Symp­toms of dis­tress

H1N1 flu fight adds to bur­den of pub­lic health agen­cies al­ready suf­fer­ing from years of un­der­fund­ing and the long-run­ning re­ces­sion

Modern Healthcare - - Special Report - Jes­sica Zig­mond

When the deadly H1N1 in­fluenza virus emerged last spring, fed­eral health of­fi­cials re­ported a fact that sur­prised many Amer­i­cans: About 36,000 peo­ple in the U.S. die from the sea­sonal flu each year. A dis­turb­ing statis­tic on its own, that in­for­ma­tion is even more trou­bling to­day for state and lo­cal health de­part­ments as they man­age wide­spread flu ac­tiv­ity dur­ing a global pan­demic while a tight U.S. econ­omy con­tin­ues to hurt an al­ready weak­ened pub­lic health in­fra­struc­ture.

State and lo­cal health de­part­ments, as well as hos­pi­tals, have made progress in pre­pared­ness ef­forts and vac­cine dis­tri­bu­tion for the virus—pop­u­larly re­ferred to as swine flu—which the World Health Or­ga­ni­za­tion re­ports has claimed more than 4,500 lives around the world as of early Oc­to­ber. And the U.S. gov­ern­ment has re­sponded with $1.9 bil­lion in fund­ing and an ad­di­tional $5.8 bil­lion in con­tin­gency funds (See chart, p. 29).

But much of the re­spon­si­bil­ity for manag­ing the dis­ease falls to the states, which find them­selves in dire sit­u­a­tions. Trust for Amer­ica’s Health re­ports that “prepa­ra­tions are tak­ing place in the con­text of a pub­lic health sys­tem that has been chron­i­cally un­der­funded for decades.”

That’s be­cause the na­tion’s health­care sys­tem has tra­di­tion­ally fo­cused on med­i­cal care rather than on pub­lic health, says Robert Pe­stronk, ex­ec­u­tive di­rec­tor of the Na­tional As­so­ci­a­tion of County and City Health Of­fi­cials, or NACCHO.

“What we should have in place is a sys­tem to vac­ci­nate every­one in the com­mu­nity who wants or needs to be vac­ci­nated for the flu,” Pe­stronk says. “We shouldn’t have 36,000 peo­ple a year dy­ing from in­fluenza,” he says, adding that it’s a “fail­ure” of the na­tion’s cur­rent health­care de­liv­ery sys­tem.

As a for­mer lo­cal health of­fi­cial in Michi­gan for 22 years, Pe­stronk says he has seen how a bat­tered econ­omy can place ad­di­tional bur­dens on lo­cal health de­part­ments. But he says he has never seen things this bad, nor this per­va­sive, for the na­tion’s health de­part­ments as they are to­day.

Short­handed staffs

Con­sider th­ese statis­tics from his or­ga­ni­za­tion: Lo­cal health de­part­ments doc­u­mented the loss of about 7,000 jobs for all of 2008, while those de­part­ments lost 8,000 staff po­si­tions in the first six months of 2009 alone. Mean­while, 12,000 lo­cal health depart­ment em­ploy­ees were sub­jected to re­duced hours or manda­tory fur­loughs. And bud­get cuts are only com­pound­ing the work­force prob­lem.

In the past 12 months, 55% of lo­cal health de­part­ments have made cuts to pub­lic-health pro­grams such as ma­ter­nal and child health, en­v­i­ron-

men­tal health and emer­gency pre­pared­ness, while only 14% of de­part­ments re­ceived fund­ing from the Amer­i­can Re­cov­ery and Rein­vest­ment Act of 2009, ac­cord­ing to a sur­vey re­leased by the NACCHO last month.

Pe­stronk says it is im­por­tant that state health de­part­ments re­ceive suf­fi­cient and sus­tained fund­ing in or­der to ad­e­quately pre­pare.

“What we’ve seen is cycling down, then some cycling up,” Pe­stronk says, adding that con­stancy is vi­tal for plan­ning pur­poses.

And plan­ning is cru­cial given that it’s just the start of the reg­u­lar flu sea­son, which runs through next May. A new re­port this month from Trust for Amer­ica’s Health shows that 15 states could run out of hospi­tal beds dur­ing the peak of an out­break if 35% of Amer­i­cans were to get sick from the H1N1 virus.

Con­sid­er­ing that there are about 47 mil­lion Amer­i­cans without health in­sur­ance cov­er­age, that could mean that about 15 mil­lion unin­sured might be­come sick and not seek care, or else they’ll seek care in emer­gency rooms.

The sur­vey was pub­lished shortly be­fore the release of a study in the New Eng­land Jour­nal of Medicine that found that of the 272 pa­tients who were hos­pi­tal­ized for at least 24 hours for flu-like ill­nesses and tested pos­i­tive for the H1N1 virus be­tween April and mid-June, 25% were ad­mit­ted to an in­ten­sive-care unit and 7% of those pa­tients died.

