Public Health Engagement Aff Notes

U.S. and China have a vested interest in working together on global health

Because there is no universal consensus for the definition of global health, some approaches focus on transnational health risks, which lie beyond the reach of national governments, whereas other approaches stress the global commitment and responsibility to address health inequities and to support health.13 We have adopted a framework of global health as characterised by health and related transnational flows of diseases, people, money, knowledge, technologies, and ethical values.14–16 Four domains capture these globalisation processes (figure 1). First, health aid aims to advance global health equity. It is the traditional area of official development assistance (ODA) coordinated by organisation for economic cooperation and development (OECD) countries. Second, global health security should be ensured by management of interdependence in global health and mutual protection against shared and transferred risks, such as epidemic diseases. Third, health governance is needed for global stewardship to set ground rules as mediated by health diplomacy. Fourth, knowledge exchange is needed, which includes the sharing of lessons and knowledge production, ownership, and application worldwide. Knowledge centrally affects all four pillars of global health and global health governance is recognised to be central to all four domains (figure 1).

China is interested in investing more in public health diplomacy since the 2003 SARS outbreak

Brown et al. 13 (Matthew Brown, Bryan A. Liang, Braden Hale, and Thomas Novotny, Senior Advisor at Office of Global Affairs, US Department of Health and Human Services - ‎US Department of Health and Human Services, “China's Role in Global Health Diplomacy: Designing Expanded U.S. Partnership for Health System Strengthening in Africa”, Global Health Governance, Volume 6, No. 2, CL)

How did SARS change China’s global health engagement? The SARS epidemic exposed serious weaknesses with China’s lack of transparency related to public health issues.80 The first SARS case in China appeared in November 2002.81 The WHO’s Global Outbreak and Alert Response Network (GOARN) received reports of a “flu like outbreak” in China through Internet monitoring.82 WHO requested information from the Chinese government regarding the outbreak on December 5 and 11, 2002.83 However, according to CNN news reports and several journal reports, Chinese government officials did not inform WHO of the outbreak until February 2003.84-85 This initial lack of transparency about the epidemic delayed the global community’s response to a novel and highly dangerous infectious disease agent.86-87 It brought economic and political pressure on China’s government for lack of transparency and limited cooperation. China later apologized for the initial delay during the outbreak of the SARS epidemic, confirming the importance of timely reporting and engagement in the response to emergent global health issues.88 China’s official report of SARS in February 2003 and apology for delaying international notification demonstrates the newfound Chinese governmental authorities’ recognition of the importance of cooperation with WHO and other member states.89 International officials largely credit the increase in communication with the international community to the leadership of the then new President Hu Jintao and Prime Minister Wen Jiabao.90 SARS also marked an increase in cooperation among Chinese scientists, WHO epidemiologists, and U.S. CDC scientists, although there continue to be criticisms of China’s global public health efforts.91 Discussions held during the SARS outbreak led to the HHS’s Health Attaché based at the U.S. Embassy in Beijing and the Chinese MOH’s Division of International Cooperation, America’s Division, to initiate a joint project on emerging infections.92 In October 2005, the Chinese MOH and the U.S. Secretary of HHS met to sign an MOU, the U.S.-China Collaboration of Emerging and Reemerging Infections (EID).93 The EID collaboration has produced dozens of peer-reviewed original research papers and maintains a biennial meeting between the HHS Secretary and the Chinese MOH.94 Also as a result of SARS, the Chinese CDC developed a real-time Internet-based disease surveillance system to help increase monitoring and reporting on adverse health events.95 This electronic disease reporting tool is linked to nearly every health institution in the country and is used to allocate resources, characterize threats, and monitor disease patterns. This system is additional evidence of China’s increased transparency around public health events of national and international importance.96 SARS was a watershed event for the Chinese health system and its governmental authorities.97-99 It jumpstarted the development of China’s modern health system by illuminating the critical need to detect and respond to public health threats of international importance in a timely and coordinated manner with the global community.100 China’s rapid growth in public health systems and disease reporting infrastructure post-SARS could provide valuable insights, lessons, and practices for both African and American diplomats.101 Additionally, using the lens of global heath diplomacy, examining these lessons and practices can join nations around shared needs of greater health impact and security.

