PreParing for a Pandemic influenza - A Pr mer for Governors and Sen or State Offic als - National Governors ...
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Preparing for a
Pandemic Influenza
A Primer for Governors and Senior State Officials
The National Governors Association (NGA),
founded in 1908, is the instrument through which the na-
tion’s governors collectively influence the development and
implementation of national policy and apply creative leader-
ship to state issues. Its members are the governors of the 50
states, three territories and two commonwealths.
The NGA Center for Best Practices is the nation’s only dedi-
cated consulting firm for governors and their key policy staff.
The Center’s mission is to develop and implement innovative
solutions to public policy challenges. Through the staff of the
Center, governors and their policy advisors can:
· quickly learn about what works, what doesn’t, and
what lessons can be learned from other governors
grappling with the same problems;
· obtain assistance in designing and implement-
ing new programs or in making current programs
more effective;
· receive up-to-date, comprehensive information
about what is happening in other state capitals and
in Washington, D.C., so governors are aware of
cutting edge policies; and
· learn about emerging national trends and their
implications for states, so governors can prepare to
meet future demands.
For more information about NGA and the Center for Best
Practices, please visit www.nga.org.
Copyright © 2006 by the
National Governors Association Center for Best Practices.
All rights reserved.
ISBN: 1-55877-402-5
iiPREPARING FOR A
PANDEMIC INFLUENZA
A PRIMER FOR GOVERNORS AND SENIOR STATE OFFICIALS
Preparing for a Pandemic Influenza
Foreword
History’s greatest killer always has been disease. Small- business owners, and individuals; and government efforts to
pox alone has killed hundreds of millions of people, more manage the public’s response could be complicated by the
than that Black Death of the Middle Ages and all the wars myriad sources of information—including the Internet—on
of the 20th Century combined.1 Even as some of history’s which people rely for guidance.
most infamous scourges—smallpox, polio, tuberculosis— Preparing for a Pandemic Influenza: A Primer for Governors
are brought under control through vaccines and antibiotics, and Senior State Officials offers an overview of these and other
others—AIDS, SARS, Ebola, Marburg, Monkeypox, West issues governors and state officials must consider as they de-
Nile Virus, Hantavirus—emerge. velop plans to respond to pandemic influenza or other dis-
Against this backdrop, the world watches the spread of an ease outbreaks. This document focuses on state policies and
influenza virus among the global bird population. At time of responsibilities, and is intended to complement the federal
publication, the H5N1 virus had been found in 47 countries. guidance issued by the White House Homeland Security
Millions of birds had been culled in an effort to keep the virus Council, the Department of Health and Human Services,
out of commercial poultry flocks. A confirmed 224 people in and the Department of Homeland Security.
10 countries had been infected with the virus, mostly through The report was authored by Dr. Stephen Prior, who is the
close contact with infected chickens or, in rare cases, sustained, founding Research Director of the National Center for Criti-
close contact with infected individuals such as family mem- cal Incident Analysis, a Distinguished Research Professor at
bers. Of those 224 known human cases, 125 proved fatal. the National Defense University in Washington, DC, and
The H5N1 influenza virus may not provide the spark for an- president of Quantum Leap Health Sciences, Inc. in Arling-
other human pandemic. Nonetheless, history has shown that ton, Virginia. Trained as a life scientist with qualifications in
such pandemics do occur periodically. Prudence therefore microbiology and biochemistry, he has more than 20 years
dictates states achieve a level of preparedness that ensures, of research experience in a wide range of multinational and
at a minimum, the maintenance of essential services during biotechnological environments.
times in which widespread disease affects the health care sys- Dr. Prior is an acknowledged leader in the field of medical
tem, the broader economy, and society as whole. Steps taken defense against the threat posed by biological weapons and
now to prepare for what could be a severe pandemic will have bioterrorism and has advised and worked closely with gov-
benefits throughout the health care system and will prepare ernment and commercial defense staffs worldwide to develop
states for a range of health- and disaster-related challenges. medical countermeasures. A native of the United Kingdom,
Pandemic preparedness involves more than stockpiling phar- his career has included appointments to the UK Ministry of
maceuticals and planning for surges of patients at hospitals. Defense, North Atlantic Treaty Organization (NATO), and
A severe pandemic will affect all sectors of society: high rates the U.S. Department of Defense. He recently has applied his
of worker absenteeism could affect the operations of water skills to helping governments understand the implications of
treatment facilities and power plants; efforts to slow or stop and prepare for a possible pandemic influenza. As Dr. Prior
the spread of the disease could limit the availability of food, has noted, “Mother nature has no peer as an inventor of bio-
cause schools to be closed for significant periods of time, and logical threats.”
create economic hardships for state and local governments, June, 2006
iiA Primer for Governors and Senior State officials
Acknowledgements
The author would like to acknowledge the following individ-
uals for their valuable contributions to this document: Emily
Falone, Chief of Public Health Preparedness in the state of
Delaware; Dianne Mandernach, Commissioner of Health
for the state of Minnesota; and Chris Logan, Senior Policy
Analyst for Homeland Security in the NGA Center for Best
Practices.
iiiPreparing for a Pandemic Influenza
Summary
A comment made at a recent briefing for congressional staff sources and effort to effectively respond. To prepare for a pan-
on a pandemic influenza outbreak succinctly captures the po- demic, governors and state officials must consider not only
tential magnitude of this uncertain but urgent threat: “Once how to manage the outbreak itself, but also how to maintain
a pandemic happens, we will divide forever the progress of critical operations during the outbreak. Four key facts will in-
our nation as pre-pandemic and post-pandemic.” When a form these efforts and help shape response actions:
pandemic occurs, the impact of the disease will join the lexi- • The effects of a pandemic flu will be broad,
con of nation-changing incidents on the scale of 9-11 and the deep, and simultaneous, and states must focus
2005 Hurricane Season. In every state, governors and senior resources to ensure continuation of essential
officials will be at the forefront of protecting public health, services. Populations worldwide will be affected
maintaining critical services and infrastructure, and leading at the same time and the ability to function and
the public from crisis to recovery. deliver services throughout the public and private
An episode of pandemic influenza is the viral equivalent of a sector will be compromised. Delivery of products
perfect storm. Three essential conditions must be met for an throughout the world and within the United States
outbreak to begin: may be interrupted and essential services may be
strained. Excess medical or other personnel will not
• A new flu virus must emerge from the animal reser- be available to fill gaps. Consequently, states must
voirs that have produced and harbored such virus- be prepared to set priorities on service delivery and
es—one that has never infected human beings and facilitate self-reliance.
