Retrospectivas (Look Backs) Facilitadas

Nueva herramienta para mejorar la calidad del manejo de la influenza de rutina anual y pandémica

Julia E. Aledort, Nicole Lurie, Karen Ricci, David Dausey, Stefanie Stern

TR-320-DHHS

Febrero de 2006

Preparada por la Oficina del Subsecretario de Preparación para Emergencias de Salud Pública del Departamento de Salud y Servicios Humanos de los EE.UU.

Contenidos

Prólogo
Resumen
Reconocimientos
Siglas
Chapter One.  Introduction and Methods
¿Qué podemos aprender sobre la influenza de rutina anual?
¿Qué es un “Look-Back” (Retrospectiva)?
¿Cómo elaboramos un “Look-Back” (Retrospectiva)?
Chapter Two.  Conducting a Look-Back at Routine Annual Influenza
Marco general
Temas de discusión y sondeos
Preguntas esenciales de discusión
Chapter Three.  Translating Knowledge into Practice
Hallar formas para mejorar el manejo de la influenza de rutina anual y pandémica
Informes posteriores a la acción
Elaborar un plan de acción o un plan de mejoras
Chapter Four.  Design Issues and Implementation Challenges
Chapter Five.  Selected Lessons Learned by State Public Health Agencies
Appendix A.  Look-Back Planning Checklist
Appendix B.  Sample Look-Back Presentation
Appendix C.  Template for an After Action Report
Referencias
Información sobre derechos de propiedad intelectual: Rand Corporation

Números

2.1. Marco general para una Retrospectiva de la influenza de rutina anual
A.1. Agenda de ejemplo

Prólogo

One of the challenges of pandemic influenza preparedness is the relative infrequency of pandemics and the consequent inability of public health agencies to improve preparedness by learning from direct experience.  The occurrence of predictable, yet variable, routine annual influenza offers important opportunities for public health agencies to identify lessons from each influenza season that may be broadly applicable to some aspects of pandemic influenza and even to other public health preparedness activities.

This document describes a tool that public health agencies can adopt to regularly “look back” at each routine annual influenza season, with the goals of  (1) systematically institutionalizing knowledge from one influenza season to the next; (2) continuously  improving the public health response to routine annual influenza; and (3) incorporating lessons into preparedness activities for pandemic influenza and other public health emergencies. We developed and piloted this “Look-Back” methodology with three state public health agencies (SPHAs) in different regions of the United States between June and August 2005. This document provides SPHA leaders with the basic information necessary to conduct influenza Look-Backs at routine annual influenza with their staff members and to tailor the discussion to their own needs and experiences. In addition, we report on some design issues and lessons that emerged from our pilot tests that may be of interest to SPHAs.

Este informe fue preparado para la Oficina de Preparación de Emergencias de Salud Pública, aunque debe ser de interés para los formuladores de políticas, profesionales de la salud pública y personas que participan en el manejo de la influenza de rutina anual y la influenza pandémica y en la preparación para emergencias de salud pública. Este trabajo fue patrocinado por el Departamento de Salud y Servicios Públicos de los EE.UU. y fue implementado a partir de octubre de 2004 hasta octubre de 2005 dentro del RAND Health Center for Domestic and International Health Security (Centro RAND Health para la Seguridad de la Salud Nacional e Internacional. RAND Health es una división de RAND Corporation. Un perfil del Centro, extractos de sus publicaciones e información de solicitudes pueden encontrarse en www.rand.org/health/centers/healthsecurity. Más información sobre RAND está disponible en nuestro sitio Web en http://www.rand.org.

Resumen

Debido a que las pandemias de influenza¹ are relatively infrequent, public health agencies have limited opportunities to learn from direct experience with them.  In contrast, routine annual influenza occurs each year with some predictability, and this routine occurrence offers important opportunities for public health and pandemic preparedness. Each routine annual influenza season presents unique challenges and lessons that may be applicable to pandemic influenza and other public health preparedness activities. For example, unanticipated events in the past decade, such as influenza vaccine shortages, high numbers of influenza-associated deaths among U.S. children, and unexpected surges in demands for patient care, have underscored the need for better preparation—specifically, the importance of early planning and responsiveness to different contingencies that may arise. 

With the specter of pandemic influenza before the American populace, the RAND team sought to harness opportunities arising from the annual occurrence of influenza to help public health agencies improve their response to routine annual influenza and to incorporate lessons into pandemic and emergency public health preparedness planning.  Specifically, we set out to develop and test a “Look-Back” methodology to assist state public health agencies (SPHAs) in systematically assessing their experiences from each routine annual influenza season and translating those experiences into future public health practice.

A Look-Back is a quality improvement tool that seeks to identify relevant and applicable lessons for routine annual and pandemic influenza preparedness by asking a broad and diverse group of participants who have been involved in routine annual influenza activities to critically evaluate their management of the past routine annual influenza season. We developed the Look-Back by focusing primarily on an SPHA’s role in routine annual influenza activities. Because of the SPHA’s role in these routine activities, we pilot-tested the Look-Back with three SPHAs and relevant stakeholders between June and August 2005. 

Al involucrar un amplio y diverso grupo de participantes, a través de las Retrospectivas se busca promover un análisis abierto, sincero y sin echar culpas a nivel de los sistemas del manejo de la influenza de rutina anual. Una Retrospectiva trata la serie de acontecimientos que se produjeron durante la temporada pasada de influenza, las decisiones principales que fueron tomadas por diversos grupos interesados y cómo esas decisiones fueron interpretadas y cómo otros actuaron de acuerdo con éstas.

El marco general para una Retrospectiva incluye a un moderador independiente y objetivo o un líder de discusión que ayuda a estimular la discusión y guía a los participantes en una evaluación crítica de los recientes acontecimientos históricos y en las actividades basadas en tales áreas de los temas generales como la estructura organizativa para la toma de decisiones, vigilancia de la influenza, compra y distribución de vacunas, campañas de rutina de vacunación contra la influenza de rutina anual, administración de vacunas, grupos de prioridad y las implicaciones del cambio de prioridades, estrategias para la no vacunación y la salud pública, comunicación, y acontecimientos inesperados.

In advance of the Look-Back, the facilitator and the SPHA will need to select from three to six discussion topics, as well as suggested questions, or probes, that the facilitator may use to keep the participants on track and to ensure that particularly relevant or timely issues are not overlooked.  In addition to topic-specific issues, we developed the following core questions, which are broadly applicable to all of the discussion topics:

• ¿Cuáles son las actividades, los roles y las responsabilidades durante una temporada de
  la influenza de rutina anual?
• ¿Cuáles fueron los problemas específicos que surgieron el año pasado?
• ¿Qué resultó bien, y los logros pasados están debidamente institucionalizados? ¿Cuáles fueron los problemas específicos que surgieron?
• ¿Qué es lo que se podría haber hecho de manera diferente?
• ¿Qué es lo que se debe hacer de manera diferente en el futuro?
• ¿Cuáles son las lecciones para la influenza pandémica?

El Apéndice A proporciona una planificación anticipada y las listas de planificación logística para las Retrospectivas. Las diapositivas sugeridas para una presentación se pueden usar para guiar la Retrospectiva, las mismas están contenidas en el Apéndice B

To translate the new information that emerges from the Look-Back into concrete steps to improve future public health practice and preparedness, we ended each topic session with a discussion dedicated to eliciting specific lessons learned. We then ended the overall Look-Back with a session to review, prioritize, and document all such lessons.  An after action report (AAR) is a summary of the general discussion that highlights specific strengths and systems-level improvements identified by the group. It addresses all participants’ needs and serves as an important vehicle for broadly disseminating past successes, strengths, and lessons learned.  It also facilitates incorporation of new individuals or functions into routine annual influenza season management. A suggested outline for an AAR is provided in Appendix C.

The AAR also informs the development of an Action Plan, or Improvement Plan. Following development and review of the AAR, specific strengths, lessons, and systems-level ideas for improvement identified during the Look-Back can be developed into a detailed, comprehensive plan that outlines specific steps, or actions, and that identifies individuals accountable for those actions, as well as explicit performance benchmarks.  The Action Plan is the means by which lessons learned are translated into concrete, measurable steps that result in improved response capabilities.

Evaluamos la metodología de la Retrospectiva solo con tres de las SPHA y los grupos interesados de su comunidad. No obstante, hemos identificado cuatro problemas de diseño y cambios de implementación que fueron comunes entre los sitios:

1. La planificación y la investigación anticipadas permiten personalizar las Retrospectivas.
2. La objetividad y la autonomía del moderador son cruciales.
3. Elaborar AAR que sean eficaces y aceptados ampliamente es un desafío.
4. Los AAR pueden promover un valioso diálogo si son ampliamente difundidos y revisados por personas que no participan comúnmente en las actividades anuales de rutina de la influenza.

El cuarto punto es especialmente apropiado porque incluye también a otros aparte de los que participan en una Retrospectiva específica: Por lo menos en dos casos, tanto las tensiones individuales como organizativas fueron causadas por la separación funcional del manejo de los preparativos para la influenza de rutina anual y la influenza pandémica. En un caso, la amplia difusión del AAR dió como resultado un nuevo nivel de compromiso del epidemiólogo estatal en la influenza de rutina anual. Anteriormente, los epidemiólogos estaban sujetos a la división de planificación y de preparación para emergencias lo que los llevaba a ver la influenza de rutina anual como algo externo a su competencia.