Spending has increased, but China still lacks the resources necessary to adequately address healthcare issues

Huang ’16 (Yanzhong Huang, Senior Fellow for Global Health, Council on Foreign Relations, and professor of Diplomacy and International Relations at Seton Hall University, “China’s Healthcare Sector and U.S.-China Health Cooperation”, April 16, Council on Foreign Relations, CL)

Healthcare demands are hard to measure. For a country of nearly 1.4 billion people, the challenge of financing healthcare is overwhelmingly mounted. It is estimated that diabetes alone may consume more than half of China’s annual health budget if routine, state-funded care is extended to all the diabetes sufferers. Compared to many countries, share of healthcare expenditure in total GDP remained relative low in China. In 2013, China spent 5.6% of its GDP on healthcare, which accounted for only 3% of the global healthcare spending (compared to 17% in the U.S.). In other words, China addresses healthcare needs of 22% of the world’s population with only 3% of the world’s healthcare resources.

In the 1980s, driven by market-oriented economic reform, government spending as a percentage of total health expenditures dropped precipitously—from 40 percent in 1982 to 15 percent in 1999. China’s economic take-off and the implementation of the tax-sharing reform in 1994 nevertheless carved out more fiscal space for healthcare spending. In the 2000s, two developments boosted government incentives to invest in the health sector. The first was the 2002-03 SARS crisis, which uncovered the vulnerabilities in China’s healthcare system and the drawbacks in the government’s single-minded pursuit of economic growth. The second was the 2008 global financial crisis, which made it imperative to construct a social safety net to encourage domestic consumption. Between 2009 and 2013, government spending on healthcare has grown 20 percent annually. Consequently, government spending in total health expenditure increased from 15% in 1999 to 30% in 2013, and out of pocket spending dropped from 60% to 34%. Still, compared with OECD countries the share of government health spending in total fiscal expenditure remains relatively small. Even using the government adjusted figure (12.5% in 2013), China’s share is still lower than that of the US (21%), UK (16%), and Japan (17%), although it might be higher than other BRICS countries.

U.S. Tech = Most Advanced

U.S. scientific dominance is by no means being threatened

Herper '11 (Matthew Herper, covers science and medicine for Forbes from the Human Genome Project, "The Most Innovative Countries In Biology And Medicine", Forbes, March 23, www.forbes.com/sites/matthewherper/2011/03/23/the-most-innovative-countries-in-biology-and-medicine/2/#2c0d63796b13, CL)

It’s a threat deeply rooted in the American psyche, placed there sometime between Thomas Edison and Sputnik: the idea that we’re losing our scientific and technological edge over the rest of the world. Intel founder Andy Grove said it in 2003; Time Magazine said it in 2006; former Lockheed Martin chief executive Norm Augustine said it this year. Hardly a month goes by that we don’t hear that we’re losing this edge or that, falling behind in one way or another. Is it true? And if it is, why haven’t we fallen behind yet? To delve into this a little bit, I decided to go to SciVal Analytics, a consulting group at the giant publisher Elsevier that has access to a database called Scopus, which contains more than 18,000 scientific journals — just about the entire scientific publishing universe. They ran three analyses for me: which countries produce the most publications in biology and medicine, which are tops in information technology, and which do the most in clean technology. I’m publishing the biology and medicine data today. Come back tomorrow for a look information tech, and Friday for clean tech. I’ll also wrap up what I’ve learned from the data dump. Of almost 3,000 articles published in biomedical research in 2009, 1,169, or 40%, came from the United States. As the line graph below demonstrates (that’s the number of publications on the Y axis, and the year of publication on the X axis), the output of every other single country in the world is dwarfed by what America produces. The closest contender is Great Britain, which comes in at about 300 articles. But aren’t the other countries catching up? Actually, the number of publications from the U.S. is grew about 7% between 2005 and 2009, which is a little above average. It’s true that countries like South Korea (annualized growth: 32%), China (26%), and Ireland (22%) are growing a lot faster, but they are also starting from a smaller base. It’s certainly possible that the U.S. is publishing entirely low quality data, but another data point, the citation score, seems to indicate that isn’t true. The citation score is the number of times an average paper was referenced by other scientific papers. In the graph below, the Y axis is the citation score and the X axis is the number of publications in total. The U.S. doesn’t come through with flying colors – Switzerland and the Netherlands score higher on citation score – but that’s probably partly because it publishes so much more than other countries, with volume tending to bring down the average. Another interesting stat: not only is the U.S. producing more research, it is producing a greater share of those publications with other countries. The bar chart below shows how many of the total papers produced over a five-year period involved co-authorship between different countries (for instance, between the U.S. and China, or Japan and Germany). Papers published by U.S. researchers were much more likely to have had foreign co-authors, which the SciVal analysts think means that the U.S. is more collaborative as well as being a bigger research force. So when it comes to biology and medicine, U.S. researchers are publishing more than those in other countries. And this probably shouldn’t come as much of a shock. You can see the effect of the U.S. dominance in biology and medicine in the behavior of big drug companies. Novartis, a Basel, Switzerland-based drug giant, nonetheless chose to place its research headquarters in Cambridge, Mass., near Harvard and MIT, and to put a Harvard doctor and biologist, Mark Fishman, in charge of R&D. Sanofi-Aventis gives nearness to the U.S. research hubs as one of the reasons behind its pending purchase of Genzyme, the U.S. biotechnology giant. And pushes to establish other countries as research challengers to the U.S. in medicine have often proceeded with fits and starts. For a while, it appeared that South Korea was making a go of it when it came to stem cells and cloning, but then it turned out that one of its leading researchers, Hwang Woo Suk, had faked results. There is a big movement to move some drug research to China — Pfizer just moved its antibiotic research to Shanghai — but the bulk of the work is still very much U.S.-centered. There may be threats to America’s position in biomedicine, but at best they are hoof beats in the distance, not imminent dangers.

