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    Implications for Continued COVID-19 Preparedness and Response HS Today

    HackWatchitBy No Comments37 Mins Read

    Abstract 

    The novel coronavirus disease (COVID-19) has tested the global governmental and public agency  response to pandemic emergencies with regard to a number of areas. This essay focuses on  major agency involvement in the United States as well as relevant historical comparisons to  highlight important aspects of our current challenges in mitigating the COVID-19 pandemic.  Analysis of previous pandemics including both domestic and international response inform our  suggested best practices for public agency involvement in ongoing pandemic operations in the  United States and abroad. 

    Introduction 

    Since being first recognized in December 2019 and declared a global pandemic on March 11,  2020, by the World Health Organization (WHO), the 2019 novel coronavirus disease (COVID-19)  outbreak has caused severe damage in terms of human life, healthcare systems, and the  economy both in the United States (U.S.) and around the world. In the United States alone,  the death toll has surpassed 500,000 as states forge ahead with reopening to continue the  economic recovery process and ease social unrest. COVID-19 represents the latest of several  disease outbreaks that have afflicted society in the 21st century, including SARS-CoV in 2003,  H1N1 Influenza in 2009, and MERS-CoV in 2012. While COVID-19 is structurally related to other  coronaviruses causing severe acute respiratory syndrome (SARS) in SARS-CoV and MERS-CoV,  there is substantial evidence of significant differences from these previous outbreaks, including  a further delayed onset of symptoms, which has led to increased transmission.1 Undoubtedly,  COVID-19 continues to be one of the most formidable public health challenges in recent history. 

    An abundance of literature has been written about the importance and impact of monitoring,  travel restrictions, social distancing, and other mitigation strategies to reduce community  transmission of COVID-19.2 Generally, pandemic preparedness in the U.S. has centered on the  four pillars of surveillance, vaccine delivery, communication and coordination, and emergency  response.3 A study analyzing how our pandemic preparedness has evolved since the 1918 Flu  Pandemic points to far advanced capabilities in each of those four pillars in the U.S. through the  Centers for Disease Control and Prevention (CDC).4 However, these capabilities have been tested severely in the U.S., given critical supply shortages of personal protective equipment (PPE) and  ventilators, sub-optimal testing rates, and knowledge gaps in the critical care setting to treat the  disease.5 While there is uncertainty and unpredictability regarding the presence and severity of a second wave, there is a consensus that the U.S. must be better prepared for future events,  including continued surveillance, risk mitigation, vaccine development, serologic testing, and  general healthcare preparedness.6 

    A key identified emergency management area and effective pandemic response is the interplay  between federal, state, and local governments, along with their respective supporting agencies.  This collaborative dynamic is an inherent concept within the discipline of public health.  A fundamental difficulty governments and public health agencies face when dealing with  infectious disease outbreaks is the need to adjust human behavior, such as through effective  communication and public health messaging.7 Over the past few decades in the U.S., the federal  government has recognized that successful pandemic response relies on well-prepared state  and local governments, providing an impetus for increased federal funding to state governments  for state-specific pandemic planning.8 Through this model, it is believed that state and local  governments might be better able to influence the necessary behavior change. 

    Coordinated federal and state planning has yielded many effective programs in the U.S. In  the 2009 H1N1 response, the CDC administered funds to all 50 state health departments and  additional localities in the form of the Public Health Emergency Response (PHER) grant, which  was reported to have increased partnership strength and response efficacy.9 The CDC quickly  mobilized resources through its International Reagent Resource to public health laboratories  across the U.S. for virus surveillance.10 Additionally, coordinated case reporting between state  health departments and the CDC improved H1N1 national surveillance.11 It has been noted  in the 2009 H1N1 response that federal officials relied on state and local health officials to  encourage people to get vaccinated, given their credibility within their locales.12 Another  potential mechanism that may contribute to better outcomes in such collaboration and  partnerships is the informal networks accompanying interagency coordination that promotes  effective public health preparedness.13 Of course, sharing institutional knowledge as it pertains  to coordinated public health emergency response is helpful as well. 

    This essay seeks to explore key federal agency actions and government partnerships and lessons  learned from both past pandemic responses in the United States and the initial response to  COVID-19 worldwide. Our objective is to further the literature that asserts federal, state, and  local government and agency partnerships strengthen the pandemic response. In doing so, we  hope to provide insight into avenues for improved preparedness for potential events in the  coming months and years, such as mitigation of COVID-19 recurrences and future pandemics. 

    Preparing for the “Next” Wave 

    Previous pandemics are consistently characterized by a pattern of successive waves of disease,  each with a varying impact.14 An examination of the A/H1N1 pandemic from 1918 to 1919  reveals that an initial low mortality wave in the summer of 1918 preceded the catastrophic  wave of the fall of 1918.15 The initial wave of the A/H2N2 influenza pandemic occurred in the fall  of 1957 and was followed by a second wave in the winter of 1959 as well as a third wave in the  winter of 1962.16 Further, the three waves showed almost equivalent mortality.17 This pattern is  documented again during the 1968 A/H3N2 pandemic, which had a mild herald wave during the winter of 1968 that was followed by a severe second wave in the winter of 1969.18 Lastly, during  the first year of the 2009 H1N1 pandemic, the USA experienced two waves of influenza – one in  the spring and one in the fall.19 We have already experienced multiple waves and recurrences of  the COVID-19 pandemic, with public health officials worldwide being wary of future outbreaks. 

