We Cannot Let This Happen Again!
Pandemic Preparations, United States
Mary C. Vrtis, Ph.D., MSN, RN, OCN, NEA-BC, FCN
Pre-COVID Pandemic Preparations, United States
The United States has some of the most knowledgeable infectious disease specialists and medical research scientists in the world. The U.S. has a well-established, science driven, multi-layered public health network that includes federally funded, state and local programs, as well as public/ private partnerships with universities and philanthropic organization. There are also programs under the U.S. Department of Defense. U.S. scientists and medical experts regularly collaborate with global networks of similarly prepared experts to produce and publish research that ultimately translates into evidence-based guidelines for most medical and nursing specialties.
Recent advances in pathogen genetics, worldwide networks of infection control experts, databases that allow for real-time collaboration between scientists and medical experts throughout the world, all offered the potential for early containment. There is more known today about the invisible world of pathogens than ever before. The U.S. and most of the developed world was extremely well prepared to effectively respond to the evolving, world-wide COVID-19 pandemic.
An Ebola outbreak in West Africa caused 11,000 deaths in 2014 to 2016. The causative organism had reached the U.S. and Europe, but the virus was successfully contained. Mosquito borne Zika virus infected 32,000 U.S. citizens in Puerto Rico, including 2,000 pregnant women causing numerous, severe birth defects before the outbreak was contained. Lessons learned from these situations prompted then President Obama to request a study with recommendations for improving pandemic preparation that was published in 2016.
Pandemic Prediction and Forecasting Science and Technology Working Group of the National Science and Technology Council (2016). Towards epidemic prediction: Federal efforts and opportunities in outbreak modeling. https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/NSTC/towards_epidemic_prediction-federal_efforts_and_opportunities.pdf
In fact, several potentially disastrous situations had already been prevented through timely, global responses. Outbreaks of Coronavirus related severe acute respiratory syndrome (SARS) in 2003, and Middle Eastern respiratory syndrome Coronavirus (MERS-CoV) in 2012 had been averted due to early and successful collaboration of world-wide medical experts and scientists. The lessons learned from these outbreaks helped to inform medical experts within the U.S. Centers for Disease Control and Prevention, comparable organizations in most countries, and the World Health Organization of the actions needed to control the evolving epidemic.
There were countless decisions made at all levels from top government officials to the nurses that instructed patients to self-quarantine that were fully appropriate. Well educated and informed public health officials across the globe worked long hours to get out the messages that told people exactly what they needed to do to protect themselves and others from the SARS-CoV-2 virus. Nurses, other healthcare providers, and first responders put their own lives at risk while trying to keep those infected from death’s doorway. Many quite literally worked themselves to death.
Bad Decisions and Factors that Fueled the Pandemic
As discussed throughout this work, this massive failure to prevent the pandemic and the deaths of more than 7 million people cannot be attributed to a single country or a single person. There are countless decisions made by leaders at all levels throughout the world that exacerbated the situation, decisions that resulted in increased numbers of infected people and preventable deaths. Before we discuss the pandemic prevention structure in the U.S., we will summarize some of the underlying factors that came together to make this pandemic so much worse than it had to be, at least here in the United States.
Characteristics of SARS-CoV-2 virus that made it deadly, the virus was/ is:
- A novel virus which no human being had ever encountered before and to which humans had no immunity.
- Extremely good at mutating in response to human interventions and had in fact already developed variants within the bodies of first few victims.
- Highly contagious, spread by virus containing water droplets suspended in the air, airborne virus floating in the air, direct contact from the sick individual, and indirect contact through contaminated objects and surfaces.
- Able to mutate to evade the innate human immune system, and the vaccine induced immune response.
- Capable of spreading through infected people who showed no symptoms and did not know they were sick.
- Virulent, able to cause severe illness, end organ damage, and death.
- Proficient at developing resistance to pharmacological treatments.
