Ethics and Childhood Vaccination Policy in theUnited States

Ethics and Childhood Vaccination Policy in the
United States
Childhood immunization in-
volves a balance between par-
ents’ autonomy in deciding
whether to immunize their chil-
dren and the benefits to public
healthfrommandatingvaccines.
Ethical concerns about pediatric
vaccination span several public
health domains, including those
of policymakers, clinicians, and
other professionals.
In light of ongoing develop-
ments and debates, we discuss
several key ethical issues con-
cerning childhood immunization

in the United States and de-
scribe how they affect policy
development and clinical prac-
tice. We focus on ethical con-
siderations pertaining to herd
immunity as a community good,
vaccine communication, dis-
missal of vaccine-refusing fam-
ilies from practice, and vaccine
mandates.
Clinicians and policymakers
need to consider the nature
and timing of vaccine-related
discussions and invoke delib-
erative approaches to policy-
making. (Am J Public Health.
2016;106:273–278. doi:10.2105/
AJPH.2015.302952)

Kristin S. Hendrix, PhD, Lynne A. Sturm, PhD, Gregory D.
Zimet, PhD, and Eric M. Meslin, PhD, FCAHS
Following the December2014 measles outbreak at
a popular amusement park in
California,1,2 which spread to
other states, Canada, and Mex-
ico, there has been increased
attention to US childhood im-
munization practices. A recent
study attributed the outbreak
to underimmunization,3 and
several policymakers have called
for an end to religious and phil-
osophical (i.e., personal-belief)
exemptions altogether, with the
state of California passing legis-
lation removing the option of
personal-belief exemptions.4,5
Political candidates have
expressed various viewpoints on
vaccination.6 In light of these
developments, we discuss several
key ethical issues concerning
childhood immunization in the
United States and describe how
they affect policy development
and clinical practice. There are
a myriad of ethical issues re-
garding such topics as vaccination
development, administration,
communication, and safety
monitoring. We focus on a few
key ethical issues concerning

childhood immunization in the
United States—what we refer to
as a “vaccine ethics” approach—
and describe how such an
approach affects policy develop-
ment and clinical immunization
practice.
VACCINE ATTITUDES
AND BEHAVIORS
In a time of growing hesita-
tion, uncertainty, and opposition
concerning childhood vaccines,
the developed world is witness-
ing a resurgence of vaccine-
preventable illnesses.7–9 Although
the spread of antivaccine and
vaccine-fear sentiments has be-
come common through social
networks, both online and in
person,10,11 a growing body of
research argues that such senti-
ments are multidimensional and
nuanced.12,13
Although sensible public
policy is often consistent with
public sentiment, there are in-
stances in which empirical data
can give conflicting input about
the ethical acceptability of policy.
In vaccine policy, this is especially
true when one distinguishes be-
haviors from attitudes. Although

related to one another, attitudes
about vaccination may differ
from actual behaviors; indeed,
they can at times be orthogonal
constructs that interact uniquely
depending on individual and
contextual factors. For example,
a mother who seeks vaccination
for herself and her children is
exhibiting provaccine behavior,
but may nonetheless feel hesitant
or uncertain about vaccines. In
this case, her behavior may be
a response to school-entry re-
quirements and employer poli-
cies. In contrast to her provaccine
behavior, however, her
underlying vaccine-hesitant atti-
tudes about vaccination may be
driven by religious reasons,
skepticism about science, or the
influence of personalities she
trusts on other matters.
A different mother may hold
provaccination attitudes, but may
not vaccinate herself or her
children because of access barriers
such as difficulties securing
transportation to a health care
provider or inability to pay for
vaccination. Moreover, some
parents may resist particular
vaccines rather than all vac-
cines.14 They may mistakenly

believe that vaccination is ap-
propriate for others but not for
their children or family, perhaps
believing that they are in-
vulnerable to an illness.15,16
Thus, studies that capture either
attitudes or behaviors, but not
both, provide an incomplete
portrait of the larger vaccination
landscape. It is the group of
parents who both hold
vaccine-opposing (or vaccine-
hesitant) attitudes and exhibit
nonvaccinating behavior that are
the primary focus of this essay.
This is the group that is at the
center of the “public health vs
personal choice” debate.
Some may believe that a few
nonvaccinating parents will have
ABOUT THE AUTHORS
Kristin S. Hendrix, Lynne A. Sturm, and Gregory D. Zimet are
with the Department of
Pediatrics and Eric M. Meslin is with the Center for Bioethics,
Indiana University School of
Medicine, Indianapolis.
Correspondence should be sent to Kristin S. Hendrix, PhD,
Children’s Health Services
Research, 410 W 10th St, HITS Suite 1000, Indianapolis, IN
46202 (e-mail: [email protected]
edu). Reprints can be ordered at http://www.ajph.org by
clicking the “Reprints” link.

This article was accepted October 12, 2015.
doi: 10.2105/AJPH.2015.302952
February 2016, Vol 106, No. 2 AJPH Hendrix et al. Peer
Reviewed Public Health Ethics 273
AJPH LAW & ETHICS
mailto:[email protected]
mailto:[email protected]
http://www.ajph.org
no appreciable impact on out-
break likelihood or management.
Although this belief might seem
at least somewhat justified for
some diseases that may be elim-
inated or nearly eradicated (such
as polio) or that have relatively
low levels of transmissibility, it is
not justifiable for highly in-
fectious diseases like measles. It
does not take many unvaccinated
individuals to approach the tip-
ping point at which vaccine
coverage levels are too low and
are thus ineffective in preventing
disease spread. This tipping
point is called “herd immunity”
or “community immunity.”17,18
For measles, the herd immunity
threshold is somewhat fragile
in that it requires a large pro-

portion (96%–99%) of a given
population to be vaccinated to
confer maximal protection.19,20
Importantly, when that critical
threshold of immunity is
achieved, the benefits of pre-
venting the spread of an in-
fectious illness also extend to
those who cannot themselves be
vaccinated (e.g., young infants),
the immunocompromised (e.g.,
those undergoing chemother-
apy), those for whom immunity
may have gradually worn off
over time, or those who have
incomplete vaccination status.
Illustrating this concept, news
headlines have recently featured
stories of individuals who are
immunocompromised and
whose avoidance of vaccine-
preventable illnesses lies in herd
immunity—that is, in the hands
of others who chose to vaccinate
(or not).21
THE TRAGEDY OF THE
(HERD IMMUNITY)
COMMONS
Some scholars liken the anti-
vaccine movement to a type
of “free-rider” problem22
reminiscent of Hardin’s iconic

1968 “Tragedy of the Com-
mons.”23,24 The analogy would
work as follows: a population that
is appropriately vaccinated
against highly infectious diseases
is a common good to the very
society of which its members are
a part. Like Hardin’s fields that
must be maintained and replen-
ished over time, the failure of
which depletes the community
resources, so too must a com-
munity maintain its immunity to
ensure its health and wellness.
Maintaining this common good
requires that all vaccine-eligible
individuals be vaccinated.
However, some individuals re-
fuse to vaccinate themselves and
their children for nonmedical
reasons. Ultimately, as with
Hardin’s Tragedy of the Com-
mons, as more individuals behave
in a manner that fails to consider
the common good, there is
a detrimental effect on the overall
well-being of the group and,
therefore, on the well-being of
each individual, including those
individuals who chose to forgo
vaccination. More specifically, in
the case of childhood immuni-
zations, the individual interest
at stake is the parents’ right to
refuse immunization for their
children, with the refusal often-

times based on inaccurate
information or lack of un-
derstanding of the safety and ef-
ficacy of vaccines. One may
question whether deference to
individual parental decisions ex-
tends to situations in which the
parents’ decision is (1) factually
baseless and (2) potentially det-
rimental to the health of both the
children and the community.
There is evidence that forgo-
ing vaccination for oneself
because others are vaccinated
(free-riding) is evident in some
adults’ vaccine decisions for
themselves.22,25–27 However,
published data are mixed or
unclear regarding both the ef-
fectiveness of communicating to
the public the societal benefits of
immunization and theprevalence
of free-riding among parents
deciding about vaccination for
their children.28–31 Some parents
do invoke the herd immunity
argument as a reason not to
vaccinate, suggesting that it is
unnecessary that they expose
their child to the risk of side-
effects from vaccination if ev-
eryone else is vaccinated to a level
that prevents the spread of ill-
nesses.32 Parental decision-

