Public Health on the Front Lines to Combat Flu

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: preparing for another flu season; using lessons past and present to inform pandemic readiness.

DR. DANIEL JERNIGAN:
If you have a very robust, very efficient seasonal infrastructure for surveillance, vaccine manufacturing, distribution, prevention, etc., if you have that in place, that is really the best way to prepare for one of these global pandemics that could have a significant impact on a population.

CHRISTOPHER SHIELDS:
Some of our large medical locations, they're geographically dispersed, but they don't get down into the neighborhood; whereas the sites that we identified post H1N1, they get it down to half the neighborhood level, and then we can bring our personnel in and the materials right into the community.

DR. CARA CHRIST:
We're always using the opportunity to practice and to get ready because we know pandemic flu is one of those things that keep us up at night here in Arizona. Just any opportunity that we have to practice, we use it.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, flu fighters from all corners of public health are gearing up for another season of immunization drives, awareness campaigns, and, unfortunately, emergency room visits. The goal is to manage the flu to keep it in check, holding cases to a minimum, avoiding a pandemic; using the lessons of the past to improve systems and protocols that can help people weather flu illnesses or prevent them all together.

Dr. Cara Christ is director of the Arizona Department of Health Services. Christopher Shields is the assistant commissioner of the Chicago Department of Health. Both have teams working to help their communities get ready. They'll be along shortly to discuss those efforts.

We begin with comments from Dr. Daniel Jernigan, director of the influenza division within the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention.

JERNIGAN:
Influenza circulates in humans, but it also circulates in animals. And so, if you look at the sort of weight of influenza around the globe—where is the most influenza occurring—it's actually in migratory waterfowl and ducks and geese, and those kinds of birds. Lots of different flu viruses are in that population.

If you look at what's circulating in humans, it's pretty much just happening in humans as what we refer to that as seasonal influenza—it is also called epidemic influenza—it comes each year in the Northern hemisphere in the winter. That's what's occurring in humans all the time.

There are chances where a bird influenza virus, for instance, and a human influenza virus might get together in a pig. When that happens, they have an opportunity, those influenza viruses, have an opportunity to share their genes. The genes are just the instructions for how the influenza virus makes copies of itself. When they exchange those genes, you can come up with a brand-new influenza virus that nobody has seen before.

And if that particular virus is able to be transmitted from one person to another, over and over, then you can get what's called a pandemic. And that is when there is a new virus and the whole population has never seen it before and doesn't have any immunity, and it can travel relatively quickly around the globe.

Those pandemics—we've had four of them in the last hundred years, 1918 being the worst of them. If you look back at that 1918 virus, it was from a bird origin and got into humans and caused a significant amount of disease. An estimated 50 million people died back in 1918.

And so, we're doing surveillance. We're monitoring what's happening in the avian population and hoping to be able to detect quickly if one of those unusual influenza viruses were to emerge.

JOHNSON:
And that's a year-round activity?

JERNIGAN:
CDC maintains surveillance in the United States at a pretty robust amount. We look at about a hundred thousand respiratory specimens per year and, of those, do very detailed characterization of the viruses that we identify.

We also work with the National Influenza Centers, or NIC, around the globe—there's at least one of those per country in most countries. We help support their testing, we provide technical assistance, we serve as a reference or collaborating laboratory and receive those viruses from them.

You have to really maintain global surveillance for human influenza so that we can make sure that vaccines that we use every year are updated, but also for detecting these animal viruses, mostly for the birds, and characterizing them as well.

JOHNSON:
How does, then, the seasonal influenza planning prepare our nation and our healthcare professionals for a pandemic?

JERNIGAN:
From a preparedness standpoint, we feel that if you have a very robust, very efficient seasonal infrastructure for surveillance, vaccine manufacturing, distribution, prevention, etc., if you have that in place, that has really the best way to prepare for one of these global pandemics that could have a significant impact on a population.

So, having the infrastructure in place—and having the decisions made about how you would respond to a pandemic prepared and all that done ahead of time and being used routinely in seasonal influenza prevention—having that in places is going to make you really prepared for a pandemic when it does occur.

JOHNSON:
States and territories, of course, are your partners. They're beginning their planning as we speak—it's probably been underway for a while, actually.

How do you gear up to support them as this starts to unfold in a few weeks?