therefore one for which no person has developed
antibodies. • Medical response capability in a pandemic will be
limited, strained, and potentially depleted during
• The virus has to make humans sick (most do not). a pandemic, and other measures will be needed
• It must be able to spread efficiently, through cough- to control the spread of the disease. Anti-viral
ing, sneezing, or a handshake. drugs may or may not prove effective and certainly
The avian flu virus H5N1 already has met the first two con- will not be available for the entire general popula-
ditions: transfer to humans has been documented and the ef- tion. Vaccines likely will be developed but not in
fects are deadly, with 30 percent to 70 percent lethality, but sufficient quantities or time to inoculate the popu-
the transmission rates to humans and between humans are lation before a pandemic starts. Medical treatment
still relatively low. Recent reports suggest the virus is mutat- also will be limited by lack of equipment—such
ing and could change in ways that allow it to fulfill the third as ventilators—and more importantly by lack of
criterion. When the human-to-human transfer begins, unless trained personnel to operate the equipment. Con-
it is controlled rapidly in the locality of the outbreak, current sequently, in addition to coordinating care, states
levels of international travel could help foster a pandemic in will need to focus on curbing the spread of the dis-
a matter of weeks. ease through actions like restricting public gather-
ings, limiting travel, closing schools, and stressing
This document examines the key issues governors and their personal hygiene (more draconian measures, such
top officials may face should a pandemic occur. It is not in- as isolation and quarantine, may be effective only in
tended to serve as a guidance document for preparing a re- the earliest stages).
sponse plan; the federal government—primarily the De-
partment of Health and Human Services—has provided • Government must work closely with the private
excellent guidance for such planning. Instead, this document sector to ensure critical operations and services
introduces senior state officials to many of the considerations are maintained. Many individuals may be sick and
they will face in developing such plans. incapacitated, affecting a wide range of key servic-
es—such as food, energy, and health care—that are
A pandemic virus may cause a large number of disease in- delivered by the private sector. Economic activity
cidents and deaths; it will cause anxiety and possibly panic will be disrupted severely, but basic services must
among our citizens; and it will cost the nation significant re- still be maintained. States will need to create ad-
ivA Primer for Governors and Senior State officials
visory councils with industry to sustain such func-
tions as food delivery and energy supply. States also
will need to define and communicate the leadership
roles, responsibilities, and lines of authority needed
to maintain government operations. Development
of continuity of operations plans (COOP) will be
critical for both government and business.
• A pandemic will force many key decisions to
be made in a dynamic environment of shifting
events, and partnerships must be built now and
tested to ensure appropriate and rapid action.
The impact of the disease, areas affected, capabili-
ties available, and stages of recovery must be con-
sidered constantly when determining response. For
this reason, states, the federal government, and the
private sector will need to test and evaluate pan-
demic flu plans through periodic exercises that ex-
pose gaps and build relationships among and across
all levels of government and institutions. The abil-
ity to make good decisions “on the fly” will be as
important as good planning made in advance of a
pandemic.
Today, policy makers—and the general public—are becom-
ing well informed about the issues and concerns surrounding
a pandemic. But that does not mean we are fully prepared
to respond. Aggressive planning at the state level must move
forward. Proper planning and training for a pandemic flu will
produce benefits even if a pandemic proves very mild or does
not occur because the preparation involved is transferable to
virtually any type of public health emergency. Done well, pan-
demic flu planning will help the nation become better pre-
pared for all types of hazards.
Preparing for a Pandemic Influenza
Introductioni
When the next pandemic occurs, the impact of the disease the emerging threat of avian influenza and the possibility of a
and our response to it will join the lexicon of nation-changing subsequent pandemic influenza episode.
incidents like Hurricane Katrina and the 9-11 attacks. The
magnitude of this episode will divide forever the progress of Distinguishing Among Risks: When is “Flu”
our nation between its pre-pandemic and post-pandemic his- Not “the Flu”?
tory. It is very difficult with all of the pressures on budgets,
To develop effective solutions for managing in a pandemic, it
time, and resources to respond to a threat that has not yet
is important to understand the distinction between seasonal
manifested on our shores, but some threats are just too great
influenza, which causes yearly epidemics of usually mild respi-
to ignore. Given the potential impact of a pandemic on our
ratory disease; avian flu (or bird flu), which is a severe disease
nation, we must begin our preparation efforts now, when we
almost exclusively affecting poultry; and pandemic influenza,
have the luxury of time.
which will affect humans but have an undetermined impact
A pandemic and the required responses will be like nothing because of uncertainties about when it will occur, the extent
we have witnessed previously. The virus may cause a large of the disease, and the likely number of deaths.
number of disease incidents and deaths; it will cause anxiety
and possibly panic among our citizens; and it will cost the Seasonal Influenza
nation significant resources and effort to effectively respond.