making about vaccination lends
itself to analysis using game the-
ory,33 which we will not pursue
here, except to support the no-
tion suggested by Shim et al. that
vaccination decisions are not
simply selfish or selfless but may
involve complex relationships
between these motivations.34
This degradation of the
community resource of herd
immunity is portrayed in stark
reality in the recent California
measles outbreak. Furthermore,
when we consider data doc-
umenting geographic clusters of
underimmunization around the
United States,35 it becomes clear
that some locations have not
attained thresholds necessary to
stop vaccine-preventable illness
outbreaks, putting people—
especially unvaccinated young
children, the immunocompro-
mised, and the elderly—at in-
creased risk for contracting an
illness.
VACCINE ETHICS, THE
PUBLIC’S HEALTH,
AND PERSONAL
CHOICE
Vaccine ethics can be con-
ceptualized as a set of issues at the

intersection of public health
policy, clinical ethics, and pro-
fessional ethics. The ethical
implications concerning
vaccine-related public health
policy are numerous and at
the forefront of much recent
discussion—for example, man-
dating vaccines for school entry
and excluding unvaccinated
children from schools in the case
of outbreaks. Worth noting is
that US vaccine policy decisions
can have ethical implications
for other countries. For example,
when the Centers for Disease
Control and Prevention (CDC)
and the Advisory Committee on
Immunization Practices with-
drew recommendations to give
the rotavirus vaccine to 2-, 4-,
and 6-month-old children in
1999 in response to rare in-
tussusception cases,36 it became
difficult to distribute the vaccine
in developing countries where
rotavirus had much higher
morbidity and mortality
rates.37,38
The ethics of public health
policy surrounding childhood
immunization extend to issues
beyond individuals’ vaccination
decisions; they also include issues

such as vaccine mandates and
how easily and by what process
exemptions may be obtained. In
an article published in March
2015, Gostin argues that vaccine
mandates are a medium through
which the social contract of
public health is upheld.24 He
further contends that states offer
exemptions for religious and
philosophical reasons not out of
legal concerns but out of politi-
cally motivated concerns.
Clinical and professional
ethics emerge when deciding
about how best to assess one’s
ongoing responsibility to
vaccine-refusing families in one’s
primary care practice.39,40
However, professional ethics also
involve the judgment of non-
clinicians, such as policymakers,
public health personnel, and
researchers; for example, in
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274 Public Health Ethics Peer Reviewed Hendrix et al. AJPH
February 2016, Vol 106, No. 2
determining how best to com-
municate with vaccine-hesitant

families via public health mes-
saging and how a researcher
might communicate with
vaccine-hesitant or vaccine-
opposing study participants.
Ethical questions in this vein
include whether it is acceptable
to leverage knowledge of human
psychology to capitalize on
phenomena like “anticipatory
regret” to persuade or nudge
individuals to engage in healthy
behaviors such as vaccine
uptake.
How can a vaccine ethics
approach inform the debate
about herd immunity? At its core,
vaccination is an action that im-
plicates several fundamental
ethical principles. It invokes dis-
tributive justice insofar as benefits
and burdens are allocated to those
who vaccinate and those who do
not. It requires society to resolve
issues such as the following: Who
bears the burden of vaccination
and who benefits from herd
immunity? Should individuals be
allowed to benefit when others
assume some level of risk (e.g.,
from vaccination) and they do
not? It invokes beneficence and
nonmaleficence precisely be-
cause the benefits and harms to
individuals and communities are

seen to be in dispute, and it speaks
to the foundational importance
of respect for personal autonomy
insofar as individual choice (and,
where children are involved,
surrogate decision-making) is
a hallmark of informed consent.
In some ways, the herd immunity
debate is about finding ways to
honor the informed decisions
that individuals wish to make
while protecting those who are
not capable of being vaccinated
themselves.
Others have made similar
observations. Relying on ethical
principles outlined by Beauchamp
and Childress41 and focusing on
human papilloma virus vaccina-
tion, Field and Caplan42 propose
anethicalframework,characterizing
vaccine mandates as a debate in-
volving competing ethical values—
specifically, the values of individual
autonomy and the principles of
beneficence, nonmaleficence, jus-
tice,andutilitarianism.Therefore,in
a very real sense vaccination debates
are similar to other types of deci-
sions that constitute the unspoken
social contract—membership in
a community often places citizens
in the position of supporting actions
or policies judged to be for the

overall benefit of society but that
might contradict individual beliefs
about what is in the best interests
of a particular person.42
Although we have focused on
health care providers, public
health personnel, and policy-
makers, we recognize that there
are many other actors contrib-
uting to considerations sur-
rounding vaccine ethics. For
example, there is the consider-
ation that regulatory bodies
within a government have ethical
responsibilities to monitor vac-
cines for safety after they are li-
censed,43 which is an important
means of fostering public trust.44
However, the CDC’s funding for
such monitoring has been his-
torically limited compared with
funding for purchasing and pro-
moting immunizations.44 The
budget requested for the CDC’s
Immunization Program, which
includes safety monitoring, de-
creased by $51.5 million from
2014 to 201545 and by $50.3
million from 2015 to 2016.46
Importantly, the perspective
of patients and patients’ parents as
immunization decision-makers is
also critical. These individuals

may or may not take into con-
sideration social responsibility
and how their choices affect the
health of others. Ethical consid-
erations include whether
patients (or their parents) bear
a responsibility to consider that
their immunization decisions can
affect others. Is there a line to be
drawn between respecting vac-
cine refusers’ choices and maxi-
mizing the greater good through
herd immunity? Is there a re-
sponsibility on behalf of practi-
tioners, policymakers, and
researchers to be empathetic to
the rationale underlying vaccine
refusers’ decisions?
We have focused on the
perspectives of policymakers and
clinicians in a developed setting
in which there is infrastructure to
offer childhood immunizations,
track administration, and enforce
policies. In resource-limited
settings, however, such in-
frastructure may not exist or
individuals may not have op-
portunities to receive vaccines.
To address this critical need and
ethical obligation, there have
been multiple calls for govern-
ments of developed and
resource-limited countries to

work together to improve
childhood immunization cover-
age around the world.47,48
Developing sound and in-
formed policy, clinical practice,
and ongoing research efforts
will require incorporating the
perspectives of all stakeholders in
this milieu of vaccine consider-
ations. Deliberative processes49
may be an approach to in-
corporate the perspectives of
various stakeholders, although
reconciling diverse attitudes and
recommendations is challeng-
ing.50 One example of a de-
liberative approach focusing on
public input is citizens’ juries,51 in
which the public’s attitudes,
beliefs, and recommendations
are incorporated into policy
decisions.
As with many public health
problems, however, it is often
difficult to satisfy all principles
and professional obligations si-
multaneously. We consider this
problem in light of the current
debate about family refusal of the
measles vaccine.
PARENTS WHO

REFUSE VACCINES
Families who refuse or resist
vaccination for their children
often defend their position on the
basis that what they believe is in
the best interests of their chil-
dren.52 Their reasons vary,
however, with some believing
that vaccines will harm and not
help or that vaccination is “un-
natural” and “natural” immunity
is preferable.53 Others believe
that they will enjoy herd im-
munity without subjecting their
child to the risk of vaccinating
(free-riding).28 Still others may
cite various nonmedical objec-
tions, ranging from the seemingly
justifiable (e.g., that there is no
need to vaccinate one’s children
for eliminated illnesses) to
conspiracy theories (e.g., that
a government entity could
be conducting intelligence-
gathering operations under the
auspices of a vaccination pro-
gram).54,55 To some observers,
these reasons are not equally
defensible—it is one thing to
reject vaccines because families
believe it is inconsistent with
their sincerely held religious be-
liefs (more defensible), but it is
another to reject vaccines because
of a belief in a government

conspiracy (less defensible).
Similarly, there is a range of
views regarding the appropriate
response toward parents who
take these positions. Some
prominent bioethicists argue that
nonvaccinators should be held
accountable56—legally liable57,58
and perhaps even financially re-
sponsible59—for their decisions.
There is a comparable argument
that holds that parents should
be held accountable for acting (or
failing to—for example, when
AJPH LAW & ETHICS
a parent objects to a blood
transfusion on religious grounds)
in a manner that exposes their
children to the risk of harm.60
These arguments invoke
many of the principles discussed
in this essay. This is a distributive
justice issue: everyone who is
able should bear the burden of
vaccination to receive the benefit
of being protected from the

