R E P O R T T O T H E P R E S I D E N T

O N U. S . P R E PA R AT I O N S F O R

2 0 0 9 -H 1 N1 I N F L U E N Z A

Executive Office of the President

President’s Council of Advisors on

Science and Technology

August 7, 2009
ii 

About the President’s Council of Advisors on 

Science and Technology

The President’s Council of Advisors on Science and Technology (PCAST) is an advisory group of the 

nation’s leading scientists and engineers, appointed by the President to augment the science and technology advice available to him from inside the White House and from cabinet departments and other 

Federal agencies. PCAST is consulted about and often makes policy recommendations concerning the 

full range of issues where understandings from the domains of science, technology, and innovation 

bear potentially on the policy choices before the President. PCAST is administered by the White House 

Office of Science and Technology Policy (OSTP).

For more information about PCAST, see www.ostp.gov/cs/pcast.
iiiii

The President’s Council of Advisors on 

Science and Technology

Co-Chairs

John P. Holdren

Assistant to the President for 

Science and Technology

Director, Office of Science 

and Technology Policy 

Eric Lander

President and Director

Broad Institute of Harvard

and MIT

Harold Varmus

President

Memorial Sloan-Kettering 

Cancer Center 

Members

Rosina Bierbaum Mario Molina 

Dean, School of Natural Resources Professor, Chemistry and Biochemistry 

and Environment University of California, San Diego 

University of Michigan Professor, Center for Atmospheric Sciences at the 

Christine Cassel Scripps Institution of Oceanography 

President and CEO Director, Mario Molina Center for Energy and 

American Board of Internal Medicine Environment in Mexico City

Christopher Chyba 

Professor, Astrophysical Sciences and 

International Affairs 

Ernest J. Moniz 

Cecil and Ida Green Professor of Physics and 

Engineering Systems 

Director, Program on Science and Global Security 

Princeton University 

Director, MIT’s Energy Initiative 

Massachusetts Institute of Technology

S. James Gates, Jr. 

John S. Toll Professor of Physics 

Director, Center for String and Particle Theory 

Craig Mundie 

Chief Research and Strategy Officer 

Microsoft Corporation

University of Maryland, College Park Ed Penhoet 

Shirley Ann Jackson 

President 

Director, Alta Partners 

Chairman of the Board, Immune Design 

Rensselaer Polytechnic Institute Chairman of the Board, Metabolex

Richard C. Levin William Press 

President Raymer Professor in Computer Science and 

Yale University

Chad Mirkin 

Integrative Biology 

University of Texas at Austin

Rathmann Professor, Chemistry, Materials 

Science and Engineering, Chemical and 

Biological Engineering, Biomedical Engineering, 

Maxine Savitz 

Vice President 

National Academy of Engineering

and Medicine Barbara Schaal 

Director, International Institute of Chilton Professor of Biology 

Nanotechnology Washington University, St. Louis 

Northwestern University Vice President, National Academy of Sciences 
iv 

Eric Schmidt Ahmed Zewail 

Chairman and CEO Linus Pauling Professor of Chemistry and Physics 

Google, Inc. Director, Physical Biology Center 

Daniel Schrag 

Sturgis Hooper Professor of Geology 

Professor, Environmental Science and 

Professor, Chemistry and Physics 

Director, Physical Biology Center 

California Institute of Technology 

Engineering 

Director, Harvard University-wide Center for Staff

Environment Deborah Stine 

Harvard University Executive Director, PCAST

David E. Shaw 

Chief Scientist, D. E. Shaw Research 

Senior Research Fellow, Center for 

Mary Maxon

Deputy Executive Director, PCAST

Computational Biology and Bioinformatics, 

Columbia University
ivv

EXECUTIVE OFFICE OF THE PRESIDENT

PRESIDENT’S COUNCIL OF ADVISORS ON SCIENCE AND TECHNOLOGY

WASHINGTON, D.C. 20502

August 7, 2009

President Barack Obama

The White House

Washington, DC 20502

Dear Mr. President:

We are pleased to transmit to you the report, U.S. Preparations For 2009-H1N1 Influenza, prepared by your 

Council of Advisors on Science and Technology (PCAST). This report examines the strategic issues raised by 

the likely resurgence this fall of the novel influenza virus called 2009-H1N1. 

The report reviews the full range of response options for minimizing negative impacts from a fall 2009-H1N1 

epidemic and provides an integrated set of recommendations about how to think about hard issues and 

key policy decisions regarding the epidemic. The nation’s response to the threat of a fall epidemic involves 

decisions by government on a wide range of issues --- medical, scientific, social, and financial. We have tried 

to assess these, keeping in mind your interest in having the best available scientific insights and perspectives 

to inform your thinking about the nation’s response to the continued spread of this new virus. 

To provide a solid scientific basis for our recommendations, the Council assembled a PCAST Working Group 

of non-governmental experts, including one other member of PCAST, from a number of relevant fields (virology, public health, pediatrics, medicine, epidemiology, immunology, and others). On July 16-17, the Working 

Group met with government officials and others to discuss various aspects of the 2009-H1N1 pandemic, 

and then developed an in-depth report based on its own knowledge, the information provided during the 

meeting, and additional consultations with government, academic, and industry experts. The results of that 

report were presented to PCAST at its meeting on August 6-7, and the Council then approved an Executive 

Report of findings and recommendations for transmittal to you along with the in-depth Working Group 

report to PCAST.

 The Working Group report discusses the complexities posed by influenza epidemics, and the uncertainties 

inherent in an epidemic that is still in progress. The report identifies the key decisions and actions to be 

taken, while recognizing that many decisions (for example, relating to use of vaccines and to school closures) 

cannot be resolved now but will need to be made rapidly as the epidemic unfolds. In these instances, the 

Working Group report instead offers guidance about how decisions should be made over the coming weeks 

and months.

PCAST hopes that its Executive Report and the full Working Group report help lay a foundation for the medical, scientific, social, and financial decisions you and others in the Federal Government must make this fall. 

We are grateful for the opportunity to serve you and the country in this way.

Sincerely,

John P. Holdren 

Co-Chair

Eric Lander 

Co-Chair

Harold Varmus 

Co-Chair

vii

The President’s Council of Advisors on 

Science and Technology

Executive Report

U.S. Preparations for the 2009-H1N1 Influenza

In April 2009, a novel influenza A (H1N1) virus (2009-H1N1) appeared in Mexico, causing pneumonias 

and 59 deaths in Mexico City alone. The virus soon spread to the United States and to other continents. 

Within two months, the World Health organization (WHO) declared that the viral outbreak met the 

criteria of a level 6 pandemic. Although initial concerns of an extremely high fatality rate have receded, 

the expected resurgence of 2009-H1N1 in the Fall poses a serious health threat to the United States. 

Since the initial report of the outbreak, the Federal Government, through various departments, agencies, and offices, has been actively studying the course of events, responding to them, and planning 

for a resurgence of the pandemic this fall. In late June, President Obama requested that his Council of 

Advisors on Science and Technology (PCAST) undertake an evaluation of the 2009-H1N1epidemic and 

the nation’s response to a probable recurrence. 

In this Executive Report, PCAST assesses the emerging Federal response to a second wave, identifies critical questions and gaps in this response, and suggests additional opportunities for mitigation. PCAST’s 

observations, conclusions, and recommendations presented here are based on the analysis of its 2009-

H1N1 Working Group, consisting of 3 PCAST members and a further 11 non-governmental experts in 

virology, public health, pediatrics, medicine, epidemiology, immunology, and other relevant scientific 

fields. The Working Group’s deliberations were informed by discussions with government officials and 

others on various aspects of the 2009-H1N1 pandemic.

2009-H1N1 in Historical Context

Based on the history of influenza pandemics over the past hundred years, PCAST places the current 

outbreak somewhere between the two extremes that have informed public opinion about influenza.  On 

the one hand, the 2009-H1N1 virus does not thus far seem to show the virulence associated with the 

devastating pandemic of 1918-19; moreover, medical science now has many potent tools at our disposal 

to mitigate an influenza pandemic in ways that were not possible ninety years ago. On the other hand, 

the 2009-H1N1 virus is a serious threat to our nation and the world, unlike the “swine flu” episode in 

1976 that led to the vaccination of over 40 million Americans in the absence of any spread of the virus 

beyond an initial four cases at a single Army base. 
viii 

The Current Situation and a Plausible Scenario

Indeed, the 2009-H1N1 influenza is already responsible for significant morbidity and mortality worldwide — from its appearance in the spring, its continued circulation in the U.S. this summer, and its spread 

through many countries in the Southern Hemisphere during their winter season. While the precise 

impact of the fall resurgence of 2009-H1N1 influenza is impossible to predict, a plausible scenario is 

that the epidemic could: 

• produce infection of 30–50% of the U.S. population this fall and winter, with symptoms 

in approximately 20–40% of the population (60–120 million people), more than half of whom 

would seek medical attention. 

• lead to as many as 1.8 million U.S. hospital admissions during the epidemic, with up to 

300,000 patients requiring care in intensive care units (ICUs). Importantly, these very ill patients 

could occupy 50–100 percent of all ICU beds in affected regions of the country at the peak of 

the epidemic and could place enormous stress on ICU units, which normally operate close to 

capacity.

• cause between 30,000 and 90,000 deaths in the United States, concentrated among children and young adults. In contrast, the 30,000–40,000 annual deaths typically associated with 

seasonal flu in the United States occur mainly among people over 65. As a result, 2009-H1N1 

would lead to many more years of life lost. 

• pose especially high risks for individuals with certain pre-existing conditions, including 

pregnant women and patients with neurological disorders or respiratory impairment, diabetes, 

or severe obesity and possibly for certain populations, such as Native Americans. 

There is an important issue with respect to timing:

• The fall resurgence may well occur as early as September, with the beginning of the school term, 

and the peak infection may occur in mid-October. 

• But significant availability of the 2009-H1N1 vaccine is currently projected to begin only in midOctober, with several additional weeks required until vaccinated individuals develop protective 

immunity. 

This potential mismatch in timing could significantly diminish the usefulness of vaccination for mitigating the epidemic and could place many at risk of serious disease. 

PCAST emphasizes that this is a planning scenario, not a prediction. But the scenario illustrates that an 

H1N1 resurgence could cause serious disruption of social and medical capacities in our country in the 

coming months. The circumstances underscore the importance of:

• ensuring that the nation’s complex and distributed healthcare systems are prepared to deal 

with the potential surge in demand, especially with respect to critical care.

• ensuring that all feasible steps are taking to protect the most vulnerable populations.
viii ix

Preparations for the Pandemic: Observations and Recommendations

Preparation for the predicted fall resurgence has been constrained by time and materials: the virus 

appeared in late spring and its resurgence is anticipated in early fall, while vaccine production currently 

requires at least 6 months. On the other hand, the development of preparedness plans was greatly 

stimulated by the recognition a few years ago of the threat posed by a highly lethal avian influenza; 

preparations developed for this potential threat facilitated the response to the current, quite different 

strain of influenza virus. 

PCAST is impressed by the efforts underway across our government—including the breadth and depth 

of thinking, energy being devoted, and awareness of potential pitfalls. The response is probably the 

best effort ever mounted against a pandemic, reflecting past preparedness efforts and the quality and 

commitment of the people involved. 

Still, PCAST found some aspects of the decision-making and preparation processes that we believe could 

be improved, even in the short time remaining before the fall. These findings and recommendations 

are discussed at considerable length in its Working Group report. 

Reflecting the rapid pace of response in the Federal Government, some of the suggested actions are 

already being considered, planned, or initiated by relevant agencies. In these cases, our recommendations are intended to provide support and additional focus to such efforts. Our recommendations fall 

into seven major categories:

1. Coordination. We suggest that coordination of the decision-makers could be more effectively 

orchestrated if a single person in the White House were assigned the responsibilities of clarifying 

decision-making authorities and processes, ascertaining that all important issues are resolved 

in a timely fashion, and reporting to you about actions to be taken.    

2. Scenarios. We believe that preparations could be strengthened if the Federal Government 

developed and disseminated a few specific planning scenarios that Federal, state, local, and 

private entities could use to assess their capacities and plans for medical and non-medical 

interventions.

3. Surveillance. The ability to respond to the epidemic will depend on reliable and timely information about its course at the national, regional, and local level. We believe there are opportunities 

to make important upgrades to existing national surveillance systems in time for the expected 

fall resurgence. 

4. Response. There are four critical pillars of a mitigation effort: vaccines, anti-viral drugs, medical 

care, and non-medical interventions that diminish virus spread. In particular, we focus on decisions that could reduce instances of severe disease and death by accelerating the delivery and 

use of vaccines; developing integrated plans to protect especially vulnerable populations; and 

ensuring access to intensive care facilities.

5. Barriers. Some legal, social, and financial barriers exist that may reduce compliance with some 

recommended measures for mitigation and we propose ways that the Federal Government and 

others could work to overcome such barriers.
x 

6. Communication. Communication plans for relaying to the states, health workers, and the general public the government’s recommended actions for mitigation are in some cases inadequate 

and should be strengthened.   

7. Future Preparedness. The current outbreak highlights gaps in our capacity to combat epidemics caused by influenza and other agents. We outline steps that can be taken in the next few 

years, including improving vaccine production and design, anti-viral drug development, and 

health surveillance systems.      

Action Items

In the report, PCAST makes a number of recommendations about specific aspects of the national preparations. Several are of special importance and warrant consideration for immediate or near-term action. 

Specifically, PCAST proposes that the President:

i. Designate a senior member of the White House staff, preferably the President’s Homeland 

Security Advisor, to be responsible for coordination of all major decision-making about the 

2009-H1N1 pandemic.

and that the relevant Federal agencies:

ii. Produce and disseminate several planning scenarios and work with Federal, state, local, and 

private entities to anticipate potential ‘surge’ demand (especially for critical care, e.g., ICUs 

and respirators) and develop logistical plans for such contingencies. 

iii. Expand CDC’s existing surveillance systems to track information about influenza-like illnesses 

from an integrated network of sites, including data from population sampling, emergency 

rooms, and hospitals, with emphasis on critical care units.

iv. Accelerate production of an initial quantity of finished vaccine as early as mid-September, 

to allow vaccination of up to 40 million people, with emphasis on the most vulnerable age and 

disease groups, as soon as initial data are available on safety and immunogenicity. This decision 

would need to be made almost immediately.

v. Develop focused plans to identify, reach, and protect members of the most vulnerable 

groups and their health care providers in time to make use of the protective methods at the 

nation’s disposal.

vi. Prepare a communication plan that would deliver appropriate and effective messages about 

the range of available medical and non-medical interventions, including especially vaccination, 

to the public in a timely fashion.

vii. Organize a multi-agency effort, under the direction of the National Security Council, to 

improve the design and production of influenza vaccines, so that effective vaccination 

programs can begin more promptly in the course of future epidemics caused by new strains 

of influenza virus.
xix

Caveats About the Report

The urgency of an ongoing pandemic, one that is likely to worsen in the next month or two, has compelled PCAST and its Working Group to perform its tasks rapidly. Under these circumstances, some of 

the information gathered by the Working Group for this report (such as the schedule for availability of 

vaccines and clinical data on infected individuals) must be viewed as provisional and subject to change.

Given the complexity of the situation and the many activities underway to deal with it, PCAST recognizes that the Working Group could not analyze the problem from every perspective and has doubtless failed to acknowledge all of the useful work that is already being done by members of the Obama 

Administration. In particular, the report does not rigorously address the measures that might need to be 

taken in the unlikely event that the pandemic proves to be much more severe than we currently envision. 

Next Steps

PCAST hopes that its report and that of its Working Group help guide the urgent work that the 

Administration has undertaken to mitigate the effects of the 2009-H1N1 pandemic. PCAST and its 

Working Group are prepared to respond to additional questions that members of the Administration 

might have in the coming months. 

xiii

The President’s Council of Advisors on 

Science and Technology

2009-H1N1

Working Group Report 

xv

PCAST

2009–H1N1 Working Group

Co-Chairs

Eric Lander

President and Director

Broad Institute of Harvard and MIT

Harold Varmus

President

Memorial Sloan-Kettering Cancer Center 

Members

Ann M. Arvin 

Lucile Salter Packard Professor of Pediatrics and 

Professor of Microbiology & Immunology

Vice Provost and Dean of Research

Stanford University

Emilio A. Emini 

Executive Vice President

Vaccines Research and Development

Wyeth Pharmaceuticals

Harvey V. Fineberg

President

Institute of Medicine

Don Ganem

Investigator, Howard Hughes Medical Institute

Professor of Microbiology and Medicine

University of California San Francisco

Marcelle Layton

Assistant Commissioner

Communical Disease Program

New York City Department of Health 

Marc Lipsitch

Professor of Epidemiology

Director, Center for Communicable

Disease Dynamics

Harvard School of Public Health

Arnold S. Monto

Professor of Epidemiology

University of Michigan School of Public Health

Peter Palese

Horace W. Goldsmith Professor

Chair, Department of Microbiology

Professor, Department of Medicine

Mount Sinai School of Medicine

Ed Penhoet

Director, Alta Partners

Chairman of the Board, Immune Design 

Chairman of the Board, Metabolex

Rajeev Venkayya

Director, Global Health Delivery

Bill & Melinda Gates Foundation

Robert G. Webster 

Rose Marie Thomas Chair in Virology

Department of Infectious Diseases

St. Jude Children’s Research Hospital

Richard J. Whitley

Distinguished Professor

Loeb Scholar

Professor of Pediatrics, Microbiology, Medicine 

and Neurosurgery

University of Alabama at Birmigham

Staff

Deborah Stine

Executive Director, PCAST

Peter Emanuel

Assistant Director, Chemical & Biological 

Countermeasures, OSTP

xvii

Table of Contents

I. Introduction and Charge .................................................................................................1

II. The U.S. Experience with Influenza Over the Last Century .........................................7

 Introduction ............................................................................................................................................... 7

 1918-19 Influenza Pandemic ................................................................................................................ 8

 1976 Swine Flu “Fiasco” ........................................................................................................................... 8

 Other Pandemics ...................................................................................................................................... 9

 Avian Flu ....................................................................................................................................................10

 Lessons for Fall 2009 ..............................................................................................................................11

III. Anticipating the Return of 2009-H1N1: Envisioning Scenarios .............................. 13

 Introduction .............................................................................................................................................13

 The Need for Concrete Scenarios for Response Planning .......................................................15

IV. Ensuring Adequate Data for Decision Making: Surveillance Systems ................... 21

 Introduction .............................................................................................................................................21

 Existing Data Streams ...........................................................................................................................22

 Shortcomings of Current Data Streams .........................................................................................23

 Recommendations .................................................................................................................................24

 Conclusions ..............................................................................................................................................29

V. Responding to the Pandemic ..................................................................................... 31

 Introduction .............................................................................................................................................31

 Vaccines and Antiviral Drugs ..............................................................................................................34

 Medical Response ..................................................................................................................................39

 Non-medical Mitigation Measures ...................................................................................................41

 International Considerations Presented by the Pandemic .....................................................42

 An Improbable Scenario Requiring More Stringent Non-Medical Measures ...................44
xviii 

VI. Lowering Financial and Regulatory Barriers to Effective Response ...................... 47

Introduction .............................................................................................................................................47

Emergency Funding for Federal, State and Local Actions .......................................................48

Lowering Barriers to Hospital Care ...................................................................................................48

Non-medical Mitigation Activities ...................................................................................................50

VII. Improving Communications .................................................................................... 53

Introduction .............................................................................................................................................53

Communication with State and Local Health Departments ...................................................54

Communication with Health Care Providers ................................................................................55

Communication with the General Public ......................................................................................55

VIII. Planning for More Effective Future Strategies Against Influenza ........................ 59

Accelerate Speed and Increase Yield and Effectiveness of Vaccine Production ..............60

Facilitate Development of Additional Antiviral Drugs ..............................................................61

Facilitate Development of Rapid Point-of-Care Diagnostics ..................................................62

Improve Medical Surveillance ............................................................................................................62

Enhance Animal Surveillance Measures.........................................................................................64

References ........................................................................................................................ 65

Acknowledgements ......................................................................................................... 67
xviii 1

I. Introduction and Charge

CHAPTER SUMMARY

In April 2009, a novel influenza A/H1N1 virus (2009-H1N1) appeared in Mexico, causing pneumonias and 

59 deaths in Mexico City alone. The virus soon spread to the United States and to other continents. Within 

two months, the World Health Organization (WHO) declared that the viral outbreak met the criteria of a 

level 6 pandemic. As of August 2009, the virus continues to spread in the United States and elsewhere.

