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Preparing for the next pandemic: Key issues facing the next administration

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March 16, 2017

Experts stress importance of community preparedness, funding, and support from the new administration

If history is bound to repeat itself, then the newly elected Trump administration will undoubtedly face a disease outbreak at a level similar to that of its predecessors.

The only two questions that public health officials have are: How bad will it be, and how prepared is the country for the next pandemic?

For Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases—who has advised five different presidents on issues pertaining to infectious disease outbreaks and testified before congressional committees approximately 250 times—the looming threat of a major disease outbreak is almost a certainty.

“History tells us we will definitely get surprised in the next few years,” he said during a keynote address at “Pandemic Preparedness in the Next Administration,” a discussion hosted by the Center for Global Health Science and Security at Georgetown University Medical Center, in partnership with the Harvard Global Health Institute. 

In a Health Affairs article published after the conference, Fauci reviewed the outbreaks that occurred under each of the last five presidents, dating back to the beginning of the HIV/AIDS epidemic under President Ronald Reagan to the modern-day concerns tied to Ebola and Zika under President Obama.

“If history has taught us anything, it is that the new administration is likely to experience at least one infectious disease crisis of significance,” he wrote. “We have learned from the past decades that it is important to have strong global surveillance systems; transparency and honest communication with the public; strong public health and healthcare infrastructure, or capacity building efforts where needed; coordinated and collaborative basic and clinical research; and the development of universal platform technologies to enable the rapid development of vaccines, diagnostics, and therapeutics. We also have learned that it is essential to have a stable and pre-established funding mechanism to utilize during public health emergencies similar to a FEMA-like emergency disaster fund.”

Other global health experts echoed his predictions and added their own concerns.

“It’s quite reasonable we’ll see a large-scale pandemic in our lifetime,” said Rebecca Katz, co-director of the Center for Global Health Science and Security at Georgetown University Medical Center, during the event, underscoring the progress made at the local level to strengthen preparedness and integrate data to improve decision-making.

But Ashish Jha, MD, MPH, director of the Harvard Global Health Institute and K.T. Li professor of health policy at the Harvard T.H. Chan School of Public Health, argued that as a country, the U.S. is still largely unprepared for an infectious outbreak, even after recent scares associated with Zika and Ebola.

“I would argue—still today—in many ways we are not ready for the next big pandemic, which is going to come at some point,” Jha said during opening remarks. “So, the question is how do we get ready? How do we help our government play a more efficient role in preparing the American public and the globe in preventing the next big pandemic?”

For many, the answer boils down to the approach initiated by the country’s incoming administration, the funding mechanisms associated with pandemic response and—perhaps more importantly—the efforts initiated at the community level.

The new administration’s perspective

As with any transition between presidential administrations, there are bound to be some policy changes that can trickle down to the public health sector and impact preparedness efforts.

But several former high level public health officials have expressed concern about President Donald Trump’s foreign policy stance, particularly his isolationist rhetoric that they say doesn’t bode well for global health initiatives or pandemic preparedness in general. 

During the Ebola outbreak in 2014, Trump roundly criticized the Obama administration on Twitter for allowing infected clinicians that were treating Ebola patients overseas to return to the U.S. for treatment. Trump called President Obama a “psycho” and “incompetent” for not stopping incoming flights from West Africa.

“The U.S. cannot allow EBOLA infected people back. People that go to faraway places to help out are great—but must suffer the consequences!” Trump tweeted.

Experts say this perspective does not align with the response necessary to combat a large-scale pandemic.

“The idea that somehow the United States can cut itself off from the rest of the world; that we can build a wall—physically or metaphorically—high enough to keep out pathogens, to keep out disease, to protect the American people from disease, and that would make the world a safer place, is so badly misguided,” said Ronald Klain, the former Ebola response coordinator for the Obama Administration at the Georgetown conference.

“There is no isolationist policy that will protect us from disease,” he added.

Former CDC director Tom Frieden, MD, has also highlighted the importance of preparing for a disease outbreak, telling the Washington Post that his biggest fear has always been an influenza pandemic. He added that making the necessary investments in global health and pandemic preparedness is a long-held presidential tradition.

“The Bush administration made important investments in public health, global public health, and in influenza preparedness, and in the Obama administration, we have built on those,” he said. “It’s a baton that gets passed. Preparedness is really important.”

Global policies have significant sway when it comes to addressing pandemic preparedness on a broader level. In a recent study published in The BMJ, researchers found a “remarkable consensus” regarding what went wrong during the Ebola response, but very little has been done to close those gaps.

“Ebola, and more recently Zika and Yellow Fever, have demonstrated that we do not yet have a reliable or robust global system for preventing, detecting, and responding to disease outbreaks,” the authors wrote.