spread of vaccine-preventable
illnesses through herd immunity.
It is also a matter of beneficence
in that we should vaccinate to
help protect those who cannot be
vaccinated.42,57,59,61 Some legal
scholars argue that, under tort
remedy, as long as causality can be
demonstrated (an admittedly
difficult undertaking), there is
a potential for recourse to hold
nonvaccinators responsible
should their failure to vaccinate
lead to infecting others.58 Argu-
ments like these also invoke the
concept of retributive justice—
how to punish those who com-
mit actions that may harm
others.62 This line of thinking
would consider such issues as the
following: Should unvaccinated
children be subject to distancing
or exclusion policies, such as
being prevented from going to
school, participating in after-
school sports, or holding jobs?
Should parents who opt to
forego vaccinations for their child
have tax benefits withheld or
reduced? There are corollary
examples of adults who refuse to
vaccinate themselves. In some
instances, there are punitive
measures for failure to vaccinate
oneself—for example, health
care workers facing employment

termination for refusing in-
fluenza vaccination.63
Related to the issue of
whether to hold parents re-
sponsible for refusing vaccina-
tion, health care providers are
debating the ethics of refusing to
treat or dismissing from one’s
practice families who refuse
vaccines for nonmedical reasons.
Encountering families who op-
pose some or all vaccines is
common among physicians. In
one survey, 54% of pediatrician
respondents indicated they had
encountered one or more fami-
lies who opposed all vaccines.64
Moreover, in this same survey,
39% of pediatricians said they
would dismiss families who re-
fused all vaccines, with 28%
reporting they would dismiss
families who refused some vac-
cines. More recent research has
indicated that 25% of surveyed
pediatricians say they would al-
ways, often, or sometimes dismiss
families from their practice for
refusing any vaccines in the pri-
mary childhood immunization
series.65 It has been long known
and recently reiterated that
nonvaccinating patients pose

a risk to others in the waiting
room, especially infants who
are not yet old enough to be
vaccinated or individuals
whose immune systems are
compromised.66,67
Physicians’ dismissal of
vaccine-refusing families runs
counter to recommendations
from the American Academy of
Pediatrics (AAP) Committee
on Bioethics.68,69 The AAP
stresses that health care providers
should address vaccine refusal
through hearing the family’s
concerns and discussing the risks
that accompany not vaccinating
one’s child. They argue that each
encounter with a vaccine-refusing
family is an opportunity to
describe the importance of
vaccination—an opportunity lost
if thefamily sought careelsewhere.
The AAP position tries to craft
a middle ground, acknowledging
the positions held by parents and
believing that ongoing engage-
ment is better than disrupting or
altogether severing the therapeutic
relationship through dismissal.
RESOLUTION
THROUGH BETTER
COMMUNICATION

Ethical issues also underlie
the emerging body of research
on how best to communicate
with vaccine-hesitant and
vaccine-opposing families. Some
argue that taking a “pre-
sumptive” approach during
clinical encounters—in which
the physician assumes the family
will agree to recommended
vaccinations—results in higher
rates of vaccination uptake
than with a “participatory”
approach—in which the physi-
cian makes no such assumpti on
and solicits the family’s input
on whether to vaccinate.70,71
Others have argued for a non-
adversarial,72 “guiding” ap-
proach12 in which the health
care provider addresses the
family’s specific concerns to ulti-
mately help them decide to
vaccinate.
All 3 of these communication
approaches have strengths and
potential drawbacks. The pre-
sumptive approach is thought to
result in less vaccine resistance
among parents; however, some
are concerned that, with the re-
duction or absence of shared
decision-making, such ap-
proaches may make families feel

that the provider does not care
about their perspective or that
their autonomy is being
encroached on.12,73 Alternately,
with the participatory and guid-
ing approaches, patients could
leave the provider’s office un-
vaccinated for a period of time,
perhaps putting children at risk
for exposure to illness; however,
health care providers and re-
searchers argue that approaches
like these are likelier to foster the
therapeutic relationship between
patients and their providers.12
Moreover, related to the chal-
lenges and emotionally charged
nature of vaccine discussions,
health care providers may feel
moral distress74 in determining
the degree to which they should
nudge vaccine-hesitant or op-
posing families to immunize their
children. This moral distress
would likely result from an eth-
ical conflict between doing
what the provider sees as best for
the child and for society
(i.e., vaccinating) and what is
best for fostering the therapeutic
relationship with that patient
and the patient’s family
(i.e., respecting the family’s
wishes and not pushing the family

too hard). Such distress is likely
to be compounded by discomfort
caused by counseling on an
emotionally charged issue such as
vaccination.
WHERE TO GO FROM
HERE
Given the documented diffi-
culty of communicating with
vaccine-hesitant and vaccine-
opposing families in a way that
addresses their concerns and re-
spects their autonomy, coupled
with challenges in communicat-
ing the greater good of vaccina-
tions in typical face-to-face
clinical encounters, it is time to
rethink how health care practi-
tioners, policymakers, and com-
municators approach vaccine
education and communication.
From a policy and clinical ethics
perspective, this might mean
making the informed-consent
process more educationally in-
tensive and applicable not only to
parents choosing to immunize
their children but also, and es-
pecially, to those refusing or
declining immunizations or
requesting a modified schedule.
Although findings regarding the
impact of educational and mes-
saging efforts on vaccine attitudes

and intentions are mixed, one
approach worth investigating
AJPH LAW & ETHICS
might be an informed opt-out
process in which parents are
presented with information re-
garding what it is like to see one’s
child suffer from a vaccine-
preventable illness such as
measles.75
From a policy perspective, it
may mean reevaluating the ease
with which nonmedical ex-
emptions are handled, with in-
creased attention toward
ensuring that parents are making
informed decisions, especially
when they opt out of vaccina-
tion. The state of California re-
cently passed legislation that
removes the option of personal
belief exemptions.5 This has led
to much public deliberation as to
whether the state has overstepped
its authority by encroaching on
individual parental rights in the
name of promoting public
health, with some arguing that

mandatory vaccinations also vi-
olate the Nuremburg Code.76
We disagree with both of these
claims. Regarding the former, it is
precisely the business of state
actors to make these decisions,
and the acceptability of such
decisions will be adjudicated at
the ballot box. Regarding the
latter, we fail to see how a
6-decade-old statement crafted
after a military tribunal for
unethical human experiments
applies to the present case.
Given the reality of limited
clinical encounter time and the
challenges of tailoring large-scale
public health media campaigns,
it might make sense to illustrate
concepts through other means of
information transmission. For
example, parents of pediatric
patients could be directed to
online video narratives of in-
dividuals describing their expe-
riences with vaccine-preventable
illnesses, or to decision-support
instruments and educational
Web sites that can present in-
formation that is targeted or,
ideally, tailored to parents’ spe-
cific concerns. Researchers are
developing and refining such

tools.77,78 The timing of in-
formation provision could also
be fine-tuned, adding prenatal
visits as an opportunity for fam-
ilies and providers to discuss
childhood immunizations as well
as to identify opportunities and
resources for vaccine education
well before an infant’s first
vaccines.
Striking a balance between
respecting parental rights and
autonomy and maximizing the
greater good of herd immunity
may seem an intractable problem,
especially in the current climate
of heated vaccine debates. It
undoubtedly calls for a multifac-
eted set of interventions; how-
ever, deliberate efforts must be
made now. The alternative—
permitting opinions and attitudes
alone (which may be based on
erroneous information or mis-
perceptions) to support behavior
—is as great a threat to public
health as the unvaccinated pop-
ulation itself. Although this most
recent measles outbreak has
largely subsided, it is likely that
another, potentially worse out-
break will occur. Developing
sound policy now will help to
reduce the severity of or alto-
gether stop future outbreaks.