The U.S. is the number one advanced country in medicine

Jevtic '15 (Aleksandar Jevtic, Institut de Robòtica i Informàtica industrial, 10 Most Advanced Countries in Medicine", Insider Monkey, August 20, www.insidermonkey.com/blog/10-most-advanced-countries-in-medicine-364917/, CL)

3. Germany: The first winner of Nobel Prize for medicine was a German, Emil Adolf von Behring in 1901. He got it for his work on a serum against diphtheria. Ever since then Germany has been one of the forerunners in the field of medical research. 2. England: The UK health care system is divided territorially, with England, Scotland, Wales and Northern Ireland each having their separate systems. In terms of research and advancement, England is leading the way. 1. The United States of America: Despite all the bashing America receives every time someone mentions medical care, it remains the most advanced country in medicine. The sheer number of research papers published every year is higher than the next 5 countries on our list combined. America’s medical scientists are also first in number of researchers that have foreign collaborators, illustrating their willingness for cooperation with their colleagues from around the globe, which is a contributing factor to their overall success.

No Tradeoff

No trade-off between welfare and economic development

Wong et al. ’05 (Chack-kie Wong, professor of the Social Work Department at the Chinese University of Hong Kong, “China's Urban Health Care Reform: From State Protection to Individual Responsibility, Lexington Books, November 22, https://books.google.com/books?id=hee1AQAAQBAJ&pg=PA100&lpg=PA100&dq=china+health+care+tradeoff+with+economy&source=bl&ots=XyPweyWVgD&sig=uOCf-BTJ4FZAgydPYLBZ9_WAD1o&hl=en&sa=X&ved=0ahUKEwjGvdrFifvNAhWHVz4KHREtDcIQ6AEIVzAG#v=onepage&q=trade-off&f=false, CL)

The Perception of the Relationship Between Economic Development and Health Care:

We not consider whether the findings of the two social surveys support any linkage between health care protection and the need for economic development. The first statement in table 5.9 suggests that an overwhelming majority of the respondents from both groups disagree that “the primary role of the government is economic development and not welfare improvement”—84.6 percent of the employed group and 85.7 percent of the patient group; there is no difference in terms of statistical significant between the two groups. In order words, the respondents do not see a trade-off between economic development and welfare development. Welfare development has a life of its own. Does this response pattern reflect an endorsement of social developmentalism? The following survey findings might provide us with some pointers. It can be assumed that if there is a fine balance between economic growth and health care protection, respondents will be inclined to agree more with statements about the affordability of medical treatments. This is not the case in the response patterns for the following two statements. Nearly three quarters of respondents from both groups agree, to different extents, that “medical expenses exceed what our country can afford under the current economic condition” (table 5.9, statement 2). No statistical significant between the two groups is detected. Implicitly, from the perceptions of the respondents, medical expenses are costly in relation to China’s level of economic prosperity. In a related question, somewhat more respondents from both groups, 86.1 percent of the employee respondents and 84.7 percent of the patient respondents, agree that “the current medical examination and treatment expenses exceed what the general public can afford” (table 5.9, statement 3). Here also, there is no statistical significant between the two groups. Taking all of these responses together as evidence, there has not been an appropriate balance, in the perceptions of the respondents, between economic growth and healthcare protection. The findings do not tell us where the right balance lies; however, it is clear that, at present, affordability is a critical and major issue in the perception of the respondents. ON the basis of this discussion, it can be inferred that the respondents generally endorse the principal tenet of social developmentalism and that the state has a role in harmonizing social and economic development. They think that the present model for the funding of medical services is not right because it exceeds what the economy and the general public can afford.

