Mass vaccination for the 2009 H1N1 pandemic: approaches, challenges, and recommendations

The 2009 H1N1 pandemic stimulated a nationwide response that included a mass vaccination effort coordinated at the federal, state, and local levels. This article examines a sampling of state and local efforts during the pandemic in order to better prepare for future public health emergencies involving mass distribution, dispensing, and administration of medical countermeasures. In this analysis, the authors interviewed national, state, and local leaders to gain a better understanding of the accomplishments and challenges of H1N1 vaccination programs during the 2009-10 influenza season. State and local health departments distributed and administered H1N1 vaccine using a combination of public and private efforts. Challenges encountered during the vaccination campaign included the supply of and demand for vaccine, prioritization strategies, and local logistics. To improve the response capabilities to deal with infectious disease emergencies, the authors recommend investing in technologies that will assure a more timely availability of the needed quantities of vaccine, developing local public health capacity and relationships with healthcare providers, and enhancing federal support of state and local activities. The authors support in principle the CDC recommendation to vaccinate annually all Americans over 6 months of age against seasonal influenza to establish a standard of practice on which to expand the ability to vaccinate during a pandemic. However, expanding seasonal influenza vaccination efforts will be an expensive and long-term investment that will need to be weighed against anticipated benefits and other public health needs. Such investments in public health infrastructure could be important for building capacity and practice for distributing, dispensing, and administering countermeasures in response to a future pandemic or biological weapons attack.     

Climate change and local public health in the United States: preparedness, programs and perceptions of local public health department directors

While climate change is inherently a global problem, its public health impacts will be experienced most acutely at the local and regional level, with some jurisdictions likely to be more burdened than others. The public health infrastructure in the U.S. is organized largely as an interlocking set of public agencies at the federal, state and local level, with lead responsibility for each city or county often residing at the local level. To understand how directors of local public health departments view and are responding to climate change as a public health issue, we conducted a telephone survey with 133 randomly selected local health department directors, representing a 61% response rate. A majority of respondents perceived climate change to be a problem in their jurisdiction, a problem they viewed as likely to become more common or severe over the next 20 years. Only a small minority of respondents, however, had yet made climate change adaptation or prevention a top priority for their health department. This discrepancy between problem recognition and programmatic responses may be due, in part, to several factors: most respondents felt personnel in their health department--and other key stakeholders in their community--had a lack of knowledge about climate change; relatively few respondents felt their own health department, their state health department, or the Centers for Disease Control and Prevention had the necessary expertise to help them create an effective mitigation or adaptation plan for their jurisdiction; and most respondents felt that their health department needed additional funding, staff and staff training to respond effectively to climate change. These data make clear that climate change adaptation and prevention are not currently major activities at most health departments, and that most, if not all, local health departments will require assistance in making this transition. We conclude by making the case that, through their words and actions, local health departments and their staff can and should play a role in alerting members of their community about the prospect of public health impacts from climate change in their jurisdiction.     

The key to enabling biosurveillance is cooperative technology development

The world population will continue to face biological threats, whether they are naturally occurring or intentional events. The speed with which diseases can emerge and spread presents serious challenges, because the impact on public health, the economy, and development can be huge. The U.S. government recognizes that global public health can also have an impact on national security. This global perspective manifests itself in U.S. policy documents that clearly articulate the importance of biosurveillance in providing early warning, detection, and situational awareness of infectious disease threats in order to mount a rapid response and save lives. In this commentary, we suggest that early recognition of infectious disease threats, whether naturally occurring or man-made, requires a globally distributed array of interoperable hardware and software fielded in sufficient numbers to create a network of linked collection nodes. We argue that achievement of this end state will require a degree of cooperation that does not exist at this time-either across the U.S. federal government or among our global partners. Successful fielding of a family of interoperable technologies will require interagency research, development, and purchase ("acquisition") of biosurveillance systems through cooperative ventures that likely will involve our strategic allies and public-private partnerships. To this end, we propose leveraging an existing federal interagency group to integrate the acquisition of technologies to enable global biosurveillance.     

Assessing a decade of public health preparedness: progress on the precipice?

