Hearing Notes: U.S. Public Health Response to the Zika Virus - Continuing Challenges

On May 23, the U.S. House Committee on Energy and Commerce held a hearing to explore continuing challenges in the U.S. public health response to the Zika virus. Drs. Luciana Borio (Acting Chief Scientist, FDA), Rick A. Bright (Director, BARDA, HHS), Anthony Fauci (Director, NIAID), Timothy Persons (Chief Scientist, GAO), and Lyle Peterson (Director, Division of Vector-Borne Diseases, NCEZID, CDC) testified.

Common themes that emerged were the uncertainty of long-term impacts of Zika infection; the importance of steady, predictable funding for public health response, including mosquito control and diagnostic and vaccine development; and the need to conduct effective risk communication to at-risk populations.

Some highlights:

Zika epidemiology

  • Every state besides Alaska has reported a Zika case
  • 84 countries have evidence of vector-borne Zika cases

We still don’t know …

  • Actual number of infections
  • Enough about the long-term health impacts of Zika infection in men and children who are born to infected mothers
  • No good model for how virus will spread this year

Public health needs

  • A case definition and understanding of how the virus spreads
  • Development and use of diagnostic tools and new vaccines
  • Mosquito control 
  • Effective communication on all levels

Witnesses

Dr. Persons

  • Stressed need to figure out biological mechanisms and risk factors, and short-and  long-term outcomes
  • Identified two key epidemiological research challenges: insufficiency of data and lack of computer models to predict spread, and a lack of time and funding to conduct research 
  • Identified a key diagnostic manufacturer challenge: lack of samples and FDA communication
    • He noted that HHS has led the way in progress but many challenges still remain
    • He said officials must determine which tests are most effective

Dr. Petersen

  • Noted that it will be important to follow the development of microcephalic babies to understand long-term effects

Dr. Borio

  • Said that FDA’s central role in response to public health emergencies is to support the development and availability of diagnostic tests, vaccines, and therapeutics 
  • Added that FDA also helps to ensure a safe blood supply (preventing 400 infected donations to date), advance strategies for vector control, and protect the nation from fraudulent products
  • Noted that vaccine candidates progressing at rapidly expedited pace

Dr. Fauci

  • Said that NIAID is conducting research to develop countermeasures, including rapid, specific, low cost diagnostic tools
  • molecular, serological (detect immune response of someone already infected)
  • Referenced a study in Brazil on 10,000 pregnant women  
  • Reported that NIAID is currently investigating five candidate Zika vaccines, including (from Dr. Fauci’s written testimony):
    • A DNA vaccine developed by the NIAID Vaccine Research Center – phase 2a/2b trial began in March, 2017
    • A live-attenuated Zika vaccine – will enter Phase 1 trials in late 2017
    • A Zika purified inactivated vaccine (ZPIV), codeveloped by NIAID, BARDA and WRAIR – phase 1 trials began in November, 2016
    • A mRNA vaccine - will enter Phase 1 trials in late 2017
    • A Zika vaccine developed on the rVSV platform – in preclinical development

Dr. Bright

  • Reported that BARDA is currently supporting the development of four candidate Zika vaccines (from Dr. Bright’s written testimony):
    • Moderna’s mRNA-based Zika vaccine
    • Sanofi Pasteur - an extension of the BARDA/NIH/WRAIR collaboration described above
    • Takeda Pharmaceuticals
    • Instituto Butantan

How does this vaccine response compare to other infectious diseases?

  • Dr. Fauci: Zika is the fastest vaccine development we’ve ever had 
    • Three months between time we uncovered sequence to putting it in an animal

 Should we have an emergency fund for issues like this?

  • Dr. Fauci: Yes, because money is being moved from other areas like Ebola in order to work on other urgent issues like Zika
    • “This whole thing is a marathon. We have to have consistent support to be prepared for consecutive years.”  
  • Best possible scenario for vaccine: efficacy signal by mid-2018 for FDA evaluation
    • “While we have begun clinical testing of several Zika vaccine candidates, a safe, effective, and fully licensed Zika vaccine likely will not be available for several years."

Why does CDC think pace for emerging infectious diseases is accelerating?