    Based on our review of previous pandemics, it is likely that actions taken during the initial  COVID-19 crisis by public health agencies, along with federal and state governments, dictate  the severity of subsequent waves. The occurrence of multiple waves throughout previous  pandemics underscores the need for action on a global scale in the form of case monitoring.  International cooperation and partnership are vital for exchanging medical information that  could lead to better treatment methods and help to identify the best population-based  strategies to mitigate the severity of future waves of a pandemic. Further, international  collaboration continues to facilitate vaccine development, perhaps the most powerful tool to  prevent mortality from additional pandemic waves. For example, most of the deaths in Europe  and Asia would have been prevented during the A/H3N2 pandemic had an effective vaccine  been available one year after the initial wave.20 

    While the exact cause of different pandemic waves requires further investigation, we speculate  that one source could be the disease’s public perception. Often after the initial wave of a  pandemic, the perceived threat of disease diminishes substantially. For example, acceptance  of the H1N1 vaccination lacked in the fall of 2009 among certain healthcare providers and  personnel. Later in December of 2009, during the second wave of H1N1, much of the U.S.  population remained unvaccinated despite an ample supply.21 Healthcare professionals, public  health agencies, and the government must decide if it is worthwhile to press the issue of  pandemic preparedness. Subpar vaccination rates, declines in disease-mitigating behaviors such  as social distancing, and new disease strains are worrisome for COVID-19 recurrence. 

    CDC EOC and Identification of Infectious Disease Outbreaks 

    The United States Center for Disease Control and Prevention (CDC) is one of the Department of  Health and Human Services’ major operating components. During a public health emergency,  the CDC works directly with both state and local health officials. Not only does the CDC provide  guidance on how to proceed in the given situation, but they also send people to help with field  activities. When the situation calls for an agency-wide response with centralized management,  the CDC manages its response from a central location known as the CDC Emergency Operations  Center (EOC).22 To date, the EOC has responded to over 60 public health threats.23 To coordinate  responses to various public health emergencies, the CDC EOC utilizes the National Incident  Management System (IMS). An IMS is an internationally recognized model that can be used to  respond to emergencies.24 

    The EOC is the central point of contact for reporting public health threats and supports the  Secretary’s Operations Center (SOC) of the U.S. Department of Health and Human Services  (HHS).25 The SOC’s overarching goal is to protect the health, safety, and security of the country. 

    They accomplish this by serving as the main center for the collection of both public health and  medical information. The SOC then analyzes and shares this information with the public.26 

    The CDC played a major role in response to the 2009 H1N1 pandemic. This pandemic originated  in the United States before spreading to other countries. The CDC approximated that from April  12, 2009, to April 10, 2010, there were 60.8 million H1N1 cases, 274,304 hospitalizations, and  12,469 deaths in the U.S.27 The first two patients infected in the U.S. were living in California  and were identified through laboratory testing at the CDC on April 15th and 18th of 2009. The  CDC worked rapidly with various health officials to trace both patients’ contacts to determine  where each patient contracted their infection. Just a few days later, the CDC activated its EOC  to initiate a robust response to this clear threat. Following this, the U.S. Government declared a  nationwide public health emergency. In response, the CDC started to release supplies from the  Strategic National Stockpile (SNS) that would be helpful in the fight against influenza.28 

    A similar timeline of events occurred with COVID-19. On January 19, 2020, a man arrived at  an urgent care clinic in Washington state. His presenting complaint was a history of cough  and fever for around four days. Additionally, he reported that he recently traveled to China.  Given the presenting situation, the urgent care clinician and Washington Department of Health  immediately notified the CDC Emergency Operations Center, and specimens from the patient  were collected and sent to the CDC. The very next day, the CDC reported back that the patient’s  swabs tested positive for 2019-nCoV.29 In response to this, the CDC activated its EOC.30 

    Despite the CDC’s initial robust actions in identifying the novel coronavirus disease, top health  officials around the country agree that the CDC’s response throughout the rest of the pandemic  could have been better. In an interview with the New York Times, Dr. Ashish Jha, the director  of the Harvard Global Health Institute, stated that the CDC is “no longer the reliable go-to  place.”31 This is likely because the CDC was using outdated technology in conjunction with a  subpar public health reporting system. The CDC’s current and former employees also claim that  the Division of Viral Diseases, the group within the CDC responsible for the first phases of the  response, was understaffed and not as experienced in communicable pulmonary infections.32 However, it is essential to remember that the CDC is just one of many players handling the  global emergency. Therefore, not all blame for the pandemic’s ongoing nature in the U.S. can be  placed on them. The strained relationship between the U.S. federal government and the CDC  undoubtedly made it more difficult for the country to contain the pandemic effectively. 

    FEMA’s Response to COVID-19 

    The Federal Emergency Management Agency (FEMA) of the United States Department of  Homeland Security is in charge of preparing the nation before disasters occur, managing  resources during disasters and coordinating recovery in their wake. A pandemic presents a  unique challenge for FEMA, as it usually faces disasters that are less expansive in scope and  scale, such as hurricanes, wildfires, and earthquakes.33 These are usually limited to specific  regions of the nation, whereas the COVID-19 pandemic has left no part of the country  unscathed.34 When President Trump invoked the Stafford Disaster Relief and Emergency  Assistance Act on March 13, 2020, in response to the COVID-19 pandemic, FEMA was brought to the center of the federal pandemic response.35 The Stafford Act was previously invoked by  President Obama in response to the H1N1 outbreak of 2009, but as it turned out, much less  was required of FEMA at that time than has been required in response to COVID-19 due to the  relative severity of each pandemic, respectively.36 

    The COVID-19 pandemic has created critical shortages of medical supplies, such as personal  protective equipment and ventilators.37 One source of emergency medical supplies is the  Strategic National Stockpile (SNS), which HHS manages. In response to the COVID-19 pandemic,  the SNS has delivered over 12,000 tons of cargo to states in need.38 However, the SNS has not  met the demand for supplies sufficiently, as it was not originally conceived to meet a threat  of this scale.39 Expanding the SNS to respond to a nationwide shortage of medical supplies  effectively may be necessary to prepare for future pandemics adequately. 