Además de tener problemas de diseño general y de implementación en común, nuestras tres SPHA piloto compartieron varias lecciones importantes y áreas de mejora en relación con la temporada de influenza 2004-2005. Las Retrospectivas con las tres SPHA revelaron que varias áreas de planificación son particularmente importantes para mejorar el manejo de la influenza de rutina anual y la preparación para las pandemias en el futuro, incluyendo (1) aprovechar los recursos y la infraestructura estatales para la preparación para emergencias, (2) establecer canales claros de comunicación con la SPHA y entre las SPHA, las agencias de salud pública estatales (LPHA), los proveedores de atención médica, y el público, y para (3) facilitar la distribución y la administración de vacunas.

Las Retrospectivas tienen utilidad como una herramienta relativamente eficaz y sencilla para mejorar la calidad que en cualquier nivel jurisdiccional pueden usarse para evaluar sistemáticamente los acontencimientos recientes para fortalecer los sistemas de manejo y de comunicaciones relevantes para la influenza de rutina anual y pandémica futuras. La adopción e implementación de las Retrospectivas con una frecuencia regular (es decir; anualmente) por las agencias de salud pública aprovecharán la influenza de rutina anual para prepararse mejor para la influenza pandémica (una oportunidad poco frecuente en la salud pública); documentar y dar carácter formal al conocimiento de los logros y también de los problemas, promover el seguimiento de las lecciones aprendidas, y reforzar el rol de la salud pública durante la influenza de rutina anual y pandémica, también durante otras emergencias de salud pública. Si bien hemos evaluado experimentalmente a las Retrospectivas solamente con las SPHA, la herramienta puede también ser relevante para las LPHA. Esta guía por lo tanto debe ser de interés general para los formuladores de políticas, profesionales de la salud pública, y personas que participan en el manejo de la influenza de rutina anual y en la preparación para emergencias.

Reconocimientos

Agradecemos a todo el equipo RAND en este proyecto, cuyos esfuerzos ayudaron a elaborar nuestras ideas y nuestro enfoque para este trabajo.

Developing this guide involved the participation of public health professionals from state public health agencies across the country, and that of numerous other influenza stakeholders.  We are deeply grateful for their willingness to participate in the pilot tests and to provide us with constructive feedback about the design of these discussions. We would like especially to thank Kathleen Toomey, MD, MPH, Center for Homeland Defense and Security, Naval Postgraduate School, and Melinda Moore, MD, MPH, Senior Natural Scientist at the RAND Corporation, for their in-depth reviews of this document. 

We also acknowledge the assistance and guidance of Dr. William Raub, Deputy Assistant Secretary for Public Health Emergency Preparedness and Science Advisor to the Secretary, Lara Lamprecht, Program Analyst, Office of Public Health Emergency Preparedness, U.S. Department of Health and Human Services, and Dr. Pascale Wortley,  Medical Officer, U.S. Centers for Disease Control and Prevention. Their commitment to developing tools and resources to help public health agencies improve the country’s public health preparedness was the driving force behind this work.

Siglas

Capítulo primero

Introducción y Métodos

¿Qué podemos aprender sobre la influenza de rutina anual?

Influenza pandémica² is potentially catastrophic, but also, fortunately, very rare. Only three pandemics occurred during the 20th century.  The most notorious of these was the “Spanish influenza” of 1918-1919, which is estimated to have killed between 500,000 and 675,000 people in the United States and about 50 million people worldwide. Two other 20th century pandemics are the Asian influenza of 1957 and the Hong Kong influenza of 1968. Increasing global anxiety today about human-to-human transmission of influenza A (H5N1)—an influenza A virus subtype that is highly contagious and deadly among poultry—and the likelihood that vaccine and antiviral supplies will be inadequate in a pandemic significantly increase the importance of traditional public health measures to prevent disease spread. However, since pandemics are relatively infrequent, there are limited opportunities for public health agencies to learn from direct experience with them.

Unlike pandemic influenza, routine annual influenza occurs each year with some predictability and therefore offers important opportunities for public health and pandemic preparedness. Routine annual influenza is a contagious viral illness marked by abrupt onset of constitutional (e.g., high fever, myalgias), and respiratory (e.g., cough, sore throat) symptoms; it causes an estimated 36,000 deaths and 200,000 hospitalizations each year in the United States (U.S. Centers for Disease Control [CDC] and Thompson et al., 2004).  Peak incidence typically occurs between the months of December and February.  Most people who contract influenza recover in one to two weeks; however, some people develop serious and potentially life-threatening medical complications, such as pneumonia.  People over the age of 65, people with chronic medical conditions, and children under the age of 2 years are at greatest risk of developing complications.  For several decades, the influenza vaccine has helped people who come in contact with the virus avoid or mitigate influenza illness and its complications. Moreover, influenza antiviral medications are an important adjunct to influenza vaccine in the prevention and treatment of influenza. Antiviral drugs are most often used to help control influenza outbreaks in institutions, for example, in nursing homes or in hospital wards, where people at high risk for complications from influenza are in close contact with each other.

Each recurrent influenza season presents unique challenges and potential lessons relevant to some aspects of pandemic influenza and other public health preparedness activities. For example, in October 2004, when one of two major vaccine manufacturers announced that it would not release any vaccine for the 2004-2005 season because of potential contamination issues, the United States lost nearly half of its anticipated influenza vaccine supply.  As a result, the CDC issued recommendations to the states that doses of the vaccine be restricted to high-risk priority groups only. Although health officials took actions to distribute the limited supply of vaccine, reports persisted of shortages among persons in need, and of individuals who were turned away and never returned when supplies became available. 

The influenza vaccine shortage in 2004-2005 was an unexpected challenge for those managing influenza that season. In turn, it underscored the need for better preparation for routine annual influenza, specifically, the importance of early planning, responsiveness to unexpected contingencies (in the 2004-2005 case, mechanisms to make vaccine available), and effective communication to ensure that available vaccine is targeted to those who need it most.  Moreover, it revealed significant fissures in pandemic preparedness at the federal, state, and local levels, and motivated new investigations into the current state of the Strategic National Stockpile (U.S. GAO, 2005).

Other influenza seasons in our recent past have similarly presented unanticipated problems.  For example, in the 2003-2004 season, a substantial number of influenza-associated deaths occurred among young U.S. children (Bhat et al., 2005).  In October 2000, the U.S. Food and Drug Administration (FDA) announced that lower-than-expected production yields of the new influenza A H3N2 strain and manufacturing problems at two companies would cause a delay and temporary shortages in the availability of influenza vaccine (U.S. FDA, 2000).  And during the 1999-2000 season, an earlier-than-anticipated arrival of influenza caused an unexpected surge in demand for patient care and subsequent overcrowding of emergency rooms, insufficient bed supply, and ambulance diversions around the country (Schoch-Spana, 2000).

With the specter of pandemic influenza before the American populace, the RAND team sought to harness opportunities arising from routine annual influenza to help state public health agencies (SPHAs) learn from the challenges, lessons, and solutions that arise each year and apply them to future influenza seasons and, more broadly, to pandemic influenza and other public health preparedness activities. Specifically, we set out to develop and test a “Look-Back” methodology to help SPHAs systematically assess their experiences after each routine annual influenza season and translate them into future public health practice. Adoption of this tool by public health agencies might also help to educate members of the community about the role of public health during routine annual influenza and to reinforce its significance in managing a pandemic emergency.  The contents of this guide should be of interest to policymakers, public health professionals, and individuals who are involved in routine annual influenza management and pandemic and public health emergency preparedness.

¿Qué es un “Look-Back” (Retrospectiva)?

A Look-Back at routine annual influenza is a facilitated discussion that occurs at the end of each influenza season with SPHA leaders, key staff, and relevant community stakeholders. Look-Backs seek to foster open, candid, no-fault systems-level analyses of routine annual influenza management by asking a diverse group of participants involved in routine annual influenza activities to critically evaluate their management of the past influenza season. To meet the objective of identifying relevant and applicable lessons for routine annual and pandemic influenza preparedness, a Look-Back traces the series of events that unfolded during the past influenza season, the key decisions that were made by various stakeholders, and how those decisions were perceived and acted upon by others. 

Unlike tabletop exercises, which simulate a hypothetical public health emergency and ask participants to describe how they would respond in the future to a specific issue (e.g., surge capacity) if the situation were real, a Look-Back by definition reviews a past real-world event, critically examines how participants did respond, and draws on a wealth of practical experience and a broad range of perspectives to inform future responses. 

 Although these Look-Backs focus on the SPHA’s role in routine annual influenza management, the framework is generally applicable to any public health agency. For instance, a Look-Back could easily be tailored by many state, local, and/or district public health agencies and their community partners to evaluate their joint ability to coordinate across jurisdictional lines (e.g., national, state, county, city).  State and local public health agencies may elect to set up a regular Look-Back schedule with key influenza and emergency preparedness partners and stakeholders.

The breadth and strength of community engagement in the Look-Back will depend in some measure on how well SPHAs are able to reach out to a wide range of community stakeholders who have participated in any aspect of routine annual influenza management or who may offer assistance in the future.  For example, relevant stakeholders outside of public health who could participate in a Look-Back could include hospital representatives; nursing home and long-term care representatives; professional medical organizations; managed care organizations; insurers; pharmacies; the American Association of Retired Persons (AARP) and other advocacy groups; university-based health services; representatives from commercial enterprises offering influenza vaccine to the public (grocery stores provide a substantial proportion of vaccinations in some areas); emergency response groups that might have a role to play in influenza; and leaders from the business community, including large employers that provide vaccinations for their employees through worksite wellness programs. Many such businesses have a medical director or other representative who could be part of the planning process.  (See Appendix A for a suggested list of Look-Back participants.)

¿Cómo elaboramos un “Look-Back” (Retrospectiva)?

