Key Elements of Departmental Pandemic Influenza Operational Plans

August 2008 

The National Strategy for Pandemic Influenza Implementation Plan requires Federal departments and agencies to develop plans addressing (1) protection of employees, (2) maintenance of essential functions and services, (3) support for the Federal response, and (4) communication with stakeholders about pandemic planning and response. The Federal departments, agencies, and independent organizations are hereinafter referred to as "agencies." In November 2006, Homeland Security Council (HSC) staff requested that department and agency heads certify in writing to the HSC that their respective department or agency was addressing the applicable elements of pandemic planning set forth in a checklist developed and published at http://www.flu.gov. That checklist provided a mechanism to assist agencies in developing their pandemic plans and ensured uniform preparedness across the U.S. Government. 

The Ongoing Nature of Planning and Preparedness: Since 2006, preparedness efforts have matured, new challenges have been identified and addressed, and more Federal guidance has been released. Pandemic planning is not a static process; as a result, agencies have been encouraged to participate in interagency meetings, monitor the central web-based repository for all Federal guidance at http://www.flu.gov/professional/federal/, and to revise their own plans and procedures accordingly. In August 2008, the checklist below was updated following an HSC interagency process to reflect current Federal Government guidance. It is for internal agency use only, and is not intended to serve as a reporting mechanism to any third party. 

General Instructions: Agencies should address all applicable elements of pandemic planning set forth in the updated checklist below. Each planning element question is complemented with Comments and Supporting Documents fields (for internal agency use to document how and where the applicable elements are addressed). New or updated planning elements are identified in the Comments field. Agencies should implement the applicable planning elements and synchronize pandemic planning with the Stages of the Federal Government Response.¹  Pandemic response activities should align with CDC’s Intervals, Triggers, and Actions framework (see Appendix A). Agencies should plan with the assumption that up to 40 percent of their staff may be absent for periods of about 2 weeks at the height of a pandemic wave with lower levels of absenteeism for a few weeks on either side of the peak. In addition, agencies should plan for Pandemic Severity Index Category 5 (a severe pandemic) and therefore, plan for prolonged implementation of community mitigation measures² that could impact workforce absenteeism such as school closure for up to 12 weeks. 

Department and Agency Certification: In order to ensure that agency pandemic plans are current and to ensure uniform preparedness across the U.S. Government, the HSC has requested that all agency heads certify in writing to HSC, by October 15, 2008, that their agency is addressing the applicable elements of pandemic planning set forth in the updated checklist below. 

Essential Functions: As with all continuity plans, Federal Continuity Directives 1 and 2 guide the identification of essential functions. Agency pandemic influenza plans should ensure continuity of Primary Mission Essential Functions (PMEFs) and Mission Essential Functions (MEFs) throughout a pandemic. Due to the extended duration of a pandemic, essential functions addressed within pandemic plans would also include functions that cannot be deferred for 12 weeks or more without impact to an agency’s mission. In addition, agency plans may address non-essential functions that could be deferred, but can be continued through telework or otherwise modified operationally to keep employee(s) from being at risk while performing those functions (as with all essential functions). The functions (and services supporting them) addressed within pandemic planning may be performed by Federal agency employees or contractors
  

Appendix A 

Pandemic Intervals, Triggers, and Actions 

In November 2005, the President of the United States released the National Strategy for Pandemic Influenza, followed by the Implementation Plan in May 2006.  These documents introduced the concept of “stages” for Federal Government response.²⁰ The six USG stages have provided greater specificity for U.S. preparedness and response efforts than the pandemic phases outlined in the World Health Organization (WHO) global pandemic plan.²¹ The stages have facilitated initial planning efforts by identifying objectives, actions, policy decisions, and messaging considerations for each stage.  While the stages have provided a high-level overview of the Federal Government approach to a pandemic response, more detailed planning for Federal, State, and local responses requires a greater level of specificity than is afforded with the current USG stages.  

The Pandemic Intervals 

The incorporation of known principles regarding epidemic influenza transmission, along with the adoption of well-defined triggers for action, will enhance the development of more detailed plans and guidance.  Moreover, these refinements will facilitate better coordinated and timelier containment and mitigation strategies at all levels, while acknowledging the heterogeneity of conditions affecting different U.S. communities during the progression of a pandemic. 

