# Presentation: 440122

## Limited Resource Allocation Strategies in a Pandemic: Sizes of Potential Target Populations

- Elizabeth Falcone
- National Vaccine Program Office
- April 20, 2005

**Notes:**

Hello –I will be speaking today on limited resource allocation strategies ... in a  pandemic – focusing specifically on the sizes of potential target populations.

Before I begin I would like to thank Ben Schwartz for his help in putting together this presentation.

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## Key Issue

- What are the population sizes of groups that contribute to the critical infrastructure?

**Notes:**
The key issue I will talk about over the next half hour is: What are the population sizes of groups that contribute to the critical infrastructure.  

This question however can actually be broken down into two separate and distinct questions - 

What are the critical groups necessary to counteract the characteristics of an influenza pandemic?

What are the population sizes of such critical groups?

While I do not propose to provide the necessary groups, I would like to highlight some are seemingly important ones and show that there may be potential stratification within them.  By stratification I mean a division of the larger groups into the smaller groups appropriate to the issues we are addressing.

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## Goals of a Pandemic Response

- Optimally reduce morbidity and mortality
- Decrease social and economic disruption
*US Draft Pandemic Influenza Preparedness and Response Plan*
*Synopsis page 8*

**Notes:**
Before I begin with the specifics of defining such groups – I would like to highlight the goals of a pandemic response – as it is these same basic goals that should be used when developing such priority groups.  These overall goals are - to

1)optimally reduce morbidity and mortality 

2) decrease social and economic disruption

The second goal of decreasing social and economic disruption inherently leads itself to an idea that there is an infrastructure that must be maintained.   As well, protecting those in workforces that play a role in dealing with public health can have a direct effect on the first goal of reducing morbidity and mortality.

It is with these goals in mind that I will try to provide more education on the ideas of developing priority groups.

## What is Infrastructure?

- The framework of _interdependent networks and systems comprising identifiable industries, institutions and distribution capabilities that provide a reliable flow of products and services_ essential to the defense and economic security of the of the US, the smooth functioning of government at all levels, and society as a whole.
*President’s Commission on Critical Infrastructure Protection, *
*Critical Foundations Protecting American’s Infrastructure, October 1997*

**Notes:**
To help us begin to look at certain priority groups, I provide here a broad definition of infrastructure – defined by the President’s Commission on Critical infrastructure Protection in 1997

This definition focuses on defense and government security --- and economic functions.

While it does not have to be this working group’s specific definition, it does provide a good base to understand what is looked at when defining priority groups by infrastructure.

However, this definition does not provide any insights into specific critical infrastructures as they relate to an influenza pandemic

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## What is Critical Infrastructure?

|   | national defense | economic security | pubic health and safety | national morale |
| --- | --- | --- | --- | --- |
| telecommunications information networks | x | x |   |   |
| energy | x | x |   |   |
| banking finance |   | x |   |   |
| transportation | x | x |   |   |
| water |   |   | x |   |
| emergency services |   |   | x |   |
| government |   |   | x |   |
| health services |   |   | x |   |
| national defense | x |   |   |   |
| foreign intelligence | x |   |   |   |
| law enforcement |   |   | x |   |
| foreign affairs | x |   |   |   |
| nuclear facilities, in addition to power plants |   |   | x |   |
| special events |   |   |   | x |
| food/agriculture |   |   | x |   |
| manufacturing |   | x |   |   |
| chemical |   |   | x |   |
| defense industry | x |   |   |   |
| postal/shipping |   |   | x |   |
| national monument icons |   |   |   | x |

- Congressional Research Service, *Critical Infrastructures: What Makes an Infrastructure Critical?*, January 2003.

**Notes:**
However, once one begins talking about the idea of critical infrastructure there is no single definition.

Shown here is a chart created by the Congressional Research Service in 2003, which is a visual to a report that hopes to help define critical infrastructure.  It is based upon the types of threats anticipated, and designates infrastructures critical if they are required for either national defense, economic activity, public health and safety or national morale.   The threats are located on the horizontal axis - while the various infrastrtucres are on the vertical axis - they are deemed critical if an x is placed in its box.

As we are looking at the impact on pandemic influenza on the country, I have highlighted in yellow those suggested as critical to public health and safety.  