Thus, as media attention to this
subject waxes and wanes, we
implore readers to keep the topic
of vaccine policy and ethics at the
forefront.
CONTRIBUTORS
K. S. Hendrix contributed to the essay’s
ideas and drafted, made revisions to, and
submitted the manuscript. L. A. Sturm,
G. D. Zimet, and E. M. Meslin contrib-
uted to the essay’s ideas and made revisions
to the article.
ACKNOWLEDGMENTS
K. S. Hendrix is supported by National
Institutes of Health (NIH) grant
K01AI110525 and E. M. Meslin is sup-
ported by NIH grants UL1TR001108 and
2R25TW006070-05.
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POLICY MAKING TO BUILD RELATIONSHIPS: A
GROUNDED THEORY ANALYSIS OF
INTERVIEWS AND DOCUMENTS RELATING TO
H1N1, EBOLA, AND THE U.S. PUBLIC HEALTH
PREPAREDNESS NETWORK
NATHAN MYERS

Indiana State University
ABSTRACT
In the last five years, the American public health emergency
preparedness and response system has been tested by two
significant
threats, H1N1 and Ebola. While neither proved as dangerous as
initially
feared, these viruses highlighted on-going issues with
collaborations in
the field of public health and health care. Strengths were
identified
within the network, but also challenges that must be resolved
before the
U.S. faces a major pandemic. Employing interview data from
public
health emergency response practitioners and documentary
evidence
from the H1N1 and Ebola responses, this qualitative analysis
uses the
grounded theory approach to identify key areas for collaborative
improvement. The grounded theory developed calls for a
stronger
policy framework at the federal level to facilitate more
collaboration
between U.S. agencies and facilitate more collaboration at the
state and
local level.
INTRODUCTION

Between 2009 and 2015, the American public
health and health care systems have seen the emergence of
two potentially serious challenges, H1N1 influenza and the
Ebola virus. The response to these two different but serious
health threats highlighted the importance of collaboration
and coordination between different levels of government in
the U.S., as well as between government and partners in the
private and non-profit sector. However, the responses also
demonstrated that these collaborations will need to be
314 JHHSA WINTER 2016
strengthened in preparation for a more virulent and
widespread emergency. This grounded theory qualitative
study examines data derived from interviews, government
and non-profit organization reports, news accounts,
budgetary requests, congressional testimony, and policy
documents to examine strengths and challenges in the area
of public health emergency preparedness and response and
identify key areas for improvement. This is an important
field of inquiry as many public health and medical experts
believe that the U.S. will eventually have to confront a
pandemic of significant magnitude (see Morens,
Taubenberger, and Fauci, 2013).
This study will begin with a review of the literature
regarding collaboration, in particular collaboration in
public health emergency preparedness. This will be
followed by a description of the data collection process,
which involved interviews and documentar y research. The
process of grounded theory qualitative analysis will then be
described, including the open coding of information,
formation of core categories, and development of grounded
theory. Finally, the core categories and grounded theory

will be discussed in light of the existing literature to discuss
how the findings bolster existing knowledge and suggest
new approaches to building more collaborative capacity.
LITERATURE REVIEW
Collaboration between levels of government and
between government agencies and other public, non-profit,
and/or private entities has been a subject of extensive study
in the public administration and public health literature.
Agranoff and McGuire (2003, 4) define collaborative
management as “the process of facilitating and operating in
multi-organizational arrangements to solve problems that
cannot be solved, or solved easily, by single organizations”
(as cited in Kiefer and Montjoy, 2006). Thomson and Perry
JHHSA WINTER 2016 315
(2006) write that collaboration “occurs as organizations
interact formally and informally through repetitive
sequences of negotiation, development of commitments,
and execution of commitments” (p. 21). Bryson, Crosby,
and Stone (2006) suggest that collaboration can be viewed
as an acceptance that we live in a world where power must
be shared and that any single government or organization
will only enjoy so much success acting alone.
Logsdon (1991) writes that collaboration emerges
from recognized self-interest and acknowledged
interdependence. The failure of one sector (public, private,
or non-profit) to successfully solve a problem is viewed as
a necessary precondition for the creation of a collaboration.

In fact, the goal of a collaborative organization shoul d be to
create a public value which cannot be provided by one
sector (Moore, 1995, as cited by Bryson, Crosby, and
Stone, 2006). The public health emergency response
literature offers many examples of collaboration to improve
capacity. Rosselli et al. (2010) investigated the North
Carolina Division of Public Health partnering with the
North Carolina Center for Public Health Preparedness to
assist 85 local health departments in developing pandemic
influenza plans. One outcome of this was many of the local
health departments creating new multi-agency planning
groups to develop a structured process for response
planning, as well as creating connections with local
agencies, such as social service organizations, to assist
vulnerable populations.
Beitsch et al. (2006) found that many state
preparedness programs adopted a regional structure that
encompassed many local agencies and aligned with
existing public health, homeland security, and emergency
management regions. More work needs to be done to
encourage collaboration between public health agencies
and health care systems in regard to emergency
preparedness (Markiewicz et al., 2012). Lurie et al. (2013)
proposed employing a diversity of research networks to
conduct research during an emergency in order to develop
new knowledge with which to improve practice. Such
networks would be overseen by a scientific research
incident commander to coordinate the work. Gebbie, et al.
(2008) proposed more collaboration between practitioners
and academics to further understanding of public health

legal competencies, as well as including the competencies
in law enforcement and judicial training programs and
creating communities of practice, both vertically and
horizontally, to develop specific practices for specific
communities and events.
Gray (1996) found that one factor which frequently
generates conflict within collaborative organizations is
control over resources and, on the other hand, a number of
scholars have cited resource availability as a key factor in
collaboration success (Provan and Milward, 1995; Rainey
and Busson, 2001, as cited in Kiefer and Montjoy, 2006).
Research has shown that local health departments support
cooperative agreements because they benefit in terms of
workforce (Beitsch et al., 2006). Personnel are a key
resource to any successful response, making it important
for a collaborative effort to manage risk to and provide
protections for personnel involved in the effort (Scanlon,
2004; Upshur et al, 2007 as cited in French and Raymond,
2009). While the willingness to respond to a pandemic
emergency regardless of severity among public health
employees is variable (9-27%), it is theorized that a worker
who sees a threat as legitimate and believes they are well
equipped to address it will give high priority to recovery
efforts (Barnett et al., 2012). The literature highlights the
importance of providing training and exercise opportunities
to public health personnel (Khan et al., 2015), as well as
providing support early on for the immediate families of
first responders so that they do not feel as if they are
choosing between their families and the larger population
(Barrett and Brown, 2008). Personnel can be vital in

building bridges and improving communication between
different institutions, as North Carolina demonstrated with
their program to place public health epidemiologists into
hospitals (Markiewicz et al., 2012). Even as the federal
government seeks to recruit more specialized personnel to
conduct research during an emergency (Lurie et al., 2013),
46,000 state and local public health positions have been cut
since 2008, presenting 21% of the public health workforce
(Walsh et al., 2015).
Direct funding and financial incentive programs
have long been used as carrots to promote collaborative
partnerships in emergency management (Waugh, 2002, as
cited in Waugh and Streib, 2006), and were valuable assets
in the response to H1N1. Funding has been identified as a
strong motivator for participation in emergency planning
and response activities (Harris and Mueller, 2013). Loss of
funding at the local level and the accompanying job losses
have led to diminished performance in areas like
surveillance, investigation, and legal preparedness (Davis,
Bevc, and Schenk, 2014). Previous research suggests that
scenario-based federal funding affects willingness to
respond among local public health personnel. In one study,
personnel expressed more willingness and efficacy to
respond to bioterrorism or influenza than a radiological
attack, possibly because more funding is available to train
for such incidents (Barnett et al., 2012). A Congressional
Research Service report indicated that hospital
preparedness funding has decreased from $940 million in
Fiscal Year 2002 to $663 million in Fiscal Year 2014
(Lister, 2014). Even when funds are made available,
allocation of those funds may prove difficult. Yeager,
Hurst, and Menachemi (2015), in a study of allocation of
PHER funding during H1N1, found that purchasing barriers
and other administrative barriers such as fund transfer
issues hindered the allocation of H1N1 funds.