Typically, epidemic curves are used to monitor an outbreak as it is occurring or to describe the outbreak retrospectively.  While epidemic curves are useful during an outbreak or retrospectively for noting the possible effects of interventions (graphically showing when they are or were implemented relative to the rise and fall of the epidemic), model epidemic or pandemic curves can also be used to describe likely events over time.  These hypothetical models may be particularly valuable prospectively for anticipating conditions and identifying the key actions that could be taken at certain points in time to alter the epidemic or pandemic curve.  Classic epidemic curves have been described in the literature as having a: growth phase, hyperendemic phase, decline, endemic or equilibrium phase, and potentially an elimination phase.^22,23 

For the purposes of pandemic preparedness, the Federal Government will use intervals representing the sequential units of time that occur along a hypothetical pandemic curve.^24,25   For State and local planning, using the intervals to describe the progression of the pandemic within communities in a State helps to provide a more granular framework for defining when to respond with various interventions during U.S. Government stages 4, 5 and 6 (Figure 2).  These intervals could happen in any community from the time sustained and efficient transmission is confirmed.  

While it is difficult to forecast the duration of a pandemic, we expect there will be definable periods between when the pandemic begins, when transmission is established and peaks, when resolution is achieved, and when subsequent waves begin.  While there will be one epidemic curve for the United States, the larger curve is made up of many smaller curves that occur on a community by community basis.  Therefore, the intervals serve as additional points of reference within the phases and stages to provide a common orientation and better epidemiologic understanding of what is taking place.  State health authorities may elect to implement interventions asynchronously within their States by focusing early efforts on communities that are first affected.  The intervals thus can assist in identifying when to intervene in these affected communities.  The intervals are also a valuable means for communicating the status of the pandemic by quantifying different levels of disease, and linking that status with triggers for interventions. 

The intervals are designed to inform and complement the use of the Pandemic Severity Index (PSI) for choosing appropriate community mitigation strategies.²⁶ The PSI guides the range of interventions to consider and/or implement given the epidemiological characteristics of the pandemic.  The intervals are more closely aligned with triggers to indicate when to act, while the PSI is used to indicate how to act.

Figure A: Periods, Phases, Stages, and Intervals

Definitions of the Different Pandemic Intervals 

For each interval shown in Figure A, a definition of the interval is provided below for communities, States and for the Nation. 

For States that are “affected” (i.e., they have met the definition for the interval), selected actions to initiate during the interval are provided.  For States that are “unaffected” (i.e., they have not met the definition for the interval at a time when other States have met the definition), selected actions and preparations are provided.  Questions regarding the use of these intervals can be obtained at intervals@cdc.gov. 

“Investigation” Interval – Investigation of Novel Influenza Cases:  This pre-pandemic interval represents the time period when sporadic cases of novel influenza may be occurring overseas or within the United States.  During this interval, public health authorities will use routine surveillance and epidemiologic investigations to identify human cases of novel influenza and assess the potential for the strain to cause significant disease in humans.  Investigations of animal outbreaks also will be conducted to determine any human health implications.  During this interval, pandemic preparedness efforts should be developed and strengthened.  Case-based control measures (i.e., antiviral treatment and isolation of cases and antiviral prophylaxis of contacts) are the primary public health strategy for responding to cases of novel influenza infection.  The national case definition for novel influenza is located at http://www.cdc.gov/ncphi/disss/nndss/casedef/novel_influenzaA.htm. 

Affected State – A State where a sporadic case of novel influenza is detected.

• Voluntarily isolate and treat human cases
• Voluntarily quarantine if human-to-human transmission is suspected, monitor, and provide chemoprophylaxis to contacts
• Assess case contacts to determine human to human transmission and risk factors for infection
• Share information with animal and human health officials and other stakeholders, including reporting of cases according to the Nationally Notifiable Diseases Surveillance System and sharing virus samples
• Disseminate risk communication messages

Unaffected State – A State not currently investigating novel influenza cases.

• Continue to maintain State surveillance
• Continue to build State and local countermeasures stockpile
• Continue to develop and promote community mitigation preparedness activities, including plans and exercises
• Continue refining and testing healthcare surge plans

“Recognition” Interval – Recognition of Efficient and Sustained Transmission:  This interval occurs when clusters of cases of novel influenza virus in humans are identified and there is confirmation of sustained and efficient human-to-human transmission indicating that a pandemic strain has emerged overseas or within the United States.  During the recognition interval, public health officials in the affected country and community will attempt to contain the outbreak and limit the potential for further spread in the original community.  Case-based control measures, including isolation and treatment of cases and voluntary quarantine of contacts, will be the primary public health strategy to contain the spread of infection; however, addition of rapid implementation of community-wide antiviral prophylaxis may be attempted to fully contain an emerging pandemic. 

