The measurable level of national planning and preparedness for a serious pandemic threat or biological attack continues to be a subject of great discussion, debate, and concern in the United States and around the world. This level of readiness continues to be a challenge as identified in regular studies, reports, and articles.
A review of the valuable daily and weekly collection of articles and reports from UPMC Center for Health Security, Global Biodefense, ProMED, and other valuable information sharing organizations provides additional evidence of the emerging and re-emerging global health threats and many areas for improvement. As these public health threats expand in an exceptionally globalized world of rapid trade and travel, the level of preparedness becomes even more critical and essential. Unfortunately, a review of the public health headlines and findings each day often does not provide a great deal of comfort.
Beyond negative reports, and at times overly dramatized articles, there continues to be legitimate reasons for concern for lessons do not appear to be learned and recommendations are often shelved with the completion of a strategy or report. Even though it appears that the Zika virus has replaced the Ebola virus as the public health threat du jour, a novel highly pathogenic influenza may be the next severe global health security crisis that the communities are not fully prepared for even with existing strategies and plans.
Departmental Pandemic Planning
The existence of strategies and plans does not always translate into successful and maintained planning and preparedness. In August 2014, the Department of Homeland Security (DHS) Office of Inspector General (OIG) issued a report entitled “DHS Has Not Effectively Managed Pandemic Personal Protective Equipment and Antiviral Medical Countermeasures” (OIG-14-129). The audit reviewed the internal preparedness of DHS and its components to continue their mission essential functions during a pandemic threat. DHS OIG found that:
DHS did not adequately conduct a needs assessment prior to purchasing pandemic preparedness supplies and then did not effectively manage its stockpile of pandemic personal protective equipment and antiviral medical countermeasures. Specifically, it did not have clear and documented methodologies to determine the types and quantities of personal protective equipment and antiviral medical countermeasures it purchased for workforce protection. The Department also did not develop and implement stockpile replenishment plans, sufficient inventory controls to monitor stockpiles, adequate contract oversight processes, or ensure compliance with Department guidelines. As a result, the Department has no assurance it has sufficient personal protective equipment and antiviral medical countermeasures for a pandemic response. In addition, we identified concerns related to the oversight of antibiotic medical countermeasures.
DHS OIG made 11 recommendations to improve the efficiency and effectiveness of the department’s pandemic preparations for which DHS concurred with the intent of all of them.
In January 2016, DHS OIG released an audit report regarding the department’s response to the 2014 Ebola virus outbreak. The audit found that DHS components did not ensure that all personnel received adequate training on the passenger screening process or the use of certain protective equipment. The report identified 10 recommendations for the department and its components.
In October 2016, DHS OIG released a follow-up report, entitled “DHS Pandemic Planning Needs Better Oversight, Training, and Execution,” OIG-17-02). The report identified progress in planning and preparedness from the 2014 audit, but stated that DHS cannot be assured that its preparedness plans can be executed effectively during a pandemic event. The 2016 audit found:
- Components’ pandemic plans did not meet all department requirements;
- DHS pandemic personal protective equipment planning guidance and oversight needs improvement; and
- DHS pandemic reporting and exercising requirements need additional oversight.
This 2016 DHS OIG report identified seven recommendations to improve oversight, readiness, timeframes, training, and exercises. These audits regarding the preparedness of a major federal department bring into question the status and relevancy of previous comprehensive national strategies for pandemic preparedness and the progress truly achieved and maintained after many different global public health threats.
Broader Pandemic Strategy & Planning
There have been numerous essential national strategies, plans, and policies issued in the past decade, many to address the most recent outbreaks or evolving public health concerns. Two of the most notable and foundational documents may be the “National Strategy for Pandemic Influenza” (2005) and “National Strategy for Pandemic Influenza – Implementation Plan” (2006). These documents are important due to their broad focus and wide inclusion of international, federal, state, tribal, local, and private sector partners for a threat that is likely to have the greatest global impact.
The Implementation Plan identified more than 300 critical actions and requirements to address the threat of pandemic influenza. It is unknown how many of these actions and expectations continue to be priorities and implemented at this time. Many of the actions have been re-identified in subsequent strategies, policies, plans, and after action reports for the emerging and evolving pathogens since 2006. However, a review of many after action reports, studies, and hearings indicates that there remains significant room for improvement in planning and preparedness.
Beyond what has been identified in the previous DHS OIG audits for one department, there are various critical actions that merit review and discussion for the entire nation. In Chapter 8 of the Implementation Plan, entitled “Law Enforcement, Public Safety and Security,” the following was stressed:
If a pandemic influenza outbreak occurs in the United States, it is essential that governmental entities at all levels continue to provide essential public safety services and maintain public order. It is critical that all stakeholders in State and local law enforcement and public safety agencies, whose primary responsibility this is, be fully prepared to support public health efforts and to address the additional challenges they may face during such an outbreak. Federal law enforcement and military officials should be prepared to assist in a lawful and appropriate manner, and all involved should be familiar with the established protocols for seeking such assistance and have validated plans to provide that assistance.
To support this priority, there are specific actions, with numerous sub-actions, that require a candid assessment of the status and readiness for a serious pandemic threat such as:
- 8.1.1. Develop federal implementation plans on law enforcement and public safety, to include all components of the federal government and to address the full range of consequences of a pandemic, including human and animal health, security, transportation, economic, trade, and infrastructure considerations. Ensure appropriate coordination with state, local, and tribal governments.
