Protecting Older Adults During Public Health Emergencies

CDC Congressional Testimony

Testimony before the Special Committee on Aging United States Senate

Richard Besser, M.D.
Director, Coordinating Office for Terrorism Preparedness
and Emergency Response
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Good morning, Chairman Kohl, Ranking Member Martinez, and other distinguished members of the committee. I am Dr. Rich Besser, Director of the Coordinating Office for Terrorism Preparedness and Emergency Response at the Centers for Disease Control and Prevention (CDC). I thank you for the opportunity to discuss our continuing work to better protect older adults, who are among the most vulnerable to the negative health effects of emergencies, such as the current influenza pandemic.

Public health threats are always present. Whether caused by diseases, natural disasters, or intentional acts, there are continual threats that can lead to public health emergencies. Being prepared to prevent, respond to, and recover rapidly from public health threats can save lives and protect the health and safety of the public and emergency responders.

CDC′s Role in Public Health Preparedness

CDC plays a key role in preparing our nation for all types of threats to public health. CDC works with its sister agencies and offices within the Department of Health and Human Services, such as the Administration on Aging, the Agency for Healthcare Research and Quality, and the Office of the Assistant Secretary for Preparedness Response, to better address the needs of older adults during public health emergencies.

CDC′s preparedness activities are an integral part of the agency′s overall mission: collaborating to create the expertise, information, and tools that people and communities need to protect their health. CDC achieves this mission by building capabilities that can be applied universally to all hazards, whether due to biological agents, natural disasters or environmental exposures, chemical and radiological materials, or explosions. CDC is preparing for the possibility of responding to more than one emergency simultaneously, such as an increase in the spread or severity of the pandemic H1N1 influenza virus and a hurricane.

Vulnerability of Older Adults during Emergencies

In 2008, the U.S. Census Bureau estimated there were nearly 54 million persons aged 60 or older, accounting for 18% of the total U.S. population; by 2025, this group is expected to represent 25% of the total population. Older adults are at a substantially increased risk of severe illness and death during public health emergencies. And this risk to older adults is serious. A 2006 study conducted by the AARP Public Policy Institute indicated that more than 70 percent of the people who died in Louisiana as a result of Hurricane Katrina were older than age 60. Most died in their homes, in hospitals, or in nursing homes.

This increased risk occurs for a variety of reasons related to health and disability status, reliance on home- and community-based health care and social services, and need for assistance with transportation. More than 80% of older adults have at least one chronic condition, such as diabetes or heart disease. Most chronic diseases require one or more prescribed medications. Response plans must consider the need for specialized medical equipment and uninterrupted access to medications for people with chronic conditions. Providing care for people with chronic diseases, especially older adults, has been a priority in hurricane response efforts, and is also relevant to any public health emergency where the health care system is disrupted or where people must evacuate their homes. During emergencies, extreme weather conditions, the absence of clean water and other essential services, and disruptions in the health care system put older adults with chronic conditions at especially high risk.

Progress in Protecting the Health of Older Adults during Emergencies

We have made progress in recent years toward strengthening the nation′s ability to protect the health of older adults during emergencies, and we continue to learn from each emergency response. Public health preparedness to help older adults and other vulnerable populations, such as children, pregnant women, and other individuals who have special needs in the event of a public health emergency, requires strong community engagement and planning before an emergency occurs. Each community has different planning and response needs based on its demographics. Responders need to know who the most vulnerable populations are and what support they need to mitigate the adverse health effects of emergency events and their aftermath, such as overburdened health systems, closure of pharmacies, and loss of health records.

Recent planning efforts have focused on preparing for an influenza pandemic, but the progress made in collaborating across sectors helps improve preparedness and strengthens the ability to help older adults during all types of emergencies. For example, within each state′s pandemic influenza operation plan, actions have been identified to increase the ability to help older adults during emergencies, such as forming community-wide planning coalitions to include hospitals, long-term care facilities, nursing homes, home health care agencies, emergency medical services, and other health care, supportive service, and response organizations. These planning efforts are crucial for older adults because they may have serious health problems that require specialized care; and they may be without either facility- or home-based care during emergencies due to a lack of health care workers, loss of power, diminished social services, or other problems.