Awareness Solves

Even if the plan doesn’t significantly solve, mobilization and awareness alone significantly reduces risks of pandemics

Hughes and Wilson '10 (James M. Hughes is Professor of Medicine and Public Health with joint appointments in the School of Medicine (Infectious Diseases) and the Rollins School of Public Health (Global Health) at Emory University and Co-Director of the Emory Antibiotic Resistance Center, and Mary E. Wilson is Adjunct Professor of Global Health and Population at Harvard University, "The Origin and Prevention of Pandemics", Clinical Infectious Disease, Volume 50 Issue 12, p. 1636-1640, cid.oxfordjournals.org/content/50/12/1636.full, CL)

Current global disease control focuses almost exclusively on responding to pandemics after they have already spread globally [23]. Nevertheless, dramatic failures in pandemic control, such as the ongoing lack of success in HIV vaccine development 25 years into the pandemic, have shown that this wait-and-respond approach is not sufficient and that the development of systems to prevent novel pandemics before they are established should be considered imperative to human health. Had we had such mature systems in place, we may have averted the H1N1 influenza pandemic that is currently unfolding. The early detection of emergent threats to human health is all the more important given the speed with which disease causing agents are now capable of being distributed around the globe through air travel [24] and the global trade of animals as potential reservoirs of disease [25]. Because the success of a pathogen depends on its ability to spread from human to human and on the number of susceptible humans, our ability to cross continents in a single day poses a unique new challenge to emerging infectious disease control. Past studies have highlighted the importance of global travel to the spread of pandemic disease [26–28], and the recent emergence and subsequent global spread of H1N1 influenza virus eloquently illustrates how our global interconnectedness can affect the worldwide distribution of a new virus, one that may otherwise have remained a regional phenomena in an era before global transit. The Committee on Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin was convened by the Institute of Medicine and the National Research Council to assess the feasibility, needs, and challenges of developing a future and sustainable global disease surveillance program [29]. As the committee's report comprehensively expresses, our current disease surveillance system and our ability to identify emergent diseases early are inadequate. Implementing all of the committee's recommendations would represent a significant step forward in achieving a well-integrated zoonotic disease surveillance system, but we are still far from realizing this goal. Given the fact that more than one-half of emerging infectious diseases have resulted from zoonotic transmission [1] and that the human-animal interface is so pivotal to the process of disease emergence, it stands to reason that the most effective strategy in terms of early detection of an emergent pathogenic threat would focus on conducting surveillance of humans highly exposed to animals and within the animal populations to which they are routinely exposed. Despite this, there exists no systematic global effort to monitor for pathogens emerging from animals to humans in “at-risk” populations, and we are probably years from having such a system in place. Although a global surveillance system for pandemic prevention is still far from reality, there may be more immediate, interim measures that may be taken to mitigate the risk of zoonotic transmission, even in the absence of a global surveillance effort. In situations where humans and animals are in close contact, behavioral change approaches may be a preventative step to reducing the risk of zoonotic transmission. Behavioral modification campaigns have previously been used in combating outbreaks of known infectious diseases [30–32]. For instance, a behavioral modification campaign was launched in Sierra Leone to reduce cases of Lassa fever [32]. The intervention involved incidence mapping, contact tracing to warn relatives of the dangers of secondary infection, and education to exposed populations in methods of avoiding exposure to rodents, the reservoir of the disease. Prevention posters included graphic depictions to instruct villagers in techniques for protecting food from rodents, trapping rodents, dealing safely with carcasses of dead rats, and symptom recognition. As part of the campaign, local musicians were even commissioned to write and perform songs about routes of transmission of Lassa fever and preventative measures. These outreach activities were an attempt to increase awareness of the disease and to promote behavior change aimed at reducing incident cases of Lassa fever through reducing the risk of exposure to animals, in this case rodents.