JERNIGAN:
When we think about the U.S. infrastructure for both seasonal influenza and for responding to a pandemic, it is absolutely dependent on state health departments and local health departments. Those are the folks that are actually doing the collection of the specimens, doing the testing, finding out what's circulating, and then being able to communicate back to their own populations about the best ways to prevent influenza.

In addition, the state health departments and the local health departments are the ones that are often administering the programs for vaccinating children and for vaccinating others. All of that infrastructure would be used and was used to respond to a pandemic, notably in 2009. For us at CDC, there's absolutely no way the work at preventing influenza could occur without those folks.

JOHNSON:
What all do you provide to the states in terms of support and information that they can use to do their jobs?

JERNIGAN:
From a vaccine standpoint, the Vaccines for Children program—and other vaccine purchasing programs that CDC helps—supports the making of an influenza vaccine available every year. That's a very large program that all of the states and locals have access through their providers in those jurisdictions.

We also provide individuals, our immunization managers, in each of the larger jurisdictions; but also, from an influenza specific standpoint, influenza coordinators are supported with federal support as well.

In addition, most states also can use money through the Epidemiology and Laboratory Capacity Grant Program to support their laboratory staff.

And then the CDC provides the reagents to do the testing for influenza through an online storefront called the International Reagents Resource, which is kind of like Amazon for flu reagents. Those are the kinds of things that are provided as infrastructure for routine surveillance.

We also support, through the Association of Public Health Laboratories and through other groups, communication electronically of the information from the laboratories to CDC for automated reporting.

When there is a pandemic, like when we have a severe influenza season, there are a lot of other resources that are made available. There's a thing called Flu Vax Finder, which is an online tool that a lot of state health departments link to that helps somebody, you know, looking to get vaccinated. They can put their zip code in and find out where vaccine is near them.

And then, starting this year, there will also be Flu Med Finder, which is a tool that allows somebody to do the same kind of thing—put in their zip code and find out where antiviral drugs are at pharmacies near them. We know that that was a problem in 2017-18 and said, "This is a solution that the CDC has made available to help folks to find those things."

JOHNSON:
That's a new tool rolling out this year?

JERNIGAN:
Correct.

And so, those are some online tools, but there are also large programs that help support state and local readiness in terms of overall preparedness as well, and pandemic influenza preparedness is supported and helped through those larger grant programs as well.

JOHNSON:
Are those pandemic tools useful if you are only dealing with a seasonal situation?

JERNIGAN:
Getting back to the point that having a robust infrastructure for seasonal response makes it good for pandemic, that's where the Flu Vax Finder, Flu Med Finder, and other programs that are available—getting them able to be used for seasonal flu will really help us when there is a pandemic. So, those tools are mostly for seasonal, but when we do have a pandemic, they certainly will be useful.

There are other tools that have been developed that are pandemic-specific, ways of determining the severity of what's happening in the community, information about how to respond using non-pharmaceutical interventions—like closing schools, or stopping large gatherings, social distancing—there's a lot of that kind of information and those tools that have been developed that are relatively specific to a pandemic, especially a severe pandemic.

Those are all available online. And those are the kinds of things that states would want to use for the exercise and do this run through a test of what they would do for a pandemic, because that's another part of getting prepared, is exercising.

JOHNSON:
Are these tools utilized as much as you'd like them to be used? Or could we do a better job on that front?

JERNIGAN:
You know, when we go back to say 2006, 2007, there was a real push to have a state pandemic preparedness plans. And then we had the biggest exercise for a pandemic that we've ever had, and that was the 2009 emergence of the H1N1 outbreak of '09. That really allowed us to see what works, what doesn't work.

And since that time, we continue to have exercises, and states are still doing some of that work, but I think there is a move now to try and incorporate more of pandemic influenza preparedness into some of the state planning that happened from the state and local readiness groups here at CDC.

JOHNSON:
Like most other states, Arizona has spent the last several months updating plans and incorporating lessons from past flu seasons to get ready for the one that's coming soon.

We asked Dr. Cara Christ, director of the Arizona Department of Health Services, about those plans. Here's what she had to say.

CHRIST:
We work with our healthcare coalitions, with our local media to initiate vaccine campaigns.

We work with our healthcare providers to try and get those working in hospitals to get vaccinated.

This year, we're going to do a university challenge where we're planning a challenge with all of our university partners to increase flu vaccines in those communities.

