HomeMy WebLinkAbout2009- June File Copy
Jefferson County
Board of 3leaCth
Agenda
.tel inutes
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June 18, 2009
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JEFFERSON COUNTY BOARD OF HEALTH
June 18, 2009
Jefferson County Public Health
615 Sheridan Street
Port Townsend, WA
2:30—4:30 PM
DRAFT AGENDA
I. Approval of Agenda
II. Approval of Minutes of May 21, 2009 Board of Health Meeting
III. Public Comments
IV. Old Business and Informational Items
1. First West Nile Virus Identification
2. Review of Jefferson County Board of Health Bylaws
V. New Business
• 1. Influenza A/SWH1 ("Swine Flu") Lessons Learned, Preparedness and
Response Challenges
2. Washington State Department of Health Budget Cuts: Impacts on Local
Health Jurisdictions
2. National Health Reform: A Role for Local Health Policy Makers
VI. Activity Update
1. Washington State Board of Health Meeting, Port Ludlow, July 8, 2009
VII. Agenda Planning
VIII. Next Scheduled Meeting: July 16, 2009
2:30—4:30 PM
Jefferson County Public Health
•
JEFFERSON COUNTY BOARD OF HEALTH
MINUTES
Thursday, May 21, 2009 2:30 PM—4:30 PM
Health Department Conference Room, 615 Sheridan Street, Port Townsend
Board Members Staff Members
Phil Johnson, County Commissioner District#1 Thomas Locke,MD,Health Officer
David Sullivan, County Commissioner,District#2 Jean Baldwin,Public Health Services Director
John Austin, County Commissioner,District#3 Julia Danskin,Nursing Services Director
Michelle Sandoval,Port Townsend City Council
Sheila Westerman, Chair, Citizen at large(City)
Chuck Russell, Vice Chair,Hospital Commissioner,District#2
Roberta Frissell, Citizen at large(County)
Chair Sheila Westerman called the meeting of the Jefferson County Board of Health to order at
2:30 PM.
Members Present: John Austin, Roberta Frissell, Phil Johnson, Chuck Russell, David Sullivan,
Sheila Westerman
Absent: Michelle Sandoval,
Staff Present: Dr. Thomas Locke, Julia Danskin
• A quorum was present.
APPROVAL OF AGENDA
Member Russell moved and Member Austin seconded for approval of the agenda. The
agenda was approved unanimously.
APPROVAL OF MINUTES
Member Austin moved for approval of the minutes of April 16,2009; Member Sullivan
seconded. The minutes of April 16,2009 were approved unanimously.
PUBLIC COMMENTS
There were no public comments.
OLD BUSINESS and INFORMATIONAL ITEMS
• Member Austin announced that the State Board of Health may stop by for a brief visit during this
BOH meeting.
Page 1 of 10
Correspondence to Health and Recovery Services Administration •
Dr. Locke briefly reviewed the April 22 letter from Jean Baldwin and Ford Kessler to Doug
Porter, Health and Recovery Services Administration, regarding potential reduction of County-
level prevention services and anticipated adverse impacts if this does occur.
NEW BUSINESS
Appeal Hearing: Denial of Waiver Request for a Holding Tank on Parcel#701 185 009
Chair Westerman opened the hearing. Member Sullivan inquired as to process and asked
whether there was a script for Chair Westerman to follow. Dr. Locke explained that he would
begin by briefly describing the case, which would be followed by a presentation by the appellant,
Mr. Thomas Brotherton. The hearing would then be open to questions and discussion by the
BOH. The Board packet contained a collection of documents submitted by the Health
Department and the appellant.
Dr. Locke reviewed the history of this case, beginning with the NOCV (Notice and Order to
Correct Violation) in October, 2008 followed by the waiver request for use of a holding tank for
non-commercial, residential use filed in November, 2008. He explained that Washington State
does not allow holding tank use for residential use. Local health officers have the authority to
waive requirements of State public health codes, if it is determined that the waiver application
meets the intent and standards of that code. The appellant had every right to seek a waiver,the •
arguments for which are set out in the documents included in the packet. Dr. Locke said his
conclusion, after careful consideration and reconsideration at each step of the process, is that use
of a holding tank does not meet the intent and standards of the State on-site septic code. The
primary purpose of the code is public health protection. He noted that although protection of the
environment is also important, the primary basis for the code is protection of people. The
specific technical standards are directed at treatment and disposal of waste. At this site, there is
an alternative readily available, and that is to connect to the existing on-site system. Dr. Locke
said that he had polled the Environmental Health Directors across the state and none of the
respondents allowed holding tanks for residential use or for RVs on residential property. Mason
County does allow holding tanks for certain types of RVs with restrictions. For Park Model
trailers, Mason County requires a building permit and does not allow use of holding tanks.
Chair Westerman sought clarification on the basis of the distinction between commercial and
residential use of holding tanks. Dr. Locke said that commercial applications include, for
example, seasonal recreation vehicle parks where holding tanks can be monitored and pumped
on a regular basis. There are also uses of holding tank applications at short-term project
locations where the tank will be removed at the close of the project. Staff noted that holding tank
permits are sometimes used at State and County Parks. In Jefferson County, there are no permits
for commercial operations at this time. Holding tanks may be permitted as a temporary or
emergency solution when failing septic systems are being repaired. For residential wastewater
disposal, the goal is to dispose of sewage on-site, which also has the benefit of aquifer recharge
at the location where water is drawn. •
Page 2 of 10
Dr. Locke said that in the final analysis,there is an excellent alternative for the appellant, and
that there is no compelling reason to grant a waiver from the requirements of the state on-site
sewage code.
Member Sullivan asked for clarification on the status of the holding tank and when it was
installed. Dr. Locke said that the tank had been installed prior to the application for waiver. He
had agreed to place further enforcement action on hold during the waiver application and
administrative review process. He said the goal is to make every effort to help solve the
problem.
Chair Westerman then asked the appellant, Mr. Thomas Brotherton, to present his case. Mr.
Brotherton stepped through a 25-slide presentation entitled Appeal to the Health Board: Public
Health Department Denial of Request to use a Holding Tank Sewage System at a part-time use
RV.
Mr. Brotherton explained that when he decided to purchase and install his Park Model RV (420
square feet)and holding tank he had made an erroneous assumption about the State and County
regulations with regard to the holding tank. He stated that he and his wife are well educated, and
had thoroughly considered the use and capacity issues before installation. They believed they
were making reasonable, responsible choices.
Mr. Brotherton reviewed his understanding of the State and Jefferson County regulations and of
• the procedural background of this case. He identified two policy issues: 1) Should the County
follow the State regulations for on site septic systems and 2) Should holding tanks be the
preferred OSS (On-site Sewage System) for part-time usage situations?
Mr. Brotherton then provided a brief history and overview of septic system design and use. He
discussed the evolution of design issues and features of septic systems over time. He said the
Washington State OSS rules are actually"Design Requirements"based on soil characteristics,
load and site dimension/topography. He reviewed the purpose and content of WAC 246-272A-
001, and its references to RCW 43.20.050; RCW 43.70.310; RCW18.210 and WAC 196-33.
He also reviewed WAC 246-272A-0420, Waiver of State regulations.
Mr. Brotherton said that he had concluded that the term "waiver" is inappropriate, and is
inconsistent with the way the State uses the"waiver" process. That is, it is used to address
uncommon applications, where the standard OSS requirements do not fit. He discussed the Class
A, "pre-approved' waiver; he said the State automatically approves this waiver if certain
conditions are met. He said that the alternative must still meet the health protection requirements;
it is not a lesser solution. He questioned why Jefferson County has a policy that follows only
part of State rules.
Mr. Brotherton reviewed his interpretation of the State's "pre-approval", provided that certain
conditions are met. He said that the County does not follow that portion of State code.
• The second major issue Mr. Brotherton discussed is whether or not holding tanks should be the
preferred OSS for part-time usage? First, he reviewed the "worst case scenario"that is
Page 3 of 10
� w
frequently cited as the justification for not allowing holding tanks, stating that this failure
situation has never happened. He noted that holding tanks have no design issue because they do
not discharge to the environment, and that the waiver rules are intended to ensure that they are
properly operated.
Mr. Brotherton said that he wishes to be as environmentally sensitive as possible, and that being
forced to connect to his existing septic system will cause more pollution than use of a holding
tank. He said it is not a question of cost, but of adding more pollution to the environment than
necessary. He said the BOH is charged with protection of the environment as well as the health
of the public.
He cited studies by the EPA showing the effectiveness of septic systems in removing fecal
coliform,phosphorus and other contaminants versus a holding tank, assuming contents are
hauled to a community sewage system for treatment. He also reviewed the design and operation
of a typical septic tank, noting that that an installed system does not perform optimally for the
first few months of operation. In addition, he said they do not perform well when not used
regularly, steadily and continuously. He reviewed concerns about septic systems and the factors
which can contribute to septic system failure.
Mr. Brotherton reviewed the comparative 20 year costs of septic systems versus holding tanks.
He said that for his own situation the costs would be comparable, i.e. in the same range. In
summary, he said that for"occasional use" situations, a holding tank is the only environmentally
sound solution.
In closing, Mr. Brotherton requested that the BOH adopt two policies: 1) "Jefferson County
Public Health shall follow the state regulations for On Site Septic Systems and approve those
waiver applications for WAC 246-272A which meet the state conditions."and 2) "Holding tanks
shall be the preferred OSS for part-time usage situations where the average inactive period is
greater than 4 weeks."
Chair Westerman opened the floor to questions from the BOH. Member Johnson requested
clarification on Mr. Brotherton's statement about the total absence of holding tank failures in the
State. Mr. Brotherton said that he had spoken with a State official (Mr. Roosevelt) who said he
had no recollection or records of such a failure. Mr. Brotherton stated that the EPA estimates
that more than half of all installed septic systems are not functioning properly. He cited an
example in Brisbane,Australia, where water pollution problems led to the discovery that 80%of
the septic systems were not functioning properly. He repeated his assertion that a septic tank
solution in his case was not the best solution. He said that if State code is interpreted properly,
and if the intended meaning of"waiver" is recognized, he should be granted the right to the
holding tank solution.
Chair Westerman said that in her reading of this issue, she believes the State is using the term
waiver in the same way one would use the term conditional use permit. She cited her experience
with the process of conditional use permits and participation in City Council hearings. She said
that this applies to circumstances in which a permit applicant cannot meet the current
regulations, and that is what is being dealt with in the"waiver policy" issue under discussion. •
She said that the working policy provides that meeting the current regulations is preferred. If
Page 4 of 10
not, then there is a process to follow for determining a possible alternative. She said she did not
wish to allow this body to become distracted from the essential issues.
Chair Westerman referred to reference 76,page 54 of 65, Washington Department of Health
publication number 337-006. She pointed out that this permitting information appears in several
places in the packet. She cited the passages under 2.1.1 Emergency Use and 2.1.2 Permanent
Use, i.e. where the local health officer may permit Holding Tank Sewage Systems. She said that
although the state waiver system may be somewhat confusing, this section clearly indicates when
a holding tank solution may be permitted, and that this case does not fit those conditions. She
said she was impressed with the appellant's presentation, but that this section shows why the
holding tank is not permissible: it is not an emergency, it is not a part-time commercial use
situation, and it is not a repair of an on-site sewage situation. Chair Westerman said she agreed
with much of what the appellant had said about the effectiveness of municipal sewage
treatments. She also said that septic systems are very effective when properly designed and
maintained. She also noted that there are monitoring and enforcement issues for both septic and
holding tank scenarios. She said that she believes there have been few or no failures of holding
tanks because very few have been permitted, and that they have generally been discouraged.
Lastly, she said that she would support the Health Officer's decision.
Mr. Brotherton stated that there are built in guarantees that his holding tank would be in
compliance and safe. He referred to the Waiver Application Guide and the requirement that his
system would be inspected by a licensed inspector. He said he had signed a contract to that
effect.
• Dr. Locke said that there is a semantic misunderstanding, but it is not with regard to the issue of
waiver, but of pre-approval. He said that prior to 1994 the State Department of Health had to
approve any waiver granted by a local health jurisdiction. This authority was removed by the
Washington State Legislature in 1994. Under the current rules, the decision rests with the local
jurisdiction. The power of the State is to review these waivers and if they determine there is a
pattern of misuse of the waiver authority, they may withdraw the ability for that local jurisdiction
to grant waivers. For so called "pre-approved waivers", the conditions cited are the minimum
criteria that must be met for the state to consider the waiver to be appropriate. The fundamental
responsibility to make the decision of whether or not the waiver meets the intent and standards of
the code lies with the local health officer, not the State. He added that he did not believe that
anyone at the State Department of Health would say that Class A waivers are a guarantee or
entitlement that anyone who meets the standards will receive a local waiver. It is up to the local
health officer to review the specific conditions of each case and approve or deny a waiver based
on these case-specific circumstances.
Dr. Locke also addressed the issue of hauling waste to treatment facilities on either a large or
small scale. He noted that although the environmental impact is not the primary focus of on-site
sewage codes, it is incorrect to assume that use of holding tanks has a smaller carbon footprint
and less adverse environmental impact than on-site systems. Holding tanks require commercial
pumpers to physically transport wastewater to treatment facilities, consuming large amounts of
fossil fuels. He also noted that the pumped/hauled waste is not always treated at a treatment
• facility with optimal processing, such as the Port Townsend municipal facility; the destination
facility is determined by the pumper. The consistent policy of the State is that holding tanks
Page Sof 10
have very limited application. He said the way to lower the environmental impact is to ensure •
that the main septic system on the property is working at peak efficiency. He also noted that the
"start up" issue mentioned by the appellant is avoided when wastewater is combined with an
existing system.
Member Austin asked for clarification on whether the appellant would be required to install/
upgrade to a new septic system or simply connect to the existing one. Dr. Locke said there are
two options. Mr. Brotherton has the legal right to build a free standing septic system, since there
are adequate soil conditions and adequate acreage. A more cost effective solution would be to
tie into the existing system.
Mr. Brotherton stated that his current system is designed for a 2 bedroom house and he had
reservations about placing greater demand on that system. He also said he did not wish to be
forced, in effect,by the government to add additional pollution to the environment.
There was a question from Member Johnson about the authority for the State rules. Dr. Locke
said that, in the document referenced above (DOH publication 337-006), there is a restatement of
WAC 246-272A which does have the force of law.
Member Russell stated that he agreed with Chair Westerman's comments and citations, and
pointed out the importance of the previous sentence in the same section: "The local health officer
may permit Holding Tank Sewage Systems only in the following cases:"
In response to a question from Member Johnson, Dr. Locke said that the holding tanks in this .
setting are very clearly prohibited by State code. Exceptions or waivers to that pollicy can
nsbe his
made by the local jurisdiction on a case by case basis. In this particular case,
decision is that the case does not meet the criteria for this type of waiver, so the State law stands.
The intent of the code is to assure the safe local disposal of waste water generated on the site and
disposed of on the site, unless connected to a sewer system.
Mr. Brotherton asked Dr. Locke to point out the code source for the above named intent. Dr.
Locke said that goal is embodied in the whole code and is the reason for the existence of the
code and its detailed operationalholding rt nks is that. He said the one not mayse holding tank in a
ards are specific design
requirements. The standard for
residential setting.
Mr. Brotherton stated that the above is only a partial statement; a complete statement would be
that one may not use a holding tank in a residential setting,unless ..... He said such a statement
is not in the code because the State is not allowed to make partial solutions. He said that
everything the State approves must meet the requirements. He said his entire concern is the
assumption that the citizen will not comply with the regulations.
Member Sullivan stated that the County does not have the capacity to manage these types of
exceptional situations now or in the future to ensure that the intent will be followed. He said the
County must treat everyone the same and cannot create a system to accommodate these special
situations. •
Page 6 of 10
Chair Westerman referred to packet log 158,page 50, i.e. the text of WAC 246-272A-0240. She
• read aloud lines (1), (2), (a), (b), and(c). She said that Mr. Brotherton clearly did not meet the
criteria for a waiver.
Mr. Brotherton repeated his differing interpretation of the WAC and the Waiver Application
Guide. Chair Westerman restated that the word "may" is a very specific word. She said it gives
the local health officer direction, i.e. three cases in which he "may"grant the waiver. Further, if
the waiver is granted, then it provides requirements for the holding tank system. The waiver is
prerequisite to application of the criteria in(3, a, b, c). Meeting the criteria in(3) does not entitle
one to a waiver, simply by skipping(2).
Mr. Brotherton maintained that the structure of the WAC should be interpreted to mean that if
the conditions of(3) are fulfilled, the holding tank is permitted.
Member Austin acknowledged that Mr. Brotherton had made an articulate case for the use of
holding tanks. However, he said the County must uphold the law, as it is written, and holding
tanks are not permitted in residential settings. He suggested that Mr. Brotherton would need to
make his recommendations to the legislature.
Mr. Brotherton responded to Member Sullivan's earlier comments. He stated that there would be
no extra enforcement or effort by the County if a holding tank waiver was granted to him, based
on the contracts that are in place.
• Member Frissell stated that Mr. Brotherton is challenging State law and that it is not the purview
of the BOH to change the State regulations.
Member Sullivan stated that Mr. Brotherton had mentioned his position as a County deputy
prosecutor. He asked Mr. Brotherton if he had consulted with the County Prosecutor regarding
interpretation. Mr. Brotherton said that he had spoken with Ms. Dalzell earlier in the day. Chair
Westerman indicated that if the BOH wished to have the County Prosecutor review WAC 246-
272A-0240 that could be arranged prior to ruling on this appeal.
Dr. Locke said that Deputy Prosecutor Alvarez had been informed of this case at the point of
waiver denial and has kept him apprised of the appeal process. Mr. Alvarez had elected not to be
part of this BOH hearing, on the basis that it may be a potential conflict if there were to be
related litigation in the future. Dr. Locke said the authority to make waiver decision of this type
is a judgment call for the health officer. He again briefly explained the reasons for his decision
to deny the waiver. In addition, he commented that it would be a horrible precedent to grant a
waiver simply because the applicant does not wish to meet the requirements of the code.
Member Austin moved that the BOH uphold the decision of the Health Officer; Member
Sullivan seconded. The motion was approved unanimously.
Chair Westerman thanked Mr. Brotherton for his presentation and closed the hearing at 4:10 PM.
Mr. Brotherton provided copies of his PowerPoint presentation to staff and left the meeting at
• this time.
Page 7 of 10
I
H1N1 Influenza ("Swine Flu"): Jefferson County Pandemic Preparedness Activities
Dr. Locke stated that Swine Flu Response has involved a great deal of work in recent weeks,
with more anticipated. The first case in Jefferson County had been identified earlier in the day.
The response started on Friday, April 24 when Dr. Locke was contacted by the Kitsap County
Health Officer to alert him regarding the national level over the n Mexico weekend,
ty. He said that
eergency response had goneand there had long hours of
work for several weeks. He described the rapid spread of the virus,which is in a class know as
"triple re-assortment viruses". There are three ways that viruses mutate; reassortment is one of
them. Prior to the emergence of this virus,reassortment viruses have only been a threat to pig
handlers. These were diseases of swine that people could contract occasionally. There were 11
known cases of triple assortment viruses in the US since 2005. This one has become
transmissible from human to human. The place of origin hasenvironmentnoteen to the disease to spread.
. With a
population of 22 million people, Mexico City has an ideal
Initial reports from there indicated a high death rate and a new virus which prompted a rapid and
intense public health response.
Chair Westerman asked whether or not the cause of the high death rate there is known. Dr.
Locke said that initially there were reports of a 5 to 10%mortality rate, which would be twice
the 1918 pandemic mortality rate of 2.5%. At this time,there are in excess of 45 confirmed
deaths in Mexico City,but it is likely that there have been hundreds of thousands, possibly •
millions, of cases that were relatively mild. He said that it is now believed that because this
strain is mild, many people did not know they had swine flu or were not diagnosed/reported.
The complication rate is very low. He said we have become less fearful as evidence has
emerged, but realize that this may be followed by a more serious second wave, possibly in the
fall of 2009. Dr. Locke said that the virus will likely spread to the Southern Hemisphere during
their winter flu season that is just now beginning.
In response to a question about vaccine protection, Dr. Locke said that the capability to produce
a vaccine exists; a decision would need to be made by mid June. But,there would be insufficient
time to produce enough for the entire population before the flu season, unless certain new
technologies could be ramped up quickly. He noted that the current technology, using up to 3
fertilized eggs to create each dose of influenza vaccine,was created in the 1930s. Cell culture
techniques are under development and would enable much faster mass production of vaccines.
In response to a question, Dr. Locke confirmed that the under 50 age group (predominantly
under 20), are more likely to get the disease. This suggests that older populations have some
residual immunity from previous forms on influenza.
With regard to the first case reported in Jefferson County, Dr. Locke said he would be speaking
with the provider directly after the meeting. The exposure could have taken place within the
State, and was not necessarily due to travel in Mexico.
•
Page 8 of 10
Chair Westerman asked if triple reassortment viruses could become more lethal over time, and
• what is the mechanism at work. Dr. Locke said that the influenza virus carries its genes in 8
discreet, swappable packets. The new H1N1 virus is composed of 2 parts Avian, 3 parts North
American Swine, 3 parts Eurasian swine, and one part human influenza. All parts are
interchangeable. There it is the possibility that additional swapping will occur,producing am
more dangerous form of influenza.
Member Johnson asked if it was possible for people who had the swine flu this season to get the
same flu again in the next flu season. Dr. Locke said it is possible but not probable. There was
further discussion about a strategy that would allow most people to risk getting the disease now,
which would protect them in the next wave. Dr. Locke pointed out that any flu can be lethal and
the normal rate of 1 death per 1,000 cases. Also, one of the biggest fears is that a mutation will
occur that combines the swine flu virus with another of the circulating seasonal flu strains.
The fact that this became a level 5 pandemic alert triggered distribution of the national pandemic
stockpile. The County accepted a supply of 1,000 doses based on the severity and risk
information available at the time, and in consideration of the Hood Canal bridge closure. The
amount of Tamiflu available at local pharmacies and the hospital was fairly low, as well. Julia
Danskin said that the Health Department will make certain sufficient supplies are on hand for the
fall.
Dr. Locke discussed the relatively low efficacy of Tamiflu with seasonal flu, which is generally
reserved for the severely ill or those who are at high risk for complications. It shortens the
duration of illness by 12 to 24 hours, and it must be used in the first 48 hours. With seasonal flu,
it lowers the rate of hospitalization by 1%.
Jefferson County Lakes Update For Toxic Algae
Dr. Locke said that there is a new type of blue-green algae present in Lake LeLand, i.e.
Oscillatoria. The other forms are Anabaena, Aphanizomenon and Microcystis (otherwise called
Annie, Fannie and Mike). Oscillatoria produces a neurotoxin; Lakes Leland and Anderson are
still "hot", with levels going up. These lakes, especially Lake Anderson, are apparently good
habitat for these algae. He said that it may be prudent to change the fishing season to winter
months, when algae levels are lowest.
In response to a question regarding treatment to kill algae, Dr. Locke said that most measures
actually cause more toxins to be released into the water. Normally, the toxins produced do not
get into the water. The decaying material falls to the bottom and is broken down into the
sediment. However, much is still unknown about these toxins. No clearly discernable patterns
regarding timing and volumes of the toxic algae have yet been determined.
•
Page 9 of 10
110
Adjournment
Chair Westerman adjourned the meeting at 4:32 PM.
JEFFERSON COUNTY BOARD OF HEALTH
Sheila Westerman, Chair
Phil Johnson, Member
Chuck Russell, Vice-Chair
John Austin,Member
410
Roberta Frissell, Member
David Sullivan,Member
Absent
Michelle Sandoval, Member
•
Page 10 of 10
JEFFERSON COUNTY BOARD OF HEALTH
• MINUTES
Thursday, May 21, 2009 2:30 PM—4:30 PM
Health Department Conference Room, 615 Sheridan Street, Port Townsend
Board Members Staff Members
Phil Johnson, County Commissioner District#1 Thomas Locke,MD,Health Officer
David Sullivan, County Commissioner,District#2 Jean Baldwin, Public Health Services Director
John Austin, County Commissioner,District#3 Julia Danskin,Nursing Services Director
Michelle Sandoval,Port Townsend City Council
Sheila Westerman, Chair, Citizen at large(City)
Chuck Russell, Vice Chair,Hospital Commissioner,District#2
Roberta Frissell, Citizen at large(County)
Chair Sheila Westerman called the meeting of the Jefferson County Board of Health to order at
2:30 PM.
Members Present: John Austin, Roberta Frissell, Phil Johnson, Chuck Russell, David Sullivan,
Sheila Westerman
Absent: Michelle Sandoval,
Staff Present: Dr. Thomas Locke, Julia Danskin
• A quorum was present.
APPROVAL OF AGENDA
Member Russell moved and Member Austin seconded for approval of the agenda. The
agenda was approved unanimously.
APPROVAL OF MINUTES
Member Austin moved for approval of the minutes of April 16, 2009; Member Sullivan
seconded. The minutes of April 16, 2009 were approved unanimously.
PUBLIC COMMENTS
There were no public comments.
OLD BUSINESS and INFORMATIONAL ITEMS
• Member Austin announced that the State Board of Health may stop by for a brief visit during this
BOH meeting.
Page 1 of 10
Correspondence to Health and Recovery Services Administration
Dr. Locke briefly reviewed the April 22 letter from Jean Baldwin and Ford Kessler to Doug
Porter, Health and Recovery Services Administration, regarding potential reduction of County-
level prevention services and anticipated adverse impacts if this does occur.
NEW BUSINESS
Appeal Hearing: Denial of Waiver Request for a Holding Tank on Parcel#701 185 009
Chair Westerman opened the hearing. Member Sullivan inquired as to process and asked
whether there was a script for Chair Westerman to follow. Dr. Locke explained that he would
begin by briefly describing the case, which would be followed by a presentation by the appellant,
Mr. Thomas Brotherton. The hearing would then be open to questions and discussion by the
BOH. The Board packet contained a collection of documents submitted by the Health
Department and the appellant.
Dr. Locke reviewed the history of this case, beginning with the NOCV (Notice and Order to
Correct Violation) in October, 2008 followed by the waiver request for use of a holding tank for
non-commercial,residential use filed in November, 2008. He explained that Washington State
does not allow holding tank use for residential use. Local health officers have the authority to
waive requirements of State public health codes, if it is determined that the waiver application •
meets the intent and standards of that code. The appellant had every right to seek a waiver, the
arguments for which are set out in the documents included in the packet. Dr. Locke said his
conclusion, after careful consideration and reconsideration at each step of the process, is that use
of a holding tank does not meet the intent and standards of the State on-site septic code. The
primary purpose of the code is public health protection. He noted that although protection of the
environment is also important,the primary basis for the code is protection of people. The
specific technical standards are directed at treatment and disposal of waste. At this site, there is
an alternative readily available, and that is to connect to the existing on-site system. Dr. Locke
said that he had polled the Environmental Health Directors across the state and none of the
respondents allowed holding tanks for residential use or for RVs on residential property. Mason
County does allow holding tanks for certain types of RVs with restrictions. For Park Model
trailers, Mason County requires a building permit and does not allow use of holding tanks.