  • Dr. Petersen: Growth of world population and mega cities, increases in travel and trade that bring viruses to every corner or earth very quickly, climate change 
  • He added that we need to increase efforts toward innovation and discovery: surveillance, mosquito control (sustained effort to rebuild infrastructure), and develop a more national and sustained approach toward vector-control

What are the roles contraceptives and preventive care measures play in combating Zika?

  • Dr. Petersen: Half of the pregnancies in the United States are unplanned, two-thirds in Puerto Rico are unplanned. Our job is to provide women with most accurate info possible so they can make their individual decisions alongside physicians
  • Dr. Fauci: lifetime care of microcephalic baby that survives costs millions of dollars

Why is strong public health infrastructure key to avoiding epidemics we see play out in other parts of the world?

  • Dr. Fauci: You can’t prevent an outbreak of a new infection. The trick is to prevent it from becoming an epidemic or pandemic
  • We have systems in place and the best public health agency in the world to track and control all threatening outbreaks  

How do we make predictive modeling to forecast future cases given that 80 percent of those infected do not have symptoms?

  • Dr. Persons: We have to take current models on sexually transmitted infections and vector-borne diseases. They’ve never been conjoined until now, so we have to come up with a new model that uses both. Consistent research is the only way to do this
  • Dr. Bright: BARDA’s scope does not currently include vector control. However, if enough data is collected to prove vector control significantly reduces infection, then there would a significant role of federal government in implementing vector control measures
  • Dr. Fauci: Work is being done to try to develop a universal flaviviruses vaccine using a common part of all flaviviruses  

$300 million has already been spent to develop vaccine. The Army is not guaranteeing a fair price. What if the vaccine is priced out of reach of many? 

  • Dr. Fauci: It’s important for it to be available to as many people as possible, but I am not sure we have the measures in place to make that happen  

More information on the hearing and witnesses is available at energycommerce.house.gov.

Zika Virus and Maternal and Child Health: Not an Either / Or

On April 14th, The New York Times posed an important question concerning Zika – “Should they [federal health officials] advise American women to delay pregnancy in areas where the virus is circulating?” We bring this up because we asked the same question in March and on further reflection, have not reached the same conclusion as the New York Times.

To recap, last month, the Centers for Disease Control and Prevention (CDC) recognized Zika virus infection as a cause of microcephaly and other developmental complications in-utero. Though there are still many unknowns, this is the first time in history where an arbovirus appears to be causally linked to severe congenital anomalies and developmental disorders. Clearly, as this epidemic unfolds, women of child-bearing age who are pregnant, may become pregnant or would like to become pregnant and who live in countries where Zika is actively circulating bear the brunt of the risk. In Latin America and the Caribbean several governments have advised women to completely avoid conceiving for varying time periods. With the continued spread of the virus, and an increasing number of imported and sexually transmitted cases, the question now is: should the US be doing the same for women in areas which are at highest risk for Zika importation?

As a Zika vaccine is not expected to be developed in the near future, and US mosquito abatement programs will likely struggle to control Aedes aegypti populations to the point where expecting mothers can be 100% sure that they will not be bitten by an infected mosquito, avoiding pregnancy is the lone guarantee that you will not have a child with Zika-related birth defects. However, as of yet, there are no federal advisories recommending avoiding pregnancy specifically. The reason for this lack of guidance is presented in the Times as a dilemma in which health officials either controversially infringe on women’s rights to reproduce or allow these terrible birth defects to occur when more could have been done. Presenting the information in this way poses a false dichotomy.

If science says that waiting to conceive is in the best interest of the mother and infant, then the CDC and other relevant public health officials should make that (non-binding) recommendation and allow women to make decisions accordingly. We should be providing complete information and possible options so that women can make the best-informed decision with their partner and healthcare provider. Doing so empowers women to make the best decision possible for themselves and their families.

We think it would be most helpful if federal health officials provided clear information, including risks and reasoning, for all affected demographics. What follows are some notional guidance for different risk groups in the United States:   

Women who want to or who are trying to become pregnant

In places where we see active transmission, it can be hard to avoid mosquito bites entirely, thus there will be some risk to the fetus if a woman becomes pregnant and is then infected. The only real way to completely avoid this risk is not to become pregnant during an outbreak or when you or your partner has been infected. Women and their partners should be advised to weigh these risks, with their doctor, when deciding whether to conceive during a time and in a place where disease exists. Public health professionals should provide their best current estimates of the risks of getting infected and the risk of the fetus being affected if the mother has the virus to inform these decisions. Additionally, they should provide information regarding the risks of using insecticides containing DEET and how those risks compare to those from Zika.