Increases Access to Marginalized Communities

Measures enabled by the plan would improve basic health standards for marginalized communities who didn’t have access before

Institute of Medicine '07 (Institute of Medicine Forum on Microbial Threats, "Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary.", National Academies Press, www.ncbi.nlm.nih.gov/books/NBK54163/, CL)

Hygienic measures to prevent the spread of respiratory infections are broadly accepted and have been widely used in both influenza pandemics (APHA, 1918) and also, although with uncertain benefits, the SARS outbreaks (WHO, 2003; CDC, 2005a). These hygienic methods include hand-washing, disinfection, the use of personal protective equipment (PPE) such as masks, gloves, gowns, and eye protection, and respiratory hygiene, such as the use of proper etiquette for coughs, sneezes, and spitting. It is important that the public be informed of the need for hygienic measures, and that accurate information, including the uncertainty of the effectiveness of the recommended interventions, be provided. In past epidemics misinformation has been rampant, and this has led to substantial public anxiety, to reliance on word of mouth for knowledge, and to the purchase of ineffective and expensive products (Rosling and Rosling, 2003). The situation raises issues of distributive justice because ineffective or inaccurate communications have the greatest effects on marginalized members of society, as they are the least likely to have access to alternative credible sources of information and are the people for whom wasting resources would have the greatest adverse effects (Gostin and Powers, 2006). Furthermore, a consideration for personal dignity implies that individuals should be provided with adequate information to make informed decisions about their own health. Public education campaigns should be grounded in the science of risk communication, as the acceptability of health measures is vital to community adherence. The information disseminated through public education campaigns should be accurate, clear, uncomplicated, not sensationalistic or alarmist, and as reassuring as possible (SARS Commission, 2006).7

Pandemic control measures like increased access to vaccinations benefit children, elders, and pregnant women the most—empirics prove that they become a focus

Reintjes et. al '16 (Ralf Reintjes is ‎a Professor of Epidemiology and Surveillance - ‎Hamburg University of Applied Sciences, “Pandemic Public Health Paradox”: Time Series Analysis of the 2009/10 Influenza A / H1N1 Epidemiology, Media Attention, Risk Perception and Public Reactions in 5 European Countries", National Center for Biotechnology Information, March 16, www.ncbi.nlm.nih.gov/pmc/articles/PMC4794201/, CL)