According to the National Strategy for Pandemic Influenza2: In the United States, influenza is a largely misunderstood,
underestimated, and often overlooked disease. Influenza in its
Influenza viruses do not respect the distinctions of routine, seasonal appearance causes 30,000 to 40,000 deaths
race, sex, age, profession or nationality, and are not each year in the United States and 250,000 to 500,000 deaths
constrained by geographic boundaries. The next worldwide. It ranks (with related pneumonias) in the nation’s
pandemic is likely to come in waves, each lasting top 10 causes of death. Seasonal flu is managed by the same
months, and pass through communities of all sizes basic approach each year, i.e., a medical component (princi-
across the nation and world. While a pandemic pally a flu vaccine) that seeks to prevent and treat the disease,
will not damage power lines, banks or computer and an augmenting nonmedical component that seeks to
networks, it will ultimately threaten all critical in- minimize the societal impact.
frastructure by removing essential personnel from
the workplace for weeks or months. This makes Seasonal influenza is as dif- Seasonal influenza
a pandemic a unique circumstance necessitating ferent from pandemic flu as a causes 30 to 40
a strategy that extends well beyond health and tidal surge is from a tsunami. thousand deaths
medical boundaries, to include the sustainment of Both diseases cause illness and
deaths, but they are very differ-
each year in the
critical infrastructure, private-sector activities, the United States,
movement of goods and services across the nation ent in terms of magnitude and
and the globe, and economic and security consid- impact. The annual response ranking it among
erations. The uncertainties associated with influ- to seasonal flu is well charac- the nation’s top 10
enza viruses require that our Strategy be versatile, terized and well understood, causes of death.
to ensure that we are prepared for any virus with involving annual flu shots for
pandemic potential, as well as the annual burden persons most at risk from the disease and staff absenteeism
of influenza that we know we will face. due to illness lasting three to four days. It is also worth not-
ing that despite the numbers of U.S. deaths each year, the
The strategy accurately states that the pandemic threat re- seasonal flu does not invoke significant psychological or psy-
quires “the leveraging of all instruments of national power, chosocial reactions from the general public. However, excep-
and coordinated action by all segments of government and tions from this norm can occur; in 2004, with vaccines in
society.” Governors and lead state officials should prepare for short supply and reports of a possible increase in childhood
i
This paper presents an overview of the most critical issues governors and senior state officials must consider in preparing for a pandemic influenza. It is not intended to
serve as a guidance document from which to construct a detailed state plan. The federal government—particularly the White House Homeland Security Council, Depart-
ment of Health and Human Services, and Department of Homeland Security—is providing such guidance. Instead the purpose of this document is to help state planners
understand the issues involved in response and to motivate state planning efforts.
A Primer for Governors and Senior State officials
deaths, there was greater concern and some degree of panic and processes. At present, the threat to the U.S. agriculture
in a public conditioned to a normal flu season and a normal industry is considered low and the virus is not present in the
medical response. country. Moreover, past experiences with monitoring U.S.
flocks for the development of diseases, including avian flu
Avian Influenza caused by viruses other than H5N1, have shown that early
detection and prompt action can limit the infection to the im-
The H5N1 virus—the cause of the current major concern
mediate locality of the first reported case—the last few out-
about an avian or bird flu in large parts of the world—was
breaks have not progressed beyond the immediate confines
first identified in Hong Kong in 1996. Further outbreaks oc-
of the poultry shed where they were
curred in subsequent years, and in 2001
detected.
the virus began a much wider spread, The current H5N1 avian flu
causing the largest documented out- is chiefly an animal disease, This experience gives a reasonable de-
break of avian flu in the last 50 years. gree of confidence that the nation is
having nearly 100 percent
The spread of a single avian flu virus watchful, aware, and ready to rapidly
(H5N1), demonstrating an as yet un-
lethality in certain bird species. respond to avian flu with plans, poli-
stoppable movement across large parts It does not infect humans cies, and procedures that have proven
of Asia, Eurasia, Africa, and most re- readily; most cases of H5N1 effective against diseases similar to an
cently Europe, appears to signal the influenza infection in humans H5N1-initiated avian flu. However, if
presence of the virus in migratory bird have resulted from contact the H5N1 virus does become estab-
populations. This means that we now lished in a domestic poultry flock, it
with infected poultry (e.g., could be the forerunner of a pandemic
must consider the global spread of this
virus to be an immediate possibility. domesticated chicken, ducks, and undoubtedly will begin to influ-
and turkeys) or surfaces con- ence public perception and behaviors.
The current avian flu virus is generat-
ing concern about the threat to domes- taminated with secretion/ex- Because of its potential for infecting hu-
tic poultry and allied industries in the cretions from infected birds. So mans, an avian flu outbreak of H5N1
affected countries, creating a drain on far, the spread of H5N1 virus will have immediate behavioral and
internal resources and representing a from person to person has been economic effects in an affected country
considerable problem in their relations or state. France, which saw its first re-
limited and has not continued
with neighboring countries and trading ported cases of H5N1 avian infections
partners. However, merely spreading the
beyond one person. However, in February 2006, is reporting an eco-
avian virus does not represent a chal- it has demonstrated high rates nomic impact of over $48 million per
lenge that will be equal in all countries. of lethality in infected humans. month because of depressed demand
for chicken. Italy, also recently infected
Countries with highly regulated, indus-
by H5N1, reports a 70 percent drop in demand for poultry
trial-scale housing of domesticated poultry are less suscep-
and poultry products. The public is responding to the fear
tible and better able to respond to an imminent threat than
of a pandemic by changing behaviors, and similar behavior
those countries with backyard flocks and domestic birds,
should be anticipated in the United States.
which represent an uncontrolled environment for the spread
of the virus and a logistical nightmare for testing and control.
In Asia and Africa, there is uncontrolled spread of avian flu Pandemic Influenza
in countries with poultry farms and, importantly, backyard An episode of pandemic influenza is the viral equivalent of
flocks. The spread in Europe appears to be much more lim- a perfect storm. Three essential conditions must be met for
ited and may indicate what would happen if the virus reaches an outbreak of pandemic influenza to begin. Fortunately they
the United States. rarely converge; unfortunately they are impossible to predict.
