Shiloh
Editor, Senior Moderator
Source: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090406/REG/904039965&nocache=1
Pandemic peril
With other healthcare issues getting top priority, flu preparedness is getting short shrift. But the threat hasn?t gone away.
By Jessica Zigmond
Posted: April 6, 2009 - 5:59 am EDT
Three years ago, Congress appropriated billions of dollars to HHS for the agency?s pandemic influenza plan after animal outbreaks of the extremely pathogenic avian flu virus were discovered in a dozen countries throughout the world. Today, even though scientists say the threat of a pandemic is still very real, the nation?s interest in the issue has subsided, and HHS says it does not have the requested resources to fully implement the plan it proposed.
And that leaves the nation?s hospitals?already operating under tight budgets?not only with less funding, but also with the decision whether to expend resources preparing for a catastrophic event that might not occur for years.
At the height of interest in pandemic flu in late 2005, President George W. Bush requested a total of $7.1 billion in emergency funding for pandemic influenza preparedness activities, of which $6.7 billion was to implement the HHS Pandemic Influenza Plan. The funding was requested in fiscal 2006 to ?ensure the nation could effectively respond in the event of a pandemic,? according to a January 2009 report to Congress from HHS. Subsequently, Congress in December 2005 appropriated $3.3 billion in emergency funding to HHS for the first year of the plan and $2.3 billion for the second year of funding in June 2006.
But those big plans have not been realized. ?The full promise of the progress HHS anticipated cannot be achieved as HHS does not have the requested resources to fully implement the plan it proposed,? the report said, adding that the fiscal 2008 appropriations bill did not include the $870 million initially requested by the president to support the plan?s next phase.
In a February report on pandemic flu, the Government Accountability Office acknowledged the work of the previous presidential administration in developing a national strategy and implementation plan, but said more needs to be done. Three years ago, the GAO developed a strategy for its work to support Congress? decision-making and oversight related to pandemic flu planning. That strategy?which was built on a body of work that included reviews of other national disasters such as the 9/11 terror attacks, hurricanes Katrina and Andrew, and emerging infectious diseases such as severe acute respiratory syndrome?targets six themes: performance and accountability; leadership, authority and coordination; detecting threats and managing risks; information sharing and communication; capacity to respond and recover; and planning, training and exercise.
Since 2006, the GAO has issued 11 reports and officials testified twice at congressional hearings on influenza pandemic planning, making 23 recommendations based on its findings. Federal agencies have acted on 13 of those recommendations, but have not implemented 10.
?At the same time, however, national priorities are shifting as a pandemic has yet to occur, and the nation?s financial crisis and other national issues have become more immediate and pressing,? the report said in its opening letter to Rep. Bennie Thompson (D-Miss.), chairman of the House Committee on Homeland Security. ?Nevertheless, an influenza pandemic remains a real threat to our nation and the world.?
In addition to the federal dollars allocated specifically for pandemic flu, hospital preparedness funding from HHS? Office of the Assistant Secretary for Preparedness Response, or ASPR, is allocated to the nation?s states and territories for all hazards, according to Gregg Pane, an emergency physician who is the director of national healthcare preparedness programs at ASPR. The program began in 2002 and was coordinated by HHS? Health Resources and Services Administration before legislation in 2006 transferred the program to ASPR. When it began, the program allocated $125.1 million to states. It then jumped to $498 million in 2003 and 2004, but dipped to $470.8 million in 2005. Since then, the funding level has declined steadily to $460.2 million in 2006, $415 million in 2007, and to $398 million last year.
Shifting priorities
Roslyne Schulman, senior associate director for policy at the American Hospital Association, said as the nation?s priorities have shifted, there is great concern that federal funding for hospital preparedness could decline even more. Meanwhile, she said, hospitals continue to prepare for all types of disasters, including a pandemic, as they look for more direction on how to prepare for a surge or altered standards of care.
?Yes, hospitals are looking for more guidance, and, honestly, they look to the federal government for guidance,? Schulman said. ?By definition, a pandemic will affect many areas simultaneously ? it would be the situation where the need for care would completely overwhelm the capacity of hospitals.?
That?s why Pane said planning efforts should be shared in a community. ?We emphasize collaboration with others,? Pane said. ?The biggest problems are communication and coordination. That?s really what it?s all about.? Pane also said last year?s $398 million, which is disbursed to 62 states and territories and 4,000 hospitals, is ?not a lot of money,? something that state health departments and hospitals understand well.
Some see the funding priorities as too federally focused. ?Way too much of the money that is allocated from your tax dollars and mine goes to propping up large, federal bureaucracies like CDC,? said Jim Mackin, the public health preparedness director at the Alaska Department of Health & Social Services. ?The very large staff, the very large budget?they don?t develop plans at the local level. They?re heavily invested in the federal process? as is HHS and Office of the Assistant Secretary for Preparedness Response, he added. ?Virtually every outfit out there says: ?If we?re serious about this, we need to provide more and consistent funding to the local and state organizations doing the heavy lifting.?