And then, our local health departments utilize every seasonal flu as an opportunity to practice for pandemics. So, they will do their emergency preparedness exercises as mass vaccination clinics but provide flu vaccine. So, you're increasing access, but you're also preparing and practicing for if we do get a pandemic flu.

JOHNSON:
Does that work to prepare and get ready for the worst case?

Does that change from year to year, or does it come out of the same playbook each time?

CHRIST:
So, it comes out of the same playbook, but as we identify better practices or find things that have worked better, we will update our plans.

So, we've had an influenza pandemic plan since about 2000. We revised it back in 2011 from lessons learned during the 2009 H1N1. So, we are always updating it and updating our practices so that we can be ready to respond if there was a pandemic.

JOHNSON:
Really all you can do is prepare, right?

I mean, that's the name of the game here, practice and be on alert.

CHRIST:
Absolutely.

So, we use every season of flu to practice for the pandemic. So, we have a pretty good surveillance system in Arizona to identify potential novel events: so we have sentinel labs that are always sending in flu samples when they're positive; we are able to, kind of accordion style, that we can scale up on our current activities and make them adaptable during a pandemic; we've identified ways to electronically order flu vaccine in large doses—and that was one of the best practices we identified during the H1N1.

But we're always working with our partners, our community partners, to make sure that they know the data is presented on a dashboard, it's interactive, they can go find data on their specific community so that they can see where we are in our flu season and kind of what we're anticipating.

JOHNSON:
You're driving a lot of that from your perch atop of the public health infrastructure in Arizona.

How is the rest of the state doing at the county and local level?

CHRIST:
In Arizona, we're a home rule state. So, the counties actually are our boots on the ground. They take the lead in local responses.

But in influenza, we actually work hand in hand with our local partners. So, we give them the data that they need in order to be able to identify where they need to hold vaccination clinics, where are we, are we at widespread, are we at seasonal.

And then, they work with the coalitions to make sure that hospitals are prepared in case there is a surge in patients; getting those messaging out to their communities about, you know, when you should go seek care in the emergency room and helping us message with vaccines.

So, at this point, it's a very coordinated effort in Arizona all the way from the federal government down to the local healthcare providers and partners.

JOHNSON:
Are you doing that all year round, or does it start now?

CHRIST:
We do that all year round and then expand as the flu season opens up. So, we have lab reporting that continues all year round, and then we also have our sentinel labs that send in positive flu strains so we can see what's coming in.

As we reach different points in the season, we scale that up; so, more providers will come on board, more reporting is required, and we work with the county health departments to get that messaging out.

But our laboratories and our partners, because we've been doing this for so long, are very used to our reporting mechanisms in Arizona.

JOHNSON:
From your vantage point, do you see any gaps in knowledge or capability that you'd like to see taken care of soon?

CHRIST:
We always like to say in Arizona that flu is predictably unpredictable.

A lot of people don't take it seriously—they think it only affects older adults and young children. So, really our challenge is how do we increase uptake of that vaccine and get people to want it—not only when there was a shortage or a pandemic that's having, you know, drastic outcomes, but every year just to provide that ongoing protection against flu. So, that was one of our gaps.

But the other gap that we identified—so we established a vaccine and antiviral prioritization advisory committee as we wait, like, that would be how we would prioritize those things as we wait for guidance from CDC because we have a lot of unique things here in Arizona.

We have 22 tribal nations that we have to consider, and while our tribal Indian population only accounts for 5% of the state's overall population, we know that they have worse outcomes when it comes to Flu. We're a border state, we know that we get a lot of influx into our border hospitals during flu season. At what point would—that's our question, like at what point would we activate that prioritization advisory committee, because that's a big step.

And so, the other thing that we do have in Arizona is we are a healthcare provider shortage area. And so, you know, worker absenteeism—especially during a pandemic—is going to cause a lot of challenges here in order to be able to provide the care that we anticipate we would need, but also to keep infrastructure going.

JOHNSON:
And you're not predicting a pandemic this season, you're just always getting ready for one in the event that it happens.

CHRIST:
Absolutely.

So, we would rather be prepared and be ahead of the curve than to think, "Well, pandemic's not going to hit this year," and then you have something that's already out of control.

So, we're always acting as if every year is going to be pandemic flu; and then, you know, hope that it just ends up being seasonal.