Although initial concerns of an extremely high fatality rate have receded, the expected resurgence of 

2009-H1N1 in the fall poses a serious health threat to the United States. Further, although most cases are 

mild, serious complications arise in some individuals, especially those with underlying medical complications such as pregnant women and those with neurological conditions. Under some models, seriously 

ill influenza patients could require 50 to 100 percent of intensive care unit (ICU) beds at the epidemic’s 

peak, stressing the medical and public health systems to the point of overwhelming some hospitals, 

and could cause from 30,000 to 90,000 deaths, concentrated among children and young adults. 

Since the initial report of the outbreak, the Federal Government, through various departments, agencies and offices, has been actively studying the course of events, responding to them, and planning for 

a resurgence of the pandemic this fall. 

Under the aegis of the President’s Council of Advisors on Science and Technology (PCAST), a 

Working Group on 2009-H1N1 influenza was formed in response to the President’s request for an 

expert external review of the epidemic and the nation’s response to an anticipated resurgence in 

the fall of 2009. Overall, the Working Group was deeply impressed by the efforts underway across the 

Federal Government—including the breadth of issues being anticipated and addressed, the depth of 

thinking, the overall level of energy being devoted, and the awareness of potential pitfalls. 

The Working Group did identify some potential ways to strengthen the response, and it has provided 

recommendations. In many cases, the relevant agencies are already aware of these opportunities and 

are taking steps in these directions. The Working Group’s recommendations are intended to provide 

support for and additional focus to such efforts. 

On April 15, 2009, the first case of infection with novel influenza A (H1N1) virus (“swine flu,” hereafter 

“2009-H1N1”) was confirmed in the United States. In March and April, Mexico had experienced an 

outbreak of unexplained pneumonia, with hundreds of reported cases and 59 deaths in Mexico City 

alone. It soon became clear that 2009-H1N1 was associated with the Mexican pneumonia outbreak and 

that the virus was spreading within North America; it was soon detected in many other countries. On 

April 29, the World Health Organization (WHO) raised its influenza pandemic alert level to Phase 5, just 

short of declaring that a global influenza pandemic was underway. In those early days of the outbreak, 

severe cases were the most readily counted because they were usually hospitalized. As of April 29, 8 of 

148 individuals with confirmed 2009-H1N1 infection worldwide had died (5.4 percent), initially raising 
2 

REP O RT TO T H E P RE S I D EN T O N U. S . P REPA RAT I O N S F O R 2009 - H 1 N 1 I N F LU EN Z A

the possibility that the virus was extremely virulent, comparable to or even worse than the viral strain 

that caused the 1918-19 influenza pandemic. But uncertainty about the number of unconfirmed cases—

especially infected individuals with mild or no symptoms—made it impossible to assess severity accurately. In fact, subsequent data revealed that the case-fatality ratio was actually much lower—although 

still a cause for serious public concern.

As more cases were confirmed around the United States in late April and early May, the Centers for 

Disease Control and Prevention (CDC), in coordination with state and local public health departments, 

increased surveillance efforts and issued interim guidance to control the virus’s spread. Intensified surveillance rapidly clarified that many mild cases had been missed in the early phases of the epidemic, 

easing concerns that the new virus was extremely virulent, but still leaving uncertain the overall spectrum of illness and incidence. Media coverage was intense. Advisories warned against travel to Mexico 

and soon against travel to the United States. In regions of the United States with reported cases, some 

schools were closed just days or weeks short of the end of the school year. By June 11, the virus had 

spread to 74 countries and all continents but Antarctica, and WHO declared the outbreak an influenza 

pandemic (Phase 6) on the basis of its geographic spread. As summer began and schools adjourned, 

travel advisories were rescinded and media and public attention waned. 

Although influenza usually becomes almost undetectable during the summer, transmission of 2009-

H1N1 virus continues in the United States (albeit at a lower level) and in other Northern Hemisphere 

countries, notably the United Kingdom. While monitoring of clinical outcomes to date suggests that 

most 2009-H1N1 infections are mild, there have been notable reports of people with severe illnesses, 

many of them requiring intensive hospital care, and deaths, predominantly among relatively young 

people. Certain groups—such as the First Nation people in rural Manitoba, Canada—appear to have 

been particularly hard hit. And even mild outbreaks have in many cases been socially disruptive.

The Southern Hemisphere’s regular influenza season is now underway, and 2009-H1N1 has spread 

rapidly within Argentina, Australia, Chile, and New Zealand, appearing to eclipse infection with the 

expected seasonal influenza virus and stressing the medical and public health systems to the point of 

overwhelming some hospitals and filling some intensive care units (ICUs) to capacity. For example, in 

Australia, 11 percent of over 20,000 confirmed cases of 2009-H1N1 influenza have been hospitalized. 

And of the 410 cases now hospitalized, 110 are in ICUs. 

As the influenza season in the Northern Hemisphere approaches and schools reopen, the pandemic 

is expected to accelerate, with the potential for significant health consequences in the United States, 

Europe, and other regions. Based on past pandemics, this acceleration is likely to occur before the normal 

(i.e., seasonal) influenza season, starting in September and peaking in October. In a typical (non-pandemic) season, influenza becomes prevalent in winter and causes an estimated 30,000 to 40,000 deaths 

in the United States, with about 90 percent of those deaths occurring in patients ages 65 years or older. 

A plausible scenario, given current data (and described in more detail in Chapter 3), is that 2009-H1N1 

influenza could place enormous stress on U.S. medical and public health systems, as well as on an 

American economy already under stress. It could cause anywhere from 30,000 to 90,000 deaths in the 

United States in fall 2009, mainly among younger adults and children (unlike the situation with seasonal 

influenza, which causes death mainly in the elderly) and those with certain pre-existing conditions. 
23

I . Introduction and Charge

Moreover, as much as 50 to 100 percent of ICU capacity in the United States could be required solely 

to treat 2009-H1N1 patients at the peak caseload, in hospital units that typically run at 80 percent of 

capacity. Such stress on ICUs and emergency departments would cause severe disruption of hospital 

function, necessitating marked curtailment of all but the most urgent admissions and surgeries. 

These estimates assume that the clinical severity of infection with the 2009-H1N1 virus will be the 

same this fall as it was in the spring. Even so, the estimates of serious disease and death could be off 

by several-fold because the total number of infected persons to date—and proportion of severe infections—remain extremely uncertain. In addition, there is a possibility, difficult to quantify, that severity 

could change, either up or down, as the virus evolves (see Box 1A). Various public health measures can 

be taken to attempt to mitigate the pandemic. It is clear, however, that many of the decisions about 

whether and when to employ these mitigation measures will have to be made rapidly, before many 

uncertainties are resolved. 

Since the outbreak began in late April 2009, the Federal Government—through various departments, 

agencies, and offices, especially the Department of Health and Human Services (DHHS), the Department 

of Homeland Security (DHS), and components of the White House staff—has been actively studying 

the course of events, responding to them, and planning for a resurgence of the pandemic this fall. As 

a consequence of concerns since 2004 about the possibility of a pandemic involving the highly pathogenic avian (H5N1) influenza virus, the United States has been especially well positioned to organize a 

response to the 2009-H1N1 pandemic. Preparedness activities have included: 

• releasing antiviral drugs from the national stockpile; 

• contracting with several pharmaceutical companies to develop and manufacture vaccines 

against 2009-H1N1 as quickly as possible; 

• removing restrictions on the use of unapproved medical treatments and tests under public 

health emergency conditions; 

• increasing surveillance at multiple levels (e.g., virus identification and characterization; data on 

outpatients, hospitalized patients, and mortality);

• convening a summit of states, tribes, and territories to plan responses to the epidemic;

• overseeing congressional passage of an emergency funding measure (described in greater detail 

below) for a variety of uses, including purchase of vaccines and drugs, support of non-Federal 

public health initiatives, and additional needs at CDC and the Food and Drug Administration 

(FDA); 

• providing funds to state and local public health offices and health care systems to step up their 

preparedness efforts;

• undertaking public communication efforts; and

• issuing guidance for the general public, clinicians, laboratories, pregnant women, schools, and 

communities.
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REP O RT TO T H E P RE S I D EN T O N U. S . P REPA RAT I O N S F O R 2009 - H 1 N 1 I N F LU EN Z A

BOX 1A: THE 2009-H1N1 INFLUENZA VIRUS 

In the few months since its first isolation, the 2009-H1N1 influenza virus has been quickly subjected to 

intense study of its molecular properties, illustrating the capacities of modern virology and genetics. 

Like other influenza viruses, the genes of the 2009-H1N1 virus are arrayed on eight segments of 

single-stranded RNA that, in the aggregate, constitute the viral genome. Genomes of these viruses are 

inherently unstable, with frequent changes in each RNA segment accounting for genetic “drift,” and 

reassortment of segments when cells are co-infected with two or more viruses, accounting for more 

dramatic genetic “shift.” The 2009-H1N1 virus is a “triple reassortant,” as it contains RNA segments from 

avian-, human-, and swine-origin viruses. The majority of RNA segments, including the segment coding for the hemagglutinin protein, come from swine-origin viruses. Hemagglutinin mediates immune 

protection against influenza viruses, is notable for rapid changes in its composition, and forms the basis 

for the annual reformulation of influenza virus vaccines. It is also one of the two major proteins on the 

viral surface, hemagglutinin (H) and the neuraminidase (N), that determine the subtype classification 

of type A influenza viruses as ‘H1N1,’ ‘H3N2,’ etc. 

Of all of the H1 subtype hemagglutinins in viruses isolated from humans in the 20th and 21st centuries, 

the hemagglutinin of the 2009-H1N1 appears to be genetically most similar to those of the 1918-19 

H1N1 pandemic virus and of the H1N1 virus of swine-origin that caused the limited human outbreak at 

an army base in New Jersey in 1976. It is less closely related to the hemagglutin in other strains of H1N1 

virus responsible for seasonal influenza in recent years. 

The relatively low virulence of 2009-H1N1 virus may be attributed, in part, to the absence of a major 

determinant of virus virulence—the expression of a protein called PB1-F2 that is known to cause cell 

death and was found in viruses responsible for the major influenza pandemics of 1918-19 (H1N1), 1957 

(H2N2), and 1968 (H3N2). 

The 2009-H1N1 virus is atypical in some ways, including its transmissibility during warm seasons and its 

apparent infection of the gastrointestinal tract in approximately one-third of serious cases. These and 

other properties of the new virus will be subject to more intensive study and comparisons with earlier 

isolates in the near future in order to understand its mode of pathogenesis, virulence, transmission rate, 

and immunogenic properties. 

On June 24, 2009, President Obama signed into law the Supplemental Appropriations Act, 2009 (Public 

Law 111-32). Within the Act, Congress appropriated $7.65 billion to DHHS to prepare for the 2009-H1N1 

influenza outbreak, including a $5.8 billion contingent appropriation. After spending an initial $1.85 

billion on procurement of vaccines, expansion of surveillance activities, and preparation for a possible 

immunization campaign, on July 16 the President designated an additional $1.825 billion as emergency 

funds to support additional measures related to influenza vaccination efforts, leaving $3.975 billion in 

reserve as contingency funds.

In early July, President Obama asked his Council of Advisors on Science and Technology (PCAST) to 

provide an expert external assessment of the epidemic and to offer guidance about the nation’s plans 
45

I . Introduction and Charge

to respond to its likely resurgence in the fall. PCAST established a Working Group on 2009-H1N1, cochaired by Drs. Harold Varmus and Eric Lander, consisting of experts in the fields of virology, public 

health, and medicine, with experience in the academic, governmental, philanthropic, and industrial 

sectors. 

PCAST’s charge was several-fold:

• to identify critical questions for which timely answers are needed by decision-makers; 

• to survey and assess preparations currently underway in the Federal Government; 

• to highlight major challenges and gaps; and

• to make specific recommendations concerning additional opportunities to help mitigate a 

serious 2009-H1N1 flu pandemic this fall. 

The Working Group worked on an accelerated schedule during the month of July 2009 to respond 

to its charge. It met July 16–17, 2009, in Washington, D.C., to hear presentations from Federal agency 

leaders, epidemiologists, state and international public health officials, vaccine and drug developers, 

and experts in social mitigation strategies, including public information and marketing. In addition, 

interviews were conducted at other times with government officials and experts on various aspects of 

the influenza epidemic.

The Working Group’s goal was not to predict the severity of any next wave of the epidemic or to prescribe specific responses. Instead, the goal was to provide guidance to support and strengthen the many 

efforts already underway to prepare the country for the expected resurgence of 2009-H1N1 in the fall. 

MAIN CONCLUSION

Overall, the Working Group was deeply impressed by the efforts underway across the Federal 

Government—including the breadth of issues being anticipated and addressed, the depth of thinking, the overall level of energy being devoted, and the awareness of potential pitfalls. The response 

is probably the best effort ever mounted against a pandemic, reflecting both past preparedness 

efforts and the quality and commitment of the people involved. 

The Working Group did identify some potential ways to strengthen the response. In many cases, 

the relevant agencies are already aware of these opportunities and are taking steps to address 

them, while recognizing that time is short and that some goals may not be achievable. The Working 

Group’s recommendations are intended to provide support for and additional focus to such efforts. 

To present its observations in a logical narrative, this report is organized in chapters focused on the 

Nation’s prior experience with influenza; scenario planning; surveillance of the current epidemic; 

decision-making about measures to mitigate the epidemic; lowering legal and economic barriers to 

response; communications; and steps to strengthen the response to future epidemics. In addition to 

providing specific guidance to relevant agencies, the report aims to provide sufficient background to 

be readable by members of the general public, who are understandably concerned about the current 

outbreak and the Nation’s response. 

7

II. The U.S. Experience with Influenza Over 

the Last Century

CHAPTER SUMMARY

Seasonal influenza epidemics occur every winter and are estimated to cause some 30,000-40,000 deaths 

in the United States alone, primarily in young children, the elderly, and others with underlying medical 

conditions. Several times in the last century new subtypes of influenza have swept through the human 

population—which has little or no immunity to them—and caused global pandemics. 

Preparation for influenza pandemics is shaped in large part by the experiences of the pandemic of 

1918-19, when 40-100 million people perished worldwide, and the swine flu “fiasco” of 1976, when 45 

million Americans were vaccinated for a virus that never spread beyond a tiny cluster. In 2005, concerns 

that the highly lethal avian H5N1 virus could precipitate an influenza pandemic led to significant investments and improvements in Federal preparedness, although significant transmission among humans 

has fortunately not occurred to date. Based on available information, the influenza pandemics most 

analogous to the current 2009-H1N1 outbreak may be those of 1957 and 1968, in which the death rates 

were two- to four-fold higher than normal.

The main lessons from these experiences are that vigorous preparation and action can save lives, but 

that it is critical to maintain situational awareness and flexibility as a pandemic unfolds.

Introduction

Seasonal influenza epidemics occur every winter, peaking between December and February, and are 

estimated to cause 30,000 to 40,000 deaths in the United States alone, primarily in children under age 

2 and adults over age 65, and more than 250,000 hospitalizations per year. The economic impact of 

seasonal influenza is estimated at $37 billion each year. 

Since 1977, two influenza A virus subtypes and one influenza B subtype have circulated each winter. 

Seasonal influenza viruses undergo frequent mutations that can cause small changes in proteins necessary for entry into human cells, allowing them a measure of protection against immune responses, 

even in people who were infected with prior strains. (Influenza viruses are classified by these proteins, 

called hemagglutinin [H] and neuraminidase [N]; see Box 1A in Chapter 1.) This genetic variability means 

that people experience repeated influenza infections over their lives and vaccine formulations must be 

updated nearly every year.

At irregular intervals, new subtypes of influenza burst on the scene and sweep through the human 

population, which has no significant immunity to them. Such global pandemics appear to occur three 

to four times per century. In the twentieth century, pandemics were caused by new variants of influenza 
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A virus in 1918 (H1N1), 1957 (H2N2), and 1968 (H3N2). These pandemics varied in severity, for reasons 

related both to the level of pre-existing immunity in the human population and to the genetic makeup 

of the virus. In spite of extraordinary scientific advances in understanding influenza viruses, they remain 

highly unpredictable.

Responses to new pandemics should be informed by historical experience. The severe pandemic of 

1918–19 offers some lessons about the benefits of rapid action, and the swine flu vaccination campaign 

of 1976 is instructive about the risk of an overly aggressive response to an unproven threat. Over the past 

five years, the emergence of human cases of a highly pathogenic avian H5N1 influenza has stimulated 

unprecedented pandemic planning efforts. 

1918–19 Influenza Pandemic

The 1918–19 pandemic was the worst natural calamity of the twentieth century, with an estimated mortality worldwide of 40–100 million lives. In the United States, between 500,000 and 750,000 perished at a 

time when the U.S. population was one-third its current size. In contrast to seasonal influenza, mortality 

was especially high among previously healthy young adults. In cities that adopted early measures of 

“social distancing,” such as cancelling public gatherings and closing schools, the epidemic appeared to 

have spread more slowly and reached a lower peak incidence.

What is most informative about the 1918–19 pandemic for current planning purposes is its pattern 

of spread. A first, or spring, wave began in March 1918 and spread unevenly across the United States, 

Europe, and Asia. Although illness rates were high, death rates in most locations were not significantly 

above those of seasonal influenza. The spring outbreak was mild enough that the public health and 

medical communities saw no cause for alarm. However, a second, fall wave spread globally from 

September to November 1918, with death rates approximately ten-fold higher than in the spring. Cities 

that responded rapidly by closing schools, churches, and theaters, restricting public gatherings, and 

otherwise discouraging social interaction appear to have reduced transmission and mortality while the 

measures were in effect. However, most cities could not sustain these measures, and many experienced 

the return of influenza as control efforts lapsed. In some places, a third wave occurred in early 1919. 

Death from pneumonia was a hallmark of the 1918–19 fall and winter waves. The 1918–19 pandemic 

vividly illustrates what can happen when the public health and medical communities lack knowledge, 

contingency plans, and effective vaccines or treatments.

1976 Swine Flu “Fiasco”

The events of 1976 serve as an example of a public health response premised only on the “worst case” 

scenario, which ended up being a false alarm. In January 1976, a novel H1N1 virus first appeared in a 

group of army recruits at Fort Dix, New Jersey. Four were hospitalized and one died. In March, on the 

advice of public health experts, President Gerald Ford announced on television that he was asking 

Congress for $137 million “to inoculate every man, woman, and child in the United States” against swine 

flu. Within 10 weeks of the launch of the fall vaccination campaign, about 45 million people, or 1 in 4 

Americans, had received swine flu immunizations. Public confidence, however, was soon shaken by the 

deaths of three elderly adults in Pittsburgh soon after they received their swine flu shots. Although such 
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events are expected by chance, local public health officials and the media raised the possibility that 

the deaths were due to the immunizations. Later reports found Guillain-Barré syndrome, a paralyzing 

neuromuscular disorder, to be associated with 1976 vaccination at a frequency of approximately 1 per 

100,000 vaccinations. With no disease from the swine flu virus having appeared since the outbreak at 

Fort Dix, even this relatively rare complication was enough to lead to the suspension of the immunization program. 