Pregnant Women

Women who are pregnant in an area with active Zika transmission should be provided with information about preventive measures, including:  

  • Limiting time outdoors
  • Keeping their homes free of mosquitoes
  • Eliminating breeding sites
  • Using bug repellant (correctly and effectively)-
  • Wearing protective and/or treated clothing
  • Using a condom the correct way every time
  • Avoiding sexual contact that might increase the risk of getting Zika infection.

For women who become infected, the importance of close coordination and communication with their doctors in order to monitor the health of the fetus should be emphasized. Early recognition and close monitoring will provide women with the best information and of the most choices about their pregnancy.

Parents of young children and babies

There is some question as to whether and to what extent Zika infection can impact newborns, infants and toddlers. Until we know more, there should be advice about how to protect babies and children from being exposed, including advice about breast feeding, insect repellent, protective clothing, and limiting time outdoors.

All women and men

All US citizens should understand all of the measures they can take to avoid getting the virus. This includes limiting time outdoors, keeping their homes free of the mosquitoes, eliminating breeding sites, using bug repellent (correctly and effectively), and wearing protective and/or treated clothing, using a condom the correct way every time, and avoiding risky sexual behaviors.

As we learn more about Zika and its connection to fetal birth defects, the guidance issued by CDC and other public health authorities will continue to be refined. Conveying uncertainties about the risks, and the need for constant reassessment of the situation in the US should also be highlighted in all communication materials. Until we know more about what the risks are and about specific measures that will limit those risks, the best thing for public health officials to do is present all of the relevant information and allow people to make their decisions accordingly. 

California: From Governator to Vaccinator

On June 30, California Governor Jerry Brown signed into law Senate Bill 277, removing personal belief and religious childhood vaccine exemptions across the state.[i]  With the new law, California becomes only the third state to limit vaccination exemptions to medical only—joining Mississippi and West Virginia.  This effort, on the heels of a measles outbreak at Disneyland that resulted in more than three hundred cases in seven states (as well as Mexico and Canada),[ii] is seen by many as a signature victory for public health (although not renowned vaccine expert, Jim Carrey). 

While there will undoubtedly be challenges in implementing the law statewide, the true test lies in quantifying its effect and determining the feasibility of similar measures nationwide.  Because California was known, historically, for its relatively lax childhood vaccination policies, the transition to the new, considerably stricter exemption policy provides a near-perfect test case for public health policy.  In order to effect positive change far beyond the state line, the California Department of Public Health (CDPH) needs to accurately measure the social and public health impact of SB 277 and share their experiences with other states seeking to update decades-old immunization policy.

At present, CDPH publishes yearly data, by school, for the number of children who are “up-to-date” on vaccinations, have a “permanent medical exemption” and have a “personal belief exemption”—broken down by those counseled by a healthcare practitioner and those who have not (“religious belief exemption”), after a law passed in 2013 requiring the counseling for non-religious personal belief exemptions.  These data are collected and reported for childcare facilities, at kindergarten enrollment and at seventh grade enrollment for all schools statewide.[iii]  The personal belief and religious exemptions will be phased out over the next several years as children progress to the next checkpoint (kindergarten or seventh grade), and the rates for vaccination and medical exemptions, in conjunction with incidence of vaccine-preventable diseases, will provide a baseline picture of the public health impact of SB 277.  CDPH does not currently collect data on the personal or family history conditions warranting medical exemptions.  In fact, there is currently no official form for documenting medical exemptions; a physician letter to the child’s school—maintained in the student’s file—is sufficient.[iv]  Additionally, CDPH does not publish data on exemptions broken down by individual physicians or providers.

While continuing to collect medical exemption rates and communicable disease incidence data is vital, these data alone may not provide a complete picture of the new law’s impact.  Incidence of vaccine-preventable diseases is expected to steadily decrease over the implementation period; however, it will not necessarily change dramatically.  Students are only assessed for vaccination status in preschool childcare, kindergarten and seventh grade, so it will take several years before all of the existing personal belief exemptions are fully phased out.  Additionally, in the absence of another significant event like the 2014-15 measles outbreak at Disney or the 2010 pertussis epidemic, the decrease in communicable disease cases in the coming year will be primarily driven by a return to baseline levels rather than an increase in vaccination.  The full impact of SB 277 may not be known for years to come, but there are vital data to be collected in the meantime.