Coordination of resources, whether of personnel,
funding, or items such as medical countermeasures,
requires coordination of policy. Courtney, Sherman, and
Penn (2013) noted the value of policy tools such as new
drug applications and emergency use authorizations in
place prior to an emergency to speed the development and
use of new medical countermeasures during a response.
They further point to the potential usefulness of other pre-
event policies, such as emergency guidance and allowing
certain products to be held beyond the due date. At the state
level, public health emergency declarations can be valuable
in providing greater flexibility and guidance to responders.
However, to be effective it must be clear as to who has the
authority to issue the declaration and the public health law
infrastructure must be functional.
Public health preparedness capabilities associated
with Public Health Emergency Response (PHER) grant
funding is another policy area that may benefit from
improved coordination. Griffith, Carpender, Artzberger
Crouch, & Quiram (2014) found that health service regions
in the State of Texas needed additional tools to link
mitigation strategies to grant capabilities. In their study,
Jacobson, Wasserman, Botoseneanu, and Wu (2012) found
that state and local officials were concerned by the lack of
coordination among federal preparedness programs which
tended to lead to ambiguous and possibly conflicting
guidance. States have shown some success aligning
emergency preparedness regions with regions associated
with homeland security, trauma and emergency
management to improve communication. Improvements in

integration and communication have also be seen in
aligning Centers for Disease Control and Prevention (CDC)
and Health Resources and Services Administration (HRSA)
grants (Beitsch et al., 2006). Some have advanced the idea
of linking preparedness with public health accreditation as
a way of promoting capacity (Kun et al. 2014).
Another issue that can complicate an effective
public health emergency response is lack of a clear
understanding of the law governing the response. In
interviews, Jacobson, Wasserman, Botoseneanu, and Wu
(2012) found that most practitioners relied on their own
understanding of the law, rather than consulting an
objective reference. Bernstein (2013) outlined the four core
elements of public health legal preparedness: laws and legal
authorities, competency in using the law wisely,
coordination of legally-based interventions across
jurisdictions, and information on public health laws and
best practices. Gebbie et al. (2008) recommended
incorporating public health legal competencies into the
curricula of health provider and legal professional
education programs.
Ospina and Saz-Carranza (2010) emphasized the
importance of having unity of mission in collaborations
without sacrificing the diverse perspectives, knowledge,
and tools which the different organizations can contribute.
The literature on collaborative governance suggests that
successful leadership of such organizations requires skill as
a boundary spanner (Thompson, 1967), which involves
managing the use of information and resources across
organizational boundaries. The importance of effective

communication and information management is evident in
the public health emergency preparedness and response
literature. Gibson, Theadore, and Jellison (2012) noted the
importance of a comprehensive framework for responding
to pandemic influenza, which should include daily
meetings to share information and consult on planning and
the management of resources. Surveillance information like
emergency department use and lab results also need to be
appropriately disseminated, while trends in the general
population are monitored. Public information efforts need
to be implemented to educate the public about risks and
alert emergency personnel to changes in recommendations
for treatment (Gibson, Theadore, and Jellison, 2012).
Kun et al. (2014) highlights the importance of
having a clear messaging strategy and engaging
communities meaningfully through training, exercises, and
planning for recovery. Due to budget cuts and job losses,
local health department capacity for surveillance and
investigation has diminished (Davis, Bevc, and Schenk,
2014). Markiewicz, et al. (2012) found evidence to suggest
improvement in communication between public health
agencies and hospitals created by placing public health
epidemiologists in the hospitals.
In a study of literature regarding communication
with the public during H1N1, Lin, Saviola, Agboola, and
Kasiomayajula (2014) found that adoption of infection
prevention practices was affected by factors that included
the public’s trust in the source of information and
individuals’ information-seeking behaviors. They

recommended targeting information at the young, less
educated, and the indigent as they are likely to lack
awareness. Non-traditional communication channels should
be used to reach out to these groups, and officials should be
conscious of the literacy level of messages. They also
called upon the media to provide a consistent flow of
information to counter misinformation (Lin, Saviola,
Agboola, and Kasiomayajula, 2014). Communication and
education were among the cross-cutting themes Khan et al.
(2015) noted in the PHER literature, along with
surveillance and public health information. Issues like trust
and message preference have been explored, but more
research needs to be done in regard to emerging
technologies (Khan et al. 2015). French (2011) suggested
that engagement and transparency on the part of public
health officials toward the public is helpful for assuring
citizens that government’s decisions during a pandemic
response were made out of ethical concern for individual
rights and public safety. In his view, transparency and
engagement would facilitate better understanding and
implementation of response measures.
The literature lays out a number of factors that can
strengthen or challenge a collaborative public health
emergency response. The remainder of the study will be
spent qualitatively analyzing evidence from practitioner
interviews and documentary evidence from the H1N1 and
Ebola responses to develop a grounded theory regarding
public health emergency response to support and expand
the existing knowledge.

DATA
The qualitative data for this project is drawn from a
combination of interviews with professionals in the State of
Indiana actively involved in public health emergency
response and a range of documentary evidence regarding
the responses to H1N1 and Ebola in the U.S. Six interviews
involving seven public health preparedness professionals
were conducted by phone between January 30, 2014 and
July 10, 2014. The interview participants included three
employees of Indiana hospitals, an employee of a local
public health department, a county emergency manager, a
former leader of a hospital preparedness coalition and
hospital executive, and a business manager for a hospital
preparedness coalition. Documentary evidence was drawn
from H1N1 after-action reports from state, local, tribal, or
national public health organizations. These reports were
either obtained through on-line searches or by contacting
the organization and obtaining it directly. The reports
represent a mix of public health perspectives from different
levels of government, as a well as a geographic mix within
the U.S. Other evidence associated with the H1N1 response
and included with the data was the National Response
Framework, which was used as a governing document for
the H1N1 response, the Fiscal Year 2011 budget request for
the CDC which was made in the wake of the H1N1
response, and Secretary Kathleen Sebelius’ testimony
before the U.S. Senate Committee on Homeland Security
and Government Affairs regarding the federal response to
the virus.

Evidence regarding the U.S. response to the Ebola
virus included contemporaneous news accounts of the
federal, state, and local responses to the infections in the
U.S. in The McClatchy Tribune, The Washington Post, and
The Los Angeles Times. Articles were located using the
Lexis-Nexis Academic database and searching for news
articles including the key terms “CDC,” “Ebola,” and
“Dallas” to identify articles focusing on the response to
Ebola in the U.S. Of the newspapers identified, The
Washington Post (58 articles collected) and The Los
Angeles Times (47 articles collected) were chosen based on
their level of coverage of the event, the national scope of
their coverage, and their different geographic orientation.
The McClatchy Tribune was selected as a national
publication that offered significant focus on response at the
local level.
Other documentary evidence associated with the
Ebola response in the U.S. was eight CDC Mortality and
Morbidity Weekly Reports addressing the U.S. response to
Ebola in its borders, the Fiscal Year 2016 CDC budget
request made in the wake of the federal Ebola response,
and the testimony of HHS Secretary Sylvia Matthews
Burwell to the U.S. Senate Committee on Appropriations
regarding the national response. In addition to documents
pertaining especially to H1N1 and Ebola, summaries of the
Pandemic All-Hazards Preparedness Act of 2006 and 2013
were reviewed as well. The data sources are summarized in
Table 1.
Table 1
Summary of Qualitative Data Sources

Primary Data Sources
Interviews with Indiana Public Health Preparedness Personnel
Hospital Preparedness Representative (January 30, 2014), Local
Public
Health Representative (March 4, 2014), Former Hospital
Preparedness
Representative and Hospital Executive (June 3, 2014),
Two Hospital Employees Involved with Emergency
Preparedness (June
4, 2014),
County Emergency Management Agency Director (June 20,
2014),
Hospital Preparedness Coalition Business Manager (July 10,
2014)
Federal, State, Local and Tribal Government After-Action
Reports
Association of State and Territorial Health Officials (June
2010)
Billings Area Health Services Area (Montana/Wyoming)
(November
2010)
Coalition for Local Public Health (Massachusetts) (October,
2010)
Florida Department of Health (July 30, 2010)
Iowa Department of Public Health (No Date Provided)
New Hampshire Dept. of Health and Human Services and Dept.
of
Safety (July 31, 2010)
Northern Illinois Public Health Consortium (Winter 2011)
Oregon Department of Human Services: Public Health Division
(No
Date Provided)