The key policy error in 1976 was to bundle all decisions (e.g., make the vaccine, immunize everyone, 

make a Presidential announcement) into a single “go” or “no-go” decision, with no provision for the 

monitoring of the situation and continual reconsideration of policy directions based on new evidence. 

The experience of 1976 highlights the challenge of coordination horizontally across different agencies 

of the Federal Government; vertically across the various levels of government (Federal, state, local); 

among public officials and health professions and institutions; and between the public and private sectors. The 1976 swine flu immunization program highlighted other lessons, including the importance of 

communication to the public, the long-term need to preserve credibility, and the need for preparations 

relating to vaccine liability insurance anticipation of coincident deaths in a mass immunization program, 

the potential impact of vaccine side effects, and the role of chance.

In applying these lessons to present circumstances, it is worth noting a number of crucial differences 

between then and now. Among them: (1) the current 2009-H1N1 is continuing to spread, unlike the 

single, self-quenching outbreak at Fort Dix; (2) a wider array of interventions, including antiviral medications, is available; (3) more sophisticated characterization and surveillance systems for circulating viral 

strains are in place; (4) the Federal Government has a more complex structure and a larger number of 

relevant agencies and officials; (5) the media are vastly more varied and operate on a continuous news 

cycle; and (6) widespread international travel contributes to accelerated transmission around the world.

Other Pandemics

The two other influenza pandemics in the last century also provide insight into the current situation. 

The so-called “Asian Flu” of 1957 appeared in the United States in late spring. Small outbreaks occurred 

over the summer, but transmission accelerated in the late summer through early fall, peaking in October 

before vaccine supplies were widely available. Public health authorities learned an important lesson 

about the potential value of early protection against influenza. After a lull following the October peak, 

there was a smaller upsurge in transmission in early 1958, in which the elderly were disproportionately 

affected. Mortality in 1957–58 was high—an estimated 70,000 deaths in a population of about 170 

million. Although death rates were highest among the elderly, about 30 percent of all deaths occurred 

in those under age 65. 

The mildest of the twentieth century pandemics occurred in 1968, with an estimated 34,000 deaths in 

a population roughly two-thirds of today’s; death rates were highest in the elderly, but about half of all 

deaths occurred in people under age 65. The 1968 virus emerged first in Hong Kong in mid-1968 and 

appeared in the United States in September, but did not peak until December 1968/January 1969. One 

reason for the slower spread and reduced death toll during the 1968 pandemic may be that the virus 

(H3N2) shared some similarities with the virus that was already circulating (H2N2), so the population 

may have been partially immune. 
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In the decade following each of the twentieth-century pandemics, seasonal epidemics continued and 

excess deaths in younger age groups remained elevated above normal seasonal levels. These recent 

pandemics illustrate that the timing of peak pandemic activity may be earlier than that of normal flu 

season, but unpredictable in that younger age groups suffer more during pandemics than during seasonal influenza outbreaks, and that the impact of new strains on these younger groups persists into 

subsequent seasons.

Avian Flu

In Hong Kong in 1997, a highly pathogenic avian H5N1 virus was found to have infected large numbers 

of poultry and a small number of humans. Following initial control by extensive slaughter of poultry 

flocks, the virus disappeared, only to reappear in 2003–2004. The virus was felt to be a potential pandemic threat because, although the rate of bird-to-human transmission was low and person-to-person 

spread was rare, the mortality rate was over 60 percent.

The possibility that H5N1 could acquire the ability to transmit efficiently between humans and thereby 

start a new and severe pandemic spurred major pandemic-planning efforts at the state, Federal, and 

global levels. Beginning in 2005, the Federal Government undertook a number of initiatives to address 

this threat, including: (1) developing a “National Strategy for Pandemic Influenza” to guide the preparedness efforts of Federal departments and agencies, state and local authorities, businesses, and 

the public; (2) requesting that Congress appropriate $7.1 billion to establish a domestic stockpile of 

antiviral medications and pre-pandemic vaccine and to significantly expand domestic influenza vaccine production capacity; (3) developing guidance on pandemic influenza preparedness for the public 

and a broad spectrum of stakeholders outside of the Federal Government; (4) establishing policies to 

guide the pandemic response in areas such as border management and prioritizing allocation of prepandemic vaccine; and (5) creating the International Partnership on Avian and Pandemic Influenza to 

facilitate global surveillance and preparedness actions.

These and other efforts in response to the H5N1 threat have informed and guided many of the actions 

undertaken in response to the 2009-H1N1 outbreak to date.
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Lessons for Fall 2009

Given the concern about avian influenza and awareness of the catastrophic results of the 1918–19 pandemic, much of the effort for pandemic planning has been directed toward responding to an extremely 

severe pandemic. This worst-case-scenario planning has led to improvements in the efficiency of vaccine 

production and testing, stockpiling of antiviral drugs, and other measures that will be valuable in the 

fall, if used appropriately. However, unless the severity of the 2009-H1N1 influenza increases markedly, 

it is unlikely that community mitigation on the scale envisioned for a more severe pandemic will be 

required. On the other hand, as described in the next chapter, it is already clear that the current pandemic 

is no false alarm (as in 1976) and has the potential to cause serious health consequences, especially in 

relatively young age groups and in individuals with certain pre-existing medical conditions.

While the features of 2009-H1N1’s next wave cannot be accurately predicted, history teaches us that 

the most effective responses will be achieved by advanced planning, knowledgeable judgments about 

the range of possible events, continued situational awareness about the pandemic, and flexibility in 

thinking and decision making. 

13

III. Anticipating the Return of 2009-H1N1: 

Envisioning Scenarios

CHAPTER SUMMARY

While the course of the 2009-H1N1 pandemic cannot be accurately predicted, it is important to have a 

clear picture of our current knowledge and to envisage a range of specific scenarios against which to 

make plans and assess our capabilities. 

Our current knowledge is that the virus is readily transmissible, especially to younger age groups, and 

causes severe clinical manifestations in a small but significant proportion of cases, with most of the 

severe cases in people under age 65. The proportion of influenza cases that ends in death appears similar 

to that for seasonal influenza (perhaps 1 per 1,000 patients seeking medical attention), but the absolute 

number of deaths is expected to be at least as high, if not substantially higher, than for seasonal flu 

because a higher proportion of the population is likely to become infected (perhaps 40 to 60 percent 

for pandemic flu versus perhaps 5 to 20 percent for seasonal flu). Moreover, the distribution of deaths is 

likely to cause a greater loss of expected years of life because the virus predominantly affects younger 

people. Some specific individuals appear to be at much higher risk, including patients with neurological disorders, pregnant women, and patients with asthma. Certain ethnic groups also may be at higher 

risk, such as Native Americans. Notwithstanding these observations, there remains great uncertainty 

about the likely course of the pandemic.

The Working Group believes that planning activities would be aided by development of a small number 

of specific, shared scenarios describing the possible evolution of the pandemic. 

We believe it would be valuable for DHHS to develop a limited number of specific scenarios for dissemination to Federal, state, local and private decision-makers, to be used for assessing capabilities 

and planning responses. 

For planning purposes, we describe a plausible scenario in which the pandemic causes between 

30,000 and 90,000 deaths and requires at its peak 50 to 100 percent of ICU beds in affected regions of 

the country, placing extreme stress on a system in which 80 percent of ICU beds are already otherwise 

occupied. Analysis of this scenario and alternative scenarios should facilitate decision making about the 

use of mitigation methods in response to new information about the epidemic.

Introduction

Because the course of the 2009-H1N1 pandemic cannot be accurately predicted, it is important to have 

a clear picture of our current knowledge and to envision a range of specific scenarios against which to 

test our planning and capabilities. While changes in the virus remain possible, the current picture of 

2009-H1N1 is as follows: 
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• The virus is transmitted readily between people at a rate comparable to that estimated for previous pandemic strains. In most places where surveillance is available, there is clear evidence of 

ongoing transmission even through the summer.

• Confirmed cases are concentrated in younger age groups, up to age 24. According to CDC, infection 

risk in the 0 to 24 age group is 4 to 5 times greater than for those in the 25 to 49 age group, and 

20 times greater than those over age 65.

• Almost all severe cases are in people younger than age 65. To date, 83 percent of deaths and 71 percent of hospitalizations from 2009-H1N1 in the United States have been in people between the 

ages of 5 and 64. This is in stark contrast to seasonal influenza, in which two-thirds of hospitalizations and almost 90 percent of deaths occur in persons 65 or older. This means that the years 

of anticipated life lost per death are much greater than is usual as a result of seasonal influenza.

• The case-fatality ratio (i.e., proportion of infected individuals who die as a result of the infection) 

appears to be similar to seasonal influenza—possibly on the order of 0.1 to 0.3 percent of medically 

attended cases (i.e., those infections requiring hospitalization or primary care), and perhaps 0.05 

to 0.2 percent of all symptomatic cases, whether or not medical care is sought. However, these 

numbers are highly uncertain, in particular because the number of medically attended cases 

is not well measured and the number of mild cases that do not come to medical attention is 

essentially unknown. 

• Despite a similar case-fatality ratio as for seasonal influenza, the number of deaths from 2009-H1N1 

is likely to be substantially higher and the deaths and severe illness in the population will likely be 

concentrated among much younger people than is the case for seasonal influenza. Because most 

of the population lacks significant immunity to a new pandemic strain, the proportion of people 

infected in a pandemic is usually substantially higher than for seasonal flu (50 to 70 percent 

for pandemic flu versus perhaps 5 to 20 percent for seasonal flu). Second, as noted above, the 

consequences of infection in this epidemic are already known to be far more severe for children 

and young adults, and seemingly milder for people over age 65 (with deaths mainly among 

children and young adults, compared to seasonal influenza).

• Individuals with certain underlying medical conditions—including those with neurological disorders 

and pregnant women—appear to be at substantially elevated risk of severe outcomes. According to 

CDC, as many as one-third of fatal cases and one-fifth of hospitalizations have been in persons 

with neurological (e.g., neurocognitive, neuromuscular, seizure) disorders. Pregnant women 

accounted for 8 percent of deaths and 6 percent of hospitalizations, although they make up 

about 1 percent of the population. Asthma, diabetes, immunodeficiencies, chronic obstructive 

pulmonary disease (COPD), and other chronic conditions appear to be associated with severe 

outcomes as well.

• Certain populations appear to be at elevated risk of severe outcomes, including Native American 

groups. American Indians and Alaska natives historically are at high risk for severe respiratory 

infections; while it is unclear what toll they have suffered from 2009-H1N1, a cluster of severe 

2009-H1N1 disease among First Nation people in remote Manitoba, Canada, suggests that 
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these groups may be at high risk. Cases of 2009-H1N1 virus infection in these clusters have had 

rapidly progressive, diffuse, lower airway disease (compared to seasonal influenza, which more 

commonly involves the upper airway), resulting in development of acute respiratory distress 

syndrome (ARDS) and prolonged ICU admission.

The Need for Concrete Scenarios for Response Planning

The Working Group is concerned that uncertainty about the course of the 2009-H1N1 pandemic may 

be hampering planning. While uncertainty is inherent in pandemics, planning activities may be aided 

by development of a limited number of specific, shared scenarios that describe the possible evolution 

of the pandemic. Dissemination of a limited number of plausible scenarios would provide a framework 

against which decision-makers at the Federal, state, and local levels could test current capabilities and 

also structure specific plans and decision points. In the absence of such frameworks, decision-makers 

may fail to adequately assess capabilities relative to potential needs. They also may fail to foresee key 

decision points and be forced into hasty decisions in the “heat of battle.” A scenario-based approach 

already has been embraced by the United Kingdom, which has defined and made public its planning 

assumptions for a “reasonable worst case” scenario. 

MAIN RECOMMENDATION (CHAPTER 3)

We recommend that DHHS rapidly develop a limited number of specific scenarios and disseminate 

them to Federal, state, local and private decision-makers for planning purposes. Components of 

these scenarios ideally would include:

i. timing and magnitude of the fall epidemic;

ii. peak burden on primary care providers, emergency rooms, hospital admissions, and ICUs;

iii. number of doses and timing of vaccine availability;

iv. dosing requirements and efficacy of vaccine; and 

v. efficacy and supply of antiviral drugs and medical materiel.

These scenarios would allow Federal, state, local and private entities to assess their capacity and 

develop plans for deployment and targeting of medical and non-medical interventions under the 

various scenarios. 

In addition, it would be valuable for DHHS to define trigger points related to changes in circumstances (e.g., change in severity) to facilitate timely action, as well as the data and data streams 

that will be required to activate these trigger points.

To illustrate this approach, we describe in Box 3A a scenario that we consider to be a reasonable model 

for planning, followed by sample decision points that might be appropriate. We also suggest indicators 

and triggers to redirect decision making should an unanticipated event emerge within the scenario. 

The assumed characteristics of the model scenario are described in Table 3-1.
16 

BOX 3A: A MODEL SCENARIO: A POSSIBILITY, NOT A PREDICTION 

One plausible scenario is that there will be resurgence in transmission of 2009-H1N1 this fall that is comparable to that 

seen in spring-summer 2009 but with higher rates of transmission due to the resumption of school and the cooler, 

drier weather. Following a relatively steady or declining burden of cases in August, the number of new cases will 

begin to rise exponentially in the first week of September, growing 10-fold about every 10 to12 days. Hypothetically, 

the peak incidence of infection nationally will occur around October 15, with minor variations across the country such 

that peak incidence almost everywhere will occur during the month of October. At this peak, perhaps 1 to 2 percent 

of the population will become infected each day.

Predicting demand on the health care system during this peak is fraught with uncertainties, but the following numbers 

from one possible scenario are illustrative. During the peak, 1 or 2 out of every 2,000 Americans might be hospitalized. Cases requiring mechanical ventilation or intensive care could reach 10 to 25 per 100,000 population, requiring

50 to 100 percent or more of the total ICU capacity available in the United States and placing great stress on a system 

that normally operates at 80 percent of capacity. Because adult ICUs are not prepared to care for pediatric patients, 

there could be a particular shortage of facilities for sick children. In particular locations, the stress on the health care 

system could grow even more acute, as large outbreaks occur in prisons, schools, and isolated communities with 

limited health care access, such as Native American reservations. As awareness of the pandemic spreads, pressure on 

emergency departments could mount, with long lines and a need for triage of mild cases and non-influenza cases. 

Alongside these health-related burdens, substantial absenteeism from work and school could occur, as sick children 

stay home, schools with large outbreaks close, and parents are forced to stay home either because of their own illness or to take care of sick children. Key members of the social infrastructure, such as police officers and firefighters, 

are increasingly home ill. Exposure of healthcare workers to sick patients is continual and antiviral supplies prove 

inadequate for ongoing prophylaxis of these workers. Retail pharmacies run out of antiviral supplies in late September 

or earlier, and states face the demand to replenish these supplies from state stockpiles and state Strategic National 

Stockpile allocations; however, many states lack the ability to move antiviral drugs into the retail supply chain and 

focus on delivery to hospitals. Hospitals face competing pressures to dispense antiviral drugs for prophylaxis of their 

workers, to provide them to patients appearing in the emergency room, or to save them for the sickest admitted 

patients. Debates intensify about the value of antiviral use for long-term prophylaxis or early treatment for mild 

infection in high-risk groups such as pregnant women and immunocompromised patients, treatment of severely ill 

patients, and prophylaxis of essential healthcare workers. 

In this model scenario, around October 15, as the epidemic peaks, a major supply of 2009-H1N1 influenza vaccine 

becomes available. Immunization starts within days, with considerable geographical variation in the rate at which 

administration occurs. Immunization of priority groups is completed by early or mid-November, resulting in immunity 

in vaccinated adults by mid-late November, as the epidemic wanes in most populations. Children require two doses 

and do not acquire immunity until December, when new infections will have become rare. 

By the end of 2009, 60 to 120 million Americans would have experienced symptomatic infection with 2009-H1N1; 

nearly 1 to 2 million would have been hospitalized, with about 150,000-300,000 cared for in ICUs; and somewhere 

between 30,000 and 90,000 people would have died, the majority of them under 50 years of age. 

We emphasize that this is a plausible scenario, not a prediction. By way of comparison, it is less severe by a factor of 

three (in terms of expected deaths per capita) than the “reasonable worst case” planning assumptions, publicized 

by the UK government, for the H1N1 resurgence in that country. 
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TABLE 3-1: A POSSIBLE (NOT PREDICTIVE) SCENARIO TO HELP PLAN FOR 

THE FALL RESURGENCE OF 2009-H1N1 INFLUENZA IN THE UNITED STATES

Peak incidence date (unmitigated) October 15

Peak incidence of symptomatic disease 1–2% of U.S. population (3–6 million people)

on the U.S. epidemic’s single peak day

Percent of U.S. population (and approximate numbers) assuming no change in virus

Infected (indicated by seroconversions,

with or without symptoms) 30–50% (90–150 million)

Symptomatic 20–40% (60–120 million)

Needing medical attention 15–30% (45–90 million)

Needing hospital care 0.3–0.6% (0.9–1.8 million)

Needing Intensive Care Unit (ICU) facilities 0.05–0.1% (150,000–300,000)

Deaths 0.01–0.03% (30,000–90,000)

Peak occupancy of ICU beds due to 

2009-H1N1 10–25 ICU beds/100,000 population1

Peak occupany of hospital beds due to 

2009-H1N1 50–150 hospital beds/100,000 population2

High-risk groups for death or hospitalization

Pregnant women; children (0–4 years old); 

patients with neuromuscular/neurocognitive 

disorders, asthma, chronic obstructive pulmonary disease, cardiovascular disease, diabetes, 

severe obesity, or immunocompromising 

conditions3

Notes:

1

 The United States has 20 ICU beds/100,000 population. The number of ICU beds available for pediatric patients is especially limited.

2

 The United States has 211 hospital beds/100,000 population.

3

 Cetron M, 2009 Pandemic Novel Influenza A (H1N1): Community Mitigation, powerpoint presentation to PCAST H1N1 Working Group,

July 16, 2009.
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Beyond this scenario, alternative scenarios are needed to take into account the possibility that major 

assumptions are incorrect. In particular, four variations are of notable importance:

1. A milder scenario in which the number of deaths and severe cases is much lower than outlined 

here, perhaps because many mild cases or infections without symptoms were missed in the 

spring, leading to an overestimate of the severity. 

2. A modified scenario in which a large fraction (e.g., one-third) of 2009-H1N1 cases are resistant 

to oseltamivir (Tamiflu) by the peak of the epidemic, reducing the effectiveness of an important 

method for mitigating the epidemic.

3. A more severe scenario, in which changes in the virus result in elevated rates of hospitalization, intensive care demand, and death. In this case, the focus of severe disease may shift more 

toward the general population, making focused attention on groups that showed high-risk in 

the spring less of a priority.

4. A delayed scenario in which transmission does not increase dramatically in the early autumn, so 

that vaccine availability precedes the peak of the epidemic, reducing the number of subsequent 

cases by conferring protection through immunization.

We emphasize again that the baseline scenario and the alternatives above are given as examples for 

planning purposes; they are not predictions of what will happen. DHHS should exercise its own expert 

judgment in defining the most relevant scenarios, with the caveat that scenarios other than the most 

likely also should be considered. In addition, planning should include at least one scenario in which the 

peak of the epidemic precedes the availability of significant vaccine supplies. 

To illustrate the value of scenario-based analysis, it is useful to consider issues in vaccine allocation, since 

the timing of availability of significant quantities of vaccine is still uncertain. 

• In the model scenario, we assume that vaccine administration will commence around the peak 

of the pandemic, with substantial population-level immunity occurring only 2 to 8 weeks after 

the peak. In this case, vaccination will have limited value in reducing transmission. There may be 

a strong rationale for vaccinating certain high-risk groups as rapidly as possible, by accelerating 

the availability of at least some vaccine. 

• If transmission is substantially delayed compared to the model scenario, vaccination of children 

may be of high value epidemiologically: it may be possible to immunize many before exposure, 

protecting them and decreasing spread. 