As of Oct. 15 the Cen­ters for Dis­ease Con­trol and Preven­tion says there have been more than 1 mil­lion cases of H1N1 and 833 deaths from the virus since April, in­clud­ing 81 chil­dren un­der the age of 18.

To pre­vent the H1N1 virus from spread­ing more widely, the CDC is rec­om­mend­ing the vac­cine as the great­est pro­tec­tion against the dis­ease.

“I think my great­est con­cern right now about over­all re­sponse to pan­demic flu is that we need peo­ple as ur­gently as pos­si­ble to take the vac­cine be­cause that is go­ing to be our best de­fense,” says Jef­frey Levi, ex­ec­u­tive di­rec­tor at Trust for Amer­ica’s Health. “That leads to the big­gest con­cern ex­pressed in the re­port: even a rel­a­tively mild pan­demic can over­whelm the sys­tem.”

The nasal form of the H1N1 vac­cine was first ad­min­is­tered on Oct. 5, and the in­jectable form was avail­able the fol­low­ing week. Ac­cord­ing to the CDC, the fed­eral gov­ern­ment has pur­chased a to­tal of 250 mil­lion doses of the H1N1 vac­cine, and about 40 mil­lion doses are ex­pected to be avail­able by the end of Oc­to­ber.

Preg­nant women, health­care and emer­gency med­i­cal ser­vices per­son­nel, care­givers of small chil­dren younger than 6 months of age, peo­ple ages 6 months through 24 years old, and those be­tween 25 years old and 64 years old who have con­di­tions that put them at greater risk for in­fluenza are the pri­or­ity groups for re­ceiv­ing the vac­cine, ac­cord­ing to the CDC.

The flu vac­cine is manda­tory for health­care work­ers in New York state, where sev­eral nurses are ex­pected to file a law­suit this week in Al­bany County to fight the man­date. Work­ers at HCA, the na­tion’s largest hospi­tal chain, also are re­quired to re­ceive the vac­cine.

Ready or not?

Ac­cord­ing to Trust for Amer­ica’s Health, HHS con­ducted a re­view of state pan­demic plans in 2008 and found that only 29 states and the District of Columbia were ad­e­quately pre­pared to meet mass vac­ci­na­tion ca­pa­bil­i­ties based on their plans. A closer look at the prob­lems af­fect­ing one lo­cal health depart­ment in the Mid­west gives a bet­ter idea of why it’s so dif­fi­cult for some states to be suf­fi­ciently pre­pared.

For ex­am­ple, the city health depart­ment in Lorain, Ohio—which serves a pop­u­la­tion of about 90,500—re­ceived some bad news this year from the mayor and City Coun­cil: Lo­cal fund­ing, which ac­counts for part of the depart­ment’s rev­enue, would be cut by 54% (the health depart­ment also re­lies on rev­enue from things such as birth and death records, en­vi­ron­men­tal pro­grams, im­mu­niza­tions, home vis­its and other pro­grams).

Fac­ing those se­vere bud­get cuts, but want­ing to avoid lay­offs, City Health Com­mis­sioner Terrence To­maszewski pro­posed a four-day work­week for all em­ploy­ees, beginning last April. And he’s not get­ting much re­lief from the state ei­ther. To­maszewski says the depart­ment’s sub­sidy from the state health depart­ment has been steadily de­clin­ing in re­cent years.

In 2008, the depart­ment re­ceived 30 cents per capita for the pop­u­la­tion it serves, while it re­ceived 25 cents per capita for 2009. That num­ber will fall to 20 cents per capita for both 2010 and 2011. So now a depart­ment with a tighter bud­get and a shorter work­week for its em­ploy­ees will have to man­age a large pro­gram to vac­ci­nate the lo­cal pop­u­la­tion against H1N1.

To­maszewski has or­dered 30,000 vac­cine doses and is tar­get­ing the last week of Oc­to­ber or early Novem­ber for the first vac­ci­na­tion clinic.

“It’s a ma­jor pub­lic un­der­tak­ing for pub­lic health, and I can’t see where I could pull this off if not for this stim­u­lus,” To­maszewski says of fed­eral emer­gency grant fund­ing that was al­lo­cated to the states in Au­gust specif­i­cally for the H1N1 out­break. He says the depart­ment ex­pects to re­ceive about $89,000 from the first phase of the al­lo­ca­tion in early Novem­ber and nearly $130,000 in the sec­ond phase early next year.

While lo­cal health de­part­ments such as Lorain’s de­vise creative so­lu­tions to pro­vide vac­ci­na­tions for their pop­u­la­tions, some polls sug­gest many Amer­i­cans may de­cide not to be vac­ci­nated. That was a find­ing in a re­cent sur­vey from the Deloitte Cen­ter for Health So­lu­tions, which re­ported that 41% of re­spon­dents who were sur­veyed said they do not plan to get vac­ci­nated. Re­spon­dents who are un­der­in­sured or who have in­ad­e­quate in­sur­ance are even less likely to get vac­ci­nated than the unin­sured: 46% com­pared with 49%.

