How Should the U.S. Prepare for the Next Pandemic?

WASHINGTON -- What's the best way to prepare for the next pandemic, and how much will it cost? Those are the questions facing members of Congress as they seek to reauthorize the Pandemic and All-Hazards Preparedness Act (PAHPA) before it expires on Sept. 30.

"We need to pass the authorization, and that is a challenge that Senator [Bernie] Sanders [I-Vt.] and I have," Sen. Bill Cassidy, MD (R-La.), ranking member of the Senate Health, Education, Labor, & Pensions (HELP) Committee that Sanders chairs, said in late March at an event hosted by the Johns Hopkins Center for Health Security. He noted that the committee has many competing priorities to deal with as it looks at PAHPA reauthorization.

Having lived through COVID, "we all know the importance" of preparedness, Cassidy said. "We don't want to have to depend upon a non-systematic approach in order to address issues as great as this."

Preparing for the next pandemic will require having a capable health workforce in place, Sanders said last week at a committee hearing on the reauthorization. "That's not just nurses and doctors, but also public health officials -- our disease detectives -- who can tell us where to set up a vaccination clinic for example. If there is an outbreak developing in the West Coast, can we learn about it immediately so the rest of the country is alerted?"

A Long History

The original PAHPA was passed in 2006; it has been reauthorized twice since then -- the last time was in 2018, with a 5-year reauthorization timeline. At the time, the Congressional Budget Office estimated the cost of the measure at $11.9 billion.

The act divides funding into three basic areas: one part controlled by the HHS's Assistant Secretary for Preparedness and Response (ASPR), which includes the Biomedical Advanced Research and Development Authority (BARDA); a second part controlled by the CDC, which administers public health emergency preparedness grants; and a third part for other PAHPA preparedness grants. There are also special authorities the act confers, such as the authority given to the FDA to make sure its staff are trained in reviewing applications for medical countermeasures.

"Most of the time when people say 'PAHPA reauthorization' the first thing that comes to mind is ASPR and BARDA, but there are other kinds of components along with that," Shana Christrup, MPH, director of public health at the Bipartisan Policy Center, said in a phone interview.

In preparing for the reauthorization, the HELP Committee had sought comments from the public about what should be included. The Johns Hopkins Center for Health Security responded with a 17-page set of recommendations, including:

• Development of a "Disease X" medical countermeasures program to protect against unknown viral threats
• Development of prototypes for next-generation reusable respirators
• Implementation of a National Diagnostics Action Plan that would make rapid diagnostic tests available in the event of another pandemic
• Coordination of "bioattribution" efforts across and outside of government to more easily identify the source of future pandemics

"In taking these actions, Congress can ensure that critical gaps in national pandemic prevention and preparedness are filled and that the country's public health, economy, and national security are made more resilient," Thomas Inglesby, MD, the center's director, wrote in an introduction to the response.

Infectious Disease Doctors Weigh In

One of the other respondents was the Infectious Diseases Society of America (IDSA), which issued its own set of recommendations. IDSA's top priority was passage of the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance (PASTEUR) Act, which would, among other provisions, establish a federal government "subscription" system for paying drug companies who develop new antimicrobials, regardless of how much product they sell.

"There are fewer than 50 new antibiotics in development, and only a handful address the most urgent threats. Most large pharmaceutical companies have exited antibiotic R&D, and small biotechs in this space are struggling to stay afloat," wrote IDSA president Carlos del Rio, MD. "The PASTEUR Act's subscription model is an innovative way to pay for novel antimicrobials that will revitalize the pipeline and support appropriate use."

IDSA's other major recommendation was to increase the infectious disease (ID) workforce. "Nearly 80% of counties in the U.S. do not have a single ID physician," said Rios. "In the 2022 Match, through which medical residents selected specialty fellowship training programs, only 56% of ID fellowship programs filled their slots, compared to 90% or more of other specialty programs, which reinforces the urgency to build a stronger ID workforce pipeline."

IDSA recommended increasing reimbursement for ID physicians generally and in particular, "creation of a payment modifier that could be attached to existing billing codes to provide increased reimbursement for care and services directly related to outbreak response during a public health emergency. This approach could utilize guardrails to ensure the modifier is used as intended, such as clearly defining the circumstances, patients and services that could be eligible for increased reimbursement."

Missing Elements

Irwin Redlener, MD, senior research scholar for the National Center for Disaster Preparedness (NCDP) at Columbia University in New York City, praised the Johns Hopkins response, noting that the Center for Health Security "is a very important organization in this field and their recommendations are sound, they're scientific." He liked the IDSA recommendations, too, but noted that they were very specialty-specific.

Redlener said there are two areas that have been missing from the recommendations he's seen. First, the Johns Hopkins recommendations regarding Disease X and bioattribution are very important; however, "there is insufficient emphasis on international cooperation," he said. "We can't do this alone; these are global problems, and [yet] we can't seem to get beyond own borders in our thinking ... We're extremely provincial in our research and collaboration, and those two issues are where we must think internationally."

The other issue that concerns Redlener is "what has happened to funding for public health agencies and hospitals. Since 2003, in the aftermath of Sept. 11, there have been cuts in funding for both of those programs ... PAHPA should be an opportunity to get both of those programs funded at a level they need to be. Otherwise, I don't care what we do academically, if our health systems aren't ready to take care of people, to do surveillance, treatment, and all the things public health agencies need to do, then we're going to be redoing the nightmare scenario of the COVID pandemic."

Looking Inward

Bob Moffit, PhD, a senior research fellow at the Heritage Foundation's Center for Health and Welfare Policy, said the PAHPA reauthorization is a good opportunity to look internally at what went wrong during COVID. "The federal government failed at the beginning of the whole process by not having a central agency to coordinate responses to the COVID-19 virus," he said in a phone interview. "You have the CDC, the White House task force, ASPR -- a lot of lines of authority, but those lines of authority were being confused. That impaired the government's response."

He cited a 2022 Government Accountability Office (GAO) report which found that HHS was at "high risk" of being vulnerable to waste, fraud, abuse, or mismanagement due to issues with how HHS's leadership prepares for and responds to emergencies, including COVID-19, other infectious diseases, and extreme weather events, such as hurricanes. "It seems to me Congress [is] going to have to scrutinize [ASPR] to make sure its performance is OK, and see how it is interacting right now with CDC, the Public Health Service, and other agencies outside HHS," he said. If Congress wants to make ASPR the central agency for response coordination, that would have to be done by statute, he added.

In addition, the CDC failed dramatically in the area of effective collection and dissemination of real time public health data, Moffit said. "Congress voted to spend $175 million for public health data modernization for CDC, and they've got to continue oversight on the CDC's handling of that ... Between now and the time they authorize the [PAHPA] legislation, they've got to make sure this time they've got it right, because they haven't had it right since 2006."

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