Seattle and King County Public Health (August 1, 2010)
U.S. Department of Health and Human Services (June 15, 2012)
Texas Department of State Health Services (August 30, 2010)
Addition Data Sources
CDC Federal Budget Requests for FY2011 and FY2016
CDC Morbidity and Mortality Weekly Reports: October 17,
2014;
November 21, 2014; December 12, 2014; January 30, 2015;
February
13, 2015; March 6, 2015; April 3, 2015; April 10, 2015
Library of Congress Summaries of the Pandemic and All
Hazards
Preparedness Act of 2006 and 2013
The National Response Framework for 2009-H1N1 Influenza
Preparedness and Response
Table 1, continued
Newspaper Articles Covering the U.S. Ebola Response
Retrieved from Lexis-Nexis Academic from the following
publication:
McClatchy Tribune, Washington Post, Los Angeles Times
Testimony of Health and Human Services Secretary Kathleen
Sebelius
before the Senate Committee on Homeland Security and
Government
Affairs, Oct. 21, 2009
Testimony of Health and Human Services Secretary Sylvia M.
Burwell
before the Senate Committee on Appropriations, Nov. 12, 2014

This interview data and documentary evidence was
selected in an attempt to gather a full range of perspectives
on public health emergency preparedness and the variety of
aspects involved. An attempt was also made to find an
appropriate balance between evidence regarding the H1N1
and Ebola responses. Reviewing documents like the
National Response Framework and the federal legislation
helped to provide a wider view of how pandemic
preparedness is approached at the national level. Finally, an
attempt was made to reach a point of theoretical saturation
of data (Saumure and Given, 2008, as cited in Marshall and
Rossman, 2016) through the use of multiple data sources.
In the next section, the methods involved will be reviewed.
METHODS
Interviews were conducted by phone using a semi-
structured interviewing technique wherein a particular set
of predetermined questions were used, but the interview
allowed for follow-up or clarification questions. Semi-
structured interviewing approaches employ “pre-
determined questions, improvised improvisational probes,
and responsible follow-up questions” (Luton 2010, p. 23).
Questions are not treated as a “binding contract” (Glesne
2006, p. 79). Interview questions are the tools used to gain
information with which to answer research questions.
Questions should be derived from theory (Glesne 2006). In

this case, questions came from the public administration
and public health literature on collaboration.
The interview process was in keeping with Marshall
and Rossman’s (2006) perspective on qualitative in-depth
interviews, in that they introduced topics that allowed the
participants the freedom to structure their own response and
convey the value of the participants’ points of view.
However, it is also important to be mindful of Luton’s
(2010) admonition that an interviewer must exert control in
an interview situation to gain greater understanding of the
problem under discussion. Also as suggested by Luton, an
interview guide was employed for this purpose. It is
important to keep in mind that the researcher is not just
pursuing knowledge, but understanding as well (Luton
2010, p. 22).
There are, of course, strengths associated with the
in-depth interviewing approach (collecting a large amounts
of data efficiently) as well as weaknesses (participants may
feel uncomfortable sharing information or may lack a
certain degree of awareness). The primary purpose of the
research was to solicit the participants’ subjective views on
the issues, although where possible the primary researcher
attempted to confirm facts using publicly available
documents. This research may also be seen as falling under
the category of elite interviewing, as all participants were
selected based on their depth of experience with the subject
matter (Marshall and Rossman, 2006). Interview
participants should be selected based on their depth of
knowledge and willingness to share knowledge, and the
interview process should be approached as a partnership
(Luton, 2010).
This research utilized the grounded theory approach
as described by Glaser and Strauss (1967) and summarized

in Figure 1.
Figure 1
Stages in Grounded Theory Research
Stage 1: Identify a topic of interest and select the grounded
theory research approach
Stage 2: Determine purpose(s) for the research
Stage 3: Select a group or sample to study
Stage 4: Collect data
Stage 5: Open (preliminary) coding of data as it is collected
Stage 6: Theoretical coding for theory development
Stage 7: Develop theory
(McNabb 2008)
After the transcription was complete, the primary
investigator used open coding of sentences or paragraphs
within the transcripts to identify key concepts emerging
from the data and linking them together under themes.
During the process, the investigator assigns the themes that
emerge from the data to broader categories, called core
categories, which highlight the relationships between the
themes (Lee, 1999). These core categories are then used to
create broader categories in order to facilitate theory
development (Lee, 1999). Table 2 provides the themes that
emerged from open coding of the interview transcripts:

Table 2
Themes Derived from Open Coding of Interview Transcripts
Theme Definition
Collaboration Information relating to public health/health care
agencies working with public, non-profit, or
private entities on preparedness/response
activities
Resources Information relating to funding, material, or
personnel used or needed for
preparedness/response activities
Communication Information relating to efforts to convey
information to preparedness/response partners or
to the public
Logistics Information related to performance of actions
during a public health response, such as
delivering vaccine or sharing protective
equipment
Involvement of
First Responders
Information related to the involvement of first
responder agencies, such as police and fire
departments, in public health preparedness and
response activities
Internal
Management

Information related to the governance of
organizations or groups of organizations
involved in public health preparedness and
response collaboration
The next step in the process involved open coding
of the H1N1 after-action reports from the state, local, and
tribal health departments. Sentences were again the unit of
measurement, although complete paragraphs were coded if
the entire paragraph was addressing the same subject
matter. The open coding of those documents produced the
themes in Table 3, some of which coincided with themes
from the interviews:
Table 3
Themes Derived from Open Coding of H1N1 After-Action
Reports
Theme Definition
Logistics* Information related to performance of actions during
a public health response, such as delivering vaccine
or transporting and disposing of medical waste
Collaboration* Information relating to public health/health care
agencies forming groups with public, non-profit, or
private entities for preparedness/response activities

Coordination Information relating to public health/health care
agencies working together to accomplish different
actions related to public health preparedness and
response.
Communication* Information relating to efforts to convey
guidance to
preparedness/response partners or educational
information to the public
Information
Management
Information related to the sharing of key data
between response partners, including
biosurveillance data and data regarding the
distribution of vaccine
Resources General references to material needed for public
health preparedness and response
Funding More specific references to money necessary for
public health preparedness and response
Personnel More specific references to huma n resources
necessary for public health preparedness and
response
Policy Information related to government directives and
guidance for public health preparedness and
response
Relationship
Building

Information related to actions undertaken in order to
strengthen connections between collaborative
organizations prior to a public health response
Planning Information related to planning activities prior to a
public health response
Preparedness Information related to preparedness activities
prior
to a public health response, such as exercises or
testing equipment
*=Those themes with asterisks also emerged from open coding
of the interview transcripts
After completion of the open coding of both sets of
data, segments from the documents associated with the
codes were separated out and put into their own document.
This document was then loaded into the qualitative analysis
program QDA Miner, Version 3, developed by Provalis
Research. The codes associated with the open coding for
both sets of data were entered into the project and
organized into the following themes:
Table 4
Open Codes Organized by Themes
Implementation
Logistics
Resources
Resources-Personnel

Resources-Funding
Network
Collaboration
Coordination
Relationship Building
Involvement of First
Responders
Intelligence
Communication
Information Management
Governance
Policy
Planning
Preparedness
The appropriate codes were then applied to the
interview transcript segments and the segments from the
after-action reports in QDA Miner. It should be noted that
multiple codes could be applied to multiple sentences
within the data. After this work was completed, the
additional qualitative documents were loaded into QDA
Miner and coded with the same coding scheme.
The coded data was then analyzed in the following
two ways. First, all coded segments related to the Network
theme were retrieved and then manually organized
according to whether and how they related to the other
codes, in this case ignoring the coding for the other themes
in QDA Miner. The researcher then went through all of the

coded segments for the Network theme associated with
other codes and summarized them in a brief sentence or
phrase to highlight the key information within the segment.
These summaries were then reviewed and combined
together as appropriate to determine core categories. Table
5 provides the core categories associated with that process.
Table 5
Core Categories Derived from Manually Sorting Network
Codes by Association with Other Codes
Logistics
Working with private organizations on the distribution of
medications
and PPE
Working with charitable organizations to meet the humanitarian
needs
of those in isolation/quarantine
Better coordination is needed for vaccine distribution
Issues regarding the disposal of medical waste need to be
resolved.
Schools have strong potential for vaccination centers, but
logistical
issues still need to be resolved.
Discussion of attempts to create a coordinated network to deal
with
patients and prospective patients
Communications
Need for communication with vulnerable/at-risk populations
Need for improved coordination of federal agencies/department s
Improvements needed in the flow of information to and from the