“I think the only ad­di­tional two chan­nels that could make this a more ur­gent re­sponse (are) em­ploy­ers and physi­cians,” says Paul Keck­ley, ex­ec­u­tive di­rec­tor of the Deloitte cen­ter. “We don’t see in some cases as much real proac­tive work on the part of physi­cians,” he says, sug­gest­ing that physi­cians could e-mail alerts to pa­tients about what they think of the vac­cine and how they will make it avail­able to them.

Com­pa­nies such as group pur­chas­ing or­ga­ni­za­tion No­va­tion, Irv­ing, Texas, are work­ing to ed­u­cate hos­pi­tals on the H1N1 virus and how to pre­vent its spread. Stephanne Hale, the com­pany’s se­nior clin­i­cal man­ager for safety, says No­va­tion sug­gests that its mem­ber hos­pi­tals buy an ad­di­tional 25% of what they would or­der dur­ing a typ­i­cal flu sea­son of prod­ucts such as per­sonal pro­tec­tive equip­ment like gloves; gowns; masks; res­pi­ra­tors; al­co­hol-based, hand-hy­giene prod­ucts; soap; phar­ma­ceu­ti­cals that are ef­fec­tive against the flu; IV tub­ing and flu­ids; and IV pumps.

No­va­tion looks to the CDC and the WHO for guide­lines on preven­tion ef­forts, which in ad­di­tion to the vac­cine in­clude em­pha­siz­ing hand­wash­ing, cough eti­quette (sneez­ing in a tis­sue, or your arm) and “so­cial dis­tanc­ing.” Hale de­scribes so­cial dis­tanc­ing as keep­ing 6 feet from a per­son who is ill.

In its re­port, Trust for Amer­ica’s Health de­fines so­cial dis­tanc­ing as those mea­sures taken to de­crease the fre­quency of con­tact among peo­ple, such as the clos­ing of schools, shop­ping malls, movie the­aters or the can­cel­la­tion of large pub­lic events.

Tak­ing ex­tra pre­cau­tions

Re­strict­ing vis­i­tors is an­other preven­tion tool that some hos­pi­tals are us­ing. On Oct. 7, 326-bed Ball Memo­rial Hospi­tal in Mun­cie, Ind., be­gan lim­it­ing visi­ta­tion to no more than two healthy vis­i­tors per pa­tient through­out the fa­cil­ity; re­strict­ing visi­ta­tion in the hospi­tal’s neona­tal in­ten­sive-care unit only to those vis­i­tors who re­ceive spe­cific wrist­bands; and pro­hibit­ing chil­dren age 14 and un­der from vis­it­ing the hospi­tal dur­ing flu sea­son.

Cen­tura Health in En­gle­wood, Colo., is im­pos­ing sim­i­lar re­stric­tions. Any vis­i­tors who dis­play flu symp­toms are told to avoid vis­it­ing Cen­tura’s fa­cil­i­ties (ex­cept as pa­tients), and the sys­tem also rec­om­mends that chil­dren un­der the age of 18 do not visit Cen­tura’s hos­pi­tals or se­nior­liv­ing fa­cil­i­ties.

In its study of the com­ing chal­lenges re­lated to the H1N1 virus, Trust for Amer­ica’s Health rec­om­mends a wide range of sug­ges­tions for the gov­ern­ment and providers to man­age the dis­ease, such as de­vel­op­ing bet­ter tracking sys­tems when the vac­cine is ad­min­is­tered; im­prov­ing pay­ment sys­tems for ad­min­is­ter­ing the vac­cine; fully fund­ing and im­ple­ment­ing sur­veil­lance sys­tems that are up-to-date; and de­vel­op­ing and dis­sem­i­nat­ing strong pub­lic mes­sages from providers and health de­part­ments about ways to prac­tice good hy­giene and un­der­stand symp­toms and reme­dies.

Progress has al­ready been made in th­ese ar­eas, ac­cord­ing to the CDC. “The CDC, state and lo­cal pub­lic-health de­part­ments have made great strides around sur­veil­lance for in­fluenza, and sur­veil­lance con­tin­ues to be a high pri­or­ity,” Von Roe­buck, a spokesman for the agency, said in an e-mail. “CDC cer­tainly agrees that in­fluenza sur­veil­lance along with all pre­pared­ness and re­sponse ac­tiv­i­ties can al­ways be en­hanced.”

All of this ac­tiv­ity, of course, will come at a cost dur­ing a time when the fed­eral, state and lo­cal bud­gets are al­ready strapped.

Says the NACCHO’s Pe­stronk: “I’m hop­ing the chal­lenges faced with this epi­demic” are “a re­minder of the need for a strong, ef­fec­tive pub­lic health sys­tem.”

Health­care work­ers re­ceive a dose of the H1N1 vac­cine dur­ing a clinic Oct. 5 at Wishard Memo­rial Hospi­tal in Indianapolis.

Pe­stronk: An­nual flu death toll points to a “fail­ure” of the cur­rent health­care sys­tem.

Keck­ley: Physi­cians could make a big­ger push for flu vac­cine.

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