JOHNSON:
With so many unique characteristics affecting the way you administer public health in Arizona, are there any tools that you have developed there that others in your profession around the country and the territories might look to for guidance in their own circumstances?

CHRIST:
One of the things that we do have in Arizona is, because of our relationships with our tribes, we have a tribal liaison. We can pull together all of the tribes for a consultation, if we need to, to get their input on how would they like to receive vaccine, what's the best way to distribute it to their nations.

So, that's one of the things that we rely on during almost any health issue—we relied on it during our opioid emergency when Governor Ducey declared that it was a public health emergency. So, we'll pull them together for information on how to best work with their communities; and we do the same thing with our local health officers, and then we also do the same thing with our hospitals. And in that partnership, we get a lot of direct communication, and that has been very beneficial.

JOHNSON:
The bottom line—fighting the flu in Arizona or elsewhere is about a lot more than just getting people vaccinated, even though that's important.

There's a lot of work going on behind the scenes all year long.

CHRIST:
As I'm sure all public health professionals know, you know, public health can't do it alone.

And so, we do rely heavily on our community partners, our local public health partners, our hospitals, and they do a lot of the major lifting and messaging and getting people vaccinated and, you know, making sure that they are up to date on their pandemic plans, as well as their hospital emergency plans.

JOHNSON:
Looking back over your experience in this position and previous positions within the state health department, is there anything that you've learned from past flu seasons that has informed the way forward?

CHRIST:
You know, one of the things that encouraged us to ensure that we had a crisis standards of care plan was we did have a season where we had an abnormally large number of people requiring ECMO [Ed. note: extracorporeal membrane oxygenation, also known as extracorporeal life support]. And with limited resources and limited hospitals that could provide that high level of, you know, ICU level care, we were afraid that we we're going to have to start prioritizing who got that level of care.

It didn't reach that, but that was kind of our call to action to bring together all of the partners so that we could establish that crisis standards of care plan. It had always been in the works, but that was one of the things that prompted us to finalize it. That's been really helpful.

The other thing is just making sure that we really have good communication with our public health departments on how, if we needed to mass vaccinate, how do we get the vaccine out to them, especially when all 50 states that are going to be trying to get the same vaccine and get it out to their communities as well.

JOHNSON:
Chicago didn't wait for cooler temperatures to begin its flu preparations.

Christopher Shields is assistant commissioner of the Chicago Department of Health.

SHIELDS:
We can look at 2009 as the first time we had to turn on some partner agencies that we hadn't previously worked with.

We started looking at that larger immunization neighborhood, that whole group which includes, you know, pharmacists and first responders; the people that are not your traditional vaccinators—adult providers and OB/GYN providers.

We started pushing messages out to get to places that may or may not just look to the health department for information—so, your large religious congregation, pushing out messages that way; pushing them out through your traditional mechanisms—so, your provider groups, and your HMOs, and PPOs; and kind of going to a grassroots level to kind of increase that base level knowledge amongst a lot of people who may or may not be paying attention.

JOHNSON:
Even grocery stores and pharmacies have become big promoters of the flu vaccine.

I don't know if that started in 2009, but it feels like it hasn't been that way forever.

SHIELDS:
The pharmacies have always been in the vaccination game, but—and I hate to say this—there's an economic impact to doing business. In every process you basically engage in, there's a cost.

H1N1 kind of drove home to the pharmacy network that they had a service, they have the ability to provide a service, and they have deep penetration into the community—locally, here in Chicago, you probably can't go more than two or three blocks without running into a Walgreens or a CVS. So, they are well positioned within the community. So H1N1 started them off on that.

And what we've seen over the last 10 years is we use them as part of our provider network now. So when we, as the city of Chicago, identify that we're going to be getting into influenza season, we also list all the private providers that are providing the vaccine. So, instead of waiting for a health department clinic to open, I can just go down to the local pharmacy and get my vaccination.

JOHNSON:
That's where I've gotten mine every time.

I assume that you've done more, though, than just activate the partners that you weren't using traditionally.

SHIELDS:
We've actually done a lot of expansion in several areas.

Going after our provider network—and that's for the groups that do vaccine for children, so, your low-income people—we're doing a lot of work with them. We opened, here in the city, 70-80 pop-up clinics during influenza season just to kind of help span the gap between what people are getting into private providers versus what they're going to get if they wait for one of our larger medical clinics to open up.