    In responding to the COVID-19 pandemic, FEMA’s primary role has been to alleviate supply  shortages. The Supply Chain Stabilization Task Force was created to do so. The task force’s  proposed activities were based on a four-pronged approach: 1) preservation of current medical  supplies, 2) acceleration of manufacturing, 3) expansion of the medical supplies industry, and  4) data-driven allocation of resources to the areas that need them most.40 This task force has  yielded some genuine successes, such as Project Airbridge, which organized over 200 flights  containing PPE shipments between March 29 and June 18, 2020. At that point, the project was  phased out due to the apparent stabilization of the supply chain.41 

    Another aspect of FEMA’s role during emergencies is coordinating between government  entities,42 but coordination between states and the federal government has proved to be a  challenge for FEMA during COVID-19. Given the greater scale of the COVID-19 pandemic than  the usual disasters that FEMA is tasked with, FEMA’s ability to coordinate effectively with states  may have been strained. While FEMA has striven for a whole-of-America response,43 it has at  times fallen short of that goal. In a time of shortage, the federal government’s role should be  to coordinate offers to suppliers to avoid bidding wars and price gouging. This is consistent  with FEMA’s mission to coordinate the national response to crises.44 However, FEMA’s failure  to cooperate with states has resulted in states bidding against each other, and occasionally  against FEMA itself, for critical supplies, according to state and local officials.45 FEMA has  been inconsistent in this response, sometimes commandeering deals that have been made  independently by states. Governors in Connecticut, Michigan, Maryland, and New York have  all called for FEMA to better coordinate supplies based on need and end competition between  states and the federal government to secure critical resources.46 In California, FEMA reportedly  seized a shipment of supplies while it was going through customs, according to San Francisco  Mayor London Breed.47 These practices have led some states, like Colorado, to make their  private deals for fear that FEMA will swoop in and undercut their offer.48 For its part, FEMA has  denied any seizure of supplies from states.49 However, FEMA acknowledges that it has used  its power of priority in making deals with suppliers, granted by the Defense Production Act  (DPA).50 This authority is consistent with FEMA’s mission to coordinate the federal response.  Unfortunately, the federal government’s mixed messaging has impeded our ability to reach the  goal of a whole-of-America response. When questioned in March about his hesitation to use the  full extent of the DPA at that time, President Trump laid the responsibility to secure resources  on states themselves, suggesting that the federal government’s role should be as limited as possible.51 This message, taken with FEMA’s actions only weeks later using the DPA’s authority  to step in ahead of states to secure private contracts, has caused confusion and distrust. One of  the critical lessons learned from the COVID-19 pandemic is that cooperation, coordination, and  communication between all government levels are necessary for an effective response. 

    Vaccine Production and Distribution 

    Medical countermeasures are crucial to the governmental and public health response to  manage pandemics, and vaccines are the most effective medical countermeasure to combat  the spread and health impact of an infectious disease pandemic.52 Given the successful  development and production of multiple COVID-19 vaccines, rapid and widespread vaccine  distribution is now a primary challenge in COVID-19 response.  

    Historically, prophylaxis with vaccines and other antiviral medications was wildly unsuccessful  during the 2009 influenza pandemic.53 Despite the HHS’s $1 billion allocations of funds in May  2009, the availability of H1N1 vaccines was too delayed to limit the virus’s spread effectively.54 In the 2009 pandemic, the U.S. government distributed antiviral medications and vaccines  

    through the Strategic National Stockpile (SNS).55 A tactical optimization model for distributing  the stockpile during a pandemic was proposed based on the antiviral medications but can be  applied to any pandemic policy model.56 The simple SNS distribution plans, such as releasing a  fixed quantity each month from the stockpile to states proportional to each states’ population  size, were optimal for mitigating the virus’s spread and effects.57 However, this is most likely  attributed to influenza’s mild contagious effect, whereas more contagious strains, such as  COVID-19, will require additional courses from the Federal SNS and more optimal policies to  include greater-quantity early releases.58 

    An effective production and distribution plan will be crucial in combating re-emergence  of COVID-19. Rapid, efficient, and equitable vaccine distribution will be critical in reducing  morbidity and mortality and ameliorating the harmful effects on social functioning and essential  services.59 In 2009, H1N1 vaccines were shipped directly to vaccination provider sites (public  and private) from the central distributor.60 States then deployed various distribution plans via  a combination of state and local public health authorities, private healthcare providers, and  pharmacies.61 While some states relied on local health departments for distribution, others  received all of their vaccine supply and coordinated the physical distribution to vaccine provider  sites without partnerships with various agencies.62 The heterogeneity in distribution plans  was reported to have caused communication challenges, especially in the states where each  local health department deployed a unique distribution plan.63 Given limited quantities of the  COVID-19 vaccine, priority groups and allocation plans to state distribution centers need to drive  efficient distribution.64 

    The current CDC Pandemic Vaccine Program, which is scalable to distribute nearly 900  million doses, consists of CDC distribution from vaccine manufacturers to public and private  healthcare providers, who can then transport vaccines to clinical sites for immediate use.65 This program uses national, regional, state, and local vaccination covering monitoring to tailor  communications among states and distribution patterns to meet specific needs.66

    In past pandemic management efforts, many state-level immunization programs collaborated  with state emergency preparedness programs while using incident command structures (ICS)  and emergency operation centers (EOC).67 The federal government encourages states’ use of ICS  and EOC operations. Both have been proven to help the organization of personnel and resources,  particularly in the 2009 H1N1 vaccination campaign.68According to a survey conducted by  Chamberlain et al., more than three-quarters of immunization program managers, used an ICS,  and about half utilized an EOC to manage vaccine distribution.69 The majority of participants  agreed that the use of ICS helped them work effectively with their emergency preparedness  collaborators.70 Immunization managers stated that the use of previous pandemic influenza  plans provided a crucial framework for carrying out the immunization campaign operations  and providing the campaign with previously established affiliations with hospitals and federally  qualified health centers, both of which are central to the campaign objectives.71 Prior collaboration  among state-level immunization programs and emergency preparedness programs was also  regarded as beneficial in the mass vaccination campaign, indicating that inter-program exercises of  responding to real-life events may contribute to future successful collaborations.72 