Nevertheless, pandemic influenza’s potential impact on societal functions may involve other infrastructures not highlighted.  These could include transportation, telecommunications and other economic or national defense activities.  

However, this chart does provide a good base to start developing which at specific categories should be looked at.

## Methodology

- Critical Infrastructure Designations
- Public Health Agency of Canada
- White House, *The National Strategy for the Physical Protection of Critical Infrastructures and Key Assets*, February 2003
- Congressional Research Service, *Critical Infrastructures: What Makes an Infrastructure Critical?*, January 2003.
- Population Size Data
- U.S. Department of Bureau of Labor Statistics
- November 2003 data
- Break down into the Standard Occupational Classification System and North American Industry Classification System

**Notes:**
In order to more fully answer the first part of my question – to determine which certain groups may be included in critical – I used a variety of sources – including Congressional Research service.  I was aided by charts developed by those at the Public Health Agency of Canada.  I read reports compiled the White House, the Department of Homeland Security, and the Congressional Research Service.  The most helpful were the papers by the CRS and the White House, which explicitly pointed out groups and explained the complexities in defining industries.

To answer what are population sizes, I took data from the bureau of labor statistics.  The BLS took a variety of surveys and are extrapalated data to make the estimates you will see here.  

I used both the standard occupational classification (SOC) which details 770 occupational profiles, as well as the North American Industry Classification System which classifies occupations by major economic activity.  

All data is current as of November 2003 survey.

## Limitations and Uncertainties

- The data from the U.S. Bureau of Labor Statistics does not include self–employed workers.
- Potential duplications in population sizes
- Unsure where there is some flexibility in absenteeism for different industry categories
- Potential barriers to stratification

**Notes:**
While I tried to put together the most complete and coherent information, there are some limitations and uncertainties to be noted upfront.  

To begin with, data from the Bureau of labor statistics website regarding number of employees in a certain occupation, does not include workers who are self-employed, leading some numbers to be lower than in actuality.  This is somewhat irrelevant for most occupations, however in the healthcare field this may be important.  

Secondly, there may be some duplications in some population sizes. Emergency physicians are mostly likely counted in the separate categories for healthcare workers in hospitals and those in known as emergency are providers.  

As well, there is some question regarding flexibility of absenteeism within certain industries. In many industries tasks may require full staffing to continue effectively function, while others may be able to have a higher level of absenteeism and maintain functionality.  

In addition there are potential barriers to stratification including legal restrictions and union membership. 

## Potential Essential Services

**Healthcare – 12.6 million workers**
**Emergency Care Providers – 1 million workers**
**Public Safety – 2.3 million workers **
**Utilities – 740,000 workers**
**Transportation – 5 million workers**
**Other community Services – 1.2 million workers**

**Notes:**
In the next several slides I will begin by defining and breaking down potential essential services.  These include 6 broad categories -
 healthcare, ambulatory services, public safety, utilities, transportation, and other community services.

Each service, as you can see, has a fairly large group of workers associated with them.  However, as I hope to show each category can be broken into various industries and occupations.

In addition there may be potential for other categories not listed here including, telecommunications which I will talk about at the end.  

I would like to call attention to the handout which provides the breakdown of the numbers all together – as well as sources for the data.

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## Healthcare workers: Inpatient vs. Outpatient

- _Inpatient_
- Hospitals
- General Medical and Surgical Hospitals
- Psychiatric and Substance Abuse Hospitals
- Specialty Hospitals

- _Outpatient_
- Nursing and Residential Care
- Home Health Care Services
- Offices of Physicians, Dentists, and other Health Practitioners
- Outpatient Care Centers
- Medical and Diagnostic Laboratories

**Notes:**
Given the goal is to decrease morbidly and mortality, an obvious category to begin with is healthcare workers.  These can be broken down immediately into two subdivisions.

Impatient and outpatient settings

The Impatient group is made up of hospitals.

Outpatient settings include nursing and residential care, home health services, outpatient care centers, offices, and laboratories.

The scope of outpatient care is much larger in inpatient care – however this may not be the case when dealing with critical workers.

