Abstract
With the aim of improving emergency immunization efforts, the Chamberlain et al article offers insights into the perspectives of immunization program managers on work done before and during the H1N1 immunization program. Although conditions differed in states, there are at least 3 general lessons. The first is that the routine, everyday public health systems are the foundation for public health responses. The second lesson is that an effective planning process must delineate how those everyday systems will be adapted to create a unified response system, where capabilities from multiple public health areas must work together. And third, an exercise and training program is necessary to assure that the people who will be staffing the response understand and have practiced their roles as envisioned in the response plan. We briefly review these 3 lessons and what the Chamberlain et al article teaches us about the collaboration between state preparedness directors and immunization program managers.
In retrospect, it may seem obvious that efforts to distribute and administer the monovalent H1N1 vaccine had to rely heavily on state public health vaccination programs, the routine public-private partnership that is the basis for U.S. vaccination efforts, and similarly obvious that these systems, by themselves, would not be sufficient. 3 The H1N1 pandemic, and any substantial public health emergency, will require mobilization of the public health workforce, of which only a portion is routinely involved in preparedness efforts. The closer the response work is to the everyday work, the simpler the adaptation to the needs of the response. The Chamberlain et al article describes the value of immunization information systems (IIS) that were used during the response to track vaccine use and enhance follow up of children who required a second dose of vaccine, and it describes how these systems facilitated enrolling new providers to administer H1N1 monovalent vaccine. As electronic health records move into wider usage and populate immunization information systems, as encouraged in the Health Information Technology for Economic and Clinical Health (HITECH) Act, the role of these systems in emergencies will inevitably expand, providing benefits to patients and simplifying the work of response managers.
These examples show that routine immunization systems are, in fact, emergency response systems. The ability to adapt this routine system to an emergency system is highly dependent on the immunization program staff that operate the system day in and day out. Building a more robust national immunization system—particularly for adolescent and adult immunization, where immunization coverage for routine vaccines is lower than it is for young children—will inevitably result in a more robust capability to vaccinate during an emergency.
Effective emergency public health responses are based on a planning process that defines how the public health system must be reconfigured to respond effectively. This planning process requires assumptions about the future event, assumptions that inevitably will be incorrect to some extent. The key to an effective planning process is the engagement of the leadership and staff that will have to respond. While the planning process aims to produce a plan, the more important outcome may be the personal and institutional relationships that are developed through the process. As General Eisenhower said, “In preparing for battle, I have found plans useless, but planning indispensable.” The result of the planning process should be an increase in trust among the groups of people who will work together during the response. Chamberlain et al report that most program managers found the plans—and the planning process—important, despite the assumption of a more severe pandemic, along the lines of the 1918 influenza pandemic. Planners need to remember that the process of planning is more important than the plan itself.
An exercise and training program supports the planning process by teaching responders of all levels. Ideally, an exercise program spans the gamut from small-scale efforts to work out details of standard procedures, to individual training on response organization, to larger-scale exercises that enable participants to understand how the numerous response elements function together. Exercises should help responders understand the ambiguities and pressures that are inherent in emergencies. For leaders, exercises are a means to practice decision making in the face of uncertainty and to identify gaps and incongruities in plans. Chamberlain et al described the value of mass vaccination exercises conducted in the years before the pandemic, but they do not tell the readers what other kinds of training or exercises program managers found valuable.
Although this report provides important insights, it is difficult to attribute program accomplishments, such as coverage with H1N1 vaccine, to particular issues addressed in their survey. Other factors—routine seasonal influenza vaccine coverage, the availability of vaccine, whether disease was on the rise or decline when vaccine became widely available, and specific outreach efforts—likely influenced the ultimate coverage rate with H1N1 monovalent vaccine. The coordination and perceived effectiveness of collaboration between immunization program managers and preparedness directors contributed to the conclusion of 59% of Americans that the government's management of the H1N1 emergency was excellent or good. 4
Chamberlain et al provide assurance that state preparedness programs and state immunization programs were working closely before and during the H1N1 response, and they provide specific examples of practices in states with excellent collaboration—examples that merit examination for states seeking to improve collaboration between these 2 programs. The article shows clearly that public health departments, beyond preparedness programs, have expanded their missions to include the role of emergency responders, consistent with the all-encompassing mission of protecting the health of the public. Given the role of immunization programs in emergency response, there is an opportunity to provide greater clarity on the capabilities required, both of immunization programs and preparedness programs, in an emergency where immunization is a primary intervention, such as a pandemic. These program responsibilities can be clarified through revisions in grant guidance—both immunization grant guidance and preparedness grant guidance—though the roles each program will play will vary from state to state. With the potential for eroding budgets for public health, assuring efficient collaboration is more important than ever.
The H1N1 response was a major test for public health; efforts to upgrade public health response capabilities in the preceding decade unquestionably improved health departments' abilities to vaccinate large numbers of people in ways that would not have been possible in the years before. The Chamberlain et al article provides a timely assessment of the status of the collaboration between state immunization and preparedness programs and can guide efforts to improve future responses.