Concern about the threat of H5N1 to the domestic poultry 1. A new flu virus must emerge from the animal res-
and allied industries has led to the creation of response plans ervoirs that have produced and harbored such
Preparing for a Pandemic Influenza
viruses—one that has never in- countries with confirmed cases of the disease,
HHS estimates that in a
fected human beings and there- and some sectors such as the travel and hotel
fore one for which no person has moderate influenza pan- industries were affected more than others.
developed antibodies. demic, the United States
SARS caused more than 8,000 cases and
2. The virus has to make humans might experience 209,000 nearly 800 deaths worldwide. Estimates of the
sick (most do not). deaths, with 128,750 economic impact indicate the greatest decline
3. It must be able to spread efficient- patients requiring ICUs in GDP in Hong Kong at 2.6 percent, fol-
ly, through coughing, sneezing, or and 64,875 patients need- lowed by China (1.1 percent) and Taiwan and
a handshake, or through contam- ing mechanical ventilators. Singapore (0.5 percent). Individual economic
inated media such as doorknobs. sectors show more marked affects—for ex-
In a severe pandemic (simi- ample, a decline in retail trade in Hong Kong
The avian flu virus H5N1 already has lar to 1918), the numbers of 15 percent. A study by the Bank of Canada
met the first two conditions: transfer estimated that the SARS crisis cut Canada’s
to humans has been documented and
could rise to 1.9 million
GDP in the in the second quarter of 2003 by
the effects are deadly, with 30 percent deaths, with 1.5 million
0.6 percent.
to 70 percent lethality. However, the needing ICUs and 742,000
transmission rates to humans and be- needing ventilators. Under SARS was a relatively short-lived outbreak
tween humans are still relatively low. 3 that lacks some of the more worrisome char-
both scenarios, 30 percent of acteristics of a pandemic influenza. It can
Recent reports4 suggest the virus is mu-
the population (90 million) be anticipated that a pandemic would have
tating and adapting in ways that may
increase its probable fulfillment of the would contract the illness an even more disruptive effect on societies
third criteria. Once adapted, the avian and 45 million would need and economies. With unlimited geographic
flu will have the potential to become a outpatient care. spread, a pandemic could rapidly affect popu-
pandemic and time will be short. When lations, social infrastructures, and economies
the human-to-human transfer begins, unless it is rapidly con- in all countries, painting a grim picture for the
trolled in the locality of the outbreak, it is estimated that with whole world. Given the greater level of disease and death that
current levels of international travel it will become a pandem- a pandemic would cause, the effects could be magnified sev-
ic in a matter of weeks.5 eral-fold.
Three pandemics occurred in the last century—in 1918, 1957, In a recent report, the U.S. Congressional Budget Office esti-
and 1968. Each caused significant human morbidity (illness) mated the impact of a severe outbreak of pandemic influenza
and mortality (deaths). Some experts have estimated that would cause a decline in U.S. GDP of five percent in the year
the worst of these, the 1918 pandemic, may have caused over it occurred, equivalent to
50 million deaths worldwide in less than 12 months. In the Epidemics could last six $500 billion in 2004 dol-
opinion of many experts and organizations such as the World to eight weeks in affected lars. A moderate outbreak
Health Organization (WHO) and the U.S. Department of areas. Multiple waves of would have less impact but
Health and Human Services (HHS), a new pandemic based illnesses are likely, with still cause a 1.5 percent de-
on effective transmission of the H5N1 flu virus will have a each wave lasting two to cline, equivalent to $160
significant—but as yet unquantifiable—impact. billion in 2004 dollars
three months. During
and comparable to the im-
In addition to their human toll, pandemics can have enormous each wave, absenteeism pact of SARS on affected
social and economic consequences. For example, in 2003 the rates could reach 40 per- countries in 2003.
more localized epidemic of severe acute respiratory syndrome cent in a severe pandemic
(SARS) caused economic losses and social disruption far be- Avian flu presents an un-
from illness, caring for certain but potentially
yond the affected countries and far out of proportion to the sick family members, and significant threat of a new
number of cases and deaths. Most experts agree the greatest fear of social contact.
impacts of the SARS outbreak were on the economies of the human pandemic. As of
A Primer for Governors and Senior State officials
March 1, 2006, WHO re- our personnel, and our state prepared to prevent or minimize
ported 174 confirmed cases The SARS out- the human morbidity and mortality, the social disruption,
of H5N1 infection in hu- break—though disrup- and the economic consequences caused by an influenza pan-
mans and 94 deaths, dem- tive—lacks some of the demic?” It is the entire question that needs to be answered,
onstrating a mortality rate more worrisome char- not merely the issue of a medical response to the death and
of around 50 percent of in- acteristics of a pandemic disease caused by this uncertain threat.
fected people. At this level,
the H5N1 virus is one of
influenza. For example, Management of an outbreak, including a considerable medi-
SARS carriers typically cal and public health component, has been the primary fo-
the most deadly human dis- cus of the pandemic planning at the national and state levels.
eases ever reported, on par exhibited symptoms
However, maintaining operations during an outbreak is rap-
with the Ebola and Marburg (e.g., fever) while conta- idly becoming an equal concern because of the impact that
viruses in terms of lethality. gious and required close the disease will have on economic, social, and political aspects
Moreover, viruses that are contact to spread the in- of our nation’s day-to-day routine.
closely related to H5N1 fection. A pandemic flu State and local officials must address not just the immediate
(so-called Type A Influen- carrier might not show outbreak of influenza, but also the interpandemic phase and
za viruses) have shown an the possibility that the worst effects may occur in a second or
ability to evolve to become any symptoms for up to
two days while still third wave. Based on a historic review of pandemic episodes,
effectively passed (transmit- it is likely that the initial pandemic episode (or wave) will last
ted) from human to human. shedding the virus, thus 8-12 weeks. It will be followed by a second and possibly even
If this form of H5N1 is making it harder to a third wave of disease that will occur 8-12 weeks after the
established and effective isolate. initial wave of the disease has passed. The entire pandemic
human-to-human transmis- period may take over a year to complete the three phases.
sion occurs, it will be very easy for the highly infectious virus During each interpandemic phase, there will be an opportu-
to spread rapidly in human populations and across the globe. nity to recover and prepare for a future outbreak, but this will
In our interconnected and interdependent world, with rapid represent a time of considerable stress for the public and an
and extensive international and intercontinental travel, it is exhausted responder community.