Gauging the public reaction to the new law will require careful data collection and monitoring of trends beyond just exemption rates and disease incidence.  The number of medical exemptions alone (by school or provider) will not provide a complete vaccination picture for California.  For example, it is likely that a small but motivated percentage of parents who currently have personal belief exemptions for their children may seek to obtain unwarranted medical exemptions rather than have their children vaccinated.  Schools with recent outbreaks of pertussis or measles may have a high number of medical exemptions for these immunizations due to the number of children who recently had the disease.  Additionally, physicians or practices who specialize in treating immunocompromised children (e.g., HIV or pediatric cancer patients) would likely issue a disproportionate number of exemptions.  CDPH does not currently collect information on the medical conditions provided to justify medical exemptions, and these data, particularly their geographic distribution, may give state and local officials information vital to targeting public health interventions and maintaining herd immunity in schools and communities.  To fully understand changing trends in medical exemptions, California should consider implementing measures to identify the conditions associated with them.  Both of the other states that limit immunization exemptions to medical only have mechanisms in place to provide some measure of oversight for the exemption process.  West Virginia requires the approval of the State Immunization Officer in order to obtain a medical waiver,[v] and physicians in Mississippi must provide the medical condition for exemptions to their District Health Officer.[vi]  CDPH needs to consider ways to collect data on the conditions cited on medical exemptions, even if the state does not intend to manage the exemption process directly.  The California state Health and Safety Code grants local health departments complete access to health information relating to students’ immunization status,[vii] so this may be a mechanism through which to collect these data.  Regardless of how state and local public health officials monitor medical exemptions, data beyond the mere numbers need to be collected and analyzed to measure the full impact of the new policy.

In addition to data collection, CDPH public outreach programs to promote vaccination could strengthen the impact of SB 277.  The state of California should continue offering education for physicians emphasizing the importance of vaccination, providing communication strategies for use with reluctant parents and reinforcing the public health and legal implications of the new law for the practice of medicine.  Additionally, similar education efforts should be targeted at school officials and parents to increase awareness during the implementation of the new policy.  Continued public outreach initiatives are vital to ensuring the positive impact of SB 277.

The new vaccination policy was only recently signed into law, so CDPH is likely still in the early stages of planning with respect to establishing implementation and monitoring protocols.  California is poised to move forward as a leader in public health policy, and CDPH has a tremendous opportunity to accurately quantify the impact of the new policy on statewide public health.  Additionally, from a purely public health perspective, it has an obligation to share this information with other states considering similar measures.  In order to do so, CDPH officials must determine now, prior to the law taking effect in 2016, how best to collect and analyze data.  Some questions to ponder include:

  • How do they intend to identify or limit specific conditions related to medical exemptions? 
  • Will they consider monitoring exemption rates for individual physicians or practices? 
  • How much of these data will be provided to the public and in what form? 

Given the far-reaching implications of this new law on public health practice nationwide, California should be diligent and systematic as this law is implemented.  Active and directed collection of data now will provide a solid foundation for analysis, and a dedicated multi-year effort will ensure that social and public health trends are identified early to facilitate intervention as necessary.  California is in an ideal position to assess the impact of statewide vaccination policy, and it has an opportunity to make a lasting, positive impact on the health of the public across the state and far beyond its borders.

 

[i] California State Senate. Senate Bill 277. http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160SB277. June 30, 2015. Accessed: July 17, 2015.

[ii] Chang, Alicia. Large Measles Outbreak Traced to Disneyland is Declared Over. The Big Story. Associated Press. http://bigstory.ap.org/article/f6c2abefb29d4c70ab89ffdb88672916/large-measles-outbreak-traced-disneyland-declared-over. Accessed: July 17, 2015.

[iii] California Department of Public Health. Immunization Levels in Child Care and Schools. July 9, 2015. https://www.cdph.ca.gov/programs/immunize/Pages/ImmunizationLevels.aspx. Accessed: July 17, 2015.

[iv] Shots for School. Immunizations > Exemptions. http://www.shotsforschool.org/laws/exemptions/. Accessed: July 17, 2015.