Widespread viral activity within the country, led UK to move from containment to treatment phase on 2nd July 2009. Laboratory testing was no longer required for all cases and case-tracing was stopped. Further, antiviral treatment was only offered to clinical cases [33]. To relieve some of the pressures on the health system, the National Pandemic Flu Service was launched in England on 23rd July. This was an online and telephone self-care service that allowed people outside the “at-risk” groups to be assessed for pandemic flu, and if required, to get access to antiviral treatment without the need to consult a physician [33]. Denmark moved to a mitigation strategy on 7th July. The focus was on preventive treatment of persons at risk. Only risk group patients or persons with close contact to a risk group patient needed to be swabbed. Further, antiviral treatment was administered to risk group persons only, and prophylactic antiviral treatment was given to contacts of laboratory-confirmed cases only if the contact belonged to a risk group. This included persons with chronic pulmonary conditions, cardiovascular diseases, diabetes, immunodeficiency, HIV-Infection and pregnant women (2nd and 3rd Trimester). Furthermore, it was recommended that pregnant women in their 1st trimester, children < 5 years and severely obese patients should be closely monitored [34, 35]. On 27th July, Spain officially moved from containment to mitigation, although response measures had already changed towards mitigation in late June, i.e. contact tracing was ceased. Case-based reporting in the community was stopped, and antivirals were only given to cases requiring hospitalization and to those at risk of complications [36, 37]. From early August 2009, Germany applied a mitigation strategy, which predominantly focused on risk groups. In this strategy, contact-tracing was stopped. Isolation was recommended for cases with contact to vulnerable persons only. Antivirals were only given to cases in at-risk groups with signs of developing severe illness and case-based reporting requirements were relaxed [27]. Czech Republic started with a mitigation strategy on 9th July [38]. Further details of the strategy could not be retrieved. Vaccination In late September 2009 (week 40), the European Commission granted approval for two influenza A H1N1 vaccines, Focetria® (Novartis) and Pandemrix® (GlaxoSmithKline), in all EU Member States as well as Iceland, Liechtenstein and Norway [39]. The third vaccine for influenza A H1N1, Celvapan® (Baxter), was approved in early October 2009 [40]. All five study countries implemented a vaccination program around the time of the second wave (starting between week 40 to 44; week 48 in CZ) [Table 2] [4, 41–45] initially focusing on priority groups which in many cases was extended to the general public. Media attention In all researched countries media attention, defined as the number of published news reports on influenza A H1N1, was highest in week 18 [Table 2], when the WHO declared pandemic phase 4 and shortly thereafter, pandemic phase 5. Media attention rapidly waned in all countries and was followed only by smaller peaks in news coverage over the remaining course of the pandemic Figs ​Figs11–5. Media attention curves differed among countries. Germany: News reporting showed a small surge in media attention in week 24 coinciding with the WHO’s official pandemic declaration, and another peak in week 30 contemporaneous with the first wave of influenza A H1N1 transmission. The start of a third surge in attention corresponded with the official German definition of vaccine priority groups; its peak in week 43–45 paralleled with the start of the mass vaccination program. United Kingdom: In week 28, after the first and largest wave of transmission, a second surge in media attention began peaking in week 30. Other smaller peaks coincide with the introduction of pandemic control measures (mitigation strategy; introduction of vaccination). Denmark: After the first large peak in media attention, three smaller peaks could be observed. The first occurred in week 31–32 concurrent with the first wave of transmission, the second in week 37 following the first fatality abroad from Danish origin, and the third coinciding with the first national fatal case and the start of the mass vaccination program. Spain: Following the initial peak, media attention was substantially lower over the remaining pandemic course than in the other countries. A smaller surge in media attention, coinciding with the agreement of priority groups for vaccination, began in week 33, peaking during weeks 35 to 36. It is notable that the peak began the week before the agreement, and ceased at approximately the time of agreement. In week 45 another peak emerged, which corresponded with a second wave in influenza A H1N1 transmission and the start of the national vaccination campaign. Czech Republic: Media attention remained low until week 42, when two contiguous media attention peaks emerged. The first one, peaking in week 45, coincided with the first fatal case although not entirely triggered by it. The second one, peaking in week 48, corresponded with the start of the national mass vaccination program. During the second wave of the epidemic, when most influenza-related deaths occurred, relatively little media attention was seen in all five study countries. In late November 2009, the Gallup Organization conducted a survey named Flash Eurobarometer in 30 European countries to assess public opinion about influenza and pandemic influenza A H1N1. In this survey, 69% of the German (N = 1001), 61% of the Czech (N = 1002), 58% of the Danish (N = 1008), and 49% of the UK participants (N = 1000) believed it was not at all likely or rather unlikely that they would personally catch the A/H1N1 influenza. The majority of the participants from ES (66%), DE (62%) and DK (60%) also stated that is was not likely or not at all likely that they would get vaccinated against the pandemic A/H1N1 virus. This proportion was considerably lower in the UK (37% of the participants) and the CZ (47% of the Czech interviewees) [Table 2] [25]. For the included countries, the vaccination coverage of persons with underlying diseases as well as the overall uptake, if available [4], is shown in the green hexagon in Figs ​Figs11–5. In the UK, the vaccine uptake in clinical risk groups was assessed using data collected from a sentinel group of GP practices in England. The vaccination uptake among the “under 65” clinical risk groups is reflected in the green curve in Fig 2. In this group as well as in the over 65 years age group (curve not shown), the vaccine uptake increased steadily until week 4/2010. Overall, the national vaccine uptake in patients in clinical risk groups aged under 65 years was 35.4%, this included pregnant women. It was 40.4% in those aged 65 years and over. Another survey assessed the vaccine uptake among healthcare workers in all 389 NHS Trusts in England on a weekly basis from 8th November 2009 to 4th April 2010. The vaccine uptake among healthcare workers increased sharply in the first weeks after the vaccine was available and leveled out at approximately 40% from week 4 of 2010 [46].

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