While the national interest in pandemic flu has waned, scientific study of the issue has not, according to Scott Dowell, director of the global disease protection program at the Centers for Disease Control and Prevention.
?In public health, we have to deal with a relatively short attention span,? said Dowell, who added that the greatest concern for a pandemic is still H5N1, the strain known as bird flu, which has been present since 2004. Dowell worked extensively on avian flu in Thailand, where people died from the virus. ?We believe, in our judgment, that the threat is still there even though the public isn?t maintaining attention.? As Dowell explained, the H5N1 strain, which has been transmitted from animals to humans, is still not able to transmit from person to person. Now scientists are studying what will happen if the avian flu does not hit for another five to 10 years.
?Is training and equipping all that we need to be doing?? Dowell said. ?The obvious answer is no. We are trying to take the big threat of a pandemic off the table. The best way: quickly vaccinate around the world if it?s detected. Our country has made efforts for Americans to be vaccinated. Most countries are way behind.?
Since the first reported cases in 2003, the death rate for the 387 human cases is a disturbing 63%, according to HHS? January report to Congress. Consider that the flu pandemic of 1918?which lasted until 1920 and killed from 20 million to 50 million people?had a fatality rate of just 2%. ?Despite the fact that there are a lot of influenza viruses, H5N1 is by far the leading concern for humans because we have no immunity,? Dowell said.
Stephen Redd directs the CDC?s Influenza Coordination Unit, which he said the CDC created about three years ago. While influenza has been a concern at the CDC for 50 years, preparedness is still relatively new there, according to Redd. He emphasized that if the H5N1 virus went away completely, the efforts would be appropriate for a pandemic stemming from another strain.
?There is a shared responsibility between the CDC and the assistant secretary for preparedness response,? Redd said. ?We?re working together to provide guidance to hospitals. It?s how to deliver the best care possible in circumstances of limited resources,? he said, adding that those include both material and human resources. ?There would be substantial absenteeism, and a larger number of people who need that care.? Since 2007, the CDC has conducted five preparedness-training exercises, with the last one held in the fall of 2008.
?Because a pandemic is potentially such a severe public health emergency, our preparedness work has made us more prepared for other emergencies,? Redd said. ?Those are scrutinized for lessons that could be applied in other emergencies. We can respond to hurricanes better because of preparedness for a pandemic, and better for a pandemic because of hurricane preparedness.?
At Banner Health?s 117-bed Fairbanks(Alaska) Memorial Hospital, the facility continues to consider pandemic flu as a real threat, especially as the state could be an entry point for the deadly virus. Clint Brooks, the facility?s director of emergency preparedness, safety and security, said the hospital takes a broader perspective in planning, something that the CDC?s Redd highlighted. Rather than developing a different plan for what Brooks calls the ?disease du jour,? the hospital instead plans for infectious diseases, regardless of the type. He said the federal government has ?made great strides,? and that federal funding is especially important for Fairbanks Memorial.
?The same every year?
?It?s basically been about the same every year,? Brooks said of the federal money the hospital has received for emergency-planning efforts. ?So we haven?t seen a huge cut in funding, but it makes a huge difference to the hospital to count on that funding for training and to buy equipment.? As an example, he said federal dollars help because it is difficult to ask a hospital CEO for $20,000 to be spent on masks that will sit in the basement, especially if the hospital needs something else, such as new surgical equipment.
In the CDC?s Division of Healthcare Quality Promotion, Deborah Levy works with healthcare providers and other community leaders as chief of healthcare preparedness. Levy said it is crucial to remember that healthcare delivery is not just hospitals, but also emergency medical services, urgent-care clinics, long-term, acute-care hospitals, home health providers and state health departments. She said pandemic flu is likely the scenario that would cause hospitals the most stress because of its duration and wide reach.
?We try and get communities to focus on how they would adjust and take care of patients,? Levy said. ?For hospitals, they?re used to planning by themselves, and this is trying to move them more into not thinking about their own planning, but with other hospitals and other components of their communities.?
She acknowledged, however, that such efforts for hospitals have taken a back seat lately as the nation?s economy struggles. ?It?s not just hospitals,? Levy said. ?It?s the whole system. You?ll need hospitals, but you need public health to help drive it. Public health departments?state and local?have seen their budgets shrink; hospitals, too, are struggling. You?re now having to worry about surviving and any other immediate urgent thing, but, well, ?Maybe a pandemic will happen, but I don?t know when,? ? she said, referring to concerns of hospitals. ?It?s very difficult when you have these other things staring you in the face.?
