'Gaps and shortcomings' in state pandemic flu preparedness
'Gaps and shortcomings' in state pandemic flu preparedness
First the good news: Regional pandemic preparedness workshops conducted by the National Governors Association (NGA) last year with 27 states and territories found there is increased awareness in state governments of the problem and potential widespread impact of a pandemic. All states had significant and wide-ranging awareness of the threat and its origin and potential impacts. And all states were aware of a pandemic's characteristics and the challenges it poses for effective planning.
In addition, NGA found, states have made notable advances in the area of preparedness, particularly in public communication and education, purchase of antiviral medicines to stockpile, and sharing information about public health tactics, and especially on school closure/student dismissal.
Now the bad: It is clear that plans for response and recovery from a pandemic episode continue to have gaps and shortcomings, an interim NGA report says. And these shortcomings translate into areas in which the states and the federal government should next concentrate their efforts.
Thus, the report says:
1. States have not adequately considered how their individual decisions on school closure will affect other states and there is no consensus among states on how to communicate with the public on that issue. NGA says federal, state, and local authorities must clearly communicate with the public about the purpose and objective of closing schools or dismissing students. They also must recognize the potential impact of those decisions on availability of workers in the public and private sectors.
2. States do not adequately understand what capabilities might be expected at the state level and how federal agencies will engage with them during a pandemic. NGA says that at some of its regional meetings, the presence of the designated Principal Federal Official for pandemic response offered most states their first opportunity to interact with these potentially valuable federal liaisons. However, continuing lack of clarity about federal roles and responsibilities, and the triggers for the federal government to take action, contribute to an overall confusion about the federal response.
3. Prioritizing the order in which antiviral medications, for either treatment or prevention, are distributed to different groups continues to challenge states. NGA says few clear examples were identified for either prioritization strategies or attendant public communication messages. While this situation will change as states continue to stockpile medications, NGA says it is clearly an area that will generate significant public discussion and should be addressed in advance of any action during a pandemic episode.
4. While the informal contacts in place among officials from states in each region have been effective in most past incidents, NGA recommends they be formalized and institutionalized because a pandemic has the potential to overwhelm informal links, particularly if key personnel become sick or are otherwise unavailable.
5. States are relying heavily on availability of privately-held infrastructure, response by volunteer organizations, or actions by other organizations outside their immediate control. But most state plans have not clearly defined those organizations' roles and responsibilities.
6. States often cited potential shortages of critical goods and services as a special challenge. However, no solutions were provided for ensuring availability of goods and services across state and national borders, and there appears to be little coordination with the private sector to develop state-based strategies.
7. Few states have conducted state-specific economic analyses of their economies under pandemic conditions, and no information was readily available at the workshops about the business of government such as collecting taxes and fees or the potential effect on states' ability to fund programs, pay vendors, or underwrite special prevention measures.
Moving target
NGA notes that accurately assessing state preparedness for a pandemic outbreak is a moving target as there is no baseline and no agreed-upon metric against which any state pandemic preparedness can reasonably be measured.
"Despite the fact that organizations such as the World Health Organization and U.S. government officials continue to characterize the pandemic threat as 'uncertain but urgent,' some of the original momentum for preparing at the state and local levels has been lost," NGA says. "This is due in part to some successes in preparedness planningan encouraging trendand in part to an apparent slowing in the spread of the current pandemic virus candidate, H5N1 influenza or 'bird flu.' Nonetheless, international and federal government health officials maintain that the threat is real, and history has shown that pandemic outbreaks do occur. The perception that the urgency of the threat has decreased, combined with the absence of an agreed measurement system, likely explains some, but not all, of the hesitancy among states to tackle some of the remaining challenges in pandemic planning."
Chris Logan, who directs the Homeland Security and Technology program for NGA's Center for Best Practices, tells State Health Watch it is understandable that to date there has been little effort to develop baseline data and assumptions on economic and other issues. "So far," he says, "pandemic planning has been focused primarily on public health and medical response issues. So states haven't looked in detail at pandemic-specific plans for infrastructure, keeping government functioning, and other social and economic issues."
Mr. Logan says that situation is changing because the federal government now is asking states to do a lot more work in the nonpublic health areas. "It's been thought of primarily as a public health event," he says. "Now it's time to start looking at other areas."
An issue raised at several of the workshops was a desire by states to have more awareness of the planned action of their neighboring states, including states not specific to the region, with respect to actions such as school closure and antiviral distribution. NGA says this issue is an important and interesting area for further investigation. And Mr. Logan says it's an area where NGA can be useful because it can help leverage relatively small amounts of money to provide a forum in which best practices can be shared.
Obtaining medications
While the focus for nearly all workshop participants to date has been on obtaining antiviral medications, both Tamiflu and Relenza, participants indicated states assume vaccines will not play a significant role in their response plans, probably because of the relatively long lead time required to develop a vaccine specific to the pandemic strain. Few states have developed priority lists detailing who would be the first to receive antivirals during a pandemic.
NGA says the workshops also revealed considerable variation in states' progress in planning and testing mitigation and response strategies. It says one overwhelming issue with which nearly every state is struggling, and which was raised at every workshop, is the question of school closure and reopening. "There is no state, regional, or national consensus on this important topic or how to communicate with the public about this issue," NGA says. "Clearly, given the reliance that many state plans have on personnelwhose availability could be directly or indirectly impacted by school closure and the attendant child care requirementsthis is an area for urgent follow-up if mitigation and response planning is to be effectively developed and tested."
NGA says four consistent messages emerged from what admittedly is a snapshot from the pandemic workshops held so far:
1. All states have dramatically increased their awareness of the potential consequences of a pandemic among the various agencies of government.
2. There is, in many areas, a lack of coordination among state, federal, and private planning efforts.
3. No states have effectively tested or demonstrated substantive measures and strategies to mitigate potentially catastrophic consequences of a pandemic and plans for closing schools for extended periods, encouraging social distancing, and taking steps to maintain essential services exist mainly on paper.
4. The lack of situational awareness to guide decision making and interstate coordination and the absence of regional or national plans for developing such a tool to provide that awareness is hampering the ability and willingness of states to move from awareness to preparedness.
"These messages are, in many ways, making one point," NGA concludes. "The lack of baseline information and assumptions (economic, infrastructure, social, or otherwise) are preventing communities across the nation from applying specific actions to mitigate a pandemic."
NGA's recommendations include:
1. creating a representative group of businesses, critical infrastructure owners, governors and their aides, security, and emergency managers to develop the framework for a common situational awareness tool for the nation;
2. establishing a mechanism for sharing local and state mitigation activities and practices established in the short-term (less than three months);
3. developing exercises that move beyond awareness-building to testing large-scale response actions, such as school closing.
Mr. Logan says progress is being made in these areas. New federal grant guidelines are encouraging states to form broad groups of stakeholders to consider issues that haven't been fully addressed. And he sees a movement toward the kinds of exercises envisioned in the third bullet point that will take pandemic planning to the next level.
Sharing information among states and local governments is important, he says, but can be difficult to accomplish because of the way money flows to individual states and may not be available for use to improve communication with other states.
Download the workshop report at http://www.nga.org/portal/site/nga/menuitem.9123e83a1f6786440ddcbeeb501010a0/?vgnextoid=c110518fa3d58110VgnVCM1000001a01010aRCRD. Contact Mr. Logan at (202) 624-5379.
First the good news: Regional pandemic preparedness workshops conducted by the National Governors Association (NGA) last year with 27 states and territories found there is increased awareness in state governments of the problem and potential widespread impact of a pandemic.Subscribe Now for Access
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