• Conversely, if an increase in severity is detected with the expected rate of transmission, broader 

administration of vaccine before complete clinical trial data are available may be appropriate, 

and the use of adjuvant (as discussed in Chapter 5) might offer an improved risk-benefit profile. 
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In addition to analyzing specific scenarios in advance, it will be important to define indicators that could 

trigger the need to make changes in plans, and to incorporate these indicators into scenarios. We believe 

that it would be valuable for DHHS to define specific triggers in advance to the extent possible, since 

this will allow orderly decision making when unexpected events arise. (It is worth noting that beyond 

these triggers, public pressure in response to events, such as a cluster of child deaths, may force certain 

communities to change their strategies.) Examples of potential triggers are shown in Box 3B. 

BOX 3B: EXAMPLES OF INDICATORS THAT MIGHT SERVE AS TRIGGERS 

FOR ACTION

Indicators of unacceptable burdens on health care might trigger guidance to intensify community 

mitigation to spread out the peak burden. 

• observations of intense burdens on health care providers, particularly emergency department visits and ICU admissions, in developed countries in the Southern Hemisphere (during our summer);

• observations of intense burdens on emergency departments and ICUs in leading areas of the 

Northern Hemisphere in autumn;

• early evidence of intense burdens on health care providers without evidence that the infection 

is peaking, including more healthy adults or children among severe cases.

Indicators of substantially increased severity that might justify changes in plans for antiviral use, 

vaccine formulation (adjuvant use), or community mitigation.

• observations of novel symptomatology in the Southern Hemisphere or in isolated Northern 

Hemisphere groups during summer, especially if combined with evidence of viral changes associated with this symptomatology; 

• increased ratios of ICU admissions to overall hospitalizations for influenza-like illnesses (ILI) (probably not observable unless very large changes occur); 

• early evidence of intense burdens on health care providers without evidence that the infection is 

peaking; changes in risk groups to include more healthy adults or children among severe cases.

In addition, concentrations of unusually severe cases could occur in a population subgroup defined by 

geography/ethnicity (e.g., a remote Native American population), by underlying medical condition (e.g., 

pregnancy or a novel risk factor), or by place of residence (e.g., nursing home, prison). In such cases it will 

be urgent to provide adequate treatment for affected persons, consider accelerating vaccine delivery 

to similar groups, and ascertain reasons for this increased severity, distinguishing viral changes from 

infectious cofactors, host factors, or other reasons.

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IV. Ensuring Adequate Data for Decision 

Making: Surveillance Systems

CHAPTER SUMMARY

Decisions about how to respond to the fall resurgence of 2009-H1N1 will have to be made quickly 

in response to rapidly evolving information about the epidemic. The quality of decision-making will 

depend on reliable and timely estimates of the number of people and specific subgroups that are 

infected, ill, seeking medical care, being hospitalized, requiring intensive care, and dying from 2009-

H1N1; changes in the virus; stresses on health systems; and effectiveness of various medical and public 

health interventions.

CDC, in close coordination with local and state public health departments, supports a number of important systems for surveillance of influenza activity. These systems have provided valuable data through 

the spring and summer, but they have shortcomings that will limit their ability to provide the data 

needed to make informed decisions. While it is not possible to remedy all of these limitations before 

Fall 2009, there are a number of short-term steps that could be taken to significantly improve the data 

available for decision making. 

The Working Group believes there is an important opportunity to upgrade national surveillance systems 

in time for Fall 2009 by knitting together and extending existing systems. We are aware that CDC is 

developing plans along these lines and strongly support these efforts. 

Introduction

Decisions about how to respond to the fall resurgence of 2009-H1N1 will have to be made quickly in 

response to rapidly evolving information about the epidemic. The quality of decision making in response 

to the 2009-H1N1 pandemic will depend on accurate and timely data to answer six key sets of questions:

1. Approximately, how many people are becoming infected, experiencing illness, seeking medical care, 

being hospitalized, requiring intensive care, and dying from 2009-H1N1? These data allow estimates of severity, which help determine the intensity of response that is justified. A subsidiary 

but important challenge is to estimate the same numbers for seasonal strains of influenza that 

may be circulating over the same period.

2. How are these numbers changing over time? Are they increasing or decreasing, and how quickly?

3. Who is becoming infected and who is at greatest risk of severe outcomes (i.e., hospitalization, ICU 

admission, death)? Specifically, what are the ages, underlying conditions, and other risk factors 

for infection and severe outcome?
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4. How is the virus changing? Most important, are there changes in illness severity, antigenic character (which could compromise immunity acquired from natural infection or a vaccine), or drug 

resistance of the circulating virus?

5. Are the medical and public health systems able to respond adequately? Is there adequate capacity 

in physician offices, emergency rooms, hospitals, ICUs, morgues, points of dispensing (PODs), 

and other public health venues set up for the pandemic?

6. How well do medical and public health responses work? Does the vaccine protect against infection or severe outcome? Is the vaccination strategy (e.g., mass vaccination clinics) able to target 

effectively the recommended population groups? Does antiviral treatment reduce severity? Do 

social mitigation measures reduce transmission? 

Federal decision-makers need data that answer these questions to inform policies and recommendations about the priority groups for vaccination and treatment, to calibrate the intensity of social mitigation interventions, and to provide guidance to clinicians about appropriate treatment and prevention. 

State and local decision-makers need the data for the same reasons, but they also need to understand 

the situation in their communities, which may differ from the national average. Clinicians need data 

especially related to questions 3 and 5 in order to target scarce treatment to the appropriate patients, 

improve clinical treatment, and implement surge capacity plans in the event of increased demands on 

the health care system. The general public needs to understand the size and severity of the epidemic and 

be motivated to comply with social mitigation measures. Historically, compliance improves when the 

epidemic is perceived to be severe. All of these data are needed as close to instantaneously as possible. 

Existing Data Streams

CDC, in close coordination with local and state public health departments, supports a large number of 

systems for surveillance of influenza activity. The output of many of these systems is summarized publicly 

on FluView www.cdc.gov/flu/weekly/, and includes measures (some more nationally representative than 

others) of outpatient consultation for influenza-like illnesses (ILI), hospitalization for influenza, pediatric 

deaths from influenza, population-wide deaths from pneumonia and influenza, and virus characteristics 

(subtype and drug resistance). Federal decision-makers have relied on these systems as the main source 

of data on trends in case numbers, age distribution, and virus characteristics. 

A second key source of data on the epidemic in the early days of the spring wave of 2009-H1N1 was 

the relatively detailed reports from state and local health departments describing individual confirmed 

cases, noting (with varying completeness) key variables such as age, underlying conditions, and outcome 

(i.e., recovery, hospitalization, ICU, death). By early May, this level of reporting had become unsustainable; 

most jurisdictions stopped testing most mild cases for 2009-H1N1 virus and ceased detailed reporting 

of individual cases. Local authorities in many communities continued gathering data on the most severe 

cases, but these data were not systematically reported to CDC. Thus the clinical picture of confirmed 

infection at the national level is relatively static, based on the first case reports in the epidemic, and it 

has not been possible to track the evolution of the epidemic in the United States.
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Shortcomings of Current Data Streams

While the data collected about 2009-H1N1 thus far have been extremely valuable, they have a number 

of limitations. The key shortcomings of existing data streams are:

• Some key data are not updated continuously. Since individual-level case reporting ended in 

early May, there has been no systematic way to update national data on high-risk groups (i.e., 

according to age and predisposing conditions) for confirmed infection and severe outcome at 

the national level. Some of these data exist locally but are not being aggregated into a national 

picture now that reporting to CDC is not at the individual level. Up-to-date information on 

these variables is needed, for example, to inform decisions on who should receive priority for 

vaccination and antiviral treatment.

• Current systems are geographically limited. Influenza activity is geographically heterogeneous, as was apparent in the spring wave of 2009-H1N1 and as is known for seasonal influenza. 

Responses, therefore, should vary locally, but they can do so only with local information. For 

national decision-makers, geographic coverage is important to ensure a nationally representative picture of the epidemic. Many of the most detailed data feeds, such as the influenzaconfirmed cases at hospitalization monitoring sites funded by CDC through the Emerging 

Infections Program (EIP), are geographically limited. By chance, during the spring none of these 

EIP sites was in an area with a heavy burden of 2009-H1N1 disease. 

• Current systems do not provide reliable estimates of influenza morbidity and mortality. For many purposes it is critical to know, for example, approximately how many people are 

infected or hospitalized, measured as total numbers of people or numbers per 100,000 population. Most of these systems do not answer that question, but instead measure what proportion 

of visits to health care providers or emergency departments are for ILI, and what proportion of 

ILI cases that undergo viral testing are positive for 2009-H1N1. 

• No systematic approach yet exists to monitor the capacity of the health care system to 

respond. Although many jurisdictions monitor emergency department volume, national integration of these data is geographically spotty. For total burden of hospitalizations and intensive 

care admissions due to influenza, few if any representative data are available. Such a system, 

called “HAvbed,” is planned by DHHS but has not yet been implemented.

• Laboratory capacity to confirm diagnosis and isolate viruses for further characterization is 

limited. Most public health laboratories now restrict virus testing to patients with severe disease 

and many laboratories will be unable to maintain even this practice if the number of cases grows 

much higher in the fall. Commercial testing for pandemic 2009-H1N1 and other viral respiratory 

pathogens is not widely available or widely used, so 2009-H1N1 infection in most patients may 

not be confirmed in fall 2009; as a result, diagnosis will be based empirically on clinical symptoms 

and knowledge of which respiratory viruses are circulating in each community. 

• Current systems cannot monitor the burden of mild illness that does not come to medical 

attention. Reliable estimates of this burden are needed to understand the severity of illness—
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the more people are becoming infected without coming to medical attention, the smaller we 

expect the overall burden of morbidity, mortality, and health care system stress to be for a given 

prevalence of infection. At present we do not know this number.

• Current systems for reporting and analyzing adverse events associated with vaccination 

may not be well suited to challenges likely to arise during a vaccination campaign for 

2009-H1N1. The Working Group has identified two concerns in this area. First, adverse event 

surveillance and analysis depends to a large degree on the ability to link vaccination to possible adverse events via medical records, but the administration of vaccine in settings other 

than traditional medical care may circumvent this linkage. Second, high-risk groups that are 

prioritized for vaccination also are likely to experience adverse health events at high rates. 

Existing systems may not be able to rigorously evaluate elevated rates of such common events 

in high-risk groups, e.g., spontaneous abortions (miscarriages) in pregnant women or various 

complications in neurologically impaired patients.

In a rapidly growing pandemic wave, most state and local health departments do not have the capacity 

to count every hospitalization or death without depleting limited public health resources. Therefore, 

more efficient and sustainable surveillance methods are necessary to obtain the key data needs during 

a moderate or severe pandemic, including a qualitative assessment of local influenza activity combined 

with virologic sampling of a representative number of viral isolates. 

Recommendations

It is not possible to address all of these limitations before the autumn wave of 2009-H1N1. (In Chapter 

8, we recommend long-term measures to erect a comprehensive and population-based influenza surveillance system that would address data needs for decision making in seasonal influenza and future 

pandemics.)

The Working Group believes, however, that CDC can take a number of steps in the coming weeks to 

significantly improve critical data for decision making.

MAIN RECOMMENDATION (CHAPTER 4)

We recommend that DHHS take rapid advantage of available opportunities to upgrade national 

surveillance systems to improve decision making during the fall resurgence The critical surveillance information for decision making includes data on influenza-like symptoms in the population, 

emergency room admissions, health system utilization, hospitalized patients, and adverse events.

Below, we suggest several specific measures that may improve situational awareness and decision 

making through the autumn wave. These recommendations attempt to balance the need for improved 

data with the practical constraints of assembling systems to acquire these data in a short time frame. We 

recognize that efforts to address many of these needs, and many other aspects of surveillance, are ongoing; we highlight here aspects that appear to be both urgent and addressable within a short time frame.
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RECOMMENDATION 4-1: EMERGENCY ROOM DATA

We recommend that CDC rapidly assemble an integrated system, by combining syndromic surveillance and emergency department data from existing local and state surveillance systems 

into a geographically representative national network, that rapidly reports total and ILI-related 

emergency visits.

Needs/gaps in existing systems and possible approaches: Most states and many large cities have implemented their own syndromic surveillance systems in emergency departments. These electronic systems 

provide valuable information on ILI trends based on symptoms that bring patients to medical care centers. These systems often collect data within 12 to 24 hours of patient visits. However, these state and 

local systems currently are not integrated, making it difficult to obtain regional or national situational 

awareness of influenza activity based on reports from individual centers.

For example, the International Society of Disease Surveillance has implemented a simple and flexible 

integrated system and collects aggregate counts of ILI syndromes by age group in order to monitor 

and compare ILI activity throughout the United States very quickly (e.g., see the International Society 

of Disease Surveillance’s DiSTRIBuTE system). However, only nine jurisdictions (a mix of cities, counties, 

and states) participate. This system could form a natural template for additional data feeds. We believe 

it may be feasible to expand this or other systems in the coming weeks and we are aware of efforts by 

CDC to do so. 

Expected benefits: This system would provide a national picture, with some local resolution, of trends in 

the numbers of patients visiting emergency departments, the percentage of such patients with ILI, and 

the distribution of ILI by age. Such information would allow Federal, state, and local officials to obtain 

a better sense of the trajectory of the outbreak (in scale, scope, and pace) in different regions of the 

United States over time. Systems of this type already are proving useful for evaluation of local control 

measures, although additional information is required to assess the severity of disease associated with 

the 2009-H1N1 virus (e.g., cases requiring hospitalization or case fatality rates). 

RECOMMENDATION 4-2: POPULATION SAMPLING

We recommend that CDC implement a system to measure the burden of ILI on a weekly basis. 

Although nationally representative data would be valuable, it may be beneficial for these surveys 

to oversample in jurisdictions that have relatively robust surveillance plans in place for tracking 

influenza-related primary care visits, hospitalizations, and deaths in order to more accurately 

monitor changes in rates of more severe illness over time.

Needs/gaps in existing systems and possible approaches: Existing systems do not establish the number 

of ILIs occurring in place and time as a rate per 100,000 population. This precludes estimates of severity 

because the severe cases, which are better ascertained, cannot be related to overall levels of infection. 
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This may be accomplished through web-based or telephone-based surveys. 

Expected benefits: These studies would provide approximate denominators of mild and medically 

attended illness against which more detailed data on hospitalizations and fatalities can be compared. 

Such denominators are especially important for estimating severity of infection and consequently for 

predicting peak burdens on health care: for a given number of severe outcomes, the overall severity 

is much less if there are many cases of mild illness or of symptoms that do not cause a patient to seek 

medical attention. Data from random public surveys would reduce, although not eliminate, the uncertainties cited above concerning overall severity. In addition, the surveys would provide an independent 

measure of the number of people affected by illness that may be attributable to 2009-H1N1 and to the 

rate of change in these numbers. The interpretation of ILI activity due to 2009-H1N1 will depend on the 

proportion of 2009-H1N1 compared to other circulating respiratory viruses in each community where 

surveillance is taking place. In the spring, 2009-H1N1 was more prevalent; but in the fall, other viruses 

will likely be circulating, such as respiratory syncytial virus (RSV) and seasonal influenza. Thus, these 

numbers will be best interpreted in conjunction with virologic data.

RECOMMENDATION 4-3: HEALTH SYSTEM UTILIZATION

Because hospital facilities may become dangerously scarce in the fall, we recommend that DHHS 

implement an integrated system to monitor health care system utilization overall and attributable 

to respiratory infection, with an emphasis on incidence and prevalence of cases occupying hospital 

beds, ICU beds, and mechanical ventilators.

Needs/gaps in existing systems and possible approaches: Hospital and intensive-care utilization are not 

routinely monitored in the United States. Southern Hemisphere countries are reporting stress on ICUs 

from 2009-H1N1 illness even during a period of school holidays, and the epidemic probably has not 

yet peaked. As noted above, DHHS is developing the HAvBED system, which may be expanded to meet 

present needs. An alternative or complementary approach may be to integrate existing state and local 

systems, such as the New York State Health Emergency Response Data System (HERDS). In any system, 

it would be valuable for such data to be immediately available to state and local providers. Since most 

hospitals maintain such information on a daily basis, the key is to implement a simple system that allows 

defined information to be regularly uploaded.

Expected benefits: Acute stress on ICUs or increased demand for ventilators may be a trigger for resource 

reallocation from less affected areas and/or for intensifying community mitigation measures. Accurate 

measures of health care system utilization would facilitate more efficient sharing of resources.
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RECOMMENDATION 4-4: HOSPITALIZED PATIENT DATA

We recommend that CDC define a mechanism to gather timely clinical, epidemiologic, and virologic 

data on a representative sample of patients hospitalized for respiratory illness and ensure that 

those data are available to inform national recommendations to clinicians, public health officials, 

and the public. Such data could be gathered by assembling a network of participating sites, such as 

sites currently specializing in influenza surveillance; healthcare systems with appropriate electronic 

record-keeping systems; and states and localities interested in participating. 

The data ideally would include:

A. Results of systematic testing of patients hospitalized for respiratory infection to determine 

the presence of respiratory viruses including 2009-H1N1. To improve representativeness of 

data, such testing would ideally be done within a defined population according to prospective criteria rather than according to clinician discretion. 

B. Clinical data—including age, predisposing conditions, course of hospitalization (whether 

admitted to ICU or ventilated), duration of hospital/ICU stay, and resolution (death, discharge), vaccine status, presence/absence of bacterial secondary infections, and identity and 

timing of antibiotic and antiviral administration—should be reported for a representative 

sample of hospitalized cases of 2009-H1N1 infection.

In addition, it would be valuable for CDC to define explicitly the most important clinical studies 

needed to guide response during the autumn wave, gain Institutional Review Board approval, identify and fund sites to perform these studies during the early autumn, and put in place a mechanism 

for rapid dissemination of results

Needs/gaps in existing systems and possible approaches: There is an important gap in our ability to assess 

the clinical features of pandemic influenza infections in an ongoing way to inform treatment and prevention decisions. CDC’s Emerging Infections Program (EIP) reports population rates of infection with 

confirmed influenza. These data are valuable but are limited by variation in the sensitivities of immunological and nucleic-acid-based assays and by clinician discretion regarding whether to test. Adequate 

personnel and funding should be available so that EIP sites have capacity to perform PCR-based tests 

(which are more sensitive) and to test systematically rather than at clinician discretion.

For clinical information, existing data streams are limited and state and local health departments are 

unable to follow up most hospital admissions to determine clinical course. Such data are particularly 

critical and may change over time as the pandemic progresses, either due to changing susceptibility 

in the population or changes in the virus. While it is not feasible to obtain clinical information for all 

hospitalized patients, sentinel hospitals or EIP sites could be used to gather detailed clinical data in 

a standardized fashion. In addition to these standard data, clinical studies—for example, on optimal 

management of severe cases that do not respond to antiviral therapy—will be needed, and little time 

is left to ensure that they will be ready to commence early enough to have maximal impact. In addi-
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tion, waiting for peer-reviewed results to be published will likely diminish the value of any findings, as 

a manuscript submitted in mid-September might not be published until November, after the possible 

peak of the epidemic.

To address these needs, CDC should work with existing sites that specialize in influenza surveillance, or 

research centers, to prospectively monitor for changes in the clinical or epidemiologic characteristics 

of the virus over time. Other states or locales that have interest and capacity to participate should be 

included, when possible, to improve geographic representativeness. These “sentinel sites” should use 

standardized protocols and data collection instruments to ensure that timely and up-to-date clinical, 

epidemiologic, and virologic data on patients hospitalized for respiratory illness are available to inform 

national recommendations to clinicians, public health officials, and the public. Adequate funding will 

be needed to support these sites. 