Chair Westerman sought clarification on the basis of the distinction between commercial and
residential use of holding tanks. Dr. Locke said that commercial applications include, for
example, seasonal recreation vehicle parks where holding tanks can be monitored and pumped
on a regular basis. There are also uses of holding tank applications at short-term project
locations where the tank will be removed at the close of the project. Staff noted that holding tank
permits are sometimes used at State and County Parks. In Jefferson County, there are no permits
for commercial operations at this time. Holding tanks may be permitted as a temporary or
emergency solution when failing septic systems are being repaired. For residential wastewater
disposal,the goal is to dispose of sewage on-site, which also has the benefit of aquifer recharge •
at the location where water is drawn.
Page 2 of 10
• Dr. Locke said that in the final analysis, there is an excellent alternative for the appellant, and
that there is no compelling reason to grant a waiver from the requirements of the state on-site
sewage code.
Member Sullivan asked for clarification on the status of the holding tank and when it was
installed. Dr. Locke said that the tank had been installed prior to the application for waiver. He
had agreed to place further enforcement action on hold during the waiver application and
administrative review process. He said the goal is to make every effort to help solve the
problem.
Chair Westerman then asked the appellant, Mr. Thomas Brotherton, to present his case. Mr.
Brotherton stepped through a 25-slide presentation entitled Appeal to the Health Board: Public
Health Department Denial of Request to use a Holding Tank Sewage System at a part-time use
RV.
Mr. Brotherton explained that when he decided to purchase and install his Park Model RV (420
square feet) and holding tank he had made an erroneous assumption about the State and County
regulations with regard to the holding tank. He stated that he and his wife are well educated, and
had thoroughly considered the use and capacity issues before installation. They believed they
were making reasonable, responsible choices.
Mr. Brotherton reviewed his understanding of the State and Jefferson County regulations and of
• the procedural background of this case. He identified two policy issues: 1) Should the County
follow the State regulations for on site septic systems and 2) Should holding tanks be the
preferred OSS (On-site Sewage System) for part-time usage situations?
Mr. Brotherton then provided a brief history and overview of septic system design and use. He
discussed the evolution of design issues and features of septic systems over time. He said the
Washington State OSS rules are actually "Design Requirements" based on soil characteristics,
load and site dimension/topography. He reviewed the purpose and content of WAC 246-272A-
001, and its references to RCW 43.20.050; RCW 43.70.310; RC W 18.210 and WAC 196-33.
He also reviewed WAC 246-272A-0420, Waiver of State regulations.
Mr. Brotherton said that he had concluded that the term "waiver" is inappropriate, and is
inconsistent with the way the State uses the "waiver"process. That is, it is used to address
uncommon applications, where the standard OSS requirements do not fit. He discussed the Class
A, "pre-approved' waiver; he said the State automatically approves this waiver if certain
conditions are met. He said that the alternative must still meet the health protection requirements;
it is not a lesser solution. He questioned why Jefferson County has a policy that follows only
part of State rules.
Mr. Brotherton reviewed his interpretation of the State's "pre-approval", provided that certain
conditions are met. He said that the County does not follow that portion of State code.
• The second major issue Mr. Brotherton discussed is whether or not holding tanks should be the
preferred OSS for part-time usage? First, he reviewed the "worst case scenario"that is
Page 3of10
frequently cited as the justification for not allowing holding tanks, stating that this failure
situation has never happened. He noted that holding tanks have no design issue because they do •
not discharge to the environment, and that the waiver rules are intended to ensure that they are
properly operated.
Mr. Brotherton said that he wishes to be as environmentally sensitive as possible, and that being
forced to connect to his existing septic system will cause more pollution than use of a holding
tank. He said it is not a question of cost,but of adding more pollution to the environment than
necessary. He said the BOH is charged with protection of the environment as well as the health
of the public.
He cited studies by the EPA showing the effectiveness of septic systems in removing fecal
coliform,phosphorus and other contaminants versus a holding tank, assuming contents are
hauled to a community sewage system for treatment. He also reviewed the design and operation
of a typical septic tank, noting that that an installed system does not perform optimally for the
first few months of operation. In addition,he said they do not perform well when not used
regularly, steadily and continuously. He reviewed concerns about septic systems and the factors
which can contribute to septic system failure.
Mr. Brotherton reviewed the comparative 20 year costs of septic systems versus holding tanks.
He said that for his own situation the costs would be comparable, i.e. in the same range. In
summary,he said that for"occasional use" situations, a holding tank is the only environmentally
sound solution.
In closing, Mr. Brotherton requested that the BOH adopt two policies: 1)"Jefferson County •
Public Health shall follow the state regulations for On Site Septic Systems and approve those
waiver applications for WAC 246-272A which meet the state conditions." and 2) "Holding tanks
shall be the preferred OSS for part-time usage situations where the average inactive period is
greater than 4 weeks."
Chair Westerman opened the floor to questions from the BOH. Member Johnson requested
clarification on Mr. Brotherton's statement about the total absence of holding tank failures in the
State. Mr. Brotherton said that he had spoken with a State official (Mr. Roosevelt)who said he
had no recollection or records of such a failure. Mr. Brotherton stated that the EPA estimates
that more than half of all installed septic systems are not functioning properly. He cited an
example in Brisbane, Australia,where water pollution problems led to the discovery that 80%of
the septic systems were not functioning properly. He repeated his assertion that a septic tank
solution in his case was not the best solution. He said that if State code is interpreted properly,
and if the intended meaning of"waiver" is recognized,he should be granted the right to the
holding tank solution.
Chair Westerman said that in her reading of this issue, she believes the State is using the term
waiver in the same way one would use the term conditional use permit. She cited her experience
with the process of conditional use permits and participation in City Council hearings. She said
that this applies to circumstances in which a permit applicant cannot meet the current
regulations, and that is what is being dealt with in the "waiver policy" issue under discussion. •
She said that the working policy provides that meeting the current regulations is preferred. If
Page 4 of 10
not, then there is a process to follow for determining a possible alternative. She said she did not
• wish to allow this body to become distracted from the essential issues.
Chair Westerman referred to reference 76, page 54 of 65, Washington Department of Health
publication number 337-006. She pointed out that this permitting information appears in several
places in the packet. She cited the passages under 2.1.1 Emergency Use and 2.1.2 Permanent
Use, i.e. where the local health officer may permit Holding Tank Sewage Systems. She said that
although the state waiver system may be somewhat confusing, this section clearly indicates when
a holding tank solution may be permitted, and that this case does not fit those conditions. She
said she was impressed with the appellant's presentation, but that this section shows why the
holding tank is not permissible: it is not an emergency, it is not a part-time commercial use
situation, and it is not a repair of an on-site sewage situation. Chair Westerman said she agreed
with much of what the appellant had said about the effectiveness of municipal sewage
treatments. She also said that septic systems are very effective when properly designed and
maintained. She also noted that there are monitoring and enforcement issues for both septic and
holding tank scenarios. She said that she believes there have been few or no failures of holding
tanks because very few have been permitted, and that they have generally been discouraged.
Lastly, she said that she would support the Health Officer's decision.
Mr. Brotherton stated that there are built in guarantees that his holding tank would be in
compliance and safe. He referred to the Waiver Application Guide and the requirement that his
system would be inspected by a licensed inspector. He said he had signed a contract to that
effect.
• Dr. Locke said that there is a semantic misunderstanding, but it is not with regard to the issue of
waiver, but of pre-approval. He said that prior to 1994 the State Department of Health had to
approve any waiver granted by a local health jurisdiction. This authority was removed by the
Washington State Legislature in 1994. Under the current rules, the decision rests with the local
jurisdiction. The power of the State is to review these waivers and if they determine there is a
pattern of misuse of the waiver authority, they may withdraw the ability for that local jurisdiction
to grant waivers. For so called "pre-approved waivers", the conditions cited are the minimum
criteria that must be met for the state to consider the waiver to be appropriate. The fundamental
responsibility to make the decision of whether or not the waiver meets the intent and standards of
the code lies with the local health officer, not the State. He added that he did not believe that
anyone at the State Department of Health would say that Class A waivers are a guarantee or
entitlement that anyone who meets the standards will receive a local waiver. It is up to the local
health officer to review the specific conditions of each case and approve or deny a waiver based
on these case-specific circumstances.
Dr. Locke also addressed the issue of hauling waste to treatment facilities on either a large or
small scale. He noted that although the environmental impact is not the primary focus of on-site
sewage codes, it is incorrect to assume that use of holding tanks has a smaller carbon footprint
and less adverse environmental impact than on-site systems. Holding tanks require commercial
pumpers to physically transport wastewater to treatment facilities, consuming large amounts of
fossil fuels. He also noted that the pumped/hauled waste is not always treated at a treatment
• facility with optimal processing, such as the Port Townsend municipal facility; the destination
facility is determined by the pumper. The consistent policy of the State is that holding tanks
Page 5 of 10
have very limited application. He said the way to lower the environmental impact is to ensure
that the main septic system on the property is working at peak efficiency. He also noted that the
II/
"start up" issue mentioned by the appellant is avoided when wastewater is combined with an
existing system.
Member Austin asked for clarification on whether the appellant would be required to install/
upgrade to a new septic system or simply connect to the existing one. Dr. Locke said there are
two options. Mr. Brotherton has the legal right to build a free standing septic system, since there
are adequate soil conditions and adequate acreage. A more cost effective solution would be to
tie into the existing system.
Mr. Brotherton stated that his current system is designed for a 2 bedroom house and he had
reservations about placing greater demand on that system. He also said he did not wish to be
forced, in effect,by the government to add additional pollution to the environment.
There was a question from Member Johnson about the authority for the State rules. Dr. Locke
said that, in the document referenced above (DOH publication 337-006), there is a restatement of
WAC 246-272A which does have the force of law.
Member Russell stated that he agreed with Chair Westerman's comments and citations, and
pointed out the importance of the previous sentence in the same section: "The local health officer
may permit Holding Tank Sewage Systems only in the following cases:"
In response to a question from Member Johnson,Dr. Locke said that the holding tanks in this •
setting are very clearly prohibited by State code. Exceptions or waivers to that policy can be
made by the local jurisdiction on a case by case basis. In this particular case, Dr. Locke said his
decision is that the case does not meet the criteria for this type of waiver, so the State law stands.
The intent of the code is to assure the safe local disposal of waste water generated on the site and
disposed of on the site, unless connected to a sewer system.
Mr. Brotherton asked Dr. Locke to point out the code source for the above named intent. Dr.
Locke said that goal is embodied in the whole code and is the reason for the existence of the
code and its detailed operational standards. He said the standards are specific design
requirements. The standard for holding tanks is that one may not use a holding tank in a
residential setting.
Mr. Brotherton stated that the above is only a partial statement; a complete statement would be
that one may not use a holding tank in a residential setting, unless ..... He said such a statement
is not in the code because the State is not allowed to make partial solutions. He said that
everything the State approves must meet the requirements. He said his entire concern is the
assumption that the citizen will not comply with the regulations.
Member Sullivan stated that the County does not have the capacity to manage these types of
exceptional situations now or in the future to ensure that the intent will be followed. He said the
County must treat everyone the same and cannot create a system to accommodate these special
situations. •
Page 6 of 10
•
Chair Westerman referred to packet log 158,page 50, i.e. the text of WAC 246-272A-0240. She
• read aloud lines (1), (2), (a), (b), and (c). She said that Mr. Brotherton clearly did not meet the
criteria for a waiver.
Mr. Brotherton repeated his differing interpretation of the WAC and the Waiver Application
Guide. Chair Westerman restated that the word "may" is a very specific word. She said it gives
the local health officer direction, i.e. three cases in which he "may" grant the waiver. Further, if
the waiver is granted, then it provides requirements for the holding tank system. The waiver is
prerequisite to application of the criteria in(3, a, b, c). Meeting the criteria in (3) does not entitle
one to a waiver, simply by skipping (2).
Mr. Brotherton maintained that the structure of the WAC should be interpreted to mean that if
the conditions of(3) are fulfilled, the holding tank is permitted.
Member Austin acknowledged that Mr. Brotherton had made an articulate case for the use of
holding tanks. However, he said the County must uphold the law, as it is written, and holding
tanks are not permitted in residential settings. He suggested that Mr. Brotherton would need to
make his recommendations to the legislature.
Mr. Brotherton responded to Member Sullivan's earlier comments. He stated that there would be
no extra enforcement or effort by the County if a holding tank waiver was granted to him, based
on the contracts that are in place.
• Member Frissell stated that Mr. Brotherton is challenging State law and that it is not the purview
of the BOH to change the State regulations.
Member Sullivan stated that Mr. Brotherton had mentioned his position as a County deputy
prosecutor. He asked Mr. Brotherton if he had consulted with the County Prosecutor regarding
interpretation. Mr. Brotherton said that he had spoken with Ms. Dalzell earlier in the day. Chair
Westerman indicated that if the BOH wished to have the County Prosecutor review WAC 246-
272A-0240 that could be arranged prior to ruling on this appeal.
Dr. Locke said that Deputy Prosecutor Alvarez had been informed of this case at the point of
waiver denial and has kept him apprised of the appeal process. Mr. Alvarez had elected not to be
part of this BOH hearing, on the basis that it may be a potential conflict if there were to be
related litigation in the future. Dr. Locke said the authority to make waiver decision of this type
is a judgment call for the health officer. He again briefly explained the reasons for his decision
to deny the waiver. In addition, he commented that it would be a horrible precedent to grant a
waiver simply because the applicant does not wish to meet the requirements of the code.
Member Austin moved that the BOH uphold the decision of the Health Officer; Member
Sullivan seconded. The motion was approved unanimously.
Chair Westerman thanked Mr. Brotherton for his presentation and closed the hearing at 4:10 PM.
Mr. Brotherton provided copies of his PowerPoint presentation to staff and left the meeting at
• this time.
Page 7 of 10
•
H1N1 Influenza("Swine Flu"): Jefferson County Pandemic Preparedness Activities
Dr. Locke stated that Swine Flu Response has involved a great deal of work in recent weeks,
with more anticipated. The first case in Jefferson County had been identified earlier in the day.
The response started on Friday, April 24 when Dr. Locke was contacted by the Kitsap County
Health Officer to alert him regarding the swine flu activity in Mexico City. He said that
emergency response had gone to the national level over the weekend, and there had long hours of
work for several weeks. He described the rapid spread of the virus, which is in a class know as
"triple re-assortment viruses". There are three ways that viruses mutate; reassortment is one of
them. Prior to the emergence of this virus,reassortment viruses have only been a threat to pig
handlers. These were diseases of swine that people could contract occasionally. There were 11
known cases of triple assortment viruses in the US since 2005. This one has become
transmissible from human to human. The place of origin has not been determined. With a
population of 22 million people, Mexico City has an ideal environment for the disease to spread.
Initial reports from there indicated a high death rate and a new virus which prompted a rapid and
intense public health response.
Chair Westerman asked whether or not the cause of the high death rate there is known. Dr.
Locke said that initially there were reports of a 5 to 10%mortality rate, which would be twice
the 1918 pandemic mortality rate of 2.5%. At this time,there are in excess of 45 confirmed
deaths in Mexico City,but it is likely that there have been hundreds of thousands, possibly •
millions, of cases that were relatively mild. He said that it is now believed that because this
strain is mild, many people did not know they had swine flu or were not diagnosed/reported.
The complication rate is very low. He said we have become less fearful as evidence has
emerged, but realize that this may be followed by a more serious second wave, possibly in the
fall of 2009. Dr. Locke said that the virus will likely spread to the Southern Hemisphere during
their winter flu season that is just now beginning.
In response to a question about vaccine protection, Dr. Locke said that the capability to produce
a vaccine exists; a decision would need to be made by mid June. But, there would be insufficient
time to produce enough for the entire population before the flu season, unless certain new
technologies could be ramped up quickly. He noted that the current technology, using up to 3
fertilized eggs to create each dose of influenza vaccine, was created in the 1930s. Cell culture
techniques are under development and would enable much faster mass production of vaccines.
In response to a question, Dr. Locke confirmed that the under 50 age group (predominantly
under 20), are more likely to get the disease. This suggests that older populations have some
residual immunity from previous forms on influenza.
With regard to the first case reported in Jefferson County, Dr. Locke said he would be speaking
with the provider directly after the meeting. The exposure could have taken place within the
State, and was not necessarily due to travel in Mexico.
•
Page 8 of 10
•
•
•
Chair Westerman asked if triple reassortment viruses could become more lethal over time, and
• what is the mechanism at work. Dr. Locke said that the influenza virus carries its genes in 8
discreet, swappable packets. The new H 1 N 1 virus is composed of 2 parts Avian, 3 parts North
American Swine, 3 parts Eurasian swine, and one part human influenza. All parts are
interchangeable. There it is the possibility that additional swapping will occur, producing am
more dangerous form of influenza.
Member Johnson asked if it was possible for people who had the swine flu this season to get the
same flu again in the next flu season. Dr. Locke said it is possible but not probable. There was
further discussion about a strategy that would allow most people to risk getting the disease now,
which would protect them in the next wave. Dr. Locke pointed out that any flu can be lethal and
the normal rate of 1 death per 1,000 cases. Also, one of the biggest fears is that a mutation will
occur that combines the swine flu virus with another of the circulating seasonal flu strains.
The fact that this became a level 5 pandemic alert triggered distribution of the national pandemic
stockpile. The County accepted a supply of 1,000 doses based on the severity and risk
information available at the time, and in consideration of the Hood Canal bridge closure. The
amount of Tamiflu available at local pharmacies and the hospital was fairly low, as well. Julia
Danskin said that the Health Department will make certain sufficient supplies are on hand for the
fall.
Dr. Locke discussed the relatively low efficacy of Tamiflu with seasonal flu, which is generally
reserved for the severely ill or those who are at high risk for complications. It shortens the
• duration of illness by 12 to 24 hours, and it must be used in the first 48 hours. With seasonal flu,
it lowers the rate of hospitalization by 1%.
Jefferson County Lakes Update For Toxic Algae
Dr. Locke said that there is a new type of blue-green algae present in Lake LeLand, i.e.
Oscillatoria. The other forms are Anabaena, Aphanizomenon and Microcystis (otherwise called
Annie, Fannie and Mike). Oscillatoria produces a neurotoxin; Lakes Leland and Anderson are
still "hot", with levels going up. These lakes, especially Lake Anderson, are apparently good
habitat for these algae. He said that it may be prudent to change the fishing season to winter
months, when algae levels are lowest.
In response to a question regarding treatment to kill algae, Dr. Locke said that most measures
actually cause more toxins to be released into the water. Normally, the toxins produced do not
get into the water. The decaying material falls to the bottom and is broken down into the
sediment. However, much is still unknown about these toxins. No clearly discernable patterns
regarding timing and volumes of the toxic algae have yet been determined.
•
Page 9 of 10
9
•
Adjournment
Chair Westerman adjourned the meeting at 4:32 PM.
JEFFERSON COUNTY BOARD OF HEALTH
01"/(' Ca/4"--'
Sheila Westerman, Chair Phil Johnson, Member
•
Chuck Russell, Vice-Chair J hn Austin, Member
, •
Roberta Frissell, Member David Sullivan, Member
Absent
Michelle Sandoval, Member
Page 10 of 10
•
Board of 3-feaCt(
Old Business
.agenda Items # IV., 1
• First 'West Nile virus
Identification
June 18, 2009
r
• 1i2tri ►€State Department of
News
Release
For immediate release: June 3, 2009 (09-096)
Contacts: Tim Church, Communications Office 360-236-4077
Donn Moyer, Communications Office 360-236-4076
West Nile virus detected in Yakima County mosquitoes — first of the season
Avoiding mosquito bites is key to preventing West Nile infection
OLYMPIA—Mosquito samples collected in Yakima County that tested positive for West Nile
virus are the first signal of the presence of the disease in Washington in 2009. It's one of the
earliest detections of West Nile virus since state health monitoring began in 2001.
Mosquito season is in full swing throughout the state, leading health officials to advise taking
steps to prevent insect bites.
• "We've seen West Nile virus in our state over the last several years," said Gregg Grunenfelder,
environmental health division assistant secretary for the state Department of Health. "And this
year, it's making an early appearance. West Nile virus can be very serious. Taking a few
precautions to avoid mosquito bites can prevent infection."
Three people infected with West Nile virus were reported as Washington cases last year.
Personal protection is a key prevention tool. "The best strategy against diseases transmitted by
mosquitoes is to use bug repellant and wear long pants and sleeves outdoors when mosquitoes
are active," Grunenfelder said. "If you can, stay indoors when mosquitoes are out. But if you're
going to be outside when mosquitoes are buzzing, do what you can to protect yourself"
Simple steps to discourage mosquito breeding can also help. Reduce mosquito larvae habitat
around the home by dumping water that collects in cans, old tires, wading pools, or pet dishes.
And it helps to keep water fresh in birdbaths, fountains, animal troughs, and other places by
changing it once or twice a week. Window and door screens should be in good working order to
• limit the number of mosquitoes that get inside the home.
—More—
West Nile virus season arrives
June 3, 2009
Page 2
For some people, West Nile infection can be very serious, and even fatal. Most people bitten by a •
mosquito carrying West Nile virus don't become ill,yet some may have mild to severe flu-like
symptoms. A small number of people may develop a serious neurological disease. People over 50
and those with compromised immune systems are at higher risk for serious illness.
In addition to the three human cases in Washington last year,41 horses, 24 birds, and 57
mosquito samples tested positive for West Nile virus in 2008. Most were in Yakima and Benton
Counties; detections were also made elsewhere in central Washington as well as west of the
Cascade Mountains.
The Benton County Mosquito Control District collected the positive mosquito samples in
Yakima County near the Benton-Yakima County line. The mosquito control district plans to
spray for mosquitoes this week. For information on the spraying schedule, contact the mosquito
control district office, 509-967-2414.
Visit the Washington Department of Health Web site at http://www.doh.wa.gov for a healthy dose of information.
•
Board-of 3Cealth
Netiv Business
.agenda Item # 1�, 1
Influenza NS1N3-11
("Swine Flue ")
• Lessons Learned, Preparedness &
Response Challenges
June 18, 2009
•
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ISSUE BRIEF Pandemic Flu Preparedness:
LESSONS FROM THE FRONTLINES
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•
he recent H1N1 (swine) flu outbreak demonstrated how rapidly a new
strain of flu can emerge and spread around the world. As of June 1, 2009,
the H1N1 virus was reported in 62 nations,with nearly 17,500 confirmed cases
and more than 100 deaths. The sudden outbreak of this novel flu virus has
tested the world's public health preparedness. H1N1 provided a real-world test
that showed the strengths and vulnerabilities in the abilities of the United States
and the rest of the world to respond to a major infectious disease outbreak.
This report examines early lessons learned more virulent strain,or if a different strain of
from the response and ongoing concerns influenza,like the H5N1 (bird) flu,emerges.
about overall U.S.preparedness for potential
Overall,the H1N1 outbreak has shown that the
pandemic flu outbreak. The first section re-
investment the country has made in preparing
views 10 key lessons based on the initial re for a potential pandemic flu has significantly im-
sponse to the H1N1 outbreak;and the second proved U.S. capabilities for a large scale infec-
section discusses 10 underlying concerns and tious disease outbreak,but it has also revealed
provides recommendations for addressing se how quickly the nation's core public health ca-
rious continued vulnerabilities in the nation's pacity would be overwhelmed if the outbreak
preparedness in the event that H1N1 returns were more widespread and more severe.
in the fall, either in its current form or as a
• JUNE 2009
PREVENTING EPIDEMICS. 14‘tl
PROTECTING PEOPLE. Robert Wood Johnson Foundation Center for Biosecurity of UPMC
SUMMARY OF TEN EARLY LESSONS LEARNED FROM
THE 2009 H I NI OUTBREAK •
I. Investments in pandemic planning and stockpiling antiviral medications paid off;
2. Public health departments did not have enough resources to carry out plans;
3. Response plans must be adaptable and science-driven;
4. Providing clear,straightforward information to the public was essential for allaying fears
and building trust;
5. School closings have major ramifications for students, parents,and employers;
6. Sick leave and policies for limiting mass gatherings were also problematic;
7. Even with a mild outbreak,the health care delivery system was overwhelmed;
8.Communication between the public health system and health providers was not well coordinated;
9.WHO pandemic alert phases caused confusion;and
10. International coordination was more complicated than expected.
SUMMARY OF TEN RECOMMENDATIONS FOR ADDRESSING CORE
VULNERABILITIES IN U.S. PANDEMIC FLU PREPAREDNESS
In addition to the lessons learned from H I N I,there are a number of systemic gaps in the nation's ability
to respond to a pandemic flu outbreak. To further strengthen U.S.preparedness,the following core
areas must be addressed:
Strategic National Stockpile and Vaccine Development Recommendations:
I. Maintaining the Strategic National Stockpile-- making sure enough antiviral medications,vac-
cinations,and equipment are available to protect Americans,which includes replenishing the stock-
pile when medications and supplies are used;
2.Vaccine development and production --enhancing the biomedical research and development •
abilities of the United States to rapidly develop and produce a vaccine;and
3.Vaccinating all Americans--ensuring that all Americans would be able to be inoculated in a short pe-
riod of time.
Adaptable, Science-Based Planning and Coordination Recommendations:
4. Planning and coordination -- improving coordination among federal,state, and local govern-
ments and the private sector preparedness and planning activities on an ongoing basis, including
taking into account how the nature of flu threats change over time;
5. School closings,sick leave,and community mitigation strategies-- improving strategies to
limit the spread of disease ensuring all working Americans have sick leave benefits and that com-
munities are prepared to limit public gatherings and close schools as necessary;and
6. Global coordination -- building trust,technologies, and policies internationally to encourage sci-
ence-based,consistent decision making across borders during an outbreak.
Core Public Health Infrastructure Improvement Recommendations:
7. Resources-- providing enough funding for the on-the-ground response,which is currently under-
funded and overextended;and
8.Workforce--stopping layoffs at state and local health departments and recruiting the next genera-
tion of public health professionals.
Surge Capacity and Care Recommendations:
9.Surge capacity--improving the ability for health providers to manage a massive influx of patients;and •
10.Caring for the uninsured and underinsured --ensuring that all Americans will receive care
during an emergency,which limits the spread of the contagious disease to others, and making
sure hospitals and health care providers are compensated for providing care.