not hard to imagine (or model) the worldwide spread of the
virus and the disease in what is called a pandemic. After a pandemic wave is over, it can be expected that many
people will have lost friends or relatives, suffer from fatigue,
The avian flu or a human pandemic can manifest in the Unit- or have financial losses as a result of the interruption of busi-
ed States through viral spread or in U.S. citizens returning ness. State governments or other state or local authorities
from travel to areas where the virus is active. If H5N1 enters will need to address these concerns while also preparing to
the United States, it will impact every facet of our daily lives respond to the next phase or wave of disease.
and potentially cause untold damage to our economy and
threaten the social fabric of our communities. These threats A key priority will be ensuring that government operations
will engage every level of government and potentially impact continue. Each agency must develop a list of service priori-
every citizen. ties and then develop
State and local officials plans for meeting those
The Role of the Governor and Lead State must address not just the priorities. Continuity of
operations (COOP) and
Officials in Managing a Pandemic immediate outbreak but
continuity of govern-
To prepare for a pandemic, governors and state officials must also plan for the inter- ment (COG) documents
consider not only how to manage the outbreak, but also how pandemic phase and the should incorporate such
to maintain continuity of operations during the outbreak. possibility that the worst plans.
Fundamentally, the magnitude of the issues inherent in pan- effects may occur in a
demic preparedness can be expressed in the question, “Are we, second or third wave.
Preparing for a Pandemic Influenza
Developing an Effective Pandemic Plan
It is important for state-level planning to address both man- • Does the state have an effective communications
aging the spread of the pandemic—focusing on medical in- plan and strategy? Are all the key state person-
terventions and enacting other measures to prevent disease nel aware of their roles and responsibilities in the
spread—and managing in the pandemic—focusing on main- communication plan? Does the state have back-up
taining continuity of operations and continuity of govern- plans in the event that one or more functions fail
ment. Managing in a pandemic—with considerable loss of due to infrastructure or manpower losses during
staff, depleted resources, a struggling economy, and a nervous the epidemic?
public—will be a considerable challenge to local and state Accordingly, plans must stress communication, intergov-
leadership. ernmental coordination, public education, health resources,
In addition, the evolving nature of the threat means the plan- curbing economic impacts, maintaining essential services,
ning process needs to be iterative and updated as new informa- using appropriate legal authority to stop disease spread, and
tion becomes available. So many of the pandemic characteris- training.
tics are uncertain, and will remain uncertain until the outbreak Clearly define and communicate leadership roles, respon-
occurs, that a fixed plan is unlikely to be a successful plan. sibilities, and lines of authority for the response at all
levels. Defining roles and responsibilities across the govern-
Key Steps in Planning for a Pandemic ment and private sectors, and designating personnel (and
Effective plans must answer the following basic questions: trained back-ups) to fulfill essential activities will be needed
prior to the incident. Prior to a catastrophic event, these roles
• Is there recognition of the potential human, social, must be communicated effectively to facilitate rapid and ef-
and economic impact of a pandemic within the fective decision-making. This framework can then inform
state and region? and create the local and community level plans that are the
• Are there public and private The efforts key to success against a major threat like the pandemic virus.
sector commitments to prepare involved in Encompass both the horizontal and vertical domains. The
for such an event? developing an plan must include all state (horizontal) assets, including gov-
• Is there a strategy on how to effective pan- ernment and private-sector capabilities, while vertically link-
involve the community in the demic plan also ing national efforts with local requirements. The National
planning process? will improve the Strategy for Pandemic Influenza states a pandemic will re-
quire “the leveraging of all instruments of national power,
• Have ethical aspects of policy state’s capacity
and coordinated action by all segments of government and
decisions been considered? Is for addressing society.” As the chief executive of the state, the governor is
there a leading ethical frame- many other uniquely positioned to provide the nexus for this horizontal
work that can be used during
the response to an outbreak to public health and vertical integration.
balance individual and popula- emergencies. In the horizontal domain, it will be essential that state of-
tion rights? ficials are able to coordinate the state-based powers vested in
the office of the governor and use them effectively to manage
• Is a legal framework in place for the state pandemic
in a pandemic. For example:
plan? Does this framework include contingencies
for health-care delivery and the maintenance of es- • Identifying the sectors that are most vulnerable dur-
sential services, and for the implementation of pub- ing a pandemic will help to determine the potential
lic health measures? impact and how the effects might be mitigated. For
example, states with significant service-based econ-
• Has the state prioritized countermeasure allocation
omies and tourism may be hard hit by restrictions
before an outbreak? Can the state update this pri-
on travel and public gatherings.
oritization immediately after the outbreak begins
based on the at-risk populations, available supplies,
and characteristics of the virus?
A Primer for Governors and Senior State officials
• Testing and assessing plans that allow staff to pro- The planned response to pandemic influenza must develop
vide critical capability while reducing pandemic a capacity to provide effective communication to the public
spread, including working from home or telecom- to minimize negative behaviors, accentuate positive actions,
muting. Many states or state agencies may find, for and—based on the Canadian SARS experience—limit the
example, that they do not have psychosocial and psychological impact
sufficient bandwidth or server HHS has developed avian and of imposing public health measures that
capacity to allow large-scale pandemic influenza communica- include movement restrictions.
telecommuting of its workforce. tion tools that draw on best prac- Developing appropriate messages and
• Addressing the problems of tices in communication science. selecting trained (and trusted) mes-
conducting state business and sengers who can communicate with the
developing new requirements These tools, or “message maps”, public should be done now. The federal
for conducting state business distill information into easily government, through the Department
(including emergency mea- understood messages written at of Health and Human Services, offers
sures) when travel, meeting, and a 6th grade reading level. Mes- a wealth of information on developing a
social contact are limited to pre- sages are presented in three short communication strategy on its Web site.