In early 2005, RAND researchers met with federal and state public health leaders to discuss what tools would be most useful to help states institutionalize knowledge from previous influenza seasons and prepare for future ones.  Based on these discussions, we developed a discussion framework to help SPHAs cultivate lessons learned during each routine annual influenza season, and we referred to this approach as a “Look-Back.”  To test the feasibility of this approach, we piloted the discussion framework in three SPHAs in different regions of the United States between June and August 2005. At the end of each pilot test, we solicited feedback about the process from participants and incorporated new guidance into the next iteration and pilot test. Below, we provide a brief description of the development of the Look-Back methodology.

Ante todo, nuestro esfuerzo por promover una discusión abierta y sincera entre un diverso grupo de personas sobre el manejo pasado y futuro de la influenza de rutina anual estuvo orientado por los siguientes estimados:

1. Si bien esto no se trata de la influenza pandémica, las actividades para la influenza de rutina anual proporcionan posibles lecciones contínuas para algunos aspectos de la influenza pandémica y otras actividades de preparación de salud pública.
2. A pesar de que muchas personas puedan proporcionar información importante acerca del pasado inmediato y otras temporadas anteriores de la influenza de rutina anual, ninguna persona conoce la historia completa o puede abordar todos los puntos de vista del relato. Por consiguiente es útil incluir una amplia variedad de perspectivas.
3. A nivel de uno de los sistemas, un análisis “sin echar culpas” de lo sucedido realizado por un grupo representativo de personas que participaron y continúan teniendo responsabilidades en el área determinarán las oportunidades de aprender a través de la experiencia y adoptar mejoras que puedan ser útiles en el futuro.
4. El aprendizaje organizativo no está completo sin un plan de acción que especifique las responsabilidades para el cambio.

Hemos hecho todos los esfuerzos posibles para personalizar cada Retrospectiva para que refleje las experiencias particulares de los tres estados con la influenza de rutina anual y para satisfacer las necesidades específicas de la SPHA y sus grupos interesados de la comunidad. Para tal efecto, colaboramos con los líderes de la SPHA para que recaben toda la información de los antecedentes posibles acerca de las actividades del estado durante una temporada típica de influenza, para determinar los asuntos claves en el manejo de la temporada anterior de influenza, y seleccionar los temas sobresalientes para la próxima discusión. Dos semanas antes de la discusión mediante una Retrospectiva, llevamos a cabo una llamada de 60 minutos con una o dos de las SPHA y/o funcionarios del programa de inmunización que estuvieron íntimamente involucrados en las actividades de la temporada de la influenza de rutina anual. En esta llamada, tratamos las siguientes preguntas en términos generales:

• En una temporada típica de influenza, ¿quiénes son los participantes principales internamente en una SPHA y en la comunidad, y cuáles son sus actividades, roles y responsabilidades?
• ¿Cuáles fueron algunos de los desafíos en el manejo de la última temporada de influenza (ej.: vigilancia, compra y distribución de vacunas, comunicación)?
• Al considerar las actividades de reparación tanto para la influenza de rutina anual como para la influenza pandémica, ¿cuáles son los temas específicos que podrían resultar beneficiados gracias a una revisión profunda?

Given this information, we collaborated with the SPHA leaders and/or their representatives to define a specific set of discussion areas and topics for the Look-Back.  Many issues arise in the course of a typical influenza season; it is difficult to cover all of them in great detail in a single focused discussion. We therefore generated a comprehensive, but by no means exhaustive, list of routine annual influenza season activities and topics to review with the SPHA as a starting point for discussion. These topics are presented in detail in Chapter Two.  Each SPHA that piloted this process selected anywhere from three to six discussion topics based on its own past experiences and the time allotted for the Look-Back.

During the meetings with the SPHA, we also solicited a list of participants, which necessarily depended on the structure of the SPHA and its relationship with local public health agencies (LPHAs) and community stakeholders during a routine annual influenza season. We encouraged the SPHAs to invite individuals who would ideally be involved in future routine annual influenza season activities, even if they had not been involved in the past (e.g., emergency management officials, commercial pharmacies, private physician organizations).  Finally, we asked the SPHA leaders to personally enlist specific individuals to provide a very brief (i.e., two-minute) overview of the typical and relevant influenza activities surrounding each discussion topic on the day of the Look-Back.  At the end of each Look-Back, participants were asked to fill out an evaluation form. RAND staff took detailed notes at all Look-Backs, guided participants in the development of initial Action Plans, and generated state-specific, de-identified after action reports (AARs) for feedback and review by each SPHA.

The remainder of this report is organized as follows:  Chapters Two and Three provide SPHA leaders with the basic information necessary to conduct annual influenza Look-Backs with their staff members and to tailor the discussion to their own unique needs and experiences.  Chapter Two provides general information about the structure and organization of a Look-Back, potential issues or challenges that may arise during routine annual influenza season that may be relevant for discussion, and facilitator probes to motivate the dialogue. Chapter Three presents tools for translating information derived from the Look-Back into public health practice, such as Action and Improvement Plans and AARs. Appendices supplement Chapters Two and Three with more specific guidance, including advance-planning and logistical checklists, a list of suggested participants, a sample agenda, sample presentation slides, and a template for AARs. 

In addition to offering detailed guidance to SPHAs about how to conduct a Look-Back at routine annual influenza, we also report on some illustrative issues and observations that emerged from our pilot tests and that may be of interest to SPHAs.  Chapter Four focuses on issues related to the design and implementation of a Look-Back; Chapter Five reviews a select sample of lessons learned as they were identified by the pilot SPHAs.

Capítulo Segundo

Dirigir una Retrospectiva de una temporada de influenza de rutina anual

Marco general

This chapter is designed to show SPHAs how to conduct Look-Backs after each routine annual influenza season.  Look-Backs can be tailored to an SPHA’s unique experiences and future needs, and they can be customized to meet specific time and resource constraints.  For example, the Look-Backs we designed and tested focused on three to six discussion topics relevant to routine annual and pandemic influenza management (presented below). They lasted between three and five hours and involved 10 to 25 participants, depending on the reach of the state’s routine annual influenza activities and partners. Participants included SPHA leaders and staff with key responsibilities related to influenza and pandemic planning; healthcare partners typically involved with routine annual influenza activities, or who should or could play a role in future years; and other partners from the community.  Appendix A includes a suggested list of Look-Back participants and outlines ways to collaborate with SPHA leaders in advance of a Look-Back to gather relevant background about the state’s activities during a typical influenza season, and to identify salient topics for the upcoming discussion. 

There are many ways to structure a Look-Back.  Figure 2.1 presents one suggested framework that we developed during our pilot tests. First, a Look-Back is led by an independent, objective facilitator, or discussion leader, who helps to stimulate the discussion and guides the participants in a critical evaluation of relevant historical events and activities based on the general topic areas presented below. To maximize the ability of the facilitator to avoid bias and ensure that all sides are adequately heard, and to prevent possible conflict of interest, someone external to the public health department employees should serve as the Look-Back facilitator.Appendix A discusses the facilitator role in greater detail and provides a reference for facilitator training; the importance of facilitator independence is addressed in Chapter Four. 

Figura 2.1. Marco general para una Retrospectiva de la influenza de rutina anual
 

The facilitator opens with introductory comments, an overview of the objectives and process, and participant introductions.  Each predetermined routine annual influenza season topic, e.g., surveillance, communications, is then discussed in turn.  For each topic, the SPHA or facilitator may elect to enlist a specific participant in advance of the discussion to briefly introduce the typical state-level routine annual influenza activities. Assigning individuals ahead of time to kick off each discussion provides participants with a common ground for each discussion and engages a variety of participants.

Al final de cada tema de discusión, el moderador obtiene de los partipantes una lista de lecciones prácticas aprendidas tanto para la la influenza de rutina anual como para la influenza pandémica que puede formar la base de un Plan de Acción y un AAR. Una revisión resumida y las prioridades de los elementos para la acción luego concluyen la Retrospectiva. Las sugerencias para iniciar y desarrollar seguimientos y Planes de Acción específicos pueden encontrarse en el Capítulo Cuarto.

The next section provides discussion topics and sample questions that facilitators may find helpful in moderating a Look-Back discussion.  Additionally, facilitators may elect to lead the Look-Back with the aid of a PowerPoint presentation.  Appendix B provides sample templates that can be modified for this purpose.  No preparatory work is required of the participants, although they are expected to share their roles and experiences from the preceding influenza season in a way that stimulates learning and feedback.

Temas de discusión y sondeos

Several weeks to a month before the Look-Back, the facilitator and the SPHA will need to select the discussion topics.  Many complex issues and activities arise in the course of each influenza season, some of which are particularly relevant for pandemic planning and preparedness.  Below, we present an overview of broad categories of routine annual influenza season activities that give rise to relevant topics from which SPHAs may choose to structure the Look-Back.  These topics were identified with the assistance of officials from the CDC, the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the three SPHAs that piloted this methodology.

Following each topic described briefly below is a list of suggested questions (probes) that the facilitator may use to keep the participants on track and ensure that particularly relevant or timely issues are not overlooked. Discussion probes are best used on a case-by-case basis, since too many leading questions may inhibit the discussion.  On the other hand, without some assistance, important points worthy of discussion might be neglected by participants.³  

1.  Organizational Structure of Decisionmaking

En años anteriores, los acontencimientos inesperados llevaron a la utilización de canales formales para la toma de decisiones para el manejo de la influenza de rutina anual, ej.: Sistemas de Comando de Incidentes(ICS)⁴ or directives invoking public health emergency authority.  At other times, more routine or typical decisionmaking channels have been appropriate.

• ¿Se activó un ICS o se dió una directiva por la autoridad para emergencias de salud pública el año pasado? ¿Por qué sí o por qué no?
• ¿Cómo se tomó la decisión de usar un ICS o de dar una directiva?
• En ausencia de una norma o proceso formal para la toma de decisiones, ¿cómo se resolvieron las decisiones claves y/o los conflictos, ej.: comités de asesoramiento, coaliciones?
• ¿Hubo lagunas críticas en la estructura organizativa y en la toma de decisiones, y cuáles son sus ideas de cómo podrían cubrirse?

