Question

CASE STUDY

The winter was somewhat mild in some parts of the United States in February 2018. Although Spring Practice for football had not officially begun at Mid-Atlantic University, the players were expected to work out on their own informally and stay in top physical condition. An extremely close-knit group of athletes, mutually dedicated to the goal of winning the national championship in the Fall. When upper respiratory infections began circulating among the players, the team physician decided to send specimens to the State Health Department where virologists examined 23 specimens and obtained a positive test for influenza virus for 15 of them. They also confirmed that most of the virus isolates contained the influenza strain A/Victoria, a common type of influenza that occurs every winter. Unfortunately, they could not identify three virus isolates and were uncertain about four others. These seven specimens were forwarded to a federal laboratory where scientists specialize in infectious diseases.

Two months prior to the outbreak at the university, health officials in Vietnam had ordered the destruction of 12 million chickens after evidence surfaced that a "bird flu" strain of virus resulted in 20 confirmed influenza cases, 12 of which proved to be fatal. Health authorities in Hong Kong confirmed that the virus involved human-to-human transmission. Shortly before the campus outbreak at Mid-Atlantic University, local health officials temporarily closed a large meat distribution company in the area that supplied food to the school because its poultry was suspected of being infected with an influenza strain.

While the specimens were on their way to the federal laboratory, more players reported feeling ill and on February 15, an offensive tight-end named Dave Murray died in the university infirmary complaining of flu-like symptoms, his position coach had told him two days beforehand to take a week off and not return to workouts until he felt 100 percent healthy.The same day that he died, an opinion piece in a national daily newspaper by a prominent virologist noted that pandemics occur approximately every 30 years or so. The last one had swept the globe four decades earlier. Over the course of the next few days, State Health Department laboratory experts were unable to identify the strain of two additional influenza-positive specimens, one of which was obtained from the player's corpse. These specimens also were forwarded to federal scientists who discovered that the three previously unidentified isolates, along with the two new ones represented a different virus type. Even more serious was the possibility that the isolates might be closely related to an avian influenza virus believed to have swept the world in a pandemic in 1918, killing an estimated 50 million persons around the world and approximately one-half million victims in the United States. Hong Kong health authorities feared that the virus uncovered there was the same as the strain implicated in that earlier pandemic.

The many deaths that occurred then were due to an accompanying bacterial pneumonia prior to the advent of modern antibiotics.

Human-to-human spread of avian influenza had not been seen in the U.S, in at least 50 years and Dr. Lionel Traister, head of the federal infectious disease agency, contacted officials from other federal agencies and major State health departments around the country and invited them to an emergency meeting at his offices on March 1. Those scientists present who possessed a sense of public health history noted that the 1918 pandemic began relatively mildly in the spring and then returned with a vengeance in the fall, accounting for the vast majority of deaths. As a group, they agreed that the university outbreak could be a harbinger of more lethal and widespread disease on the not-too-distant horizon. No precise estimate of the extent of the risk ever was voiced, however, such as indicating that there might be a 25 percent chance the nation may be headed for a serious outbreak. All that could be stated was that there was a possibility of a pandemic. A question that loomed rather large in their minds was what to do about going public with these concerns. A delicate balance existed between sounding a warning to public health officials around the country and inciting a panic. The media frenzy associated with the outbreak of other influenzas in recent years provided a cautionary lesson. They decided to wait for the results of another round of tests, which in the next three days should confirm whether the virus uncovered at the university was avian influenza. Their worst fears soon were realized. The virus was avian influenza. Another emergency meeting was called on March 7 with the invitation list extended to virologists from private clinics, universities, and pharmaceutical companies. Meanwhile, the search for a further outbreak of the virus among the football team and among the rest of the student body had not yielded any new active cases nor had it spread beyond the campus to the community nearby. Outside the U.S., the World Health Organization had not reported any outbreaks of avian flu nor were any new cases reported in Hong Kong. Had the avian flu returned to its source among poultry or was it spreading in humans sub-clinically, waiting for an explosive eruption during the next flu season?

Although no new cases had been reported, the discussion at the meeting centered around: the logistics of vaccine production and distribution, field testing and licensing vaccines, and how to go about conducting a national immunization campaign. The general consensus was that even if all the vaccine needed could be produced by the beginning of the next flu season, which could occur in September or October, it still might take another 10 weeks to immunize the entire population of the U.S. Even then, it would take an additional two weeks after vaccination for protective immunity to be conferred. Stockpiling vaccine and waiting until an outbreak of flu occurred was not viewed as a workable option since infection produced disease much faster than a needle stick provided immunity. Only one person at this meeting, Dr. Virginia Bell who was director of a State health department on the West Coast, addressed the issue of stockpiling vaccine until clearer signals emerged that would warrant the start of a mass immunization program. Her basic concern was that caution should be exercised when considering the possibility of injecting any foreign substance into the bodies of more than 300 million Americans. She wanted to know at what point do preparations to immunize the entire population stop and the plan is changed to stockpile the vaccine instead. Bell's comments were made dispassionately and seemed to have little or no impact on the group. She did not argue her case any further.