Pandemic peril
With other healthcare issues getting top priority, flu preparedness is getting short shrift. But the threat hasn?t gone away.
By Jessica Zigmond
Posted: April 6, 2009 - 5:59 am EDT
Three years ago, Congress appropriated billions of dollars to HHS for the agency?s pandemic influenza plan after animal outbreaks of the extremely pathogenic avian flu virus were discovered in a dozen countries throughout the world. Today, even though scientists say the threat of a pandemic is still very real, the nation?s interest in the issue has subsided, and HHS says it does not have the requested resources to fully implement the plan it proposed.
And that leaves the nation?s hospitals?already operating under tight budgets?not only with less funding, but also with the decision whether to expend resources preparing for a catastrophic event that might not occur for years.
At the height of interest in pandemic flu in late 2005, President George W. Bush requested a total of $7.1 billion in emergency funding for pandemic influenza preparedness activities, of which $6.7 billion was to implement the HHS Pandemic Influenza Plan. The funding was requested in fiscal 2006 to ?ensure the nation could effectively respond in the event of a pandemic,? according to a January 2009 report to Congress from HHS. Subsequently, Congress in December 2005 appropriated $3.3 billion in emergency funding to HHS for the first year of the plan and $2.3 billion for the second year of funding in June 2006.
But those big plans have not been realized. ?The full promise of the progress HHS anticipated cannot be achieved as HHS does not have the requested resources to fully implement the plan it proposed,? the report said, adding that the fiscal 2008 appropriations bill did not include the $870 million initially requested by the president to support the plan?s next phase.
In a February report on pandemic flu, the Government Accountability Office acknowledged the work of the previous presidential administration in developing a national strategy and implementation plan, but said more needs to be done. Three years ago, the GAO developed a strategy for its work to support Congress? decision-making and oversight related to pandemic flu planning. That strategy?which was built on a body of work that included reviews of other national disasters such as the 9/11 terror attacks, hurricanes Katrina and Andrew, and emerging infectious diseases such as severe acute respiratory syndrome?targets six themes: performance and accountability; leadership, authority and coordination; detecting threats and managing risks; information sharing and communication; capacity to respond and recover; and planning, training and exercise.
Since 2006, the GAO has issued 11 reports and officials testified twice at congressional hearings on influenza pandemic planning, making 23 recommendations based on its findings. Federal agencies have acted on 13 of those recommendations, but have not implemented 10.
?At the same time, however, national priorities are shifting as a pandemic has yet to occur, and the nation?s financial crisis and other national issues have become more immediate and pressing,? the report said in its opening letter to Rep. Bennie Thompson (D-Miss.), chairman of the House Committee on Homeland Security. ?Nevertheless, an influenza pandemic remains a real threat to our nation and the world.?
In addition to the federal dollars allocated specifically for pandemic flu, hospital preparedness funding from HHS? Office of the Assistant Secretary for Preparedness Response, or ASPR, is allocated to the nation?s states and territories for all hazards, according to Gregg Pane, an emergency physician who is the director of national healthcare preparedness programs at ASPR. The program began in 2002 and was coordinated by HHS? Health Resources and Services Administration before legislation in 2006 transferred the program to ASPR. When it began, the program allocated $125.1 million to states. It then jumped to $498 million in 2003 and 2004, but dipped to $470.8 million in 2005. Since then, the funding level has declined steadily to $460.2 million in 2006, $415 million in 2007, and to $398 million last year.
Shifting priorities
Roslyne Schulman, senior associate director for policy at the American Hospital Association, said as the nation?s priorities have shifted, there is great concern that federal funding for hospital preparedness could decline even more. Meanwhile, she said, hospitals continue to prepare for all types of disasters, including a pandemic, as they look for more direction on how to prepare for a surge or altered standards of care.
?Yes, hospitals are looking for more guidance, and, honestly, they look to the federal government for guidance,? Schulman said. ?By definition, a pandemic will affect many areas simultaneously ? it would be the situation where the need for care would completely overwhelm the capacity of hospitals.?
That?s why Pane said planning efforts should be shared in a community. ?We emphasize collaboration with others,? Pane said. ?The biggest problems are communication and coordination. That?s really what it?s all about.? Pane also said last year?s $398 million, which is disbursed to 62 states and territories and 4,000 hospitals, is ?not a lot of money,? something that state health departments and hospitals understand well.
Some see the funding priorities as too federally focused. ?Way too much of the money that is allocated from your tax dollars and mine goes to propping up large, federal bureaucracies like CDC,? said Jim Mackin, the public health preparedness director at the Alaska Department of Health & Social Services. ?The very large staff, the very large budget?they don?t develop plans at the local level. They?re heavily invested in the federal process? as is HHS and Office of the Assistant Secretary for Preparedness Response, he added. ?Virtually every outfit out there says: ?If we?re serious about this, we need to provide more and consistent funding to the local and state organizations doing the heavy lifting.?