TEN EARLY LESSONS LEARNED FROM THE 2009
•HINI OUTBREAK SECTION
1.Investments in pandemic planning and stock- of the spread of the virus into a community,
piling antiviral medications paid off. Federal, which resulted in the need for different policies
state,and local efforts to develop and exercise in different places.
pandemic response plans over the last several
Pdiyears enabled public health officials to react to 4' 0� clear,straightforward information to
the outbreak effectively and keep the public in- the public was essential for allaying fears and
formed. Investments in antiviral stockpiles and building trust. Informing the public about what
enhanced vaccine manufacturing capacity also is known about an outbreak, acknowledging
that certain information is not yet known, and
proved to be prudent.
updating facts as they become available is para-
2.Public health departments did not have enough mount to help contain the spread of disease and
resources to carry out plans.Federal,state,and also give people the facts they need to be pre-
local health departments are stretched too thin pared, not scared. During the outbreak, the
to adequately respond to emergencies after President and other leaders around the coun-
decades of underfunding the public health in- try served as clear spokespeople,conveying con-
frastructure. Capacity to track,investigate,and sistent,accurate information about good hand
contain cases of H1N1 has been hampered due hygiene,cough/sneeze etiquette,and the need
to lack of resources. For instance, CDC and for people to stay home if sick. Effective lead-
state laboratory testing was days to more than a ership and communication helped dispel ru-
week behind the on-the-ground reality. Also, mors and myths--from allaying concerns about
the country must make a sustained commit- the safety of imported Mexican foodstuffs to re-
ment to pandemic preparedness by providing versing the unfair characterization of Spanish-
consistent federal funding for stockpiling med- speaking people as carriers of the contagion.
icines and medical supplies,training,and plan- Public health officials also encountered the
• ning activities. However, there have been no need to explain to members of the public that
state and local pandemic preparedness funds different policies are not necessarily inconsis-
appropriated since fiscal year(FY) 2006. If the tent,but tailored to local realities.
current outbreak had been more severe, state
and local health departments likely would have
been even more overwhelmed. _ ' '
3.Response plans must be adaptable and science-
driven. For years, pandemic flu planning fo-
cused on the potential threat of the H5N1x: � '
(bird) flu that has been circulating in Asia for �,,; . -- _ i
the past 10 years. In addition, much of the 1 itell
planning anticipated that there would be a six- " " 'iiT i I I ii 1
week lead time between the time a novel flu
14Istrain was detected before it reached the i x' w j! 0 tit
United States. H1N1 showed that a new flu
strain can emerge quickly or go undetected for !s
* : ill iii
a period of time and rapidly spread throughout
the world. As the epidemic unfolded, new
knowledge required government officials to re- i 1 i, I '"r` •. , .,
II assess guidance offered to the public and the +
medical community. For example,as it became
clearer that H1N1 was circulating widely in
if
communities and largely causing mild cases,
the U.S. Centers for Disease Control and Pre-
vention (CDC) officials lifted their recommen- k
• dations on school closures to match the
changing circumstances. Different communi-
ties
ommuni ties faced different situations,such as the extent -tk
'-is '= p
1 3
COMMUNICATION WAS KEY, INCLUDING THE NEED FOR US TO BE CAREFUL TO SAY
WHAT WE DID NOT KNOW, FORESHADOWING POSSIBLE CHANGES IN POLICY, AND BEING CLEAR
AT THE OUTSET THAT WHAT WE LEARNED ABOUT BOTH SEVERITY AND TRANSMISSIBILITY
WOULD DETERMINE OUR RESPONSE. I
DAVID FLEMING, MD, DIRECTOR OF PUBLIC HEALTH, SEATTLE&KING COUNTY WASHINGTON
`�
5. School closings have major ramifications for well" overwhelmed emergency departments.2
students, parents, and employers. In areas Also,concerns about health care costs were a
where schools were closed due to H1N1,par- deterrent for many in seeking early medical at-
ents had to scramble to find alternative child tention, especially among the uninsured and
care arrangements,which were complicated underinsured.A further deterrent to seeking
by the guidance that children home from prompt medical care was fear among undocu-
school should stay separated. Many parents mented immigrants that making contact with
had to face taking sick leave from work to stay health authorities could result in deportation.
home to care for their children even if they 8.Communication between the public health sys-
were not ill, or taking days off without pay if
tern and health providers was not well coordi-
they did not have sick leave. Many families nated. During the outbreak, many private
also rely on the school meal programs and be medical practitioners reported that they did
fore and after school care, which were also not receive CDC guidance documents in a
not available when schools were closed. In timely fashion. Other practitioners noted that
the event that another outbreak occurs or the CDC guidance lacked clinically relevant infor-
H1N1 returns in the fall and schools may have mation and was difficult to translate into prac-
to close in more places and for longer dura tical instructions.
tions, these complications would become an
even bigger concern. This is especially prob- 9.WHO pandemic alert phases caused confusion0
lematic for jurisdictions that require a mini- The WHO pandemic alert phase system was not
mum number of days attended to graduate. well matched with the realities of the H1N1 out-
break,
utbreak, since most of the planning was built
6.Sick leave and policies for limiting mass gather- around concerns of a much more severe pan-
ings were also problematic. There were nu demic outbreak and focused on the geographic
merous media reports of people with spread and transmission patterns,but not the
influenza like illness continuing to go to work severity of the disease. WHO is currently con-
because they had no sick leave and feared los sidering how to revise its pandemic alert phases
ing their jobs,and some parents sent sick chil-
to address both the geographic spread as well as
dren to school because they could not stay the severity of the virus.
home to care for them. In addition,while they
were not instituted during the outbreak, it be- 10. International coordination was more com-
came clear to officials how difficult it would be plicated than expected. Despite advice from
to carry out plans to limit mass gatherings or the WHO, some countries chose to close
cancel major events if that became necessary. In their borders to Mexican citizens or banned
areas of Mexico, there were serious economic pork products from the United States and
ramifications when officials recommended peo- Mexico. These measures were not based on
ple avoid shopping and public events. either science or reasonable public health
practices and caused unnecessary economic
7.Even with a mild outbreak,the health care de- losses. Once a flu virus is circulating
livery system was overwhelmed. Even this rel throughout the population, containment
atively mild outbreak proved to be a low-level strategies, like travel restrictions, generally
"stress test" on the health system. It revealed will not work, given that it is possible to in-
significant problems and lack of preparedness fect others before a person develops flu-like
particularly for out-patient settings where there symptoms. Also, the effectiveness of some
was inadequate personal protective equipment mitigation strategies implemented (face
and a limited understanding of infection con masks in Mexico) were overstated.
trol measures. At many hospitals,the"worried
TEN RECOMMENDATIONS FOR ADDRESSING CORE
•VULNERABILITIES IN U.S. PANDEMIC FLU PREPAREDNESS SECTION
Th he investment in pandemic flu preparedness helped the country respond to the
first round of the H1N1 outbreak much more effectively than could have been
achieved a few years ago. However, the limits of the response underscored ongoing
gaps in the nation's core capabilities and the need to build up and modernize the pub-
lic health infrastructure, which has been underfunded and under resourced for
decades. Unless these gaps are addressed,our ability to respond to emergencies will re-
main inadequate.
A. STRATEGIC NATIONAL STOCKPILE AND VACCINE DEVELOPMENT
RECOMMENDATIONS
The fact that the country had stockpiled a supply the clock to develop an H1N1 vaccine for the fall
of antiviral medications made it possible to rap- of 2009 while continuing to develop vaccines for
idly deploy medicine to treat flu patients around other flu viruses.
the country, though ultimately large supplies
were not needed. The outbreak showed the lim The possible need to find ways to swiftly vacci
its of the current stockpile, which is currently nate the entire U.S. population, however, also
ad-
based on a system that relies on states to pur shows that the country does not yet have an�hase a portion of the medications,and does not equate system in place to rapidly vaccinate all
have mechanisms in place for constantly replen Americans. Nor is there a registry in place to
fishing and updating the supplies. track the two vaccinations per person.
In addition, the importance of the investment The following recommendations relate to en-
the country has made in biomedical research, surfing systems and supplies to mass treat and
and in particular vaccine development and pro vaccinate the public during a flu outbreak:
duction,is underscored as scientists race against
I. MAINTAINING THE STRATEGIC NATIONAL STOCKPILE: Purchasing antiviral medications,
vaccines,and equipment for the stockpile must be updated and restocked on an ongoing basis.
■Purchasing antiviral medications,vaccines,and •HHS needs to develop a workable plan for both
equipment for the stockpile should be a federal the use and stockpiling of antivirals.Currently,
responsibility. states are expected to purchase a portion of the
antiviral medications that would be needed to
Combined,the federal and state antiviral pur-
chases are intended to treat 25 percent of the protect citizens in their states through a pro-
gram that included 25 percent subsidy from the
U.S. population, or 75 million people. Prior
federal government. HHS must develop a plan
to the H1N1 outbreak, the U.S. Department
of Health and Human Services (HHS) had for use and distribution of stockpiled antivirals
during a pandemic. This plan should consider
completed the purchase of 50 million treat
existing federal and state stockpiles, as well as
ment courses of antiviral drugs for the federal
portion of the antiviral stockpile goal. The how to address current shortfalls. HHS must
recognize that while some states, have already
federal government should replenish its share
of the antiviral stockpile deployed to states expended resources to develop their own stock
• and localities intended for treatment during piles,others have not,either as a result of lim
the current H1N1 outbreak and purchase ad ited resources or operational constraints.
ditional courses for prophylaxis. See Appendix B for a list of state purchases
of antiviral medications as of October 2008.
In addition to antivirals and vaccines, even be- During the H1N1 outbreak, HHS released a
fore the H1N1 outbreak, the stockpile had ex- total of 11 million treatment courses to help
4411
isting shortfalls in the number of masks, states,in addition to moving 400,000 treatment
respirators,and medications needed to respond courses to Mexico to help stop the spread of th
to this and other possible pandemics, which virus. In order to replenish the Strategic Na-
must be completed to be prepared for the pos- tional Stockpile,HHS announced at the end of
sibility of other strains of flu. As of 2008,HHS April 2009 that it would purchase an additional
had purchased 105.8 million N95 respirators; 13 million antiviral treatment courses.5 States
51.7 million surgical masks; 20 million syringes have purchased 23 million courses of antivirals,
for pre-pandemic vaccine; and 4,000 ventila- as of January 2009 with the help of a federal sub-
tors.3'4 It is important to continue to evaluate sidy. (The goal is for states to purchase 31 mil-
medical supply needs for the stockpile and re- lion courses).5
plenish supplies as they are used.
2. VACCINE DEVELOPMENT AND PRODUCTION: A vaccine is the most effective way to
protect the public from an infectious disease outbreak,but current vaccine development
and production capacity is severely lacking.
■U.S.vaccine development and production ca- HHS is supporting a multi-pronged approach
pabilities must be enhanced. The National for boosting U.S.domestic production capacity
Strategy for Pandemic Influenza sets out two goals by subsidizing the construction of new manu-
related to vaccine stockpiling: To stockpile facturing plants and the renovation of existing
enough H5N1 (bird flu) pre-pandemic vac- ones; funding research and development of
cine to inoculate 20 million people at the cell-based manufacturing technology,while se-
onset of a pandemic influenza,and to be able curing an egg supply for egg-based production;
to vaccinate the entire U.S. population of and advancing the research and development
some 300 million within six months from the of adjuvants,substances that can be added to a
onset of a pandemic influenza. In light of the vaccine to boost its ability to produce an im-
H1N1 (swine flu) outbreak, the federal gov- mune system response. However,a September
ernment is embarking on a similar course of 2008 report by the Congressional Budget Office
action with respect to the first goal. HHS has (CBO) has raised serious concerns about the
issued contracts to manufacture and test pre- ability of HHS to meet these goals.'°
pandemic vaccines against the newly emerg Other factors that might impede the nation's
ing 2009 H1N1 virus for the Strategic ability to inoculate the entire population in-
National Stockpile. The goal is to build a dude cost and the public's reaction to the vac-
stockpile of at least 40 million doses of 2009 cine.According to a CDC estimate,it may cost
H1N1 vaccine to inoculate 20 million people up to $8 billion to procure 600 million doses
(this assumes two doses of vaccine will be nec of the 2009 A-H1N1 vaccine for 300 million
essary). Laboratories are already working on people (two doses per person). This figure
generating the seed viruses needed for vac does not include needles, syringes, distribu-
cine production. Once the manufacturers
tion,and the like.
have completed their seasonal influenza vac-
cine production,they will start production of Whether or not the public would be willing to
the 2009-H1N1 vaccine.'' line up for three flu shots--one to combat sea-
sonal flu and two to prevent the novel H1N1
However,with respect to the goal of vaccinating flu virus — remains to be seen. Seasonal in
the entire U.S.population within six months of fluenza vaccine uptake, even among health
an influenza pandemic,challenges remain due care workers, has yet to meet public health
to still limited U.S.vaccine production capabil goals. In the fall of 2008, more than half of
ities. U.S.production capacity is"completely in Americans in a national survey said that they
adequate," according to a report from the did not intend to be vaccinated against flu that
Congressional Budget Office (CBO).8 Former season. Among the reasons cited were the
HHS Secretary Leavitt urged his successor to thought that the vaccine was unnecessary,
ensure completion of manufacturing facilities, worry that the vaccine causes illness, and dis-•
so that in the event of a worldwide pandemic, belief in the vaccine itself"
U.S.citizens are not dependent on foreign gov-
ernments
overnments to provide a vaccine.9
I Adequate and sustained funding is needed for tools of public health must be modernized to
biomedical research and development to keep adequately protect the American people.This
pace with new technologies. includes research and development of• vac-
The federal government should enhance re cines and new technologies; and improved
search and development of vaccines and pub- chemical laboratory testing capabilities.
lic health technologies. Basic technology and
BIOMEDICAL ADVANCED RESEARCH AND DEVELOPMENT
AUTHORITY(BARDA)
The Biomedical Advanced Research and Development Authority(BARDA)was established to encour-
age and facilitate research and development(R&D)of new biomedical countermeasures, diagnostics,
and related technologies; however,the intentions of the Congress and the administration in creating
BARDA are far from being realized.The small amount of funding provided to BARDA to date only has
allowed HHS to establish an infrastructure to support a yet-to-be-seen robust advanced R&D portfo-
lio for many innovative biomedical products. To achieve the goals identified in HHS' Public Health
Emergency Medical Countermeasures Enterprise Implementation Plan, BARDA would need$3.39 bil-
lion in FY 2009 to have a 90 percent chance of developing successful medical countermeasures for
each biodefense requirement set forth in the plan.
Congress should increase the level of BARDA funding to at least$850 million as advised by 14 sena-
tors who signed a letter to the Appropriations Committee on this issue on May 7, 2009 and as re-
quested in last year's Presidential FY 2009 Amended Budget request.12
FLU VACCINE CAPACITY WORLDWIDE IS LIMITED
• Worldwide,the five egg-based flu vaccine manufacturers include the following:
®CSL Limited (Australia)which makes Afluria;
®GlaxoSmithKline Biologicals(Belgium)which makes Fluarix;
■ID Biomedical (Canada),which makes FluLaval;
I Novartis Vaccine(UK),which makes Fluvirin;and
II Sanofi Pasteur(Pennsylvania, USA),which makes Fluzone.
In addition, Medlmmune makes FluMist,which is a live attenuated nasal spray vaccine.
On May 6,2009,the U.S. Food and Drug Administration(FDA)approved a new egg-based influenza
vaccine facility in Swiftwater, Pennsylvania,which will produce 100 million doses of Fluzone when
operating at full capacity.This brings the total domestic production from Sanofi Pasteur's two-approved
facilities to 150 million doses.GSK is building a manufacturing facility in the United States, but it is not yet
operational or approved by the FDA. The lack of U.S.manufacturing capacity means the country will be
dependent on imported vaccines,which will become more difficult to obtain in the event of a pandemic.
3. VACCINATING ALL AMERICANS--the country has not developed or adequately tested a system
that will ensure that all Americans would be able to be inoculated in a short period of time.
•A robust public system is needed to be able to rected program will be necessary to oversee
vaccinate all Americans for H1N1 over a short vaccinations and coordinate delivery through
period of time. Currently, only a fraction of a combination of public and private settings.
Americans are vaccinated each year for the This will require an infusion of major re-
• seasonal flu and they typically receive shots sources to state and local health departments
through their doctors or private clinics. If the responsible for creating this system. Estimates
country is going to be successful in creating a by state and local health officials suggest that
program that can vaccinate all Americans for between $15 and $20 per person may be
H1N1 rapidly in the fall of 2009,a publicly-di- needed for administration and follow up.
O
THE CASE FORA PUBLIC SECTOR APPROACH TO DISTRIBUTION OF A
PANDEMIC VACCINE
III
The HHS Pandemic Influenza Plan states that after a pandemic vaccine becomes available,state and
local health departments will be expected to: .
▪Work with health care partners and other stakeholders to distribute,deliver,and administer pan-
demic vaccines to priority groups;
•Monitor vaccine supplies,distribution,and use;
•Monitor and investigate adverse events;
•Phase-in vaccination of the rest of the population after priority groups have been vaccinated;
•Provide updated information to the public via the news media;and
Work with federal partners to evaluate vaccine-related response activities when the pandemic is over.13
While actual delivery of vaccines may occur in both public and private settings, it is vital for the public
sector to be in charge of the overall system of delivery to assure that key public health challenges
unique to a pandemic vaccine are addressed. These challenges include: .
®A pandemic vaccine must be delivered to individuals as rapidly as possible. Americans re-
ceive their seasonal influenza vaccine over a period of many months and only a fraction of the U.S.
population receives a flu vaccine annually. Health departments will need to organize(often in con-
cert with the private sector) mass immunization clinics that can speed delivery--possibly as many
as 100-150 million doses in a month's time.
M A pandemic vaccine will be rationed at the beginning of the production cycle,targeted at
critical infrastructure workers and high-risk individuals. Unlike seasonal influenza vaccines,which
are manufactured over a long period of time but essentially distributed at one time,a pandemic
vaccine will be distributed as it comes off the production line. This will require targeting of initial
doses to those key personnel (such as health care workers)who will be central to a pandemic re- •
sponse,followed by those at highest risk for influenza complications. This kind of rationing re- .
quires careful oversight. During the 2007 seasonal flu vaccine shortage it became clear that the
private distribution and delivery system was not able to systematically follow recommendations for
priority populations,and health departments were forced to intervene.
•A pandemic vaccine may require two doses. Assuring that all individuals who receive a first
dose return for a second dose will require a centrally organized system of monitoring and re-
minders. It may well be that private sector entities (e.g., pharmacies) have systems in place to ad-
minister such call-backs, but they must all be organized and structured in a similar manner,which
can only be coordinated by a public health agency to ensure consistency with federal guidelines.
•A pandemic vaccine will require careful monitoring and reporting of adverse reactions.
Because the pandemic vaccine will be one with which there is far less experience than a seasonal
vaccine, it will be critical to assure that all adverse events are investigated. This is a public health
responsibility and the system of vaccine distribution and delivery must be designed to assure rapid
communication of this information to health departments and then to the FDA.
IN A pandemic vaccine must be distributed equitably,and should not be available based on
ability to pay. With nearly 50 million Americans uninsured,and with broad-scale vaccination critical
to protecting not just individuals but the entire population from a pandemic, it is essential that the vac-
cine delivery and distribution system not depend on private insurance and reimbursement systems. It
would be tragic if vaccines were more likely to be available based on insurance status or ability to pay.
•A pandemic vaccine distribution program will require communication and outreach to
the public. This is traditionally a public health function; public health agencies have unique levels
of trust with the public,especially vulnerable populations. That trust will be needed to ensure
compliance with a complicated system of vaccine distribution.
B. ADAPTABLE, SCIENCE-DRIVEN PLANNING RECOMMENDATIONS
During the H1N1 outbreak,it was clear that top H1N1 also showed the challenges that commu-
overnment officials were following the guid- nities face around decisions to close schools or
ance of public health experts and science was work places or limit public gatherings. There
driving policies. Government officials provided are numerous ramifications for all of these ac-
clear and consistence guidance to individuals dons that affect families and the economy. It is
about the best ways to protect themselves. In ad- essential to consider the impact of these types of
dition,the response continued to appropriately community mitigation strategies, and plan for
adapt to changing circumstances as more infor- ways to make them easier to implement,for in-
mation became known about the virus and how stance, by ensuring sick leave benefits to work-
it was evolving, such as the timely decisions ers, so they do not face the tough decision of
about when to close schools or limit gatherings. foregoing a paycheck against staying home to
The outbreak underscored the need for ongoing care for their children during an outbreak.
planning and coordination among all levels of gov- The following are recommendations for ensuring
ernment and between the government and private that planning and coordination are ongoing ac-
sector. It also reinforced the difficulties of inter- tivities and that community mitigation strategies
national coordination and planning. Without clear are updated and realistic:
lines of communication and careful planning,it is
difficult to maintain an effective response strategy.
4. PLANNING AND COORDINATION: Federal,state, local,and private planning and
coordination must be consistent and ongoing--reflecting the constantly changing
nature of the influenza threat.
•Federal, state, local and private sector pan- just when one becomes imminent. Further-
demic influenza plans should be systematically more,bringing together the creative ideas and
. reviewed in light of the experience with the collective expertise of diverse leaders and or-
outbreak and response to H1N1. It is critical to ganizations will help build community resilience
ensure that the plans build in flexibility in re- to a public health emergency. It is also impor-
sponse,given that the H1N1 virus did not be- tant for local communities and health depart-
have as many planners had anticipated--it did ments to coordinate based on the circumstances
not originate overseas and our global surveil- they face during an outbreak and issues that are
lance system did not give us the level of warn- specific to their communities.
ing desired. It is also important to review •Government at all levels should work to engage
various guidances,in particular the school do-
the private health care system and communities
sure guidance,in light of the real world expe in their plans and exercises. Sufficient resources
rience over the last two months. must be devoted to preparing for possible dis-
•The federal government should take the lead in ease threats and the government should be
increasing and better coordinating federal,state, transparent about its actions and held account-
local,
ccountlocal, and private planning and preparedness, able for protecting the public. Initial planning
and all jurisdictions should work together to cre- by HHS and other federal agencies failed to ad-
ate policies that follow best infection-control equately involve states and localities in national
practices.Often there is a flurry of planning ac- preparations for a pandemic, even though the
tivities when a potential health threat is identi- national plan relies on these efforts.14"5 HHS
fled and communication about preparation and and the White House should engage partners
response is strong. However, over time,while in updating the National Strategy and Imple-
the threat remains dormant,private-public corn- mentation Plan. The federal government, in
munication may decline. There should be on- collaboration with the states,should share states'
going and evergreen communication among pandemic preparedness plans and performance
public and private partners as to roles and re- grades with the public to increase transparency
sponsibilities during a major health crisis, not and build community resiliency.16
•
CUYAHOGA COUNTY, OHIO: COMMUNICATION KEY TO EFFECTIVE H I N I RESPONSE
The Cuyahoga County health department was formally alerted regular email briefing for local elected officials. S
• about the H I N I outbreak late on Friday,April 24, 2009. The Although Cuyahoga County has only had two confirmed cases
next day,the county activated its Northeast Ohio Health Alert of H I N I,some local schools began unilaterally closing be-
Network to communicate with other local emergency pre- cause of fears about ill students or faculty. The county health
paredness partners. By Sunday,April 26th,the state of Ohio department was able to correct the false information that was
had its first confirmed case of H I N I in a suburb of Cleveland. circulating and work with schools so that they were following
That same day the U.S.government declared a public health CDC school closure guidance. The public soon came to trust
emergency and Cuyahoga County readied guidance and infor- these local public health officials,which had the important ef-
mation to be disseminated to the public. fect of reducing panic and anxiety in the community.
On Monday,April 27th,the local preparedness working group Cuyahoga County Health Commissioner Allan attributes the
met and the 24/7 City of Cleveland/Cuyahoga County com- rapid response and mobilization,the ability to continue normal
bined Emergency Operations Center was up and running to daily operations,and the establishment of a link to the media
begin issuing clear and unified messaging on the H I N I out- and public,to the fact that"public health had formally inte-
break and to track the progress of and response to the out- grated as an essential partner in our community emergency
break. The county public information officers developed fact response system.""
sheets and updated the county website with links to the CDC.
The county health commissioner,Terry Allan,and Commis- Mr.Allan warned Congress in a recent hearing,that cuts to
sioner of the Cleveland Department of Public Health, Matt state and local preparedness dollars could seriously affect the
Carroll, began holding twice daily conference calls with part- ability of local health departments to respond effectively to fu-
ners from hospitals, nursing homes,safety forces,schools and ture public health emergencies.
universities,daycares,and businesses. They also established a
5. SCHOOL CLOSINGS, SICK LEAVE,AND COMMUNITY MITIGATION STRATEGIES:
Strategies to mitigate a major infectious disease outbreak include ensuring that all working
Americans have sick leave benefits available and that communities are prepared to limit .
public gatherings and close schools as necessary.
Clear, consistent, culturally-competent commu- policies should be clarified. The federal gov-
nication with the public is essential during a dis- ernment, in coordination with the states,
ease outbreak, so that health departments and must establish clear legal authority and guid-
providers can let people know about latest de- ance for the use of such measures to effec-
velopments, how to best protect themselves, tively limit the spread of disease.79
when they should limit their public activities and •One of the most difficult challenges during an
avoid going to work or school, and when and outbreak is managing sick leave concerns,since
where they should go for medications or vacci-
currently 48 percent of Americans have no paid
nations.18 This includes letting people know the sick days. That means during an infectious dis-
prioritization plans for vaccinations when limited ease outbreak, like a pandemic, they may be
amounts of vaccine maybe available or when it is forced to choose between a paycheck and their
more important to vaccinate a target population own health. During the recent H1N1 outbreak,
in advance of the rest of a community. anecdotal stories emerged of workers threat-
•Continued work is needed in communities ened with termination if they stayed home,de-
around the country to develop and test effec- spite being sick. Forcing sick people to go to
tive policies for slowing the spread of infec- work or school during a pandemic not only
tion that also minimize the known social and threatens their own well-being, but the health
economic consequences associated with these of coworkers,customers,and schoolmates and
measures.Such measures need to be based on undermines efforts to limit the spread of dis-
sensible and practical policies that are in line ease. The "Healthy Families Act" was intro-
with the science available at any given time of duced in Congress in response to the H1N1
an outbreak rather than responding to panic outbreak to facilitate the ability of workers to
or complacency. Current state and federal stay home when they or their family members
roles in invoking quarantine and isolation are ill,but it has not been acted upon. •
10
6. GLOBAL COORDINATION—Efforts must be made to increase coordination across borders
to build trust,improve surveillance technologies and treatment capabilities,and encourage
• science-based policies and decision making internationally.
f1 The United States should work closely with •The United States should also take
the d on
the World Health Organization to revise the improving global disease surveillance. The
pandemic phase system and to encourage President's 2009 pandemic flu emergency fund-
countries around the world to base policies ing request includes$220 million for enhanced
for detection and control on sound science. global disease detection and Congress should
provide these funds.
