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Introduction and Workshop Series Summary
Pages 1-40

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From page 1...
... that explored the public's perception of potential alternative strategies for facilitating access to antiviral medications and treatment advice during an influenza pandemic. Based on its statement of task (Box 1)
From page 2...
... These discussions will help to inform potential strategies still in the development stages at the CDC. The public was asked to consider, if an influenza pandemic were to strike, how the normal systems for prescribing and dispensing antiviral medications could be adjusted to ensure that the public has quick, safe, and equitable access to these potentially lifesaving drugs and to information about the pandemic and treatment options.
From page 3...
... Antivirals, on the other hand, can work against many different strains of influenza. Because antivirals are more effective if taken within 48 hours of symptom presentation, many public health agencies have developed preparedness plans to facilitate the rapid dispensing of antiviral medications to large numbers of people during influenza pandemics.2 However, the feasibility and timeline of these plans remain significant concerns given projections that during a severe pandemic, approximately 30 percent of the population could become ill over a 12- to 18-month period.3 In such circumstances, the normal channels through which antiviral medications are prescribed, dispensed, and distributed could easily become overwhelmed.
From page 4...
... Such pharmacists would work under formal "Collaborative Practice Agreements" with physicians who would provide supervision and consultation. The CDC also is exploring new strategies to communicate clear, accurate information about pandemic influenza and treatment to the public, including  Web-Based Tool: A web site launched during a pandemic for the purpose of helping people sick with flu-like symptoms and their caregivers to decide whether to seek medical care and to advise them when to seek treatment options, including antiviral medications.
From page 5...
... Unique ideas presented at the workshops are not attributed to individual participants, in keeping with the workshop design that intentionally excluded the recording of personally identifiable viewpoints in order to protect participant confidentiality and create an environment in which these topics could be discussed openly. Situations where several participants made similar points at all three community conversation locations are identified as "common themes." Throughout the summary, themes identified at a specific community conversation are followed by the appropriate two-letter state abbreviation of that location in parentheses.
From page 6...
... Planning and Participant Recruitment The IOM was charged with organizing community conversations in three geographically and demographically diverse locations. These sessions were to convene a total of 200 individuals representing a diverse cross-section of the local populations, including people who might need additional assistance in a crisis (e.g., elders, people with disabilities, oth
From page 7...
... The program name used on materials targeted to the general public was In a Flu Pandemic: Getting Life-Saving Medicines to the Public. The IOM and the local                                                              4 The Los Angeles session was intended to draw participants from throughout Los Angeles County.
From page 8...
... Participants were offered $50 stipends as compensation for their time and to help cover any out-of-pocket costs of attending the session. Stipends also likely facilitated the recruitment process by providing a small incentive to attend.6 Agenda and Tools The IOM planning committee developed a set of program materials to run 4-hour sessions at all three venues.7 These materials were designed to provide participants with the background and tools they would need to engage in informed discussions about alternative strategies for facilitating access to antivirals in a flu pandemic.
From page 9...
... Small-Group Scenario Discussions: Two 30-minute scenario discussions, led by table facilitators, at the core of the agenda. Participants were asked to consider specific questions about the acceptability and feasibility of possible alternate strategies for delivering medications under two sets of circumstances, described in the scenarios as:  A severe flu pandemic that has led to long delays to see health care providers who can write prescriptions for antiviral medications.
From page 10...
... Personnel Many individuals played key roles in orchestrating and leading the community conversations. Table facilitators and note takers were provided with background and program materials in advance of the community conversations, including a "Guide for Table Facilitators and Note Takers" and a briefing memorandum with additional subject-matter background and suggested answers to anticipated participant questions about pandemics and antiviral medications.
From page 11...
... , pre- and postsurvey statements related to accessing antiviral medications in a pandemic, and an evaluation of the community conversation. During these ARS surveys, electronic viewpoints were collected automatically and anonymously by means of participants' handheld response devices.
From page 12...
... Chattanooga participants were diverse in age, but had the largest representation of young adults between ages 18 and 24 of the three sessions. Participants' rate of health insurance and level of education were nearly as high as Fort Benton participants, and equivalent numbers (nearly one in five)
From page 13...
... During the introductory table exercise, participants were asked to describe their reasons for attending the community conversation, and their hopes and fears if an influenza pandemic were to strike. Although these questions do not pertain directly to the sessions' main focus on alternative strategies for accessing antiviral medications, the major themes that emerged offer a window into the mindset that these particular participants brought to the community conversations.
From page 14...
... All of the information and ideas compiled below are not generalizable to the broader population, and should not be construed as reflecting consensus or endorsement by participants in the community conversations, the Preparedness Forum, or the IOM. Goals and Values for Prescribing and Dispensing Antiviral Medications At various points throughout the sessions, participants were asked to reflect on which goals and values are most important for policy makers to advance when developing alternative strategies for prescribing and distributing antiviral medications during a pandemic.