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## Hospital Workers

**Hospitals **
**5.12 million **
- General Medical and Surgical Hospitals
- 4.7 million
- Psychiatric and Substance Abuse Hospitals
- 240,000
- Specialty Hospitals
- 180,000

**Notes:**
Out of the 12.6 million who are designated employees in the healthcare category, hospital workers make up  5.12 million or 40%.

Within the hospital category – the majority of employees work in general medical and surgical hospitals and a small group work in psychiatric and substance abuse hospitals or other specialty hospitals.

It is within the general medical and surgical hospitals that I will provide suggestion stratifications, as most acute medical care  will occur within their walls.

## Hospitals:General Medical and Surgical

- 3 million healthcare practitioners,
- technical and support occupations
- For Example....
- Registered Nurses  - 1.3 million
- Licensed Practical/Vocational Nurses - 180,000
- Nursing Aides, Orderlies, and Attendants – 360,000
- Doctors – 38,000
- 	Family and General Practitioners, Surgeons, Pediatricians, Obstetricians and Gynecologists, Anesthesiologists, Internists

**Notes:**
At the General Medical and Surgical hospitals 3 million of the 4.7 million employees hold designated healthcare practitioners, technical and support occupations..  

Listed here are some stratified breakdown of occupations within this 3 million.

Over 1.8 million practitioners are nurses...  

And 38,000 are doctors including - 
17,000 family and general practitioners
3,500 surgeons
4,000 pediatricians
2,000 Obstetricians and gynecologists
3, 000 Anesthesiologists
8,020 Internists

Other occupations not listed on the slide included include therapists, Technicians, laboratarians, and dietitians.  The largest of these other groups is various types of technicians which account for almost another half a million. ---including radiologic and cardiologic

## Hospitals:General Medical and Surgical

- For example....
- Medical and Health Managers 170,000 workers
- Office/Administrative Support 790,000 workers
- Food Preparation and Serving workers 140,000
- Education, Training and Library workers 24,000
- Building and Grounds Cleaning and Maintenance 182,000

- Support Services  - 1.7 million

**Notes:**
The other 1.7 million workers in General Medical and Surgical hospitals provide the support services.  

The largest of these employees are the office and administrative staff – with a 1/4 are Secretaries (Medical, Legal, etc)

Other staff workers are library or education based and 10% are building and grounds cleaning and maintence occupations.  While some of these maintenance workers may be tasked with keeping the electricity and heat on, others may be more focused on grounds maintenance.  

Another 10% of the support services are managers, which one would assume would be part of the pandemic responders.  

In general however, these support services do not seem to have direct patient care and may not be critical to the continuance of hospital based care over the period of a pandemic outbreak in a community.

## Outpatient care

**7.4 million workers**
- Nursing and Residential Care 2.8 million
- Home Health Care services 700,000
- Outpatient care centers 400,000
- Offices
- Physicians 2 million
- Dentists 750,000
- Other health practitioners 500,000
- Medical and Diagnostic Laboratories 180,000

**Notes:**
The largest proportion of healthcare workers are found within outpatient settings 

Of these the largest single group is those who provide for the elderly who are in residential or nursing facilities.

The next largest group are in various offices.  

Outpatient important because if they cant handle the sick then the public will flood the hospitals

Dentists- take off teeth cleaning

Can be broken up.

## Does a surge capacity exist?

|   | Licensed | employed | % Surge Capacity |
| --- | --- | --- | --- |
| Registered Nurses | 86,736 | 52,600 | 40% |
| Licensed Practical Nurses | 28,431 | 18,250* | 36% |
| Certified Nurse Aides | 40,157 | 28,040** | 30% |

- Data from Virginia and Maryland Boards of Health and BLS websites

- Virginia

- *Licensed Practical and Licensed Vocational Nurses
- **Nursing Aides, Orderlies, and Attendants

|   | Licensed | employed | % Surge Capacity |
| --- | --- | --- | --- |
| Registered Nurses  | 50,682 | 47,050 | 7% |
| Practical Nurses  | 8,821 | 8,140* | 7% |

- Maryland

**Notes:**
One uncertainty that I did not mention earlier was the that bls data only counts those that are currently working in that designated field.  As was mentioned yesterday - in the healthcare occupations there is potential for surge capacities to help out in healthcare fields during the worst of a pandemic. 