2.  Influenza Surveillance

Through the efforts of public health agencies, facilities participating in influenza research, and private physicians and laboratories, the CDC develops a national picture of influenza virus activity, the geographic distribution of influenza viruses, and the clinical impact of the circulating viruses.  State public health agencies participate in this surveillance effort by reporting the estimated level of influenza activity to the CDC every week during the influenza season (October to May).

• ¿Cómo sabe cuándo y dónde llegó la temporada de influenza en su estado?
• ¿Cuáles indicadores de vigilancia son o, serían, los más útiles para usted para el manejo de la influenza de rutina anual en su jurisdicción (ej.: información nacional contra información local; enfermedades similares a la influenza (ILI) contra casos de laboratorio confirmados, contra las muertes; indicadores de variables sustitutivas, tales como las compras farmacéuticas o el absentismo en las escuelas/en los trabajos)?
• Al determinar qué información de vigilancia recabar en su jurisdicción, ¿cómo equilibra el valor y el costo de los diferentes indicadores de vigilancia, tales como las ILI (no específicos pero más sencillos, más económicos, y potencialmente más rápidos) contra la influenza confirmada en el laboratorio (más específicas pero más costosos y con mayores demoras posibles)?
• ¿Cómo mide la eficacia del sistema de vigilancia actual, y cuán eficaz es su vigilancia?
• ¿Cómo se obtiene la información de la incidencia de la influenza de los proovedores privados?
• ¿Cuál es aproximadamente el porcentaje de casos de influenza confirmados en laboratorio en comparación con los diagnosticados clínicamente?
• ¿Cuántos laboratorios (públicos y privados) en su jurisdicción tienen la capacidad para realizar los exámenes de la influenza?
• Si hacer los exámenes se generalizara, ¿cuáles son los probables puntos vulnerables en el proceso (ej.: recolección de muestras y almacenamiento; transporte de muestras; exámenes de laboratorio efectivos y a tiempo; informar los resultados a la SPHA, los proveedores)?
• Were you able to assess vaccine effectiveness (i.e., whether people receiving vaccine were more or less likely to become sick with laboratory-confirmed influenza or ILI)?  If not, would this capability be helpful to you in managing routine annual influenza? Would it be feasible?

3.  Vaccine Procurement and Distribution

Influenza vaccine procurement and distribution in the United States are largely a private-sector responsibility, although approximately half of states handle procurement and distribution of the influenza vaccine through the SPHA during the routine annual influenza season.  As with other pharmaceutical products, influenza vaccine is sold to thousands of purchasers by manufacturers, numerous medical supply distributors, and other resellers, such as pharmacies. In a pandemic situation, these procurement and distribution systems might require adjustment to ensure that vaccine reaches priority groups.

• Does the SPHA purchase vaccine and, if so, when, by what mechanism, and for whom?           
• Is there a process by which the SPHA determines how much public- and/or private-sector vaccine is needed in the state/jurisdiction? 
• ¿Tiene la SPHA autoridad legal para hacer cumplir las recomendaciones administrativas específicas para las vacunas y/o para redistribuir los suministros públicos o privados de vacunas?
• ¿Quién o qué otras entidades (ej.: LPHA, proveedores privados, farmacias, grupos de atención médica, empleadores) adquieren las vacunas en su estado?
• ¿Puede hacer un seguimiento de cuántas vacunas se piden, cuántas se compran en un determinado año, y a quién se entregan?
• ¿Tiene formas de hacer un seguimiento de la entrega y la distribución de las vacunas casi en tiempo real, para que pueda determinar dónde son requeridas y/o necesitadas?
• Si hubo problemas debido a una distribución desigual, tales como la escasez en el lugar, ¿cómo respondió? Por ejemplo, ¿Adaptó los mensajes para los proveedores y el público en relación con la disponibilidad de las vacunas y los grupos que tenían prioridad?
• If there were vaccine shortages, did you attempt to redistribute excess private sector vaccine supply (e.g., from providers) to those without vaccine?  If so, how did you go about it, and with whom did you partner?  If not, how did you respond to unmet demand? 
• ¿Qué otros comentarios tiene sobre problemas/lagunas en la adquisición y distribución de las vacunas, y cuáles son sus ideas para resolverlos?

4.  Routine Annual Influenza Vaccination Campaigns

Los esfuerzos para promover los beneficios de la vacuna de la influenza antes de la temporada de influenza a través de las sociedades de medicina, organizaciones de servicios sociales, y el sector privado, son importantes componentes del manejo de la influenza de rutina anual.

• ¿Cómo su estado/jurisdicción estimula la demanda de las vacunas contra la influenza, incluyendo el alcance de diferentes grupos (ej.: trabajadores de la atención médica, trabajadores/residentes de las residencias geriátricas, minorías, diferentes grupos étnicos, discapacitados)?
• What is the role of immunization coalitions in your state?  How do they function in a routine year, and in the presence of a vaccine shortage?
• ¿La escasez de vacunas en el pasado alteró la demanda de vacunas, sin importar el suministro?
• ¿Qué otros comentarios tiene sobre problemas/lagunas relacionados con las campañas de vacunación de rutina contra la influenza, y cuáles son sus ideas para resolverlos?

5.  Vaccine Administration

Once vaccine arrives in the state and at a specific site (e.g., physicians' offices, public health clinics, nursing homes, and less traditional locations, such as workplaces and various retail outlets in the state), there is the additional step of ensuring that individuals who need or want vaccine receive it. 

• ¿Cuáles son los lugares habituales de administración de vacunas (ej.: proveedores privados, sitios comunitarios, farmacias, empleadores, clínicas de salud pública, establecimientos de cuidados a largo plazo, entidades comerciales)?
• ¿Cuál fue el objetivo de cobertura para las vacunas el año pasado? ¿Se cumplió? ¿Por qué o por qué no?
• Are there typically, or have there been, mass vaccination clinics or other strategies to deliver vaccines?  Who is targeted in mass vaccination efforts, e.g., high-risk groups and special subpopulations, non-high-risk individuals, the entire public without distinction of risk?
• ¿Tuvo éxito en sus esfuerzos de vacunación masiva?
• ¿Cuáles son los problemas que ha experimentado con los programas de vacunación masiva (ej.: largas filas, personas mayores/discapacitadas que esperaron muchas horas)?
• Have vaccine registry systems been used for children and/or for adults, and, if so, how well did they work? How adaptable were they for routine or pandemic influenza? Did they help you monitor vaccination coverage over the course of the season?  
• ¿Qué otros comentarios tiene sobre problemas/lagunas relacionados con la administración de las vacunas y cuáles son sus ideas para resolverlos?

6.  Priority Groups and Implications of Changing Priorities

When there is an adequate supply of vaccine, all those for whom it is recommended should get vaccinated.  However, in the presence of a vaccine shortage or other events that affect vaccine supply, vaccine prioritization is more problematic.  The following questions are specific for the management of routine annual influenza under vaccine shortage conditions:

• ¿Ha incluido grupos de prioridad en el pasado cuando hubo escasez de vacunas?
• If there was a vaccine shortage last year, did you use a construct of priority groups for targeting influenza vaccination?  Did you use and/or modify CDC guidelines? How and in what way?
• ¿Pudo identificar individuos prioritarios antes de la vacunación?
• ¿Qué mecanismos utilizó para garantizar que las vacunas fueran diferencialmente para los grupos que tenían una mayor prioridad y que los proveedores siguiesen las pautas recomendadas?

• In the event of another vaccine shortage or unusual patterns of influenza illness, how would high-risk and special populations be prioritized to receive vaccine?  What would be the most effective and efficient mechanism(s) to ensure that these populations are adequately served?
• ¿Qué otros comentarios tiene sobre problemas/lagunas relacionados con los grupos que tienen prioridad y cuáles son sus ideas para resolverlos?

7.  Non-Pharmacological and Public Health Strategies

La escasez de las vacunas contra la influenza o las demoras en el suministro de las vacunas en el pasado, y la escasa disponibilidad del suministro de las vacunas contra la influenza pandémica, aumentan la necesidad para la promoción de las intervenciones no farmacológicas y tradicionales de salud pública. Tales intervenciones incluyen la profilaxis y el tratamiento antiviral, y estrategias para el control de la infección, que incluyen el protocolo para la higiene respiratoria/tos, higiene de manos y otras medidas de distanciamiento social, tales como el cierre de escuelas y la cancelación de grandes eventos públicos.

• Are antivirals typically promoted as part of routine annual influenza management, and, if so, how? Were they promoted last year? Do you know how effective they were?  How important is it for you to know this effectiveness?
• Are infection control strategies, such as the use of masks, hand hygiene, staying home from work/school when ill, other social distancing measures, promoted as part of influenza season management?  If so, how were such measures implemented last year, and do you know how effective any such measures were?
• ¿Bajo qué circunstancias se tomarían medidas más drásticas para la salud pública (ej.: cierre de escuelas, cancelación de reuniones y eventos públicos)? ¿Quién tomaría esas decisiones?
• ¿Tiene alguna experiencia de cualquiera de las temporadas de influenza pasadas que arroje algo de luz sobre la viabilidad y la eficacia de las medidas de salud pública en cuanto a la no vacunación para controlar la propagación de la enfermedad en la población o en grupos específicos de la población?
• ¿Qué otros comentarios tiene para hacer acerca de los problemas/puntos débiles relacionados con las estrategias de salud pública en cuanto a la no vacunación, y cuáles son sus ideas para resolverlos?