From page 15...
... o In preparedness planning and emergency response o Cultural and regional competency The second discussion scenario, described in Box 2, asked participants to consider what goals and values are most important when not only are delivery systems overwhelmed, but the existing supply of antiviral medications cannot meet demand. The common cross-cutting themes that individual participants cited during this second set of conversations included  Equity and fairness o To ensure equitable access by vulnerable populations (e.g., poor, special needs, uninsured)
From page 16...
... 16 FACILITATING ACCESS TO ANTIVIRAL MEDICATIONS AND INFORMATION o To ensure equal access to communications about antiviral treatment  Integrity o Includes compliance with prescribing protocols and priorities o To prevent "gaming" of the system, for example, people calling in could learn what answers would guarantee that they got a prescription regardless of whether they had the flu o To encourage trust and, thus, public acceptance and cooperation o To reduce concerns about favoritism or bias by health care providers  Prioritize allocation of antivirals10 o To groups identified as high risk for complications or death from the flu o To children o To pregnant women o To the elderly o To medical responders o To workers who keep society running o To vulnerable groups or individuals with a special condition or need who are not designated as high risk, but require spe cial consideration  Transparency o Accurate, consistent information sharing by authorities to maintain public trust and prevent panic and unrest Goals and values in a time of scarcity that were important to several participants at one or more locations included  Preparedness (CA, MT) o Stockpile antiviral medications to minimize (or eliminate)
From page 17...
... Nurse Triage Lines Using NTLs as an alternative strategy for increasing access to prescriptions for antivirals during a pandemic received the most extensive focus at the community conversations. Participants were introduced to the concept of NTLs through several statements in the ARS presurvey, and again in the expert slide presentation.
From page 18...
... Advantages and Disadvantages of NTLs Individual participants across all three sessions recognized several advantages of NTLs as a strategy for getting antivirals to the public during a pandemic when doctors' offices, clinics, and hospital emergency departments are overcrowded with both the sick and the worried well seeking prescriptions and other treatment. Although participants were not asked to consider shortages of antivirals initially, some seemed to anticipate those circumstances.
From page 19...
...  The technology required may not function during power outages. Several disadvantages were identified by some participants in at least one location, and included  NTL nurses are not local, so will not "speak their language" or understand local conditions (MT)
From page 20...
...  NTLs should establish a mechanism for assessing callers' elec tronic medical records. Trust in NTL Nurses Many participants expressed strong confidence in the abilities and trustworthiness of specially trained, supervised nurses to prescribe antiviral drugs through an NTL if they could not be seen by their regular health care providers.
From page 21...
... When antivirals are in short supply, individual participants expressed varying levels of confidence in the efficacy and trustworthiness of NTLs and their staff. Participants were asked to consider whether they would trust NTLs to direct antivirals to those individuals who should receive them if there were not enough for everyone.
From page 22...
... Advantages and Disadvantages of Community Contact Pick-Up and Delivery   Many participants at the community conversations had generally positive reactions to the strategy of asking family and community contacts to pick up and deliver antiviral medications for the sick. This strategy's advantages are that it could  be convenient for people sick at home with flu;  help contain the spread of disease by reducing the need for sick people to congregate in public places like pharmacies;  lead community members to check in on the sick; and
From page 23...
... Some participants in Fort Benton, MT, also identified the possibility that inclement weather could interfere significantly with this strategy. Along with this discussion of the strategy's advantages and disadvantages, individual participants contributed a variety of ideas to more effectively implement this strategy, including  In addition to family and friends, pick-up and delivery of pre scribed antivirals could be organized through a network of estab lished community groups and trusted agents.
From page 24...
... Concerns About Visiting a Pharmacy During a Pandemic Individual participants identified several concerns they would have about going to pharmacies to pick up prescriptions for family, neighbors, and others sick at home with flu. A common concern was the potentially increased risk of catching flu because pharmacies might be crowded with sick people.
From page 25...
... To introduce participants to this idea, the ARS presurvey statements prompted them to think about whether this arrangement should be "allowed" and whether they could "trust" pharmacists to fulfill this role. During the small-group scenario discussions that followed, participants were asked to address several questions that pertain directly to the strategy of pharmacists prescribing antivirals under collaborative practice agreement: 1.
From page 26...
... They indicated they would have few reservations about relying on pharmacists to carry out the proposed antiviral prescribing role because they believe local pharmacists are trustworthy and knowledgeable about prescription drugs. Several participants in at least one location also attributed their trust to the following ideas:  Collaborative practice agreements offer adequate supervision of pharmacists (CA)
From page 27...
... . However, also during the small-group scenario discussions, individual participants identified a number of strategies that could be used to overcome the disadvantages mentioned above, improving the effectiveness and efficiency of pharmacist prescribing through collaborative practice agreements.
