Symptoms of distress

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. The U.S. government has responded with $1.9 billion in funding and an additional $5.8 billion in contingency funds.

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.

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, environmental 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.

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 senior-living 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.”

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