C. CORE PUBLIC HEALTH INFRASTRUCTURE IMPROVEMENT
RECOMMENDATIONS
The H1N1 outbreak highlighted many of the on- outbreak or other major disaster occurs, the
going vulnerabilities in the nation's public health health departments do not have the resources or
infrastructure. The system has been under-re- personnel in place to adequately protect the
sourced for decades,and now with the economic health of their communities.
recession leading to budget cuts in many states,
most public health departments are laying off The following are recommendations for provid
workers. The result is that health departments are ing the resources and capabilities needed to
maintain public health preparedness and for
already stretched too thin to maintain their day-to-
day responsibilities. When an event like the H1N1 bolstering the public health workforce:
7. RESOURCES: Adequate funding must be provided for on-the-ground response. Right now,
state and local health departments do not currently have enough resources to respond to a
severe outbreak.
Congress should assure a reliable funding stream ing to the Center on Budget and Policy Prior-
for all core public health activities as part of ides (CBPP),at least 46 states face shortfalls to
health reform--both to prevent and address the their 2009 and/or 2010 budgets. CBPP esti-
on-going public health responsibilities of state mates that combined budget gaps for states in
and local government and to ensure back up ca- the remainder of 2009, 2010, and 2011 could
pacity is available to respond to a major public total more than$350 billion.22
health emergency.Sustained funding to ensure a
fully operational and fully staffed public health •To adequately support public health prepared-
system is critical to emergency response. During ness needs,Congress should:
an emergency such as a flu pandemic,all public A Complete the funding to implement the National
health workers will be needed to mount a the re- Strategy for Pandemic Influenza. The President
sponse. Frequent budget cuts to non-prepared- originally requested$7.1 billion to carry out re-
ness programs undercut the capacity of state and search and development for vaccinations,phar-
local health departments to gear up in response maceuticals, and medical devices needed to
to the H1N1 outbreak. respond to a pandemic. $870 million of this has
111The federal government should update never been funded. This money is needed to
needed,fully fund,and promptly carry out the continue pandemic R&D. This funding was orifi
President's National Strategy for Pandemic In- finally included in the proposed 2009 stimulus
bill,but it was removed before the bill's passage.
flue=Implementation Plan.2o,2' The National
Subsequently, in April 2009 President Obama
Strategy and Implementation Plan should be
submitted a request for$1.5 billion in emergency
evergreen documents, updated as the science
evolves and the White House assesses the effec funding for pandemic preparedness. Congress
tiveness of implementation on an ongoing basis. should approve this supplemental funding.
A Provide resources for state and local health de-
At present,public health departments around
. the country are under-funded and over-ex parents to adequately prepare for outbreaks.
State and local officials are the front line re
tended to manage the demands of their ongo-
ing responsibilities. In the current economic sponders to outbreaks, yet they have not re
climate,public health departments are facing ceived any new federal funding for pandemic
severe cutbacks around the country. Accord- flu preparedness since 2006. $350 million is
needed annually to adequately maintain state Preparedness cooperative agreements, which
and local pandemic preparedness activities. have been cut 25 percent over the last five years.
The President's FY pandemic flu emer-
A The federal government should modernize and
gency supplemental includes$350 million for provide sustained support of disease surveil-
state and local pandemic preparedness,which lance systems,public health laboratories, com
should be enacted. munications systems, and other core public
A Maintain investments in state and local pre- health capabilities needed for rapid detection
paredness efforts through federal grant pro- and response to public health threats.
grams such as the Public Health Emergency
CURRENT STATUS OF STATE PREPAREDNESS
A Government Accountability Office(GAO)report published According to federal guidelines,state plans are required to demon-
in September 2008,found that the HHS-led review of state strate the state's ability to accomplish a range of expectations,but
pandemic influenza response plans found"many major gaps" in states have not been adequately funded to meet these demands:26
state pandemic planning in 16 out of 22 priority areas.23 The 7 Ensure public health continuity of operations during each
GAO concluded that"while the federal government has pro-
phase of a pandemic;
vided some support to states in their planning efforts,states
and localities have had little involvement in national planning for 7 Ensure surveillance and laboratory capability during each
an influenza pandemic....even though the National Pandemic phase of a pandemic;
Implementation Plan relies on these stakeholders efforts."24 7 Implement community mitigation interventions,e.g.,school clos-
A January 2009 "Assessment of States' Operating Plans to ings or cancelation of large public events;
Combat Pandemic Influenza" report from HHS to the White
4 Acquire and distribute medical countermeasures,like Tamiflu®
House Homeland Security Council found that many states or Relenze);
scored well in areas such as protecting citizens and administer-
ing mass vaccinations, but found major gaps in such areas sus- 7 Ensure mass vaccination capability during each phase of a
taining state operations, developing community mitigation pandemic;and •
plans,and maintaining key infrastructure.25 7 Ensure communication capability during each phase of a
pandemic.
SEATTLE & KING COUNTY, WASHINGTON: RESPONSE TO SWINE FLU
AMID BUDGET CUTS AND EVOLVING POLICIES
A month into the outbreak,Seattle&King County had more daycares,were slated,as a result of previous budget reduc-
than 160 cases of H IN I and several schools were closed to tions,to receive their lay-off notices two weeks later.28
prevent the further spread of the novel flu virus. The local re The budget cuts also are likely to severely strain local and state
sponse to the H I N I outbreak was undertaken amidst con laboratory testing capability. According to Dr. Fleming,"Limita-
cerns about steep cuts in local public health funding. In fact, tions in testing capability in our local laboratory,at the state lab
the last day of the 2009 Washington state legislative session--
oratory,and at CDC led to a national picture of the outbreak as
in which Seattle&King County's public health funding was cut reported in the national media that was a week to 10-days-old
by$14.4 million from$201.6 million to$187.2 million was from the front line reality. We had widespread community ill-
the same day as cases were first identified in the United States. ness before CDC posted a single confirmed case in Seattle."
According to the Seattle Post Intelligencer,the King County op-
erating budget deficit for 2010 could be$50 million and the Dr.Fleming believes the key to Seattle&King County's success to
2009 budget may have to be further revised downward.27 date in containing the H I N I outbreak is attributable to communi-
cation,and local health officials being careful to say what they
A major concern is that two programs which helped in the re didn't know,foreshadowing possible changes in policy,and being
• cent response face an uncertain future without additional fund clear at the outset that what they learned about both severity and
ing:the childcare health program,which allowed nurses to transmissibility would determine their response. "In that context
work with schools to screen for possible cases,and the corn-
the community work that had been done on pandemic prepared
municable disease program. According to Dr. David Fleming, ness,while key,was a barrier,"Dr.Fleming says. "Changing poli- S
Director of Public Health for Seattle&King County,at the cies to match those indicated by a less severe strain was difficult
height of concern the public health nurses who were workingbecause that's not what people had been trained to do."
overtime conducting education and outreach to schools and
6 I
I
1
8. WORKFORCE: The public health workforce is seriously strained,and budget cuts are re-
sulting in additional layoffs.
OFederal, state, and local governments must ■Despite tough economic times,it is important
take action to recruit, train, and retain the to sustain the public health workforces to pro-
next generation of public health profession- tect America's health. In the past year, public
als in public health. From first responders to health departments around the country are
scientists who detect and contain diseases,the being forced to layoff experts and professionals
nation's public health workforce is vital to needed to protect communities from threats
protecting the nation's health. There is a like pandemic flu. A preliminary survey of
shortage of public health workers in the local health departments by the National As-
United States, and as Baby Boomers retire, sociation of County and City Health Officials
there is not a new generation of workers (NACCHO) has found both budget cuts and
being trained to fill the void of expertly workforce reductions to health departments.A
trained public health workers. The country survey of 2,422 local health departments no-
has an estimated 50,000 fewer public health tionally in November-December 2008 found
workers than it did 20 years ago, and one- that more than half of local health depart-
third of the public health workforce in states ments have either laid off employees or lost
is eligible to retire within five years, and 20 them through attrition.Because of the current
percent of the local public health workforce is budget limitations, health departments have
eligible to retire within two years. been unable to replace the lost workers, and
they anticipate more cuts in 2009 and 2010.29
These cutbacks have serious consequences for
responding to a health emergency.
SACRAMENTO COUNTY: H I N I CRISIS RESPONSE IN THE FACE OF BUDGET
• CUTS AND LAYOFFS
On Friday,April 24, 2009 Dr.Glennah Trochet, Sacramento County's chief public health officer as-
sembled her staff to deliver some bad news:job cuts were a near certainty due to severe budget cri-
sis facing California and the weak national economy.
That same day health officials were warned about a novel influenza virus that was killing otherwise
healthy young adults in Mexico. When the first case was diagnosed in Sacramento County on April
26,a panicky public jammed telephone lines with questions and "worried well"descended on local
health care facilities,while lab technicians labored to diagnose and differentiate H I N I flu cases from
seasonal flu.
Dr.Trochet sounded the alarm and her local public health workforce jumped into action. A squad of
50 Sacramento County health workers began putting in I2-hour shifts and logged more than 1,200
hours over the first five days of the outbreak.
That kind of dedication in the face of looming budget cuts and layoffs is emblematic of the U.S. public
health workforce. Across the country,the economic recession is leading to severe cuts in public
health budgets. In 2008, local health departments across the country lost$300 million and 7,000
staffers to budget cuts and could lose an equal number of workers this year,according to NACCHO.
In Sacramento County, over the past two years the Division of Public Health has seen its budget
slashed in half—dropping from$9.8 million to$5.I million. The department has been forced to let go
more than a quarter of its staff. According to the Sacramento Bee, in 2008, 57.4 full-time positions
were shed;an additional 31 or more could be lost in 2009, bringing staffing below 228 full-time-equiv-
alent positions. "I hope the public realizes how much work is going on to keep them safe and to keep
them well,"said Dr. Trochet. "It's only when we fail that the public notices that there is a public
health disaster."3°
F
D. SURGE CAPACITY AND CARE RECOMMENDATIONS
While the H1N1 outbreak was relatively mild and return of H1N1 in the fall and/or the potential of
limited in duration in the United States in early other outbreaks, caring for a major surge of pa
�
2009,hospitals and clinicians across the country re- tients remains one of the most difficult challenges
ported major surges in patients,including individ- for the public health and health care systems.
uals with the flu,flu-like symptoms,or the`worried The following are recommendations for ways to
well." As health providers prepare for a potential better prepare for a massive influx of patients:
9. SURGE CAPACITY:The ability for health providers to manage a massive influx of patients
during an emergency remains a major challenge for emergency public health preparedness.
During a major emergency like a pandemic out- out of supplies very quickly if they have to treat
break,the health care system will be significantly a major surge of patients. In addition, hospi-
stretched beyond normal capabilities. In the best tals are likely to run short of ventilators and de-
of times,most emergency rooms already face bed contamination units very quickly.
shortages and staffing issues. During disasters, •Staff: Workforce shortages plague hospitals and
health providers have to adapt their regular prac health care facilities even in the best of times.
tices to treat a large number of patients very According to a June 2008 report from the Cen-
quickly. Many of the surge capacity problems ter for Studying Health System Change, "the
have been identified--including having enough
day-to-day shortages of key health personnel—
stuff,staff,and space to treat patients but solu-
such as nurses,physicians,pharmacists,labora-
tions to these problems are often lacking. tory technicians,and respiratory therapists—ex-
The HHS Pandemic Influenza Plan projects that acerbate the challenge of having sufficient
a pandemic could result in 45 million additional numbers of health workers in an emergency.
outpatient visits, with 865,000-9,900,000 indi- One way to increase workforce capacity is to pro-
viduals requiring hospitalization,depending on vide incentives to medical providers,such as pri-
the severity of the pandemic. Such a major dis- ority status for receiving medications or
aster would cross state lines and quickly over- vaccinations. Another is to recruit health car
whelm health care systems. providers outside of the emergency systems to
serve as volunteers during disasters. Liability
■The federal government must take a lead in protection concerns for volunteers must be ad-
providing guidelines to states on surge capacity dressed as part of the planning process. An
planning. Currently, definitions of appropri analysis in 2008 found that eight states have low
ate"disaster standards of care"are lacking,ac levels of protections for health care volunteers
cording to the New England journal ofMedicine.31 during times of emergencies, meaning that
Although various federal agencies have pub states have only Good Samaritan or similar laws
lished surge guidance,there have been few in under which volunteers may be provided with
centives or unified directions to enable states an affirmative defense,but not necessarily im
to implement surge planning. During mass munity from liability. In addition,26 states did
emergencies,measures must be put in place to not have statutes that extended some level of li
care for a potential surge of patients,including ability immunity to groups and/or organizations
creating alternative care sites and recruiting providing charitable,emergency,or disaster re-
additional health care personnel. Surge plan lief services.33
ning includes planning for altered standards of
care and addressing legal and ethical concerns ■Space: Hospitals and other facilities will have
before an emergency occurs. Hospitals must to address limited numbers of hospital beds
also consider how to provide continued care and space to care for sick individuals. They
for daily emergencies and chronic care when will have to manage issues like rapid dis-
they are also responding to a major outbreak. charging of patients, canceling elective sur-
geries and procedures, reducing the use of
•Stuff: Today's hospitals and health care facili tests and ancillary services,converting single
ties operate using a"just-in-time supply chain," rooms to accommodate more people, using
which means very limited supplies are stored cots and portable beds, and finding unused.
on-site and instead are replenished on an as space to treat or triage patients.
needed basis,so many health providers will run
•
.
.r
•
•
•
MEDICAL RESERVE CORPS: VOLUNTEER HEALTH CARE PROFESSIONALS
RESPOND TO H I N I OUTBREAK
The Medical Reserve Corps(MRC)is a national network of community-based volunteer units that support
local public health and provide for an adequate supply of volunteers in the case of a public health emer-
gency. During the H I NI outbreak,MRC units across the nation were activated to assist in the response.
Arizona
The Navajo County MRC volunteers dispatched four members to help the Navajo County Public Health
Department in the receiving,inventorying,and sorting of Strategic National Stockpile(SNS)pharmaceuti-
cals. Six MRC volunteers from this unit later assisted in the distribution of SNS supplies to local hospitals.
Florida
The Sarasota County MRC sent three MRC nurses to staff a H I N I triage phone line.Over six days
they worked a total of 27 hours at two community health department sites. These volunteers were
also trained in personal protective equipment(PPE)protocols to conduct physical assessments of
walk in patients who possibly were ill with H I N I flu.
Louisiana
IN Calcasieu Parish MRC helped the Regional Office of Public Health in Lake Charles, Louisiana,with calls
to hospitals,doctors'offices and other health care facilities to check on their needs and current avail-
ability of supplies.They also delivered test kits to health care facilities. Approximately 22 volunteers
also were involved in community mitigation efforts,teaching proper hand washing at local schools.
New York
M New York City MRC physician volunteers assigned to the NYC Department of Health and Mental
Hygiene helped to staff the Provider Access Line call center to answer questions related to H I N I.
Utah
Davis County MRC conducted a point-of-dispensing(POD)training course in anticipation of future mass
vaccinations.
Washington
Whatcom County MRC volunteers were involved in respirator fit testing for the local hospital. They
ran four fit test stations over one weekend.Their goal was to perform fit testing on 1,000 people
over 20 days.They also staffed a telephone triage call line. Whatcom County MRC also developed a
potential Alternate Care Facility for surge capacity in event of hospital overflow. Whatcom County
MRC staffed a phone bank in conjunction with Peace Health St.Joseph's Hospital.
• Wisconsin
Southeast Wisconsin MRC volunteers staffed call centers,and clinics where they performed diag-
nostic testing on patients.
Source: All information provided to TFAH by the Office of the Civilian Volunteer Medical Reserve Corps.
10. CARING FOR THE UNINSURED AND UNDERINSURED: A"State of Emergency" health
benefit should be created to ensure that all Americans will be cared for during emergen-
cies. Providing care is not only important for the individual patient, but since individuals 0
are contagious,it also helps limit the spread of disease to others.
With more than 15 percent of Americans lack- and treatment and not be delayed due to con-
ing health insurance coverage,the financial im- cerns about their inability to pay for services.
pact on the country's public health and health Delayed diagnosis may complicate public
care systems could be disastrous if hospitals, health officials' abilities to control the spread
community health centers,and primary care fa- of infection. Similarly, delayed diagnosis
cilities treat large numbers of uninsured."4 Like- might render useless potential treatment with
wise, if uninsured or underinsured patients antivirals, since such treatment is most effec-
hesitate to seek treatment because of fears of tive when begun early after infection.
out-of-pocket costs,treating and containing the U The Public Health Emergency Response Act
further spread of a pandemic would be nearly (PHERA)is an example of legislation that would
impossible. According to the Center for Biose address this concern. The act calls for bolster-
curity,U.S. hospitals could lose as much as$3.9 ing public health preparedness as part of a re
billion in uncompensated care and cash flow formed health system. It would address
losses in a severe pandemic.35 payment streams for hospitals and health care
Health reform offers the opportunity to find providers during emergencies, and it supports
ways to ensure all Americans would be covered major equipment upgrades and maintenance of
during an infectious disease outbreak and that capacity for hospitals and health care facilities."
health providers would be compensated for pro Currently, hospital preparedness is financed
viding care. through the Hospital Preparedness Program
■However,if universal health insurance cover- (HPP),which focuses on improving the clini-
age is not achieved, the federal government cal response to a large-scale health emergency.
should act now to create emergency health Initially run by the Health Resources and
coverage and reimbursement. It would have Services Administration (HRSA),HPP is now
to guarantee providers some level of corn- run by the Office of the Assistant Secretary fo
pensation for the services they provide during Preparedness and Response (ASPR) as man-
a pandemic,while encouraging individuals to dated by the 2006 Pandemic and All-Hazards
come forward for diagnosis or treatment. Preparedness Act. ASPR awards one-year
funding grants to hospitals and other health
For the health care system,the emergency ben care facilities to improve surge capacity and
efit would mitigate the economic impact of pro-
enhance community and hospital prepared
viding such a high level of emergency care,much ness for all hazards, including bioterrorism
of which may be uncompensated,while also for and pandemic influenza. The funding system
going revenue generating activities,such as elec-
is viewed as unpredictable and insuffi
five surgeries,which could place hospitals and cient.37'38'39 Hospitals only receive an average
other health care providers in financial jeopardy. of $82,500 a year per hospital.
The benefit would also encourage the unin Appendix C examines options for funding an
sured or underinsured who fall ill to access emergency health benefit.
primary care services for prompt diagnosis
LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH:
KEEPING MESSAGES SIMPLE AND FOCUSED
• Even though the events are still unfolding,the significant steps that of the next public health crisis,and that instead,overall respira-
the Los Angeles County Department of Public Health(LACDPH) tory disease and emergency preparedness should be the core
enacted in their emergency response provide important lessons focus.LACDPH also continued to hold a balanced view of the
learned and guidance for future actions and policies--not just for role of antivirals during a pandemic not promoting a strategy that
H I N I or flu pandemics,but for most public health events. antivirals can be used for community-wide prophylaxis.Instead of
assuming they could affect a pharmaceutical response to preven-
Be quick to respond, but keep messages measured.
Upon first confirmation of person-to-person spread in Mexico, tion during a pandemic,they stressed a behavioral response
(washing hands,staying home when sick,etc.).A lesson learned
LACDPH's emergency command operations were activated.
This occurred weeks before the first confirmed case in Los An- from the current H I N I situation is that novelty and transmissibil-
ity does not necessarily equate to severity.The core pubic mes-
geles and well before there were any notable changes in our
sage was to communicate the particular severity profile of this
seasonal flu disease surveillance.Activating the emergency
pandemic in the United States(like seasonal flu),and frame the
command was not meant as a declaration of alarm, but recog-
nition that an effective response would require increased inter-
prevention messages in reference to seasonal flu. Flu is always a
action among the multiple units within Public Health as well as serious disease and every season is the opportunity and the rea-
son to prepare.And now that H I N I has morphed into seasonal
a close collaboration with many of our communities'agencies
in the 88 cities in Los Angeles County. Public Health officials circulation,this emphasis is especially relevant.
were aware they would need to serve as the primary emer- While the message focus was generally successful,an area where
gency response entity. Bringing key internal and external officials felt they could be better prepared for was the great de-
groups together from the very beginning of the response mand for tailored information and guidance to many different
helped them develop cohesive message,shared goals,and plan groups and populations. They rapidly developed many guidances,
coordinated action from the onset. In addition, because the in- complied information and documents in multiple languages and
cident command structure is not a method of operations most pushed out information through their Web site and other channels.
are familiar with,and is certainly not how Public Health rou- However,it continues to be an ongoing challenge to effectively
tinely conducts business,this early activation allowed for clarifi- reach and reframe the guidance for the great diversity of the popu-
• cation of the flow of information and the process of assigning lations that comprise the 10 million persons in Los Angeles County
tasks before tensions increased and in advance of any crisis.
Every crisis is a potential opportunity.
Similarly,very early into their response, LACDPH enacted Pandemic and emergency planners cannot overlook the many
several other steps--steps that typically only occur after an "silver linings"to these events.Officials feel they have been fortu-
emergency has had local impact, but their early initiation nate that,at least to date,the overall severity of this disease has
greatly improved our preparations and set the stage for our been relatively mild;and yet it has heightened awareness in the
ongoing operations.This included hosting an early joint press general public of the need to prepare for a pandemic and also
conference with Public Health and several of our core corn- forced some quick resolution to some policy issues that needed
munity partners;this helped to solidify the collaboration and attention,but were resolved until the emergency arose. For in-
further emphasized the roles, messages,and basic recommen- stance,school settings have always been recognized as an envi-
dations.Very early into the response they also initiated the ronment for the potential spread of disease;but closing schools
process to declare a local emergency and to present key infor- has to be considered very carefully as an approach to prevent dis-
mation to our Board of Supervisors;this allowed for arranging ease transmission,and this practice can have serious unintended
supportive fiscal and functional options in anticipation of the impact on the function of our communities.As a result of the as-
challenges they would face in the response.The presentation sessments during the local response they developed a decision
to the Board further clarified Public Health's role in this type framework for school closing and did not close any schools.
of event and helped to amplify public educational messages. LACDPH has been developing innovative modeling projects de-
Keep the message simple:focus on facts and promote signed to provide a range of hypothetical scenarios and alterna
protective actions. tive solutions during a pandemic.The H I N I events provided a
valuable opportunity to test their model and to enact and refine
Because LACDPH held a pragmatic view of pandemic planning,
an actual response to what was previous a hypothetical solution.
an area where they excelled was in their educational messages.
The core messages were of value before H I N I events occurred, The events also allowed officials to put their pandemic flu plan into
applicable during,and still ring true today. For instance,they al- action:to identify its strengths and begin to consider improvements
ways stressed that it is wrong to assume that birds are the sole where it is lacking.The events significantly strengthened existing
source of a novel virus--agencies that incorrectly used the term partnerships and provided a valuable opportunity to develop new
"bird flu"as a synonym for"pandemic flu"in their educational partnerships that had been overlooked.Planning is essential to ef-
materials and planning documents were caught unprepared when0 fective emergency response and officials learned that the many
the swine-based H I N I virus emerged.The importance of this hours spent on pandemic flu exercises and community collabora-
distinction was to emphasize that they cannot predict the cause tions could be successfully transferred into a real-life application.
PANDEMIC FLU PLANNING BACKGROUND
APPENDIX
•
HOW IS PANDEMIC FLU DIFFERENT THAN SEASONAL FLU?
Most Americans are familiar with seasonal flu, a respiratory illness that strikes annually.
Seasonal flu kills approximately 36,000 people in the United States every year and hospitalizes more
than 200,000, but experts generally consider it a predictable public health problem, since many peo-
ple have some form of immunity to it and a yearly vaccine is available.4o
A pandemic(from Greek, meaning"of all the people") influenza is a new strain of the flu that is capable
of sustained transmission among humans and,as a result,causes a global outbreak. Because there is
little natural immunity,pandemic influenza will affect significantly more people than seasonal flu and like
seasonal flu, is easily spread from person to person. There have been at least 10 recorded flu pandemics
during the past 300 years.41
PANDEMIC FLU IS EVERYONE'S PROBLEM
If a severe pandemic occurs,it is likely to be a prolonged and widespread outbreak that could require
major changes in many sectors of society,such as schools,work,transportation,business,health care,and
government. The public can greatly reduce their risk during a pandemic by being informed and prepared
before the emergency. To be prepared for an outbreak, HHS encourages individuals, businesses,and
communities to:
Talk with your local public health officials and health care providers,who can supply information
about the signs and symptoms of a specific disease outbreak and recommend prevention and con-
trol actions; •
Adopt business/school practices that encourage sick employees/students to stay home and antici-
pate how to function with a significant portion of the workforce/school population absent due to ill-
ness or caring for ill family members;
Practice good health habits,including eating a balanced diet,exercising daily,and getting sufficient rest.
In addition,take common-sense steps to stop the spread of germs including frequent hand washing,
covering coughs and sneezes and staying away from others as much as possible when you are sick;and
•Stay informed about pandemic influenza and be prepared to respond.42
O
STATE PURCHASES OF ANTIVIRAL MEDICATIONS
III,s of June 1, 2009, 37 states and D.C. had purchased 50 percent or more of their federally subsi APPENDIX
ized antivirals to stockpile for use during a pandemic influenza.