[v] West Virginia Department of Health and Human Resources. Medical Exemptions Information. http://www.dhhr.wv.gov/oeps/immunization/requirements/Pages/Medical-Exemption-Resource-Center.aspx. Accessed: July 17, 2015.

[vi] Mississippi State Department of Health. Medical Exemption Request. http://msdh.ms.gov/msdhsite/_static/resources/6296.pdf. Accessed: July 17, 2015.

[vii] State of California. Health and Safety Code, Section 120375. http://www.leginfo.ca.gov/cgi-bin/displaycode?section=edc&group=49001-50000&file=49073-49079.7. Accessed: July 17, 2015.

Tuberculosis in the United States: The Good, the Bad and the Ugly

Number and rate of newly diagnosed tuberculosis (TB) cases among U.S.-born and foreign-born persons.  From: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6410a2.htm  

In time for World Tuberculosis (TB) Day, the US Centers for Disease Control and Prevention released a summary of the TB cases that were reported to the National Tuberculosis Surveillance System in 2014.

The data paint a mixed picture.  The good news for the US is that for the 22nd consecutive year, the total number of TB cases reported in the United States has fallen.  In 2014, 9,412 new TB cases were reported in the United States, corresponding to an incidence of 3 cases per 100,000 people.  This incidence represents a 2.2% decrease from the number of TB cases reported in the US in 2013.

But there’s bad news hidden in these statistics.  First, the 2.2% decrease in TB incidence last year in the US represents the smallest decline seen in over a decade. In the last few years, annual decreases in TB incidence have been persistently slow, and sluggish declines raise serious raises concerns about US ability to meet the TB elimination goal CDC set in 1989. The current incidence of TB cases in the U.S. still far exceeds the CDC’s TB elimination goal of <1 case per 1 million population?  And at the rate TB incidence has been declining in recent years, it may take well a hundred or more years for US to achieve TB elimination.

A second cause for concern is the continued disparity in incidence between US and foreign-born individuals.  Last year, the incidence of TB in the foreign born was 13.4 times that of those born in the US.  Efforts to slow TB incidence among the foreign-born also lag.  While last year’s incidence in TB among those born in the US decreased by 6.8%, there was only a 1.5% decrease among the foreign-born.  This is bad news because foreign-born individuals account for the majority of TB cases reported in the US. 

But why should the US care about TB?  First, TB is a leading cause of sickness and death worldwide.  In 2013, 9.0 million people developed TB and 1.5 million died.  Despite the availability of effective treatment, the daily death rate of TB (>4,000 people/day) dwarfs that of many other lethal diseases, including Ebola.

Compared to these global statistics, 9,000 or so cases of TB in the US hardly seem worth mentioning.  But global statistics have a direct connection to what we are likely to see in the US, as studies have found that ~80% of active TB cases in the US are likely caused by reactivation of prior infection--likely acquired abroad--rather than newly transmitted infections. Therefore, an inability to drive down TB incidence globally will surely slow progress towards TB elimination in the US.

As recent news reports show us, even one case of TB in the United States can have considerable impact on a community. Following the discovery of an active TB case at a Kansas high school, a public health investigation identified 27 students who also tested positive for TB.  Though the students do not have symptoms of active TB, their positive blood test indicates they are likely latently infected with TB and will have to undergo up to 9 months of treatment to ensure that their infection does not develop into active disease.

Another reason why the US should be concerned about TB here and abroad is the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB. The WHO estimates that in 2013, close to a half of a million new cases of MDR and XDR TB occurred across the globe. In some countries, as many as 35% of first time cases and 75% of previously treated cases were caused by XDR and MDR. The continued occurrence of these cases is worrisome. Compared to drug-susceptible TB, MDR and XDR are far more difficult and require much more time to treat. 

Though the percentage of US drug resistant TB cases have so far remained relatively stable in recent years, last year the US did see a small increase in the number of resistant cases.  While a few extra cases may not seem like much, at an estimated cost of $130,000-$430,000 to treat a single patient, small increases in the number of MDR and XDR TB patients can be crippling for health departments that often shoulder the bill for treating these patients.

The third reason why TB is an important issue for the US is because the ability to control TB should be a good indicator of our readiness to respond to other communicable diseases. The core of skills required for TB control—case detection, laboratory analysis, contact tracing, infection control—are foundational capabilities for communicable disease control.  Therefore, commitment to reduce TB incidence provides regular opportunities to exercise for responding to measles, Ebola and other rarer occurrences.