8.  Communication

La comunicación y la coordinación entre las SPHA, LPHA, el Gobierno Federal y los grupos interesados de la comunidad juega un rol crucial en el manejo de la influenza de rutina anual, especialmente al momento de responder ante un cambio de las circunstancias o los mensajes.

• En un año típico, ¿con quién y cómo comunica los problemas de la influenza de rutina anual (ej.: dentro de las divisiones de la SPHA, a lo largo de las jurisdicciones estatales y locales, con médicos y otros proveedores, entidades del sector privado, otros grupos interesados claves)?
• ¿Qué tan bien funcionó su sistema de comunicaciones el año pasado?
• ¿Cuáles fueron los temas claves que necesitó comunicar, con quién, y cuándo?
• ¿Qué tan bien se comunicó con el Gobierno Federal (ej.: los CDC)?
• ¿Cómo ha manejado la comunicación de riesgos y el problema de modificar mensajes para el público?
• Según sus experiencias, ¿cuáles son los puntos débiles claves que hay en la comunicación, y cuáles son sus ideas para resolverlos?

9.  Unanticipated Events

Cada temporada de influenza presenta desafíos inigualables y proporciona oportunidades para la mejora del manejo tanto para la influenza de rutina anual como para la influenza pandémica.

• ¿Qué acontecimientos inesperados (ej.: demora o escasez de vacunas, mortalidad infantil excesiva, limitada capacidad clínica y de los laboratorios para actuar en los casos de emergencia) desafiaron el manejo de la influenza de rutina anual el año pasado?
• ¿Cómo conformaron los acontecimientos inesperados el manejo de la influenza de rutina anual en su estado/jurisdicción?
• ¿Cómo han sido modificados los procesos y los canales de comunicación para permitir la adaptación en el caso de que se presenten desafíos inesperados?
• ¿Qué otros comentarios tiene sobre problemas/lagunas relacionados con las comunicaciones y cuáles son sus ideas para resolverlos?

Preguntas esenciales de discusión

Además de las asuntos de temas específicos como se describen anteriormente, también hemos elaborado las siguientes preguntas esenciales, que en términos generales se aplican a todos los temas de discusión anteriores. Nos pareció útil mostrar estas preguntas esenciales a los participantes (ej.: en una presentación de diapositivas en PowerPoint) para proporcionar algo de contexto para cada sesión de discusión:

1. ¿Cuáles son las actividades, los roles y las responsabilidades durante una temporada de influenza de rutina anual?
2. ¿Cuáles fueron los problemas específicos que surgieron el año pasado?
3. ¿Qué se hizo bien, y están debidamente institucionalizados los logros del pasado?
4. ¿Cuáles fueron los problemas específicos que surgieron?
5. ¿Qué es lo que se podría haber hecho de manera diferente?
6. ¿Qué es lo que se debe hacer de manera diferente en el futuro?
7. ¿Cuáles son las lecciones para la influenza pandémica?

Capítulo tercero

Llevar el conocimiento a la práctica

This document presents a framework to help SPHAs capitalize on the predictable recurrence of routine annual influenza and identify lessons that may improve routine annual influenza and pandemic influenza planning.  In this chapter, we briefly review some suggested strategies to translate new information that emerges from the discussion into concrete steps to improve future public health practice and preparedness.

Hallar formas para mejorar el manejo de la influenza de rutina anual y pandémica

If it is successful, a Look-Back will reveal a variety of important strengths, gaps, and ideas for improving the management of routine annual influenza.  It is therefore important to end each discussion section by eliciting specific lessons learned, and to end the overall Look-Back with a session to review, prioritize, and document all such lessons.  One suggested process that actively engages each individual participant is similar to a “hot wash,” a common practice following public health and military tabletop exercises that reserves dedicated time for participants to review the discussion and the group’s responses.⁵  For example, at the end of the Look-Back, the facilitator may ask each individual discussant to identify the two or three most important gaps in the management of the preceding influenza season and specific steps the SPHA and community stakeholders can take to improve performance.

This dedicated review allows participants to receive feedback from one another, provides them with an opportunity to critically review strengths and gaps in the management of the past influenza season, and encourages them to translate past activities and events into meaningful, actionable steps with routine annual and pandemic influenza planning and preparedness in mind.  This translation means both institutionalization of successful activities as well as changes to address gaps or problems.  Finally, this process reinforces learning by giving participants time to reflect on their individual responses and on comments made by their peers. 

Informes posteriores a la acción

An AAR is a summary of the general discussion that highlights specific strengths and systems-level improvements identified by the group and that informs the development of an Action Plan, or Improvement Plan.  The resulting official AAR should be the product of the SPHA divisions and community stakeholders that participated in the Look-Back.  The AAR addresses all participants’ needs and serves as an important vehicle for broadly disseminating past successes, strengths, and lessons learned. To this end, the AAR also facilitates incorporation of new individuals or functions into routine annual influenza season management. Given the sensitivities associated with documenting diverse and potentially competing perspectives about a past event, and the need for buy-in and approval from a range of individuals, the AAR should be circulated to participants for feedback and comments, as well as to key individuals who did not attend the Look-Back. Moreover, goodwill may be generated if the AAR documentation process is coordinated with multiple divisions within the SPHA (e.g., emergency preparedness, infectious disease, health promotion) that are (or should be) involved in routine annual and pandemic influenza planning and preparedness activities. 

An AAR can include brief summaries of the discussion topics, a bulleted list of strengths and successes from the preceding influenza season, implications deriving from qualified successes, and areas for improvement by the topic areas covered. Although routine annual influenza management successes may be overlooked, understanding and building on such successes may provide an important platform for addressing failures. After action reports may provide a useful starting point for an Action, or Improvement, Plan (discussed below).  There is no specific, formal format for an AAR; however, one suggested outline is provided in Appendix C. ⁶  

Elaborar un plan de acción o un plan de mejoras

Al seguir el desarrollo y la revisión de un AAR, las ventajas específicas, las lecciones, y las ideas a nivel de los sistemas para la mejora identificada durante la Retrospectiva se pueden elaborar en un plan detallado e integral con pasos ejecutables y responsables, y con los puntos de referencia del desempeño. Este Plan de Acción o Plan de Mejoras es el medio por el cual las lecciones aprendidas se traducen en pasos concretos y mensurables que dan como resultado capacidades de respuesta mejoradas.⁷  It is developed by the SPHA with relevant community stakeholders, and it specifically details what actions will be taken to address each recommendation, who or what division within the SPHA will be responsible for taking the action, and the time line for completion.
 
Although it is unreasonable to expect that a comprehensive Action Plan can be developed during the Look-Back itself, it may be useful to begin the process while all key participants are together.  For one or two areas targeted for improvement, the facilitator should challenge participants to outline explicit improvement goals, identify specific steps required to meet those goals, identify responsible and accountable individuals, and specify time lines for action and follow-up. For some recommendations, the course of action will be clear and can be defined immediately. For other recommendations, additional information will be required before the appropriate course of action can be defined.  Time permitting, the facilitator should help participants explore options for obtaining needed resources or for identifying necessary personnel.   Some suggested general (i.e., not topic-specific) questions to elicit initial action items include the following:  

• ¿Qué medidas específicas pueden tomar la SPHA y los grupos interesados de la comunidad para mejorar el desempeño el próximo año?
• ¿Cuáles son los objetivos?
• ¿Qué tiene que ocurrir para garantizar que estos objetivos se cumplan?
• • ¿Cuáles son las tareas iniciales?
  • ¿Quién es responsable?
  • ¿Quién más debería participar?
  • ¿Cuánto tiempo se necesita para lograr esto?
• ¿Cómo evaluará el progreso de la próxima temporada de influenza?
• ¿Cuáles son los planes para la documentación?

Capítulo cuarto

Temas de elaboración y desafíos de implementación

Aunque hemos evaluado las Retrospectivas sólo con tres SPHA y con los grupos interesados de la comunidad, hemos identificado cuatro temas de elaboración y desafíos de implementación que fueron comunes entre los sitios y que podrían ser útiles para las SPHA y otras agencias de salud pública en la planificación y en la dirección de las Retrospectivas de la influenza de rutina anual:

1.  Advanced planning and investigation allow for customized Look-Backs.

In general, we found that SPHA leadership buy-in to the Look-Back process was critical to the success of the pilot Look-Backs, and that our tailored discussions with the leadership in advance of the Look-Back inspired both interest and confidence in the process.  If the facilitator does not work within the SPHA, it is especially important that he/she collaborate with its leadership and key staff at predetermined intervals leading up to the event to (1) customize the discussion; (2) reflect state (or local) experiences with routine annual influenza; and (3) meet specific needs of the SPHA and its community stakeholders.  Appendix A provides specific ways for a facilitator to tailor a Look-Back to a public health agency’s needs.

2.  Facilitator objectivity and independence are critical.

Look-Back groups ranged from 15 to 25 participants in the three SPHAs, and all groups comprised individuals representing both pubic health agencies and a wide range of community stakeholders. Although in all three Look-Backs it was important to include a variety of community stakeholders, the resulting group size and composition mandated skilled, active, structured, and objective facilitation and mediation.  For example, in large groups, a few confident or opinionated participants may overwhelm others in the room.  To guarantee each individual an appropriate amount of “air time,” the facilitator was required on occasion to directly ask some participants to yield the floor.  At other times, it was important for the facilitator to single out quieter participants to elicit their response.  Facilitation was also required in all three pilot sites to repeatedly encourage participants to consider all options and to challenge one another’s assumptions. However, important debate about past events warranted the need to manage internal disagreement.  Therefore, Look-Back facilitators are required to be adept mediators.⁸  

Las SPHA reconocieron que la independencia del moderador es crucial para el éxito de la Retrospectiva, e hicieron eco de la necesidad de que haya moderadores que sean externos al departamento de salud pública. Concretamente, las SPHA acordaron de manera independiente que es improbable que un empleado del departamento de salud pública pueda desempeñarse activamente como la clase de moderador que se describe en la presente como resultado de un conflicto inherente que pudiere socavar su capacidad para evitar los prejuicios y garantizar que todas las posturas sean escuchadas adecuadamente.