    Perhaps the most valuable organizational tactic used in the H1N1 pandemic was immunization  information systems (IIS) or vaccine registries. The use of IIS assisted in tracking vaccine  coverage rates, the registration of non-traditional vaccine providers, sending communications  out to providers, and tracking recalled influenza vaccines.73 Fifty-seven percent of immunization  program managers who utilized IIS and had the capability of registering non-traditional vaccine  providers rated this function as beneficial to the campaign.74 Fifty-nine percent of immunization  program managers who utilized IIS and had the capability of pushing communications out to  providers rated this function as beneficial to the campaign.75 While both functionalities are  crucial in distributing a mass quantity of vaccine in an urgent situation, 40% of IIS reported  that they were unable to facilitate either action.76 Enabling more IIS with these capabilities  would significantly improve the vaccine distribution efforts soon. Vaccine data gathered by IIS  is also integral to the management of vaccines. A CDC survey analyzing the H1N1 pandemic  determined that a large number of vaccines were never administered to patients (20% of  distributed doses to NYC providers were returned).77 Vaccine data can help the U.S. Department  of Health adjust the vaccination distribution plan in certain areas to ensure the demand is met  across a diverse population.78 

    Lastly, the 2009 CDC H1N1 Vaccine Pharmacy Initiative proved to play an important role in  the vaccination efforts. In conjunction with the Association of State and Territorial Health  Officials (ASTHO), the CDC distributed vaccines directly to pharmacies to assist in the state  vaccination campaigns.79 Approximately 10% of adults who received a vaccine during the 2009  pandemic reported getting vaccinated at a pharmacy.80 As part of the response to COVID-19,  the HHS has partnered with national pharmacy and grocery retail chains including CVS, Rite AID, Walgreens, and Walmart as a part of the Community-Based Testing Program to provide  convenient COVID-19 testing available to Americans.81 This partnership has created more than  600 COVID-19 testing sites across the country, including 48 states and the District of Columbia.82 The accessibility of community pharmacies makes them a popular location for COVID-19 testing  and is often the first encounter with a healthcare professional for many Americans seeking  care. This public-private relationship is a method to leverage the private sector’s power to continue to provide convenient access to testing, which can help slow the spread of COVID-19  in communities across the country.83 Utilizing pharmacies increased the accessibility of vaccines  at a community level. Their contribution to national, regional, and local storage and distribution  can be used with large-scale administration of vaccines, which will most likely be required to  combat COVID-19. 

    Governmental Responses to COVID-19 Worldwide: South Korea Case Study 

    As COVID-19 spread worldwide, South Korea had one of the highest initial case-loads, yet  relatively quickly reduced its incidence and mortality rates to impressive numbers during a time  where these numbers trended on an upward trajectory globally.84 Being both geographically  close to the accepted source of the virus and having a high population density, South Korea and  its success in COVID-19 provides a valuable case study of government responses to pandemics  that work and why they work.  

    South Korea’s response to COVID-19 is primarily due to successful and preventative efforts  not to repeat the past. In 2015, the MERS outbreak in South Korea highlighted the inadequacy  of governmental and public health pandemic policies and preparation with subsequent  consequences; 186 confirmed cases, 38 deaths, nearly 17,000 people quarantined to control  transmission, and an economic impact valued at 8.7 billion U.S. dollars.85 Following recovery,  the Korean CDC (KCDC) and other government agencies faced fierce public outcry at their  actions or lack thereof to identify the apparent cracks in the country’s response and propose  ways to rehabilitate them.86 Modifications made focused on improving healthcare and  government infrastructure to better handle pandemics in the future. Broadly, these changes  included mitigating super-spreader events more effectively, particularly in the hospital setting  which was primarily responsible for the spread of MERS, providing adequate supplies and  facilities for hospitals to manage the infectious disease and appropriate isolation precautions,  increasing the capacity to test individuals and subsequently isolate persons with positive test  results, increasing public and private sector collaboration avenues to maximize a coordinated  response, and maintaining thorough contact tracing of positive patients and families.87 Also,  particular emphasis on aggressive quarantine strategies was recommended, especially in  healthcare settings.88 These efforts to improve pandemic response were ultimately tested in  early 2020 with the advent of COVID-19. 

    South Korea’s government launched an organized, coordinated response to COVID-19  centered on a foundation of high-volume testing and detailed contact tracing for  containment. This was bolstered by aforementioned efforts to make hospitals better equipped  to handle infectious disease after the 2015 MERS outbreak. The United States’ response was  also centered on testing and contact tracing to mitigate COVID-19. However, the U.S. was  slower in development and implementation, greatly handicapping its ability to address the  continual threat of the pandemic.89

    In South Korea, public and private partnerships were deployed early on to develop large  quantities of testing kits and ensure their subsequent expedited approval for federal agencies’  use.90 This proved beneficial, as South Korea outpaced many countries in testing early on,  testing over 300,000 individuals in just over two months from their first confirmed case.91 To  accomplish this, South Korea pioneered the use of remote testing locations, including drive through and walk-through testing sites, to ensure ease of test access for the masses while also  minimizing overflow in hospitals and emergency departments.92 Initially in the U.S., the general  population required specific need or suspicion to get tested for COVID-19 given limited supply of  testing kits and a lag in governmental approval time for various tests.93 This limitation of supply  was not unique to the United States but was detrimental to early response efforts.  

    Contact tracing was another integral element to the South Korean governmental response to  COVID-19. Contact tracing applications allowed for detailed real-time information for health  officials and citizens. In contrast to the MERS 2015 pandemic, where health information was  primarily kept private in South Korea, more detailed accounts of known and unknown cases,  including gender, age, and location, were disseminated to public health agencies and citizens  

    daily.94 For public health agencies, this provided a means through which evidence-based,  epidemiological analysis could be done to determine the efficacy of efforts and tailor the policy  approach based on findings. For citizens, this helped ensure they were well-informed and  equipped to make the changes necessary at home to minimize spread via physical distance  maintenance or other routes. Citizens could opt to allow the government to track their movement  via GPS and credit card records to provide accurate tracing as well, and many did.95 Perhaps more  South Koreans were willing to do this given their recent experiences with MERS in 2015.96 

    South Korea provides a prime example of government response modification, government  response success, and the importance of citizen involvement and commitment to realizing  governmental responses. It also opens the door to further discussion on public-private sector  collaboration, the use of technology in engaging and employing citizens as critical players  in national and international efforts, and other elements such as patient privacy during a  pandemic.97 While some parts of South Korea’s response are more accessible in implementation  or incorporation there as opposed to in the United States due to political climate, citizen  sentiment, and some health system differences, significant lessons can be learned, and policies  took and catered to the United States political climate to be effective here as well.  