37 states and D.C.have purchased have 13 states have purchased LESS than
purchased 50 percent or more of their 50 percent of their share of
federally-subsidized antivirals drugs to stockpile federally-subsidized antiviral drugs to
for use during an influenza pandemic stockpile for use during an influenza pandemic
State All Antivirals Percent of State All Antivirals Percent of
Purchased by Allocation Purchased by Allocation
Entity as of Purchased* , Entity as of Purchased**
06/01/2009 06/01/2009
Alabama 533,553 112.8% Arizona 67,717 11.6%
Alaska 77,030 113.2% Colorado 215 0.0%
Arkansas 382,398 133.5% Connecticut 22,829 6.2%
California** 2,772,922 103.2% Florida 277,798 15.6%
Delaware 121,164 141.0% Idaho 8,567 6.0%
D.C. 90,926 155.3% Massachusetts 50,662 7.5%
Georgia 474,022 52.0% Montana 8,174 8.5%
Hawaii 172,487 131.6% Nebraska 71,952 39.4%
Illinois** 516,018 50.3% New Mexico 77,409 39.2%
Indiana 650,912 100.00% Oklahoma 93,765 25.5%
Iowa 312,631 101.2% Oregon 26,523 7.1%
Kansas 286,084 100.0% Rhode Island 11,900 10.5%
Kentucky 216,224 50.0% Utah 52,033 21.1%
Louisiana 478,734 101.5%
• Maine 164,659 119.8%
Maryland 481,886 83.3%
Michigan 1,079,450 102.0%
Minnesota 340,900 64.1%
Mississippi 338,648 111.9%
Missouri 600,477 100.0%
Nevada 135,514 57.6%
New Hampshire 68,000 50.3%
New Jersey 880,293 97.0%
New York*** 2,444,836 121.2%
North Carolina 677,882 76.7%
North Dakota 57,000 85.7%
Ohio 1,388,858 115.7%
Pennsylvania 1,298,792 100.0%
• South Carolina 459,960 105.6%
South Dakota 80,310 100.0%
Tennessee 613,706 100.0%
Texas 1,662,241 71.6%
Vermont 71,036 109.2%
Virginia 828,445 107.1%
Washington 438,253 68.1%
West Virginia 248,462 130.6%
Wisconsin 363,729 63.3%
Wyoming 74,826 141.9%
40Notes:*The percent reflects total state antiviral purchases and may include unsubsidized state purchases,which is why some states exceed
•
100%of their federally-subsidized allocation. **The population count for California and Illinois does not include residents of Los Angeles
County or Chicago,respectively. These two localities,along with D.C.,received their own allocation of federally-subsidized antivirals based
on their populations. ***New York State antiviral purchases include those made by New York City
Source:http:/lwwwpandemicflu.gov/plan/states/antivirals.html
FINANCING OPTIONS FOR CREATING SURGE CAPACITY
APPENDIX
yen in a system with universal health insurance coverage, the costs of creatin
surge capacity in the medical care system will be above and beyond the usual
system of reimbursement to providers. Therefore, an additional system to finance
the creation of surge capacity will be in needed and can be addressed during the
health reform debate.
OPTION I: Establish a Preparedness Program under Medicare and Medicaid.
A Preparedness Program through Medicare and The HIT funding formula is based on hospitals'
Medicaid could be created to help hospitals and Medicare share and Medicare bed days. The for-
health providers upgrade equipment needed for mula calculation produces a dollar amount that
emergencies, and to provide a billing mecha- an individual hospital is able to access if it can
nism for care during emergencies. prove that it meets certain thresholds for mean-
ingful electronic health record use. The thresh-
Medicare olds would be defined by the HHS Secretary.
There is precedence for using Medicare Part A In the proposed Medicare Preparedness Pro-
(hospital insurance) to compensate hospitals for gram,preparedness accreditation standards and
higher operating costs they incur in providing Medicare's hospital codes of participation would
services to low-income patients, and even using be reviewed and updated by the HHS Secretary
Medicare Part A to preserve access to care for to strengthen the preparedness requirements.
Medicare and low-income populations.`'s The Dis- First year funding would be available to individual
proportionate Share Hospital (DSH) Payments hospitals on a formula-basis if they produced an
are used to mitigate the financial distress that action plan for their preparedness planning,th
some hospitals experience in serving large num- scope of which would be defined by the HHS Se.
bers of low-income, uninsured or underinsured retary. In subsequent years,formula-based fund-
patients and Medicare and Medicaid recipients. ing would be available if individual hospitals met
Medicare Part A has also been used to compensate preparedness structure and process benchmark
teaching hospitals for the higher costs associated measures defined by the HHS Secretary. The for-
with
mula would be based on hospitals' Medicare
with running graduate medical education pro- share and Medicare bed days. The HHS grams and training medical residents. The Direct
Secre-
Graduate Medical Education (DGME) provides ta y would be required to report to Congress an-
payments to hospitals for the costs of approved nually on the use of preparedness program
graduate medical education programs.44 Mean- dollars,and in year five make recommendations
while,the Indirect Medical Education (IME) pro- for improvements in the program including ad-
vides an additional payment to hospitals that have dressing any need for variations in the funding
residents enrolled in GME programs,to reflect the formula based on geography,risk-assessment,etc.
higher cost of patient care costs of teaching hos-
pitals relative to non-teaching hospitals.
In order to reach children's hospitals not reim-
A newly formed Preparedness Program would bursed by Medicare,hospital preparedness pay-
allow hospitals to meet and maintain enhanced ments would need to include a parallel funding
preparedness accreditation standards and stream in Medicaid.
Medicare codes of participation. The program
would link payment to a process involving the Medicaid is a jointly funded,federal-state health
HHS Secretary defining the scope of allowable insurance program for low-income children,the
preparedness costs. Overall,this approach would aged,blind, and/or disabled,and other people
be similar to the Health IT(HIT)incentive model who are eligible to receive federally assisted in-
included in the American Recovery and Rein- come maintenance payments. Medicaid is a state
vestment Act of 2009. The HIT program is not a administered program and each state sets its owr
traditional grant program where hospitals apply guidelines regarding eligibility and services,how-
for
owfor money to do certain things and compete for ever,the federal government sets a minimum el-
dollars, etc. It is, instead, like a lot of things igibility floor ensuring a certain level of coverage
funded on the mandatory side, formula-based. to select populations.
20
In the past,Medicaid has been used to reimburse The proposed hospital preparedness program
providers of medical assistance, including hospi- would involve a 100 percent federal match so
SOctobertals,for infrastructure upgrades. For example,in there would be no reason for states to opt out of 1972,Congress passed a law(P.L.92-603) the program. The legislation could also include
that provided for a 90 percent federal(10 percent creation of a Medicaid reimbursement for the
state)financial participation for the design,devel- state health department's role in administering ';
� .
opment, or installation of the Medicaid Manage- and coordinating the new program,as described =u
ment Information System (MMIS),a mechanized later in the Eligibility for Reimbursement and
claims processing and information retrieval system Standards for Surge Capacity section.
approved by HHS. The law also provided a 75 per-
cent federal (25 percent state) financial participa w _
tion for the operation of the MMIS.
OPTION 2: Use Direct and Indirect Payments to Reimburse Hospitals for
Surge Costs.
The Graduate Medical Education (GME) pro- surge capacity,including hiring and retaining per-
gram currently uses both direct and indirect pay- sonnel and recruiting a surge workforce.
ments to reimburse teaching hospitals for the
cost of educating medical students. Direct Grad- Centers for Medicare and Medicaid Services
uate Medical Education (DGME) provides pay (CMS) could set up a new Medicare billing code
ments to hospitals for the costs of approved or a Diagnosis Related Group (DRG) add-on that
graduate medical education programs. Mean- could be used to reimburse hospitals for capital ex-
penditures and staffing for hospital preparedness.
while, Indirect Medical Education (IME) pro
vides an additional payment to hospitals that have This approach would face some challenges to im
enrolled in GME programs, to reflect plement because Medicare currently does not re-
residents
the higher cost of patient care costs of teaching imburse through DRG unrelated to direct patient
•
hospitals relative to non teaching hospitals.45 care and the process would require ongoing au-
diting of hospitals. CMS could determine whether
The creation of a Direct PreparednessPayments having preparedness training curriculum in place
(DPP) and Indirect Preparedness Payments (IPP) could be reimbursed and perhaps whether hospi-
could help reimburse hospitals for the direct costs tals could receive an additional payment to cover
of preparedness,such as the purchase of extra sup- the higher costs of training staff in emergency pre-
plies and beds,and provide hospitals with a mod- paredness and surge capacity techniques.
est enhancement for the ongoing costs of building
Eligibility for Reimbursement and Standards for Surge Capacity
CMS,in conjunction with the Assistant Secretary ■ASPR would need to develop guidance to
for Preparedness and Response (ASPR) and states for coordination of a state program,in-
other appropriate partners,could develop stan- cluding communication between hospitals,
dards and guidelines for determining both if a triggering of surge protocols, deployment of
hospital should be eligible for (and is capable assets,and other issues.
of) developing surge and what surge capacity
•
entails. Although CMS would provide the reim In order to receive reimbursement, hospitals
bursement mechanism,ASPR, with input from would need to meet preparedness standards
Coordinating Office for Terrorism Prepared as determined by the federal rulemaking
ness and Emergency Response (COTPER), process. Examples include having a hospital
preparedness coordinator, a hospital specific
should oversee the program and provide over-
sight and technical assistance to state and hos plan that is approved by the state,an interop
-
preparedness
to ensure efficacy. A number of issues that erable communications system, and a Conti
would need to be addressed include: nuity of operations plan.
•III Through the rulemaking process,a certification By agreeing to participate,hospitals would have
to agree to participate in a state surge program,
• process would need to be developed so state
health departments could determine if a hospi- to be coordinated by the state health department
tal is eligible to participate in the program.The with guidance and technical assistance from HHS.
state would take into account the regional need ■Prior to creating the hospital preparedness billing
for surge and the capacity of individual hospi- code, CMS would have to determine for what
tals to participate,based on a state-wide plan. items it would be willing to reimburse hospitals.
Endnotes America:Modernizing the Federal Public Health System tb
Focus on Prevention and Preparedness. Washington,
D.C.:TFAH,2008,p.92.
1 Personal correspondence with David Fleming,MD, 21 U.S.House of Representatives,Committee on 0
a Director of Seattle&King County Public Health De- Homeland Security,Report by the Majority Staff.
partment,May 21,2009. Getting Beyond Getting Ready for Pandemic Influenza.
2 CNN.com."`Walking well'Flood Hospitals with—or Washington,D.C.:U.S.Congress,January 2009.
without—Flu Symptoms." May 2,2009. http://homeland.house.gov/SiteDocuments/20090
e ,, r
http://www.cnn.com/2009/HEALTH/05/02/wor-
114124322-85263.pdf(accessed January 23,2009).
ried.well.hospitals/ (accessed May 18,2009). 22 Johnson,N.,E.Hudgins,and J.Koulish.Facing Deficits,
3 Improving Pandemic Preparedness,2008. Many States Are Imposing Cuts That Hurt Vulnerable Resi-
4 Trust for America's Health. Ready or Not?2008:Pro- dents.Washington,D.C.:Center on Budget and Policy
tecting the Public's Health from Diseases,Disasters,and Priorities,October 20,2008.http://www.cbpp.org/3-
Bioterrorism. Washington,D.C.:Trust for America's 13-08sfp.htm(accessed May 20,2009).
Health,2008,p.20. 23 U.S.Government Accountability Office.Pandemic In-
5 U.S.Department of Health and Human Services. fluenza:Federal Agencies should Continue to Assist States
"Secretary Sebelius Takes Two Key Actions On Strate- to Address Gaps in Pandemic Planning.Washington,
gic National Stockpile." News Release,April 30,2009. D.C.:U.S.Government Accountability Office,2008.
http://www.hhs.gov/news/press/2009pres/04/20090 24 Ibid.
430a.html(accessed May 11,2009). 25 U.S.Department of Health and Human Services.
6 Pandemic Planning Update VI,2009. "Federal Assessment Finds Progress,Gaps in State
7 U.S.Department of Health and Human Services."2009- Plans for Pandemic Influenza." News Release,January
H1N1 Influenza Vaccine Development Next Steps: 15,2009. http://www.hhs.gov/news/press/2009pres/
Questions and Answers."Medical Countermeasures.gov 01/20090115i.html(accessed May 6,2009).
https://www.medicalcountermeasures.gov/BARDA/M 26 U.S.Centers for Disease Control and Prevention. "Eval-
CM/panflu/nextsteps.aspx(accessed May 29,2009). uation Criteria for Key Supporting Activities Linked to
8 Ibid,p.5. PHEP Funding." http://emergency.cdc.gov/cotper/
coopagreement/08/pdf/evaluation.pdf (accessed Sep-
9 Pandemic Planning Update VI,2009. tember 25,2008).
10 Congressional Budget Office. U.S.Policy Regarding 27 Grygiel,C."Swine Flu Return,Severe Flooding Big
Pandemic-Influenza Vaccines. Washington,D.C.:U.S. King County Concerns." Seattle Post Intelligence),May
Congress,September 2008,p.5. 18,2009. http://www.seattlepi.com/loca1/406276_flu-
11 Harris,KM,J Maurer,N Lurie. Midseason Influenza floodl8.html?source=mypi (accessed May 21,2009).
Vaccine Use by Adults in the U.S.Santa Monica,CA: 28 Information provided to TFAH in private communi-
RAND Corporation,2008]. cation dated May 18,2009.
12 Letter to Senator Inouye,Chair,Senate Appropria- 29 National Association of County and City Health Offi-
dons Committee and Senator Cochran,Ranking cials(NACCHO).Preliminary Findings:NACCHO Sur-
Member,Senate Appropriations Committee from vey of Local Health Departments'Budget Cuts and Workforce
14 U.S.Senators advocating for increased appropri Reductions.Washington,D.C.:NACCHO,2008.
ations for the Biomedical Advanced Development
Research Authority,May 7,2009. 30 Calvan,B.C."Cuts Add to Health Staffers'Worry."
The Sacramento Bee,May 3,2009.
13 http://www.hhs.gov/pandemicflu/plan/ http://www.sacbee.com/ourregion/story/1829626-
sup6.html#summary p2.html (accessed May 18,2009).
14 U.S.Government Accountability Office. Pandemic In 31 Okie,S."Dr.Pou and the Hurricane—Implications
fluenza:Federal Agencies Should Continue to Assist States for Patient Care during Disasters."The New England
to Address Gaps in Pandemic Planning.Washington, Journal of Medicine 358,no.1 (January,2008):1-5.
D.C.:U.S.Government Accountability Office,2008.
32 Felland,L.E.,A.Katz,A.Liebhaber,and G.R.Cohen.
15 Getting Beyond Getting Ready for Pandemic Influenza,2009. Developing Health System Surge Capacity:Community Ef-
16 Ready or Not, 2008,p.90. forts in Jeopardy.Research Brief no.5.Washington,D.C.:
17 Allan,T.M.Statement of the Cuyahoga County Center for Studying Health System Change,2008.
Board of Health to the Committee on Oversight and 33 Trust for America's Health. Ready or Not? Protecting
Government Reform,U.S.House of Representa- the Public's Health from Diseases,Disasters,and Bioterror-
tives. Washington,D.C.:Cuyahoga County Board of ism,2008. Washington,D.C.,Trust for America's
Health,May 20,2009. Health,2008.
18 U.S.Government Accountability Office. Influenza 34 DeNavas-Walt,C.,B.D.Proctor,andJ.C.Smith. Income,
Pandemic:Challenges in Preparedness and Planning. Poverty,and Health Insurance Coverage in the United States:
Washington,D.C.:U.S.Government Accountability 2007, U.S.Census Bureau,Current Population Reports,
Office,June 2008.http://www.gao.gov/new.items/ P60-235. Washington,D.C.:U.S.Government Printing
d05863t.pdf(accessed January 23,2009). Office,2008.http://www.census.gov/prod/2008pubs/
19 Trust for America's Health. Preventing and Control- P60-235.Pdf(accessed September 26,2008). •
ling Pandemic Flu and Other Infectious Diseases. Wash- 35 J.Matheny,et al."Financial Effects of an Influenza
ington,D.C.:Trust for America's Health,March Pandemic on U.S.Hospitals."Journal of Health Care
2008. http://healthyamericans.org/assets/files/ Finance 31,no.1 (Fall,2007):58-63.
10ThingsPanFlu.pdf(accessed December 4,2008).
20 Trust for America's Health. Blueprint for a Healthier
36 There is precedence for using federal funding 41 CIDRAP. "Historical Perspective."
streams to compensate hospitals for their contribu- http://www.cidrap.umn.edu/cidrap/content/in-
tion to public health. Medicare Part A has been fluenza/panflu/biofacts/panflu.html#_Historical_P
used to compensate teaching hospitals for the erspective_1 (accessed April 27,2009).
higher costs associated with running graduate med- 42 Ready America. "Pandemic Influenza." Department
ical education programs and training medical resi-
dents. of Homeland Security. http://www.ready.gov/amer-
ica/beinformed/influenza.html (accessed October
37 Katz,R and J.Levi. "Should a Reformed System Be 27,2008).
Prepared for Public Health Emergencies,and What 43 Association of American Medical Colleges. "Medicare
Does that Mean Anyway?"Journal of Law,Medicine,
and Ethics(Winter 2008):485-490. (In print.) http://Disproportionate Share (DSH)Payments."
38 Toner,E.,R.Waldhorn,B.Maldin,et al. "Hospital hosp0003.htm(accessed February 4, 009)y/teachhosp/
Preparedness for Pandemic Influenza." Biosecurity 44 Centers for Medicare and Medicaid Services. "Di-
and Bioterrorism:Biodefense Strategy,Practice and Science
4,no.2 (2006):207-217. rect Graduate Medical Education (aid
http://www.cms.h
s.gov/AcuteInpatientPPS/06_dg De Lorenzo,R.A."Financing Hospital Disaster Pre- me asp#pOfP ge(acccesdg
ed February 4,2009).paredness."Prehospital and Disaster Medicine 22,no.5 45 Centers for Medicare and Medicaid Services. "Indi-
(Sep-Oct,•
2007):436-439. rect Medical Education (IME)."
40 Trust for America's Health. "A Killer Flu?"citing http://www.cros.hhs.gov/AcutelnpatientPPS/07_im
"Questions and Answers:Seasonal Influenza,"Cen- e.asp#TopOfPage (accessed February 4,2009).
ters for Disease Control and Prevention,at URL
http://www.cdc.gov/flu/about/qa/disease.htm (ac-
cessed April 27,2009).
t k
00/
ACKNOWLEDGEMENTS TFAH BOARD OF
DIRECTORS
Trust for America's Health is a non-profit, non-partisan organization dedicated to saving lives by pro-
tecting the health of every community and working to make disease prevention a national priority. Lowell Weicker,Jr.
•
President
The Center for Biosecurity is an independent, nonprofit organization of the University of Pittsburgh For 3-term U.S.Senator
Medical Center.The Center works to affect policy and practice in ways that lessen the illness,death, and and Governor of
civil disruption that would follow large-scale epidemics,whether they occur naturally or result from the Connecticut
use of a biological weapon. Cynthia M.Harris,
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our PhD,DABT
country.As the nation's largest philanthropy devoted exclusively to improving the quality of the health and Vice President
Director and Associate
health care of all Americans,the Foundation works with a diverse group of organizations and individuals to
Professor
identify solutions and achieve comprehensive, meaningful,and timely change. For more than 35 years,the Institute of Public Health,
Foundation has brought experience, commitment,and a rigorous, balanced approach to the problems that Florida A&M University
affect the health and health care of those it serves.When it comes to helping Americans lead healthier
Patricia Bauinaum,MS,JD
lives and get the care they need,the Foundation expects to make a difference in your lifetime. Treasurer
President and CEO
REPORT AUTHORS Ann Norwood,MD,COL,USA,MC(Ret)
Bauman Foundation
Senior Associate Gail Christopher,DN
Jeffrey Levi,PhD. Center for Biosecurity of the University of Pittsburgh Vice President for Health
Executive Director Medical Center WK Kellogg Foundation
Trust for America's Health andohn W.Everets
Associate Professor in the Department of Health Policy Jennifer Nuzzo,SM J
The George Washington University
Associate David Fleming,MD
School of Public Health and Health Services Center for Biosecurity of the University of Pittsburgh Director of Public Health
Medical Center King attle County,
Thomas V.Inglesby,MD SSeeattle
on
Chief Operating Officer and Deputy Director Monica Schoch-Spana,PhD Senior Associate Arthur Garson,Jr.,
Center for Biosecurity of the University of Pittsburgh
Medical Center Center for Biosecurity of the University of Pittsburgh MD,MPH
Medical CenterLExecutive Vice Presiden
Directoraura of PublicSegal, Eric Toner,MD and Provost and the
uforPublica's Affairs Senior Associate Robert C. Taylor Professor
Trust America's Health
Center for Biosecurity of the University of Pittsburgh of Health Science and
Serena Vinter,MHS Medical Center Public Policy
Senior Research Associate University of Virginia
Trust for America's Health PEER REVIEWERS Robert T.Harris,MD
CONTRIBUTORS TFAH thanks the reviewers for their time, expertise, and Former Chief Medical
insights. The opinions expressed in the report do not Officer and Senior
Brooke Courtney,JD,MPH, necessarily represent the views of the individuals or the Vice President for
Associate organization with which they are associated. Healthcare
Center for Biosecurity of the University of Pittsburgh BlueCross BlueShield of
Medical Center David Fleming,MD North Carolina
Director of Public Health
Kimberly Elliott,MA Seattle King County,Washington Alonzo Plough,MA,
Deputy Director MPH,PhD
Trust for America's Health
Robert Kadlec,MD Director,Emergency
Former Special Assistant to the President for Homeland
Preparedness and
Crystal Franco Security and Senior Director for Biological Defense Policy Response Program
Senior Analyst Los Angeles County
Center for Biosecurity of the University of Pittsburgh This report is supported by a grant from the Robert Wood Department of Public Health
Medical Center Johnson Foundation. The opinions expressed in this report
Gigi Kwik Gronvall,PhD are those of the authors and do not necessary reflect the Theodore Spencer
Senior Associate views of the foundation. Project Manager
Natural Resources
Center for Biosecurity of the University of Pittsburgh NatunaCouncil
Medical Center Defense
meitOr
ca's Health ill
WWW.HEALTHYAMERICANS.ORG
1730 M Street, NW, Suite 900 •Washington, DC 20036
(t) 202-223-9870 • (f) 202-223-9871
..
. •
Species Affected
Jefferson County Pandemic
Preparedness and Response:
Influenza A/SWH1 Virus _ t
Genetic Reservoirs ,. H3,H7
("Swine Flu") H1,H2,H3
N1 Intermixing
June 18, 2009 _ � , .-.rAI•.a�
t ' H'',:t?
Jefferson County Board of Health nlnei`o1a
Tom Locke, MD, MPH LBMs , ' �� H10,
H1-I2 H1-2,4-7, •
Clallam County Health Officer Others fe H14-15 H9-13,15-16 ,
#: ..-
Other Aquatic AL'.
t� 1, Birds?
•
Influenza A - Virology B.Reassortment ; = 1' `,' ,
Q4:7774:" )
emeaeemnm Neemm,;d l
• 144 different characterizations of the virus, ,► 4�I
based on 16 H types and 9 N types \ / y
Influenza A-a virus"designed"for rJ 11 it:Io
•
mutation `` z — ' -`
Sy�7 �. �j �, _= -��M- PBt�
• Occurs in humans,pigs horses,birds,and • � .rip
M %4 -\
certain marine mammals C� Y \
• Human disease historically linked to H1-H3 .0:".),,,,,
1',
�. —i► _ _�' pqj
and NiN2 ad,\Y
333
' Avian flu"viruses are Influenza A viruses • ,1?-' 'R @ Nucleus
All human pantlemics have been tlue to
Influenza A
• H1-H16,Ni 1p ,°(.1.7,,,,,` Vg �i .;3-.1.-,,f,,
.
• - ( Nb) H6 and H7 typically cause
severe outbreaks in birds 7 • • = •• • •
-‘k. rim rrS`
•
1
•
Timeline of Emergence of Influenza A
Viruses in Humans in the 20th Century
Avian
Influenza
} H9 t.,‘, H7_14
Russian H
Influenza H 5 /
Asian
H1
Influenza
Spanish H3 P
Influenza `
H2 LM611 Hong Kong
H1 r — L Influenza
1918 19571968 1977 1997 2003
1998/9
•
A/SWH1 Influenza
aka "Swine Flu"
•
1
•
Demographic and Exposure Characteristics of 11 Patients Infected with Triple-Reassortant Swine
Influenza A(H1)Viruses
Teble 1.Demographic and Exposure chwaderistks of 11 Patients Infected with TriplmReassortant Swine Influenza A(H1)Viruses.
Estimated
Patient State of fate of Incubation IN Swine
No. Age Sea Residence Illness Onset Period Exposure' Repent
1 17 yr M WI Dec 2005 3 days Nutchered a pig(direct contact) Not known
2 Tyr M MO Jan.2006 Na known Reponed no contact with a pig Not known
(unknown conned(
1 4 yr F IA Nov.2006 7-10 days Had contact with patient wills sus. Yes
petted case of swine Influenza
(epidemiologically linked contact)
4 10yr F OH Aug.2007 3-4 days Exhibited swine at fair,handledpies Yes
(direct contact)
S 36 yr M OH Aug 2007 3-4 days Exhibited swine at fair,handled pigs Yes
(direct contact)
6 48 yr F IL Aug.2007 7 days Visaed fair,Ad not stop at pigpen Yes
(near vicinity)
7 16 mo M MI Aug.2007 7 days Visited Farr,came within 1 m of pigs Yes
(close promni)
8 2yr M IA Nov.2007 1-10days lived on swine farm,came within Yes
1 m ofpigs(close proximity)
9 26 yr f MN Jan.2008 9 days Visited liveanimal market,came with- Not known
in 1 on of pigpen(close proximity)
10 14 yr M TX Oct.2008 3days Visited a swine farm.brought home Yes
and handled a pig(direct contact)
11 Syr M IA Feb.2009 1-10 days Visited swine farm owned by his farm- Yes
ly,touched pigs(direct contact)
*Direct contact refers to touching or handling a pig;close proximity refers to standing within 1.83 m(6 P)of a pig,without known direct con.
rad;near vicinity refers to presence of pigs on the premises but not in close proximity;epldemiologmally linked refers to a person who is
epidemiologically linked to another person with a confirmed or suspected infection;and unknown refers to unknown contact or unavailable
contact information.
Shinde Vet al.N Engl J Med 2009;10.1056/NEJMoa0903812
OZtjm�NEW ENGLAND
JOURNALnJMEDICINE
•
Comparison of H1N1 Swine Genotypes in Recent Cases in the United States
Human H1NI Cases from Human H1N1 Cases
Triple-Reassortant Swine in California
•
PB2 P82
PRI PB1
PA PA
HA tanimmaawat HA awe®
NP laaaaaaaannwama NP eaaaiainearaas
NA NA elmtworomrla.
M aaommemir M
NS maumaaaeraa NS
aarrameee Classic swine,North American lineage
Avian,North American lineage
tr.*..r;no Seasonal H3N2
041.4441014M016 Eurasian swine lineage
Novel Swine-Origin Influenza A(H1N1)Virus Investigation Team.N Engl J Med
2009;10.1056/NEJMoa0903810
NEW ENGLAND
JOURNAL rI MEDICINE
•
2
•
New Influenza A(H1 N1( Status as of 11 June 2009
Number of laboratory confirmed cca`se o ported to WHO 10:00 GMT r ( 1 J VI r VI{ r;,p!�
f TIM
act".. ...Or, ,-v _ A Weekly Influenza Surveillance Report Prepared by the Influenza Division
-'•4,-i .�/
r ,F Weekly Influenza Activity Estimates Reported by State and Territorial Epidemiologists.
7 Q �'—� Week Ending May 30,2009 Week..
II
,r._,\cer,,\
•
%
,Ali
414 imilifra Acif.
