Worrisome Gaps In U.S. Planning For An Avian Flu Outbreak, New Analysis

Trust for America's Health (TFAH) today released a review of US
pandemic flu plans that found many planning topics remain under-addressed and additional actions could
be taken to improve preparations and reduce the risks posed by an outbreak. Some key areas of concern
include vaccine and treatment shortfalls, gaps in containment strategies, limited plans for how to keep the
public informed, and inadequate review of state plans for quality and feasibility.


The findings are particularly troubling in light of the severity of the avian influenza virus circulating in
Asia. TFAH's analysis follows warnings issued by the Centers for Disease Control and Prevention
(CDC) and the World Health Organization (WHO) about the pandemic, "killer flu" threat. Preparations
for an outbreak of the avian or pandemic flu are the topic of a Congressional hearing being held today by
the U.S. House of Representatives Committee on Appropriations, Subcommittee on Labor, Health and
Human Services, Education, and Related Agencies.


"The threat of a pandemic flu is deadly serious. Experts worldwide are calling it inevitable," said Shelley
A. Hearne, DrPH, Executive Director of TFAH. "We're not talking about the kind of flu Americans are
used to where you bounce back after a week of bed rest. There are a number of concrete steps that the
U.S. can and should take swiftly to better protect the health and safety of Americans."


Concerns with National Pandemic Flu Planning
In August 2004, the U.S. Department of Health and Human Services (HHS) released a draft plan of U.S.
strategy to deal with a flu pandemic. The plan is the first of its kind to be released and TFAH commends
HHS for the development of this very important effort that outlines proposed collaboration among
jurisdictions and preparedness and response guidelines for federal, state, and local health officials. CDC
is also working on a federal plan to address specifics needed during a pandemic in coordination with the
HHS plan. HHS has solicited comments on the plan and has received responses from many leading
experts in the U.S. and throughout the world. Some key concerns expressed include:


-- Coordination, Details, and Funding: Lack of coordination of state, federal, and international
efforts, lack of detail about how the plan would be implemented, and limits on available funding
to carry out the plan;


-- Surge Capacity Capabilities: Limited planning based on factoring of how hospitals and the
health care system would be overwhelmed;


-- Vaccine and Treatment Limitations: A gap in determining who in the government would
control and distribute vaccine and treatments, in addition to the lack of plans to stockpile stopgap
antiviral medications and vaccines, limited planning based on the small supplies of drugs that will
be available versus the need and demand, and no focus on liability issues for vaccine makers;















-- Public Information Planning: Lack of a clear action plan for what information would be made
available to the public and on what time frame; and


-- Monitoring Outbreak and Managing Containment: Gaps exist in coordinating containment
efforts, including insufficient surveillance and tracking systems to monitor and detect outbreaks,
infected persons, vaccine supply, and the readiness of infected survivors to re-enter the
workplace.


Concerns with States' Pandemic Flu Planning


Most states are developing pandemic response plans, however, a recent report by TFAH found only
between 25-30 states have made their plans publicly available. All of the plans have yet to be evaluated
for quality and feasibility. TFAH is recommending immediate action be taken to build a strong, cohesive,
fast-tracked U.S. pandemic flu strategy. These actions are consistent with guidance from the federal
government and the WHO.


TFAH Recommendations for 10 Key Components that Should Be Included in State Pandemic Plans


-- Outbreak Tracking: Ensure adequate laboratory surveillance of influenza, including the ability
to isolate and subtype influenza viruses year round. Following federal guidelines outlined by
HHS, states must report all necessary data and information to federal and other health officials as
soon as it becomes available to federal officials.


-- Securing Back-Up Doctors and Health Care Support: Conduct and maintain an inventory of
healthcare professionals including current and retired doctors, nurses, veterinarians, emergency
medical staff, and other potential volunteers. Tracking survivors, who are presumably immune to
the virus, should be done to help support treatment and care efforts.


-- Mass Vaccination and Treatment Systems: Develop and maintain a system for tracking and
distributing antiviral medication and vaccines, once they are developed. One of the best ways to
improve vaccination preparations for a pandemic outbreak is to enhance annual flu vaccination
coverage for non-traditional high-risk groups (e.g. minorities and persons younger than 50) to
facilitate access to these populations.


-- Prioritization of Who Would Receive Antivirals and Vaccines Based on Limited Supplies:
Define high priority populations, such as health care workers, prior to an outbreak. Establish
priority for which groups should receive antiviral medications and vaccines, and in what order,
particularly since the amount of available pharmaceuticals will be limited.