Following the Chain of Command

Lionel Traister was regarded as a tough, highly competent, and occasionally wily career bureaucrat. Not only was he committed to advancing public health measures, he would never be accused of failing to advance himself when opportunity knocked. The appearance of the avian flu virus seemed to be one of those rare occasions when he could be at center stage to demonstrate to a wide audience both his own and his agency's capabilities. Strict caps were imposed on spending for that fiscal year because of a serious budget deficit. Recognizing that a national immunization program would require a supplemental appropriation, coupled with the fact that the federal bureaucracy was so slow moving, he knew that quick, decisive action on his part was imperative. The key was to frame the situation in urgent terms that persons higher-up in the administrative chain would find difficult to ignore. Consequently, he prepared a document that combined a sense of extreme urgency with a set of propositions that would be difficult to counter. On March 11, he contacted his superior, Dr. Myles Borash who was the Assistant Secretary of Health, to let him know that the memorandum was on its way to him. Traister followed procedures by addressing it to Department Secretary Wilma Kester from Assistant Secretary Borash. In the chain of command, Traister was one of six agency heads reporting to Borash. As Assistant Secretary, even though Borash was a highly regarded physician, he was at the low end of the political appointments chain. Essentially, his job was to assume responsibility for official health policy within the Administration. The facts presented in the memorandum were clear and understandable.

The second option proposed a minimal response, with the federal role limited to: advising vaccine manufacturers, providing a stimulus to State/local health departments to take action, and educating the public. Reasons favoring this choice included high visibility, less responsibility for the eventual outcome if it proved to be unfavorable, and reduced federal spending. Arguments against this approach were that drug companies might not produce enough vaccine and significant portions of the population such as the poor and the aged might never be immunized. The third option called for total federal intervention. The main argument favoring this course of action was that widespread availability and distribution of vaccine would be assured. Opposing arguments were the high cost of such a campaign and the fact that the American people would not be favorably disposed to a program that left out the private sector.

The last option involved a combined approach that would have the advantage of using both public and private sectors. The federal government could purchase the vaccine needed, have it tested for safety and efficacy by federal agencies, and distribute it through health departments at all levels of government as well as in hospitals, clinics, and physician offices. This choice would provide a good vehicle for having all facets of the health care system work together cooperatively to assure that every American would have an opportunity to be immunized. The memorandum concluded with a recommendation to pursue the fourth option.

On March 13, the memorandum was discussed at the weekly meeting of the Secretary. Recognizing the likelihood that there might not be a pandemic in the making, there still was a great amount of attention focused on what happened earlier in the 20^th century. Kester indicated that she wanted to meet with Borash and Traister in her office the following morning along with the directors of federal agencies involved in licensing vaccines and overseeing research on viruses. At this session one day later, Traister recommended that the federal government undertake action as recommended in the fourth option. When Kester asked what the probability of a pandemic is, the answer from Traister was "unknown." Nobody at the meeting was willing to assign a probability, but Traister said that it is greater than zero. When asked if it was possible to produce enough vaccine and have it administered, the response was in the affirmative, but with the caveat that time was of the essence and that a decision would have to be made quickly.

Hearing no dissent and determining that every person in the room was in accord with this recommendation, Secretary Kester decided that it was appropriate to bring this matter to the attention of White House staff. Her reasons were: the government's top scientists favored a course of action, a probability of a pandemic greater than zero had to be assumed, and that there would be no credible way after a pandemic struck of telling the public that the government had not prepared to meet the threat because the probability was low and the costs of an immunization program outweighed the benefits. She also had enough political acumen to realize that even if she rejected the memorandum, it still might be leaked to the media.

Kester wrote a memorandum that same day to the head of the federal budget office, indicating that a request for a supplemental appropriation of $1 billion would be forthcoming. She stated that: "There is evidence that there will be a major flu epidemic this coming fall. The indication is that we will see a return of a virus that killed 500,000 Americans in 1918. The projections are that this virus will kill as many as one-and-one-half million persons in this country. The drug industry must be advised now in order to have enough vaccine produced for a mass immunization program. A decision will have to be made in the next week or so."

Reactions at the State Level

Hiram Waters was only one of two individuals who raised questions about a national immunization program during the widely televised Congressional hearings. His closest friend was one of 60,000 fatalities around the nation during the 1957 Asian flu epidemic. He was a staunch advocate of pediatric immunization programs, but did not believe that there was sufficient evidence to warrant what was being proposed. He indicated that his State would accept the vaccine gladly, but none of it would be distributed to local health departments, private physician offices, and hospitals until new cases of the flu began to emerge.  

Bayside was the largest city in his State. It possessed three academic health centers and because of changes in the health care delivery system occasioned by the growth of managed care, these entities were in fierce competition with one another. In medical circles, an oft-repeated question was whether all three could survive. The State already had a huge surplus of physicians, more per capita than any other State in the Union, and a large oversupply of hospital beds.

Coastal Health Center was the most aggressive of the three health centers. Not only had its executives negotiated a contract with the largest managed care company in the State, they were raiding the Atlantic Health Center, the smallest of the three entities as measured by the size of medical staff and the number of inpatient beds. Atlantic, despite its smaller size was more of a boutique operation with a worldwide reputation for providing care of the highest quality.  