IFi ' � „: �off,o,m.
tiY`ti • ty
1.„. de, 2 ,��, ,i
1p iiiiii
/-1 CI t I 1111111, lq, ❑Ro AReport
, „
,.„.
,, ,
i�w+.m more an.:4.7aEZ:ln.,a�.ex orc,SE o„ ,
❑L of
`e ❑Regional
Widecpread
world Ik,lm �.-
•.,..,••,—.....r. .e,.v.. ..manr>e.•hm" a..a `"""ei �,;urve m,�
Nap wxuced 17 JJ.a 1003 ISW GMT TTh'is 7700 04770 es yepyraphlc spread G d Joes no[7700 are the severity or Influenza acv.AW
•
Phases of Pandemic Alert - WHO The First Four Weeks of "Swine Flu"
Interpandemic Low risk of human cases 1 • Includes initial 574 lab-confirmed illnesses due to
New virus in novel H1 N1 influenza virus(A/SWH1)reported to
animals,no Higher risk of human cases 2 CDC 4/26—5/23/2009
human cases
— Based on data available by 6/3/2009
— Continue to receive data for these cases
Pandemic Alert -
• Includes cases whose testing was done at
New virus causes —WA DOH Public Health Laboratories
human cases ' R11111
Evidence of significant human 5 — Department of Defense Armstrong Laboratory(Texas)
to human transmission — Other state public health laboratories
Pandemic Efficient and sustained human 6
to human transmission
iNo
•
1
•
April 26 — May 23 Surveillance method
Number of illnesses due to NSW1-f1 virus by age group
• Goal: Rapidly show distribution of A/SWH1 virus for 574 INA residents`
in WA&determine if local transmission occurring
111-
350 _-- ----_—
• No restrictions on severity of illness for reporting 300_
• Cases identified through: g 250-
to
— Healthcare provider reports =200
— Submissions from commercial laboratories g 150-
• Samples positive for influenza A virus z'100- -
— Submissions from pathologists&medical examiners 50
0 I
— Sentinel providers 8-49 5764 >65
• 1427 rtPCR assays run at PHL Age group
'Of 574 cases,2 were missing age
•
Illnesses due to A/SWH1 virus by
age group*and hospitalization
status
Ntanber of illnesses due to PAWN.'vias by illness
onset date"for 574 WA residents Hospitalized -'
5 — Age group(yrs) Yes No Unknow
.4 0-4 8 50 11
o11
i 5-17 18 268 37
p
15 i
I
z 5 1' I 'I Iii... 50—64 6 112 119
0
U,H:',eveeea 'Im n--,,� 1'-L-:a 65+ 2 2 0
Onset date
Total 40 464 68
'Illness onset date unavailable for 46 cases,specimen collection date used
insteatl. 'Of 574 cases,two were missing age.
•
2
•
Confirmed illnesses due to A/SWH1 virus by Disposition of confirmed cases of A/SWH1
county of residence for 574 WA residents* influenza
c
q-4:, Disposition Present Status reported
t
' �1'5 Hospitalized 40(7.9%) --,'504
,\--
T4 _ , _ Critical; care/alive 6(1.3%) 472 A
� � Died 1 (0.2%) 457
_ _—
•
Reported symptoms of confirmed cases of A/SWH1
influenza
Symptom Present(%) Status reported Number of illnesses due to NSWHl vims by
"rapid Flu A"test result for 574 WA residents
Fever 488 (97%) 502 so°
«am —
Cough 456 (93%) 493 z
Sore throat 251 (61%) 415 E 200
i,o°1111
1111 Vomiting 116 (27%) 428
Posit. Neg.. Not done Test status
unknovm
Diarrhea 103 (24%) 424 Test result
Note-Among the positives,4 were A/B positive.
•
3
S
Treatment Priorities
Proportion of specimens confirmed to be
A/SWH1 infection • Hospitalized Patients with confirmed,
Total samples A/SWH1 infection probable, or suspected A/SWH1 infection-
Age(yrs) tested confirmed'
• Patients with Influenza Like Illness wit
0—19 862 406(47%) increased Risk of Influenza Complication
20—39 267 95(36%) (especially with Rapid Test A Positive
40—59 178 50(28%)
and/or contact history)
60+ 97 7(7%)
Age unknown 23 2(9%)
huA DOH PHL tested only 560 of the 574 confirmed cases.
i
Strategic Nat'l Stockpile Supplies Risk Groups for Influenza
Jefferson County Complications
• Total Supply— 15% of County Population • Infants and children aged<5 years
-; Persons with asthma or other chronic pulmonary diseases such as cystic
• Initial Disbursement 5 0 r. '. fibrosis in children or chronic obstructive pulmonary disease in adults
• Persons with hemodynamically significant cardiac disease
• 4028 total x 0.25 = 1007 treatrrien`3 ; • Persons who have immunosuppressive disorders or are receiving
courses immunosuppressive therapy
:HIV-infected persons
gnant woman
• Oseltamivir 689 75mg�'t 30 45 m 89
y, mg, Persons y with sickle cell anemia and other hemoglobinopathie
• Persons with diseases that require long-term aspirin therapy.such as
30mg rheumatoid arthritis or Kawasaki disease
• Zanamivir 228 Treatment Courses • Persons with chronic renal dysfunction
• Persons with cancer ='
• Also Personal Protective Equipment • Persons with chronic metabolic disease such as diabetes mellitus '
Persons with neuromuscular disorders seizure disorders,or cognitive
(masks gowns, gloves) dysfunction that may compromise the handling of respiratory secretions
• Adults aged>65 years
• Residents of any age of nursing homes or other long-term care institutions
•
4
•
Efficacy of Neuramindase Inhibitors
• 2003 Placebo Controlled Double Blind
Prospective Study 3464 subjects
In patients at risk for influenza complications
LRTC-associated antibiotic use reduced from
18 5%to 12 2% 34% reduction, p= 02
• Hospitalization reduced from 1 7% (placebo)to'
7% (oseltamivir) 59% reduction, p= 02
• No Change with unconfirmed influenza-like
illness
•
Next Steps
• June 11 2009: Declaration of Level 6 Pandemic
by WHO
I • Surveillance: Local, National, Global
• Prevention Vaccine Production, Infection
Control Measures
• Preparedness SNS distribution Schools and
Businesses, Medical Care Surge Capacity
(Alternate Care Sites), Buy More Antivirals?
• Response: Infrastructure. Volunteers (MRC),
Dedicated Funding
0
5
• Region 2 Public Health
• Emergency Response Plan
August 31,2007
•
APPENDIX IV
III
PANDEMIC
INFLUENZA
RESPONSE
•
Region 2 Public Health
Emergency Response Plan
August 31,2007
• Pandemic Influenza Response
INTRODUCTION
The purpose of this appendix is to provide a guide for local public health and health
care providers for detection and response to an influenza pandemic event. Which may
lessen the impact of an influenza pandemic on the residents of Region 2 (Clallam,
Jefferson and Kitsap Counties)
II. BACKGROUND
Pandemic influenza differs from seasonal influenza. Influenza is a highly contagious
viral disease. A Pandemic usually comes on suddenly and may include these
symptoms:
• Headache
• Tiredness
• Dry cough
• Sore throat
• Nasal congestion
• Body aches
• Pandemics occur because of the ability of the influenza virus to change into new types or
strains. People may be immune to some strains of the disease either because they have
had that strain of influenza in the past or because they have recently received influenza
vaccine. Depending on how much the virus has changed, people may have little or no
immunity to the new strain. Small changes can result in localized epidemics. A novel
and highly contagious strain of the influenza virus may emerge, and an influenza
pandemic will occur and affect populations around the world.
III. ASSUMPTIONS
An influenza pandemic is unlike any other public health emergency or disaster.
A. Influenza pandemics are inevitable,yet no one knows when the next one will occur.
B. There may be very little warning. Experts believe that we will have between one
and six months between the time that a novel influenza strain is identified and the
time that outbreaks begin to occur in the U.S.
C. Outbreaks are expected to occur simultaneously throughout much of the U.S.,
preventing sharing of human and material resources that normally occurs with other
natural disasters.
D. The effect of influenza on individual communities will be prolonged-weeks to
months.
E. It is likely that vaccine shortages will exist,especially during the early phases of the
pandemic.
• F. Effective preventive and therapeutic measures,including antiviral agents,will likely
be in short supply.
Appendix IV-3
Region 2 Public Health
Emergency Response Plan
August 31,2007
G. When vaccine becomes available,it is expected that individuals will need an initial •
priming dose followed by a second dose approximately 30 days later to achieve
optimal antibody responses and clinical protection.
H. Healthcare workers and other first responders will be at even higher risk of exposure
and illness than the general population,further impeding the care of victims.
IV. CONCEPT OF OPERATIONS
A. Stages of Alert
The following W.H.O. Pandemic Influenza phases will be used planning purposes
by public health and their partners.
Period Phase Definition
No new influenza virus subtypes have been
detected in humans. An influenza virus subtype
1 that has caused human infection may be present in
Inter- animals. If present in animals,the risk of human
pandemic infection or disease is considered to be low.
No new influenza virus subtypes have been
2 detected in humans. However,a circulating animal
influenza virus subtype poses a substantial risk of
human disease.
Human infection(s) with a new subtype but no •
3 human-to-human spread,or at most rare instances
of spread to a close contact.
Small cluster(s)with limited human-to-human
transmission but spread is highly localized,
Pandemic 4 suggesting that the virus is not well adapted to
Alert humans.
Larger cluster(s)but human-to-human spread still
localized,suggesting that the virus is becoming
5 increasingly better adapted to humans but may not
yet be fully transmissible (substantial pandemic
risk).
Pandemic: increased and sustained transmission in
Pandemic 6 general population.
Source:World Health Organization(WHO)and the National Center for Disease Control(CDC).
B. Roles and Responsibilities
As the pandemic develops, the World Health Organization (WHO) will notify the
Centers for Disease Control and Prevention (CDC) of progress of the pandemic from
one stage to the next. CDC will communicate with Washington State Department of
Health (DOH) and other state agencies about pandemic stages, vaccine availability, •
virus laboratory findings, and national response coordination. DoH will
Appendix IV-4
Region 2 Public Health
Emergency Response Plan
August 31,2007
• communicate with local health agencies through the Washington Secure Electronic
Communication, Urgent Response and Exchange System(SECURES).
1. The Federal Role
a. Vaccine research and development.
b. Coordinating national and international surveillance.
c. Assessing and potentially enhancing the coordination of vaccine and
antiviral capacity,and coordinating public-sector procurement.
d. Assessing the need for and scope of a suitable liability program for
vaccine manufacturers and persons administering the vaccine.
e. Developing a national"clearinghouse" for vaccine availability
information,vaccine distribution,and redistribution.
f. Developing an adverse events tracking system at the national level.
2. The State Role
a. Coordinates statewide planning for pandemic influenza;provides
recommendations for local and health care system planning.
b. Coordinates statewide influenza surveillance and case investigation.
c. Provides guidelines and recommendations for influenza detection,
• management,control and prevention measures.
d. Communicates with Centers for Disease Control and Prevention(CDC),
Health Canada,and other state,local,tribal and provincial public health
agencies.
e. Provides Biosafety level 3 laboratory facilities for influenza identification,
isolation and isolate typing;refers to non-typable strains to CDC.
f. Coordinates statewide distribution of vaccine and antivirals provided via
SNS;makes recommendations for use and prioritization of vaccine and
antiviral medication.
g. Coordinates information for media and public on course of the pandemic,
recommendations for prevention.
h. Liaison to Washington State Emergency Operations Center.
i. Liaison to the Washington State Department of Agriculture regarding
human impact of avian and animal influenza.
Reference: Annex 3 pandemic Influenza Response Plan of Appendix 1
Communicable Disease Emergency Response Plan from the DoH
Comprehensive Emergency Management Plan.
•
Appendix IV-5
Region 2 Public Health
Emergency Response Plan
August 31,2007
•
C. LOCAL RESPONSE
1. Incident Command System
Incident Command will follow the National Incident Management System
(NIMS) guidelines. Appendix V,Tab B,Emergency Coordination Center (ECC)
2. Role of Public Health
a. Health Officer
(1) Provides overall public health management of the pandemic.
(2) Uses legal authority to order isolation and quarantine as needed.
Appendix II,Tab C,Isolation and Quarantine.
(3) Assure that health care professionals receive relevant communications
from Public Health in a timely manner.
(4) Communicates with healthcare providers regarding prophylaxis and
treatment of influenza. Appendix V,Tab A,Communications.
(5) Provides recommendations to the public on strategies to prevent
exposure to influenza.
(6) Recommends appropriate infection control methodologies,including
personal protective equipment,for healthcare providers. Tab D,Infection •
Control
(7) Coordinates with the Washington State Department of Health (DoH) and
other local health jurisdictions on outbreak mitigation and control
strategies.
(8) Develop pandemic response plans that include documentation of
procedures for receipt of material via the Strategic National Stockpile.
(9) Initiates the request for the Strategic National Stockpile (SNS).
b. Region 2 Public Health Preparedness
(1) Provide consultation and technical assistance to local health
departments/districts and hospitals in planning for and responding to
pandemic influenza.
(2) Provide and facilitate training.
(3) Assist with resource sharing and communication as requested by local
health departments.
c. Administration
(1) Assures availability of trained staff to respond to pandemic.
(2) Facilitates acquisition of supplies (SNS) and physical locales (Point of
Delivery/ Neighborhood Distribution Clinics) as needed.
(3) Tracks expenditures associated with pandemic influenza response.
(4) Serves as Public Information Officer
d. Community Health •
Appendix IV-6
Region 2 Public Health
Emergency Response Plan
August 31,2007
(1) Manages the dispensing of pharmaceuticals or administration of vaccines.
(2) Manages the quarantine or isolation of individuals.
(3) Coordinates submission of laboratory specimens to the state public health
laboratory.
(4) Manages tracking adverse events following administration of vaccine or
chemoprophylaxis agents utilizing the Vaccine Adverse Events Reporting
System(VAERS).http://vaers.hhs.gov/
e. Environmental Health
(1) Provides recommendations on the protection of food and water.
(2) Assists as needed in mitigation and containment strategies.
(3) Provides staff support to epidemiology and/or emergency preparedness
and response staff.
3. Role of County Government(Emergency Management)
a. Develop a staffing plan to address surge capacity utilizing local resources
prior to requesting regional and state assistance.
b. Coordinate the community response.
c. Work with health care delivery system in monitoring bed status.
d. Share information on pandemic surveillance with health care delivery
systems.
•
e. Initiate and maintain the emergency operations center.
f. Coordinate coroner services as needed.
County Comprehensive Emergency Management Plan.
4. Role of Local Health Care Providers and Hospitals
Health care system partners participate in a health care coalition facilitated by
public health to maximize the health care system's ability to provide medical
care during a pandemic.
a. Identify and prioritize response issues affecting the countywide health
system during a pandemic.
b. Develop mechanisms to efficiently share information and resources between
health system partners, and to communicate with Public Health and relevant
emergency operations centers,as appropriate.
c. Coordinate with the Local Health Officer regarding policy level decisions
regarding the operations of the local health system.
d. Hospitals and other health care facilities will develop pandemic response
plans consistent with the health care planning guidance contained in the
health and human services pandemic influenza plan. Health care facility
pandemic response plans will address medical surge capacity to sustain
• health care delivery capabilities when routine systems are overwhelmed.
Appendix IV-7
Region 2 Public Health
Emergency Response Plan
August 31,2007
V. RESPONSE PROCEDURES •
A. NOVEL VIRUS ALERT STAGE(Phases 1-3)
A new influenza virus subtype detected in one or more humans (Phase 3), but no
human-to-human spread,or at most rare instances of spread to a close contact.
1. Surveillance
a. Meet with appropriate partners and stakeholders and review major elements
of enhanced surveillance activities; modify as needed. Appendix II, Disease
Surveillance and Response.
b. Activate enhanced local surveillance to detect importation and local spread
utilizing the surveillance mechanisms in Appendix II, Disease Surveillance
and Response.
c. Work with clinicians to facilitate the submission of ILI diagnostic specimens
and Influenza A isolates to the Washington State Public Health Lab
(WAPHL).
d. Monitor influenza bulletins from CDC and DOH regarding virologic,
epidemiologic, and clinical findings associated with new variants. Appendix
V,Tab A,Communications
2. Vaccine and Pharmaceuticals
a. Meet with hospitals, health care providers, and other partners and .
stakeholders to review major elements of the vaccine distribution plan,
including plans for storage, transport, and administration of vaccines and
antivirals. Appendix III,SNS.
b. Modify plan as needed to account for updates, if any, on recommended
target groups and projected vaccine supply.
3. Communications
a. Test local communication systems, including Region 2 Duty Officer (RDO)
and WA SECURES to ensure that local and statewide communications are
functional. Appendix V,Tab A,Communication.
b. Notify hospitals, health care providers, and other partners and stakeholders
of the novel virus alert.
c. Modify communications plan (and written materials) in collaboration with
DOH to account for updates,on projected effects of the novel virus.
d. Ensure ongoing coordination among surveillance, epidemiology, laboratory,
EMS,and other local response efforts.
e. Update press release templates. Develop materials for responding to
questions that may come from the media.
B. PANDEMIC ALERT STAGE(Phases 4&5)
Clusters of new virus subtype with human-to-human spread still localized, but not
yet fully transmissible.
•
Appendix IV-8
Region 2 Public Health
Emergency Response Plan
August 31,2007
1. Surveillance
a. Fully activate enhanced surveillance activities. Assess functionality,
timeliness, and completeness of data entry and dissemination, data links,and
feedback mechanisms through the local system. Appendix II Disease
Surveillance and Response.
b. Inform surveillance partners of the need to increase specimen collection for
detection of novel virus and alert laboratories to prepare for increased
numbers of specimens.
c. Meet with surveillance partners to increase the amount of patient
demographic information collected, in order to identify groups with
increased risk.
d. If requested, distribute specimen collection kits to hospitals and clinicians
and obtain cooperation to facilitate sending isolates to DoH.
e. Reassess inventory of medical equipment and supplies (including ventilators,
ICU equipment).
f. Recruit pharmacies to participate in reporting antiviral prescriptions filled.
g. Monitor influenza bulletins from CDC and DOH regarding virologic,
epidemiologic, and clinical findings associated with new variants. Appendix
V,Tab A,Communications.
2. Vaccine and Pharmaceuticals
• a. Monitor reports from the CDC, FDA, WHO, and DOH to obtain information
on plans for vaccine manufacture.
b. Prepare to implement plan for storing and delivering vaccine as it becomes
available.
c. Review elements of plan for vaccine delivery with partners and stakeholders.
d. Ensure that human resources, equipment, and plans for mass immunization
clinics are in place. Appendix III,SNS.
e. Obtain latest recommendations from DOH for priority groups for vaccine
allocation and modify plan as necessary based on current surveillance data
and projected vaccine supply.
3. Communications
a. Ensure communication among the epidemiology and surveillance programs
and emergency management.
b. Prepare additional fact sheets detailing responses to questions coming from
the media and the public:
(1) Include documents intended for electronic distribution on the website.
(2) Include telecommuting advice to employers, labor organizations, and
others.
(3) Include travel alert information received from the State and/or CDC
c. Notify hospitals, health care providers, and other partners and stakeholders
of the novel virus alert via blastfax or other available means.
• d. Modify communications plan (and written materials) in collaboration with
DoH to account for updates, on projected effects of the novel virus.
Appendix IV-9
Region 2 Public Health
Emergency Response Plan
August 31,2007
e. Update press release templates. Develop materials for responding to S
questions that may come from the media.
f. Begin tracking of influenza deaths and absenteeism with schools and certain
sentinel employers.
g. Request the Medical Reserve Corps from the County EOC.
h. Conduct inventory of critical equipment, supplies, and personnel, including
availability of hospital beds, antiviral pharmaceuticals, and transport for
delivery of vaccines.
i. Identify personnel and supply shortfalls.
j. Plan for implementation of emergency medical treatment sites or
neighborhood distribution centers.
k. Issue guidelines on influenza precautions for workplace, emergency
departments,airlines,schools,jails,EMS,and individuals.
1. Monitor influenza bulletins from CDC and DoH and update community
providers and hospitals with recommendations for enhanced surveillance.
C. PANDEMIC STAGE (Phase 6)
New virus subtype causing increased and sustained transmission in the general
population.
1. Surveillance
a. Outside of normal surveillance season, verify that hospital and health care •
surveillance has been activated and public health is receiving ongoing reports
of cases within the county. Appendix II Disease Surveillance and Response.
b. Report the data collected to all participating facilities as well as to DoH.
c. Analyze the surveillance data to determine which population groups are at
greatest risk and provide the information to those determining priority
groups for vaccine allocation when the supply is limited.
d. Maintain increased laboratory surveillance and other activities outlined in
the previous pandemic alert section.
e. Participate in special studies,as requested by CDC or DoH:
(1) To describe unusual clinical syndromes or pathological features in fatal
cases.
(2) To conduct efficacy studies of vaccination or chemoprophylaxis.
(3) To assess the effectiveness of control measures such as school and
business closings.
2. Vaccine and Pharmaceuticals
a. Continue activities as listed in pandemic alert stage,including meetings with
the pharmacists and medical association.
b. Increase public information effort designed to keep ill persons at home,
providing translations into Spanish and other languages commonly spoken
in the County.
c. If vaccine/pharmaceuticals delivery date is predicted by CDC,work with •
DoH to:
Appendix IV-10
Region 2 Public Health
Emergency Response Plan
August 31,2007
411 (1) Establish local delivery date.
(2) Review distribution plan and update when new information is available.
d. Request for security at immunization sites from the EOC.
e. Alert providers for the need to report adverse events to VAERS system.
f. If vaccine/pharmaceuticals are available,activate the distribution plan.
Appendix III,SNS.
3. Communications
a. Notify hospitals,health care providers,and other partners and stakeholders
of the pandemic phase via blastfax.
b. Update documents and fact sheets based on current surveillance information.
c. Provide translations of all public information messages into Spanish and the
other major languages in the County.
d. Monitor the ability of hospitals and clinics to cope with increased patient
loads.
e. Implement health education campaign with emphasis on the following:
(1) Hand washing
(2) Stay home if you are ill.
(3) Check on family,friends living alone.
(4) Vaccination clinic locations
• (5) Signs,symptoms
(6) Care of the Ill
(7) Vaccine safety and storage
f. Activate the emergency coordination center (ECC). Appendix V, ECC.
g. Implement mutual aid or other procedures to address supply and personnel
shortfalls.
h. Conduct inventory of critical supplies/personnel and solve problems:
shortage of supplies (gloves,safety needles,and ventilators),personnel
shortage (how to get alternative staff redirected).
C. RECOVERY
1. Surveillance
Once the pandemic has been declared over,by WHO,resume routine influenza
surveillance. Appendix II,Disease Surveillance and Response.
a. Analyze the surveillance data collected.
b. Report the results of the analysis to all participating facilities as well as to
DOH.
c. Participate in special studies,as requested by CDC or DoH:
(1) To describe unusual clinical syndromes or pathological features in fatal
cases.
11111 (2) To conduct efficacy studies of vaccination or chemoprophylaxis.
Appendix IV-11
Region 2 Public Health
Emergency Response Plan
August 31,2007
(3) To assess the effectiveness of control measures such as school and
business closings.
2. Vaccine and Pharmaceuticals
a. If appropriate return vaccine,pharmaceuticals and supplies to CDC/DoH.
b. Review distribution plan and update. Appendix III,SNS.
3. Communications
a. Notify hospitals,health care providers,and other partners and stakeholders
of the pandemic phase via blastfax.
b. Update documents and fact sheets based on current surveillance information.
c. Provide translations of all public information messages into Spanish and the
other major languages in the County.
d. Monitor the ability of hospitals and clinics to cope with current patient loads.
e. Deactivate the emergency coordination center (ECC). Appendix VI,ECC.
f. Conduct inventory of critical supplies,re-supply caches and/or return if
appropriate.
VI. TABS
Tab A-Risk Communication(Messages and Fact Sheets)
Tab B-Vaccine and Medication Prioritization
Tab C-Respiratory Policy •
Tab D-Infection Control
•
Appendix IV-12
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June 11, 2009
Dear Educators:
First, we want to commend teachers,parents, and administrators for the tremendous job you
have done to address the challenges so many of you have faced as a result of the HI NI flu
outbreak, particularly balancing health and safety requirements with the educational,business,
and social needs of the community. As this school year comes to a close, we urge you to begin
thinking about the next school year and how we can work together to keep our students and local
communities safe. We also offer our support toward that end.
The H 1 N 1 virus has been shown to affect school-aged children disproportionately, and children
are known to be highly likely to transmit flu viruses,especially in school and other group
settings. Furthermore, scientists and public health experts are concerned that the novel H1NI
virus may persist into the fall,potentially as a more severe strain,causing more serious and life-
. threatening illness. The Department of Health and Human Services is taking the steps necessary
to secure 1-11N1 flu vaccine for possible use in the fall. If a vaccination program is initiated,
however, the vaccine will not be available until several weeks after the school year begins.
Therefore, it will be critical for schools to begin planning non-pharmaceutical interventions to
prevent disease transmission and protect students and staff,as well as local communities, from
infection. Depending on the timing and severity of a potential fall H 1 N 1 wave, those
interventions could include: extra measures to ensure that commonly touched surfaces are
disinfected, strict enforcement of exclusion policies for students and staff with flu-like
symptoms, or extended school closures. In addition,because schools could be used as vaccine
distribution locations, schools should consider how they might accommodate such requests.
While all of us want to do all we can to keep students engaged in learning and maintain a sense
of normalcy, we need to be ready for whatever the fall may bring.
Most public schools already are required to have emergency plans, which ideally consider a
range of scenarios. The summer months ahead offer time to prepare and refine school "all-
hazards"plans and ensure that parents make their own contingency plans. To that end, we
recommend the following:
Update your emergency plans and ensure all your contact lists are up to date. If you do
not already have such a plan, we encourage you to develop one. To initiate or build upon
an all-hazards plan, visit http://www.ed.govicmergencyplan and http://rems.ed.gov.
•
June 1 I, 2009 •
Page two
• Collaborate with your state and/or local health departments. Useful information,
including health department contacts, can be found at http://www.naccho.org or
litlzywww_astho.ory...
• Consider ways to promote good hand hygiene(including teaching proper hand washing
technique, and providing opportunities and appropriate supplies for hand washing),
regular cleaning and disinfection of surfaces in schools, and other infection control
measures. More information about controlling infectious diseases at schools can be
found at http:/AA,ww.ede.gov/h in 1 flu.
▪ Develop response and communications plans to ensure that students or staff with fever or
flu-like symptoms do not come to school or are sent home; advise parents of these plans.
a Advise parents to develop contingency plans should their children become sick and need
to stay home or in the event their school is forced to close.
a Identify faith-based and community-based organizations that can assist with care and
supervision of non-infected children whose schools may be closed.