vent the spread of disease. Establish a pandemic preparedness
sentences that convey three key
• Assessing how governors can messages in 27 words. The ap- coordinating committee that repre-
use, explain, and enforce emer- sents all relevant stakeholders in the
gency powers against a back-
proach is based on surveys show- region. Such a committee should in-
ground of public unease and ing that lead or front-page media clude government representatives from
possibly panic. and broadcast stories usually all applicable disciplines (such as public
All of the above should be reviewed convey only three key messages safety, public health, homeland security,
and tested through exercises with usually in less than nine seconds agriculture, emergency management,
and education), private sector represen-
neighboring states to harmonize re- for broadcast media or 27 words
sponse actions and continuity plan- tatives from all critical service industries
for print. Each primary message (including, of course, health care), and
ning. Equally, in the vertical domain,
has three supporting messages relevant volunteer organizations. The
lead state officials will be the point
of entry for any federal engagement. that can be used when and where purposes of such a committee are to
States will need to work closely with appropriate to provide context review and coordinate procedures for
their federal partners and establish for the issue being mapped. delivering health resources, backfilling
relationships with key personnel to personnel and equipment, and continu-
See www.hhs.gov for ing operations of critical services.
ensure the speed and quality of deci- more information.
sion-making during a pandemic. Un- In particular, coordination of health care
like most other crises, a pandemic creates significant limita- assets will be crucial since they exist in the pubic, private, vol-
tions in what the federal agencies can and will provide during unteer, and faith-based domains. Assessing what is available
the incident. Gaining insight into these limitations, leverag- and taking care not to double-count assets will be very impor-
ing the individual strengths in each state that can be used, tant. For example, it may be tempting to add together public,
and acknowledging the possible loss of state assets—such as private, and National Guard EMS personnel, when in fact
the National Guard forces—to federal requirements, will all the same individual may be represented in all three categories.
be important roles for state planning and responses to the Moreover, the availability of such personnel will be affected
threat. by potential federal call-up of National Guard reserves.
Develop strategies to engage and educate the public. Pub- Assess likely economic impacts. In a pandemic situation,
lic education campaigns should be developed now to begin the most immediate economic impact might arise not from
to enhance the public’s understanding of pandemic flu and the number of cases and deaths, but from uncoordinated ef-
build a trusted relationship with the response community. forts of the general public to avoid becoming infected. The
Preparing for a Pandemic Influenza
likely result would be both a “demand shock” for service sec- society because of the essential goods and services
tors, such as tourism and mass travel, and a “supply shock” due that it provides. Moreover, it touches the major-
to workplace absenteeism, disruption of production processes, ity of our population on a daily basis, through an
and shifts to more costly procedures. In addition, emergency employer-employee or vendor-customer relation-
measures, such as quaran- ship. For these reasons, it is essential that the U.S.
tines and restrictions on The combined effect private sector is engaged in all preparedness and
travel and trade, could add of a reduction in state response activities for a pandemic. Critical infra-
to the economic disruption income and increases structure entities also must be engaged in plan-
and increase its costs. in spending will impact ning for a pandemic because of our society’s de-
pendence upon their services.
A significant loss of state state budgets signifi-
output could arise from a cantly. An assessment Review state legal instruments. Implementing some or all
reduction in the size and of the measures in a pandemic plan will require not only re-
of the economic impact
productivity of the state la- sources allocation but possibly also the use of specific poli-
bor force due to illness and of a pandemic and the cies or legal instruments. For example, state laws pertaining
death. Further losses would options to address a to movement, activity restrictions, or quarantine may need to
come from the costs of hos- budget shortfall should be used to reduce the spread of the disease. However, the dif-
pitalization and medical be done in advance of ferences between state laws may make regional action a more
treatment. The combined the pandemic outbreak. difficult proposition.
effect of a reduction in state In the case of the risks from a possible pandemic influenza,
income and increases in spending will impact state budgets concerns about differences between state laws led to federal
significantly. An assessment of the economic impact of a pan- action that can be used to augment state law and help ensure
demic and a corresponding examination of the options to ad- coordination between states and across regions. On April 1,
dress the budget shortfall are prudent actions that should be
taken well in advance of the pandemic outbreak. Governors should consider creating a state legal
Determine how to provide goods and services. During a team to review current laws and regulations and
pandemic, changes in daily routines and negative behaviors assess how they would be applied during a pan-
(such as hoarding) will deplete normal stockpiles of materiel demic. Developing expertise in this area now will
and resources. Maintaining normal daily routine activities
will be a key element in managing in a pandemic. Many criti-
aid the rapidity and appropriateness of decisions
cal resources required to manage in a pandemic are in the pri- made during a pandemic. Moreover, as part of
vate sector. The integration of those capabilities into the state preparation, a range of potential actions should
response will be essential and can be achieved most effectively be reviewed with community leaders.
through the office of the governor. The National Strategy for
Pandemic Influenza identified some of the key challenges: 2005, the President signed Executive Order 132956 that ex-
Movement of essential personnel, goods and ser- tends the federal quarantine regulations (and several other
vices, and maintenance of critical infrastructure components of the Public Health Service Act) to cover avian
are necessary during an event that spans months flu or pandemic influenza. This action provides substantial
in any given community. In order to minimize help to officials tasked with managing a pandemic influenza
public concerns during the pandemic the private episode.
sector and critical infrastructure entities must Other policies and law are not likely to be supplemented by fed-
respond in a manner that allows them to main- eral legal code and will require specific state and local actions.
tain the essential elements of their operations for For example, decisions on closure of schools, limits on use or
a prolonged period of time, in order to prevent practices on mass transit or public transport systems, restric-
severe disruption of life in our communities. The tions on public gatherings, etc., must be determined by state and
private sector represents an essential pillar of our local officials and supported by local or state policies and law.
