With the world’s many evolving and emerging threats, infectious pathogens continue to be an important area for domestic and international identification and monitoring. It is an international concern that requires continuous domestic focus, evaluation, and collaboration. The Middle Eastern Respiratory Syndrome (MERS) and H7N9 virus continue to expand their presence in animals and humans, requiring a high level of planning and preparedness. The evolution, resistance, and expansion that many virus strains have shown over the past few years have become a considerable challenge for planners and their operational partners:
- Reuters reported on 10 December 2013 that the H7N9 virus has a mutation that is resistant to Tamiflu, one of the few first-line treatment drugs;
- The University of Minnesota’s Center for Infectious Disease Research and Policy (CIDRAP) reported on 17 December 2013 that the H5N1 avian influenza has resulted in a mortality rate of 59 percent;
- Rarely encountered viruses, such as the H10N8, H5N2, H9N2, and H6N1 influenzas, are diagnosed in humans causing illness and sometimes death; and
- In December 2013, Caribbean public health officials discovered the first locally acquired case of the exotic African and Asian mosquito-borne virus Chikungunya, which was especially significant as the peak tourist season had just begun.
Only time will tell if these pathogens are emerging threats that are occurring more often, or if the nation is becoming more efficient at epidemiological surveillance, identification, and subsequent information sharing. Either way, robust and thoughtful preparedness must remain a priority.
Goals, Challenges & Findings
For those in the public health and homeland security planning and preparedness fields, it is difficult to estimate or forecast the next emerging or re-emerging epidemic or pandemic threat. However, it may be even more difficult to generate and maintain interest in these pathogenic threats when diverse and conflicting priorities exist. With so many other homeland security challenges confronting the nation each day, these distant, low-probability public health threats may not be a preparedness priority for some public health and homeland security professionals. However, there still are many achievements, lessons learned, and identified areas for improvement that these professionals can review and evaluate to assess preparedness levels and priorities.
A U.S. Department of Health and Human Services (HHS) Office of the Inspector General issued a report in 2009 that identified three findings for local pandemic preparedness regarding vaccine and antiviral drug distribution and dispensing:
- Selected localities had not addressed in their planning documents most of the vaccine and antiviral drug distribution and dispensing components and preparedness items identified in HHS pandemic influenza guidance.
- All selected localities conducted exercises related to vaccine and antiviral drug distribution and dispensing; however, most did not create after-action reports and improvement plans for these exercises.
- All selected localities collaborated with community partners to develop and exercise their plans to distribute and dispense vaccines and antiviral drugs during an influenza pandemic.
Through HHS, the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) is the coordinating body for federal agencies in charge of protecting the civilian population from potential adverse health impacts using medical countermeasures and coordination with its state, local, and tribal partners. Since the release of the 2007 PHEMCE Strategy and Implementation Plan, the nation has progressed in the development and stockpiling of medical countermeasures for emergency use. The updated 2012 PHEMCE Strategy established the following national strategic goals for the next five years:
- Identify, create, develop, manufacture, and procure critical medical countermeasures;
- Establish and communicate clear regulatory pathways to facilitate medical countermeasure development and use;
- Develop logistics and operational plans for optimized use of medical countermeasures at all levels of response; and
- Address medical countermeasure gaps for all sectors of the U.S. civilian population.
In addition to these examples of governmental guidance and assessments, private organizations also have recently conducted informative preparedness studies. A 2013 report by the Trust for America’s Health and Robert Wood Johnson Foundation found that the national ability to prevent and control infectious diseases was hampered by limited resources and outdated systems. The report provided recommendations to address gaps in areas such as infection control and emerging global illnesses. Many of these recommendations and issues are not new, but continue to require review and contemplation.
Preparedness, Planning & Progress
Of course, not all of the preparedness studies and reports are negative. The Center for Infectious Disease Research and Policy at the University of Minnesota reported progress in public health preparedness in late 2013. After a two-year effort to gather and analyze existing state-level data from a wide range of sources, a consortium of 25 public and private public health organizations awarded the nation an overall health-security preparedness score of 7.2 on a scale of 10, using 128 variables or measures. The study found strengths in health surveillance, incident and information management, and countermeasure management, in addition to areas for improvement, such as surge management and community planning and engagement.
The level of planning and preparedness for a potential novel viral public health threat or pandemic varies from report to report, but the most important consideration may be how truly prepared the nation would be for an actual large-scale incident. An exercise or assessment using current strategies, plans, and policies is based on the existing framework or recent past experiences – after-action reports and lessons learned. Difficult and probing queries stemming from the above listed pathogenic developments may identify weaknesses within current plans and exercises, which will strengthen subsequent strategic plans and discourse.
From the information listed above, HHS and surveyed jurisdictions have plans and procedures for establishing points of distribution for medical countermeasures from the Strategic National Stockpile and other established sources. This preplanning is shrewd and crucial, but it may not be deep enough for the unexpected challenges and consequences. A more-detailed assessment of security plans and procedures for safeguarding supplies and personnel during each response stage may require additional consideration and exercising by planners and responders.
Law Enforcement, Identification & Prevention
One example may be the guidance and training for law enforcement and public health officials to control access and use force, which may be necessary during times of noncompliance. Although this is a specific point, existing plans and procedures may not adequately consider the realistic loss of security and law enforcement resources – due to the worried-well, illness, or other absenteeism – for quarantine enforcement or distribution of medical countermeasures.
Plans and exercises also may not fully account for the enforcement actions during screening or medical countermeasures distribution, which may require existing personnel to execute other exigent duties and assignments – for example, expanded security, arrest processing, injured personnel, crowd control, or other defensive measures – to maintain control of the process and resources. These unanticipated duties can quickly exhaust limited personnel and require the deployment of precious resources from other assignments.
Controlling access to stores during Black Friday holiday sales can result in the loss of simple civil behavior. However, controlling access to limited and valuable medical supplies during a public health scare, when information may be inconsistent or conflicting, would likely present a greater challenge.
The Severe Acute Respiratory Syndrome (SARS) outbreak of 2003 in North America demonstrated that a domestic medical facility or laboratory – rather than an international border screening inspection – may identify and interdict an emerging public health concern. The interior identification of a public health threat greatly expands the number of jurisdictions that need to seriously and continually assess their intentions and capabilities. The unpredictability of a public health threat may greatly constrict the preparation and notification timeframe. Commonly agreed upon and well-understood plans, procedures, and training will need to evolve – with the potential threats – over time.
On 16 December 2013, the Centers for Disease Control and Prevention included the top five threats for 2014. Two of those threats – emergence and spread of new microbes, and globalization of travel – are major causes for spreading illnesses. With regular reports of common and unique pathogens evolving, emerging, or re-emerging around the world, there may not be time to adequately prepare for a threat once it expands or explodes. A previously successful tabletop exercise or comprehensive plan may not be enough to effectively oversee or support the distribution of medical countermeasures or other critical actions if a serious illness outbreak were to occur next week. Many public and private organizations have demonstrated impressive progress in recent years, but so have many of the pathogenic threats.
The opinions expressed herein are solely those of the author in his individual capacity, and do not necessarily represent the views of his agency, department or the U.S. government.