Richard Medvecky, CEO of Coastal, viewed Atlantic as a potential acquisition through merger.

He knew that if he ever made such a move, his chief competitor, Bayside Health Center, would counter it immediately. Administrators at Coastal and Bayside knew that an initial move by either side would trigger a bidding war, one in which both could end up being losers. Medvecky conceived of another way of achieving dominance in this highly charged health care environment. He began making offers to Atlantic physicians who were the chiefs of Neurology, Radiology, and Surgery to switch to Coastal. The offer consisted of: doubling their salaries, providing ten-year contracts with guaranteed hefty annual pay raises, and furnishing perquisites such as additional compensation to cover the costs of their children's college education. These offers were accepted.

Based on a case study on the outbreak of a disease along lines of avian influenza that cuts across national boundaries. Adopt the perspective of one of the actors in the situation (e.g., legislators, governmental agency directors, professional association director, vaccine manufacturers) regarding that person’s role in the episode as it unfolds and provide a critique of the performance of the other actors in dealing with the problem adequately.

Answer 1

ans.Outbreaks of epidemics call for a large number of deaths and causalities. Effective control of an epidemic outbreak calls for a rapid response. Available resources such as essential medical supplies, well-trained personnel, grocery, essential food items and other necessary items for a smooth functioning need to be deployed swiftly and needs to be managed in with available information and financial resources in order to contain the epidemic before it spread in community and cause disastrous problems. Therefore, the identifying, planning, establishing and managing of an emergency supply chain during the initial stage of the spread of virus are of high importance. The control of an outbreak calls for a prompt response. Certain control protocols should be followed and huge amounts of supplies together with the necessary human resources (medical and other personnel) should be available in order to be utilized during the containment effort. All the logistics operations such as transportation of medical supplies and commodities or the deployment of medical personnel must be managed in conjunction with available information and financial resources in order to contain the epidemic before it reaches critical proportions. This is the reason why leading international health organizations like World Health Organization and the Pan American Health Organization explicitly recognize the importance of logistics operations to any successful health task undertaken for the control of an outbreak.

In such outbreaks , countries like USA is having a difficult task controlling the virus as USA is geographically wide spread. Making resources, equipments available to the citizens, hospitals are the main task of the government at this point.The best way to stop the spread is to have countrywide lockdown for atleast 10 days. So the government and health officials can arrange for vaccine and stop the spread without much casualities. After all healthy citizen is the strength of a country. The government in this situation have to take the help of e-commerce companies like flipkart , Amazon and other delivery companies to tackle the situation.

Government bodies and hospitals in USA are well ready in advance for controlling the outbreak. This means that they should be ready with plans addressing issues like the availability of medical stocks and well-trained person, their appropriate deployment .Since its lockdown, all the transportation of commodities needs to be addressed like the essential items of food supplies to reach all the places. The first task is to classify the items as essential and non essential during this lockdown and permit the movement of only essential items. The government immediately with the help of bureaucrats and state government classified each items for their respective states.

The next thing is to transport this to different cities and villages across USA. This is a huge task in place. Arranging the different type of vehicles and drivers amid this outbreak was a huge problem. The drivers will be reluctant to drive as they thought they will starve during their trip as the hotels will be closed due to lockdown. Vehicles of different size were needed. This is when they had strategically come up with e-commerce and logistical companies to transport and also take orders of the essential items. The government should make  it easier by issuing the digital checks and passes for their vehicles and also delivery boys. The company can also ask the government to have uniform classification of essential items across states for better efficiency of delivery.

Next important thing was the handling of materials at different warehouses. The main purpose has to be reduce the possible human intervention. For this some companies and governments has to start using robots which will handle the materials. The other material handling equipments should  made to sanitize for every possible time to remove it from virus content.Another strategy that can be used is to reduce the aesthetic look of the packing and thus cut down the cost but with essential packing been done. Companies also have introduced selling of various other products in certain cities with approval of their respective state government. Ccompanies should change the  track of their marketing strategies and introduce target marketing and thus cutting down the costs. Companies should start of wholesale in the beginning of lockdown in order to sell the materials reaching expiry date in their inventory.

The companies should regularly checking the temperatures of its employees, associates, partners and support staff when they arrive at work at its different offices. The e-commerce firms must also increased the frequency and intensity of cleaning at all sites, including regular sanitisation of door handles, handrails, touch screens, scanners, and other frequently touched areas. They have to adjust practices so that teams can adhere to social distancing, whether at sites or while even while making deliveries to customers. This includes eliminating stand-up meetings during shifts, staggered shift start times and break times and spread out tables in the break rooms on site.

“Cooperation is better than competition “-Edward w Deming. These words are coming into existence in this situation lockdown. Tie-ups among brands and corporations operating in seemingly unrelated or even competitive sectors seem to be one way of getting around the supply-chain challenges. The crisis is an opportunity to focus on each other’s skills and customer base to not only create businesses for themselves but also to keep things moving. F