A Primer for Governors and Senior State officials
Imposing public health and other restrictive measures may Establish ways to exchange information with other states.
require the use of specific (new) laws and policies to address By its very nature, a pandemic will impact not just one state
pandemic-imposed problems. A comprehensive review of but all states. Governors can lead the way in ensuring neigh-
current laws and regulations, and an assessment of how they boring states work together to coordinate plans, policies, and
would be applied during a pandemic, should be undertaken procedures that will be used to respond during a pandemic.
now. Moreover, if such actions are to be seen as being fair
As previously mentioned, governors should consider creating
and equitable, they will need to be discussed with commu-
regional coordinating counsels and having their state partici-
nity leaders. Beginning the process
pate in regional exercises. The creation
of consultation in communities well Tabletop exercises can be valuable in
of clearinghouses to share information
in advance of the emergence of the
helping decision-makers test response also should be considered. Effective
pandemic disease outbreak will have
clear advantage over implementation actions. For a pandemic flu exercise, communication and sharing of plans
and concerns with fellow state officials
without consultation during the dis- states should assemble teams that will develop a sound national strat-
ease episode. include key government (state and egy, leverage the capacity for mutual
Health care and public health inter- local), private sector (essential indus- aid, and reduce redundant work that
ventions also may require state and tries), and public (media, volunteer, wastes scarce human resources and
local policies and legislation. A pan- and faith-based) stakeholders. precious time as the threat advances.
demic outbreak will impact the avail-
Representatives from a variety of Perform training exercises. Exercises
ability of personnel for essential (and
government functions should be should be planned and performed to
nonessential) functions provided by
assess current capabilities and explore
state and local agencies and the pri- included, such as public health, police,
effective options for incident response.
vate sector. Although a pandemic emergency response, education, and Initiating even the most basic exercises
likely will overwhelm the number of the office of the Attorney General. now will save lives during a future inci-
public and private health care provid- Scenarios examined might include dent. At a minimum, each state should
ers available, states still should review
one in which a pandemic virus has have answers to all of the questions
their procedures on credentialing or
licensing health care personnel from emerged but has not yet reached the noted on page 6 and have tested these
answers in a simulation or exercise that
other states. If personnel can be trans- United States, a severe pandemic
engages the appropriate personnel.
ferred from other regions, states will scenario, and a mild pandemic sce-
want to ensure there are no barriers. nario. Situations tested might include Federal partners should be included
in most if not all of the state exercises.
There will be issues with providing continuity of operations under vari- Involving the public and the media in
qualified health care and medical ca- ous absenteeism assumptions, health these exercises also will be of value
pability for both emergent pandemic
influenza victims (of which there may
care surge capacity, circumstances and and will help to inform the commu-
criteria for closing schools, restric- nication and behavioral component
be thousands in each community)
tions on public gatherings, and of a response. Finally, some regional
and for providing routine day-to-day
drills with neighboring states also are
health and medical delivery services. vaccine and/or antiviral distribu-
recommended.
It is important to note that health tion. Ideally, some exercises should be
emergencies and routine care will not
conducted with neighboring states to A key aspect of any exercise at the state
diminish during the time of the out- level should be to assess how the state
break. Some routine procedures can test resource sharing and coordinat- can continue to provide essential servic-
be delayed, but policies for providing ing actions, such as school closings or es in the absence of significant support
them need to be addressed well in ad- travel restrictions. from the federal agencies. The state
vance and should include communica- must test its ability to function without
tion with the public that will be impacted by the decisions. reliance on federal or regional assets and resources to reflect the
likely conditions that will prevail during a pandemic.
Preparing for a Pandemic Influenza
Meeting essential needs during a crisis will pose technical scared to leave home and work. Undertaking exercises and
and logistical challenges to state and local officials. Essen- using models (such as the Centers for Disease Control and
tial needs include goods (e.g., food, water, and medical sup- Prevention (CDC) FluAid and FluSurge models) to assess
plies), services (e.g., sanitation, energy, and communication), the impact on state populations will help to develop effective
public safety and security (police, fire, and rescue), financial responses at the state and local levels.
services, mental health care, and many other activities. As- The use of exercises will help to define national and state-
sessing these requirements and identifying solutions that specific requirements. Sharing of data from these exercises
combine actions by the public and private sectors can be will help prepare regions and the nation to face any pandemic
achieved most effectively through exercises undertaken well incident and can inform other incidents involving naturally
in advance of any outbreak. occurring diseases or bioterrorism threats.
In addition, personnel losses through sickness, caring for sick
family members, and forced absenteeism (e.g. taking care of
children at home when schools are closed) will be substan-
tial. They will be compounded by absenteeism by persons too
Governors’ Considerations During the Preparedness Phase
Promote Self-Reliance o How the federal government plans to communi-
cate with governors’ federal strategies to contain
• Encourage and invest in increased food storage in pan-
and mitigate situations;
tries in government facilities such as schools, pris-
ons, cafeterias, group homes, and state institutions. o Federal agreements with private companies regard-
Encourage businesses, [the] faith-based community, ing interstate commerce; waiver of primary home/
and individuals to do the same. business foreclosures; waiver of health insurance
limitations on amount of medications an individual
• Stockpile equipment and supplies which may be in
can stockpile through private insurance; etc.
short supply such as masks, ventilators, hand sani-
tizers, medications such as antivirals, and some • Conduct a legal review and discussion regarding what
antibiotics for pneumonia. circumstances would call for a State of Emergency or
Public Health Emergency and what state laws may
• Identify ways for state government to continue to pro-
need to be waived.
vide essential services during a pandemic influenza
such as employees telecommuting from home. Ask
businesses and local governments to do the same and Communications
set up a coordinating council that includes member- • Keep communities informed of the seriousness of pan-
ship of key government agencies, essential private demic influenza and what they should do to prepare.
sector industries, and the volunteer and faith-based Inform public of state strategies and response limita-
community to help plan for continuity of essential tions such as effectiveness of quarantine and isolation
operations. (effective chiefly in early stages), and priority distri-
bution of limited medications such as antivirals to
• Review and address actions and impediments for im-
health workers and others first responders before the
plementing quarantine or social distancing.
general population.
• Institute programs which promote good hygiene prac-
Knowledge
tices in schools, workplaces and other public places.
• Ensure you and your key staff have a good understand-
• Prepare emergency messages such as public service an-
ing of federal role, strategies, and agreements including:
nouncements, to reach all communities including
o Incident Command System for federal government; non-English speaking and persons with special needs.
