Over the last year, many in the public health community have reflected upon lessons learned from the first pandemic of the 20th century. In the current issue of the Journal of Public Health Management and Practice, 3 articles remind us of the importance of public health partnerships in planning for and responding to influenza pandemics and other national public health emergencies. Two articles that evaluate surveillance for influenza associated hospitalizations in New York State highlight the contribution that public health partnerships make to gathering accurate information for surveillance.1,2 A third article by Plough and colleagues addresses the role of partnerships in Los Angeles County's response to the pandemic and recommends a partnership strategy to remedy the inequity in vaccination that was observed.3
The 2009 H1N1 pandemic was perceived to be mildly severe by most measures,4–7 but the specter of widespread susceptibility combined with the early uncertainty surrounding the pathogenicity of the novel virus was alarming. As Noyes and colleagues point out, although enhanced surveillance for influenza-associated hospitalizations is conducted in some areas, measures of illness severity were not routinely part of influenza surveillance activities throughout New York State. In their description of sentinel surveillance in 6 hospitals in New York State, Noyes and colleagues highlight 2 realities of influenza surveillance that were observed in nearly all jurisdictions affected by the pandemic. First, there is a need for comprehensive influenza surveillance data, which include some measures of disease severity, such as hospitalizations or deaths, in addition to routine measures of disease burden through outpatient encounters for influenza-like illness.8 Second, local data are usually the best data. Local surveillance data that were timely and specific to areas affected by the pandemic often provided the best information on which to base local interventions. Establishing this surveillance network in the midst of the pandemic required substantial cooperation between the State Department of Health and partners in healthcare, particularly the infection control personnel who collected surveillance data in each hospital.
Noyes and colleagues compare results from the 6 new sentinel sites with those obtained from emerging infections program hospitals in New York State. Although these 2 systems employ slightly different methods, they measure the same outcome—influenza-associated hospitalizations. Noyes and colleagues argue (and we agree) that some redundancy in surveillance systems may be beneficial because different methodologies allow targeting of slightly different populations and thereby increase the evidence on which to base intervention and prevention strategies. However, the same advice regarding partnerships applies here—communication and cooperation are critical to the success of public health surveillance and response activities. This is true even for groups engaged in parallel surveillance activities, to best synchronize methods and describe results. For example, consistency in case definitions and case ascertainment methods between different systems is important if system results are to be meaningfully compared.
Barr and colleagues conduct a process evaluation of the same influenza-associated hospitalization sentinel surveillance program in New York State in a companion article. In this report, the 6 sentinel sites excelled in data quality and timeliness, 2 important attributes of any surveillance system, and perhaps especially important for systems monitoring pandemic influenza outcomes.9 The authors conclude that the sentinel sites met the state's surveillance needs during the pandemic.
The influenza-associated hospitalization surveillance data in New York State were summarized either weekly or monthly and made available to decision makers, health care providers, and the general public. This was an important element of the State's response, as surveillance data, particularly during a pandemic, are not useful unless accurate reports can be routed to decision-making stakeholders quickly and reliably. The authors credit a strong commitment of human and financial resources by the State for success of the sentinel system. Indeed, the level of surveillance evidenced in the articles by Noyes and Barr requires a substantial financial, intellectual, and resource commitment to maintain. A sentinel approach, however, is a reasonable strategy to employ when case counts are expected to exceed resources that allow case-based surveillance. Employing a sampling strategy within sentinel sites (for diagnostic testing, eg) is also a reasonable approach when disease burden threatens to overwhelm resources.10
Also in the current issue of the Journal of Public Health Management and Practice, Plough and colleagues present lessons learned from the pandemic response in California. The importance of partnerships in both planning for and responding to public health crises is a strong theme throughout the authors' assessment of the 2009 H1N1 immunization strategy in Los Angeles County. As the authors note, a major focus of the national pandemic response was production and distribution of pandemic vaccine. Despite the outreach and education efforts specifically targeted to reach African American communities in Los Angeles County, Plough and colleagues report substantial undervaccination of African Americans at free public mass vaccination clinics. These authors ascribe this poor vaccination uptake to a failure by public health officials to engage trusted leaders within African American communities, which resulted in miscommunication about the importance and safety of the H1N1 vaccine.
Public health messaging can be extraordinarily challenging during the response to a global health threat. One of the difficulties that Plough and colleagues describe—differential perception of pandemic risk by different demographic groups—is one with which public health practitioners are likely familiar.11 Based on these authors' assessment, the best time to meet this challenge is not during a pandemic, but before. Thus, preparedness plans should involve health community partners to determine how to best deliver information and interventions to populations at risk. In fact, engagement of communities and persons at high risk before the event may be just as important to vaccination success as engaging traditional public health partners such as physicians and health care facilities. Although not specific to Los Angeles County, a National Family Health Survey revealed that 38% of adults and 41% of children received their H1N1 vaccination in a non–health care setting, such as a pharmacy, workplace, or school (Centers for Disease Control and Prevention, unpublished data). These data add to a growing body of literature suggesting that it may be prudent to engage communities, opinion leaders, and nontraditional providers well before a health threat emerges, so that interventions can be delivered within a cultural context that is acceptable and convenient to community members.12–15 Race and ethnicity data are also important for disease surveillance and active involvement of community partners at the preparedness stage may pave the way for early identification of health disparities during response efforts.
As post-H1N1 assessments continue and preparations for the next pandemic begin, we would do well to remember one of the important lessons learned over the past year and a half. Thanks to our partners in state and local health departments, schools, and businesses, an abundance of information was available to describe the scope, magnitude, and severity of the first influenza pandemic in more than 40 years. Comprehensive public health surveillance and delivery of measures to prevent and control disease transmission are not possible without creating, maintaining, and refining partnerships inside and outside the public health community. Future prevention and mitigation efforts will rely upon a similar network of partners to inform and engage communities so successful strategies can be designed and implemented. Vaccination and antiviral therapy, in particular, can be effective interventions but are useless without infrastructure to distribute them and a public notion that they offer protection from infection and illness. Success in the control of pandemic influenza, as with any public health threat, requires awareness of the necessary partnerships to make surveillance and interventions possible. Succeeding in health, at a minimum, requires getting the science right, but success in public health also requires active engagement of the public, and for that, collaboration between public health and community partners is essential.
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