Public Health Feature - April 2008
By Crystal Conde
Is Texas prepared for another Katrina, another Rita, or a pandemic flu outbreak? State legislators wanted answers to those questions at a February hearing of the Texas House of Representatives committees on Public Health and on Defense Affairs and State-Federal Relations. The response they received was troubling.
Jack Colley, chief of the Governor's Division of Emergency Management in the Texas Department of Public Safety, testified the state is prepared to respond to public health emergencies.
"I tell you with great confidence that our ability to respond to all events, manmade or natural, is as good as it has ever been. We're quicker, faster, smarter than we've ever been."
But Rep. Dianne White Delisi (R-Temple), chair of the Committee on Public Health, expressed concern over a shortage of physicians and health care practitioners and limited hospital capacity. She said she is unconvinced Texas is prepared for a widespread emergency, such as pandemic flu, when the infrastructure appears to be stretched to the breaking point.
Steve McCraw, director of the Texas Office of Homeland Security, responded to her concerns by acknowledging that there is room for improvement.
"We have to recognize that we're not perfect right now. Until the outbreak occurs, we have no perfect solution. It's a catch-up game at this point," he said.
Further compounding the state's ability to prepare for a public health emergency is a possible reduction in federal funding.
Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, notified the committees that a preliminary conversation he had with a project officer at the U.S. Centers for Disease Control and Prevention (CDC) indicated that federal funds could be cut. A 10- to 12-percent cut for hospital and public health preparedness would harm a system that relies on those monies to improve its capabilities.
In addition, Dr. Lakey said, the $11 million in the state budget for pandemic influenza in 2007 drops to zero in 2009.
The looming monetary drought from reduced federal and state funding is particularly worrisome because 70 percent of public health emergency preparedness funds flow through to local health departments.
"We've [DSHS] had conversations with local health departments to determine priorities and what can no longer be funded with the absence of those federal funds," Dr. Lakey said.
Rep. Richard Raymond (D-Laredo), a member of the Committee on Defense Affairs and State-Federal Relations, called on Dr. Lakey to help the committees develop recommendations for funding.
The Flu Threat
John Carlo, MD, medical director of the Dallas County Department of Health and Human Services, testified on the Texas Medical Association's behalf. Chief among his apprehensions and those of lawmakers was how the public health infrastructure would handle a pandemic influenza outbreak.
"The biggest fear that I will have is what happens in emergency rooms, what happens to the clinicians, when all of a sudden the full system experiences more," Dr. Carlo said.
DSHS does have a pandemic influenza preparedness plan. Physicians on TMA's Infectious Diseases Committee and association staff members helped develop the plan, posted at www.dshs.state.tx.us/idcu . Click on Pandemic Influenza Preparedness Plan.
Mr. McCraw said the strength of Texas' response capability lies at the local level and insisted that the state can't be satisfied with mediocrity.
"What keeps us up at night, of all the threats - whether it's wildfires, floods, hurricanes, tornadoes, an act of terrorism - you get right back to it, it's infectious disease; it's pandemic flu. It's invisible, it's seamless, and it can have … the potential of severely impacting public health," he said.
The reduction in federal funding that Dr. Lakey warned of represents a shift in public health and hospital preparedness, according to Scott Lillibridge, MD, assistant dean at Texas A&M University School of Rural Public Health. He testified the state should place greater emphasis on developing capacities, not just on finding infrastructure needs and gaps.
He said it's essential the state fund exercises, testing, and evaluation that result in greater ability to feed, shelter, and transport large numbers of people.
Dr. Lillibridge contends Texas should focus on targeting threats through an expanded program of exercises and evaluation to measure capacities. He said the program can be implemented regionally and can be funded for about $10 million per year from a portion of the preparedness funds.
"It is in Texas' interest to have such a program, independent of the federal government's preparedness activities. I want to keep Texas ahead of the pack, and we're still vulnerable," he said.
There is some good news on state funding. The legislature last year appropriated $10 million to increase the state's Tamiflu stockpile by purchasing 677,000 courses, bringing the state's supply to about 850,000. Dr. Lakey is developing a plan for distributing the drug in a pandemic. The drug won't expire for seven years, in accordance with FDA and CDC guidelines.
According to Dr. Lakey, Texas is in good shape when it comes to its strategic national vaccine stockpile, scoring 97 out of 100 in a CDC evaluation.
CDC also designated two components of the DSHS pandemic influenza preparedness plan best practices to be shared with other states -the communications plan and the antiviral allocation distribution and storage plan. And DSHS is collaborating with primary care physicians to enhance the surveillance system to make sure DSHS learns of a flu outbreak early on.
The potential impact of disaster on hospitals is a high priority for Dan Stultz, MD, president and chief executive officer of the Texas Hospital Association. He testified about Texas hospitals' increasing struggle to care for a growing aging population. He lamented that inappropriate use of hospitals in a pandemic would cripple their effectiveness.
"The state needs to prepare public service announcements now to teach the general population how to care for their loved ones if a physician's office or hospital is unavailable in pandemics. These could be implemented on short notice," Dr. Stultz said.
DSHS is concentrating on a "Ready or Not" media campaign encompassing radio and television ads and billboards to educate families and make sure they have medicines and necessary information during emergencies. The agency also has established a Web site at www.texasprepares.org.