However, there is not one national database has been developed to demonstrate if this potential surge capacity exits nationally–this slide illustrates the surge situation within two different states.

Which, as this slide shows, surge capacities can vary somewhat vary significantly between states.  

Virginia with about 87,000 nurses currently licensed only has 53,000 currently being paid – creating a 40% surge capacity.  This is quite large in contrast to Maryland which has a 7 surge capacity with only 51,000 active licenses and 47,000 currently paid employees. 

The discrepancy between these states and need to get more info and potential for why there are differences.

While some of this data proves promising for extra aides during a pandemic – it is still unsure how one would organize and communicate with these “surge” nurses, leading to a question of how much actual surge capacity is available.

## Emergency Care Providers 

| Total number of workers | ~ 1 million |
| --- | --- |
|  |  |
| Emergency Physicians (in clinical practice) | 32,000 |
| Emergency Nurses | 90,000 |
| EMS Providers (includes EMT basics, EMT intermediates, paramedics, and first responders) | 820,000 |

*Data from American College of Emergency Physicians (acep.org)*

**Notes:**
While emergency care providers certainly could be considered healthcare workers, I choose to separate the 1 million ambulatory workers from them specifically

The separation of ECP from healthcare workers was important as those working in “emergency medicine” will most likely be those to come in first contact with the initial cases of the pandemic virus – thus essential the pandemic responders and should be considered in high priority groups.

Note, that over 80% majority of so called workers come from the EMS providers, while 9% comes from the emergency nurses.

Already there is some overlap between those who are counted as emergency nurses and physicians and those nurses and physicians in hospitals – an issue I mentioned in the uncertainties.  

## Public Safety

| Police | 805,000 |
| --- | --- |
| First-Line Supervisors/ Managers of Police and Deceives | 100,00 |
| Deceives and Criminal Investigators | 90,000 |
| Police and Sheriff's Patrol Officers | 610,000 |
| Fire Fighters | 1.1 million |
| First-Line Supervisors/ Managers of Fire Fighters 
and Prevention Workers | 56,000 |
| Fire Fighters | 270,000 |
| Fire Inspectors and Investigators | 12,000 |
| Volunteer Fire Fighters | 780,000 |
| Correctional Service Officers | 450,000 |
| First-Line Supervisors/ Managers of Correctional Officers | 36,000 |
| Correctional Officers | 414,000 |
| National Guard | 500,000 |

**Notes:**
Public safety accounts for a total 2.3 million workers.  The three major categories that are well known are the police, the fire fighters and the correctional service officers are shown here

However, as a pandemic is a more major health event – I have also provided a total US figure of the national guard who could potentially be called in to assist the public safety workers if needed.  The half a million guardsmen are not included in my total number – Many are stationed in Iraq and may not be able to contribute to a pandemic response that would happen in the near future.

The number of fire-fighters includes almost 800,000 volunteer fire fighters.  While a somewhat different situation than the potential surge capacity nurses, there may be some issue in providing vaccine doses to the volunteer fire fighters.  They may be hard to identify, and an extremely large group.  This is further complicated by the fact that the volunteers firefighters may be the only firefighters employed in rural communities – thus it may become critical to include them in a priority group.

Overall, public safety appears to be a category to consider– as in the event of an influenza pandemic they may be severely impacted by disease and absenteeism.

## Utilities

- Pipeline (including crude oil and natural gas) - 40,000
- Electric Power Generation,
- Transmission and Distribution – 420,000
- Natural Gas Distribution - 112,000
- Water, Sewage and Other Systems - 48,000
- _____________________________________________
- Nuclear Power Reactors Operators - 4,000
- Chemical Plant and Systems Operators - 61,000
- Chemical Equipment Operators and Tenders - 51,000

**740,000 employees**

**Notes:**
Utilities is another broad category which is somewhat vague.  In my research I have found an overall group about three quarters of million workers.

This includes these workers involved in the pipeline transportation of crude oil and natural gas.  AS those who deal with electric power, natural gas, and water and sewage distribution.  These numbers encompass industry wide employees at plants.

