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Ready or Not 2008, Part One

January 3, 2009

trustThe Trust for America’s Health published the latest version of their “Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism” report, this one for 2008. The full pdf report can be downloaded from here, and the Ready or Not page is here. The Trust also developed a video promoting this year’s report, which can be seen here, which is pretty cool.

I’ve never been a huge fan of these reports, as I’ve read them as blaming local and state health departments for poor performance and lack of planning. Underinvestment in preparedness specifically and public health in general, coupled with a brand new mandate to actually do planning was a recipe for being under-prepared. This argument, however, loses force over time, and I’ve become increasingly accepting of the reports. By now, states and CRI cities that are under-prepared should be called out. Enough money has been spent to ensure a minimum level of preparedness. And the feds shouldn’t be given a free pass, either. They should be setting the curve for public health preparedness. If they aren’t, they deserve some of the fire, too.

This year, the folks at the Trust changed the format of the report, and I’m a big fan of that change. Instead of just calling out the individual states for being under-prepared (which they still do), they focus much more on the overall level of collaboration and preparedness efforts between the feds, states and cities–which is what real preparedness looks like. Overall, I think this was the Trust’s most valuable and best put together report.

A quick note to you all, going through the indicators turned out to be much longer than I originally expected, so I broke this post into two. I didn’t spend much time reading the Hospital Emergency Preparedness or Additional Issues and Concerns sections as I’m less confident with those subjects, and won’t be reviewing them.

The first section is the traditional review of the 50 (+1) states preparedness levels. Of the 50 (+1), only five scored 10/10 and eight scored 9/10 (go Pennsylvania!). Scarily, six scored only 5/10.

Several of the indicators are really no-brainers, others require some real work.

The first indicator is about having an SNS distribution plan. Simply put, every state should have a fully developed SNS distribution plan. They’ve been getting money for years and future funding from the CDC will be tied to the quality of that plan. Every state got credit for this, but I wonder about how useful this question is. All a state had to do was score above a 69 on the TAR evaluation tool. Yes, this was the benchmark set by the CDC last year, but they’ve already raised it for the upcoming year. Remember, 69 is the line between passing and failing, while the difference between 70 and 100 is HUGE. The CDC is required to give a minimum level, but the Trust should strive for something higher.

The second indicator tests whether each state has purchased more than half of the federally subsidized antiviral meds (Tamiflu and Relenza) alloted to their state for pandemic planning. 34 (+1) have, as of the publication date, done so. I go back and forth on the utility of this indicator. Currently circulating influenza virii are increasingly resistant to Tamiflu, and some H5N1 avian influenza infections have shown resistance. So, the usefulness of a Tamiflu stockpile is already diminished. That said, the recent antiviral guidance out of HHS counts on all 81 million courses of antivirals being available for the implementation of the plan. And, really, that plan is better than a sharp stick in the eye. Basically, having stockpiled antivirals isn’t a bad idea–and having a plan to distribute them is an even better idea. Finding a good way to rotate that stockpile (read: coordination between the states, hospitals and manufacturers to rotate stock at each level, similar to how the DoD and VA plan to rotate stock) will ensure that it’s available for any widespread virus that might affect the public’s health. So, while it’s stated use might not actually happen, it can be a useful tool in the toolbox. Shame on those 16 states, this should be done.

The third indicator is about the availability of state public health labs. This indicator confused me because I don’t understand how, in today’s world, a state cannot deliver and receive lab samples 24 hours a day, seven days a week. Contract it out, open your labs. This is inconceivable to me.

The fourth indicator is also about lab preparedness. This is also a no-brainer. State lab directors were asked if their labs met the expectations laid down in the state’s pandemic response plan. I wonder about this one because the report doesn’t say if the state’s labs could fulfill their role, but cannot at the time of the questionnaire because of budget and personnel cuts. On the other hand, though, if the plans were written and over-extended the labs capabilities, then that’s cause for concern.

The fifth indicator is about National Electronic Disease Surveillance System (NEDSS) compatibility. NEDSS is a real-time disease surveillance system that allows participants across the country to see cases that might grow into an outbreak. In today’s real-time media world, this is critical. I understand how difficult (read: expensive) this is, though, and wish there was some real effort made at the federal level to fully fund a nation-wide biosurveillance system that includes monies to upgrade existing state and local surveillance systems. There will be a number of reports out in the first half of 2009 dealing with biosurviellance efforts at the federal level, so hopefully something constructive will come out of that.

The sixth and seventh indicators deal with legal liabiliy protections for health care volunteers and charitable organizations. This is another tough one. We all know how slowly state legislatures work, and something as complicated as liability protection for medical professionals and entire organizations is as thorny an issue as they’ll face all year. That 42 (+1) and 24 (+1) states, respectively, have some level of protection is impressive, and something that groups such as the Centers for Public Health Preparedness should focus on and begin developing model acts for passage in the many states.

The eigth indicator is kind of weak. I understand where the Trust was going with it, but still… 34 (+1) states reported that they had an MRC Coordinator. That’s it. The report even notes that this role might be filled by the state’s ESAR-VHP Coordinator. Weak. Next year, the report notes, the Trust will test if the MRC units are NIMS compliant and integrated into the state’s ESAR-VHP program. I wonder why not test that this year, though?

The ninth indicator is probably the most scary, even as it’s the toughest to understand (based upon how the report was written). 30 states were able to identify food-borne pathogens associated with outbreaks in more than 44% of the outbreaks. Read another way, almost half of the states could not identify the pathogen responsible for half of their food-borne outbreaks from 2004 – 2006. And the report has this great line right after the scores are reported:

Approximately 76 million Americans — one in four — are sickened by foodborne disease each year. Many of these cases go unreported although there are an estimated 325,000 individuals who are hospitalized annually due to foodborne illness and 5,000 who die each year.

That’s a sad state of affairs, and an indictment of the surveillance system in our country today.

The final indicator is hugely important, and one that should be in every TFAH report from here on out. Has the level of public health funding (note, not preparedness) increased or stayed the same year over year? I say, time after time, that public health benefits from preparedness activities and vice versa. But, as public health funding gets cut more and more, preparedness activities will suffer, and the public’s health will suffer. Unfortunately, I expect this the score from this indicator to get worse next year as state budgets are continually cut and forced to make up budget shortfalls. Additionally, the report notes that PAHPA funding must be matched bythe states going forward. With any luck, the new federal administration will live up to their promises to focus on public health and public health preparedness issues and remedy this situation with dedicated public health funding.

I’ll follow this post up with one covering the rest of the report as this has become interminably long. Keep an eye out.

Image credit: TFAH


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