Another improvement is the ability of CDC′s Strategic National Stockpile to procure chronic disease medications to help emergency response. The Strategic National Stockpile is a national repository of medicine and medical supplies to protect the American public if there is a public health emergency severe enough to deplete local supplies. During Hurricane Katrina, many people who needed chronic disease medications were evacuated and did not have enough medications with them or were not able renew prescriptions. CDC was called upon to deliver medications for these individuals with chronic conditions, and was able to support those requests through various procurement methods to meet the demand. CDC′s Strategic National Stockpile has strengthened this ability through partnerships with pharmaceutical distributors to quickly acquire and deliver medications to help older adults and others with chronic disease.

Supporting State and Local Preparedness and Response Efforts

CDC also supports state and local public health departments—the first responders in public health—in their efforts to protect older adults during emergencies. CDC′s Public Health Emergency Preparedness cooperative agreement provides funding and technical assistance to 50 states, 8 U.S. territories and freely associated states, and four localities (Chicago, Los Angeles County, New York City, and Washington, DC). Supported activities include improving public health departments′ ability to help older adults and other vulnerable populations during an emergency response. Examples of these efforts include:

• In Florida, creating the Interagency Special Needs Sheltering Committee, enhancing shelter infrastructure, staff development, and shelter supplies; and guidelines for improving shelter operations and discharge planning.

• In Wisconsin, obtaining feedback on emergency plans by hosting a series of focus groups for seniors with varying cultures, religions, and medical conditions, as well as long-term care agency representatives.

• In Kansas, implementing a web-based geographic information system (GIS) for tracking facilities, such as long-term care and assisted living facilities, as well as home health agencies that serve vulnerable populations.
• In Louisiana, developing a database and fingerprint recording system to identify Medicaid long-term care recipients who may need to evacuate to emergency shelters. With this system, authorized staff will be able to identify the recipient’s emergency medical information, such as the primary care physician and current medications.
• In North Carolina, developing an agreement with the Division of Aging and Adult Services to provide pandemic influenza educational materials and thermometers to persons served in Area Agencies on Aging meal programs.

In addition, response during the 2008 hurricane season demonstrated progress in the ability to evacuate special needs medical patients, including older adults and their caregivers. Many nursing homes and hospitals were evacuated before hurricanes hit, a marked improvement compared to the evacuation that occurred during Hurricane Katrina. For the 2009 hurricane season, state and local emergency planners are anticipating the need to pre-evacuate older special needs individuals who may be in hospitals or nursing homes, or who live in the community.

CDC is also supporting state and local preparedness efforts through research and training. Protecting older adults and other vulnerable populations in emergencies is a research priority at CDC. CDC recently funded Preparedness and Emergency Response Research Centers to focus on this and other research priorities, such as improving emergency communications and preparing the public health workforce. For example, the center at Emory University will focus on improving disaster planning for nursing home, home health, and dialysis providers. This assessment will help improve the preparedness plans of nursing homes and dialysis facilities and develop stronger connections between these facilities and state and local disaster planners.

In addition, the CDC-funded Centers for Public Health Preparedness, a network of schools of public health across the country, are working to improve emergency preparedness and response for older adults and other vulnerable populations. These Centers organize workshops, outreach programs, tabletop exercises, seminars, and online courses to better prepare public health professionals to serve these populations special needs in a response. The Centers are also implementing academic programs for graduate students and public health and healthcare practitioners on how to identify and address the needs of vulnerable populations during a disaster.

Older Adults and the Pandemic H1N1 Influenza Virus

On June 11, 2009, the World Health Organization declared the novel H1N1 influenza outbreak to be an influenza pandemic. Helping older adults during an influenza pandemic is a priority area for CDC′s preparedness and response efforts. CDC has developed guidance on pandemic influenza for vulnerable populations, including older adults, and for the clinicians who care for them. Guidance documents are available at https://www.cdc.gov/h1n1flu/guidance and http://www.pandemicflu.gov/plan/index.html .

Current information indicates that older adults are at a lower risk of contracting the pandemic H1N1 influenza virus compared to children and younger adults. For seasonal influenza, older adults are at higher risk of complications from flu. So far, few cases of pandemic H1N1 influenza have been reported among older adults. At this time, we do not know what the risk of complications will be in older adults. However, we do know that certain chronic medical conditions, which are common in older adults, increase the risk of complications from seasonal influenza and also appear to increase the risk of complications from the pandemic H1N1 flu virus. For example, we have found that persons with chronic cardiovascular disease and cerebrovascular disease (CVD) are at increased risk of experiencing an acute exacerbation of disease during influenza epidemics.