- 8.1.2. Continue to work with states, localities, and tribal entities to establish and exercise pandemic response plans.
- 8.1.3. Provide guidance to individuals on infection control behaviors they should adopt prepandemic, and the specific actions they will need to take during a severe influenza season or pandemic, such as self-isolation and protection of others if they themselves contract influenza.
- 8.1.4. Develop credible countermeasure distribution mechanisms for vaccine and antiviral agents prior to and during a pandemic.
- 8.3.1. Encourage all levels of government, domestically and globally, to take appropriate and lawful action to contain an outbreak within the borders of their community, province, state, or nation.
- 8.3.2. Determine the spectrum of infrastructure-sustainment activities that the U.S. military and other government entities may be able to support during a pandemic, contingent upon primary mission requirements, and develop mechanisms to activate them.
In other areas of the Implementation Plan, critical actions and requirements, with numerous sub-actions, are identified for critical infrastructure, border control, containment, quarantine, and isolation responsibilities:
- 4.1.7. Develop credible countermeasure distribution mechanisms for vaccine and antiviral agents prior to and during a pandemic.
- 4.2.5. Develop and exercise mechanisms to provide active and passive surveillance during an outbreak, both within and beyond our borders.
- 4.2.7. Develop screening and monitoring mechanisms and agreements to appropriately control the movement and shipping of potentially contaminated products to and from affected regions if necessary, and to protect unaffected populations.
- 4.3.1. Work to develop a coalition of strong partners to coordinate actions to limit the spread of a virus with pandemic potential beyond the location where it is first recognized abroad in order to protect U.S. interests.
- 4.3.2. Where appropriate, use governmental authorities to limit movement of people, goods, and services into and out of areas where an outbreak occurs.
- 5.3.1. Encourage all levels of government, domestically and globally, to take appropriate and lawful action to contain an outbreak within the borders of their community, province, state, or nation.
- 5.3.2. Where appropriate, use governmental authorities to limit non-essential movement of people, goods, and services into and out of areas where an outbreak occurs.
- 5.3.4. Provide guidance to activate contingency plans to ensure that personnel are protected, that the delivery of essential goods and services is maintained, and that sectors remain functional despite significant and sustained worker absenteeism.
- 6.1.13. Develop credible countermeasure distribution mechanisms for vaccine and antiviral agents prior to and during a pandemic.
- 6.3.1. Encourage all levels of government, domestically and globally, to take appropriate and lawful action to contain an outbreak within the borders of their community, province, state, or nation.
- 6.3.2. Provide guidance, including decision criteria and tools, to all levels of government on the range of options for infection control and containment, including those circumstances where social distancing measures, limitations on gatherings, or quarantine authority may be an appropriate public health intervention.
The few actions listed above demonstrate the enormous undertaking for the public sector to plan and prepare for a highly pathogenic pandemic influenza or other significant public health threat. It is unknown when all of these actions were last fully reviewed and evaluated by the identified and responsible departments, agencies, and organizations. It is an extremely important question to have answered. Fortunately, nongovernmental organizations and other private sector partners continue to support and fund the planning and preparedness for epidemics and pandemics.
Private Sector Collaboration
In August 2016, the Coalition for Epidemic Preparedness Innovations (CEPI) was founded in the United Kingdom at the Wellcome Trust Headquarters. CEPI is collaboration between the Wellcome Trust, the Bill and Melinda Gates Foundation, the World Economic Forum, and the government of Norway to prepare the world for future outbreaks of disease.
In September 2016, the Blue Ribbon Study Panel on Biodefense announced that it received over a million dollar grant from the Open Philanthropy Project to continue assessing the nation’s biodefense systems, issuing recommendations and advocating for their implementation, and informing policymakers and lawmakers on viable avenues for needed change. In the same month, Mark Zuckerberg and his wife Priscilla Chan announced that they planned to invest at least three billion dollars in the Chan Zuckerberg Initiative over the next decade to focus on preventing, curing, and managing all diseases by the end of the century.
In October 2016, the Trust for America’s Health released the “Blueprint for a Healthier America 2016: Policy Priorities for the Next Administration and Congress.” The report identified key strategies for improving the health of Americans through a new approach to health by prioritizing improving health and addressing major epidemics in the United States.
Although not a truly private sector organization, the World Bank created the Pandemic Emergency Financing Facility to provide funds during outbreaks of specific infectious diseases to become more actively engaged in pandemic preparedness and response.
An Honest Assessment
The involvement of influential private foundations, initiatives, and organizations is essential for this monumental planning and preparedness tasking. They are crucial partners for success and leadership. However, the need for thoughtful, continued, and consistent planning by governmental organizations is just as important for emerging public health and biosecurity threats.
Although dated, the Pandemic Influenza Strategy and its Implementation Plan are two of the strongest frameworks for evaluating the current whole of community preparedness when used to make an honest assessment. The subsequent strategies and plans over the past decade have addressed the most recent specific pathogenic concerns, but they often are quite focused in topic and very frequently forgotten upon the arrival of the next emergence or international incident. There continues to be a necessity for an expansive, inclusive, and implemented strategy for all pandemic threats because a novel highly pathogenic influenza may be the next serious global public health crisis that the nation is not ready for – with massive catastrophic consequences. To be better prepared, these are two critical documents to review, assess, and absolutely update in 2017.