CDC.
There is a need for individuals with specialized communication
expertise.
Communication networks must be inclusive.
Public-private partnerships are valuable to craft effective
messaging
and to disseminate it.
Relationships are valuable to better disseminate
communications, but
relationship building can be restricted by a lack of resources.
Table 5, continued
Information Management
Disease surveillance and monitoring is improved through
collaboration.
Collaboration is valuable to track adverse reactions to vaccines.
Federal government has instituted a number of efforts to
promote
information sharing.
Efforts made to promote better state and local government
communication, but more needs to be done in the area of
relationship
building.
Resources
Collaboration borne of limited resources.
Resources-Funding
Positive changes stemming from grant requirements in regard
to
participation/collaboration
Difficulties stemming from grant requirements in regard to
participation/collaboration

There is a recognized need to better align/coordinate grant
requirements
Grant funding is important to incentivizing collaboration, and
the
absence of grant funding may lead to the loss of collaborations.
Resources-Personnel
Inadequate supplies and shifting standards regarding
personalized
protective equipment create challenges for health care
providers.
Improved coordination is needed to clarify roles during an
emergency,
allow personnel from one organization to be assigned tasks by
another
organization, and to communicate protocols and procedures to
personnel.
Innovation and flexibility is needed to fill gaps in personnel
resources.
Policy
CDC has an important role in making and promoting policy that
governs the U.S. public health infrastructure, but the changing
nature of
guidance from the organization can create disruptions.
Federal agencies/departments regularly collaborate on the
formation of
policy in a public health emergency.
States grant and/or share power in regard to the making of
policy
regarding issues such as quarantine/isolation.
Numerous issues can create policy conflicts in the national
public
health system, including political division, shifting and/or
incompatible
policy, lack of coordination, fear, confusion, and
legal/scientific
pressures.

Table 5, continued
Legislation and regulations include provisions to
require/encourage
collaboration (i.e. designation of Ebola treatment centers).
Legislation and regulation can also include barriers to
collaboration
(i.e. lack of a clear state strategy inhibiting a regional
response).
Departments, agencies and different levels of government
coordinate
policy making in preparation for or during an emergency (i.e.
coordination regarding an emergency use authorization for
antiviral
drugs during an emergency).
Planning
Planning must incorporate a diverse range of partners, including
all
sectors that could be affected or may prove useful.
Relationship building is important for effective public health
preparedness response, and planning has been found to be an
effective
tool for relationship building.
Preparedness
Regular drills are important to test readiness, hone skills, and
keep lines
of communication and relationships active.
Collaboration must span across all areas of health care, public
health,
and emergency management (i.e. hospital systems, emergency
management, and mental health agencies).

Important that hospitals and public health work with national
professional and charitable organizations to build capacity and
make
sure that when an event occurs the needs of those infected are
met.
Next, the researcher used the QDA Miner program
to find co-occurrences for all of the Network codes and the
codes associated with the other themes: Implementation,
Governance, and Intelligence. Coded segments were
summarized in brief sentences or phrases to capture the key
information within the segment. These summaries were
then combined as appropriate, with the process producing
the core categories presented in Table 6.
Table 6
Core Categories Derived from Co-Occurrences between
Network Themes and Other Themes Found Using QDA Miner
Network/Governance
Aligning grant standards with other professional standards has
value.
CDC guidelines/information insufficient or frequently changing
Difficulties with disposing of medical waste created by unclear
or
conflicting policies
Power and enforcement delegated from one level of government
to
another
Uncertainty among health care workers regarding safety due to

changing policy/protocols
Public health response helped by work done to address previous
emergencies
Policies can be put in place in advance to respond to an
emergency (i.e.
emergency use authorizations, or EUA’s).
Network/Implementation
Federal funding of demonstration projects regarding
communication
and logistics has led to improvements.
Tabletop exercises are used to gauge preparedness in
information
management/logistics.
Network/Intelligence
Importance of a national biosurveillance network to improve
situational
awareness
Elements of an effective information campaign: coordinated,
relevant,
modulated, appropriate, fluid, addresses non-English speakers
Some types of communication ineffective, some types of
communication not used effectively enough
National organizations acted as partners in communication.
Need to be inclusive in what health entities are involved in
education,
training, communication, and surveillance
The two sets of core categories were then compared
and combined into a final, integrated set of core categories
presented in Table 7:

Table 7
Condensed and Integrated List of Core Categories
Network/Governance
CDC has an important role in making and promoting policy that
governs the U.S. public health infrastructure, but the changing
nature of
guidance from the organization can create disruptions. CDC
guidelines/information were insufficient or frequently changing.
Difficulties with disposing of medical waste were created by
unclear or
conflicting policies. Issues regarding the disposal of medical
waste
need to be resolved.
Power and enforcement is delegated from one level of
government to
another. States grant and/or share power in regard to the making
of
policy regarding issues such as quarantine/isolation.
Uncertainty among health care workers regarding safety due to
changing policy/protocols.
Departments, agencies, and different levels of government
coordinate
policy making in preparation for or during an emergency (i.e.
coordination regarding an emergency use authorization for
antiviral
drugs during an emergency).
Planning must incorporate a diverse range of partners,
including all
sectors that could be affected or may prove useful.
Network/Intelligence
Regular drills are important to test readiness, hone skills, and
keep lines
of communication and relationships active. Tabletop exercises

are used
to gauge preparedness in information management/logistics.
Disease surveillance and monitoring is improved through
collaboration/Importance of a national biosurveillance network
to
improve situational awareness must be considered.
Elements of an effective information campaign include
coordinated,
relevant, modulated, appropriate, fluid, and addresses non-
English
speakers. There is need for stronger communication with
vulnerable/at-
risk populations.
There is a need for individuals with specialized communication
expertise. Some types of communication are ineffective, some
types of
communication are not used effectively enough.
Table 7, continued
National organizations acted as partners in communication.
Communication networks must be inconclusive.
Organizations need to be inclusive in what health entities are
involved
in education, training, communication, and surveillance.
Network/Implementation
There is a recognized need to better align/coordinate grant
requirements/aligning grant standards with other professional
standards.
Inadequate supplies and shifting standards regarding
personalized

protective equipment create challenges for health care
providers.
Important that hospitals and public health agencies work with
national
professional and charitable organizations to build capacity and
make
sure that when an event occurs the needs of those infected are
met.
After careful consideration and prioritization of the
combined set of core categories, the following theoretical codes
are proposed:
• Public health planning and preparedness policy at all
levels of government needs to be revised and
strengthened to do away with policy barriers that impede
planning and action.
• The building and maintenance of relationships at the
federal, state, local, and tribal levels is essential to
effective public health planning and response.
Based on these theoretical codes, the following grounded theory
is proposed:
Public health planning and preparedness policy needs to be
revised and strengthened, particularly at the federal level,
to provide resources and break down barriers, thus
facilitating essential relationship building and maintenance
at the federal, state, local, and tribal levels.

DISCUSSION
The federal government must work to create a stronger
policy infrastructure to allow states and localities to
respond to different and changing public health
emergencies. This includes further coordinating grant
requirements to allow hospitals and public health
organizations to more easily work with other emergency
responders on planning and preparedness. One interview
participant commented:
Getting all of these grants coordinated has been
very difficult in some cases because you have the
hospitals, who are getting their grant money from
ASPR (Assistant Secretary for Preparedness and
Response), which is HHS (U.S. Department of
Health and Human Services), you have the public
health department that is getting their emergency
planning funding through CDC, and then you have
the homeland security side getting their funding
through federal homeland security. I sometimes
wonder if these three groups ever talk to each
other. It's getting better now, but it's taken quite a
while (Interview, June 3, 2014).
This supports the findings of Jacobson, Wasserman,
Botoseneanu, and Wu (2012) that state and local officials

want more coordination among federal programs which
will hopefully produce clearer guidance. Some evidence of
this can be found in the alignment of CDC and HRSA
grants. Previous research has found that alignment of
regions associated with different types of preparedness has
yielded positive results (Beitsch, et al., 2006).
Improved coordination is also needed in regard to
anticipatory public policy, like the CDC and the U.S. Food
and Drug Administration’s collaboration on the issuance of
EUA’s. The value of this was discussed in the U.S. Health
and Human Services Department retrospective on H1N1:
Because FDA and CDC had been working
together over the preceding three years on two test
approvals, CDC was able to rapidly provide the
needed data on test performance to allow FDA to
grant an Emergency Use Authorization (EUA).
This authorization allowed CDC to distribute 2009
H1N1 reagents to state public health laboratories.
Without this authorization, states would have had
to order their own reagents and independently
validate their own assays for detection of the novel
influenza strain. Because of this preparation and
the strong partnership between CDC, FDA,
industry, and state laboratories, CDC was able to
prepare and ship 372 kits to qualified laboratories
under the EUA within one week and to all
laboratories within two weeks of the initial
detection of 2009 H1N1 influenza virus in
Southern California (HHS Retrospective, 2012).