Expected benefits: Such data streams, and CDC’s guidance based on them, would be of primary benefit 

to clinicians and to vaccine planners in targeting prevention and treatment to groups at high-risk of 

severe disease. Changes in risk groups or changes in clinical spectrum (e.g., more rapid progression 

to death, increasing need for ICU care or ventilation among hospitalized cases) may be early signs of 

changes in the virus or in other factors, such as bacterial superinfection, that would warrant changes in 

control measures or clinical management. Such changes are not observable now because of the lack of 

ongoing clinical characterization of severe cases. A rapid means to disseminate clinical data and results 

of key clinical studies would provide clinicians with needed information while it is most valuable.

RECOMMENDATION 4-5: ADVERSE EVENTS

We recommend that DHHS ensure the adequacy of surveillance systems and signal evaluation 

systems for vaccine-associated adverse events (VAE), with particular focus on the risk of common

adverse events that are likely to occur at high rates in high-risk populations (e.g., pregnant women) 

and whose association with vaccination may be difficult to assess rapidly. 

In addition, we believe it would be valuable for DHHS to assess the adequacy of existing systems 

for VAE reporting to detect rare events in settings of nontraditional vaccine distribution (e.g., in 

public settings, such as malls) and take steps to improve these systems where needed.

Needs/gaps in existing systems and possible approaches: Existing VAE detection systems and surveillance 

planned for the fall focus on detection of rare complications, such as Guillain-Barré syndrome. In an 

atmosphere of heightened public concern, common adverse events occurring in high-risk groups likely 

to be early candidates for vaccination (e.g., spontaneous abortions) may be expected to occur frequently 

among early vaccine recipients, even if the vaccine is perfectly safe. A mechanism is needed to evaluate 

the possible contribution of vaccine to such common adverse events to address public concerns, even 

if the plausibility of such associations is low. 

Major existing adverse event detection systems such as CDC’s Vaccine Safety Datalink rely on linked 

medical records, including vaccination and adverse events for the same persons. If public distribution 
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of vaccine occurs, these systems might not accurately record vaccination status, hence may be unable 

to function as normal to detect and evaluate signals of adverse events.

Expected benefits: Systems to address vaccine safety are crucial to the success of any vaccination program 

but will be of particular importance this fall given likely heightened awareness of such issues during a 

pandemic and during a rapid mass vaccination campaign.

Conclusions

Given the short time until the expected resurgence of 2009-H1N1, it is not feasible to create entirely new 

surveillance systems. Nonetheless, we believe that it may be feasible to significantly improve surveillance capabilities by upgrading existing systems. Such improvements could have the following direct 

benefits for decision making. 

• Continuously updated clinical information will provide a basis for national recommendations 

to physicians, with reliable data on who is at highest risk and which treatments are most effective for such patients. 

• Emergency department surveillance, combined with a system to monitor demand on hospitals, 

can provide a considerably stronger basis for decisions about resource allocation to overtaxed 

areas and for assessing the need for enhanced community mitigation measures to slow demand 

on the health system. 

• Emergency department surveillance and population-based surveys will inform estimates of the 

current stage of the epidemic and its trajectory. 

• Adequate reporting and analysis of adverse events is crucial to ensuring vaccine safety and to 

maintaining public acceptance of the vaccine.

We are aware that CDC is developing plans to expand its surveillance efforts for fall 2009 and we strongly 

support such efforts. 

31

V. Responding to the Pandemic

CHAPTER SUMMARY

The impact of influenza epidemics can be mitigated by four methods: vaccination, administration of 

anti-viral drugs, symptomatic medical care, and non-medical interventions that reduce viral transmission. Decisions to implement these approaches depend on a variety of factors, especially the nature and 

course of the epidemic and the availability of materials, personnel, and delivery systems.

Because the influenza virus spreads rapidly and often efficiently, little time is generally available to 

respond once medically significant outbreaks occur. It is thus critical that scenario-based plans be made 

in advance for each of these interventions. It is equally important that a well-defined process for decision 

making be established, with clear assignments of responsibility and logical, agreed-upon guidelines 

for evidence-based decision making. 

The Working Group was impressed with the very active engagement by many highly competent people 

in multiple Federal agencies who are thinking about the decisions that need to be made. However, as 

the fall resurgence nears it is especially important to be certain the roles and responsibilities of these 

individuals in decision making, as well as the processes used to arrive at decisions, are clear. The Working 

Group believes that it would be valuable to (1) clarify decision-making authorities and processes, and 

(2) adopt a more structured decision-making framework for certain key decisions. 

We recommend that the Homeland Security Advisor assume responsibility for identifying the people, 

agencies, and processes for making decisions in the next phases of the 2009-H1N1 pandemic; for guaranteeing that all necessary decisions are made in a timely fashion; and for presenting recommended 

courses of action to the President. 

In addition, we examine critical issues in each of the four areas of intervention and make specific recommendations about the processes and information required for decision making in those areas. In 

particular, we encourage the responsible agencies to focus immediately on decisions that could reduce 

severe disease and death in especially vulnerable populations by accelerating the delivery and use of 

vaccines, increasing the appropriate use of anti-viral drugs, and ensuring access to intensive care facilities.

Finally, we comment on the ways in which decisions made to mitigate disease in the United States might 

affect the many other countries likely to be affected by the 2009-H1N1 pandemic. 

Introduction

Influenza epidemics cannot be prevented with currently available tools, but four categories of methods 

are available to mitigate the effects of an epidemic:

1. Vaccines to prevent infection. For seasonal influenza, vaccines reduce the risk of serious disease 

in infants and children, pregnant women, older adults, people who have chronic medical conditions, or those who might infect high-risk people through their work or household contact. 
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2. Antiviral drugs to decrease the likelihood of infection or severe disease in uninfected individuals (usually those with known or suspected exposure); to reduce the severity and duration of 

disease in patients already infected and ill; and to lower the rate of virus shedding in infected 

individuals, thereby decreasing the likelihood of transmission to others. 

3. Medical care to manage clinical illness, which may range from mild to extreme, delivered at 

home, in out-patient clinics, hospitals, and intensive care units.

4. Non-medical mitigation practices, including isolation of infected individuals, hand washing, 

and several forms of social distancing such as school closures, cancellation of sporting events, 

etc., to lower the chances of person-to-person transmission of virus.

Because the influenza virus spreads rapidly and often efficiently, little time is generally available to 

respond once surveillance methods reveal medically significant information. For this reason, it is critical 

that plans be made in advance for the production, acquisition, and delivery of medical interventions, 

such as vaccines and drugs; the provision of facilities and materials for patient care; the mobilization 

of necessary health personnel; and the communication of information about both medical and nonmedical mitigation strategies. In addition, a well-defined process for decision making needs to be 

established well in advance, with clear assignments of responsibility and logical, agreed-upon guidelines 

for decision making.

Responding to the anticipated 2009-H1N1 influenza epidemic in the coming months will require complex coordination—across different agencies of the Federal Government, vertically across the various 

levels of government (Federal, state, local), between public officials and health professions and institutions, and between the public and private sectors. “Coordination” across agencies and participants 

can be wasteful and frustrating if there are ambiguous responsibilities and unclear lines of authority. 

Rather than focusing on coordination per se, it is more productive to emphasize clarity about leadership, 

responsibilities, roles, and communication. 

The Working Group has been impressed by the active engagement by many highly competent people 

in multiple Federal agencies who are thinking about the decisions that need to be made about efforts to 

mitigate the effects of the spread of 2009-H1N1 influenza virus in the United States this fall and winter.

The Working Group has some concerns, based on conversations with representatives of the various 

agencies involved, that decision-making authorities and processes may not be completely clear in all 

cases. Primary Federal responsibilities for response to an epidemic are lodged in two departments (DHHS 

and DHS), with significant involvement of others (Education, Defense, State, Agriculture, Labor), and 

coordination by White House staff. While the National Strategy for Pandemic Influenza Implementation 

Plan provides a comprehensive list of assignments for a multitude of offices, agencies, and departments 

involved in the Federal planning process, the large number of tasks and responsible units tends to 

obscure the primary seat of responsibility. (Seewww.pandemicflu.gov/plan/federal/pandemic-influenzaimplementation.pdf.) The Working Group believes it would be valuable to clarify these matters before 

events accelerate in September and assign to the Homeland Security Advisor the responsibility for 

ensuring that all of the important decisions are made in a timely fashion and with appropriate consultation with the President.
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V

In addition to clarifying authorities, the Working Group believes it would be valuable to adopt structured 

frameworks for making certain key decisions. At the time of our study, agencies had not yet formalized 

decision frameworks but were moving to do so. We strongly endorse these efforts. We urge that they 

attempt to be as precise as practical with respect to overall goals, scenario-based assumptions, required 

data elements, quantitative trigger points, expected benefits, and expected costs. It would be valuable 

to circulate these analyses within the government. Where feasible, it could also be desirable to share 

them publicly through an appropriate channel to gain the benefit of expertise outside government; 

this would be consistent with the Administration’s commitment to open government.

MAIN RECOMMENDATION (CHAPTER 5)

As the fall resurgence nears, important decisions will have to be made rapidly and based on limited 

data. It is important to be certain that roles and responsibilities in decision making, as well as the 

processes used to arrive at key decisions, are clear. The Working Group believes that the White 

House is best positioned to ensure that these systems are in place, building upon the strong coordination role it is already playing.

We recommend that the White House designate an individual, preferably the Homeland Security 

Advisor, to be responsible for coordinating all policy development for the 2009-H1N1 response; 

identifying the people, agencies, and processes for making key decisions; guaranteeing that all 

necessary decisions are made in a timely manner; and presenting recommended courses of action 

to the President.

Concerning decision-making authority, it will be important to identify the individual(s) responsible 

for organizing the decision-making processes for each of the mitigation measures. For most key 

decisions discussed in this Chapter, the responsible individual should be the Secretary of DHHS. 

Concerning decision-making processes, it would be valuable to employ structured decision frameworks incorporating scenarios—including an assessment of required data, specific trigger points 

for action, and a forecast of benefits (e.g., decreased morbidity and mortality, decreased transmission) and costs (e.g., financial loss and social disruption). We are aware of and endorse efforts 

already underway to create such structured analyses. Such documents should be shared within 

government and, where feasible, shared with experts outside government.

The most urgent attention should be given to the priority decisions necessary to support vaccine 

and antiviral allocation and deployment, the national medical response, and the implementation 

of non-medical mitigation strategies, as described below.

In the sections that follow, we discuss specific issues that should be addressed in making decisions 

about each of the categories of mitigation methods, and we offer specific recommendations about 

how to approach those issues. 
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 Vaccines and Antiviral Drugs

The two main medical lines of defense are vaccination and antiviral drugs. Vaccination constitutes the 

best defense against an epidemic, but its effectiveness depends on timing and coverage of the population. Both inactivated and live attenuated influenza vaccines are approved for use. (See Box 5A) Antiviral 

drugs can provide a powerful tool for prophylaxis for exposed individuals and for treatment, especially if 

used within 48 hours of the appearance of symptoms, but with possible benefits for treatment of severe 

cases thereafter. Two inhibitors of influenza neuraminidase, oseltamivir and zanamivir, are approved and 

effective against 2009-H1N1 virus. (See Box 5B)

BOX 5A: INFLUENZA VIRUS VACCINES

Two types of vaccines are FDA-approved, recommended for seasonal influenza among the elderly 

and young children, and now being manufactured at five pharmaceutical companies in response 

to orders from the Federal government for use in the 2009-H1N1 influenza pandemic.

Inactivated vaccines are the most widely used. They are prepared by growing viruses in embryonated chicken eggs and then inactivating them by treatment with ethyl ethers or detergents. 

Inactivated vaccines contain all the viral structural proteins and are administered via injection, usually in a single 15 microgram dose that is made available in multi-dose vials or single-dose syringes.

Live attenuated vaccines are made from cold-sensitive variants of the virus that are also produced 

in chicken eggs, partly purified, and administered to the nasal mucosa, usually with a nasal spray 

device.

Other approaches to making influenza vaccines by growth of virus in cell culture or by recombinant 

DNA methods are being studied and are described in Chapter 8. In addition, it may be possible to 

augment the effectiveness of influenza vaccines through the use of adjuvants, substances that 

stimulate the immune response to viral proteins. Use of adjuvants with influenza vaccines has not 

yet been approved by the FDA, but is permitted in Europe. Depending on the outcome of clinical 

tests, adjuvants could be added to 2009-H1N1 vaccines under the terms of an Emergency Use 

Authorization (EUA) from the FDA.
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BOX 5B: ANTIVIRAL DRUGS FOR INFLUENZA

Two classes of antiviral drugs have been developed and approved for use in the treatment of 

influenza. 

One class, the amantadines, blocks the virus life cycle by interfering with a small viral protein 

called M2. This class of drug is not effective in the treatment of either 2009-H1N1 virus or the current seasonal influenza viruses and is thus not considered further here.

The second class, the neuraminidase inhibitors, includes two agents—oseltamivir (TamiFlu, 

taken orally) and zanamivir (Relenza, inhaled)—that are FDA-approved and widely used as prophylaxis against disease (among those known or likely to be exposed to infected individuals) and 

as treatment (for patients diagnosed with influenza). Treatment is most successful when begun 

soon after infection; the agents also reduce the amount of infectious virus produced by infected 

individuals. The drugs are often used in the management of severe influenza, but intravenous 

delivery of these two agents, or of a third agent (peramivir), in advanced stages of development, 

has not yet been approved by the FDA. Resistance to these agents, especially oseltamivir, as a result 

of viral mutation or genetic recombination, can be a major factor limiting antiviral effectiveness; 

seasonal influenza viruses increasingly show resistance to oseltamivir, but thus far only a few of 

the many isolates of 2009-H1N1 virus have shown resistance to oseltamivir.

The Working Group has identified several important decisions that need to be taken—immediately 

in some cases, rapidly in all cases—if these two mitigation measures are to be employed to maximum 

effect this fall:

(1) Accelerate vaccine production. The expected timing of vaccine availability poses significant challenges, as seen from the following considerations: 

• Although revisions of the schedule are under consideration by DHHS, plans announced in July 

by the HHS Secretary would provide the first significant quantities of 2009-H1N1 vaccine in 

mid-October; an effective immune response would take another 2 to 4 weeks to develop after 

vaccination. Under the model scenario described in Chapter 3, the resurgence of the epidemic 

would start in September and peak in mid-October. If this model is approximately correct with 

respect to timing, a vaccination campaign would not begin to protect vaccinees until well after 

the epidemic had peaked. 

• Certain groups are already known or suspected to be at high risk for serious complications and 

death from 2009-H1N1, and are likely to account for a significant minority of serious morbidity 

and mortality. Based on current information, groups at relatively high risk include pregnant 

women, individuals with certain neurological impairments, asthmatics, and others (see Chapter 

3). In addition, high numbers of severe cases and deaths were observed among children and 

young adults. These groups would disproportionately benefit from early access to vaccine.
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Given these circumstances, it is important to consider options for accelerating the availability of vaccine supplies, at least for individuals at elevated risk, estimated to represent nearly 40 million in the U.S. 

Currently, vaccine availability is gated by results of clinical studies concerning safety and optimal dose 

(expected in mid-September), after which manufacturers can “fill and finish” the vaccines at the appropriate doses (which requires another 3–4 weeks). Inactivated vaccine for seasonal influenza is usually 

administered at a dosage of 15 micrograms; a similar dosage is expected to work for the 2009-H1N1 

vaccine, but this will not be known with certainty until results from clinical studies are available.

RECOMMENDATION 5-1: ACCELERATING VACCINE AVAILABILITY FOR 

HIGH-RISK GROUPS

We recommend that DHHS accelerate the availability of a portion of the vaccine supply to midSeptember by having manufacturers begin to “fill and finish” a subset of the bulk vaccine product 

at 15 micrograms. Such a decision would need to be taken almost immediately. 

We thus recommend a “hedged” strategy in which an initial amount of product is packaged “on risk,” 

assuming a 15 microgram dosage, and the remainder is packaged when dosing and safety information 

becomes available in mid-September following the first results of clinical trials conducted by the NIH and 

industry. The risks of this course of action appear to be relatively low: some vaccine product could be 

wasted by filling vials at sub-optimal doses. If a somewhat larger dose is required, however, physicians 

can administer additional vaccine (e.g., a second dose of 15 micrograms to achieve 30 micrograms). 

The optimal amount of vaccine will need to be determined from immunological responses in clinical 

tests and an appropriate decision analysis. However, it seems clear that filling and finishing up to 40 

million doses could have a substantial effect on the incidence of disease and death in these vulnerable 

populations. 

The Working Group recognizes that there are important considerations for manufacturers as they contemplate reconfiguring their “fill and finish” operations to meet accelerated deadlines. If DHHS elects 

to follow this approach, a highly knowledgeable Federal decision-maker would need to work promptly 

with one or more of the pharmaceutical companies already contracted to produce vaccine to execute 

this strategy.

We note that the National Biodefense Science Board has also encouraged accelerated production and 

that the strategy is under consideration by the relevant DHHS agencies. 

(2) Focus on protecting those at highest risk. Because the most severe outcomes appear to be concentrated in certain groups, based on data thus far with 2009-H1N1, it is logical to assume that focusing mitigation efforts on those groups will have disproportionate public health benefits. In addition to 

accelerating the availability of vaccine, it is important to develop clear guidance about the means of 

access and appropriate use of vaccines and anti-viral drugs for these groups and to communicate that 

guidance to them and their health care providers promptly and effectively (discussed in Chapter 7). We 

note that the complex and distributed nature of the U.S. healthcare system poses logistical challenges 

in accomplishing these goals, which will require considerable planning.
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This strategy will require attention to important questions about the specific recommended interventions, both medical and non-medical. To cite just one example, what guidance concerning antiviral 

prophylaxis should be given to a pregnant schoolteacher whose class has two students who are at home 

after contracting symptoms of 2009-H1N1 influenza? 

RECOMMENDATION 5-2: PROTECTING HIGH-RISK GROUPS

We recommend that DHHS undertake a focused program to identify and maximize protection of 

individuals at high risk of severe outcomes if infected with 2009-H1N1.  

This process should include:

A. reviewing existing knowledge about nH1N1 hospitalizations, ICU admissions and deaths to 

strengthen the list of groups at highest risk for these events;

B. developing plans to mobilize these groups (and their health care providers), generate guidance for members of these groups to follow in deciding when to use such medication, and 

dispense antiviral drugs when indicated;

C. using these mobilization strategies to reach the same groups for vaccination, and begin 

offering vaccine as soon as supplies become available; and

D. considering plans to offer existing vaccines against other respiratory pathogens to members 

of such groups (severe consequences of influenza virus infection often result from secondary 

infection, such as pneumococcal pneumonia).

(3) Manage anti-viral stockpiles. The United States currently has Federal and state stockpiles of approximately 90 million courses of antivirals (consisting of roughly 80 percent oseltamivir and 20 percent 

zanamivir). Each course represents one week of treatment; an individual taking prophylaxis for three 

months would thus consume 12 courses. There is little or no additional supply available for purchase 

through the end of 2009. The existing stockpile must thus be used prudently.

The Working Group has heard concerns expressed that there is a risk of depleting the stockpile if it is not 

managed properly (for example, if used for widespread and prolonged prophylaxis of health care workers 

or the general public). It is important that antiviral drugs be available for treatment and for prophylaxis 

for those at greatest risk of serious illness (prioritized groups directly exposed to virus). Once antiviral 

drugs are released from the national stockpile, the states and localities control their use. Still, CDC has 

an important influence through its guidelines on the use of these drugs. The Working Group heard concerns that the existing CDC guidelines may not be sufficiently strong and clear to promote optimal use.
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RECOMMENDATION 5-3: ANTIVIRAL DRUGS

We recommend that CDC clarify and strengthen its guidelines for use of antiviral drugs, including 

for treatment, pre-exposure, and post-exposure prophylaxis, and contingency plans for the development of drug resistance. These guidelines and plans, and their rationales (including preservation 

of limited supply for those in greatest need), should be clearly communicated to state and local 

health departments, health care practitioners, and the public. State and Federal supplies of antiviral 

drugs should be monitored on a frequent basis.