• Consider alternative mechanisms for delivery of education content,leveraging
community resources if appropriate and possible. SeeIlttgaree.ed.gov.
• Consider alternative mechanisms for delivery of school meals to at-risk children.
• Work with local and/or state health departments to collect real-time data on school
closures and rates of illness and absenteeism that will be shared with the Department of
Education and the Centers for Disease Control and Prevention.
•
We are also collaborating with mayors, governors, and state and local public health officials
about contingency plans. Our hope is that the summer months can be used to develop and share
a coordinated public health strategy that aims to protect our children and families and minimize
disruptions.
We face an uncertain situation. Nevertheless,there are measures we can all take to meet the
potential public health challenges that lie ahead, and your commitment to that end is critical to
the overall effort. We want to work closely with you to ensure you have the support you need to
provide a safe learning environment for our nation's students. You may call on us and our staffs
at any time, and we will check in with you throughout the summer and the school year. In the
meantime, you may find helpful information at these Web sites: www.ed.gov and www.cdc.gov.
If you have questions for the Department of Education, feel free to send them to fluMed.gov.
Again, thank you for all your efforts. We look forward to continuing to work with you.
Sincerely,
!iv N
Arne Duncan Kathleen Sebelius
Secretary of Education Secretary of Health &
Human Services
Board of Health
Netiv Business
.agenda Item # T., 2
1/17.A State Department of
Health Budget Cuts:
Impacts on Coca(Health Jurisdictions
June 18, 2009
•
Department of Health 2009—2011 Operation Budget Reductions
Affecting Local Health Jurisdictions "AP- �t,,r;ti= reit Stab'D pard?=ar
Slane 5, 2009---Draft 5 rr mea t
Reductions in Pass-through/Direct Funds to LHJ
Reduce Tobacco Prevention Funds -$22,000,000
The Department's expenditure authority for tobacco prevention and awareness activities
is reduced to the level of actual spending in FY 2008. Funding for tobacco prevention
public awareness campaigns, such as television and radio advertisements, are suspended
during the 2009-11 biennium. The program is directed to identify additional savings
through administrative and programmatic reductions. (Tobacco Prevention and Control
Account-State). DOH Contact: Terry Reid, 360-236-3665, terry.reid@doh.wa.gov.
Reduce Public Health Enhancement -$4,000,000
In the 2007-09 biennial budget, $20 million was provided to local health jurisdictions to
be spent on core public health functions of statewide significance as defined in Chapter
259, Laws of 2007 (E2SSB 5930). Funding for those purposes is reduced by 20 percent.
(General Fund-State; Tobacco Prevention and Control Account-State). DOH Contact:
Marie Flake, 360-236-4063, marie.flake@doh.wa.gov
Reduce State Family Planning Grants -$4,000,000
Enhanced funding provided during the 2007-09 biennium for family planning clinics and
local health jurisdictions to provide family planning services is reduced by ten percent for
• FY 2010 and seventy percent for FY 2011 in anticipation of increased federal funding to
support eligible clients through Department of Social and Health Services. DOH
Contact: Sharon McAllister, 360-236-3403, Sharon.mcallister@doh.wa.gov
Colon Screening -$1,700,000
The Washington Colon Health Program provides free colorectal cancer exams to
individuals between ages 50 and 64 who are below 250 percent of the federal poverty
level. Funding first provided in the 2008 supplemental budget to support the loss of
federal funding to the Washington Colon Health Program and to expand the program to
nine counties is downscaled to a pilot in one county. (General Fund-State). DOH
Contact: Pama Joyner, 360-236-3589, pama.joyner@doh.wa.gov.
Reduce Group B Water System Program -$1,160,000
Funding to local health jurisdictions for Group B drinking water systems (those which
provide drinking water to between two and 14 households and serve less than 25 people
per day) is eliminated. DOH Contact: Gregg Grunenfelder, 360-236-3050,
gregg.grunenfelder@doh.wa.gov.
Reduce AIDSNET Grants -$1,067,000
Funding for the six regional AIDS networks (AIDSNETS) is reduced by seven percent of
total expenditures. The AIDSNETS conduct planning activities for coordinating
community services for individuals who are HIV-positive or have AIDS. DOH Contact:
John Peppert, 360-236-3427,john.peppert@doh.wa.gov.
Other Reductions That Impact LHJs
Vaccine Program Transition -$55,300,000
State funding for the operation of a universal purchase program for immunizations - less
the reduction for the human papillomavirus vaccine - is eliminated no later than May 1,
2010 or earlier if the funds are exhausted before then. When state funds are exhausted,
Washington State will transfer to "VFC +Underinsured" status which will allow federal
Vaccines for Children(VFC) and 317 Direct Assistance (DA) funds to cover low-income
children in Medicaid and other state-funded health care programs. Once the "VFC +
Underinsured" program is established,the department will use existing 317 DA funds as
well as those that come available per the American Recovery and Re-investment Act to
insure continued coverage of those low-income children who do not qualify for the VFC
program. (General Fund-State)(General Fund-State, General Fund-Federal). DOH
Contact: Janna Bardi, 360-236-3568,janna.bardi@doh.wa.gov.
Governor-Directed Freeze -S5,695,000
In response to rising energy prices and other economic conditions, in August 2008, the
Governor directed state agencies to cut gasoline consumption and freeze new hiring, out-
of-state travel,personal service contracts, and
equipment purchases not related to public safety or other essential activities. These
savings are continued into the 2009-11 biennium. (General Fund-State)
Governor-Directed 1% Cut -$2,064,000
In October 2008,the Governor directed agencies to find an additional $240 million in
savings. These savings are continued into the 2009-11 biennium. (General Fund-State)
•
Reduce State WIC Funds -$1,015,000
State funding that supplements the federal Women, Infants and Children program to
support administrative functions is eliminated.
Pesticide Incident Reporting -$842,000
Funding for pesticide investigations conducted by the Department of Health is reduced.
The Pesticide Incident Reporting and Tracking Panel will continue to exist as does the
expectation for an annual summary report.
Eliminate Lead Poisoning Screening -$576,000
Funding for education and screening activities related to elevated blood lead levels,
particularly in children under six, is reduced.
Reduce Drug Lab Cleanup Assistance -$136,000
Funding for rule making and technical assistance to local health jurisdictions for the
assessment and clean up of contamination at properties used as clandestine drug
laboratories is eliminated.
•
Department of Health 2009-2011 Operating Budget Reductions Page 2 of 2
Affecting Local Public Health
June 5,2009
5930—Funding Update for Local Health Jurisdictions (LHJs)
• 6-5-09
2009—2011 Biennium Reductions to 5930/Blue Ribbon Commission Funds
The 2009 Legislative Session entertained a number of different proposals related to funding for local public health. Some
has specific implications for the 5930 funds-some proposed altering how the funds are used and others proposed to alter
the amount of money in this funding stream.
In the end, 2009-2011 biennial state budget altered both the amount of state general funds directed to this purpose and
the source of those funds. Due to state budget shortfalls, the total biennial amount has been reduced from $20 million /
biennium to$16 million/biennium. This is a 20% reduction. In the state budget, these funds are now called Public
Health Enhancement.
Additionally, the $16 million / biennium was taken out of the Tobacco Prevention and Control Account. This means less
money is available for the Tobacco Prevention and Control Program. Also, these $16 million are one-time funds; once
spent, they are gone.
Implementation of 5930 Funding Reduction
The reduction will be implemented across the board—state and local. Each agency will receive 20% less than they did in
2009.
State fiscal year 2010 (SFY 10) begins July 1, 2009. There will be 20% less money available to DOH for 5930 activities
beginning July 1, 2009. LHJs receive 5930 funds each January and have already received their full allotment for calendar
year 2009. There will be 20% less money available to each LHJ for 5930 activities beginning January 1, 2010.
Performance Measures
The performance measures and reporting measures remain unchanged at this time. These are the measures public
416,‘
ealth leaders selected and committed to focus the new funds on for the first two years. Data for these measures are
_ing summarized on a calendar year basis, which coincides with funding to LHJs.
A report is due to the legislature November 2009 and biannually thereafter. It is to describe the distribution of funds,
performance measures adopted and any impact of the 5930 funding on these measures and health status indicators.
Public health leaders will soon be discussing the future focus for these funds and related performance and reporting
measures.
Background
The 2006 Washington Legislature created the Joint Select Committee on Public Health Funding, a bipartisan study
committee of the House and Senate, to address the persistent public health funding shortfall. In response to the
committee's request for information, local and state public health officials developed and presented a report titled Creating
a Stronger Public Health System: Setting Priorities for Action http://www.doh.wa.qov/phip/5930PM/product.htm. The
report ordered a list of statewide priorities"for the next investment in public health" as follows and specified how different
levels of investment should be allocated among the priorities and for what activities.
• Stopping communicable diseases before they spread,
• Reducing the impact of chronic disease,
• Investing in healthy families,
• Protecting the safety of drinking water and air,
• Using health information to guide decisions, and
• Helping people get the health care services they need.
The Joint Select Committee on Public Health Funding unanimously concluded that"the lack of a stable source of funding
provided specifically for public health services has eroded the ability of local health jurisdictions to maintain a reliable
statewide system that protects the public's health." It recommended that the state "provide additional funding in the
ount of approximately$50 million annually during the 2007-2009 biennium, as an initial investment" and that a
edicated account for public health revenues" be established. Finally, it recommended that these actions be considered
"the first step in what must be continuing state and local efforts to fund the public health system at a level that provides the
capacity to effectively deliver the five core functions." (www.leq.wa.gov/Joint/Committees/PHF)
The 2007 Washington Legislature passed E2SSB 5930 Section 60-65, now codified in RCW 43.70.512, 514, 516, 518
and appropriated an additional $20 million/ biennium for local public health in the 2007-2009 state budget. A budget
proviso specified the distribution formula and timing. Beginning in January 2008, annual allotments have been distributed •
to each LHJ each January.
The 5930 funds, also known as Blue Ribbon Commission Funds, are a funding stream and not a program. As directed by
the new law, at the beginning of this new funding stream, state and local public health leaders worked together to identify
statewide priorities for their use. They referenced the priorities identified in the "Building a Stronger Public Health System"
document and selected the top two statewide priorities: 1) stopping communicable diseases before they spread and 2)
reducing the impact of chronic disease. Then, focusing on available data, they selected performance measures for each,
including: improved uptake of childhood immunizations, more timely communicable disease investigation, and efforts to
stop the obesity epidemic.
Local public health agencies are using these funds for new and additional activities in their communities that are deemed
to have the greatest potential to affect these statewide priorities and performance measures.
More information is available at http://www.doh.wa.gov/phip/5930PM/overview.htm
DOH Contact: Marie Flake, 360-236-4063, marie.flake(a�doh.wa.gov
•
•
5930— Funding Update for LHJs Page 2 of 2
6-5-09
Group B water system funding cuts
• June 12, 2009
What are the implications of the Group B funding cut?
• About $450,000 per year LHJ pass-though eliminated.
• Reduction of 1 FTE at DOH; position managed local health contracts and
provided drinking water support to LHJs.
When will the funding cuts be implemented?
• All funding associated with Group B work ends July 1, 2009.
• Ongoing funding to LHJs will continue through Consolidated Contracts for Group
A water system work(e.g., sanitary surveys, technical assistance).
How will the program be affected in the short term?
• The current Group B rule remains in effect (Chapter 246-291 WAC).
• We anticipate little change to DOH's approach to Group B's in the near term. We
will continue to:
➢ review new system submittals;
➢ respond to acute health concerns; and
➢ provide limited technical assistance in counties without a Group B program.
• • We will not amend Joint Plans of Responsibility (JPRs). As a part of the rule
development process, we will evaluate whether JPRs should be continued as a
part of the program.
• Both DOH and LHJs will have to do the best they can with reduced resources.
What is the future of the Group B program?
• DOH presented a Group B rule proposal to the SBOH last fall. The framework
for the rule proposal included requirements for limited ongoing water quality
monitoring of Group B systems.
• SB 6171 authorized the SBOH to limit the scope of the Group B rule to initial
design and construction approval, with no obligation for ongoing water quality
monitoring.
• After DOH develops a rule proposal, the SBOH is responsible for adopting the
final Group B rule. The SBOH will hold public hearings before adopting a final
rule.
• We may be meeting with the SBOH in July.
• We will work with the EH Directors' Water Committee, LHJ staff, stakeholders
and the public to develop rule language.
• For further information: DOH contact: David Christensen at (360) 236-3153,
or david.christensen(i0oh.wa.gov
•
Board of Health
Netiv Business
.agenda Item #`V., 3
• National3-Cealth Reform:
Role for LocaCHealth
Policy _Makers
June 18, 2009
7411
II
Forks
OLYMPIC
14111
Community
MEDICAL CENTER Hospital
Clallam County Court House
223 East 4th Street, Suite#14
Port Angeles, WA 98362-3015
Phone: 360-417-2274/ FAX: 360-417-2519
Ms. Nancy-Ann DeParle
White House Office of Health Reform
Washington, D.C.
Dear Ms. DeParle;
We the undersigned members of the Clallam County Board of Health and Clallam County Public Hospital
Districts#1 and #2 write to express our shared concerns regarding the urgent matter of health care
system reform. Clallam County, Washington is home to over 70,000 rural residents, 22.1%over the age
• of 65. This demographic profile offers a preview of how the entire country will look after the "baby
boomer" generation has retired in 2025. Many of the health care system challenges that the U.S. health
care system will face as its population ages are already occurring in Clallam County: high number of
uninsured residents, health care workforce shortages, lack of access to primary care, public hospitals
serving high percentages of Medicare patients but receiving less than the cost of those services in
reimbursement, lack of focus on chronic disease management and the spiraling costs of medications.
As the elected and appointed health care policy makers for Clallam County, we would like to
recommend specific priorities for much needed health care system reform. We are encouraged by the
high priority given to health care system reform by the new administration and the concerted effort to
gather public input during the transition period preceding President Obama's inauguration. Our
concerns and recommendations fall into the following categories:
Uninsured Residents: Clallam County has approximately 9,000 uninsured residents which represents
13-14%of the population. The number of uninsured is growing due to the economic recession.
Hospitals and other providers in Clallam County had unreimbursed charges of over$8 million in 2008 for
needed medical care for the uninsured.
Recommendation: Provide universal basic coverage for all US citizens with universal responsibility for
the costs of the coverage (coverage for all, paid for by all).
Health Care Workforce: While 20%of the U.S. population resides in rural areas,only 9%of health care
providers do so.This serious imbalance is worsening with each passing year and has its origin in the wide
• salary differential between rural and urban job markets. In Clallam County, our high proportion of
elderly citizens makes these workforce shortages all the more critical.
Recommendation: In addition to addressing existing salary inequities, a major national initiative, similar
41111
to the Civilian Conservation Corp of the 1930's, needs to be launched to promote health careers in rural
communities.
Cost of Medications: Rapidly escalating costs are putting health care out of reach for more and more
county residents. Pharmaceutical costs are a major component of this rise and stress on the budgets of
public hospital districts serving large numbers of Medicare, Medicaid and uninsured patients.
Recommendation:The federal 340B drug purchasing program has helped restrain pharmaceutical costs
for Veterans Administration Hospitals,Tribal Health Programs and other governmental health services.
340B purchasing should be expanded to include Critical Access Hospitals and Rural Public Hospital
Districts serving high percentages of Medicare/Medicaid patients.
In addition, reform Medicare Part D to remove the Insurance companies from the Formulary selection,
and let Medicare be the payer therefore creating one formulary. Medicare would have more purchasing
power to reduce drug costs 17%to 25%, and reducing the approximate 23%operating costs of Medicare
D to Medicare's approximate 3%operating cost. Then offer the same pricing to State Medicaid funds,
much the same as Congress and the Veterans Administration does with one controlled formulary.
Inefficiencies of Private Insurance Carriers:A significant part of the U.S. health care system is funded by
private insurance purchased by employers or by individual families. In theory,this profusion of
competing private insurance plans should lead to lower costs, wider range of consumer choices and
higher quality of care. Instead, we have a system where care is fragmented, pre-existing health
conditions are excluded, administrative costs are high and health care providers and their patients are
•
forced to deal with mountains of paperwork in order to receive payment for covered services.
Recommendation:The health insurance system is in need of a fundamental overhaul. Claims processing
costs need to be dramatically reduced by simplification and standardization of claims forms.The
administrative burdens insurers impose on health care providers and their patients must be strictly
regulated, pre-existing condition exclusions need to be eliminated and affordable insurance options
must be made available to employers and individuals alike. A growing number of health care providers
believe these goals can only be achieved by implementing a single payer system of health care financing.
Lack of Access to Primary Care: Multiple studies have shown the importance of a primary care "medical
home" as a strategy for improving quality of care, coordinating complex medical care services and
avoiding unnecessary tests and treatments. Uneven reimbursement policies have caused a serious
imbalance in the ratio of primary care to subspecialty care physicians (39%vs. 61%) and of the numbers
of primary care physicians choosing rural practice locations vs. urban ones (55/100,000 rural vs.
93/100,000 urban). In Clallam County, more and more people find themselves "medically homeless",
unable to find a primary care practitioner even if they are insured.
Recommendation: Reimbursement policies must be changed to promote communication, care
coordination, disease prevention and chronic disease management in a "medical home" setting rather
than fragmented subspecialty services. Medical schools and residency programs need strong incentives
to encourage primary care careers and provide the necessary training and support.
Investing in Prevention: Few disagree that prevention of disease is preferable to its treatment. Financial •
incentives within the health care system seem perversely designed to achieve the opposite outcome,
however. Health care providers are paid for treating disease, not preventing it. Reimbursement is based
on the number and complexity of services provided, not their outcome. Investing in prevention will
require a fundamental rethinking of the goals in a health care system and a rebalancing of the
proportionate investment in disease and injury prevention vs. their treatment.
Recommendations: Health care providers need greater incentives to provide clinical preventive services
such as screening appropriate populations for cancer, certain types of infections and metabolic
conditions. Our crumbling governmental public health system needs to be repaired and revitalized. But
most of all, there needs to be a fundamental rethinking of how best to apply our growing scientific
awareness of the causes and prevention of disease,to the redesign of a system whose chief product
should be health not individual units of service.
Lack of focus on Chronic Disease Management: Our current health care system is focused on waiting
until someone is sick before intervening to improve health (sickness based system). This works poorly
for people with diabetes, heart failure, asthma and other chronic diseases.
Recommendation: Revise reimbursement systems to focus on outcomes from chronic disease
management rather than the number of procedures or visits. Educate patients on the importance of
disease management and provide incentives, such as lower deductibles, for patients that manage their
chronic diseases well.
End of Life Care: The health care system does little to encourage best practices for patients at the end
of their lives. Often large amounts of resources are used, which result in no improvement in quality or
length of life. The cost to Medicare during the last 6 months of patients' lives is twice as high in Florida
• compared to patients in Washington State.
Recommendation: The health care system must reward best practices at the end of life and encourage
end of life planning with the patient,family, physician and other care givers.
Summary: Clallam County residents are justifiably concerned about their deteriorating access to quality
health care. There is a profound and growing perception that the current health care financing system
has failed and that this failure jeopardizes the physical and economic health of our citizens. Some would
argue that the Nation's current economic condition will not allow ambitious health care system reform.
We would argue the exact opposite. It is precisely because of our economic crisis, and the central role
our dysfunctional health care financing system plans in causing this crisis, that we have no option other
than to undertake fundamental reform.
It may not be possible to achieve change of this scope in all states simultaneously. Some may need to go
first, and Washington State, long regarded as an innovator in health care delivery, would be an excellent
choice to be among the early adopters. It may even be necessary for pilot projects to begin within states
as communities band together to create a sustainable health care system for the 21st Century. If this is
the case, the closely knit communities of the North Olympic Peninsula would be very interested in
playing this pioneering role.
Clallam County is justifiably proud of its reputation of putting together innovative community
partnerships to undertake complex and challenging tasks. We the health policy makers of Clallam
• County find no larger challenge than the need to design and implement a health care system that
provides every resident a medical home where they can form a lifelong partnership with a trusted
health care professional and pursue the mutual goal of maintaining good health.
Sincerely,
Clallam County Board of Health:
Michael Chapman, Stephen Tharinger
County Commissioner County Commissioner
Chair, Board of Health
Howard "Mike" Doherty Jr. Jeanette Stehr-Green, MD
County Commissioner Board Member
Board Member
Betsy Wharton Thomas Locke, MD, MPH
Deputy Mayor, City of Port Angeles Clallam County Health Officer
Board Member
Forks Community Hospital, Public Hospital District#1:
Camille Scott Daisy Anderson •
Administrator/CEO Board Member
Vice-Chair, Clallam County Board of Health
Don Lawley - Gerry Lane
Board Member Board Member
Olympic Medical Center, Public Hospital District#2:
Jim Leskinovitch John Beitzel
Board President Board Member
Member, Clallam County Board of Health
Jean Hordyk Jim Cammack
Board Member Board Member
Gary R. Smith Arlene Engel
Board Member Board Member
John Nutter Eric Lewis •
Board Member Administrator/CEO
•
Board-of Cealth
.Media Report
•
June 18, 2009
•
• Jefferson County Public Health
May/June 2009
NEWS ARTICLES
1. "'Catch and release'," Peninsula Daily News, May 15th, 2009.
2. "Toxins rise at Leland," Peninsula Daily News, May 17th, 2009.
3. "Case of swine flu in Jefferson confirmed," Peninsula Daily News, May 26th, 2009.
4. "County to consider water inventory plan," Peninsula Daily News, May 26th, 2009.
5. "Toxin threat increases in Anderson," Peninsula daily News, May 26th, 2009.
6. "Swine flu found here," Port Townsend Leader, May 27th, 2009.
7. "Giving circle pioneers: a new way of giving," Port Townsend Leader, May 27th, 2009.
8. "Officials report first Clallam swine flu case," Peninsula Daily News, May 31st, 2009.
9. "Anderson, Leland lakes still off limits," Peninsula Daily News, May 31st, 2009.
10. "Health program to raise rates," Peninsula Daily News, June 9th, 2009.
11. "County approves conservation funds," Peninsula Daily News, June 9th, 2009.
•
`Catch and release' release"fishery only.
IYour front-page article other words,keeping
Wednesday announced the (and eating)fish caught in
• good news that the levels Gibbs Lake is illegal and
of toxic algae in Gibbs subject to substantial pen
Lake have reduced suffi- alties.
ciently for some restric-
tions to be lifted.; Port Townsend
Now permitted,the arti-
cle states,is eating fish
caught from the lake.
It should have been
stated,however,that it is
illegal to retain fish caught
in Gibbs lake.
Washington Department
of Fish and Wildlife
regulations designate
Gibbs as a"catch and
•
_ .
411,
/-/,•vi•
•
. . __,-)-7/02/e9
Toxins
rise a • .
•
Leland •
Algae: Anderson :closed
Jefferson health CONTINUED FROM Al the history of toxic algae from fertilizer,sewage, lake
1 t blooms in Anderson Lake, sediments or other sources,
officials post - Lake Leland's algae Washington State Parks,in Harrington said.
bloom is composed of sev- consultation with the county County public health
eral species of blue-green Public Health Department, officials also are collecting
warning at lake algae of the genera oscilla- is keeping the lake closed. samples for nutrient analy-
toris, aphanizomenon and Jefferson County Public see and physical data to
microcystis,he said. Health has been collecting determine possible causes
BY JEFF CHEW The county Public Health and submitting water qual- of blue-green algae blooms.
PENINSULA DAILY NEWS Department is warning the ity/algae samples from Lake The study is funded by a
QUILCENE-Blue-green algae tox- public to avoid drinking Leland, Anderson Lake, grant from the state Depart-
lefty levels'flared up in Lake Leland last' Leland Lake water, not to Sandy Shore and Gibbs ment of Ecology.
week, forcing Jefferson County Public' swim in the,lake,avoid vis- Lake to determine what Jefferson County Public
Health officials to downgrade the lake to ible algal scums and don't species of algae are present Health maintains an
a warning notice, which discourages eat its fish. and at what concentration updated database of lake
swimming and consuming fish caught in Some toxins from algae they are present since 2006. monitoring information at
the lake. are harmful to the liver. Other local lakes are www.jeffersoncountypublic •
• Anderson •Lake, People with liver problems, sampled if they appear to health.org.
est resultsT
between Port Had- such as chronic hepatitis, be undergoing a blue-green The department can be
lock and Chimacum, should exercise additional algae bloom. reached at 360-385-9400.
received remains..closed to. caution. Water samples are taken Lake samples are not
Friday recreational use after Jefferson County's Gibbs from the lakes on Mondays tested in Clallam County,
from Salri les water quality testa Lake remains open with a and tested at King County where health officers visu-
p show no change in county Public Health"cau- Environmental Labs. The ally monitor lakes for signs
taken Monday the level of toxins , tion"notice posted there. results are 'routinely of algae bloom.No cautions
from Lake from' . blue-greenThat means the public released to the public on or warnings havebeenissued
algae there, .,.but, should avoid drinking lake Fridays. in Clallam County.
Leland Anderson Lake State water and any visible algal Wanner weather—or at Algae blooms in Clallam
showed a high Park remains open scums,but swimming,boat- least sunlight — seems to County lakes should be
Concentration to recreational activi- ing and catch-and-release contribute to blooms of blue- reported to Clallam County
ties outside the lake, fishing are allowed in Gibbs green algae,which can pro- Department of Health and
•
of both blue such as hiking, bik- Lake. duce toxins.Scientists don't Human Services environ-
ing and horse-riding. Jefferson County Public know why algae becomes mental health division at
green algae
.I just put. a Health is continuing sea- toxic. 360-417-2258.
and the warning up on sonal sampling of recre- Algae blooms in fresh
neurotoxin Leland, which is ational lakes for toxic blue •water lakes, which occur
t really a bummer," green algae. Port Townsend-Jefferson
3na.OX1.. .: g naturally, are fed by nutri-
Neil Harrington' County Editor Jeff Chew can be
Because of the risk of ents such as nitrogen or reached at 360-385-2335 or at Jeff
county water qual- exposure to the toxin and phosphorus,which can come chewepeninsuladailynews.com.
ity manager,said late Friday afternoon.
Test results received Friday from _
samples taken Monday from Lake .
Leland — a county recreational area
north of Quilcene-showed a high con-
centration of both blue green algae and
the neurotoxin anatoxin-a.
"That's the really nasty,one,"-•Har
rington said.
Same toxins in Anderson Lake
It is the same toxin that is found in
Anderson Lake.Exposure to anatoxin-a
can cause convulsions and death by
respiratory paralysis.
Two dogs died in,spring 2006 after
drinking water from Anderson Lake,
prompting the first summer closure of
the popular trout-fishing lake.