September 11 and the subsequent anthrax attacks marked the beginning of significant investment by the federal government to develop a national public health emergency response capability. Recognizing the importance of the public health sector's contribution to the burgeoning homeland security enterprise, this investment was intended to convey a "dual benefit" by strengthening the overall public health infrastructure while building preparedness capabilities. In many instances, federal funds were used successfully for preparedness activities. For example, electronic health information networks, a Strategic National Stockpile, and increased interagency cooperation have all contributed to creating a more robust and prepared enterprise. Additionally, the knowledge of rarely seen or forgotten pathogens has been regenerated through newly established public health learning consortia, which, too, have strengthened relationships between the practice and academic communities. Balancing traditional public health roles with new preparedness responsibilities heightened public health's visibility, but it also presented significant complexities, including expanded lines of reporting and unremitting inflows of new guidance documents. Currently, a rapidly diminishing public health infrastructure at the state and local levels as a result of federal budget cuts and a poor economy serve as significant barriers to sustaining these nascent federal public health preparedness efforts. Sustaining these improvements will require enhanced coordination, collaboration, and planning across the homeland security enterprise; an infusion of innovation and leadership; and sustained transformative investment for governmental public health.     

The route to a national health policy lies through the states.

National health program legislation has been becalmed in the Congress for almost 80 years. Despite periodic cries of "crisis," legislation never emerges from committee. Periodically, campaigns have been mounted without success. Tactical efforts to circumvent direct action by legislating bits and pieces of related programs, Medicare and Medicaid, health maintenance organization support, and pre-budgeting, have complicated operation of the medical care system and stimulated intractable cost inflation. For the first 150 years of American history, responsibility for public health and welfare legislation rested with the states. Most public health policies originated in a state or a few states and then later became national legislation. The state efforts were, in effect, natural experiments. After the Depression and the flood of funding from the federal government in subsequent years, the states faded as innovators. It is proposed that funding a few state models to restimulate state initiative in this regard will provide a more effective route to a national health program.     

Disease intervention specialists as a resource in a public health emergency

With the current shortage of qualified staff at state and local public health departments, a flexible public health workforce could fill critical gaps in staffing. Disease intervention specialists (DISs) are public health outreach workers who are responsible for finding and counseling people with sexually transmitted diseases and their contacts. DIS skills and job duties parallel those that would be needed to respond quickly and efficiently to urgent public health problems, including bioterrorism. Including DISs in public health preparedness planning could be a practical way of providing surge capacity for departments of public health. In many states, DISs are already being used for functions that fall outside their traditional duties. However, planning and DIS training are essential for effective utilization of DIS skills in a public health emergency. North Carolina has included DISs in their bioterrorism response plans and currently deploys them on an as-needed basis for nonroutine activities.     

Legal and regulatory concerns about transgenic plants in Brazil

Brazil has a biosafety law that was approved in 1995. This law provides for a horizontal type of regulation that coordinates other existing regulatory frameworks in the areas of agriculture, health and environment. Various federal government departments are responsible for implementing the law. The National Technical Biosafety Commission is the national competent authority on biosafety with overall responsibility. In the case of Bt plants or any insecticidal organism, the Agrochemical Law also applies and authorization for laboratory, greenhouse and field studies must be obtained from the Plant Protection Secretariat, the Brazilian Institute of Environment and the National Agency of Health. Furthermore, the National Environmental Council must issue a license for commercialization of any GMO. There is pressure needed for capacity building and to harmonize the regulatory and administrative frameworks among the different federal departments involved. Some perspectives and challenges for the commercial registration of transgenic crops are discussed.     

Human mobility and population health. New approaches in a globalizing world

The globalization of economies in the last 25 years has greatly increased both the number of people on the move and the rapidity of their movement, and has brought attention to global disparities in health determinants and to the health of migrant populations themselves. Differences in epidemiological disease risk (prevalence gaps) may have negative, neutral, or positive health consequences for the migrant or receiving population. Population mobility represents a growing challenge to the development of public health programs and legislative policies to prevent the importation of disease, and to promote and protect the health of migrants and the local, receiving population. The inability to detect and contain imported disease threats at national borders requires a shift in immigration, quarantine, and public health approaches to health and mobile populations. A new paradigm is needed to facilitate the development of policies and programs to address the health consequences of population mobility.     

