different set of important challenges that remain in preparing for a future infectious disease emergency. Col. Larsen, in his closing remarks, reminded the audience that it was the unanimous conclusion of the WMD Commission that the threat of large-scale bioterrorism is very real and that the country remains ill-prepared in many key ways.
Suggested Background Reading:
- Henderson DA, Courtney B, Inglesby TV, Toner E, and Nuzzo JB. Public health and medical responses to the 1957-58 influenza pandemic. Biosecur Bioterror. 2009;7(3).
- Lipsitch M, Hayden FG, Cowling BJ, Leung GM. How to maintain surveillance for novel influenza A H1N1 when there are too many cases to count. The Lancet. 2009;374(9696).
- Smith LM, Gronvall GK. Influenza vaccine production for the U.S. market. Biosecur Bioterror. 2009;7(3).
- Sell TK, Nuzzo JB, Toner E. Where does H1N1 influenza information come from? An overview of influenza surveillance in the United States. Center for Biosecurity of UPMC website. November 2, 2009.
- Nuzzo JB. Border restrictions: Not an effective means of preventing the spread of swine flu. Center for Biosecurity of UPMC website. April 28, 2009.
Welcome & Opening Remarks
Thomas V. Inglesby, Director, Center for Biosecurity of UPMC
What the Flu Pandemic Can Teach Us About Future Biothreats
Nicole Lurie, Assistant Secretary for Preparedness and Response, US Department of Health and Human Services
Panel Discussion—How Should the U.S. Prioritize & Distribute Vaccine in Future Influenza Pandemics?
- Richard Waldhorn, Distinguished Scholar, Center for Biosecurity of UPMC, Moderator
- Anne Schuchat, Assistant Surgeon General, Director, National Center for Immunization and Respiratory Diseases, CDC
- John Colmers, Secretary of Health and Mental Hygiene, Maryland
- Marc Lipsitch, Professor of Epidemiology, Harvard University
- Paul Etkind, Senior Analyst, National Association of County and City Health Officials
- David Lakey, Commissioner, Department of State Health Services, Texas
Public Health Response to the H1N1 Pandemic
Thomas Frieden, Director, CDC
Ensuring a Prepared Nation Through Public Engagement-the Intersection Between Media and Social Change
Richard Besser, Senior Health and Medical Editor, ABC News; former Acting Director, CDC
Panel Discussion—Large Scale Bioterrorism-Anthrax: How Can the Healthcare Response to Catastrophic Events be Improved?
- Eric Toner, Senior Associate, Center for Biosecurity of UPMC, Moderator
- Kevin Yeskey, Director, Office of Preparedness and Emergency Operations, HHS
- Daniel Sosin, Acting Director, Office of Public Health Preparedness and Response, CDC
- Dan Hanfling, Special Advisor, Emergency Preparedness and Response, Inova Health System
- John Hick, Medical Director, Office of Emergency Preparedness, Minnesota Department of Health
- Scott Cormier, Director, Emergency Preparedness & Management, Hospital Corporation of America
Panel Discussion—SARS-like Emerging Infectious Disease: What Roles Should Disease Containment Measures Play in Controlling International Epidemics?
- Jennifer Nuzzo, Associate, Center for Biosecurity of UPMC, Moderator
- Jeffrey Levi, Executive Director, Trust for America's Health
- D.A. Henderson, Distinguished Scholar, Center for Biosecurity of UPMC
- Ronald St. John, Former Director General, Centre for Emergency Preparedness and Response, Public Health Agency of Canada
- Marcelle Layton, Assistant Commissioner, NYC Department of Health and Mental Hygiene
- James Blumenstock, Chief of Public Health Practice, Association of State and Territorial Health Officials
H1N1 Response Shows Need for Better Emergency Medical Plans
Randall Larsen, Executive Director, Commission on the Prevention of Weapons of Mass Destruction Proliferation and Terrorism
Thomas V. Inglesby, Director, Center for Biosecurity of UPMC
- David Abramson, NCDP, Columbia University
- Terry Adirim, U.S. Department of Homeland Security
- Phyllis Arthur, Biotechnology Industry Organization
- Sid Baccam, IEM, Inc.