    Lessons Learned and Implications  for Future COVID-19 Response 

    The novel coronavirus disease (COVID-19) outbreak has resulted in millions of fatalities,  upended the global economy, and tested worldwide governmental policies, plans, and  procedures for pandemic preparedness and response. In this essay, we have sought to  emphasize the significant agencies in the U.S. government’s response to pandemics, highlight  important aspects of our current challenges in mitigating the COVID-19 pandemic, and  propose how state and federal government collaboration might best solve these challenges. By  analyzing the U.S. response to previous pandemics and a case-study comparison between the 

    United States and South Korean governmental responses to COVID-19, we hope to provide a  foundation on which governmental agencies can best act, collaborate, and cater their response  for maximum efficacy during such unprecedented times. 

    COVID-19 has highlighted key departments and institutions within the United States  government that play vital roles in a coordinated state and federal response to a pandemic.  The CDC has been crucial in the U.S. response to COVID-19 and previous pandemics. Their  role in identifying disease outbreaks and activating the EOC is vital in slowing disease spread  at the onset of an outbreak. In the future, improvements in their technology and increases  in staffing and resources will improve the CDC’s ability to respond effectively to emergent  situations such as COVID-19. While normally responding to national disasters of a different  nature, FEMA continues to play a key role in mitigating pandemics by coordinating federal and  state government responses and allocating supplies appropriately. COVID-19 has highlighted  shortcomings in FEMA’s response. This essay makes recommendations to address these  shortcomings, including the expansion of the Strategic National Stockpile (SNS), locating  and acting on supply source delays proactively and aggressively, and addressing issues in  cooperation, coordination, and communication that have been insufficient in the United States’  handling of the coronavirus pandemic. 

    Two key barriers to resolving the coronavirus include the development and distribution of an  effective vaccine and the looming potential for continued virus resurgence. Through extensive  analysis of past large-scale vaccination efforts in the U.S., we have developed several key aspects  to keep in mind during production and dissemination efforts of an effective SARS-CoV-2 vaccine.  These include continued partnerships to foster financial support between the public health  sector and biotechnology industries, effective planning for vaccine distribution, prioritization  of at-risk population groups, and a plan for adequate record-keeping and reporting of vaccine  data to state and federal health departments to ensure vaccination plans are modified to evolve  with the populations’ changing needs. As the federal and state governments prepare for the  subsequent waves of COVID-19, we propose initiatives that will best help mitigate its severity,  including global-scale case monitoring, international cooperation and partnership in all aspects  of the pandemic response, attention to the role of citizens in pandemic preparedness with  particular emphasis on non-medical interventions like social distancing, and continued support  of vaccination initiatives in production and distribution.   

    The COVID-19 pandemic has called upon governments worldwide to be proactive, adaptative,  and assertive in an unprecedented manner. How individual governments have chosen to do  this has varied significantly and this provides the opportunity for the United States to compare  observations and strategies as it continues to mitigate COVID-19 and bolster pandemic  preparedness moving forward. As a democratic country deemed successful in its COVID-19  mitigation efforts, South Korea serves as an important case study for the U.S. A key takeaway  is the importance of harnessing citizen sentiment and involvement and the science of human  behavior in planning pandemic response policies. This comparison with South Korea also raises  questions regarding the federal government’s ability to fast-track processes through public private partnerships, our nation’s HIPAA privacy laws during times of crisis, and the unique  challenges and implications posed by economic and political systems.

    The United States’ governmental response to pandemics at both the state and national level is  vast and intricately complex. We hope to continue the conversation on this response model’s  essential aspects as we move forward in our mitigation efforts for the COVID-19 pandemic and  future pandemic preparedness.