Anderson Lake was closed this year
on April 24, the day before the trout-
fishing season opened,and"still has an
ongoing bloom"of algae, made up pre-
dominately of blue green algae of the
genera microcystis and anabaena,which
produces anatoxin-a,Harrington said.
TURN TO ALGAE/A7 •
r III
4';rflf// '
in asc • sv�.�ncflu ..
• Jefferson confirmed
firmed swine flu cases
PT woman recovers, "
, :-., - Washington state,
nty
no reason for alarm, r mostlyOin King eCducas
4 "�` One confirmed case
M means that there are
health official says ," "r , probably about 20
ie t unknown cases of swine
C,t WY 5 44 4+ flu on the Peninsula,
BY TOM CALLIS T rr ' ' L Locke said.
PENINSULA DAILY NEWS
He declined to pro-
PORT TOWNSEND A young Port Locke vide any more informa-
Townsend woman, who had the first con- tion about the woman,
firmed case of swine flu on the North such'as her name, age or occupation
Olympic Peninsula,has already recovered. because he didn't want to identify her.
A state health lab confirmed the infection He also declined to say if her family and
on Thursday but—as with many of those in friends are at risk for infection for the
the 42 countries where the flu has spread same reason.Locke said there is no reason
—her illness was mild,said Dr.Tom Locke, for alarm, and Jefferson County Public
health official for the Jefferson County and Health Department officials are not con-
Clallam County health departments. sidering taking any measures because of
The lone case in Jefferson County is one the one confirmed case.
of 58 new cases announced by state health
officials Friday. There are now 574 con- TURN TO FLu/A9
Flu: First Peninsula case
CONTINUED FROM Al from either swine flu or cultures are sent to the lab
seasonal flu are children for testing for swine flu,
Closing schools or pub- younger than 5, adults Locke said.
lic facilities wouldn't work, older than 65, people with Anyone with any type of
anyway,he said. chronic heart'or lung prob- flu should stay home, he
"We pretty much aban- lems and pregnant women. said.
Boned that as a control What should people do Locke said people sick
strategy,"he said."We would if they think they have with the flu should wash
have to close all schools to swine flu? their hands regularly and
slow transmission." "Usually,they should to cough and sneeze into tis-
Because the flu is so deal with it like if you have sues or their sleeves.
mild, it's difficult to know seasonal flu,"Locke said. Jefferson County has a
who has swine flu or just "They should call their stockpile of 1,000 doses of
seasonal flu, so closures regular medical provider. anti-virus medication, and
wouldn't accomplish much, They will usually ask some Clallam County has 2,500
Locke said. questions over the phone doses that can be given to
"The circumstance of and decide whether this is people infected with swine
this outbreak didn't justify something that needs to be flu.
it,"he said. examined." Locke declined to say if
Locke said there is rea- Results from a state the Port Townsend woman
son to believe,based on the health lab in Shoreline, received a dose of the med-
death rate, that swine flu which has the only capabil- ication.
is even less dangerous than ity to test viral cultures for
seasonal flu. swine flu,take about a day, Reporter Tom Callis cart be
• He said those who are at he said. reached at 360-417-3532 or at torn.
the highest risk of death Only Type A influenza vallis@peninsuladailynews.com.
County to consider
•
water inventory plan
PENINSULA DAILY NEWS ' ' on Wednesday, but have not
Eye on posted an agenda.
The three Jefferson County ....„.. The agenda will be posted
commissioners will consider I
lueff ..atm
ell on Tuesday, according to the
approval of implementation ''• port's Web site at www.
of a multi-agency water
portofpt.com/agenda.htm.
resource inventory plan when administrator is scheuled for The port commission's sec-
they meet Tuesday. 1:30 p.m.at the same location. ond meeting of the month is
The project involves the,,
at 6:30 p.m. at the adminis-
Jefferson : County' Public i Port Townsend schools tration office building, 375
Health Department,plallam „. .,at Point Hudson.
. , . . The Port Townsend School Hudson St
'
County government, the city Board will consider a resolu-
of Forks and the Hoh, Quile- tion to transfer$228,937 from Port Townsend city
ute and Makah tribes. the general fund to the capi- No session of the Port
The commisSioners will tal projects fund when it Townsend City Council is
• address the agenda item meets Tuesday.
planned this week, although
when they meet at 10 a.m.in The board will meet at
7 several committees will meet.
their chambers on the ground p.m. for a closed executive
The city offices will be
floor of Jefferson County session, and at 7:30p.m. for closed Monday for Memorial
Courthouse, 1820 Jefferson an open meeting at the Lin- Day
St. 'coln Building,450 Fir St.
City committee meetings
County offices will be The current capital proj- are:
closed Monday in observance ects fund budget is $14,254.
II Wednesday,3:30 p.m.—
of Memorial Day.. • The board will 'consider
. Climate Action Committee,
The commissioners at 9:30 increasing it by $228,937 for
•
Pope Marine Park Building.
a.m.will consider adoption of a new budget of$243,191.
II Thursday,4 p.m.--City
their consent agenda, which The transfer is need to pay
Council Finance and Budget
includes awarding a contract for projects related to the do-
Committee, first floor confer-
sures of Mountain View Ele-
to Lakeside Industries of Port ence room at City Hall, 250
Angeles for a low bid to pave .
mentary School in June, and — .
maaison bt.
d t
the relocation of stu en pop-
2 miles of Center Road.
II Thursday, 7 p.m. —
ccording to a staff
ulations 'a '
The commissioners will ' Planning Commission work-
open their meeting at 9 a.m. memo. _ shop in council chambers at
with a public comment period Port of Port Townsend City Hall.
and conduct a briefing session I Friday, 10 a.m. — Pub-
at 9:35 a.m. . The Port of Port Townsend lie Art Committee, first floor
A briefing with the county commissioners plan to meet conference room at City Hall.
i
. . .
•
P 04
'171'24/
V .
•
, ' •
Toxin threa
• increases
in Anderson
BY JEFF'CHEW
PENINSULA DAILY NEWS Anderson Take, located by respiratory paralysis.
froPORT. TOWNSEND — off Anderson Lake Road Lake Leland's algae Water samples are taken
Stay away from Anderson about a mile west of Chi- bloom is composed of sv- and the lakes on Mondays
Lake during the Memorial mecum, was closed speciesblue-green and tested at King County
eral of
Day holiday. of algae for the first tu�ie<in algae of the genera oscilla EnThe re ental Lags.
June 2006 after two"dogs toria, aphanizomenon and Ther to t are routinely
The toxic. blue-green were killed from ingesting microcystis. released to the public on
algae threat is the worst it the water` and one nearly The county health Fridays. .
Jeffe
has been this year. died after having a seizure. department is continuingJefferson County Public
Although Lake Leland is In 2007 and 2008,it was seasonal sampling of recrHealth maintains
showing some improvement closed because of algae tox- ational lakes for toxic blue updated' database of lake
in levels of toxins, it's still ins for part of the summer. green algae. morutormg information at
not safe to swim in the water This year, it was closed on Anderson Lake contin wwwje ffersoncountypublic
or eat fish caught in it. April 24,the day before the ues to have a bloom made lwalth.org,
Results of water samples trout-fising season opened up predominately of blue The department can be
from both lakes show the — the earliest date in the reached at 360-les re
water quality remains the green algae of the genera Lake sem
same as was st week, season that the toxin level microcystis and anabaena, Ales are not
Neil as it was Jefferson has been so which produces anatoxin-a. tested in Clallam Chanty
Cyanobacteria, or blue- Because of the risk of where health lakes for visa_
County water quality man- green algae, is present in exposure to the toxin and all monitor for signs
• ager,said Friday. most bodies of water and the history of toxic algae of algae bloom. No cautions
Leland looked a little usually causes no problems blooms in Anderson Lake, or wings have been issued
bit this week,but it's for humans or animals, in Clallam County.
still has better advisoryagainst Washington State Parks,in Algae blooms in Clallam
g But when the right con- consultation with the county County lakes should be
swimming and eating fish ditions align — the water health department,is keep-
caught in the lake,"he said. is calm relatively warm ing the lake closed. reported nt of Heof He County
Department
"Anderson is looking and overly rich in phos- Since 2006 Jefferson County
and
even worse.Toxicity results phates, a chemical com- County Public Health has Human Services environ-
were up a little bit . . . It's monly found in lawn fertil- been collecting and submit- mental health division at
right on schedule." izers — it can bloom into � ting water quality/algae 360-417-2258.
high concentrations, samples from Iake Leland,
Ideal conditions Blue-green algae toxicity Anderson Lake,Sandy Shore Port Townsend-Jefferson
Sunshine and a lack of level; flared up in Lake and Gibbs Lake to determine County Editor Jeff Chew can be
wind pronide ideal algae Leland the week before last, what species and concentra- reached at 360-385-2335 or at Jeff.
blooming conditions this, forcing county public health tions of algae are present. chew@peninsuladailynews.corn
time of year, Herrin on officials to downgrade the Other local lakes are
lake to a warning notice sampled if they appear to
explained, a repeat of the discouraging swimming be having a blue-green
lake's three-year history of and consuming fish caught algae bloom.
toxic algae. in the lake.
The count ,health
Although the popular Results from samples department also is collect-
trout-fishing lake is closed taken from Lake Leland- ing samples for nutrient
to use,Anderson Lake State show high concentrations of analyses and physical data
Park remains open to all blue green algae and the to determine possible causes
recreation not involving the neurotoxin anatoxin-a. for the blue-green algae
lake, including hiking, bik- gr
ing and horseback riding. It is the same toxin found blooms.
Swimming is allowed in in Anderson Lake,anatoxin- The study is funded by a
the county's, Gibbs w dke a, and exposure to it can grant from the state Depart-
cause convulsions and death ment of Ecology
which remains at the concen-
tion" "cau-
level of warning for The toxins can those who use the lake for, trate in .skin and organs,
recreation. especially the liver.
"Just don't drink the People with liver prob-
"Just
and avoid algae lems, such as chronic hepa-
scums,"Harrington stressed. titin, should exercise addi
tional caution.
Swine flu found here
A young Port, Townsend There is no vaccine for the
woman•is they first, but likely swine flu,but there is an anti viral
not the last; person in Jefferson medication that can be used to
Comity/to be diagnosed with treat those who need it.There are
swipe flu 1,000 doses of the medication in
7Jefferson County ' Health Jefferson County, at the hospital
Qfficer Dr. Tom Locke: said and at pharmacies,he said.
„
Tuesday,the.young woman did As of Sunday,there were 574
not require hospitalization and confirmed cases of swine flu in
had already recovered. She had Washington state.
not traveled and,had probably Respiratory and hand hygiene
contracted the flu-in Jefferson are highly effective in preventing
1.04e said,yesterday spread of influenza
ForherpFiVacy,because Port Children and adolescents
Townsend is a small community, are more susceptible to the new
Locke declined to'give her age virus, while older individuals
'or Other,information that might 'appear to have some immunity
•
identify her from seasonal flu strains that have
LoCke said he expects more circulated in the past
people hi Jefferson County. to
be diagnosed with the swine flu,
which,also is called 1-11N1 influ,
enza.
"For ,every confirmed case
we detect, there are probably 20
or more cases out there," Locke
• said."Swine flu is spreading pret- •
ty wildly. It's kind,of blending in
there with the common cold!! •
_ .
•
•
F „. ,,..„;„,,,,..,,,,,,,4,,, I , &1, Assessment and Analysis ••
4, x . . � *E--,6 M r : t y , I, 4' s- "'L 4, ; Outcomes Project
r � st�#�� crirsra 1 q, What the health department�e �? t > w, , "j !I '� `� y wanted to do is what the women
fi4. a K ultimately wanted to do-make a
1
:`*. 1
' 'i,,+ r���},� . , , change,sustain the change,make
11
a a-r I t 1 :yea i .;4 '� i t a difference. •
+t '''•-•".., ,. k "a i 4.... J§�'t''�! :1, 1” Theprogramprovides screen-
,` J i *_,t 1 ing to pregnant women and fami-
•^-"` - 1'.,k,r "4 I,,,4, lies but hasn't hada way to iden-
x' • :+ # y A tify priority areas and patterns
t i+ t r to ensure the people who might The women also note that
11 r1'}x��A g there is an accountability provi-
iti i , E , +kvVkt need help down the line will get sion.The health department will
f' t5 .gk 'S} fir 'The long-term results of this report back.to the women in six
.+ ?� s .a ; r 7 ytl a months to share its progress.
r 3 , t' 'p�' ftaJ,�, tr , r grant will be both a better under-y i rrf�, f ` +,�s+ kV�c t standing of the community of "It isn't just about giving
At?.f iimoney," McGough wrote in an
6 s -� ;# tt ',.f j,f,a" ,?,,v.,4,.,,>' families with young children and " g
i ,E„ ` €`i r' '�� 3 ,it 1, . ,x< , a strategy to all email. It is thinking about what
,� t; r ,� r t?Y allocate resources
f > r `Iyy ;,r,, r tra � i the needs are,and how c provide
i - '•----.
."; .;: I Y° tr^ ' ., it tiv1,5 h,t2`A a and improve program efficacy," support in a way that can really
-4111, said Quen Zorrah,the lead inves-
tigator for the health department make a difference.Not many peo-
ple•
IS
who will be collecting and using can give a lot but many people
i _ vi,�....-iii �i3; can give a little.
Z "'�+a► x �,..^ computer data about families to "We chose our amount to give
refine what services the depart-
,
epart- and the number of people we
,,, ment provides. wanted in the p
,4 So the grant,then,funds some group, but that
' '-‘,--"'• � Y is flexible and completely depen-
.cQ.. „ .1V"`w thing that is both "systemic"and dent upon the giving circle mem-
Ruth Merryman(far left in back)stopped in at the Jefferson County Public Health Department to chat with Shena "sustainable."
Ruth e r Yuko U le team leader Quen Zorrah and Kelly VonVolkll(at the computer)on a project Merryman and 12 Merryman said she had an bers,"she wrote.
other women are helping fund through the first giving Kelly
'jri Jefferson County.Photo by Allison Arthur "aha" moment mid-presents- A conversation about the first
tion when she realized that.the giving circle seems to end with
■ ■ women weren't talking about the women suggesting there are
G .
ving circle many more causes in Jefferson
pioneers: how the agency would spend the County worthy of giving circles.
money but how the money would "Why don't you start a giving
be used specifically to meet the circle?"is a question the'wo
needs of the community. men
■ ■ ty often end up asking someone
a new
way
O� giving
worked social services they meet these days:
here, and I thought I knew the
needs [of the community],"
Merryman said of moving.the
By Allison Arthur of The Leader conversation from money to
Giving circle women wrote down the various needs and ensuring the money is
interests and causes they already used for what it is intended.
A good conversation led one See jccfgives.org;or„google"giv- supported with contributions.The In fact, several women in the
woman to act And then anoth- ing circle.” list included children's programs,
And then another- until 13 giving circle saidtheous se of arts,social service programs, getting to know the groups
k-
en who didn't know'each "What attracted me to the environmental groups and educa- es to
er had joined in the convey- ing funding opened their eyes to
group is that I would often give tion.
cation and created Jefferson $25 here and there. I'd write With the help of consultant how much need there is in the
County's first giving circle. Ms Mayer, of the community
the check and go on and havey JCCF, the
They hope it will be the first women started to talk more about There are enough issues
for a no
of many. idea where the moneywould
go," Merryman said of being the needs of the community than Sta lesozen giving circles," Skid
"The birth of the circle came a frequent contributor to good of theirjndividual desires or spe- P
Affordable housing .was
from a conversation I had with
causes. cific programs.
my sister-in-law in California," For those unfamiliar with g iv- -''a'The'•women also agreed to one several of them suggested.
explained circle co-chair Anne Schneider says hern social
justice ing circles, the women explain "do things by consensus," said started one based on social
Schneider, also a founder and Schneider. justice
that giving circles have been issues.
president of the Jefferson County formed by women, .men andThere were no egos.No one Or how about a Men Who
Community Foundation (JCCF), groups of often different people was going to be the leader,"said
an organization that supports and who share a common interest Staples.. Care group or a Kids Who Care
oversees gift giving in the cpm- and want to pool their resources The group asked'prospective group?
oversees
Merryman noted that National
The Women Who Care Givingto give to organizations that share nonprofits what were the"emerg- Public Radid recently did a story
their values, ing issues - and children and on a 12-yearold boy who set an
Circle that Schneider also started In Jefferson County, the giv- families kept coming up more and
is using the JCCF as an umbrel-ting circle pioneers are Schneider, more,"Schneider explained. example in hisn like community by
la nonprofit organization under Merryman, Staples, Rachel The women opted to interview raisingosomething him.$8 million
which to operate. for a cause dear to
Gaspers, Gay Eisenber er, Teri various groups and went outside Ri ht here in
friends," BaJeerson
rd e Roth t aMgroup of McComas, Darlene puree,Jane their interest areas to learn more County,there are so many needs
Henery, Teresa Goldsmith, Ka about organizations they' hadn't
co-chair of the circle. ysaid Merryman.
Goetz, Mary Ann Verneuil, Gail given to in the past A social After stud m man
"I didn't know anyone really e g y of those
well." admitted circle member Boulter and Carol McGough. worker interviewed educators, needs for a year,Merryman said
y Staples. In the beginning,the women for example. she recently wrote a check to
Marilyn didn't know what cause they "And there was no preset
While the women weren't an agency she would ever haveo
wanted to help-only that they agenda. Wagreed to put it all known about before had it not
in the same social circle, what wanted to make a difference and aside. I don't think any one of
they did have in common a year help.the community. been for her work-and learning
us,on her own,would ever have
ago when they started meeting 'This group of women all came&._;given money to the health depart- -with the giving circle.
was the ability to pledge$1,000 a together with the desire to make ' meat,"said Schneider. The women also say they got
year for three consecutive years to know each other,often through
to a charity they wouldochoose a difference,but none of us really emails.
understood the journey on which FIRST OF THREE
together. • we were embarking.We.were all Ultimately, the Jefferson "I think this whole thing stuck
together because of emails,
Corn
from very diverse backgrounds
tyPublicHealment Staples said of the conversa-
• and interests. Some of us knew was the one that won the
one or two people in the group, $13,000 grant won thefirst
but none of us knew everyone," The health department's tions.
wrote Carol McGough of her Proposal is a mouthful to pro-
experience. pounce-Jefferson County Public
At the first meeting, the Health Family Support Programs }}
!-7-«/r r t i-ICC-
1
01.--Z2-2 of
.
Officialsletiort .
. first Clallam
. . .•
swine flu case . .
Sequim woman contracted
illness locally, not abroad
By Tom CALLIS takes less than a week.
PENINSULA Davi News At least a dozen samples
have been sent to the state
SEQUEM — A Sequhn lab from ClaIlam and Jeffer-
woman in her 30s is the first son counties each so more
person in Clallam County to fi .. ' •
con. rmect cases are likely,he
have been diagnosed vrith said.
swine flu. . .
The case was confirmed
"We only know about the
•
"
Friday morning,but just like tip-of-the-iceberg cases,
• a Port Townsend woman Locke said.
who was diagnosed with the..: :,Swine flu patients;are
illness on May 22,shelia.s..',.10ore' likely to experience
•
since recovered and was not.''nausea,vomiting and diar-
hospitalized, said,On,Tom .rhea than seasonal flu
Locke, public health.officer.•Patients,he said. .., .:.
for Clallam and Jefferson . ..,Although.swine flu cases
counties.
have shown to be typically
•
Locke said the,,Port mild,about.6 percent of peo-
Townsend case infected, ple =firmed to have the
young woman yotatier than' 1:illness haVe"been hospital-
• 20. •• ized in the state,Locke said. •
Locke also said there is That is higher than sea- •
no reason to believe that the sand flu,which has 1-per-
two women had any contact cent hospitalization rate.
with each other.Neither con- Locke said the higher
tracted the virus through Percentage of hospitalization
travel outside of the North probably doesn't present an
• Olympic Peninsula,he said, accurate picture,since health
"Once again,we think it's officials aren't aware of the
• local transmission," Locke cases that are not reported.
said. . Locke said the Sequim
He estimated at least 20 woman works in Port Ange-
unknown cases of swine flu les.He said her co-workers
for each confirmed case.But were not notified that she
he said there is no reason for had the illness.
alarm because the illness is Locke said the case was
typically no more severe too mild to justify telling her •
than seasonal flu. co-workers.
For the same reason, Because the H1N1 strain
Locke said the health depart- of swine flu has become
menta for Clallam and Jef- widespread nationally and
ferson counties are not con- statewide,the state Depart-
sidering any school or facility men t of Health is no longer
closures or quarantines, posting daily updates of all -,
The health departments probable and confirmed
are recommending that peo- cases of swine flu on its Web
ple who are ill should stay site at www.doh.wa.gov I
home and always cover their swineflu I defaulthtm.
coughs and sneezes to pre- Instead,it will update the
• vent spread of the virus, site weekly—at 3 p.m.Fri-
Since it is a new strain of days—and include only a
flu, no vaccine is available running statewide total of
for it. hospitalized and fatal cases,
Jefferson County has a the department said.
stockpile,of,f1,000,closaiy;of The latest talIMPOsted on
• anti-virus medication,Aind Tuesday, is.5:74.-confirrlied •
Clallamr-Cohntythaii-2.000, caseiztathwitithow,—p i
doses that can be given toLocke said the.median
people infected with swine age of people infeaed in the
flu. state is 13,which suggests
that older generations have
Testing developed immunities from
being exposed, to similar
To determine if someone '
has swine flu,Locke Said trains cf flu'
physicians on the Peningula • The 'federal Centers for Disease Control reports
test patients with flu-like
.. 8,9.75 cases nationwide
symptoms for influenza type nationwide.
information,see
A,which is the category the For more
virus falls under,by swab- the state health department
bing their nostrils.
Web site or phone its flu
The sample is taken to information telephone line
either Olympic Medical Cen- at 1-888-703-4364.For more '
ter or Jefferson Healthcare about federal efforts,see the
for testing. If the virus is CDC Web site at www.cdc.
confirmed to be influenza gov I hInlflu I jade,-htm.
type A,a sample is sent to a
state lab,in Shoreline to be, Reporter Tom Callis.can be
" . tested for swine flu. , reached Si 360-417-3532 or at tom
Locke said that process callisOpeninsuladailynews.com. •
.
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��//9
Health program to raise rates
THE ASSOCIATED PRESS will increase the average a 2/-year budget deficit of
—People cov monthly premium by about about $9 billion, the Legis-
OLYMPIAered by the state subsidized $25,to nearly $62, starting lature cut spending on the
Basic state-subsidized
bsiwill pay in January. The yearly program by more than 40
moreasout Healthot pocket,but the deductible also will increase, percent, saving about $250
state will not kick huge from$150 to$250. million.
numbers of people off the Even a modest price hike Majority Democrats
• plan,despite previous warn will be difficult for the poor- warned that the budget cut
that could est families who rely on could lead to tens of thou-
ings
abruptly lose 40,000heir ovcouldage Basic Health for coverage, sands of people being booted
to save the state money. •
administrator Steve Hill from the program amid a
said Monday, "but this major recession. But the
The Basic Health Plan families
option offers taxpayer-supported achoicevNoes tone equalified program's whoportadministrators,to Gov. Chris
health coverage to people for the program will be arbi- Gregoire,decided instead to
mthefederal lss poverty double
.trarily removed." raise rates and find efficien-
which is equal to about Earlier this year, facing cies.
•
• $44,000 for a family of four.
It's intended for the
"working poor" — people
who have jobs, but don't
qualify for Medicaid and
can't afford their own health
insurance. About 100,000
are enrolled in the plan,
which is bankrolled entirely
by the state. 411
The new pricing scale
S
pp d
County pp a rov s
•0 Preservation:
conservation funds
$270 0oo will help unanimously recommended
approvingthe Brown Dairy and Funds granted
to preserve dairy Quimper Wildlife Corridor proj-
ects but only five voted for the CONTINUED FROM Al ity of life,information from
wildlife refuges Tarboo project. the county states.
Tammy Pokorny, Jefferson The Conservation In the past, Conserve-
County's representative oversee- Futures Fund,established tion Futures has funded
B
B JEn' DAILY NEWS ing the Conservation Futures by the county commission- Chimacum Creek Estuary,
Fund advisory board, said three ers in 2002,is derived from East Tarboo Creek,
PORT TOWNSEND — The board members did not support a tax levy of just more Finnriver Farm in Chi-
three Jefferson County commis funding the Tarboo Wildlife Pre- than 4 cents per $1,000 of macum, Gateway Buffer,
sioners approved $270,000 Mori serve because it was a "less assessed property valua- Glendale Farm in Chi
day in Conservation Futures impressive project. tion and a fraction of the macum, Quimper Wildlife
funding for three preservation timber tax receipts the Corridor,Sunfield Farm in
projects—Brown Dairy property Do not underestimate Tarboo county receives. Port Hadlock, Tamanowas
in Chimacum, Quimper Wildlife Peter Bahls, president of Each year, the funds Rock near Lake Anderson
Corridor in Port Townsend and Northwest Watershed Institute, available to new projects between Hadlock and Chi-
Tarboo Wildlife Preserve near told the commissioners during varies but has been run- macum,Tarboo Creek con-
told Bay. ning at least $180,000 a
Monday public hearing on the servation.area and Winona
The commissioners' action year.
funding proposals that he dis Wetland buffer.
makes the following allocations:
agreed that the Tarboo preserve The program requires
was not as important. Current balance the participation of both
Funding allocations County Commissioner John The current balance in an applicant landowner
■ $82,500 toward the pur- Austin agreed with Bahls, say- the Conservation Futures and a project sponsor such
chase of a perpetual conservation ing,"I think we should not under- Fund is$730,284. as Jefferson Land Trust.
easement on 50 acres of Brown estimate the value of those woodsfa
The program's purpose
above [TarbooCreek]."
TCreek]."
Dairy at 9165 Rhody Drive. is to provide public open
Austin saidarbox was just Port Townsend-Jefferson
■ $137,500 toward the pur- spaces for the health,wel-
chase of 30 lots in the Fowlers not as visible as the Brown Dairy fare, benefit and safety of eachedEdit Editor
Jeff Chew aon r be
Park Addition of the city of Port or Quimper Wildlife Corridor. count residents and to County at
Townsend in the Quimper Wild- He said preserving Quimper improve the county's qual- corn.hew®peninsu/adail}news.
life Corridor. Wildlife was a "very positive"
• $50,000 toward the pur- action for the future.
chase of a perpetual conservation Johnson also voiced support
easement of 10 acres east of for the Tarboo projects,saying he
Dabob Road in the Tarboo Valley has hiked that area and wit
north of Quilcene. nessed salmon return to the
The Conservation Futures creek.
Fund advisory board of eight had TURN TO PRESERVATIONIA6
•' •
/j