- Randy Beardsworth, Catalyst Partners
- Kavita Berger, American Association for the Advancement of Science
- Richard Besser, ABC News
- James Blumenstock, ASTHO
- Robert Borowski, The Tauri Group
- Nidhi Bouri, Center for Biosecurity of UPMC
- Katie Brewer, ANA
- Rick Bright, PATH
- Kathryn Brinsfield, U.S. Department of Homeland Security
- Mallory Bulman, U.S. Government Accountability Office
- Meghan Butasek, Baltimore City Health Department
- Amy Caouette, Systems Planning and Analysis, Inc.
- Ellen Carlin, House Committee on Homeland Security
- Eileen Choffnes, National Academy of Sciences
- Anita Cicero, Center for Biosecurity of UPMC
- Kenneth Cole, Department of Defense (ATSD(NCB))
- John Colmers, Maryland Dept. of Health & Mental Hygiene
- Francesca Cook, PharmAthene
- Scott Cormier, HCA
- Brooke Courtney, Center for Biosecurity of UPMC
- John Cross, TMTI A&AS Support
- Victoria Davey, Department of Veterans Affairs
- Shana Deitch, U.S. Government Accountability Office
- Molly D'Esopo, Center for Biosecurity of UPMC
- Diane DiEuliis, OSTP
- Anil Diwan, NanoViricides, Inc.
- Joe Donovan, Beacon Capital
- Lydia Duckworth, U.S. Dept. of Health & Human Services
- Michael Dunaway, U.S. Department of Homeland Security
- Patricia Elliott, Logan Circle Policy Group LLC
- Peter Emanuel, White House OSTP
- Joanna Engstrom-Brown, Center for Biosecurity of UPMC
- Gerald Epstein, AAAS
- Paul Etkind, NACCHO
- Janet Fang, Nature
- Caroline Fichtenberg
- David Fox, U.S. Government Accountability Office
- Jackie Fox, Center for Biosecurity of UPMC
- Maggie Fox, Reuters
- Crystal Franco, Center for Biosecurity of UPMC
- Thomas Frieden, U.S. Centers for Disease Control and Prevention
- Andrew Garrett, National Disaster Medical Center
- Joel Gaydos, Armed Forces Health Surveillance Ctr., U.S. Department of Defense
- Charlotte Gaydos, Johns Hopkins University School of Medicine
- Bruce Gellin, U.S. Dept. of Health & Human Services
- Asha George, House Committee on Homeland Security
- Jennie Gromol, U.S. Department of State
- Gigi Kwik Gronvall, Center for Biosecurity of UPMC
- Garrick Groves, U.S. Dept. of Health and Human Services
- Fred Guterl, Newsweek
- James Guyton, PRTM Management Consultants, LLC
- Lydia Hall, Drinker Biddle
- Richard Hamburg, Trust for America's Health
- Dan Hanfling, Inova Health System
- Mary Beth Hansen, Center for Biosecurity of UPMC
- Judie Hantman, U.S. Dept. of Health and Human Services
- John Hardham, U.S. Department of Defense
- Clare Helminiak, U.S. Dept. of Health and Human Services
- D.A. Henderson, Center for Biosecurity of UPMC
- John Hick, HCMC
- Penny Hitchcock, The Tauri Group
- Seta Hovagimian, U.S. Government Accountability Office
- William Huff, Defense Threat Reduction Agency
- Noreen Hynes, Johns Hopkins University School of Medicine
- Paula Imbro, The Tauri Group
- Thomas V. Inglesby, Center for Biosecurity of UPMC
- James James, AMA
- Peter Jutro, NHSRC, U.S. Environmental Protection Agency
- Peter Katona, UCLA
- Rebecca Katz, U.S. Department of State
- Larry Kerr, ODNI
- Lynne Kidder, Business Executives for National Security