    Notes 

    1. D.L.Heymann and N. Shindo, “COVID-19: What is Next for Public Health? The Lancet. 2020, 395(10224):542-545. 2. A.S. Fauci, H.C.Lane and R.R. Redfield, “Covid-19 – Navigating the Uncharted,” N Engl J Med. 2020;382(13):1268- 1269; S.J. Stratton, “COVID-19: Not a Simple Public Health Emergency,” Prehospital and Disaster Medicine 35 (2), (2020):119. 
    2. J. Iskander et al., “Pandemic Influenza Planning, United States, 1978-2008,” Emerging Infectious Diseases 19 (6),  (2013):879-885. 
    3. B. Jester B, T. Uyeki & D.Jernigan, “Readiness for Responding to a Severe Pandemic 100 Years After 1918,”  American Journal of Epidemiology 187 (2), (2018):2596-2602. 
    4. M.L. Ranney, V. Griffeth &, A.K. Jha, “Critical Supply Shortages — The Need for Ventilators and Personal  Protective Equipment during the Covid-19 Pandemic,” New England Journal of Medicine. (382)18, (2020):e41;  B. Sen-Crowe M. McKenney & A. Elkbuli, “COVID-19 Response and Containment Strategies in The U.S., South  Korea, and Iceland: Lessons Learned and Future Directions, “The American Journal of Emergency Medicine 38  (7), (2020):1537-1539; S.Murthy, C.D. Gomersall & R.A. Fowler, “Care for Critically Ill Patients With COVID-19, “  JAMA. 323 (15), (2020):1499-1500. 
    5. P.B Fontanarosa & H. Bauchner, “COVID-19—Looking Beyond Tomorrow for Health Care and Society.” JAMA. 323  (19), (2020):1907-1908. 
    6. S.J. Stratton, “COVID-19: Not a Simple Public Health Emergency,” Prehospital and Disaster Medicine. 35(2),  (2020):119. 
    7. J. Iskander et al., “Pandemic Influenza Planning, United States, 1978-2008,” Emerging Infectious Diseases. 19(6),  (2013):879-885. 
    8. K.E. Kun et al., “State, Territorial, and Local Health Departments’ Reporting of Partnership Strength before and  after the H1N1 Response,” Prehospital and Disaster Medicine 28(6), (2013):580. 
    9. B. Jester, T. Uyeki, & D. Jernigan, “Readiness for Responding to a Severe Pandemic 100 Years After 1918,”  American Journal of Epidemiology 187(12), (2018):2596-2602. 
    10. K.L. Escuyer, E Fuschino &, K. St George, “New York State Emergency Preparedness and Response to Influenza  Pandemics 1918–2018,” Tropical Medicine and Infectious Disease. 4(4), (2019):132. 
    11. N. Myers, “Evolution of Collaboration among Federal, State, and Local Agencies,” Public Manager. 42(2),  (2013):25. 
    12. F. Bdeir, J.W. Crawford & L. Hossain, “Informal Networks in Disaster Medicine. Disaster Medicine and Public  Health Preparedness 11(3, (2017):343-354. 
    13. A.G. Hoen et. Al., “Epidemic Wave Dynamics Attributable to Urban Community Structure: A Theoretical  Characterization of Disease Transmission in a Large Network, “ J Med Internet Res 17(7), (2015):e169. 15. M.A. Miller et al., “The Signature Features of Influenza Pandemics — Implications for Policy,” New England  Journal of Medicine 360(25), (2009):2595-2598; V. Andreasen V, C. Viboud & L. Simonsen, “Epidemiologic  Characterization of the 1918 Influenza Pandemic Summer Wave in Copenhagen: Implications for Pandemic  Control Strategies,” The Journal of Infectious Diseases 197(2), (2008):270-278. 
    14. M.A. Miller et al., “The Signature Features of Influenza Pandemics — Implications for Policy,” New England  Journal of Medicine 360(25), (2009):2595-2598; S.L. Knobler et al., “The Story of Influenza,” Paper presented at:  The Threat of Pandemic Influenza: Are We Ready? Workshop Summary 2005. 
    15. S.L. Knobler et al., “The Story of Influenza” Paper presented at: The Threat of Pandemic Influenza: Are  We Ready? Workshop Summary 2005; W.J. Housworth & M.M. Spoon, “The Age Distribution of Excess  Mortality During A2 Hong Kong Influenza Epidemics Compared With Earlier A2 Outbreaks,” American Journal  of Epidemiology 94(4), (1971):348-350; R.E. Serfling, “Methods for Current Statistical Analysis of Excess  Pneumonia-Influenza Deaths,” Public health reports78(6),(1963):494. 
    16. M.A. Miller et al. “The Signature Features of Influenza Pandemics — Implications for Policy,”: 2595-2598; S.L.  Knobler et al. “The story of Influenza” Paper presented at: The Threat of Pandemic Influenza: Are We Ready?  Workshop Summary 2005. 
    17. S.A.Truelove et al. “Comparison of Patients Hospitalized With Pandemic 2009 Influenza A (H1N1) Virus Infection  During the First Two Pandemic Waves in Wisconsin,” The Journal of Infectious Disease 203(6),(2011):828-837.
    18. M.A. Miller et al., “The Signature Features of Influenza Pandemics — Implications for Policy,”:2595-2598. 21. B.Y. Lee et al., “Vaccination Deep into a Pandemic Wave: Potential Mechanisms for a ‘Third Wave’ and the  Impact of Vaccination, “American Journal of Preventive Medicine 39(5), (2010) :e21-e29; K.M. Harris et al.,  “Interim Results: Influenza A (H1N1) 2009 Monovalent and Seasonal Influenza Vaccination Coverage Among  Health-Care Personnel—United States, August 2009-January 2010,” JAMA, The Journal of the American Medical  Association 303(22), (2010):2242-2244. 
    19. S.S. Papagiotas et al., “From SARS to 2009 H1N1 Influenza: The Evolution of a Public Health Incident  Management System at CDC,” Public Health Reports 127(3), (2012):267-274. 
    20. D.J. Brencic et al., “CDC Support for Global Public Health Emergency Management. Emerging Infectious Diseases  23(Suppl 1), (2013): S183. 
    21. CDC Emergency Operations Center | CDC. https://www.cdc.gov/cpr/eoc/eoc.htm. Accessed June 17, 2020. 25. CDC Emergency Operations Center: How an EOC Works | CDC, https://www.cdc.gov/cpr/eoc/how-eoc-works. htm. Accessed June 17, 2020. 
    22. U.S. Department of Health and Human Services, HHS Secretary’s Operations Center, https://www.phe.gov/ about/offices/program/icc/soc/Pages/default.aspx, Published September 20, 2019. Accessed July 18, 2020. 27. CDC, 2009 H1N1 Pandemic (H1N1pdm09 virus) | Pandemic Influenza (Flu) | https://www.cdc.gov/flu/ pandemic-resources/2009-h1n1-pandemic.html, Published June 11, 2019, Accessed July 18, 2020. 28. CDC Novel H1N1 Flu | The 2009 H1N1 Pandemic: Summary Highlights, April 2009-April 2010, https://www.cdc. gov/h1n1flu/cdcresponse.htm, Accessed June 17, 2020. 
    23. M.L. Holshue et al., “First Case of 2019 Novel Coronavirus in the United States,” New England Journal of  Medicine 382(10), (2020):929-936. 
    24. CDC Emergency Operations Center Activations | CDC, https://emergency.cdc.gov/recentincidents/, Accessed  June 17, 2020. 
    25. “The C.D.C. Waited ‘Its Entire Existence for This Moment.’ What Went Wrong?” The New York Times, https:// www.nytimes.com/2020/06/03/us/cdc-coronavirus.html, Accessed July 18, 2020. 
    26. Ibid. 