10A Primer for Governors and Senior State officials
Continuity of Operations and Government Plans
A pandemic has unique characteristics when compared with • Who are the core people required to manage the
a more “typical” disaster, and some of these characteristics will pandemic contingency plan?
impact how government (and businesses) can operate. It will • Does the state have any systems that rely on pe-
be important to consider how existing Continuity of Opera- riodic physical intervention by key individuals to
tions Plans (COOP) and Continuity of Government (COG) keep them going? How long would the system last
plans can be modified to account for a pandemic episode. without attention?
COOP and COG plans will need to be reviewed to ensure Once the core people and skills are identified, the state must
they can withstand significant staff absences and other pan- ensure key personnel are aware of their position and how they
demic-related risks. The impact of a pandemic on staffing lev- will be managed in the event of a pandemic. Plans should con-
els is not confined merely to those who are sick or deceased. sider strategies for minimizing the possibility that these peo-
Staff absences can be expected for many reasons: ple will become ill with influenza, e.g., allowing them to work
• suspected illness or recovery from actual illness; from home even in the very early stages of a pandemic, or
use other social distancing measures. If working from home
• caring for the ill; is not a well-established practice in the office, agencies and
• looking after school-aged children (as schools are businesses may wish to conduct some large-scale tests with
likely to be closed); employees to iron out any procedural or technological issues,
• feeling safer at home (e.g., to keep out of crowded such as bandwidth, access, server capacity, and security.
places such as public transport); and Finally, when considering the impact on the state, it will be
• fulfilling other voluntary roles in the community. essential to maximize performance and resilience among
state and local leaders and personnel providing critical infra-
With the exception of incapacitated staff, most of the absen- structure capacity. This task will be particularly challenging
tee workforce can provide some useful functions for a govern- in light of the grief, exhaustion, anger, fear, family and self-
ment or business operation. However, this requires planning care issues, and ethical dilemmas likely facing this critical
and possibly investment in technology to permit completing group. Leaders and personnel also may be subject to social
office work in the home or elsewhere. and economic factors that
In the event of a pandemic, it is important that core people may affect their ability to Using models (such as
and core skills are available to keep essential parts of a gov- perform crucial tasks and the CDC FluAid and
ernment agency or office operating. To permit the effective functions adversely—an FluSurge models) to
implementation of COOP and COG, lead state officials important consideration estimate the numbers of
should consider: that highlights the need
to create leadership re- people in a state affected
• What are the essential parts of state government by a pandemic under
serves and “just in time”
and state business? Who are the core individuals various scenarios can
training packages.
required to keep the essential parts of the state run-
ning?
help identify needs and
effective responses at the
• What are the core skills required to keep state gov-
ernment running, including specific licensure and
state and local levels.
certification needs for key positions? Are there suf-
ficient backups for people and skills if there is a
high level of absence?
• Are there other resources (e.g. volunteers, retirees)
that could be drawn on if necessary?
• Is it possible to coordinate or operate through a
“virtual” governor’s office, remotely, using telephone
and email?
11Preparing for a Pandemic Influenza
Public Communication Strategies
Both before and during a pandemic, state and local officials crisis in a way that helps to build, maintain, or restore public
should assume responsibility for extensive interaction with trust. This can be accomplished if officials:
the public. Many of the mechanisms that are effective for • involve the public in planning efforts early and often;
communication and public education on citizens’ role in dis-
• offer guidance and statements that are easily under-
ease control and on potentially controversial subjects such as
stood;
quarantine and isolation, the management of scarce resourc-
es, and the capacity limits of the health care system can be • supply factually correct and comprehensive infor-
developed in advance of any pandemic influenza crisis. These mation;
systems, when properly implemented, will not vary much for • provide briefings about government actions with
different infectious diseases and can be adjusted to adapt to complete candor and transparency; and
the unique characteristics of specific diseases, as the situation
warrants. • tailor messages to accommodate public beliefs,
opinions, and cultural sensitivities.
It is worth noting that excellent reviews of risk communication
issues are being published in the peer-reviewed scientific litera- Communicating Before a Pandemic
ture. Some of the key findings in that research that impact the
development of guidelines and best practices for a pandemic Public education campaigns should be developed now to en-
influenza communications plan include the following: hance the public’s understanding of pandemic flu and build a
trusted relationship with the response community. Residents
• Trust is particularly important when there is inad- may be more assured if it is obvious that states with interna-
equate time or information to assess which actions tional points of entry or crowds associated with tourist attrac-
should be taken, or when the perceived threat of an tions anticipated their vulnerabilities and informed the public
immediate hazard complicates decision-making for about how they may act when the pandemic is spreading.
the individual.
Faced with the continuing spread of the H5N1 virus as an
• Communicating risk entails confronting important endemic disease in wild birds
uncertainties, some of which are irreducible.
State and local of- and the possible spread of the
• Assessment of risks is determined not by facts but ficials should assume disease by migratory birds
by emotions. to countries, it will be im-
responsibility for
• Risk is a combination of a probability of something portant for state officials to
extensive communica- remain vigilant and knowl-
happening, a feeling of the dreadfulness of the
tion with the public. edgeable about the current
event, and a context for the event.
To help ensure the status of these outbreaks. In
• There is little evidence that knowledge of risk as states with significant poul-
accurate delivery of
embodied in professional assessments influences try (or poultry-related) in-
the ways in which the general public perceives and information, state
dustries, the state agriculture,
responds to risks and dangers. officials should brief commerce, and public health
• Fear disturbs the balance between rational and ir- and inform key local staff likely are well prepared.
rational behavior. media representatives It will be important for most
• Mass communication is mediated or filtered in dif- on the states’ com- other states to maintain a
ferent ways, through the diverse groups that com- munication plans and good situational awareness
about the disease and to en-
prise society. spokespeople. Good
sure they have plans for ef-
• The public extracts the gist of any information— media relationships fective responses that can be
not the detail—to make decisions. built on trust will help implemented at short notice.
The primary goal for public officials, especially at the state ensure the rapid flow It also will be important for
and local level, will be communicating with the public in a of good information. all states to consider what will
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