-- Surge Capacity Capabilities: Account for the likelihood that hospitals would be quickly
overwhelmed, by developing auxiliary sites (such as shelters, schools, nursing homes, hotels, and
daycare centers) for surge capacity treatment and for treatment of the "walking well." States
should be conducting surveys of potential sites and obtaining agreements.


-- Measures to Manage Mass Death: Conduct and maintain an inventory of facilities with
sufficient refrigerated storage to serve as temporary morgues.


-- Public Information Campaign in Place: Identify and train spokespersons (in multiple
languages) and educate public health officials, politicians, community leaders, partners, and the
media about what information will and will not be available during a pandemic. Create
information templates (in multiple languages) that can be used on Web sites, public service
announcements, and in other materials aimed at informing the public of the best ways possible to
protect their health and safety.


-- Ensuring Food, Water, and Other Supplies will Be Available: Ensure that food, water, and
other basic supplies will be available and able to be delivered in the case of an outbreak. Factor
in potential complications of infected food and delivery workers, possible infected store facilities,
and limitations on public interaction both for those infected and the general population at-risk of
exposure. The issue of "just-in-time" manufacturing of food and supplies must also be weighed,
since reserves of supplies would not be available. Additionally, the limitations of medical
equipment manufacturing (much of which is imported from Asia) must be addressed.


-- Quarantine Measures and Authority to Close Public Places: Clear legal authority and
emergency measures in place to be able to contain the spread of disease through the prohibition of
public gatherings, closing public facilities and schools, and placing restrictions on travel at any
stage of the outbreak.


-- Defined Roles and Responsibilities: Define and agree upon leadership, roles, and
responsibilities with respect to who is in charge of a state's public health and health care
decisions. Also a clear 'chain of command,' including designation of a liaison, must be defined
to work with federal officials.


The Pandemic Potential


The avian influenza virus circulating in Asia has killed 50 individuals since its emergence in 2003 and has
spread rapidly among bird populations. Health officials are concerned that it could become more
contagious among humans and that it could remain in a strain against which humans have no natural
resistance. The "world is now in the gravest possible danger of a pandemic," according to a statement
made in February 2005 by the WHO regional director for the afflicted Western region.
In recent months, health officials and governments around the world have taken a series of steps that
demonstrate the seriousness of the potential threat:


-- In April 2005, President George W. Bush approved use of quarantine in the event of a U.S.
outbreak of "influenza caused by novel or reemergent influenza viruses that are causing, or have
the potential to cause, a pandemic," which includes, but is not limited to the H5N1 strain of avian
flu currently in Southeast Asia.


-- In April 2005, the U.S. Department of State issued a warning statement about the avian flu and
announced it is taking measures to support the WHO efforts to contain the outbreak.


-- In April 2005, CLSA Asia-Pacific Markets, the Asian investment banking arm of Crйdit Agricole
of France, estimated that the avian influenza had already cost the region $8 billion to $12 billion,
mostly from lost revenue from poultry and related industries.
-- In March 2005, in the U.S. Department of State authorization bi

ll (S.600), the U.S. Senate
proposed including $25 million for International Famine and Disaster Assistance to prevent and
respond to a possible outbreak of the avian flu and called for a task force to coordinate U.S.
policy toward combating the avian flu.


-- As of March 2005, CDC advises travelers and U.S. citizens living in countries with known avian
flu outbreaks to avoid poultry farms and contact with animals in live food markets, to ensure
poultry and eggs are thoroughly cooked before eating, and to frequently wash their hands with
soap or alcohol-based hand rubs.


-- In March 2005, the National Institutes of Health (NIH) began a trial of an experimental avian flu
vaccine.


-- In February 2005, WHO released a report that recommended nations around the world stockpile
antiviral medication to protect against the lethal current avian strain of the flu. This is
recommended as a "stopgap" measure, since it would likely take a minimum of six months to
develop a vaccine after a widespread outbreak. The amounts of both the antiviral medication and
a vaccine would be limited and countries around the world would all be seeking supplies. On
April 5, 2005, the New York Times reported on efforts different countries are taking to stockpile
Tamiflu, produced by the pharmaceutical company Roche, which is the recommended antiviral
medication for stopgap use against the avian flu. The U.S. has stockpiled approximately 2.3
million treatment courses of the drug stockpiled in comparison to Britain which has ordered 14.6
million courses, France which has ordered 13 million, and Canada which has ordered 5.4 million.
It will take several years to fill these orders.


-- In March 2004, the U.S. Department of Agriculture (USDA) placed restrictions on imports of
poultry and poultry products from Asian countries.


Trust for America's Health is a non-profit, non-partisan organization dedicated to saving lives by
protecting the health of every community and working to make disease prevention a national priority.


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