Political and personal considerations on the part of high-level governmental decision makers resulted in the following phenomena:
- Politicians who may or may not have understood the science behind the recommendations placed higher priority on retention (or desired expansion) of personal power than on the health and well-being of constituents.
- Grandstanding by individuals in state, local, and federal government who might otherwise have been lost in the crowd created a deluge of anti-science media soundbites played over and over.
- Voices of reason from medical experts were drowned out by politicians with little to no understanding of the science who promoted misinformation and conspiracy theories for personal, political, and financial gain.
An anti-science “infodemic” of misinformation, disinformation, and conspiracy theories designed to deliberately cause harm invigorated the anti-vaccination movement and increased the number of those who believed the pandemic was a hoax.
Medical experts, public health officials and clinicians, and philanthropists supporting vaccinations and global health initiatives were vilified.
Many people refused to take personal responsibility for their health and the protection of others by following the measures designed to mitigate the disaster.
Pandemic and All-Hazard Preparedness Laws and Reports
2006 – The Pandemic and All-Hazards Preparedness Act (PAHPA), Public Law No. 109-417 was signed into law in 2006 (https://www.govinfo.gov/content/pkg/PLAW-109publ417/pdf/PLAW-109publ417.pdf).
2013 – the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA) of 2013, Public Law No. 113-5 was passed (https://www.govinfo.gov/content/pkg/PLAW-113publ5/pdf/PLAW-113publ5.pdf).
The most recent version was signed into law on June 24, 2019. PAHPAIA was signed before the world learned of the SARS-CoV-2 virus that jumped species in and infected humans in December of 2019.
2019 – the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (PAHPAIA) (https://www.congress.gov/116/bills/s1379/BILLS-116s1379enr.pdf).
PAHPAIA focus areas are:
TITLE I—STRENGTHENING THE NATIONAL HEALTH SECURITY STRATEGY
TITLE II—IMPROVING PREPAREDNESS AND RESPONSE
TITLE III—REACHING ALL COMMUNITIES
TITLE IV—PRIORITIZING A THREAT-BASED APPROACH
TITLE V—INCREASING COMMUNICATION IN MEDICAL COUNTERMEASURE ADVANCED RESEARCH AND DEVELOPMENT
TITLE VI—ADVANCING TECHNOLOGIES FOR MEDICAL COUNTERMEASURES
TITLE VII—MISCELLANEOUS PROVISIONS
Governmental Agencies, Institutes, Offices and Entities Involved in Infectious Disease and Pandemic Preparation and Response
Centers for Disease Control and Prevention/ Health and Human Services
The Centers for Disease Control and Prevention (CDC) is part of the U.S. Department of Health and Human Services (HHS). There are at least seven publicly funded entities under the HHS and CDC umbrella responsible for aspects of pandemic protection. These include: the CDC, the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), the Division of Global Health Protection and Security (DGHP), which has 12 internal programs, the Office of Public Health Readiness and Response (ORR), the Antimicrobial Resistance Lab Network (with Response Network (that includes labs in 42 countries), and the One Health Office. Table 1 includes links and descriptions for these programs.