While the national interest in pandemic flu has waned, scientific study of the issue has not, according to Scott Dowell, director of the global disease protection program at the Centers for Disease Control and Prevention.
?In public health, we have to deal with a relatively short attention span,? said Dowell, who added that the greatest concern for a pandemic is still H5N1, the strain known as bird flu, which has been present since 2004. Dowell worked extensively on avian flu in Thailand, where people died from the virus. ?We believe, in our judgment, that the threat is still there even though the public isn?t maintaining attention.? As Dowell explained, the H5N1 strain, which has been transmitted from animals to humans, is still not able to transmit from person to person. Now scientists are studying what will happen if the avian flu does not hit for another five to 10 years.
?Is training and equipping all that we need to be doing?? Dowell said. ?The obvious answer is no. We are trying to take the big threat of a pandemic off the table. The best way: quickly vaccinate around the world if it?s detected. Our country has made efforts for Americans to be vaccinated. Most countries are way behind.?
Since the first reported cases in 2003, the death rate for the 387 human cases is a disturbing 63%, according to HHS? January report to Congress. Consider that the flu pandemic of 1918?which lasted until 1920 and killed from 20 million to 50 million people?had a fatality rate of just 2%. ?Despite the fact that there are a lot of influenza viruses, H5N1 is by far the leading concern for humans because we have no immunity,? Dowell said.
Stephen Redd directs the CDC?s Influenza Coordination Unit, which he said the CDC created about three years ago. While influenza has been a concern at the CDC for 50 years, preparedness is still relatively new there, according to Redd. He emphasized that if the H5N1 virus went away completely, the efforts would be appropriate for a pandemic stemming from another strain.
?There is a shared responsibility between the CDC and the assistant secretary for preparedness response,? Redd said. ?We?re working together to provide guidance to hospitals. It?s how to deliver the best care possible in circumstances of limited resources,? he said, adding that those include both material and human resources. ?There would be substantial absenteeism, and a larger number of people who need that care.? Since 2007, the CDC has conducted five preparedness-training exercises, with the last one held in the fall of 2008.
?Because a pandemic is potentially such a severe public health emergency, our preparedness work has made us more prepared for other emergencies,? Redd said. ?Those are scrutinized for lessons that could be applied in other emergencies. We can respond to hurricanes better because of preparedness for a pandemic, and better for a pandemic because of hurricane preparedness.?
At Banner Health?s 117-bed Fairbanks(Alaska) Memorial Hospital, the facility continues to consider pandemic flu as a real threat, especially as the state could be an entry point for the deadly virus. Clint Brooks, the facility?s director of emergency preparedness, safety and security, said the hospital takes a broader perspective in planning, something that the CDC?s Redd highlighted. Rather than developing a different plan for what Brooks calls the ?disease du jour,? the hospital instead plans for infectious diseases, regardless of the type. He said the federal government has ?made great strides,? and that federal funding is especially important for Fairbanks Memorial.
?The same every year?
?It?s basically been about the same every year,? Brooks said of the federal money the hospital has received for emergency-planning efforts. ?So we haven?t seen a huge cut in funding, but it makes a huge difference to the hospital to count on that funding for training and to buy equipment.? As an example, he said federal dollars help because it is difficult to ask a hospital CEO for $20,000 to be spent on masks that will sit in the basement, especially if the hospital needs something else, such as new surgical equipment.
In the CDC?s Division of Healthcare Quality Promotion, Deborah Levy works with healthcare providers and other community leaders as chief of healthcare preparedness. Levy said it is crucial to remember that healthcare delivery is not just hospitals, but also emergency medical services, urgent-care clinics, long-term, acute-care hospitals, home health providers and state health departments. She said pandemic flu is likely the scenario that would cause hospitals the most stress because of its duration and wide reach.
?We try and get communities to focus on how they would adjust and take care of patients,? Levy said. ?For hospitals, they?re used to planning by themselves, and this is trying to move them more into not thinking about their own planning, but with other hospitals and other components of their communities.?
She acknowledged, however, that such efforts for hospitals have taken a back seat lately as the nation?s economy struggles. ?It?s not just hospitals,? Levy said. ?It?s the whole system. You?ll need hospitals, but you need public health to help drive it. Public health departments?state and local?have seen their budgets shrink; hospitals, too, are struggling. You?re now having to worry about surviving and any other immediate urgent thing, but, well, ?Maybe a pandemic will happen, but I don?t know when,? ? she said, referring to concerns of hospitals. ?It?s very difficult when you have these other things staring you in the face.?