Factors that increase the risk for older adults during an influenza pandemic include economic disadvantage (e.g., having too little money to stockpile supplies), absence of a support network, needing support to be independent in daily activities because of physical disability, mental illness or difficulty seeing or hearing, medical conditions, or trouble reading, speaking, or understanding English. To educate older adults about what they can do to protect themselves against to the pandemic H1N1 influenza virus, CDC will build on previous outreach efforts such as television interviews, print ads, and magazine articles that are specifically targeted to older adults, as well as strengthened engagement with associations such as AARP and the American Pharmacists Association.

To further address the vulnerability of older adults during an influenza pandemic, CDC collaborates extensively with partners. For example, CDC worked with the Association of State and Territorial Health Officials to develop guidance and conduct training on vulnerable populations for state, local, territorial, and tribal health departments. The guidance and training focus on identifying those at greatest risk from the consequences of an influenza pandemic in one′s own community, including older adults, communicating with these individuals, and providing clinical and nonclinical services. More information is available at http://www.astho.org/?template=at_risk_population_project.html .

In another example, CDC engaged tribal nations to assess why many older American Indians and Alaska Natives would face additional challenges in a pandemic that make them particularly vulnerable. The combination of increased vulnerability from underlying health issues, barriers to accessing health care, and infrequent use of public assistance and other services suggests that typical methods of outreach and distribution of services may not be effective for reaching older adults in American Indian and Alaska Native communities. Based on these findings, CDC led a series of Tribal Engagement meetings in the spring of 2009 with tribal and community leaders to learn from them how to best reach their communities and train them in pandemic preparedness and developing emergency plans.

CDC continues to work to better understand the pandemic H1N1 influenza virus, including the severity, transmissibility, and infectiousness. Information from investigations is helping to strengthen CDC guidance—on antiviral use, non-pharmaceutical interventions, diagnostic testing, duration of exclusion from work or school for ill persons, other community mitigation measures, and interventions targeted at special populations, including older adults—and to inform our preparations for the upcoming influenza season.

Challenges in Protecting Older Adults during Emergencies

Although we have made considerable progress, more still needs to be done to improve our ability to assist older adults during emergencies. Further improvements are needed not only to protect the health of older adults, but also to avoid additional strains on hospitals and emergency medical services during an emergency. Several continuing challenges are described below.

Ensuring availability of chronic disease medications. Public health emergencies can cause disruptions in the health care system, leading to negative health effects for older adults with chronic diseases. During emergencies, even people who have health insurance may not have access to their insurance information, the insurance may not cover them out of state, or they may have limitations on the coverage of extra prescription drugs to have on hand. The Strategic National Stockpile can rapidly procure critical medications to alleviate this problem during emergencies, but this is not a complete solution. We need to enable older adults and their caregivers to have the medications needed to avoid exacerbations of chronic disease.

Broadening the use of immunizations and other key clinical preventive services. Only about one third of older adults are up-to-date on all the preventive services recommended by the US Preventive Services Task Force. Further, only about two thirds of adults ages 65 or older received an influenza vaccine in the past year, and just over half received a pneumococcal vaccine. Regardless of the spread and severity of the pandemic H1N1 influenza virus, we need to encourage older adults to continue to get their seasonal influenza and pneumococcal vaccinations. Increasing the availability and use ofclinical preventive services will not only have a positive effect on seasonal influenza vaccination rates, but also equip communities with infrastructure to handle larger scale vaccination or other medication-delivery programs that may be needed during a public health emergency.

Improving emergency shelters for people with special medical and supportive service needs. Further work could be done to ensure that shelters can be made more appropriate to the needs of older adults. Acute exacerbation of chronic diseases can lead to severe complications or even death and was a leading concern among medical personnel treating displaced persons after Hurricane Katrina in 2005. During the 2008 hurricane season, emergency shelters cared for evacuees with a wide variety of medical needs, including dialysis, complications from obesity, and Alzheimer’s disease, but these shelters lacked nurses with the specialized skills needed to provide care for these conditions. Emergency shelters need to have the necessary capabilities, supplies, and other resources to respond to the needs of older adults and other vulnerable evacuees. Moreover, current shelter assessment tools evaluate sanitation and hygiene, but they do not evaluate either the shelter′s ability to provide specific levels of institutional care, medical care, or supportive services that older adults may need during emergencies or its ability to connect individuals with essential human services and supports that, if permitted to go unaddressed, could become medical needs.