In addition to the threat of a pandemic influenza outbreak, Dr. Lakey counts the evacuation of a large number of people as one of his anxieties in disaster planning.
Rep. Veronica Gonzales (D-McAllen), a member of the Committee on Public Health, expressed concern over the Rio Grande Valley's lack of an interstate highway or a plan to evacuate the area's 1 million residents in an emergency.
During the 2007 legislative session, Sen. Jane Nelson (R-Lewisville) and Rep. Frank Corte Jr. (R-San Antonio) authored Senate Bill 11, which creates the Texas Statewide Mutual Aid System and includes provisions to establish a Border Security Council. (See " Statewide Disaster Preparedness and Planning .")
Mr. Colley called the evacuation of the Valley the state's biggest obstacle in emergency preparations and said local elected officials should have a plan in place before a disaster, moving those with special medical needs first. The large volume of patients in highly populated areas makes mass evacuation challenging. He also acknowledged that retired physicians and health care professionals can play a pivotal volunteer role during emergencies.
The Committee on Defense Affairs and State-Federal Relations will issue recommendations for emergency preparedness this fall.
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Statewide Disaster Preparedness and Planning
The 2007 Texas Legislature addressed inadequacies in the state's disaster preparedness capabilities by passing these bills:
- Senate Bill 11 creates a Texas Statewide Mutual Aid System that integrates statewide disaster preparedness aid among local government entities without a written mutual aid agreement. It also allows information about immunizations for first responders to be included in the immunization registry, calls for quarantining people exposed to or infected with a communicable disease, and requires the news media to be notified at least an hour before any emergency meeting to address the relocation of a large number of residents in a disaster.
- Senate Bill 1658 allows pharmacists to use their professional judgment in dispensing non-Schedule II prescription drugs in an emergency. Pharmacists may dispense prescriptions without physician contact if not filling the prescription would disrupt the patient's therapy, if the pharmacist is unable to contact the physician after considerable effort, if the quantity does not exceed a 72-hour supply, or if a natural or manmade disaster prevents contact with the physician.
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WHO and FDA Recommend Flu Vaccine Changes
This year, Texas physicians had an opportunity to expand the traditional vaccination season and to reach more patients than ever before. Vaccine production and delivery went according to schedule, and expansion of two vaccines, as well as the introduction of a new manufacturer in the U.S. market, created a promising landscape for controlling widespread outbreak of a preventable disease. (See " So Far, So Good ," March 2008 Texas Medicine , pages 37-40.)
Good news on the supply side of vaccine production was overshadowed, though, by troubling reports that this season's vaccine inadequately matched circulating influenza strains. The World Health Organization (WHO) and the Food and Drug Administration (FDA) Vaccines and Related Biological Products Advisory Committee announced in late February that all three strains in the influenza vaccine needed to be changed for the 2008-09 season. Each year in the United States, more than 200,000 people are hospitalized from influenza complications, and about 36,000 people die from flu.
Nancy Cox, MD, chief of the U.S. Centers for Disease Control and Prevention (CDC) Influenza Division, explains that, based on CDC laboratory data, the H3N2 component of the vaccine - one of the influenza A components - and the influenza B component are "not optimal." This year's flu season began as primarily an H1N1 year through early January. It transitioned at that time, with H3N2 viruses dominating diagnosed cases of flu.
As of late February, about 83 percent of overall viruses were influenza A, and 63 percent were H2N2. Of the influenza A viruses, 63 percent were H3N2, 37 percent were H1N1, and less than 16 percent were influenza B.
"We know that the influenza vaccine is not perfect, even when it's optimally matched. In young, healthy adults, we expect vaccine effectiveness to be 70 percent to 90 percent," Dr. Cox said.
As of late February, CDC reported the vaccine was a good match for about 40 percent of the virus spreading in the nation.
To provide better protection, next season's vaccine will be composed of H3N2/Brisbane/10, H1N1/Brisbane/59, and Type B/Florida.
Each year, CDC participates in two vaccine recommendation sessions - one in September for the Southern Hemisphere and one in February for the Northern Hemisphere. Though the alteration in production sounds like an enormous undertaking, Dr. Cox says manufacturers are well-prepared.
"If you look back to what happened in September, you'll see that two of three strains in the vaccine that was recommended for the Northern Hemisphere … were changed. That means that vaccine manufacturers have actually had an opportunity to obtain the strains that were used for the Southern Hemisphere production and to work with those strains," Dr. Cox said. "So they're not starting with a totally clean slate."
Vaccine manufacturers in the Southern Hemisphere haven't had experience with the H1N1 strain during the production season. Updated from the Solomon Islands-like virus to a Brisbane/59/2007-like virus, H1N1 viruses have circulated globally and caused outbreaks in other countries. Because the viruses were changing and the vaccine-induced antibodies weren't covering the current strains as well, WHO recommended the vaccine be updated. The FDA concurred.
Whether the influenza vaccine will be available in time next year is unknown. One of the key factors involved in formulating, testing, and shipping the vaccine on schedule is how well the virus strains grow. Shortages and delays are possible if manufacturers encounter any problems during the growth stage.
"And, of course, when you change strains, the growth properties of the new strains are unpredictable. Some strains inherently grow better than others," Dr. Cox said.
Influenza-vaccine production takes eight months to complete. The nation's 100 million doses typically ship in August.
More information is available on the CDC Web site at www.cdc.gov/flu .
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