Doodle-Do Board

The field of dance arts education in the United States is in an entirely different place today than it was at the turn of the century. Much of this change is due to a convergence of events that involved: federal and state legislation, policy, and funding that supported dance in arts education; a forty-year transition of dance out of departments of physical education into the colleges of fine and performing arts; and the establishment of the National Dance Education Organization, which provided infrastructure (standards, assessments, research, certification, teacher training, professional development, and programs and services) that was needed to support dance taught as an art form. This infrastructure has become an integral component to building, nurturing, and sustaining strong arts-based programs over the years at local, state, or national levels.     

MENTAL HEALTH PROGRAMS—The Role of the Health Officer

Traditionally the treatment of mental illness has been a responsibility of state governments, but they have been unable to solve the problem with any degree of success.In spite of rationalizations as to why a health department should not become involved in this field, more and more local health departments in California and across the nation are initiating various services in mental health.With the widespread interest in mental health at national and state levels and in local citizens'' groups, local health officers must involve themselves in this most difficult effort.While the treatment of the emotionally disturbed and the psychotic is demanded most aggressively by the public which seeks outpatient, inpatient, and rehabilitation services on the local level, two services—consultation and education-information services—offer more hope in the promotion of mental health as contrasted with the treatment of mental illness.     

Advancing a Framework to Enable Characterization and Evaluation of Data Streams Useful for Biosurveillance

In recent years, biosurveillance has become the buzzword under which a diverse set of ideas and activities regarding detecting and mitigating biological threats are incorporated depending on context and perspective. Increasingly, biosurveillance practice has become global and interdisciplinary, requiring information and resources across public health, One Health, and biothreat domains. Even within the scope of infectious disease surveillance, multiple systems, data sources, and tools are used with varying and often unknown effectiveness. Evaluating the impact and utility of state-of-the-art biosurveillance is, in part, confounded by the complexity of the systems and the information derived from them. We present a novel approach conceptualizing biosurveillance from the perspective of the fundamental data streams that have been or could be used for biosurveillance and to systematically structure a framework that can be universally applicable for use in evaluating and understanding a wide range of biosurveillance activities. Moreover, the Biosurveillance Data Stream Framework and associated definitions are proposed as a starting point to facilitate the development of a standardized lexicon for biosurveillance and characterization of currently used and newly emerging data streams. Criteria for building the data stream framework were developed from an examination of the literature, analysis of information on operational infectious disease biosurveillance systems, and consultation with experts in the area of biosurveillance. To demonstrate utility, the framework and definitions were used as the basis for a schema of a relational database for biosurveillance resources and in the development and use of a decision support tool for data stream evaluation.     

A space-time permutation scan statistic for disease outbreak detection

BackgroundThe ability to detect disease outbreaks early is important in order to minimize morbidity and mortality through timely implementation of disease prevention and control measures. Many national, state, and local health departments are launching disease surveillance systems with daily analyses of hospital emergency department visits, ambulance dispatch calls, or pharmacy sales for which population-at-risk information is unavailable or irrelevant.ConclusionIf such results hold up over longer study times and in other locations, the space–time permutation scan statistic will be an important tool for local and national health departments that are setting up early disease detection surveillance systems.     

Southeastern Center for Emerging Biologic Threats tabletop exercise: foodborne toxoplasmosis outbreak on college campuses

The use of tabletop exercises as a tool in emergency preparedness and response has proven to be an effective means of assessing readiness for unexpected events. Whereas most exercise developers target a population in a defined space (eg, state, county, metropolitan area, hospital), the Southeastern Center for Emerging Biologic Threats (SECEBT) conducted an innovative tabletop exercise involving an unusual foodborne outbreak pathogen, targeting public health agencies and academic institutions in 7 southeastern states. The exercise tested the ability of participants to respond to a simulated foodborne disease outbreak affecting the region. The attendees represented 4 federal agencies, 9 state agencies, 6 universities, 1 nonprofit organization, and 1 private corporation. The goals were to promote collaborative relationships among the players, identify gaps in plans and policies, and identify the unique contributions of each organization-and notably academic institutions-to outbreak recognition, investigation, and control. Participants discussed issues and roles related to outbreak detection and management, risk communication, and coordination of policies and responsibilities before, during, and after an emergency, with emphasis on assets of universities that could be mobilized during an outbreak response. The exercise generated several lessons and recommendations identified by participants and evaluators. Key recommendations included a need to establish trigger points and protocols for information sharing and alerts among public health, academic, and law enforcement; to establish relationships with local, state, and federal stakeholders to facilitate communications during an emergency; and to catalogue and leverage strengths, assets, and priorities of academic institutions to add value to outbreak responses.     