(4) Intravenous antivirals. Severely ill patients may benefit from the intravenous use of neuraminidase 

inhibitors. (For example, in the model scenario described in Table 3-1, as many as 300,000 patients are 

envisioned to require treatment in an ICU). However, no antiviral drugs have been approved by FDA for 

intravenous use. There are some initial clinical data on intravenous use of the approved drugs oseltamivir 

and zanamivir and more advanced clinical data for peramivir, a new drug with a somewhat different 

resistance profile than oseltamivir. The Working Group urges FDA to work with drug manufacturers to 

determine whether these drugs can be used intravenously as a result of accelerated approval or under 

the terms of an Emergency Use Authorization (EUA).

RECOMMENDATION 5-4: INTRAVENOUS ANTIVIRALS

We recommend that FDA accelerate a decision about the availability of antiviral drugs (peramivir, 

zanamivir, or oseltamivir) for intravenous use.

(5) Trigger for using adjuvant. The effectiveness of vaccines can often be increased by co-administration with adjuvants, substances that can amplify an immune response when mixed with an appropriate 

antigen, allowing the dosage of antigen to be decreased. Thus a given amount of antigen can be used 

to immunize more individuals. This strategy may be important if a vaccine is poorly immunogenic (and 

thus requires a large quantity of antigen) or if vaccine supplies are insufficient to fill an urgent national 

need. A supply of one adjuvant (MF59) has been ordered and stockpiled for possible use with the 2009-

H1N1 vaccine. 

Adjuvants are not currently approved for use with influenza vaccines in the United States, although 

they have been approved and are being used with influenza vaccines in Europe. Accordingly, the use 

of adjuvants would require an EUA by the FDA. Given these circumstances, there is reluctance to use 

adjuvants unless they are clearly necessary to extend the vaccine supply.

The Working Group encourages DHHS to develop quantitative criteria (vaccine efficacy, severity of 

epidemic) that would trigger a decision to use adjuvants and to ensure that sufficient data are available 

for the FDA to grant an EUA. 

(6) Plan for a national vaccination campaign. A decision to vaccinate portions or the entirety of the 

U.S. population against influenza virus is an important step, but the public health consequences of that 
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decision depend heavily on the manner in which the decision is announced, the recommendations 

that are made about who should receive vaccine, and the system(s) chosen to distribute and deliver 

the vaccine. Without those additional steps, actual use of the vaccine may be low or the vaccine may 

be used inappropriately. The Working Group encourages DHHS to accelerate the planning required 

for an effective campaign, taking into consideration some of the recommendations about communication practices offered in Chapter 6. The ACIP has already proposed to CDC that up to 160 million 

people should be considered preferentially for vaccination against 2009-H1N1 virus, and a subset of 

those individuals should be prioritized according to criteria mentioned earlier in this chapter. Plans for 

a national campaign will need to incorporate appropriately those priorities and target messages about 

the vaccine. The complex and distributed nature of the U.S. healthcare system makes a coordinated 

national effort particularly challenging; considerable attention will need to be focused on the many 

logistical challenges.

(7) Surveillance of vaccine effectiveness and vaccine-associated adverse events. Clinical testing of 

an influenza vaccine allows scientists to determine whether that vaccine produces a measurable immune 

response that has been correlated with some degree of clinical protection. However, it does not directly 

determine whether the vaccine elicits protective immunity against infection that is a conclusion that 

can only be firmly drawn by studying groups of vaccinated and control individuals over longer periods 

of time. Furthermore, initial clinical tests usually are conducted with small groups of healthy individuals, 

so rare adverse events and complications associated with pre-existing medical conditions are unlikely 

to be encountered. In view of these circumstances, it will be important that CDC, FDA, and NIH develop 

a collaborative plan to monitor appropriately designated groups of vaccinees, based on age, location, 

or pre-existing conditions, to assess the effectiveness of the vaccines and study any adverse reactions. 

These observations will be especially useful if a virus closely related to 2009-H1N1 returns in future years

Medical Response

As discussed in earlier chapters, even in the absence of changes in the characteristics of the 2009-H1N1 

virus, the capacity of some communities to provide an appropriate medical response to ill patients is 

likely to be strained and possibly overwhelmed at the peak of the anticipated fall outbreak. It is impossible to predict where and when this will happen, so it is important that all communities be prepared 

for this possibility. During spring and summer 2009, the 2009-H1N1 pandemic has stressed the health 

care system in several countries, including parts of the United States, Argentina, Canada, Chile, and 

Mexico, and this has provided an opportunity to learn from the health system response in these places.

Given the structure of the U.S. health care system, the response to these “surge” requirements will be 

addressed at the local, state, and regional levels, with the majority of capacity coming from private and 

non-profit facilities that are outside of government. Nevertheless, the Federal Government will play 

a critical supporting role in this response—by providing guidance to communities on strategies that 

address the medical requirements; by relaxing legal and regulatory constraints; by mobilizing Federal 

personnel to assist in the response; and, in some cases, by providing medical materiel from the Strategic 

National Stockpile. Furthermore, while the Working Group recognizes that the potential inadequacy of 

the Nation’s medical “surge” capacity cannot be closed in the immediate future, we believe that use of 
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existing capacity can be improved and made more equitable by expanded monitoring and allocation 

of scarce resources (such as ICU beds and ventilators) used to care for the most critically ill patients, as 

described in Chapter 4 (see Recommendation 4-4) and by the development of procedures to mobilize 

equipment, personnel, or patients.

RECOMMENDATION 5-5: MEDICAL RESPONSE

In its efforts to prepare the Nation’s complex health care system for the likely increase in cases 

of severe 2009-H1N1 influenza, we recommend that DHHS emphasize the following approaches:

A. Using planning scenarios, forecast requirements for hospital beds, ICU beds, personnel, 

equipment, and medical materiel to inform state and local authorities in their planning 

efforts. Special attention should be given to the capacity to care for critically ill infants and 

children, as most adult ICU facilities are not fully equipped to handle these patients, and 

potentially high-risk populations for whom the Federal Government has specific responsibilities, such as American Indians/Alaska Natives. Guidance should be offered on (1) strategies 

and best practices to close critical gaps, and (2) Federal resources available to assist in this 

effort (e.g., through the Strategic National Stockpile).

B. Use national surveillance systems, in collaboration with state health authorities, to maintain 

up-to-date situational awareness of the medical response across the country, as recommended in Chapter 4 (see Recommendation 4-4). These efforts should aim to determine 

which locations are under the greatest duress; track clinical presentation of infection and 

effectiveness of interventions; and understand which medical surge strategies are most 

effective. 

C. Determine the authorities, protections, and guidelines necessary to maximize a community’s 

ability to allocate scarce resources in the most appropriate, ethical, and just manner, without 

fear of inappropriate penalties. The intent is to ensure uniformity in the allocation of scarce 

and perhaps life-saving medical resources, such as ventilators, across communities.

D. Consult with relevant professional societies and health care organizations to ensure that 

guidance for protection of health care workers from the effects of 2009-H1N1 is supported 

by the evidence, feasible to implement, and is harmonized among multiple sources. Relevant 

societies include the Society for Healthcare Epidemiology of America (SHEA), the Infectious 

Diseases Society of America (IDSA), and, where recommendations concern children, the 

American Academy of Pediatrics (AAP). 

E. Work closely with state and local health personnel to prepare the public to self-triage and 

manage illness at home or at alternative care facilities when appropriate, using scalable solutions such as national toll-free phone lines and web-based instructions where appropriate 

(as discussed further in Chapter 6). 
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Non-medical Mitigation Measures

The Federal Government’s planned response to a pandemic virus includes community mitigation 

measures, including “social distancing,” cancellation of public gatherings, voluntary home quarantine, 

and school closure. Implementation of these measures has been linked to the severity of the pandemic, 

which the Federal Government has codified through a “Pandemic Severity Index” or PSI. The PSI for the 

2009-H1N1 pandemic proved to be very difficult to assign early in its course in North America: the PSI 

depends primarily on the “case fatality rate,” which cannot be calculated with certainty when the total 

number of infected persons is unknown. Implementation of the more significant interventions, such as 

school closure, has proved to be controversial, due to a perceived imbalance between the negative financial and social consequences of the intervention relative to the perceived mildness of the pandemic virus.

Valuable lessons about community mitigation have been learned in the United States, the United 

Kingdom, Japan, Mexico, and elsewhere since the emergence of the 2009-H1N1 virus, and have also 

been gleaned from historical accounts of past epidemics. The Working Group believes it is essential to 

capitalize on these lessons and ensure that communities are prepared to implement appropriate community mitigation measures depending on the course of the pandemic this fall. 

The importance of such preparations is underscored by the following observations: (a) it is possible that 

the virulence of the virus could increase in subsequent waves, as happened in 1918–19; (b) even at the 

current level of virulence, the demand on the health care system in some communities is likely to exceed 

available capacity, necessitating measures to slow the spread of the virus; (c) the sheer number of cases 

in a given community, along with concern among the public, may lead to unplanned school closure and 

absenteeism in the workplace; and (d) it is unlikely that significant proportions of the population will 

have vaccine-mediated immunity at the time the 2009-H1N1 virus returns to a given community this fall.

The Working Group recognizes that many components of the Federal Government, including DHHS/

CDC, NSC, and the Departments of Labor, Homeland Security, State, and Defense are engaged in discussions of non-medical mitigation methods and that national guidance is being developed. We suggest 

that adequately resolving these issues will require a greater quantitative specificity, in particular, of 

the trade-offs between the medical benefit gained and social disruption caused by school or institutional closure. The costs and benefits of these measures have not, to our knowledge, been adequately 

weighed in quantitative terms. For example: although there is significant evidence, as well as logic, to 

support the idea that school closure (and presumably similar social distancing actions) can reduce virus 

transmission, clear analyses are needed of what specific effects on the spread of infection in different 

types of communities are likely to result from school closures at different infection prevalence. Even 

more difficult to assess are the economic and social costs of implementing such measures. Although 

evidence-based estimates of such costs are difficult to make and inherently imprecise, they can help to 

advance the rationality of the debates, especially if performed in the context of specific scenarios for 

the severity of an epidemic.

Finally, we note that there currently appears to be no value in using border closures or travel restrictions as social mitigation measures, as the H1N1 influenza virus is already well-established in the U.S. 

This situation could change if a more virulent or drug-resistant variant of 2009 H1N1 in another country 

became a serious threat.
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RECOMMENDATION 5-6: NON-MEDICAL INTERVENTIONS

We encourage CDC, working with other components of DHHS, the Departments of Education, 

Homeland Security, Commerce, Labor, and others as appropriate, to prepare a document that 

provides general guidance on non-medical interventions to mitigate the predicted recurrence of 

the 2009-H1N1 pandemic in the United States. This document could be the basis for communication 

of key messages to several different constituencies, including local governments, school officials, 

leaders of institutions and businesses with high concentrations of personnel, and organizers of 

various kinds of public events, and it should include several important components:

A. A description of the lessons that have been learned about community mitigation measures 

as a result of the experience in the United States, Japan, Mexico, and other places where 

these measures were implemented during the 2009-H1N1 pandemic, as well as a summary 

of lessons from earlier epidemics.

B. An account of the second- and third-order consequences of measures such as closure of 

schools and other institutions or cancellation of public events, and strategies to limit their 

impact. 

C. An articulation of the goals of community mitigation measures if implemented (e.g., reduction in community-wide transmission, reduction in peak burden on health care system, protection of those most at risk for severe complications, reactive in response to absenteeism) 

under various scenarios, and the impact this would have on implementation. 

D. Triggers for implementation and adjustment of community mitigation strategies, based on 

data that are likely to be readily available to decision-makers. These plans should include 

strategies for communicating the recommendations to the public and state and local stakeholders, as discussed in Chapter 6.

E. Methods for monitoring the effectiveness or ineffectiveness of these interventions during 

the expected fall outbreak, both to guide continued use in the fall and to gather knowledge 

for use in future influenza outbreaks.

International Considerations Presented by the Pandemic 

In preparing for the resurgence of the 2009-H1N1 epidemic, protecting the U.S population is the Federal 

Government’s primary responsibility. In addition, the Federal Government is concerned about the impact 

of the pandemic on other countries in terms of health effects (diseases spread rapidly across borders 

and epidemics do not end until they subside everywhere); economic consequences (pandemics can 

disrupt the global economy, trade, tourism, political stability, and foreign policy); and, importantly, 

humanitarian reasons (rooted in deeply held national values).

There is reason to believe that under-resourced countries may be at special risk during influenza epidemics. For instance, a recent study projected that, if a 1918–19-like pandemic were to happen today, 
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96 percent of the deaths would occur in the developing world. Given the relatively young demographic 

profile, the widespread prevalence of co-morbidities such as malnutrition, HIV/AIDS, and tuberculosis, 

and the fact that many of these countries do not have functional health systems, the 2009-H1N1 pandemic could have a devastating impact on developing nations. Serious outbreaks already have been 

observed in underserved populations in the developed world. For example, aboriginal populations of 

Manitoba, which represent 10 percent of the population, appear to have accounted for 30 percent of 

cases of 2009-H1N1 influenza in the province so far and the majority of 2009-H1N1-infected patients 

requiring intubation in ICUs in Winnipeg. 

While recognizing that issues with basic health infrastructure in developing countries cannot be remedied in the short run, the availability of materials—including 2009-H1N1 vaccine, antiviral medications, 

antibiotics, personal protective equipment, and other essential medical materials—may help mitigate 

the impact of the epidemic. Unfortunately, global supplies of the most important of these items—vaccines and antiviral medications—are expensive and severely constrained; thus, large quantities are 

unlikely to be readily available to developing nations. The vast majority of production capacity for 2009-

H1N1 vaccine, for instance, already has been reserved by industrialized countries. 

Since 2005, the United States has taken a number of steps, often in conjunction with WHO, to support 

global pandemic preparedness, including the open sharing of information about novel influenza viruses 

and establishing capacity in developing countries to rapidly detect and respond to influenza viruses 

with pandemic potential (see Box 5C). 

BOX 5C: SAMPLING OF U.S. ACTIONS TO SUPPORT GLOBAL PANDEMIC 

PREPAREDNESS

• Sharing viral isolates, sequence information, and technical expertise with WHO and regional 

and national laboratories;

• Providing technical assistance to support country-level pandemic planning over the past 

several years, including adaptation of community mitigation strategies to developing world 

contexts;

• Providing technical assistance to support in-country public health and medical responses,, 

including adaptation of clinical guidelines and implementation of medical surge plans;

• Providing resources to WHO, as well as personnel and technical assistance;

• Supporting the WHO Global Access Plan to establish vaccine production capacity in developing countries and the WHO-managed stockpile of antiviral medications;

• Providing extensive support of in-country laboratory and surveillance efforts; and 

• Supporting the response to 2009-H1N1 influenza in Mexico this spring, including a donation 

of 400,000 courses of oseltamivir.
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Mindful of the urgency of protecting the U.S. population, the Working Group nonetheless believes that 

the United States can play an important role in efforts to reduce the impact of the 2009-H1N1 pandemic 

in developing countries, both independently and in collaboration with other countries and WHO. We 

recognize that the current lack of a U.S. Agency for International Development (USAID) Administrator 

and a Director of the Office of Global Health Affairs at DHHS has limited the institutional capacity to 

work on these issues. Nonetheless, we believe these issues should be addressed. 

RECOMMENDATION 5-7: THREE ACTIVITIES TO REDUCE THE IMPACT 

OF THE EPIDEMIC ON DEVELOPING COUNTRIES

A. Take action to produce, purchase, or redirect vaccines, antiviral drugs, antibiotics, and medical materiel to developing countries in need of such support; 

B. Use the influence of the United States, in collaboration with WHO, to convince other developed nations to pay close attention to the needs of developing countries during the pandemic and to encourage manufacturers to make vaccines and drugs available under donation 

and/or tiered-pricing schemes to those developing countries that have the plans and the 

capacity to use them effectively, and in the same time frame as these materials are made 

available to developed countries;

C. Incorporate the international consequences of mitigation plans into Federal decision-making 

processes for the pandemic—for example, by recognizing that efforts to conserve antigen by 

use of adjuvants in vaccines or to conserve antiviral drugs by restriction on inappropriate use 

could liberate valuable materials for use in poor countries severely affected by the epidemic

An Improbable Scenario Requiring More Stringent Non-Medical Measures

The 1918–19 pandemic was characterized by a relatively mild first wave of illness in spring 1918, followed by much more severe second and third waves. This pattern could conceivably be repeated with 

the 2009-H1N1 virus, leading to a far greater strain on communities than described in Chapter 3 or currently anticipated by the Federal Government. While the Working Group views this specter as highly 

unlikely and inappropriate as a driver of Federal preparedness efforts, the possibility of such a “step 

change” in the severity of the pandemic (e.g., to “Category 5” in the current Pandemic Severity Index) 

cannot be entirely ignored. If it should occur, the Federal Government would be confronted with a 

national crisis and the prospect of hundreds of thousands of deaths, millions of hospitalizations, and 

a dramatic impact on the functioning of communities due to school closure, workplace absenteeism, 

and fear-driven changes in people’s behavior.

Such an event would stress the Federal Government in ways that are not discussed in this report. 

The Federal Government may be unable to respond to the number and scope of requests for Federal 

assistance from state and local authorities, whether for support of the healthcare infrastructure or the 

preservation of law and order. Communities may be unable to provide medical care to everyone in 

need, raising the prospect of rationing of services and mortality that would otherwise be preventable. 
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Federal, state, and local authorities may take unilateral action such as border closure, seizure of essential 

commodities, or curtailment of individual freedoms, out of fear or as a result of public pressure.

Under these circumstances, it would be necessary for the Federal Government to have streamlined 

mechanisms for decision making and coordination of the national response. The capability for such 

coordination extends well beyond the processes described earlier in this chapter, and falls into the realm 

of “national incident management.” The Federal Government has spent a great deal of time developing systems for such coordination; the National Response Framework and associated documents are 

the result of that work. But these systems have never been tested by an event of the scope and scale 

described here. For this reason, it is essential that the Administration examine these systems of coordination and the roles and responsibilities of all players—particularly the Departments of Homeland 

Security, Health and Human Services, Justice, Defense, State, and Education—to ensure that the Federal 

response can be scaled to the magnitude of the health crisis as warranted by the circumstances.

47

VI. Lowering Financial and Regulatory 

Barriers to Effective Response

CHAPTER SUMMARY

Legal, social or financial obstacles may prevent institutions and individuals from taking useful actions 

to confront an epidemic.

In this chapter, the Working Group describes several such barriers to effective actions and proposes 

ways to overcome them in times of public health emergencies by providing funds, suspending certain 

medical regulations, reducing financial impacts on hospitals, using special authorities, and encouraging 

action in the private sector.

We also recommend that the National Security Council, led by the Homeland Security Advisor, undertake 

a systematic review of potential legal, social, and financial barriers to action, to determine which might 

reasonably be ameliorated during the time of the anticipated epidemic and to set plans in motion to 

reduce or remove such barriers in accord with the observed severity of the epidemic. 

Introduction

As discussed in previous chapters, influenza epidemics can be mitigated through medical and nonmedical interventions. To achieve their full benefit, such actions require the compliance of individuals 

and organizations in many sectors, as well as adequate funding. The purpose of this chapter is to identify 

the potential social, financial, and regulatory barriers to compliance and to recommend ways to lower 

those barriers. Because the list of barriers and solutions below is likely to be incomplete, it would be 

valuable for the Administration to undertake a systematic analysis of these issues. 