Despite the importance of TB to US public health, US commitment towards TB elimination is lagging. While the number of cases of TB in the US may have decreased in the last 20 years, the costs of TB control certainly have not.  Many factors—from the availability of more powerful, but more costly, laboratory tests, the continued occurrence of drug resistant TB and other more complicated forms of TB, and the high costs of treatment infections—have all placed additional strains on public health agencies in charge TB control programs.

The ugly news is that despite these persistent—and arguably growing challenges—US  funding for TB control has declined.  The President’s Fiscal Year 2016 budget would cut USAID’s international TB control efforts by 19%. Domestically, federal funding for state/local TB control activities has remained flat for the last 10 years, which, factoring in inflation, has meant that that the amount of resources available for TB control have declined substantially.  Combined with state budget cuts following the recent recession, declining federal support for TB control has forced health departments to make tough choices.  A survey conducted by the National Tuberculosis Controllers Association found that sixty percent of TB control programs have had to eliminate staff as a result of shrinking budgets.  Twenty-five percent of programs reported having to restrict some essential TB activities, such as provision of directly observed therapy, contact and outbreak investigations.

Taken together, the news of disappointing declines in TB incidence and evidence that TB control programs are scaling back activities in light of declining budgets, raise important doubts about the prospects of eliminating TB from the United States and about our readiness for other infectious disease emergencies. In support of World TB Day, we should re-think this penny wise, pound foolish approach.

 

The Growth and Future of Healthcare Emergency Preparedness Coalitions

From: MSCC Handbook, PHE.gov

From: MSCC Handbook, PHE.gov

Last week I attended the 3rd annual National Healthcare Coalition Preparedness Conference in Denver. This has grown to be one of the premier healthcare preparedness meetings with well over 700 attendees from all over the country. There were a number of interesting presentations on a wide variety of preparedness topics, including my own presentation on allocation of scarce resources in a disaster that I will address in a future post. In this post I will focus on the tremendous growth that has been seen in preparedness coalitions and their possible future.

Phenomenal growth

In a really informative presentation by Melissa Harvey Deputy Director of the Hospital Preparedness Program (HPP) in the Office of the Assistant Secretary for Preparedness and Response (ASPR) in the Department of Health and Human Services (HHS), I learned that there are now approximately 500 coalitions. These coalitions have almost 24,000 members, which represents a 47% increase since last year. Most of the coalitions include the “big 4” as members: hospitals, public health, emergency management and emergency medical services (EMS). As we and many others have said in the past, all coalitions are different and that “if you have seen one coalition you have seen one coalition”. But many speakers at the conference endorsed the notion that many different coalition structures can be effective.    

Going forward, HPP’s goal is to broaden coalition membership to the “next 3” namely: home health, dialysis centers and nursing homes. They also want to increase coalition membership by another 100% to 48,000 in the coming year. This seems like an ambitious goal but they think that the coming emergency preparedness rule from the Centers for Medicare and Medicaid (CMS), which is due out in about a year, will provide a strong incentive for healthcare facilities to join in coalitions. While the CMS draft rule does not mandate coalition membership, it does require CMS providers to collaborate with local partners and encourages coalition membership.

Future sustainability

While on the one hand this growth in coalition is very encouraging, I see potential financial problems down the road. The CMS rule is a stick without a financial carrot. Healthcare facilities will be penalized for not meeting the requirements but are not provided additional funds to do so. Currently most hospitals get this funding from the HPP; however, the HPP has seen an almost 50% decrease in budget over the last 10 years and its future after 2017 is not guaranteed. So the question of financial sustainability of coalitions looms large in the minds of many coalition leaders as expressed at the conference.

One intriguing potential solution to this dilemma, articulated by Brendan Carr from ASPR, is to expand the scope of coalitions beyond emergency preparedness and response.  Coalitions largely overlap with regional referral networks (such as trauma, cardiac and stroke referral systems). As we as a nation move gradually to a healthcare system organized around regionally determined outcome measures, existing coalitions could be a vehicle through which healthcare facilities collaborate to improve population based outcomes and constrain costs.  This should be food for thought for coalition leaders and healthcare planners alike.