The Wilderness Act and Fish Stocking: An Overview of Legislation, Judicial Interpretation, and Agency Implementation

Many high-elevation lakes in designated wilderness are stocked with native and nonnative fish by state fish and game agencies to provide recreational fishing opportunities. In several areas, this practice has become controversial with state wildlife managers who support historical recreational use of wilderness, federal wilderness managers who assert that stocking compromises some of the ecological and social values of wilderness, and different public groups that support one or the other position. Herein we examine this controversy from the perspective of the 1964 Wilderness Act, its judicial interpretation, the policies of the federal agencies, and formal agreements between federal and state agencies. Although some state stocking programs restore native fish populations, other programs may compromise some of the ecological and social values of wilderness areas. Further, although current federal regulations recognize state authority for fish stocking, judicial interpretation gives federal agencies the authority for direct involvement in decisions regarding fish stocking in wilderness. Where there are differences of opinion between state and federal managers, this judicial interpretation strongly points to the need for improved cooperation, communication, and coordination between state wildlife managers and federal wilderness managers to balance recreational fishing opportunities and other wildlife management activities with wilderness values. Received 28 March 2000; Accepted 16 August 2000.     

Aspects of wetland law and policy in Australia

The existence of laws and policies in Australia that affect wetland protection and rehabilitation has been ascertained. There is a diverse range of environmental legislation, primarily at the state level, that potentially affects wetlands. There are environmental planning instruments made under legislation in New South Wales and Western Australia, which are specifically directed to the protection of wetlands. These are legislative-backed mechanisms providing legal protection to wetlands. Whilst there is no national policy on wetlands, a draft Commonwealth policy has been circulated and is expected to be released in final form in February 1997. New South Wales is the only state with a current wetlands policy, whilst some other states have draft policies. These policies do refer to wetland rehabilitation. The present federal government indicated it wished to finalize a national wetlands policy in the lead up to its election in March 1996. This is not likely to happen soon and any national policy will probably be an implementation framework for the policies of individual governments. It is suggested that a commonwealth policy, whilst useful in providing consistency in commonwealth government decision making affecting wetlands, does not go far enough. Given that only one state in Australia has a wetland policy, it may take the formulation of a national policy to get the remaining states and territories in Australia to finalize their own policies.     

The evolution of law in biopreparedness

The decade following the terrorist attacks on September 11, 2001, and ensuing anthrax exposures that same fall has seen significant legal reforms designed to improve biopreparedness nationally. Over the past 10 years, a transformative series of legal changes have effectively (1) rebuilt components of federal, state, and local governments to improve response efforts; (2) created an entire new legal classification known as "public health emergencies"; and (3) overhauled existing legal norms defining the roles and responsibilities of public and private actors in emergency response efforts. The back story as to how law plays an essential role in facilitating biopreparedness, however, is pocked with controversies and conflicts between law- and policymakers, public health officials, emergency managers, civil libertarians, scholars, and others. Significant legal challenges for the next decade remain. Issues related to interjurisdictional coordination; duplicative legal declarations of emergency, disaster, and public health emergency; real-time legal decision making; and liability protections for emergency responders and entities remain unresolved. This article explores the evolving tale underlying the rise and prominence of law as a pivotal tool in national biopreparedness and response efforts in the interests of preventing excess morbidity and mortality during public health emergencies.     

Ethical models underpinning responses to threats to public health: a comparison of approaches to communicable disease control in Europe

Increases in international travel and migratory flows have enabled infectious diseases to emerge and spread more rapidly than ever before. Hence, it is increasingly easy for local infectious diseases to become global infectious diseases (GIDs). National governments must be able to react quickly and effectively to GIDs, whether naturally occurring or intentionally instigated by bioterrorism. According to the World Health Organisation, global partnerships are necessary to gather the most up-to-date information and to mobilize resources to tackle GIDs when necessary. Communicable disease control also depends upon national public health laws and policies. The containment of an infectious disease typically involves detection, notification, quarantine and isolation of actual or suspected cases; the protection and monitoring of those not infected; and possibly even treatment. Some measures are clearly contentious and raise conflicts between individual and societal interests. In Europe national policies against infectious diseases are very heterogeneous. Some countries have a more communitarian approach to public health ethics, in which the interests of individual and society are more closely intertwined and interdependent, while others take a more liberal approach and give priority to individual freedoms in communicable disease control. This paper provides an overview of the different policies around communicable disease control that exist across a select number of countries across Europe. It then proposes ethical arguments to be considered in the making of public health laws, mostly concerning their effectiveness for public health protection.     