MAIN RECOMMENDATION (CHAPTER 6)

The effectiveness of mitigation efforts can be improved by (a) identifying potential legal, social, and 

financial barriers to action in the face of an influenza pandemic; (b) developing specific solutions 

and identifying triggers for implementing these solutions when feasible; and (c) ensuring that 

relevant actors know about the intentions to deploy the solutions. We describe several potential 

barriers, propose some solutions, and suggest that barrier-reducing activities be led by the National 

Security Council and the Homeland Security Advisor. 
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Emergency Funding for Federal, State and Local Actions

Responding to any widespread health emergency, such as an influenza epidemic, requires substantial 

resources from public and private sources, and the current economic recession is a potentially limiting 

factor in the provision of such funds.

The President and Congress have already taken commendable action through the Supplemental 

Appropriations Act, 2009 (P.L. 111-32), to provide financial support for efforts to control the current 

2009-H1N1 pandemic by securing emergency response funds and allocating a substantial portion to 

support mitigation methods, as described in Chapter 1. We presume that the Office of Management 

and Budget will continue to closely monitor Federal expenses for influenza mitigation, so that additional 

emergency appropriations can be sought if necessary.

Using these funds, the Federal Government also has taken an important step to help already overburdened state and local public health organizations respond to the pandemic by providing $350 million 

from the emergency appropriation, through DHHS, to state and local governments and hospitals. 

It is likely that additional funds will be required for various activities. In Chapter 4 we discuss the importance of enhancing surveillance systems—for example, to enlarge the capacity to diagnose 2009-H1N1 

infection. In many states, public health laboratories are the only facilities offering this testing. If such 

laboratories are overwhelmed, key decisions about prophylaxis, treatment, and school closure may be 

delayed by diagnostic uncertainty. More funds would likely be required for such laboratory expansions.

RECOMMENDATION 6-1: DHHS MONITORING

We recommend that DHHS monitor the financial situation of state and local governments to 

determine whether they have sufficient financial resources and personnel to carry out necessary 

surveillance (including monitoring trends in respiratory virus activity and at least a minimal level 

of viral surveillance) and to respond to the public health situation, which may vary from one jurisdiction to another. 

Lowering Barriers to Hospital Care

Hospitals may face regulatory and economic disincentives to care for patients acutely ill with influenza. 

In large outbreaks, hospitals—and in particular their pediatric wards, emergency departments, and 

ICUs—may quickly become overwhelmed. This may lead to the need for alternative care sites such 

as schools, hotels, stadiums, recreation centers, and churches. In addition, as we have already seen in 

other developed countries coping with influenza outbreaks this year, hospitals may need to reduce 

the number of beds available for elective surgeries and other activities that provide a major source of 

revenue. Further, overcrowded ICUs may require hospitals to transport some patients outside of the 

immediate area. Because rates of hospitalization for 2009-H1N1 are highest in children, hospitals can 

also anticipate needing more pediatric equipment than is typically available. 
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VI . Lowering Financial and Regulator y Barriers to Effecti ve Response

To respond appropriately to these pressures, hospitals may require relief from certain regulatory provisions that normally limit the number of severely sick patients who can be seen; require that all patients 

be subjected to routine tests or procedures that may be irrelevant during a pandemic; or prevent the 

rapid triaging of patients who are only mildly ill. 

Two actions typically are necessary for these usual assurances to be waived. First, the DHHS Secretary 

must declare a Public Health Emergency. When this action is taken, the Secretary can gain access to a 

special fund called the Public Health Emergency Fund. (We note, however, that this access is currently 

since Congress has not appropriated any public monies to the Fund.) Second, the President must make 

a declaration under the Stafford Act or National Emergencies Act. When both of these actions have been 

taken, DHHS can waive or modify a number of administrative requirements of the Emergency Medical 

Treatment and Active Labor Act (EMTALA), Medicare, Medicaid, and the Children’s Health Insurance 

Program (CHIP). For example, the Secretary can waive conditions of participation or certification requirements, allowing health providers to offer care even if not licensed by their state to do so. In addition, an 

“1135 waiver” of EMATLA could enhance the ability of hospitals to respond to a pandemic by allowing 

• Diversion of less ill patients from emergency departments to alternative care sites for triage and 

treatment without being subject to penalties and fines;

• Provision of emergency care for patients regardless of their ability to pay; and

• Earlier care of patients in emergency departments, by eliminating the requirement for a medical 

screening exam before evaluation by a health provider.

During the spring 2009-H1N1 outbreak, a Public Health Emergency was declared nationwide but the 

Stafford Act was not invoked. Because both actions are required for DHHS to issue an 1135 waiver, hospitals were not authorized to divert individuals to off-site alternate care sites, even if their emergency 

departments were overwhelmed. In addition, the Public Health Emergency Fund, though authorized, 

is currently unfunded.

RECOMMENDATION 6-2: PUBLIC HEALTH EMERGENCY

We recommend that if the Secretary of DHHS declares a Public Health Emergency, the President 

consider issuing a Stafford Act declaration so that hospitals can more effectively triage and treat 

patients. 

Alternatively, the Administration could ask Congress to amend the Social Security Act preemptively 

so that the ability to issue 1135 waivers is linked automatically to the declaration of a Public Health 

Emergency.

In addition, we recommend that Congress provide funding for the Public Health Emergency Fund.

In addition to regulatory barriers, hospitals face significant financial disincentives for vigorous planning 

and implementation of appropriate disaster operations. For example, a resurgence of 2009-H1N1 may 

fill large numbers of hospital beds with individuals who are in need of expensive care but are either 
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uninsured or have insurance that will reimburse the hospital at unfavorable rates. Moreover, a 2009-

H1N1 resurgence could preoccupy hospital personnel; trigger expensive contagion control procedures; 

and force the postponement of more profitable cases or their diversion to other providers. All of these 

factors can have a detrimental effect on hospital finances. Hospitals also may need to rely upon alternative care sites and standards, which may not be subject to the usual reimbursement rules, raising the 

potential for non-reimbursed care.

RECOMMENDATION 6-3: EXAMINATIONS AND REIMBURSEMENT

We recommend that DHHS’s Centers for Medicaid and Medicare Services (CMS), which reimburse 

hospitals for care provided through Medicare, Medicaid, and the Children’s Health Insurance 

Program (CHIP), examine the financial implications for hospitals of actions they might take in 

responding to the pandemic. Such an analysis should examine the economic implications of 

hospital reimbursement for the care of 2009-H1N1 patients in conventional and alternative care 

sites, while also considering the financial losses that hospitals might incur by deferring elective 

procedures.

Non-medical Mitigation Activities

A key element in mitigating the spread of an epidemic is compliance with social distancing measures—

for example, staying home from work or school or avoiding public gatherings such as concerts or 

sporting events when ill. However, compliance is unlikely when economic or other disincentives punish 

individuals for these behaviors. It is critical that appropriate Federal officials take the lead in identifying 

these disincentives and removing or minimizing them. Since immunizing large segments of the population likely cannot be completed before late November or early December, the use of social mitigation 

measures may represent the most effective means for reducing transmission of virus in the fall when it 

is spreading most efficiently. 

Because crowding in schools is extreme and prolonged and because the risks of infection with 2009-

H1N1 to the relevant age groups are high, special consideration should be given to ways to encourage 

potentially infectious students to remain at home rather than attend school.
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RECOMMENDATION 6-4: COMMUNICATING WITH SCHOOLS

We recommend that the Department of Education, working with the Department of Health and 

Human Services and the Department of Labor, meet with representatives from state and local 

school districts in August 2009 to identify the financial needs and regulatory barriers that would 

discourage decisions to close schools when public health conditions warrant such closures and to 

consider actions that Federal, state, and local authorities could take to reduce those disincentives. 

Examples of possible actions include waivers on the minimum required number of school days, 

meals for children who are in school meal programs, access to online or “drop off” educational 

activities and programs, and childcare options for parents who work. Because actions might need 

to be taken rapidly, it is important that these plans be well publicized to institutional actors, including school principals.

We also recommend that the Department of Education develop clear and effective 2009-H1N1 

contingency plans by October 1, 2009, and designate a health professional who is familiar with 

public schools to provide guidance to school districts. 

Individuals sick with 2009-H1N1, and those who need to care for affected family members, face a loss of 

income or employment if they stay home from work. Similarly, holders of tickets for travel or sporting 

events face potentially substantial economic losses from nonrefundable ticket expenses. Such barriers may make them less willing to participate in social mitigation strategies that the government may 

propose. Both government and private organizations may need to take actions to lower such barriers. 

For example, the government can encourage businesses to promulgate more flexible sick leave and 

ticket reimbursement policies in response to an outbreak of influenza.

RECOMMENDATION 6-5: COMMUNICATING WITH BUSINESSES

We recommend that the Domestic Policy Council and the Assistant to the President for 

Intergovernmental Affairs and Public Liaison meet with leaders of small businesses, industry, 

and labor to identify mechanisms that might encourage individuals to stay home while sick—for 

example, by alleviating economic losses employees might otherwise sustain from such responsible 

actions. These leaders could identify actions the President might advocate to reduce barriers to 

social mitigation actions, such as more liberal worker leave policies, flexible union rules, and refundable tickets for airlines, trains, or buses or for concerts, athletic, or other public events. 

We also recommend that the Federal Government immediately initiate policies that, in the event 

of increasing spread of influenza virus, would allow Federal employees with respiratory illness (or 

those caring for a child with same) to stay at home without financial penalty.

53

VII. Improving Communications

CHAPTER SUMMARY

Communication will be one of the most formidable challenges in managing the anticipated resurgence 

of 2009-H1N1 this fall, due to the rapidly evolving nature of the outbreak, the number and complexity 

of the messages, and the myriad channels through which the public will be receiving information. 

CDC is the lead Federal agency for communication with state and local health departments, health care 

providers, and the general public. CDC’s communications plans for the first two groups appear to be 

proceeding well, although we offer some suggestions. 

Concerning communications with the general public, the Working Group believes it would be desirable 

to have well-developed communications plans that cover a variety of contingencies and is concerned 

that the planning for such communications may be somewhat behind schedule. 

We recommend that CDC expand its efforts to develop a full range of communication plans for various contingencies. In view of the fact that 2009-H1N1 particularly affects young people, these plans 

would ideally include outreach not only to traditional media but also new media and social networking 

channels.

Introduction

One of the lessons of prior influenza epidemics is the importance of timely, clear, and effective communication among government officials, medical professionals, and the public. In spring 2009, CDC reacted 

well in terms of communications with both professionals and the public. CDC maintained a steady flow 

of up-to-date information and admitted the limitations of its knowledge as the situation evolved. 

During the expected fall resurgence of 2009-H1N1, communication will again pose a formidable challenge for officials and others trying to manage the pandemic. But the communications challenge will 

be fundamentally different than in the spring, when the epidemic arrived unexpectedly and CDC’s 

stance was necessarily reactive. For the anticipated fall resurgence, CDC’s approach must be pro-active. 

The fundamental difficulties are that (i) the messages will be more numerous and more complex and 

(ii) the precise content of the messages is uncertain for now and will depend on the specifics of how 

the public health situation unfolds. Nonetheless, the existing data give planners enough knowledge to 

envision different scenarios of how events could play out (see Chapter 3). This makes it possible—and 

we believe imperative—to have carefully considered communication plans prepared in advance, ready 

for many contingencies.

For instance, if only limited supplies of vaccine are available initially, it is likely that diverse groups at 

particularly high risk of severe disease will be prioritized for vaccination and potentially for antiviral 

medications, as described in Chapter 5. Communication plans need to be developed to reach individuals 
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who belong to the designated high-risk groups and their health care providers—for example, through 

patient advocacy groups, provider organizations, radio and TV spots, and social networking. The content 

and format of the outreach materials should be considered in advance. Contacts should be made in 

advance with leaders of relevant media or patient organizations so they can prime their networks for 

rapid delivery of the relevant messages. 

CDC clearly is the lead Federal agency for communication with three constituencies: (1) state and local 

health departments, (2) health care providers, and (3) the general public. The Working Group reviewed 

CDC’s communications plans in these areas for the anticipated epidemic this fall. 

The Working Group expressed confidence in CDC’s communications plans with the public health 

departments and health care providers; the Group’s primary suggestion for communication with these 

groups is that CDC work to harmonize recommendations with relevant medical societies. In contrast, 

the Working Group expressed some concern that CDC’s plans for public communications appear to be 

inadequately developed at present and somewhat behind schedule. In addition, the Group was concerned that CDC had not adequately planned to engage the full range of communications channels. 

Because 2009-H1N1 will particularly affect young people, there is an opportunity and need to engage 

new media and social networking channels. 

MAIN RECOMMENDATION (CHAPTER 7)

We recommend that CDC accelerate its planning efforts for public communications. Given the 

limited time frame and the wide range of uncertainties, we recommend that CDC systematically 

identify the full range of messages that may need to be communicated, particularly messages 

about actions that may be required of the public under various scenarios; prepare well-developed 

plans for these communications; and begin outreach to relevant communications channels as soon 

as possible. 

We also recommend that CDC engage not only traditional media, with which CDC has deep experience, but also new media and social networking channels, especially given the propensity of the 

2009-H1N1 virus to infect young people. For this purpose we recommend that CDC draw heavily 

on the expertise of the office of the Federal Chief Technology Officer. 

Communication with State and Local Health Departments

CDC deserves high marks for its coordination of information flow to and from state and local health 

departments during the spring 2009-H1N1 outbreak. It clearly articulated what was known and 

unknown, provided useful updates in real time, and assimilated large amounts of regional data to provide an evolving picture of what was happening on the national level. 

In Chapters 3 and 4, the Working Group recommends that CDC (i) define and disseminate specific scenarios concerning the pandemic and (ii) improve various surveillance systems. These steps should feed 

into and enhance communications with state and local health departments. In addition, the Working 

Group urges CDC to prepare materials to help Federal, state, and local health officials deal with potential 
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VI I . Improving Communications

misunderstandings relating to adverse events. It is certain that, by chance, some adverse events will occur 

following vaccination (e.g., on any given day, some elderly individuals will die and pregnant women 

will miscarry). It is important that CDC has well-developed materials completed in advance to set such 

events in context, as well as to help experts recognize truly unexpected occurrences.

Communication with Health Care Providers

Medical professionals rightly regard CDC as the authoritative source for public health information, 

especially during emerging epidemics. In general, CDC has discharged this function well during the 

present crisis. However, there have been several instances in which its recommendations have been 

controversial—particularly those regarding hospital infection control, which have sometimes been 

based on hypothetical concerns rather than epidemiological data. Some of these recommendations 

generated controversy and even outright opposition from caregivers. For example, CDC’s recommendation for use of N95 respirators by those caring for hospitalized 2009-H1N1 patients is at variance with the 

views of several other expert bodies. Such conflicts can generate confusion and anxiety at many levels 

in the hospital workplace, impair effective compliance with proper infection control, and undermine 

physician confidence in CDC and public confidence in local infection control measures at a time when 

confidence levels need to be maximized.

RECOMMENDATION 7-1: HARMONIZE RECOMMENDATIONS

We recommend that CDC work to harmonize its recommendations with those of relevant professional societies prior to their public release. As discussed in Chapter 5, relevant societies include the 

Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America 

(IDSA), and, where recommendations concern children, the American Academy of Pediatrics (AAP). 

Communication with the General Public

CDC and other Federal agencies must communicate with the public in two broad areas: (1) medical 

interventions (vaccines and antiviral medications); and (2) non-medical, community-based interventions (e.g., social distancing and isolation of sick individuals). The Working Group has some concerns 

with the communications plans in both areas. Since they have different origins, the two sets of concerns 

are considered separately.

Medical Interventions: CDC has a long history educating the public about seasonal influenza and the 

vaccine that provides protection against it. Despite this experience, efforts to prepare the influenza 

public information campaign for fall 2009 have been hampered by several factors, including:

• the need to divert staff to communicate urgently with the public regarding the spring 2009-

H1N1 outbreak

• uncertainties about the 2009-H1N1 vaccine (including how much will be available, on what 

schedule it will arrive, how many doses may be needed, and who should receive vaccination); 

and
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• the inherent complexity of a public health message that encompasses two vaccines for two 

different types of influenza (2009-H1N1 and a seasonal strain), especially if two doses of 2009-

H1N1 vaccine are required.

For these and other reasons there is much communications work ahead, and very little time to complete 

it. CDC’s information campaign will need to: 

• refocus the public’s attention on 2009-H1N1 influenza, which has largely receded from public 

consciousness (due in part to the media’s sporadic attention to the topic), and its relationship 

to seasonal influenza;

• keep the public updated about the severity of the epidemic;

• educate the public about when to seek medical attention and where to do so;

• inform the public about personal and community-wide action that may be necessary this fall, 

and steps people can take to be prepared;

• reach groups at particularly high risk; and

• respond effectively to unexpected events, such as reports of adverse events that occur following 

(but not necessarily because of) vaccination.

To accomplish these missions, it is critical that CDC have well-developed public communications plans 

that can be launched rapidly. The planning for various contingencies should be completed now, before 

all the relevant information is available. Contacts with various media should be established soon, and 

messages and materials should be developed and tested. 

We particularly encourage CDC to work with new media and social networking channels. Beyond simply 

transmitting CDC’s own messages, we believe there are opportunities to engage and encourage the 

creativity of the social networking community to create content and collect information. Members of 

the Working Group were impressed by a recent paper by researchers at Google and CDC demonstrating 

that an analysis of Google searches related to influenza-like symptoms was able to identify outbreaks 

earlier than conventional surveillance systems. Examples could include: 1) websites with information 

about initial self-diagnosis and treatment, up-to-date information about the epidemic, and perhaps 

even ways to share personal information that could help inform national surveillance; 2) mobile phone 

“apps” with similar content; 3) videos that convey messages in unusual ways; and 4) Facebook quizzes 

on influenza, shared among friends. In support of efforts to fight the influenza virus, we advise the use 

of communications tools designed to facilitate their “going viral.” Such tools are more likely to be created 

by members of the public than by the government. However, it may be possible to encourage such 

efforts through contests and other mechanisms. 
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VI I . Improving Communications

RECOMMENDATION 7-2: CDC COMMUNICATION EXPANSION

We recommend that CDC expand its efforts to develop a robust communications plan covering the 

full range of potential public messages about medical and non-medical interventions. We strongly 

suggest that communications efforts be launched prior to September 1. 

A. With respect to traditional media, we suggest that CDC reach out to major communication 

channels (e.g., editorial boards and medical reporters at newspapers, TV and radio stations, 

and magazines) to inform them about issues, to interest them in running stories to promote 

awareness, and to maintain connections that will facilitate communication when unfolding 

events demand rapid responses. 

B. With respect to new media and social networking, we suggest that CDC reach out to key 

companies (e.g., Facebook, Twitter, Google, Apple) and other innovative entities and individuals (those who maintain prominent websites and blogs related to health in general 

and influenza in particular). In this outreach, CDC could benefit by working closely with the 

Federal Chief Technology Officer.

C. In addition, we urge CDC to expand its capacity to develop rapid responses to misinformation 

appearing in traditional media and on the Internet

Non-medical Interventions: Compared to communications about medical interventions, communications about social actions to mitigate spread of the influenza virus can be crafted in relatively finished 

form despite uncertainties about details of the epidemic. Public understanding about such personal 

measures and their public health value are particularly important given the likelihood that vaccine will 

not be available as rapidly as desirable. The Working Group expressed some concern that public communications plans for such measures appear to be incompletely developed.

Fundamentally, there are two main categories of personal actions to mitigate viral spread, hand hygiene 

awareness and individual efforts at social distancing, which can be summarized in two simple messages: 

“Keep your hands clean” and “Stay home when you’re sick.” Although these messages are simple, the 

educational campaign is difficult because it involves persuading people to change established patterns of behavior and requires broad adoption to be successful. Campaigns to encourage these actions 

should strive for clarity and simplicity; use diverse and complementary channels of communication; 

and incorporate thoughtful policies to mitigate barriers to compliance (see Chapter 7). Importantly, 

such campaigns will need to educate the public about why the measures are needed as well as how to 

comply with them. 