    27. Federal Emergency Management Agency, We Are FEMA; Helping People Before, During, and After Disasters, 2019, https://www.fema.gov/media-library-data/1574183469075-e7242c3d822c3e7d8e8ef12b18e32e77/ pub1_english.pdf, Accessed June 22, 2020. 
    28. CDC COVID-19 Response Team, Geographic Differences in COVID-19 Cases, Deaths, and Incidence – United  States, February 12-April 7, 2020. US Department of Health and Human Services/Centers for Disease Control  and Prevention, https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6915e4-H.pdf, Published April 17, 2020.  Accessed June 22, 2020. 
    29. D. Trump, Letter From President Donald J. Trump On Emergency Determination Under The Stafford Act | The  White House, https://www.whitehouse.gov/briefings-statements/letter-president-donald-j-trump-emergency determination-stafford-act/, Published March 13, 2020, Accessed June 22, 2020. 
    30. White House Press Office, President Obama Signs Emergency Declaration For H1N1 Flu, Whitehouse.gov.,  https://obamawhitehouse.archives.gov/blog/2009/10/25/president-obama-signs-emergency-declaration-h1n1- flu, Published October 25, 2009. Accessed June 22, 2020. 
    31. M.L. Ranney, V.Griffeth, & A.K. Jha, “Critical Supply Shortages — The Need for Ventilators and Personal  Protective Equipment during the Covid-19 Pandemic,” New England Journal of Medicine 382(18)(2020):e41. 38. Office of the Assistant Secretary for Preparedness and Response, et al., Stockpile Responses. U.S. Department  of Health and Human Services, https://www.phe.gov/about/sns/Pages/responses.aspx, Published July 2, 2020,  Accessed July 4, 2020. 
    32. A. Nicholson et al., The Nation’s Medical Countermeasure Stockpile: Opportunities to Improve the Efficiency,  Effectiveness, and Sustainability of the CDC Strategic National Stockpile: Workshop Summary, 2016. 40. Federal Emergency Management Agency, FEMA Supply Chain Task Force Leads Four-Pronged Approach To  Securing Needed Supplies And Equipment In COVID-19 Fight | FEMA.gov., https://www.fema.gov/fema-supply chain-task-force-leads-four, Published April 7, 2020, Accessed June 22, 2020. 
    33. Federal Emergency Management Agency, FEMA Phasing Out Project Airbridge, fema.gov., https://www.fema. gov/news-release/2020/06/18/fema-phasing-out-project-airbridge, Published June 18, 2020, Accessed July 6,  2020. 
    34. Federal Emergency Management Agency, We Are FEMA; Helping People Before, During, and After Disasters, 2019, https://www.fema.gov/media-library-data/1574183469075-e7242c3d822c3e7d8e8ef12b18e32e77/ pub1_english.pdf, Accessed June 22, 2020.
    35. Federal Emergency Management Agency, FEMA Supply Chain Task Force Leads Four-Pronged Approach To  Securing Needed Supplies And Equipment In COVID-19 Fight | FEMA.gov., https://www.fema.gov/fema-supply chain-task-force-leads-four. Published April 7, 2020, Accessed June 22, 2020. 
    36. Federal Emergency Management Agency, We Are FEMA; Helping People Before, During, and After Disasters, 2019, https://www.fema.gov/media-library-data/1574183469075-e7242c3d822c3e7d8e8ef12b18e32e77/ pub1_english.pdf, Accessed June 22, 2020. 
    37. S.Mervosh & K.Rogers, “Governors Fight Back Against Coronavirus Chaos: ‘It’s Like Being On EBay With 50  Other States,” https://www.nytimes.com/2020/03/31/us/governors-trump-coronavirus.html. Published March  31, 2020, Accessed June 22, 2020. 
    38. Ibid; L. Hogan L & G.Whitmer, “Larry Hogan and Gretchen Whitmer: What Governors Need from Washington  during This Health Emergency,” The Washington Post, https://www.washingtonpost.com/opinions/2020/03/30/ larry-hogan-gretchen-whitmer-what-governors-need-washington-during-this-health-emergency/, Published  March 30, 2020, Accessed July 6, 2020. 
    39. A. Pereira, “Breed Says SF‘s PPE Orders Have Been Diverted To France And ’Confiscated’ By FEMA,” SFGate, https://www.sfgate.com/coronavirus/article/Breed-SF-PPE-orders-diverted-to-france-FEMA-15224831.php, Published April 24, 2020, Accessed June 22, 2020. 
    40. K.Morfitt, “Gov. Polis Says He‘s Making Coronavirus Supply Purchases In Secret: ’It’s A Global Free For All’,”  CBS Denver. https://denver.cbslocal.com/2020/05/01/colorado-polis-coronavirus-secret-supply-purchases/ Published May 1, 2020, Accessed June 22, 2020. 
    41. S.L. Knobler et al., “The Story of Influenza,” Paper presented at: The Threat of Pandemic Influenza: Are We  Ready? Workshop Summary 2005. 
    42. P.T. Gaynor et al., FEMA Administrator April 15, 2020, Letter To Emergency Managers. fema.gov., https://www. fema.gov/news-release/2020/04/15/fema-administrator-april-15-2020-letter-emergency-managers. Published  April 15, 2020, Accessed July 6, 2020. 
    43. The White House, Remarks By President Trump, Vice President Pence, and Members Of The Coronavirus Task  Force In Press Briefing, https://www.whitehouse.gov/briefings-statements/remarks-president-trump-vice president-pence-members-coronavirus-task-force-press-briefing-6/, Published March 19, 2020, Accessed July 6,  2020. 
    44. “Vaccine and Other Medical Countermeasures,” Centers for Disease Control and Prevention, Centers for Disease  Control and Prevention, 28 Apr. 2020, www.cdc.gov/flu/pandemic-resources/planning-preparedness/vaccine medical-countermeasures.html.
    45. K.L. Escuyer et al., “New York State Emergency Preparedness and Response to Influenza Pandemics 1918–2018,  Tropical Medicine and Infectious Disease 4(4), (2020):132. 
    46. Ibid. 
    47. N.B.Dimitrov et al., “Optimizing Tactics for Use of the U.S. Antiviral Strategic National Stockpile for Pandemic  Influenza,” PloS one 6(1),(2011):e16094. 
    48. Ibid. 
    49. Ibid. 
    50. Ibid. 
    51. New York State Department of Health, Pandemic Influenza Plan, February 2006, Available online: https:// www. questar.org/wp-content/uploads/2017/08/Pandemic_influenza_plan.pdf (accessed on 14 February 2019). 60. Institute of Medicine (U.S.) Forum on Medical and Public Health Preparedness for Catastrophic Events, The  2009 H1N1 Influenza Vaccination Campaign: Summary of a Workshop Series, Washington (DC): National  Academies Press (US), 2010. 3, Vaccine Distribution. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK54182/.
    52. Ibid. 
    53. Ibid. 
    54. Ibid. 
    55. New York State Department of Health, Pandemic Influenza Plan, February 2006, Available online: https:// www. questar.org/wp-content/uploads/2017/08/Pandemic_influenza_plan.pdf (accessed on 14 February 2019). 65. “Pandemic Vaccine Program Distribution, Tracking, and Monitoring,” CDC: National Center for Immunization and  Respiratory Diseases, 20 Apr. 2020, www.cdc.gov/flu/pdf/pandemic-resources/pandemic-influenza-vaccine distribution-9p-508.pdf.
    56. Ibid.