3.  It is a challenge to produce effective and broadly agreed-upon AARs.

By design, a Look-Back (and the resulting Action Plan and AAR) does not seek to capture historical “truth,” but, rather, perceptions of what occurred in the past.  To this end, in a group of diverse individuals, there will necessarily be competing perspectives and sensitivities, and not all relevant players may be present on the day of the discussion to represent their views.  These factors can conspire to create important tension between developing a candid AAR that actually reflects the discussion on the day of the Look-Back and a more politically sensitive document that may be accepted more widely but that may not be as successful in stimulating change. 

Across all three sites, we found that the resulting AAR (which included initial improvement steps, to the degree that participants were willing and able to accept responsibility for a future action item) caused some degree of controversy or debate.  For example, once the AAR had been circulated to Look-Back participants by the SPHA, key staff or community stakeholder participants on at least two occasions challenged some of the reported discussion as being factually inaccurate. On two occasions, participants or their superiors requested background supplements to the AAR that had not been addressed at the discussion, or that the AAR more accurately reflect historical “truth.” 

SPHAs that are planning on conducting their own Look-Backs may want to clarify at the start of the Look-Back that the discussion and the resulting AAR will specifically seek to reveal critical systems-level strengths and weaknesses in past routine annual influenza management, with the express hope of stimulating change.  Moreover, it may be useful to set some guidelines about the documentation of the Look-Back, e.g. that the SPHA will circulate the AAR, and while all panelists will have the opportunity to review it, the AAR will not be changed to accommodate revisions to restore historical accuracy.

4.  AARs can generate valuable dialogue if they are broadly disseminated and reviewed by individuals not typically involved in routine annual influenza activities.

We found that when the AAR was broadly disseminated by the SPHA across agency departments (e.g., public health, emergency preparedness) the contents of the AAR generated important attention from key individuals and departments that had not been involved in the Look-Back.  Specifically, we found in at least two cases that both individual and organizational tensions resulted from the functional separation of annual influenza management and influenza pandemic preparedness. In one particular case, the broad dissemination of the AAR resulted in a new level of engagement in routine annual influenza by the state epidemiologists who were functionally tied to the division of emergency planning and preparedness and who previously viewed routine annual influenza as outside of their purview.  

En términos generales, observamos que involucrar a personas y funciones claves que no estuvieron en la Retrospectiva y que no participaron en la elaboración inicial del Plan de Acción y del AAR puede mitigar las posibles susceptibilidades entre las diferentes divisiones o jurisdicciones y promover una mejor disposición y una mayor aceptación para los cambios que pueden tener un impacto y alcance generales.

Capítulo quinto

Lecciones aprendidas seleccionadas por las agencias de salud pública estatales

Además del diseño general y los temas de implementación comunes, observamos que nuestras tres SPHA piloto compartieron varias lecciones y áreas importantes para mejoras con respecto a la temporada de influenza 2004-2005 influenza season. That particular influenza season was characterized by influenza vaccine shortage, and as such, many of the lessons learned and areas for improvement focused on the management of vaccine shortages and related events.  Specifically, Look-Backs in all three SPHAs revealed that several areas of planning are particularly important for enhancing routine annual influenza management and pandemic preparedness in the future, including (1) leveraging state emergency preparedness resources and infrastructure; (2) establishing clear lines of communication within the SPHA and between and among SPHAs, LPHAs, healthcare providers, and the public; and (3) facilitating the distribution and administration of vaccine.

1.  Leveraging state emergency management resources and infrastructure may facilitate emergency response by “traditional” state public health agencies.

Despite some concerns about integrating public health and emergency management functions, the benefit of capitalizing on a broader range of existing state emergency preparedness resources and infrastructure to improve public health management of influenza emerged as one lesson from the 2004-2005 influenza season that is particularly relevant for future influenza seasons and pandemic influenza preparedness.  One SPHA commented that having the state’s public health emergency preparedness infrastructure in place greatly improved the health department’s capacity to respond.  Specifically, Health Resources and Services Administration (HRSA) funding in that state provided a link to emergency medical systems and hospitals, and because of that link, SPHA and hospital staff were familiar with the idea of ICS and its contributions to flexible and immediate response.⁹  

Although only one of the three SPHAs we visited formally activated ICS, thus activating emergency response, all three SPHAs explicitly considered using ICS to manage the influenza vaccine shortage during the 2004-2005 season. In the state in which ICS was activated, certain programs, such as radiation and nuclear control, were accustomed to responding to emergencies under a unified command hierarchy, but ICS had not been widely used to coordinate a response across other areas of public health.  When ICS was activated, staff members were reassigned to different functions, and a state call center was established to respond to public demand for information. 

Two SPHAs explicitly decided against ICS activation, and for similar reasons.  Although both states could have activated their Emergency Operations Center, both ultimately decided to handle the vaccine shortage within the state influenza program and the SPHA’s own channels of supervision.  SPHA leaders in both states were wary of ICS and did not want to “militarize” their response or cause public panic.  Broader emergency preparedness assets and systems were therefore not involved in the resulting response, although one local district used the 2004-2005 influenza season as an opportunity to train and practice ICS.  In general, ICS was felt to be too foreign to the SPHAs’ staff responsible for managing routine annual influenza and counter to the more consensus-oriented approach of public health. Despite their concerns, these SPHAs recognized the potential benefit of emergency management resources and specified the following in their action and improvement plans:

• Resolver el debate interno sobresaliente dentro de la SPHA y entre los socios claves acerca de la viabilidad y la utilidad del ICS para un mejor manejo de la escasez de las vacunas contra la influenza y de otros acontecimientos inesperados en el futuro.
• Determinar si hay otros recursos o métodos para la preparación para emergencias que puedan ser utilizados para facultar a la SPHA en las temporadas de influenza o en la emergencia de pandemias futuras para movilizar los grupos interesados de la comunidad.
• Develop a plan well before influenza season about whether and when ICS should be initiated, who will make that decision, who will be involved, and what their roles will be. 
• Determinar si la versión modificada del ICS (ej.: ICS con diferentes niveles de ajuste adaptados a las necesidades de salud pública) podría prestar asistencia a la SPHA para hacer circular la vacuna en todo el estado bajo condiciones de escasez de vacunas, para motivar a los proveedores privados a que reúnan recursos, establecer claramente la comunicación organizacional y mitigar el estrés individual.
• Aunque existe el consenso general de que, en el caso de una pandemia, las funciones de manejo de emergencias tendrán el control y el ICS será implementado, los planes y los ejercicios de práctica deben ser revisados para identificar y evaluar el punto específico en el que una pandemia será declarada y para garantizar que los canales de comunicación y las directivas y los controles para una pandemia estén claramente designados.
• El ICS debe ser ensayado, especialmente para familiarizar a los funcionarios de salud pública que históricamente están menos acostumbrados al mismo.

Two SPHAs used public health emergency authority to issue directives for establishing rules and priorities for distribution and use of influenza vaccine and to manage public anxiety.  In addition, one SPHA used such a directive to require all health care providers, hospitals, pharmacies, etc., to report the number of influenza vaccine doses they had in stock via a Web-based reporting system.  These two SPHAs both found that while the directives were essential to supporting the initial rationing of limited vaccines, they did not prove to be adequately flexible to respond to the evolving situation. Specifically, when the priority groups changed mid-season, and when more vaccine became available, new directives were required, thus hindering the timeliness of the response.  One SPHA observed that, in future years, decisions about how and when to lift a public health emergency directive would be essential.

One state invoked the public health emergency authority for the first time since the early 1940s. Remnants of the old law that attached penalties for refusing to comply with the order were maintained in 2004 to reinforce the significance of the vaccine shortage and also to allow the state government to intervene (e.g., if an employer attempted to administer vaccine to employees in non-high-risk groups).  Backlash ensued from physicians who feared the order would prevent them from providing adequate care to their patients.  In another state, reliance on a public health emergency authority raised concerns that, in a pandemic emergency, a federal response would significantly diminish the authority of state, local, and private entities.  At the same time, however, vaccine administrators in both states seemed relieved that the SPHA had asserted critical leadership and authority. Moreover, we heard that providers in at least one state welcomed the cover of an official legal order for denying vaccine to patients who were not in high-risk groups.

Given the important lessons, resources, and infrastructure that emergency preparedness can offer for the management of routine annual influenza, key individuals from emergency management and preparedness functions should be included in the Look-Backs.  In some cases, emergency management personnel participated.  When representatives from the state’s public health emergency preparedness infrastructure did not participate, it was either because they were not invited or because they were unable to attend.  In one case, key individuals were identified as important after the Look-Back, as a result of the circulation of the AAR.

2.  Communication is of paramount importance.

A second consistent lesson emerging from the 2004-2005 influenza season and one that is applicable to future routine annual and pandemic influenza planning was the importance of clear communications within SPHAs and between and among SPHAs, the CDC, LPHAs, healthcare providers, the media, and the public at large.  Most challenging across all three SPHAs in the 2004-2005 influenza season was communicating with the CDC and managing communication and messaging with the media and healthcare providers.  Improving interdepartmental communication (e.g., between public health and emergency preparedness divisions) also emerged as a consistent theme.