Table 1
Pandemic Preparation: U.S. Government Programs under the HHS, CDC umbrella
| Department/ Division/ Program | Location/ Base | Description |
| Centers for Disease Control and Prevention | Atlanta, Georgia | “CDC is the nation’s leading science-based, data-driven, service organization that protects the public’s health.” |
| National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) | Atlanta, Georgia | “NCEZID works to protect people at home and around the world from emerging and zoonotic infections ranging from A to Z—anthrax to Zika. We are living in an interconnected world where an outbreak of infectious disease is just a plane ride away.” |
| CDC’s Division of Global Health Protection and Security (DGHP) | Atlanta, Georgia | 12 programs and institutes. “CDC’s Division of Global Health Protection (DGHP) works 24/7 to protect Americans from dangerous health threats around the world. Our scientists and “boots on the ground” frontline responders help contain outbreaks overseas so they don’t reach our shores.” |
| CDC’s Office of Public Health Readiness and Response (ORR) | Atlanta, Georgia | “ORR is America’s public health defense hub. Our staff work alongside our CDC peers, other federal partners, and state, local, tribal, and territorial health departments to continuously monitor for risks to the health of communities and the nation. When a concern is identified, we put decades of public health emergency expertise to work to get the right experts and resources in place to address the emergency and protect the health of Americans and people around the globe.” |
| CDC’s Antimicrobial Resistance Lab Network (ARLab Network) | Atlanta, Georgia, 50 states and Puerto Rico | “CDC’s AR Lab Network supports nationwide lab capacity to rapidly detect antimicrobial resistance and inform local responses to prevent spread and protect people.” |
| CDC’s Global Antimicrobial Resistance Lab and Response Network | Atlanta, Georgia with labs in 42 countries | “The Global AR Lab & Response Network improves the detection of existing and emerging antimicrobial resistance threats and identifies risk factors that drive the emergence and spread of resistance across health care, the community, and the environment. This global network also supports response to these threats and informs global prevention strategies for antimicrobial resistance.” |
| CDC’s One Health Office | Atlanta, Georgia | “One Health Focus Areas: zoonotic and emerging infectious diseases, pandemic preparedness and response, emergencies at the human-animal-environment interface, pan-respiratory disease surveillance, global health security and capacity building, prevent zoonoses shared between people and pets.” |
The National Institutes of Health (NIH)
The National Institutes of Health (NIH) is also under the U.S. Department of Health and Human Services. Decades of scientific research that has revolutionized medical care and provided tools for improvements in health have been funded through the 27 institutes and centers within NIH (https://www.nih.gov/about-nih/what-we-do/impact-nih-research). The National Institute of Allergy and Infectious Diseases (NIAID) was developed in 1948 with a focus on emerging infectious diseases, high risk “priority pathogens and biodefense. See table 2 for links and further information on each entity.
Table 2
Pandemic Preparation: U.S. Government Programs under the HHS, NIH umbrella
| Department/ Division/ Program | Location/ Base | Description |
| National Institute of Health (NIH) | Bethesda, Maryland 27 Institutes and Centers | “NIH works to turn scientific discoveries into better health for all. As the largest public funder of biomedical and behavioral research in the world, NIH is the driving force behind decades of advances that improve health, revolutionize science, and serve society more broadly.” |
| National Institute of Allergy and Infectious Diseases (NIAID) | Bethesda, Maryland | This institute has a focus on biodefense and emerging infectious diseases, and high risk “priority pathogens.” “NIAID conducts and supports basic and applied research to better understand, treat, and ultimately prevent infectious, immunologic, and allergic diseases. For more than 60 years, NIAID research has led to new therapies, vaccines, diagnostic tests, and other technologies that have improved the health of millions of people in the United States and around the world.” |
ASPR/TRACIE
The Administration for Strategic Preparedness & Response (ASPR), Technical Resources, Assistance Center, and Information Exchange (Tracie) is also under the U.S. Department of Health and Human Services (HHS). Entities under the HHS/ ASPR Tracie umbrella include seven programs focused on infection related preparation, as shown in table 3. The Biomedical Advanced Research and Development Authority (BARDA) focuses on chemical, biological, radiological, and nuclear incidents as well as influenza (flu) pandemics, and emerging infectious diseases. Project BioShield, under BARDA, was initiated in 2004 to provide medical countermeasures against chemical, nuclear, radiological, and biological attacks. The National Biosurveillance Integration Center is under ASPR Tracie and is charged with providing early warning about threats. The Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) under ASPR was established in 2006 and the focus is on countermeasures for emergencies. The ASPR Tracie Hospital Preparedness Program is intended to assist and provide funding to prepare hospitals for disasters. The Medical Reserve Corps (MRC) coordinates a network of more than 300,000 volunteers who can be tapped to help address widespread emergencies. The last division in this grouping charged with pandemic and mass emergency preparation is the National Strategic Stockpile (SNS) under ASPR. The purpose of SNS is to store sufficient supplies, equipment and medications that will be necessary to temporarily address national, state, and local needs in an emergency. Table 3 provides links and more information about each department under HHS and ASPR Tracie.
