From the Chief Medical Officer: Preventing Respiratory Disease Spread with Less Authority, More Influence

November 28, 2023 | Marcus Plescia

Earlier this year, CDC and other public health leaders began shifting their focus from primarily COVID to include a broader range of respiratory diseases including influenza and RSV. As COVID hospitalization rates have slowed, and with RSV and flu infections on the rise, many hospital systems are preparing for similar bed and staffing capacity challenges they saw at this time last year.

In August, ASTHO convened a workgroup of public health national organizations from CSTE, NACCHO, BCHC, APHL and AIM. In addition to facilitating opportunities for state and local public health to offer early guidance to CDC and other federal agencies, the group discussed potential scenarios for the respiratory disease season and prioritized specific strategies for state, territorial, and local public health leaders.

Shifting from Authority to Influence

With the end of the federal public health emergency in May, much of our collective response to infectious disease has shifted back to the private sector. COVID vaccine and therapeutics are now being supplied by commercial channels and are no longer being managed through public health agencies. Additionally, manufacturing issues with Nirsevimab have been frustrating. That said, public health leaders can work with commercial sector partners to address challenges and communicate to the public that we are doing everything we can to monitor, facilitate, and coordinate efforts to prevent and manage respiratory diseases in our communities.

The workgroup further recommends that state, territorial, and local public health leaders convene hospital systems and pharmacies to troubleshoot and address issues with access to vaccines and therapeutics. Public health can direct federal resources to those serving the most vulnerable populations (e.g., nursing homes and federally qualified health systems). In some instances, regional ordering systems could be organized to lower the threshold for minimum orders for individual/small providers. When there is political support, state and local policy makers could provide funding for health departments to augment federal funding and supplies for needed resources.

Public health continues to play a lead role in communicating about COVID and other respiratory diseases and is still widely regarded as a trusted source of information. As our greatest technical assistance need from federal partners, the workgroup recommends developing tested, science-based, public-facing messaging that:

• Emphasizes that viral respiratory illness is not only COVID.
• Urges the public to stay home if sick and employers/schools to support this behavior.
• Provides frequent, accurate public information regarding availability of local vaccine and therapeutic agents (e.g., where, when, and who can access them).
• Describes what federal, state and territorial, and local public health are doing to address respiratory illness and alleviate barriers or challenges.
• Condenses highly scientific guidance into clear, plain language.

Collaborating with the Healthcare Sector

Members of the workgroup suggest that public health leaders meet with healthcare system leaders to build on relationships and collaborations forged during the pandemic and to discuss how to prevent and manage potential surges in respiratory disease in the upcoming winter months. Some key strategies include:

1. Develop agreements or collaborations for healthcare systems to encourage employee vaccination and provide vaccinations on-site during work hours. In many regions, staffing capacity is a greater concern than bed capacity during an infectious disease surge. While vaccinating most staff cannot completely prevent disease transmission, it limits infections and reduces transmission to patients. Healthcare systems may be reluctant to implement vaccine mandates, and JCAHO quality measures for influenza vaccination were recently scaled back, but there are a number of effective voluntary strategies healthcare systems can take.
2. Discuss efforts to vaccinate patients who are being discharged to long-term care facilities. There are significant economies of scale to providing vaccination in health care settings, but some hospitals report that they are being cautious vaccinating nursing home bound patients who have moderate illness. During the pandemic, 90% of new patients in nursing homes were discharged from hospitals, but only 10% of these patients were vaccinated prior to arrival. In addition, emergency departments serve as the primary health care access point for up to a fifth of the U.S. population. Urgent care clinics handle more than 29% of all primary care visits in the country. Expanding COVID-19 vaccine availability via these settings can therefore increase access to vaccinations.
3. Discuss strategies for ordering, stocking, distributing, and monitoring COVID-19 and other vaccines. While pharmacies have proven a highly efficient mechanism to vaccinate motivated individuals, people who are undecided or hesitant are unlikely to use them. Making vaccines widely available in healthcare settings is crucial because people are very likely to listen to their providers' recommendations and there are a number of evidence-based strategies to increase vaccination rates including standing orders, patient reminders and provider counselling.
4. Discuss criteria to implement universal masking, other infection control strategies and crisis standards of care in healthcare settings. CDC has not fully updated its guidance for hospital infection control since 2022 but many systems have reinstated these strategies during the last wave of COVID infections. What’s more, physicians and other healthcare professionals are trained to routinely make these decisions when resources are scarce, but many state and local health departments have developed integrated crisis standards of care across systems. Understanding data, thresholds and processes healthcare systems use can help public health leaders support this effort.
5. Focus on vulnerable settings (e.g., nursing homes) and engage communities when promoting prevention and treatment strategies. In the long run, a national adult vaccination program (like the vaccines for children program) would help address access issues and give public health departments greater authority and resources to lead these efforts.

There is still time for public health leaders to adopt strategies recommended by the workgroup. Influenza and RSV rates are just beginning to rise and COVID rates have currently plateaued. These targeted vaccination strategies can be initiated quickly and make a significant impact on infection control. While public health leaders no longer have some of the authorities granted during the pandemic, we still have significant influence to impact the winter respiratory disease season.