In the Look-Backs, all SPHAs and their community partners expressed frustration about communications to and from the Federal Government.  SPHAs reported frequent calls from the CDC with conflicting messages, requests to survey and resurvey, and a consistent unavailability of informed staff to answer questions.  At least two SPHAs reported that the CDC did not forewarn the SPHA about the shortage, but, instead, communicated directly with the national public.  For example, one SPHA reported that media coverage of the vaccine shortage resulted in a large volume of calls from the community, well before the SPHA was informed of the shortage by CDC.  The SPHA felt pressure to respond to the community’s concerns as well as to those of the providers regarding who would receive vaccine, but when the CDC announced its recommendations about priority groups, the SPHA was forced to change its messages.  This experience was felt to be extremely disempowering at a time when SPHAs were working to maintain credibility.

The importance of partnerships with the media in the 2004-2005 influenza season also emerged as a consistent lesson across all three SPHAs. In all SPHAs historically, there is frustration about how public health messages are delivered to the public, especially regarding routine annual influenza.  The media play a significant role in disseminating messages to the public. But, according to participants at the three Look-Backs, messages are often skewed or counterproductive.   For example, in one state, a primetime news hour presented a fairly grim picture of the influenza clinics (e.g., long lines, people on oxygen having to wait) that was thought to account for low turnout the following day. Further damaging to public opinion, the media could not be summoned back to change the misperception once the clinics were running smoothly.  This experience reinforced the need for consistent and carefully channeled messaging with the media, which would be especially critical in a pandemic.

Communicating with providers proved equally challenging and important.  Generally, there was concern that the provider community tended to minimize the significance of routine annual influenza and, consequently, did not internalize and convey several important messages. Specifically, the SPHAs reported that providers could have done more to communicate with patients about the effectiveness of FluMist in influenza prevention and about the benefit of influenza vaccination even later in the influenza season.  For example, once supplies of vaccine increased in December and January during the 2004-2005 season, providers generally did not encourage patients who became eligible to receive the vaccine to get immunized.  In an effort to step up communication with private providers midway though the season, one SPHA sent alerts via email and blastfax to its database of practicing physicians.  Although the SPHA reached 70 to 80 percent of its database, the database was not current, and it represented only a small portion of the state’s private providers.  Moreover, the messages were felt to be ineffective because of the diminished sense of urgency surrounding influenza in the physician community.  

Regular statewide conference calls between a high-level state official and LPHAs surfaced as a major success story in the management of the previous influenza season.  These regular calls provided a critical sense of leadership and were effective in reassuring local public health officials during the vaccine shortage.  The development of regional coalitions promises to provide additional infrastructure for enhancing coordination and communication between state and local health departments, as well as among locals. 

Discusión en las Retrospectivas sobre los problemas de comunicación que dieron como resultado los temas de mejoras y acciones siguientes:

• Improve communication with the CDC, address concerns about state versus federal roles in defining target groups during times of vaccine shortages or during a pandemic or other public health emergency situation.   Moreover, encourage CDC to implement a national education campaign about the importance of regular vaccinations and to create messages that the states can tailor for their own use.
• Improve communication with the media so that reporters are a more positive facilitator for communication with the public. For instance, partner with media outlets each August to inform providers and the public about plans for the upcoming influenza season (e.g., respiratory etiquette, hand washing, social-avoidance measures). 
• Explore mechanisms for obtaining and maintaining current contact information for private providers and for improving connection to the Health Alert Network (HAN) in the private provider community. 
• Develop a statewide immunization strategy that focuses on improved communication with the large network of private providers.  An initial action item is to organize a group of representative providers (e.g., in a focus group setting) to convey their importance in the process and to enlist their support and solicit their insight and feedback. 
• Develop and implement an education campaign directed at private providers about the production and distribution of vaccine, the importance of annual immunizations, the value of FluMist, and the role of other public health measures (e.g., respiratory hygiene; hand washing in influenza prevention) to generate their interest in active community participation in influenza planning.  
• Mejorar la comunicación, coordinación, participación, roles, y responsabilidades interdepartamentales (por ej.: salud pública y preparación para emergencias) bajo condiciones de escasez de vacunas o pandemias.

3.  Broad-based coalitions and public-private partnerships may mitigate challenges SPHAs confront with vaccine distribution and administration.

A large majority of influenza vaccine in the United States is purchased privately and distributed through influenza clinics and hospitals, large healthcare providers, private practitioners, employers, and commercial entities. Consequently, the amount of publicly-held vaccine is typically quite limited, leaving many SPHAs with limited influence over the distribution of influenza vaccine. For example, in two of our pilot states, the SPHA purchases only 5 to 10 percent of influenza vaccine in a typical year.  One of the pilot SPHAs, however, was an outlier in that it typically purchases approximately half of the influenza vaccine.

Irrespective of the amount of vaccine purchased by each SPHA, a real success story of the 2004-2005 influenza season was the role of public-private partnerships in redistributing privately purchased vaccine.  When the influenza vaccine shortage was announced, all three SPHAs worked diligently through a variety of mechanisms to partner with key stakeholders to track vaccine in the state, pool resources, and redistribute vaccine to priority groups.  In one state, the delay in influenza vaccine in 2000 motivated the formation of an influenza vaccine consortium made up of representatives from hospitals, health plans, nursing homes, and provider groups, as well as the SPHA.  The express purpose of the consortium was to provide a mechanism for sharing and distributing vaccine throughout the state as needed, and to promote adult immunizations, particularly against influenza and pneumococcal disease. This consortium proved to be of great assistance in responding to the vaccine shortage in 2004-2005.

Another SPHA administered a survey of private providers to directly estimate vaccine purchases, but low response rates and poor reporting thwarted this effort.  For instance, physicians in that state overinflated their estimates, claimed they did not receive vaccine, and/or refused to give up their supply, even if they reported a surplus.  These barriers notwithstanding, the SPHA persevered, and, through discussions and meetings with community partners and through surveys and a variety of other sources, by early November 2004 had estimated the amount of influenza vaccine doses that had been received by physicians and health care organizations. Armed with this information, the SPHA encouraged private providers to administer vaccine according to the CDC recommended priority groups.  In addition, in conjunction with their community partners, the SPHA developed a plan to distribute publicly held vaccine to the Vaccines for Children (VFC) program and to high-risk indigent adults seen at community health clinics.

Elaborando a partir de las lecciones de las sociedades público-privadas, en las Retrospectivas se identificaron las lecciones y acciones siguientes:

• Consider, in advance of influenza season, how best to engage and mobilize community partners and stakeholders in tracking vaccine and pooling resources (e.g., through a community influenza consortium) under future vaccine shortage conditions or during a pandemic. 
• Incluir al sector privado en los esfuerzos de la coalición para la inmunización.
• Alentar a los proveedores privados a que sean miembros más dispuestos en un entorno futuro de escasez de vacunas o en una pandemia, educándolos acerca de la producción, suministro y distribución de vacunas en los Estados Unidos, y acerca de los rol a menudo limitado de las SPHA para hacer circular las vacunas.
• Enlist individual hospitals through the state HAN to help with vaccine redistribution in a future vaccine shortage or pandemic emergency.  Currently, many hospitals view immunizations as a public health function; if there is a role for hospitals to play in routine annual influenza season, they require education.

The above-described lessons and action items emerged from SPHA Look-Backs and demonstrate the utility of Look-Backs as a relatively simple, effective tool that any level of jurisdiction can use to systematically assess actual recent past events to strengthen management and communication systems relevant to future routine annual and pandemic influenza.  Adoption and implementation of Look-Backs with regular frequency (i.e., annually) by public health agencies will capitalize on routine annual influenza to better prepare for pandemic influenza (a rare opportunity in public health); document and formalize learning from successes as well as from problems; encourage follow-through on lessons learned; and reinforce the role of public health during annual and pandemic influenza, as well as other public health emergencies.

Appendix A.  Look-Back Planning Checklist

Este Apéndice proporciona una planificación anticipada y las listas de planificación logística, una lista de participantes sugeridos, y una agenda de ejemplo para las SPHA que planean dirigir su propia Retrospectiva.

EQUIPO

Se necesitan dos personas para dirigir una Retrospectiva:

• Un moderador, quien dirige la discusión y, si es necesario, ofrece los sondeos a los participantes. Nuestra escasa experiencia con tres SPHA sugiere que es más probable que un moderador externo, neutral o profesional pueda crear un entorno que promueva el diálogo abierto y sincero entre los participantes.
• Un escribano, para registrar la discusión, mantener un seguimiento de las lecciones aprendidas y de las aplicaciones para la influenza pandémica, y asistir en la elaboración del Plan de Acción y del informe posterior a la acción (AAR).