From page 28...
... The second strategy is a textmessaging tool targeted toward people who have been prescribed antiviral medications. Pandemic Flu Web Site Participant views were solicited about a web site that would offer self-assessment tools and information about prevention and treatment of pandemic flu, specifically:  Would you ever use a web site [designed to help people]
From page 29...
... Some participants in Fort Benton and Los Angeles expressed a preference for such tools, while some participants in Chattanooga believed that forums and blogs were a dangerous source of misinformation and fear-mongering. Nonetheless, despite that potential, individual participants in several small groups were able to identify several categories of information they might find most helpful:  Flu symptoms  Flu treatment options  When to see a health care provider  Information about antiviral medications o Where and how to obtain them o Side effects Other ideas that were described as increasing the effectiveness of a pandemic flu web site included  The web site should provide a user-friendly tool for self assessment (i.e., one that is based on a decision tree)
From page 30...
... Participants were asked to consider "a system that would send text messages to cell phones of people who have been prescribed antiviral drugs -- at their request -- to remind them to take their drugs, to advise them of possible side effects, or to provide other information about their flu treatment." Individual participants who favored this strategy listed the following advantages in favor of it:  Text messaging would be a convenient source of additional information.  Such a service would be particularly popular among younger people.
From page 31...
... The positive response of many participants at each site to the concept of an opt-in text-messaging system is reinforced by the ARS survey responses, in which many participants indicated they would like the option to receive text messages about the flu and the antiviral medications they were prescribed. When Antiviral Medications Are in Short Supply The second scenario added the complicating factor of scarcity: now, participants were told, not only are the normal channels for getting prescriptions for and acquiring antiviral medications congested, but there is not enough antiviral medication for everyone.
From page 32...
... Policies for Allocating Scarce Antiviral Medications Participants discussed whether, if antiviral medications are in short supply, the policy should be to limit distribution to members of groups identified as at high risk for complications or death. Participants also were asked to consider whether they would prefer an alternative allocation scheme such as "first come, first served" or a lottery.
From page 33...
... Some discussion in at least one location considered on other aspects of the issue of how to dispense antiviral medication in an atmosphere of scarcity, citing the idea that:  People in high-risk groups should only receive scarce antivirals if they are likely to benefit (CA, TN)
From page 34...
... Provider Uniformity or Flexibility When Prescribing Scarce Antiviral Medications The final question addressed by participants was whether all health care providers should follow the same rules when deciding who should receive scarce antiviral medications. Individual participants who agreed with this proposition also were asked to consider whether there are some circumstances under which individual health care providers should be allowed to make prescribing decisions that deviate from the rules.
From page 35...
... Suggestions included creating a hotline or other system through which providers and the general public could report noncompliance, and establishing and enforcing sanctions against providers who break the rules. Individual Participants' Ideas for Prescribing and Dispensing Antiviral Medications in a Flu Pandemic At various points throughout the community conversations, participants were encouraged to contribute their own ideas about other strategies for getting antivirals to the public quickly, safely, and fairly.
From page 36...
... Preparedness Planning Numerous participants at each site frequently noted the general need for public education and awareness prior to the onset of a flu pandemic; individual participants in Chattanooga recommended engaging the public in preparedness drills. Several in Los Angeles suggested previewing and
From page 37...
... Additional Participant Comments At each of the community conversations, ideas emerged that either represented overarching themes for that session or were not directly within the scope of inquiry, but are relevant and worthy of acknowledgment nevertheless. In Fort Benton, some participants raised the question of why the Food and Drug Administration or other federal agency could not simply approve the over-the-counter sale of antiviral medications during a flu pandemic as a way of resolving the prescribing bottleneck, considering the drugs to be relatively safe.
From page 38...
... now, there's not a possibility of rushing or overcrowding, and no chance of contamination during delivery." Participant Evaluations Finally, participants were asked to share their perceptions about the quality and value of the public engagement process through a series of ARS statements and a brief written form that provided the chance for them to identify the most valuable parts of the session, whether anything was missing, and add any other comments they might have. Participant ARS responses for all three community conversations reflected several common themes:  The information presented was trustworthy and helped them un derstand the challenges of getting antivirals to the public in a pandemic.
From page 39...
... DISCUSSION Few significant regional differences emerged across the community conversations. Individual participant commentary from all three sessions indicated widespread support for the overarching concept that public health authorities should develop alternative strategies to help people gain access to antiviral medications during an influenza pandemic.
From page 40...
... Finally, the purpose of these community conversations was not to test the general value of public engagement in the development of public health strategies. However, the depth, breadth, and quality of the information yielded by the discussions, the apparent increase in participant understanding and acceptance of the proposed strategies, and the positive responses reflected in evaluations all suggest that these types of forums offer reciprocal benefits to participants and policy makers and have a great potential to positively impact the development of public health policy.


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