Hand hygiene awareness is more than just hand washing. It includes minimizing contact of hands with 

respiratory secretions—by coughing into a sleeve rather than a hand, for example. Communication 

channels that can transmit graphic visual images (e.g., television and Internet) are likely to be the most 

effective. The public already has accepted media ads involving more sensitive bodily functions, and 

major advertising agencies know how to craft effective and acceptable messages in this regard. New 

media and social networking expertise may also be effective here. 
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Social distancing campaigns, especially those that go well beyond the simple notion of remaining 

isolated, generally at home, when ill, must enlist the participation of the general public to be effective. 

Workers and students will need to know when to stay home and for how long; they will also need guidance about proper infection control in the home. When asking the public to eschew activities that involve 

crowds at sporting events, concerts, transportation centers, shopping areas, and other gathering places, 

the messages will need to explain the rationale for such changes in behavior and provide an estimate 

of the length of time the recommendations will be in place. All channels are useful and efforts should 

be made to enlist the most effective communicators (e.g., celebrities) to deliver the relevant messages.

Such campaigns also need to enlist the support of those responsible for the venues in which susceptible and infected people are likely to congregate (e.g., employers, school and university administrators, 

church leaders, sports leagues, and rock concert promoters). Now is the time for the CDC to establish 

communication channels with corporate human resource professionals, school officials, and others to 

inform them about the public health issues surrounding 2009-H1N1 and to help them understand that 

allowing sick individuals to stay home is in their organizations’ best interest, as it will minimize large-scale 

absenteeism. Universities may require special guidance about infection control in dormitory settings.

RECOMMENDATION 7-3: CDC COMMUNICATION QUICK LAUNCH

We recommend that CDC rapidly develop and launch its communications plan concerning personal 

non-medical interventions.

In particular, we suggest that CDC: a) immediately hire a major advertising organization to help 

craft ads for non-medical interventions, targeted at various audiences (e.g., employers, the general 

public, school administrators) and b) work with the Federal Chief Technology Officer to engage new 

media and social networking channels in support of these goals. 
58

VIII. Planning for More Effective Future 

Strategies Against Influenza

CHAPTER SUMMARY

The current threat from 2009-H1N1 has highlighted critical shortcomings in public response systems to 

the emergence of new influenza strains and more generally to outbreaks of infectious diseases. 

There are important opportunities to increase national preparedness against future epidemics. These 

include steps to improve: the design, production, and use of vaccines; the range of antiviral drugs; the 

availability of rapid diagnostics; and the breadth of health surveillance systems. Some of the steps can 

be achieved quickly (within the next year), while some will take longer. 

We propose that the National Security Council coordinate a government-wide effort to increase national 

preparedness in response to the lessons learned from the 2009-H1N1 outbreak and provide periodic 

updates to the President on national progress toward these goals. 

The current situation with 2009-H1N1 has highlighted critical shortcomings in public response systems 

to the emergence of new influenza strains and more generally to outbreaks of infectious diseases. Given 

the emergence of multiple biological threats during the past decade (including SARS, avian flu, 2009-

H1N1, and at least one instance of bioterrorism), it is likely that we will face continued challenges from 

infectious diseases. While there has been substantial progress in preparedness over the past several 

years, there is much work that needs to be rapidly completed. Even while we are dealing with 2009-

H1N1, the Federal Government should take specific steps to ensure our preparedness for the next event. 

Some of these steps will also aid our national response to seasonal influenza.

MAIN RECOMMENDATION (CHAPTER 8)

There are important opportunities to increase national preparedness against future epidemics. 

These include steps to improve: the production and use of vaccines; the range of antiviral drugs; 

the availability of rapid diagnostics; and the breadth of health surveillance systems. Some of the 

steps can be achieved quickly (within the next year), while some will take longer.

We propose that the National Security Council coordinate a government-wide effort to increase 

national preparedness specifically in response to the lessons learned from the 2009-H1N1 outbreak 

and provide periodic progress updates to the President on national progress toward these goals. 

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Accelerate Speed and Increase Yield and Effectiveness of Vaccine Production

Current methods for producing influenza vaccine are too slow, cumbersome, and inefficient given the 

challenge of a rapidly spreading influenza virus epidemic. The predominant design and technologies 

used to produce influenza vaccines have not fundamentally changed in several decades: Viruses are 

grown in embryonated chicken eggs, then harvested and processed to create the vaccine. The process 

typically takes 6 to 9 months, from initial steps to develop a “seed” vaccine virus to completed product. 

Moreover, when a novel virus is isolated late in an influenza season (as was the case with 2009-H1N1), it 

is difficult or impossible to prepare and test vaccine before the resurgence in the next influenza season 

(which, moreover, tends to occur early for novel viruses). 

Recently, there has been progress on two new approaches for vaccine production:

• Cell-based vaccines, in which viruses are grown in cultured cells rather than eggs. This method 

obviates the need for large quantities of embryonated eggs and potentially permits increased 

levels of production beyond those currently achievable. The method, however, does not substantially shorten the timeline between identification of the virus strains to be included in the 

vaccine and the vaccine’s availability. This approach is currently being used by several companies 

to produce candidate 2009-H1N1 vaccines, but such cell-based vaccines have not yet achieved 

licensure in the United States. 

• Recombinant vaccines, in which molecular biology techniques are used to clone influenza virus 

vaccine proteins into various expression systems. There are several such methods currently 

under development and evaluation, including some by industry and by the Defense Advanced 

Research Projects Administration (DARPA). This approach has potential to shorten the time 

between vaccine strain identification and final vaccine production to as little as a few months, as 

well as provide a large increase in vaccine production volume. However, considerable additional 

development and clinical work is required to firmly prove the effectiveness of these technologies and to provide the necessary data for eventual licensure. 

In addition to the pursuit of these approaches, greater efforts should be made to take advantage of 

modern understanding of influenza virus epitopes (the sites on proteins that induce immunity), threedimensional protein structure, the mechanisms of immune recognition, and the sites on influenza viral 

proteins at which the most significant variation is observed. By harnessing such information to new 

methods for protein design and genetic engineering, it is possible to envision influenza vaccines of the 

future that provide longer-lasting immunity against a wider range of viral isolates. Such vaccines might 

be produced efficiently as proteins in a variety of expression systems or as attenuated viruses grown in 

cell culture systems.

In addition to improving vaccine design and technology for vaccine production, efforts need to be 

undertaken to assess and license adjuvants that are compatible with influenza vaccines. Adjuvants can 

greatly increase the potency of vaccines and thereby extend the number of people who can be vaccinated with a given supply. None is currently approved for use with influenza vaccines in the United 

States, although adjuvants have been approved and are being used with influenza vaccines in Europe. 
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VI I I . Planning for More Effecti ve F uture Strategies Against Influenza

The use of adjuvants thus currently requires Emergency Use Authorization (EUA), a step that regulators 

may be reluctant to take. Although clinical trials of 2009-H1N1 vaccines with adjuvants are planned 

for the coming months, it will not be feasible to obtain standard FDA approval in time for use this fall. 

Nonetheless, it would be desirable to achieve licensure of the currently available adjuvants for use in 

the near future. Beyond existing adjuvants, recent advances in immunology point the way to powerful 

new types of adjuvants, the pursuit of which may ultimately enhance the efficacy and lower the costs 

of influenza vaccines. 

Even while these new products are being developed and tested, it is important that the Federal 

Government ensure that capacity is maintained for influenza production by traditional approaches 

for the foreseeable future. Capacity was increased in preparation for a potential avian influenza (H5N1) 

pandemic and is thus available for response to the current 2009-H1N1 pandemic. However, if such high 

capacity levels are not needed over the coming years, companies may reduce production capacity to 

bring it more in line with the lower anticipated demand for seasonal influenza vaccine. The prospect of 

such reduced capacity, which would limit the ability to respond to novel influenza pandemics, provides 

further incentive for developing more efficient means of production. 

RECOMMENDATION 8-1: VACCINES

We recommend that the Federal Government work to:

A. ensure that influenza virus vaccines produced in cell culture, as well as vaccines formulated 

with the currently available adjuvants, proceed expeditiously through the FDA regulatory 

process for licensure;

B. fully support and encourage development of recombinant influenza vaccines and provide 

a clear regulatory path for licensure;

C. encourage and support the development of new adjuvants; and

D. ensure that adequate manufacturing capacity is maintained for production of influenza 

vaccine using currently approved methods.

Facilitate Development of Additional Antiviral Drugs 

There is an urgent need to expand the available range of antiviral drugs that can be used for prophylaxis or treatment of influenza. Currently, there is only a handful of antiviral drugs and only two that are 

licensed and expected to be effective against 2009-H1N1: the oral drug oseltamivir (Tamiflu) and the 

inhaled drug zanamivir (Relenza). There currently are no antiviral drugs approved for intravenous use 

to treat seriously ill patients—although one new drug (peramivir) and the two existing drugs are also 

being tested in intravenous formulations. 

Moreover, these options may narrow further as influenza viruses develop resistance to these drugs. Most 

seasonal influenza has already developed resistance to oseltamivir, and a handful of cases of oseltamivirresistance have been reported among 2009-H1N1 isolates (nine as of the end of July), indicating that 

this virus can also develop resistance. 
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It will be important to develop new classes of drugs to expand the armamentarium. A particularly 

promising new approach is to develop drugs that block the virus by acting on a human cellular function 

(‘host target’), rather than a viral protein (‘pathogen target’), because such drugs should be less likely 

to encounter acquired resistance.

RECOMMENDATION 8-2: ANTIVIRALS

We recommend that the Federal Government work to:

A. expedite the licensure of intravenous formulations of antivirals, and

B. stimulate the development of new influenza drugs that have novel mechanisms of action in 

order to reduce the potential for antiviral resistance.

Facilitate Development of Rapid Point-of-Care Diagnostics

Influenza can be difficult to diagnose because similar symptoms can be caused by agents other than 

the influenza virus, including adenovirus, respiratory syncytial virus, rhinovirus, parainfluenza viruses, 

mycoplasma, and other agents. Moreover, it is important to be able to distinguish among different 

influenza strains, such as seasonal influenza and 2009-H1N1 influenza, because resistance patterns and 

drug-of-choice may vary. Definitive diagnosis can be important to guide medical decisions for individual 

patients and to permit accurate epidemiological surveillance.

Accurate diagnostic tests for distinguishing different influenza strains are available, but they (i) require 

several hours to days to provide results, (ii) are not readily deployed in physicians’ offices or even 

hospital settings, (iii) have limited sensitivity, and (iv) are available in only limited capacity that will be 

overwhelmed in a serious pandemic. The Nation needs the capability to perform rapid, simple, pointof-care diagnostics. The competence and capability to develop such diagnostics exists in many places, 

including CDC, NIH, DARPA and DHS, and the importance of this issue warrants strong, mission-driven 

coordination of efforts across these agencies.

RECOMMENDATION 8-3: DIAGNOSTICS

We recommend that the Federal Government ensure the creation of a national capability to 

develop, on a rapid basis, accurate point-of-care diagnostics for any novel influenza virus. Such an 

effort might be led by DHHS, in coordination with DOD and DHS. 

Improve Medical Surveillance 

As described in detail in Chapter 4, there are substantial gaps in the Nation’s medical surveillance systems 

that limit our ability to obtain accurate, real-time information about epidemics. Some of these gaps 

can be closed quickly, but a more systematic, long-term effort to eliminate them would substantially 

improve national preparedness. 
623

VII I . Planning for More Effecti ve F uture Strategies Against Influenza

Surveillance preparedness to date has emphasized early detection of an outbreak (e.g. early knowledge 

of an anthrax attack), while underplaying the role of ongoing surveillance once an outbreak of infectious 

disease is underway. In the case of influenza, while the United States has systems to provide epidemiological and virological data on influenza, we are still not able to make confident estimates each week of 

the number of people who are infected, seek medical care, are hospitalized, or die of influenza. Notably, 

the UK measures and publicizes many of these statistics weekly. 

Such “situational awareness” is essential for an evaluation of the characteristics of the pandemic, effective allocation of resources to places of greatest need, and appropriate changes in mitigation and other 

response strategies over the course of a pandemic. Moreover, the ability to make such estimates would 

improve diagnosis and treatment of respiratory infections in general and of influenza specifically, both 

in normal and pandemic years, and would provide a basis for greater cost-effectiveness. The estimates 

could be obtained with a nationally representative electronic reporting system for primary care and 

emergency visits, hospitalizations, ICU admissions, and deaths for defined respiratory infections, combined with viral testing of a representative subset of these individuals. This would permit public health 

departments to assess the contribution of various viruses to the disease burden at each level. 

A second key shortcoming in our preparedness is the lack of a rapid system for assembling detailed 

clinical data on severe cases that can provide a statistically adequate and continuously updated picture 

of risk groups and clinical course. Current systems rely on non-standardized reports from local health 

departments and on peer-reviewed case series, which are slow to become public.

As the current pandemic continues to unfold, other key gaps in our situational awareness will likely 

emerge. These revelations should be a basis for improving public health information systems. 

RECOMMENDATION 8-4: MEDICAL SURVEILLANCE

We recommend that CDC take steps to improve surveillance systems for use in epidemics. This 

could include: 

A. working with state and local authorities to establish a dense, geographically diverse, nationwide, real-time surveillance network that can estimate population rates of primary care 

and emergency visits, hospitalizations, ICU admissions, deaths from defined respiratory 

syndromes, and (in a random sample of cases) presence of specific viruses. 

B. working with a set of large hospitals, at least one in each of the top 30 metropolitan areas 

together with the respective local authorities, to establish a system for standardized local 

and national reporting of demographic, laboratory, and clinical characteristics of hospitalized and more severe cases of defined syndromes, including but not limited to influenza. 

We also recommend that after the current pandemic DHHS undertake a comprehensive review of 

unmet needs for data, possible solutions to the problems of providing such data under emergency 

conditions, and the costs of building the necessary surveillance systems.
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Enhance Animal Surveillance Measures

Birds and pigs serve as critical intermediate hosts in the evolution of influenza viruses, including the 

current 2009-H1N1 virus. Methods for monitoring influenza viruses in swine and turkeys are powerful 

tools for following the appearance, spread, and evolution of viruses, and such surveillance would be 

valuable for both human public health and agriculture. Currently the United States lacks a reliable system 

for doing this, but a NIH-funded surveillance program of apparently healthy pigs at a slaughterhouse in 

Hong Kong has established the benefits of such a system.

RECOMMENDATION 8-5: USDA AND CDC COLLABORATION

We recommend that USDA and CDC collaborate to develop a cooperative program of human and 

animal public health that includes: 

A. prospective virological and serological surveillance of swine and turkeys, and the workers 

exposed to them, at permanent sites, to serve as an early warning system of potentially 

pandemic influenza viruses of humans, swine, and turkeys.

B. expanded sharing of influenza viruses, viral sequence information, and reagents. 
645

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Acknowledgements

PCAST wishes to express gratitude to the following individuals who contributed in various ways to 

the preparation of this report:

Richard Besser, Director, Coordinating Office 

for Terrorism Preparedness and Emergency 

Response, Centers for Disease Control and 

Prevention (CDC), Department of Health and 

Human Services (HHS)

Guthrie Birkhead, Deputy Commissioner, Office 

of Public Health, New York State Department of 

Health

Debra Birnkrant, Division of Antiviral Products, 

Food and Drug Administration (FDA) 

Joe Bresee, Branch Chief, Epidemiology and 

Prevention, Influenza Division, CDC, HHS 

Michael Callahan, Program Manager, Blue Angel 

project, Defense Advanced Research Projects 

Agency (DARPA), Department of Defense (DOD)

Martin Cetron, Director for the Division of Global 

Migration and Quarantine, CDC, HHS 

D.W. Chen, Director, Civil-Military Medicine, 

Office of the Assistant Secretary of Defense for 

Health Affairs, DOD 

Ken Cole, Medical Director, Office of the Deputy 

Assistant to the Secretary of Defense for 

Chemical and Biological Defense and Chemical 

Demiliatrization, DOD

Jose Diez, Associate Deputy Administrator for 

Emergency Management and Diagnostics, 

Animal and Plant Health Inspection Service 

(APHIS), Department of Agriculture (USDA) 

Greg Dworkin, Contributing Editor, Daily Kos; 

Founding Editor, Flu Wiki 

Anthony Fauci, Director, National Institute of 

Allergy and Infectious Diseases (NIAID), National 

Institutes of Health (NIH), HHS

Neil Ferguson, Director, Medical Research 

College (MRC) Centre for Outbreak Analysis and 

Modeling, Imperial College, London 

Keith Fontenot, Associate Director, Health 

Programs, Office of Management and Budget, 

The White House 

Bruce Gellin, Deputy Assistant Secretary for 

Health; Director, National Vaccine Program Office; 

HHS

Jesse Goodman, Chief Scientist and Acting 

Deputy Commissioner, Food and Drug 

Administration (FDA) 

Dan Hanfling, Special Advisor, Emergency 

Preparedness and Response, Inova Health 

System, Falls Church, Virginia 

Richard Hatchett, Director for Medical 

Preparedness Policy, National Security Staff, 

The White House

Frederick Hayden, Wellcome Trust

Kathi Hanna, Science Writer

Carole Heilman, Director, Division of 

Microbiology and Infectious Diseases, NIAID, NIH, 

HHS 

Thomas Inglesby, Chief Operating Officer and 

Deputy Director, University of Pittsburg Medical 

Center, Center for Biosecurity 

Michael G. Ison, Divisions of Infectious Diseases & 

Organ Transplantation, Northwestern University

Dennis Israelski, Clinical Professor of Medicine, 

Department of Medicine, Division of Infectious 

Diseases and Geographic Medicine, Stanford 

University School of Medicine;Vice President 

for Global Health, Innovative Support to 

Emergencies, Diseases, and Disasters ( InSTEDD) 
68 

Til Jolly, Associate Chief Medical Officer for 

Medical Readiness, Department of Homeland 

Security (DHS) 

Lisa Koonin, Senior Advisor, Influenza 

Coordination Unit, CDC

Peter Lammers, Vice President, Vaccines Business 

Unit, Glaxo Smith Kline 

James Lawler, Director for Medical Preparedness 

Policy, National Security Staff, The White House 

Nicole Lurie, Assistant Secretary for Preparedness 

and Response, HHS

Ben Machielse, Executive Vice President, 

Operations, MedImmune 

Howard Markel, George E. Wantz Distinguished 

Professor of the History of Medicine; Director, 

Center for the History of Medicine; Professor 

of Pediatrics and Communicable Diseases; The 

University of Michigan 

Alison McGeer, Professor, Dalla Lana School of 

Public Health, Mt. Sinai Hospital, University of 

Toronto, Canada 

William Modzeleski, Associate Assistant Deputy 

Secretary, Office of Safe and Drug Free Schools, 

U.S. Department of Education 

Beth Noveck, US Deputy Chief Technology Officer 

for Open Government Initiative, Office of Science 

and Technology Policy (OSTP), The White House

Steve Ostroff, Director, Bureau of Epidemiology, 

Pennsylvania Department of Health 

Andrew T. Pavia, George and Esther Gross 

Presidential Professor; Chief, Division of Pediatric 

Infectious Diseases; University of Utah

Rino Rappuoli, Global Head of Vaccines Research, 

Novartis 

Stephen Redd, Director, Influenza Coordination 

Unit, CDC, HHS

Barbara J. Reynolds, Crisis Communications 

Senior Advisor, Office of the Director, Centers for 

Disease Control and Prevention, HHS 

Robin Robinson, Director, Biomedical Advanced 

Research & Development Authority (BARDA), 

HHS

Lone Simonsen, Research Professor, Department 

of Global Health, School of Public Health and 

Health Services, George Washington University

Derek Smith, Professor of Infectious Disease 

Informatics, Cambridge University, UK; Member, 

Virology Department, Erasmus Medical Center, 

Netherlands; Senior Fellow, Fogarty International 

Center, NIH, HHS

John Treanor, Professor of Medicine, and of 

Microbiology and Immunology, School of 

Medicine and Dentistry, University of Rochester