PLANIFICACIÓN Y PREPARACIÓN ANTICIPADAS

Assuming that the facilitator does not work within the public health agency, he/she should collaborate with the leaders and key staff in advance of the Look-Back to customize the discussion to reflect state (or local) experiences with routine annual influenza and to meet specific needs of the SPHA and its community stakeholders.  The following are specific steps that the facilitator can take to tailor a Look-Back to a public health agency’s needs:

• Una vez que se ha determinado la fecha y la hora de la Retrospectiva, recabar tanta información de antecedentes como sea posible, acerca de las actividades del estado durante una temporada típica de influenza de una manera que minimice la tarea del equipo (por ej.: materiales sobre antecedentes relevantes suelen encontrarse en internet).
• Conocer acerca de la estructura organizativa de la SPHA (por ej.: las diversas divisiones y los niveles de autoridad).
• Dirigir una breve reunión (de una hora aproximadamente) con una o dos agencias de salud pública y/o responsables del programa de inmunización que estuvieron íntimamente involucrados en las actividades de la temporada de rutina anual de influenza previamente a la Retrospectiva. Esta reunión sirve para:
• 1. Realizar las aclaraciones de todas las preguntas sobresalientes acerca del manejo de la temporada de influenza e determinar los temas destacados para la próxima discusión(ver Capítulo segundo), por ej.:
  2. • En una típica temporada de influenza, ¿quiénes son internamente los participantes principales en una agencia de salud pública, y cuáles son sus actividades, roles y responsabilidades?
     • ¿Cuáles fueron los desafíos críticos en el manejo de la última temporada de influenza (por ej.: vigilancia, compra de vacunas, comunicación)?
     • Al considerar las actividades de reparación tanto para la influenza de rutina anual como para la influenza pandémica, ¿cuáles son los temas específicos que podrían resultar beneficiados gracias a una revisión profunda?
  3. Solicitar una lista de participantes,¹⁰ e.g.: 
  4. • Funcionarios de la Agencia de Salud Pública Estatal y el personal típicamente involucrado en los aspectos principales del manejo de la temporada de influenza:
     • • Director de salud estatal
       • Coordinador del manejo de emergencias
       • Director del programa para inmunizaciones
       • Coordinador para influenza pandémica
       • Director para el control de enfermedades contagiosas/investigación de enfermedades
       • Funcionario Local de Centros para el Control y la Prevención de las Enfermedades de los EE.UU. (CDC)
       • Coordinador de Mejoramiento de la Calidad
       • Representante del laboratorio de salud pública
       • Epidemiólogo estatal
       • Enfermera de salud pública
       • Farmacéutico
       • Funcionario especialista en comunicaciones/información pública
       • Funcionario del manejo de emergencias
  5. Otros miembros de la comunidad que ayudaron con actividades claves, administraron vacunas, y/o desempeñaron un rol importante durante la temporada pasada de influenza:
  6. • Personal de la agencia de salud pública local o de distrito
     • Representantes de hospitales
     • Representantes de residencias geriátricas y de centros de cuidado a largo plazo
     • Representantes de diversas organizaciones médicas profesionales (por ej.: filiales de la Asociación Médica Estadounidense, Academia de Pediatría, filiales de la Academia de Medicina de Familia)
     • Organizaciones de atención médica administrada (por ej.: Kaiser, GroupHealth)
     • Aseguradoras (por ej.: Blue Cross)
     • Representantes de empresas comerciales que ofrecen la vacuna contra la influenza al público (por ej.: tiendas de comestibles, Farmacias Long's)
     • Farmacias
     • Representantes de los líderes comunitarios de las minorías
     • Oficiales Militares
     • Asociación Estadounidense de Personas Jubiladas (AARP) y otros grupos de defensa
     • Servicios de salud universitaria
     • Grupos de respuesta para emergencias que podrían tener un rol que desempeñar en la planificación para la influenza (por ej.: filiales de Business Executives for National Security [BENS] (Ejecutivos de Negocios para la Seguridad Social)
     • Líderes de la comunidad empresarial, incluyendo grandes empleadores que proporcionan vacunas para sus empleados a través de sus programas de salud en los lugares de trabajo
  7. Identificar personas específicas que pueden estar enlistadas por la agencia de salud pública para proporcionar una breve (por ej.: de dos minutos) perspectiva general de las actividades típicas y pertinentes a la influenza que rodean cada tema seleccionado para discusión. La asignación anticipada de los individuos para que inicien cada discusión proporciona a los participantes una base común para cada discusión e involucra a una variedad de participantes.

EN LA RETROSPECTIVA

• Presentar los objetivos y la agenda de la Retrospectiva y proporcionar garantías a los participantes acerca de la confidencialidad y el anonimato (ver Apéndice B para una presentación de ejemplo).
• Garantizar que se tomen notas detalladas.
• Al final de la discusión, solicitar las lecciones aprendidas específicas y empezar a elaborar el Plan de Acción para mejoras.
• Cerrar la reunión pidiendo a los participantes que llenen un formulario de evaluación para solicitar observaciones acerca del proceso y sugerencias específicas para la próxima Retrospectiva.

LOGÍSTICA ADICIONAL

• Sala de conferencias con una capacidad para 15 a 25 asientos, y con una disposición en forma de U
• Computadora con Microsoft (MS) PowerPoint y proyector
• Tablero blanco, pizarra de papel, o pizarra
• Copias de la agenda y del formulario de evaluación para los participantes.

Figura A.1. Agenda de ejemplo

Appendix B.  Sample Look-Back Presentation

The following are suggested presentation slides that may be used to guide the Look-Back.  The topics for discussion are illustrative, not prescriptive.

Appendix C.  Template for an After Action Report

Información general

Date and Time: 
Ubicación:
Participantes: [Lista de participantes anónimos, es decir; por título solamente]

Visión general

On [date], [number] individuals from the [SPHA], [other organizations] participated in a facilitated Look-Back at the [year] influenza season.  The objective of the Look-Back is to assist SPHAs to regularly improve routine annual influenza season and pandemic preparedness.  This Look-Back was designed in conjunction with officials at [SPHA] in a pre-Look-Back teleconference held on [date]. The Look-Back took place at [location].

Metas y objetivos

Las metas principales de la Retrospectiva eran hacer un seguimiento de la sucesión de acontecimientos que se produjeron en la temporada de influenza de [año], para determinar las decisiones principales a las que llegaron diversos grupos interesados, y para aprender cómo las decisiones principales fueron interpretadas y cómo otros actuaron de acuerdo a éstas. Concretamente, la Retrospectiva buscaba:

• Dirigir un análisis a nivel de los sistemas, sin echar culpas, sobre las respuestas estatales de la temporada de influenza de [año]
• Identificar las lecciones aplicables a la rutina anual de la influenza estacional, la influenza pandémica y a otras emergencias en la salud pública
• Identificar oportunidades para mejoras y para un plan de acción.

Temas y preguntas esenciales

The Look-Back focused on [number] influenza season topics that were selected with [SPHA] officials in the pre-Look-Back teleconference. These broad topics included:  

• [Tema Nº. 1]
• [Tema Nº. 2]
• [Tema Nº. 3], etc.

Para cada tema que se enumera anteriormente, la discusión se centró en las siguientes preguntas esenciales:

• ¿Cuáles son las actividades, roles y responsabilidades en una temporada de rutina anual de influenza?
• What are specific issues that came up this past influenza season? 
• ¿Cuáles fueron los problemas específicos que surgieron? ¿Cómo se resolvieron?
• ¿Qué resultó bien?
• ¿Qué es lo que se podría haber hecho de manera diferente?
• ¿Qué es lo que se debe hacer de manera diferente en el futuro?
• ¿Cuáles son las lecciones para una pandemia?

Revisión de la discusión

[Tema Nº. 1]

Actividades, roles, y responsabilidades durante una típica temporada de influenza

Breve revisión de Qué ocurrió en [Año]

Lecciones aprendidas de los casos del año pasado y los temas para la acción que surgieron durante la discusión

• [Breve lista de lecciones enumeradas]

Implicaciones para la futura temporada de rutina de influenza

• [Breve lista de lecciones enumeradas]

Implicaciones para el manejo futuro de la influenza pandémica

• [Breve lista de lecciones enumeradas]

[Tema Nº. 2]

Actividades, roles y responsabilidades durante una típica temporada de influenza

Breve revisión de lo ocurrido en [Año]

Lecciones aprendidas de los casos del año pasado y los temas para la acción que surgieron durante la discusión

• [Lista de lecciones enumeradas]

Implicaciones para la futura temporada de rutina de influenza

• [Breve lista de lecciones enumeradas]

Implicaciones para el manejo futuro de la influenza pandémica

• [Breve lista de lecciones enumeradas]

Resumen

Temas para la acción sugeridos por el grupo

• [Breve lista de temas para la acción enumerados]

Referencias

Bhat, N., J. G. Wright, K. R. Broder, E. L. Murray, M. E. Greenberg, et al., “Influenza-Associated Deaths Among Children in the United States, 2003-2004,” New England Journal of Medicine, Vol.353, No. 24, 2005, pp. 2559-2567.

Dausey, D. J., N. Lurie, A. Diamond, B. Meade, et al., Bioterrorism Preparedness Training and Assessment Exercises for Local Public Health Agencies,  Santa Monica, Calif.: RAND Corporation, TR-261-DHHS, 2005.  Available online at http://www.rand.org/publications/TR/TR261/.

Office for Domestic Preparedness (ODP), The Homeland Security Exercise and Evaluation Program. Disponible en línea en http://www.ojp.usdoj.gov/odp/docs/hseep.htm.

Schoch-Spana, M., “Hospitals Buckle During Normal Flu Season: Implications for Bioterrorism Response,” Biodefense Quarterly, Vol. 1, No. 4, March 2000.

Thompson, W. W., D. K. Shay, E. Weintraub, et al., “Influenza-Associated Hospitalizations in the United States,” Journal of the American Medical Association, Vol. 292, 2004, pp. 1333-1340.

U.S. Centers for Disease Control and Prevention, Influenza (Flu). Disponible en línea en http://www.cdc.gov/flu/.

U.S. Food and Drug Administration. Availability of Influenza Virus Vaccine 2000–2001. Available online at  http://www.fda.gov/CBER/flu/flu2000.htm

U.S. Government Accountability Office (GAO), Influenza Pandemic: Applying Lessons Learned from the 2004-05 Influenza Vaccine Shortage, Washington, D.C.: GAO-06-221T, November 4, 2005.  Available online at www.gao.gov/cgi-bin/getrpt?GAO-06-221T.

Información sobre derechos de propiedad intelectual: Rand Corporation

La investigación descrita en este informe fue preparada por el Departamento de Salud y Servicios Humanos de los EE.UU. Esta investigación fue realizada en el RAND Health’s Center for Domestic and International Health Security (Centro Rand Health para la Seguridad Sanitaria Nacional e Internacional). RAND Health es una división de la RAND Corporation.

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