I have separately provided data on the operators for both nuclear reactors and chemical power plants since they have different roles and responsibilities

## Transportation

**2.5 million workers**
- Aviation
- 520,000 workers
- Transit and Ground Passenger
- 394,000 workers
- Trucks
- 1.4 million workers
- Rail
- 213,000 workers
- Water
- 54,000 workers

**Notes:**
Transportation with just 2.5 million workers, is a complex category as it encompasses many community services.

The first two sub-categories listed, aviation, transit and ground passengers, deal with moving people.  However, the last three sub-categories – trucks, rail, and water – deal with the moving of materials.

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## Transportation: Trucks

- Examples...
- General and Operational managers 21,320
- First-Line Supervisors/Managers of Transportation and Material-Moving Machine and Vehicle Operators 28,830
- Truck Drivers, Heavy and Tractor-Trailer 715,630
- Laborers and Freight, Stock, and Material Movers, Hand  96,460

- 1.4 million workers

**Notes:**
This slides shows some potential stratification in one of the sub-categories.  Of the 2.5 million transportation workers, a little under half of the workers are involved in the trucking industry.  

Of this 1.4 million truck transportation workers - the managers are 2.4% of the total workers, while the truck drivers of heavy or tracker trailers make up 50% of the total workforce.

However, it will be important to differentiate between those workers who bring food or other essential goods to the public verses those who are employed by producers of non essential items ... including beer.   

## Other Community Services

- Postal Service – 820,000 employees
- Funeral Services – 62,000 employees
- Waste Management –
- 	320,000 employees

**Notes:**
Other community services, with a noted 1.2 million workers, are potentially critical during a pandemic but may not be areas that are thought of right away.

These services include, however are not limited to, the postal service, funeral services and waste management occupations.

The postal service is often mentioned in various lists of critical infrastructure.  Like trucks these workers and items pass through various communities across the country. However the use of the internet and email could potentially supplement the functions for a short period of time.

Funeral services will be critical during with the numerous pandemic associated mortalities.  

Another important, but not oft thought of service, is waste management.  Those who pick up the trash are critical to keep the streets, cities and towns clean and free of various health hazards.  Should this service be paralyzed by lack of a workforce, there could be major implications for public health

## Other Community Services:Government and Judiciary

**Government Legislators: 64,570**
- Local Government is 61,120
**Judges and Court Personnel: 73,000**
- Judges, Magistrate Judges & Magistrates 25,000
- Administrative Law Judges, Adjudicators, and Hearing Officers 15,000
- Court Reporters 16,000
- Bailiffs 17,000

**Notes:**
Additional community services include legislators and judges

I have not counted these workers in my broad categories – but mention them here to provide the working group with a sense of scale.

Local government, as shown on the slide, provides the largest number of government workers.  Some of these workers especially at the state level - will need to make critical decisions pandemic.

## Telecommunications

**1.1 million workers**
- For example
- 130,000 Customer Service Representatives
- 25,000 Telemarketers
- 30,000 Telephone Operators
- 140,000 Telecommunications Equipment Installers and Repairers, Except Line Installers

**Notes:**
The category of telecommunications was also not on my initial list of potential essential services, however it was on both the general list developed by the White House and on the CRS list.

Note this category seems somewhat large with 1.1 million workers, but there is potential for a varied stratification within.  

## Additional Data Needed to Guide Strategy

- The number of volunteers and workers with emergency/aid organizations like FEMA and Red Cross?
- What is the minimum workforce level necessary for certain critical infrastructures to continue to function?
- What are the potential surge capacities?

**Notes:**

The number volunteers and workers with emergency/aid organizations like FEMA and Red Cross? 

What is the minimum workforce level necessary for certain critical infrastructures to continue to function?
How many people are required to sustain this service for 6 -8 weeks?

What about the potential surge capacities:
for healthcare occupations, especially nurses and doctors?
For public service employees?

## Summary and Conclusion

- No concrete definition of critical infrastructures
- Without stratification, the groups are broad and large
- There is the potential for stratification

**Notes:**
There is no single definition for essential services or critical infrastructures in the United States  Rather there is a set of 10 -15 broad categories that re often mentioned.

If all the services and there associated employees described in this presentation without any stratification were suggested for a priority groups that would be about 25 million workers or 8% of the total US population 

There is the potential for stratification within designated categories – potential barriers may limit the feasibility of this approach.

Between now and June should continue to work on honing these numbers.

Further study must be done