Courtney, Sherman, and Penn (2013) noted the value
of emergency use authorizations and new drug applications
for increasing the speed with which countermeasures can
be produced. These kinds of pre-event policies can also be
useful in providing better flexibility and guidance to public
health response personnel (Rutknow, 2014).
Another area in which national and interstate policy
conflicts need to be resolved are logistical issues like the
transportation of infected medical waste.
Dealing with this collection of pathogen-filled
debris without triggering new infections is a legal
and logistical challenge for every U.S. hospital
now preparing for a potential visit by the virus. In
California and other states, it is an even worse
waste-management nightmare. Though the U.S.
Centers for Disease Control and Prevention
recommend autoclaving (a form of sterilizing) or
incinerating the waste as a surefire means of
destroying the microbes, burning infected waste is
effectively prohibited in California and banned in
at least seven other states (Morin, 2014, Oct. 20).
The need to resolve these policy conflicts is
highlighted by Jacobson, Wasserman, Botoseneanu, and
Wu’s (2012) finding that practitioners tend to rely on their
understanding of the law as opposed to the letter of the law.

Practitioners and attorneys may better understand how to
act in such situations if legal references were more widely
available (Bernstein, 2013) and public health legal
competencies were incorporated into public health and
legal professional education programs (Gebbie et al., 2008).
In addition, improved lines of communication need
to be cultivated and maintained between the federal
government and national organizations representing public
health and health provider interests in order to be more
transparent in communicating changing thinking and
science regarding issues such as personal protective
equipment. The U.S. government should also use these
channels to solicit feedback on such guidance before it is
issued. This type of communication was helpful to
hospitals during the Ebola response.
Dameron Hospital's "pandemic response team"
has met daily since Ebola arrived and is in close
contact with state, federal and local health
agencies, Chief Operating Officer Michael
Glasberg said. That includes working with the
American Hospital Association to learn lessons
from Dallas, where the virus first appeared in the
United States (Johnson, 2014, October 28).
This is keeping with the recommendation of Gebbie et
al.(2008) to create vertical and horizontal communities of
practice to develop specific practices for specific
communities and events.

The federal government, as well as other levels of
government, should make the best use of communications
experts such as public information officers and people with
other unique communications expertise to facilitate better
sharing of information. Some of the H1N1 after-action
reports indicated that public information officers were an
extremely valuable resource at the local level.
Many counties expressed excellent coordination
between their PIO and LHD [local health
department]. There was a strong team effort for
the consistent, relevant information that met local
needs (Oregon Department of Human Services,
2010).
Thompson (1967) noted that the sharing of information
across organization boundaries is important to successful
collaboration. During the response to H1N1 in Marion
County, Indiana, the local health department used public
information resources to educate the public and alert
emergency personnel to changes in treatment
recommendations (Gibson, Theadore, and Jellison, 2012).
One thing the government appears to do exceedingly
well is collect biosurveillance information, but that
information has limited value if it cannot be disseminated
effectively. Regular testing of communication and other
preparedness capabilities is essential, as is the inclusion of
all relevant partners in that network. This was noted in
interviews with preparedness professionals.
What keeps us strong other than having the
devices is that we exercise them every month to

make sure everyone's devices are working
properly and they can communicate. And then we
have little mini-exercises with Live Process where
we'll communicate with each other through that
and make sure that people know how to use it.
Some of the barriers of that communication is that
it takes time. Like with Live Process, we are
learning it, and not everyone has the time or will
take the time to learn it well enough that you can
just sit down and handle your whole dialogue
through that. Everything that you need to do
during a disaster and be able to communicate back
and forth is in Live Process and if someone needs
a document or you need to pull up the document
you need to know how to do that in Live Process
(Interview, June 4, 2014).
The 2010 ASTHO report found that there was a
lack of unified command structure during H1N1, creating
difficulties with coordination and communication. The
report recommended that states and the federal government
use grants and cooperative agreements to build capacity to
employ an incident command system during a public health
emergency (ASTHO, 2010). Communication exercises like
the one discussed above can help to build a coordinated
system, as well as demonstrate and strengthen unity of
mission among response partners (Ospina and Saz-
Carranza, 2010). Full participation is made difficult by
recent state and local public health budget cuts and the
resulting reduction in the workforce (Walsh et al., 2015).

The difficulties this lack of resources can create for
public health emergency preparedness were illustrated in
comments by the local public health department
representative. He noted that while he was aware of one
county employee in Indiana paid for by a line-item in the
county budget, such a situation is very rare in Indiana. He
also pointed out that, in public health, preparedness is
almost always an additional duty, not a primary occupation.
This creates significant challenges for those charged with
preparedness. Some preparedness coordinators in public
health departments budget two to four hours one day a
week to handle preparedness responsibilities, according to
the public health official. Yet these individuals are
expected to accomplish the same work as someone
focusing on preparedness full time. The burdensome nature
of the grant funding process can contribute to the problem
of overworked preparedness coordinators questioning
whether pursuing grant funding is worth the cost
(Interview, March 4, 2014).
In light of funding and resource shortages, the U.S.
government must provide resources to incentivize
relationship building and build up relationships of its own
to communicate the importance of public health planning
and preparedness. A hospital preparedness representative
noted that the district he works in has two to three more
years remaining on the current grant cycle and the district is
confident its funding will continue during that time frame.
In the event the grant is cut entirely or becomes too small to
manage the district, it would gravely affect its ability to

provide planning, resources and education services. While
the hospitals in the district have explored ways to keep the
collaboration sustainable, it lacks true financial capability
outside of the grant. No hospitals he is aware of have a
dedicated budget line-item for preparedness, making most
hospital emergency preparedness efforts 100% dependent
on grant funding. If such funding were no longer available,
some larger hospital preparedness districts may attempt to
continue, but smaller collaborative groups would find it
very difficult (Interview, Jan. 30, 2014). This was
supported by other evidence.
We are federally funded and its [funding]
regulated by the state. So that's our only form of
income. The issue with that is that it's getting cut
every day. Eventually we think it is going to go
away. So the challenge is we're trying to find other
grants, other means of resources so once the
funding goes away we still have resources to
continue our mission.
At our last meeting, that was one of the big issues-
we need to come up with other resources. That is a
big issue. There's upkeep of the whole
organization that really needs funding because we
have emergency trailers and other equipment that
has yearly insurance and things like that
(Interview, July 10, 2014).
Substantial literature supports the value of using

funding programs as a catalyst to the building of
relationships, with the presence of such funds resulting in
the development of pandemic influenza plans and other
emergency planning and response activities (Waugh, 2002,
as cited in Waugh and Streib, 2006; Rosselli et al., 2010;
Harris and Mueller, 2013). Alternatively, the loss of funds
hurt capacity to engage in surveillance, investigation, and
legal preparedness (Harris and Mueller, 2013). In regard to
the importance of collaboration at the federal level, in her
2009 testimony before the Senate Committee on Homeland
Security and Government Affairs, Secretary Sebelius said,
HHS values the collaborative relationships
established with our partners at the Departments
of Homeland Security and Education and has
leveraged these relationships to develop clear and
actionable guidance for schools and businesses. In
close collaboration with the Department of
Education, CDC has released guidance and
information for K-12 schools, as well as
universities and colleges, advising administrators
on the measures that can be taken to mitigate
disease spread in educational settings while
limiting the disruption of day-to-day activities and
the vital learning that goes on in schools and
institutions of higher education (Sebelius, October
29, 2009).
The importance of collaboration between federal

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