Table 3
Pandemic Preparation: U.S. Government Programs under HHS and the Administration for Strategic Preparedness & Response (ASPR) umbrella
| Department/ Division/ Program | Location/ Base | Description |
| Biomedical Advanced Research and Development Authority (BARDA) | Washington, DC | “BARDA provides an integrated, systematic approach to the development of the necessary vaccines, drugs, therapies, and diagnostic tools for public health medical emergencies such as chemical, biological, radiological, and nuclear (CBRN) accidents, incidents and attacks; pandemic influenza (PI), and emerging infectious diseases (EID).” |
| Project BioShield | Washington, DC | Initiated with the Project BioShield Act of 2004 to provide medical countermeasures against chemical, nuclear, radiological, and biological attacks under BARDA. “Project BioShield was established to help incentivize private industry to develop vitally needed medical countermeasures by providing multi-year funding to support advanced research, clinical development, manufacture and procurement. Without this secure source, companies do not have the incentive needed to develop the medical countermeasures that are critical to national security.” |
| National Biosurveillance Integration Center | Washington, DC | “This Center focuses on providing early warning and situational awareness of biological threats and works with federal, state, local, territorial, and tribal partners to analyze and share related information.” |
| Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) | Washington, DC | “The Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) contributes to the nation’s preparedness for chemical, biological, radiological, and nuclear threats, as well as emerging infectious disease threats. It does so by enhancing timely availability and equitable use of effective medical countermeasures (e.g., vaccines, treatments, devices, personal protective equipment) to protect Americans from those threats.” |
| Hospital Preparedness Program | Washington, DC | “ASPR’s Hospital Preparedness Program (HPP) provides leadership and funding through cooperative agreements to states, territories, and eligible major metropolitan areas to increase the ability of HPP funding recipients to plan for and respond to large-scale emergencies and disasters. HPP is the primary source of federal funding for health care system preparedness and response and, in collaboration with state and local health departments, prepares health care delivery systems to save lives through the development of health care coalitions (HCCs).” |
| Medical Reserve Corps (MRC) | Washington, DC | “MRC is a national network of more than 300,000 volunteers, organized locally to improve the health and safety of their communities. MRC volunteers step up to keep their family, friends, and neighbors safe and healthy.” |
| National Strategic Stockpile (SNS) | Washington, DC | “The SNS is part of the federal medical response infrastructure and can supplement medical countermeasures needed by states, tribal nations, territories and the largest metropolitan areas during public health emergencies. The supplies, medicines, and devices for lifesaving care contained in the stockpile can be used as a short-term, stopgap buffer when the immediate supply of these materials may not be available or sufficient. The SNS team works every day to prepare and respond to emergencies, support state and local preparedness activities, and ensure availability of critical medical assets to protect the health of Americans.” |
U.S. Department of Defense
The U.S. Department of Defense also has a focus on infectious diseases, especially in relation to biological defense. The U.S. Army Medical Research and Development Command (USAMRDC) at Fort Detrick, MD, has six laboratories focused on military concerns, including infectious disease. The U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick, MD, is one of the commands under USAMRDC. The Special Pathogens Laboratory (SPL) that is part of USAMRIID is also one of the CDC’s Laboratory Response Network (LRN). Table 4 provides links and further descriptions of these programs.