And then, we've actually partnered with Blue Cross Blue Shield to do a mobile caravan. So, that van is mobile, obviously, and can go to specific locations within our jurisdiction to help support a vaccination—let's say a church wants to do a vaccination drive. We can deploy that vehicle and that it gives more providers there to provide the vaccination.

JOHNSON:
I would assume you can do a lot of vaccinations through a set up like that.

SHIELDS:
At the end of the day, there's 2.75 million people that reside within the city of Chicago, so that's a lot of deltoids we'd need to see in a vaccination campaign.

So, we attempt to push vaccine out to as many providers as possible that can deliver the services, and then we use the pop-up clinics and the mobile caravan to kind of fill in some of the gaps.

And then, if it's a bad influenza season—and last year was a bad influenza season—we activate some of our higher-level plans to open points of dispensing site, or PODS, which are super sites that can take a high volume of persons from the public into the clinic environment.

JOHNSON:
Are the locations for those, or the assignments for the mobile van, or the determinations about where to put a pop-up—are all of those locations data driven, or are they just scattered across the city?

SHIELDS:
So, what our immunization program does is they work with our epidemiologists and do geospatial cluster detection. So, they look at the last year's influenza impacts, and then they map that geosynchronously across the city to see if there are areas within our communities that have a higher prevalence of disease.

And those that are identified, moving into the next influenza season, those locations become sites where we would focus a larger portion of our media to drive people in those communities to receive services.

JOHNSON:
So, you have all of these new ways to reach people that have come to mind and are now part of the program since 2009. How are they working?

SHIELDS:
We feel good that we're reaching a large segment of the population—so, reaching the population to provide them a message.

And the population acting on that message to receive services? That's hit or miss.

Last year was a very virulent flu season. We had a higher demand for influenza vaccinations last year. We're projecting this year to be on-line with last year—so, we're expecting a higher turnout for immunization—but there's never a guarantee on the message being received and then acted upon correctly.

JOHNSON:
Right, because it's not a required immunization, it's just something you're recommending based on how this goes each season.

SHIELDS:
That's correct.

There are agencies within the city that require influenza vaccinations annually—our hospitals and healthcare providers do that—and that's more or less a mechanism by the private sector to ensure they have a viable workforce should a influenza novel virus get out of the box.

JOHNSON:
What more do you have in the works then, Christopher?

Are you working on any other ideas to help improve your vaccination rate or your ability to reach certain populations?

Is there anything going on in those areas?

SHIELDS:
We've made several enhancements over the last 10 years.

We've moved our medical environment into a dynamic place, which means that we're no longer bound by brick and mortar hardened facilities to provide services. What we found during H1N1 is when we were moving vaccine from the clinical environment out into the field, there's a time-limited factor in there of how long that product can be in the field fefore it has to go back into an FDA, more or less, regulated, controlled temperature environment.

We brought on a couple of systems. One's our vaccine management profile, and we use a technology called Green Box. It's a hundred percent biodegradable, it utilizes thermal shipping container environment and phase change panels so the temperature is consistently regulated within the thermal container. It allows us to take it backseat and keep it in the FDA-standard range of temperatures up to 72 hours without electricity.

So that makes us, in essence, more nimble to respond and not having to worry about having an electricity source or vaccine refrigerators on site.

JOHNSON:
That allows you to administer vaccinations anywhere.

SHIELDS:
That was more or less the point.

We have identified sites throughout the city that traditional vaccinations occur, and then we have a subset grouping of facilities that we can bring online in times of emergency that give us deeper penetration into the community.

Some of our large medical locations, they're geographically dispersed, but they don't get down into the neighborhood; whereas the sites that we identified post—H1N1, they get us down at the neighborhood level, and then we can bring our personnel and the materials right into the community.

JOHNSON:
What kinds of settings would you envision—or have you—used a box like that?

Where have you taken it?

SHIELDS:
On the large scale: we use our universities and colleges; we have partnered with our school districts to utilize school facilities; we partner with our park district to use park district sites; and we use our political side of the house—so our aldermen have ward offices, so we provide services in the ward offices; and then, obviously, the private sector partnership. We've worked with our local pharmacies as well.

That kind of gives us a large blanket over the city of Chicago.

JOHNSON:
Links to information about the upcoming flu season can be found in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.