Further integrating preparedness efforts for public health emergencies. Despite recent improvements, community healthcare delivery systems and community supportive services still need to be better integrated into emergency planning efforts. For example, through a series of workshops and meetings with stakeholders, CDC identified a lack of integration of long-term care facilities (LTCFs) with their community′s pandemic influenza response plans. CDC is working with stakeholders to discuss ways to better integrate LTCFs into community healthcare delivery and response plans and to identify ways through which LTCFs and healthcare delivery and other supporting sectors within communities can improve their collaborative efforts, thus making the best use of limited resources during an influenza pandemic.

Implementing electronic health records. A wide implementation of electronic health records would help improve and streamline healthcare for all Americans. During emergencies, electronic health records would help older adults obtain their lists of medications and facilitate renewal of these medications. With electronic health records, it may be easier to access medical histories and information about preexisting conditions even if patients are receiving care from a different health care provider in a different city or state. This medical history is particularly important for older adults, as they are more likely to be taking multiple medications and have ongoing health conditions that could affect treatment decisions. The number of hospitals and health care facilities with electronic health records is still small, but growing. It is crucial to ensure that the information needed by public health agencies to protect older adults and other vulnerable populations is included as electronic health record systems expand.

Making progress with resource and workforce constraints. The economic crisis has resulted in budget shortfalls at state, county, and municipal governments across the country. According to the Association of State and Territorial Health Officials, these shortfalls have led to the loss of over 11,000 public health workers in the past year, and further job losses are expected during the rest of this year. These losses exacerbate an already dwindling public health workforce. Furthermore, hospitals and health care systems are also experiencing budget shortfalls, which may reduce their ability to participate in activities that do not directly benefit their bottom line. Protecting the health of older adults during emergencies requires cross-sector partnerships, strong community engagement, and a committed focus on integrating the needs of older adults in all preparedness and response activities, all of which become more difficult with fewer resources. Nevertheless, we must remain committed to further improvements.

Conclusion

Preparing older adults for emergencies cannot be achieved by the federal government alone. Older adults and/or their caregivers need to be able to store and maintain an emergency supply kit in an easy-to-identify container in a location that is easy to get to in an emergency. Families and communities need to have a plan for how to care for older adults who live at home but have limited mobility. Health care and supportive service providers should include preparedness education in conjunction with routine care and self-management education for older adults and other persons with chronic disease and their families and caregivers. More information on what older adults can do to prepare for an emergency is available at http://emergency.cdc.gov/preparedness/mind/seniors.

The nation often views public health preparedness and health promotion as an “either/or” trade-off; either we focus on being ready for public health emergencies, or we focus on promoting health. However, these efforts are interconnected. As Dr. David Satcher, a former CDC Director and U.S. Surgeon General has noted, the same things that lead to health disparities on a day-to-day basis in the U.S. also lead to disparities in the negative impacts of public health emergencies, especially for older adults and other vulnerable populations. Reducing the burden of chronic disease in our country will help our population be healthier and more resilient during an emergency. Electronic health records will both improve quality of care and provide needed information for treatment in emergency shelters. We need to focus on the elements of preparedness and health reform that are mutually beneficial, and work to ensure that these efforts do not develop in a vacuum without realizing the shared benefits.

Preventing illness and disease are not only essential components of health reform but are also critical to our nation′s overall health protection and preparedness efforts. By focusing on prevention and wellness, we can not only stop diseases before they happen, but we can also make our homes, our communities and our families healthier, safer and stronger. Protecting our nation′s health has always been the focus of our work at CDC. This includes taking care of our most vulnerable. And I believe that our nation is only as prepared as our ability to take care of older adults and the other vulnerable members of our community.

Overall, we are more ready for an influenza pandemic or other public health emergency today than we have been at any other point in our nation′s history. CDC′s preparedness activities have reached communities across the county, helping improve the nation′s ongoing response to the current influenza pandemic. But we still need to do more. We look forward to working with you to continue to prepare the nation to protect older adults during emergencies. Thank you for the opportunity to share this information with you today. I am happy to answer any questions.