    67.A.T. Chamberlain et al., “Perspectives of Immunization Program Managers on 2009-10 H1N1 Vaccination  in the United States: A National Survey,” Biosecurity and Bioterrorism:Biodefense Strategy, Practice, and  Science10(1),(2012):142-150. 

    1. Ibid. 
    2. Ibid. 
    3. Ibid. 
    4. Ibid. 
    5. Ibid. 
    6. Ibid. 
    7. Ibid. 
    8. Ibid. 
    9. Ibid. 
    10. R.K. Marcello et al., “Distribution of Pandemic Influenza Vaccine and Reporting of Doses Administered, New  York, New York, USA,” Emerging Infectious Diseases 20(4),(2013):525-531. 
    11. Ibid. 
    12. L.M. Koonin et al., “CDC’s 2009 H1N1 Vaccine Pharmacy Initiative in the United States: Implications for Future  Public Health and Pharmacy Collaborations for Emergency Response,” Disaster Medicine and Public Health  Preparedness5(4), (2011):253-255. 
    13. Ibid. 
    14. U.S. Department of Health and Human Services, “HHS Extends COVID-19 Testing Public-Private Partnership,”  HHS.gov, US Department of Health and Human Services, 30 June 2020, www.hhs.gov/about/news/2020/06/30/ hhs-extends-covid-19-testing-public-private-partnership.html.
    15. Ibid. 
    16. Ibid. 
    17. J.Y.Choi, “ COVID-19 in South Korea,” Postgraduate Medical Journal 96(1137),(2020):399-402; J. Oh, “National  Response to COVID-19 in the Republic of Korea and Lessons Learned for Other Countries,” Health Systems &  Reform 6(1)(2020):e-1753464. 
    18. J. Oh et al., “National Response to COVID-19 in the Republic of Korea and Lessons Learned for Other Countries,”  Health Systems & Reform 6(1), (2020): e-1753464; M-D Oh, et al., “Middle East Respiratory Syndrome: What  We Learned from the 2015 Outbreak in the Republic of Korea, “The Korean Journal of Internal Medicine 33(2),  (2018):233-246. 
    19. J.Y. Choi,”COVID-19 in South Korea,” Postgraduate Medical Journal 96(1137), (2020):399-402; M-D. Oh et  al., “Middle East Respiratory Syndrome,” ; K. Lee & K. Jung , “ Factors Influencing the Response to Infectious  Diseases: Focusing on the Case of SARS and MERS in South Korea,” International Journal of Environmental  Research and Public Health 16(8), (2018):1432. 
    20. M-D Oh et al., “Middle East Respiratory Syndrome,” 233-246; K-M Lee & K.Jung, “Factors Influencing the  Response to Infectious Diseases: Focusing on The Case of SARS and MERS in South Korea,” 1432; S.R.  Kim T.Kung, & M. Abdelmalek, “Trust, Testing and Tracing: How South Korea Succeeded Where the U.S.  Stumbled in Coronavirus Response,” ABC News, https://abcnews.go.com/Health/trust-testing-tracing-south korea-succeeded-us-stumbled/story?id=70433504, Published May 1, 2020; D. Thompson, “What’s Behind  South Korea’s COVID-19 Exceptionalism?” The Atlantic, May 2020, https://www.theatlantic.com/ideas/ archive/2020/05/whats-south-koreas-secret/611215/. Accessed May 14, 2020. 
    21. M-D. Oh et al., “Middle East Respiratory Syndrome,” 233-246. 
    22. S.R. Kim, T. Kung & M. Abdelmalek, “Trust, Testing and Tracing,” “https://abcnews.go.com/Health/trust-testing tracing-south-korea-succeeded-us-stumbled/story?id=70433504. Published May 1, 2020 90. J. Oh et al., “National Response to COVID-19 in the Republic of Korea and Lessons Learned for Other Countries,”  Health Systems & Reform, e-1753464. 
    23. M.P Cheng et al., “Diagnostic testing for Severe Acute Respiratory Syndrome–Related Coronavirus-2: A  Narrative Review, “Annals of Internal Medicine, 2020. 
    24. Thompson D. What’s Behind South Korea’s COVID-19 Exceptionalism? The Atlantic, May 2020, https://www. theatlantic.com/ideas/archive/2020/05/whats-south-koreas-secret/611215/, Accessed May 14, 2020; S. Choi et  al., “Innovative Screening Tests for COVID-19 in South Korea. Clin Exp Emerg Med7(2), (2020):73-77.
    25. M.P. Cheng et al., “Diagnostic Testing for Severe Acute Respiratory Syndrome–Related Coronavirus-2: A  Narrative Review,” Annals of Internal Medicine, 2020. 
    26. Ibid. 
    27. M. Her, “How Is COVID-19 Affecting South Korea? What Is Our Current Strategy?” Disaster Medicine and Public  Health Preparedness, 2020:1-3. 
    28. D. Thompson What’s Behind South Korea’s COVID-19 Exceptionalism? The Atlantic, May 2020, https://www. theatlantic.com/ideas/archive/2020/05/whats-south-koreas-secret/611215/,. Accessed May 14, 2020. 97. R.L. Haffajee & M.M. Mello, “Thinking Globally, Acting Locally — The U.S. Response to Covid-19,” New England  Journal of Medicine 382 (22), (2020):e75. 
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