Lessons learned from North Carolina public health regional surveillance teams' regional exercises

All-hazards exercises bring together emergency response partners at the local, regional, state, and federal levels for the primary purposes of testing response plans, defining roles and responsibilities, assessing capabilities, and making necessary improvements prior to an actual incident. To better understand the benefits and challenges of conducting regional (ie, multicounty) exercises, a study was carried out by the North Carolina Preparedness and Emergency Response Research Center at the University of North Carolina Gillings School of Global Public Health. This article describes 5 all-hazards regional exercises conducted by Public Health Regional Surveillance Teams (PHRSTs) in North Carolina in 2009 and highlights 4 unique benefits that resulted from the exercises beyond meeting explicit objectives to test plans and identify areas for improvement: (1) building relationships among response partners, (2) promoting public health assets, (3) testing multiple communications systems, and (4) training exercise evaluators. Challenges of planning and conducting regional exercises also are addressed, followed by recommendations for maximizing the effectiveness of regional public health exercises.     

Adapting to the Changing Climate: An Assessment of Local Health Department Preparations for Climate Change-Related Health Threats, 2008-2012

Background

Climate change poses a major public health threat. A survey of U.S. local health department directors in 2008 found widespread recognition of the threat, but limited adaptive capacity, due to perceived lack of expertise and other resources.

Methods

We assessed changes between 2008 and 2012 in local public health departments'' preparedness for the public health threats of climate change, in light of increasing national polarization on the issue, and widespread funding cutbacks for public health. A geographically representative online survey of directors of local public health departments was conducted in 2011–2012 (N = 174; response rate = 50%), and compared to the 2008 telephone survey results (N = 133; response rate = 61%).

Results

Significant polarization had occurred: more respondents in 2012 were certain that the threat of local climate change impacts does/does not exist, and fewer were unsure. Roughly 10% said it is not a threat, compared to 1% in 2008. Adaptation capacity decreased in several areas: perceived departmental expertise in climate change risk assessment; departmental prioritization of adaptation; and the number of adaptation-related programs and services departments provided. In 2008, directors'' perceptions of local impacts predicted the number of adaptation-related programs and services their departments offered, but in 2012, funding predicted programming and directors'' impact perceptions did not. This suggests that budgets were constraining directors'' ability to respond to local climate change-related health threats. Results also suggest that departmental expertise may mitigate funding constraints. Strategies for overcoming these obstacles to local public health departments'' preparations for climate change are discussed.     

A Review of Evaluations of Electronic Event-Based Biosurveillance Systems

Electronic event-based biosurveillance systems (EEBS’s) that use near real-time information from the internet are an increasingly important source of epidemiologic intelligence. However, there has not been a systematic assessment of EEBS evaluations, which could identify key uncertainties about current systems and guide EEBS development to most effectively exploit web-based information for biosurveillance. To conduct this assessment, we searched PubMed and Google Scholar to identify peer-reviewed evaluations of EEBS’s. We included EEBS’s that use publicly available internet information sources, cover events that are relevant to human health, and have global scope. To assess the publications using a common framework, we constructed a list of 17 EEBS attributes from published guidelines for evaluating health surveillance systems. We identified 11 EEBS’s and 20 evaluations of these EEBS’s. The number of published evaluations per EEBS ranged from 1 (Gen-Db, GODsN, MiTAP) to 8 (GPHIN, HealthMap). The median number of evaluation variables assessed per EEBS was 8 (range, 3–15). Ten published evaluations contained quantitative assessments of at least one key variable. No evaluations examined usefulness by identifying specific public health decisions, actions, or outcomes resulting from EEBS outputs. Future EEBS assessments should identify and discuss critical indicators of public health utility, especially the impact of EEBS’s on public health response.