Table 4
Pandemic Preparation: U.S. Government Programs under the Department of Defense umbrella
| Department/ Division/ Program | Location/ Base | Description |
| U.S. Army Medical Research and Development Command (USAMRDC) | Fort Detrick, Maryland | “Six medical research laboratory commands execute the science and technology program to investigate medical solutions for the battlefield with a focus on various areas of biomedical research, including military infectious diseases, combat casualty care, military operational medicine, medical chemical and biological defense, and clinical and rehabilitative medicine. The Command manages a large extramural research program with numerous contracts, grants, and cooperative research and development agreements to provide additional science and technology capabilities from leading academic, private industry, and other government organizations.” |
| U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) | Fort Detrick, Maryland | “Since 1969, USAMRIID has served as the Department of Defense’s (DoD) lead laboratory for medical biological defense research. While our core mission is to protect the warfighter from biological threats, we also investigate disease outbreaks and threats to public health. Research conducted at USAMRIID leads to medical solutions—therapeutics, vaccines, diagnostics, and information—that benefit both military personnel and civilians.” |
| USAMRIID Special Pathogens Laboratory (SPL) | Fort Detrick, Maryland | Part of the CDC’s Laboratory Response Network (LRN). “The Special Pathogens Laboratory (SPL) receives and analyzes clinical, environmental and biological material for the presence of biological threat agents and disease-causing agents.” |
U.S. Department of Homeland Security
The U.S. Department of Homeland Security is also concerned with biological threats and had four facilities to address those concerns, see table 5 for descriptions and links. There are two labs within the National Biodefense Analysis and Countermeasures Center (NBACC) at Fort Detrick, MD. These are the National Bioforensic Analysis Center (NBFAC) and the National Biological Threat Characterization Center. The National Urban Security Technology Laboratory (NUSTL) in Manhattan, NY is focused on protecting first responders through research, development, testing and evaluation of protective equipment. The Plum Island Animal Disease Center (PIADC) in Orient Point, NY was founded in 1954, and is concerned with diseases that can affect livestock and animal products, see table 5.
Table 5
Pandemic Preparation: U.S. Government Programs under the Department of Homeland Security umbrella
| Department/ Division/ Program | Location/ Base | Description |
| National Biodefense Analysis and Countermeasures Center (NBACC) | Fort Detrick, Maryland | The facility has two labs, the National Bioforensic Analysis Center (NBFAC) and the National Biological Threat Characterization Center. “NBACC is a one-of-a-kind facility dedicated to defending the nation against biological threats. Its work supports intelligence assessments, preparedness planning, response, emerging threat characterization and bioforensic analyses.” |
| National Urban Security Technology Laboratory (NUSTL) | Manhattan, NY, NY | NUSTL is “a federal laboratory organized within the U.S. Department of Homeland Security (DHS) Science and Technology Directorate (S&T), NUSTL brings together the interests and initiatives of the Homeland Security Enterprise with the first responder community. The laboratory’s mission activities in test and evaluation (T&E) and research and development (R&D) help first responders prepare, protect and respond to homeland security threats.” |
| Plum Island Animal Disease Center (PIADC) | Orient Point, NY | “PIADC served as the front line of the nation’s defense against diseases that could devastate markets for livestock, meat, milk, and other animal products.” |
State and Territorial Health Departments
Perhaps most important in terms of local identification of infectious diseases, testing, contact tracing and education for the general public are the state and local health departments. There are State health departments in 50 states, Washington, DC, five territories (American Samoa, Mariana Islands, Guam, Puerto Rico, U.S. Virgin Islands), and three freely associated states (Marshall Islands, Micronesia, Republic of Palau), (CDC, n.d.). Organized within the state framework are the local county and city health departments.
U.S. State, Territory, and Freely Associated State Health Department Websites
U.S. State and Territory Health Departments
As the number of COVID-19 cases increased across the United States, territories, and freely associated states, state and local health departments played crucial roles. Local departments informed people of the number or patients identified in a jurisdiction, as well as hospitalizations and deaths. Vaccination availability and information about where to obtain the shot as well as current recommendations. This kind of information assisted decision makers about whether to open an office or continue remote work, whether to continue virtual religious services or go live in person. The websites above provided a source of accurate information for local jurisdictions.