Background

Significant progress has been made in public health and medical preparedness since September 11, 2001. State and local public health authorities are currently responsible for the majority of medication distribution and dispensing activities within their jurisdictions during public health emergencies. During both a pandemic and in routine seasonal influenza, antiviral medications are used to lessen the duration and severity of a patient’s symptoms, not to be confused with a vaccine, which is administered to the well to prevent them from getting sick. Vaccines take months to manufacture, in part because they must be specific to the influenza type. Antivirals, on the other hand, can work against many different strains of influenza. Because antivirals are more effective if taken within 48 hours of symptom presentation, many public health agencies have developed preparedness plans to facilitate the rapid dispensing of antiviral medications to large numbers of people during influenza pandemics.² However, the feasibility and timeline of these plans remain significant concerns given projections that during a severe pandemic, approximately 30 percent of the population could become ill over a 12- to 18-month period.³ In such circumstances, the normal channels through which antiviral medications are prescribed, dispensed, and distributed could easily become overwhelmed. Indeed, the 2009 H1N1 influenza pandemic brought to light several related challenges that need to be addressed during future preparedness planning initiatives.

In response, the CDC is exploring alternate delivery systems for antiviral medications during severe influenza pandemics. Potential prescribing, dispensing, and distribution strategies include a variety of non-traditional mechanisms to ensure that people sick with flu receive antiviral medicines in a timely manner. These include

• Nurse Triage Lines (NTLs): Phone hotlines that people with flu-like symptoms could call for advice, discuss whether an antiviral medication is indicated and, if so, possibly receive a prescription that the NTL would transmit to callers’ local pharmacies for dispensing (if feasible). NTLs would be staffed by nurses who would be trained to follow a specific protocol and work under the direction of a physician. In addition to prescribing antivirals, NTL nurses could provide guidance to the caller about whether to seek urgent care, as well as information about how to care for someone with flu. NTLs may be built onto an existing regional hotline infrastructure (e.g., poison control centers) and may leverage other medical hotlines currently operated by health plans, hospitals, and health agencies.
• Antiviral Pick-Up and Delivery by Community Contacts: A strategy to encourage family, friends, neighbors, and other community contacts to pick up prescribed antiviral medications from pharmacies and deliver them to people with flu at home. Public health agencies would encourage people who have been prescribed antiviral drugs to ask others to pick up and deliver their prescriptions. They also would educate the public about the benefits of encouraging sick people to stay home to prevent the spread of the virus, and encourage their active support in helping friends and neighbors. More coordinated programs might be set up through local community organizations whose staff or volunteers could provide this service.
• Pharmacist Prescribing Under Collaborative Practice Agreements: A system through which a person sick with flu could visit certain pharmacists who would be authorized to prescribe and dispense antiviral medications according to approved protocols developed by influenza experts. Such pharmacists would work under formal “Collaborative Practice Agreements” with physicians who would provide supervision and consultation.

The CDC also is exploring new strategies to communicate clear, accurate information about pandemic influenza and treatment to the public, including

• Web-Based Tool: A web site launched during a pandemic for the purpose of helping people sick with flu-like symptoms and their caregivers to decide whether to seek medical care and to advise them when to seek treatment options, including antiviral medications.
• Text-Messaging Tool: An opt-in system through which people prescribed antiviral medications could receive text messages containing information about their flu treatment, potential side effects of antivirals, reminders to take their medicine, and other relevant advice.

These strategies are not yet government policy and are still under exploration. Determining the feasibility and acceptability for these alternatives is ongoing with public health officials and private-sector entities. Before moving ahead, however, the CDC recognized the importance of also exploring the public’s perception of the safety, feasibility, and acceptability of these strategies. Therefore, it asked the IOM to design and convene community conversations in three locations across the country to engage the public on the five strategies outlined above.

About This Summary

This document is intended to summarize the discussions and key takeaway points at the three community conversations. Unique ideas presented at the workshops are not attributed to individual participants, in keeping with the workshop design that intentionally excluded the recording of personally identifiable viewpoints in order to protect participant confidentiality and create an environment in which these topics could be discussed openly. Situations where several participants made similar points at all three community conversation locations are identified as “common themes.” Throughout the summary, themes identified at a specific community conversation are followed by the appropriate two-letter state abbreviation of that location in parentheses. It is important to note that there is inherent variation in the specific discussions that took place at each community conversation, which is attributable to the individuality and diversity of each participant group. Therefore, the absence of discussion on any one specific idea in a particular location does not suggest that those participants were in favor or against that idea. Any opinions, conclusions, or recommendations discussed in this workshop summary are solely those of the individual participants and should not be construed as reflecting consensus or endorsement by the workshop, the Preparedness Forum, or the IOM.

Footnotes

1

The workshops were organized by an independent planning committee. The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Forum, the IOM, or the National Research Council, and they should not be construed as reflecting any group consensus.

2

For more information, see CDC, Antiviral agents for the treatment and chemoprophylaxis of influenza: Recommendations of the advisory committee on immunization practices (ACIP) (Atlanta, GA: CDC, 2011). Available at http://www​.cdc.gov/mmwr​/preview/mmwrhtml/rr6001a1.htm (accessed May 2, 2012).

3

Department of Health and Human Services (HHS), HHS pandemic influenza plan (Washington, DC: HHS, 2005). Available at http://www​.flu.gov/planning-preparedness​/federal/hhspandemicinfluenzaplan.pdf (accessed April 18, 2012). Further clarification provided by personal communication with Lisa Koonin, senior advisor, Influenza Pandemic Unit, CDC, February 14, 2012.