Almost unanimously, researchers and public health officials have also called for lawmakers to change the way the government funds pandemic response efforts. The government can pull from an emergency fund when a devastating natural disaster hits, but no such fund exists for a disease outbreak. This issue was brought to public light during the Zika outbreak last summer, when Congress ultimately agreed to release $1.1 billion in funding after a significant delay.

“We all know that’s a terrible way to do business and that does not leave us in a very safe place,” said Amy Pope, the former deputy homeland security advisor and deputy assistant to the president on the National Security Council during a panel discussion.

GAO outlines federal preparedness gaps

Two recent reports released by the Government Accountability Office (GAO) have addressed gaps in federal pandemic preparedness activities.

The first (www.gao.gov/assets/690/681962.pdf), released in January, addressed federal personnel reassignment and called for improved coordination between federal agencies tasked with authorizing that reassignment during emergencies. The Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA), authorizes the Department of Health and Human Services (HHS) to reassign personnel in all states, but officials at HHS were “generally unaware of the reassignment authority.” Officials at the Office of the Assistant Secretary for Preparedness and Response (ASPR) told GAO that they did not conduct targeted outreach to HHS agencies to inform them of the reassignment process or requirements.

The GAO recommended that ASPR conduct outreach to HHS agencies, including expected time frames for approving reassignment requests, and develop a plan to evaluate after-action reports from states.

“Conducting outreach to HHS agencies and offices on ASPR’s reassignment requests, review processes, and time frames would be consistent with federal internal control standards for information and communication, and would improve HHS agencies’ and offices’ awareness of expected roles, thereby preventing potential delays in decision making in the event of a public health emergency,” the GAO wrote.

The second report (www.gao.gov/products/GAO-17-150), published in February, addressed existing coordination mechanisms between the Department of Defense (DOD), HHS, and the Department of Homeland Security (DHS). The GAO determined that HHS and DHS “have plans to guide their response to a pandemic, but their plans do not explain how they would respond in a resource-constrained environment in which capabilities like those provided by DOD are limited.”

The agency noted that each agency has mechanisms in place to respond to a pandemic, but all three could improve coordination efforts with one another when resources are limited, particularly as HHS and DHS are updating existing plans.

Community coalitions are the future

Although hospitals, public health officials, and emergency preparedness experts can draw on lessons learned from previous outbreaks like Ebola, Zika, and H1N1, the fact that no two diseases are alike makes it difficult to plan for the next pandemic. It’s hard to know how to respond when no one knows what the disease will do and how it will travel between populations.

“There’s no playbook that fits the emerging infectious disease outbreak,” Pope said.

She and Jha highlighted the efforts of community coalitions, which have emerged as a critical emergency preparedness approach over the last several years. Those coalitions have made a noticeable impact during disasters such as the Boston Marathon bombing, the train derailment in Philadelphia, and the Orlando nightclub shooting.

“That’s the model for the future,” she said. “Using this vast healthcare system, that is in some cases very well-funded, and figuring out how to tap into those resources so we’re not using one individual local hospital to be our barrier against whatever is coming next in the U.S.”

The ASPR has repeatedly highlighted the benefits of community coalitions when responding to disasters of any kind.

That kind of community planning will be particularly beneficial for hospitals creating pandemic response plans that can adequately handle a potential surge of infected patients, Klain said.

“We don’t need 20 hospitals in Houston to be ready to deal with Ebola or infectious disease, but we do need one,” he said. “Figuring out what that one hospital is, how well it’s prepared, how people are drilling, and how people are funneled throughout the community are important things.”

 

Which states are the most prepared for a pandemic?

A recent report from Trust for America’s Health (TFAH) found that state preparedness for diseases, disasters, and bioterrorism varies widely across the country. As a whole, however, states are “often caught off guard when a new threat arises,” such as Zika or Ebola.

Twenty-six states and Washington D.C. scored a six or lower on 10 indicators of public health preparedness, according to the report. In a press call announcing the report, Rich Hamburg, interim president and CEO at TFAH, described an inconsistent approach to emergency response in which state governments are forced to quickly respond to an incident, but then just as quickly move on once the event is over.

“We aren’t adequately maintaining a strong and steady defense and the result is we consistently see health emergencies disrupting, derailing and diverting resources from other ongoing priorities and efforts from across government, in addition to leaving Americans at unnecessary risk,” he said.

Hamburg also noted that states have faced heavy funding cuts over the past 15 years, from $940 million in fiscal year (FY) 2002 to $660 million in FY 2016. This, coupled with a lack of biosurveillance and insufficient research and development for new vaccines, has left some states woefully underprepared.

Among the recommendations issued by TFAH was the need for more involvement from federal leadership—including the White House—a more stable source of funding, emphasizing local coalitions and prioritizing vaccination among children and adults.

The most-prepared states:

  • Massachusetts
  • Washington
  • North Carolina
  • California
  • Connecticut
  • Iowa
  • New Jersey
  • Tennessee
  • Virginia

The least prepared states:

  • Alaska
  • Idaho
  • Nevada
  • Wyoming



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