October 31st, 2007
Recent days have brought a flurry of coverage of community-based MRSA outbreaks. Methicillin-resistant Staphylococcus aureus has been a problem of long standing in the hospital setting. However, recent outbreaks in schools, and the lack of a clear explanation from officialdom for the up-tick, have clearly given new legs to what health care and public health workers know is essentially an old story.
One of the questions the MRSA cases should bring to mind for policymakers and preparedness planners, though, is the state of the underlying public health infrastructure that enables health officials to detect, contain, and treat infectious disease outbreaks and other threats to the public’s health, of both local and global origin. As has been well covered in the pages of Health Affairs, the anthrax scare of fall 2001 focused attention on a public health system infamously characterized by the 1988 IOM report as in “disarray” due to years of budgetary and political neglect. Since 2001, roughly $5 billion of federal funds has been expended to bolster key elements of preparedness capacity. The intervening years and the inevitable emergence of new, high-profile threats as seen in last year’s H5N1 avian influenza scare naturally prompt questions from policymakers and the public alike about how prepared we will be when a pathogen on the order of the devastating 1918 influenza pandemic eventually hits as predicted.
It is against such a backdrop that the Aspen Institute held its first Health Forum earlier this month in Aspen, Colorado. The goal of this important public meeting, which focused on an array of health interests, was “to help people understand what’s on the scientific horizon and how new discoveries and technologies in areas like cancer, brain science, stem cell research, aging, nutrition . . . will affect their health, their families’ health, their investments, their businesses and the global economy,” according to the institute’s magazine, the Aspen Idea. The speaker list represented many key players ranging from Nobel laureates to former U.S. Senate Majority Leader Bill Frist (R-TN) to Zeke Emanuel of the National Institutes of Health.
One of the featured sessions, titled “Pandemic Influenza Preparedness: Progress and Challenges,” was moderated by the former HHS assistant secretary for public health emergency preparedness, Stewart Simonson (now with Constella Group, LLC), and included as panelists such leading lights as Ron Atlas of the University of Louisville’s Center for Health Hazards Preparedness; David Nabarro, United Nations senior coordinator for avian and human influenza; and Margaret “Peggy” Hamburg, senior scientist of the Nuclear Threat Initiative, and former New York City health commissioner under Mayor Rudy Giuliani.
Atlas began his remarks by confirming dire predictions that “the pandemic is coming” but noted that it is unlikely to arrive in the form of the feared H5N1 viral strain of avian influenza, given the virus’s inherent inability, at present, to efficiently transmit itself from human to human. He pointed out, however, that when the big one arrives, the lag time between the development and distribution of an effective vaccine, for which there will be far more takers than doses initially, requires planners and the public to confront the difficult question of who should have priority access. Such decisions, according to Atlas, will likely be driven by the need to keep vital societal functions going. While practical, he noted that this calculus will inevitably be controversial, given that it does not put school-age children (perceived as the most vulnerable) at the front of the line. Atlas stressed the importance of effective risk communication in easing the way to societal acceptance of such difficult trade-offs.
Next, Nabarro, whose self-described job it is to “make sure that the UN system” can help the world’s population “survive the next pandemic as best it can,” discussed the critical role the UN must play by default as the only global body with the infrastructure to coordinate a global response. Part of this coordination involves not only connecting the dots between a number of siloed UN programs ranging from food distribution and humanitarian assistance to development and children’s health programs, but also moving nations away from a “sovereign” mind-set toward working collectively. He noted progress on this latter front in the form of ratification of the Revised International Health Regulations, which not only obligates signatory nations to develop the infrastructure to detect and respond to infectious disease outbreaks but also requires them to allow in international participation to contain such threats. Nabarro estimated that the global community is roughly 40 percent prepared at this point to deal with a truly pandemic threat, and that two to three more years of work will be required to deal with a threat on the order of the 1918 pandemic.
Finally, in counterpoint to Nabarro, Hamburg noted that while a pandemic is clearly a global problem, “the response ultimately is local.” One such local challenge she pointed out in preparing for a pandemic is ensuring early warning (“situational awareness”) via a public health system that, although improved, is less than robust. Equally important, though, while working locally, according to Hamburg, is monitoring events globally, given the ease and speed with which people and pathogens travel around the world in the modern era. Beyond surveillance, Hamburg, like Atlas, came back to the importance of risk communication in containing the spread of infection. People, for example, will have to be taught to avoid congregating in large groups (“social distancing”) to prevent spread. In terms of the local response to treating large numbers of sick, she noted the challenge of gearing a health system based on a “just in time” supply model to ensuring adequate medical supplies, and the reality that a large-scale epidemic will likely require moving away from the inevitably overburdened hospital setting toward a “community care” model. Also confronting policymakers and planners, according to Hamburg, will be thorny legal and ethical issues, including quarantine, compulsory vaccination, commandeering of private property, the use of unlicensed drugs and vaccines, and the disposition of corpses.
The relatively positive, collective note sounded by the panelists in pointing out progress post-2001 should hearten both policymakers and the ultimate stakeholders — the public. But therein also lies the endemic conundrum facing the public health preparedness community: that is, how best to retain public focus (and resources) without engendering unnecessary panic that, in the absence of a crisis, leads to fatigue and inattention at the wrong moment?
Useful links/related resources:
Aspen Health Forum Webcast of the Pandemic Influenza session
“Flu Terms Defined”
Draft Guidance on Allocating and Targeting Pandemic Influenza Vaccine, released 23 October 2007 (Public comments on this document are sought.)
“Projected Supply of Pandemic Influenza Vaccine Sharply Increases,” World Health Organization (WHO) press release, 23 October 2007