- Tara Kirk Sell, Center for Biosecurity of UPMC
- Akhila Kosaraju, SIGA Technologies
- Allen Krotman, MITRE
- Nicole Kunko, House Appropriations Committee
- David Lakey, Texas DSHS
- Michael Langford, BNBI
- Randy Larsen, Commission on the Prevention of WMD Proliferation & Terrorism
- James Lawler, National Security Staff, The White House
- Marcelle Layton, NYC Dept. of Health
- Justin Lessler, Johns Hopkins Bloomberg School of Public Health
- Jeff Levi, Trust for America's Health
- Dara Lieberman, Trust for America's Health
- Davia Lilly, Center for Biosecurity of UPMC
- Marc Lipsitch, Harvard School of Public Health
- Dan Lucey, Georgetown Dept of Microbiology & Immunology
- Nicole Lurie, ASPR, U.S. Dept. of Health and Human Services
- Monique Mansoura, HHS/ASPR/BARDA
- Richard Martinello, Veterans Affairs
- Craig Martinez, Senate HELP Committee
- Richard McNally, U.S. Dept. of Health & Human Services
- Gretchen Michael, ASPR/HHS
- Daniel Miller, U.S. Dept. of Health and Human Services
- Elizabeth Miller, de Beaumont Foundation
- Stephen Morse, Columbia Univ., Mailman School of Public Hlth.
- Bernard Munos, Eli Lilly & Company
- Padma Natarajan, Infectious Diseases Society of America (IDSA)
- Tom Neal, MITRE Corporation
- Lauran Neergaard, Associated Press
- Ann Norwood, Center for Biosecurity of UPMC
- Glen Nowak, U.S. Centers for Disease Control and Prevention
- Jennifer Nuzzo, Center for Biosecurity of UPMC
- Michael O'Keefe, DOD DTRA
- Paula Olsiewski, Alfred P. Sloan Foundation
- Gregg Pane, HHS/ASPR
- Sapana Parikh, U.S. Centers for Disease Control and Prevention
- Thomas Phan, (HDMA) Healthcare Distribution Mgmt. Assoc.
- Sally Phillips, AHRQ
- Frances Phillips, DHMH
- Ian Portelli, New York University, School of Medicine, Department of Emergency Medicine
- Beth Rada, XOMA
- Lewis Radonovich, Department of Veterans Affairs
- Kunal Rambhia, Center for Biosecurity of UPMC
- Corinne Ringholz, ANSER
- Robin Robinson, HHS/ASPR/BARDA
- Bob Ross, U.S. Department of Homeland Security
- Monica Schoch-Spana, Center for Biosecurity of UPMC
- Anne Schuchat, U.S. Centers for Disease Control and Prevention
- Fred Selck, Center for Biosecurity of UPMC
- William Smith, UPMC
- Brad Smith, Center for Biosecurity of UPMC
- Liza Solomon, Abt Associates
- Christine SooHoo, USUHS Medical student
- Daniel Sosin, OPHPR, U.S. Centers for Disease Control and Prevention
- David Spiro, J. Craig Venter Institute
- James B. Sprague, de Beaumont Foundation
- Ronald St. John, Retired
- Raymond Strikas, National Vaccine Program Office
- Clare Stroud, Institute of Medicine
- Jason Thomas, HHS/OGHA/Int'l Influenza Unit
- Eric Toner, Center for Biosecurity of UPMC
- Tim Trevan, International Council for Life Sciences
- Price Tyson, Center for Biosecurity of UPMC
- Jo Velardo, Homeland Security Studies & Analysis Inst.
- Richard Waldhorn, Center for Biosecurity of UPMC
- Ava Walker, The Tauri Group
- Matthew Watson, Center for Biosecurity of UPMC
- Kevin Yeskey, OPEO, U.S. Dept. of Health & Human Services
- Stephanie Zaza, OPHPR, U.S. Centers for Disease Control and Prevention