Affected State – A State where human to human transmission of a novel influenza virus infection is occurring and where the transmission of the virus has an efficiency and sustainability that indicates it has potential to cause a pandemic.  This represents the detection of a potential pandemic in the United States before recognition elsewhere in the world.

• Continue/initiate actions as above (Investigation)
• Implement case-based investigation and containment
• Implement voluntary contact quarantine and chemoprophylaxis
• Confirm all suspect cases at public health laboratory
• Consider rapid containment of emerging pandemic influenza
• Report cases according to Nationally Notifiable Diseases Surveillance System
• Conduct enhanced pandemic surveillance
• Prepare to receive SNS countermeasures
• Disseminate risk communication messages, including when to seek care and how to care for ill at home
• Implement appropriate screening of travelers and other border health strategies, as directed by CDC

Unaffected State – A State not meeting the criteria above.  This may represent either that recognition of a potential pandemic is occurring in another State, or is occurring outside the United States.

• Continue/initiate actions as above (Investigation)
• Prepare for investigation and response
• Conduct enhanced pandemic surveillance
• Prepare to receive SNS countermeasures
• Disseminate risk communication messages
• Implement appropriate screening of travelers and other border health strategies, as directed by CDC

“Initiation” Interval – Initiation of the Pandemic Wave:  This interval begins with the identification and laboratory-confirmation of the first human case due to pandemic influenza virus in the United States.  If the United States is the first country to recognize the emerging pandemic strain, then the “Recognition” and “Initiation” intervals are the same for affected States.  As this interval progresses, continued implementation of case-based control measures (i.e., isolation and treatment of cases, voluntary prophylaxis and quarantine of contacts) will be important, along with enhanced surveillance for detecting potential pandemic cases to determine when community mitigation interventions will be implemented. 

Affected State – A State with at least one laboratory-confirmed pandemic case.

• Continue/initiate actions as above (Recognition)
• Declare Community Mitigation Alert if PSI Category 1 to 3, declare Standby²⁷ if  PSI Category is 4  or 5
• Continue enhanced State and local surveillance
• Implement (pre-pandemic) vaccination campaigns if (pre-pandemic) vaccine is available
• Offer mental health services to health care workers.

Unaffected States – A State with no laboratory-confirmed pandemic cases.

• Continue/initiate actions as above (Recognition)
• Declare Community Mitigation Standby if PSI Category 4 or 5
• Prepare for investigation and response
• Prepare for healthcare surge
• Review and prepare to deploy mortuary surge plan
• Deploy State/local caches
• Prepare to transition into emergency operations

“Acceleration” Interval – Acceleration of the Pandemic Wave:  This interval begins in a State when public health officials have identified that containment efforts have not succeeded, onward transmission is occurring, or there are two or more laboratory-confirmed cases in the State that are not epidemiologically linked to any previous case.  It will be important to rapidly initiate community mitigation activities such as school dismissal and childcare closures, social distancing, and the efficient management of public health resources.²⁸ Isolation and treatment of cases along with voluntary quarantine of contacts should continue as a key mitigation measure.  Historical analyses and mathematical modeling indicate that early institution of combined, concurrent community mitigationmeasures may maximize reduction of disease transmission (and subsequent mortality) in the affected areas. ^29,30,31,32  

Affected State – A State that has two or more laboratory-confirmed pandemic cases in a State that are not epidemiologically linked to any previous case; or, has increasing numbers of cases that exceed resources to provide case-based control measures

• Continue/initiate actions as above (Initiation)
• Activate community mitigation interventions for affected communities
• Transition from case-based containment/contact chemoprophylaxis to community interventions
• Transition surveillance from individual case confirmation to mortality and syndromic disease monitoring
• Begin pre-shift healthcare worker physical and mental health wellness screening
• Implement vaccination campaigns if (pre-pandemic) vaccine is available
• Monitor vaccination coverage levels, antiviral use, and adverse events
• Monitor effectiveness of community mitigation activities

Unaffected State – A State that has not met the criteria above.

• Continue/initiate actions as above (Initiation)
• Prepare for investigation and response
• Prepare for healthcare surge
• Review and prepare to deploy mortuary surge plan
• Deploy State/local caches
• Prepare to transition into emergency operations
• Implement vaccination campaigns if (pre-pandemic) vaccine is available
• Monitor vaccination coverage levels, antiviral use, and adverse events

“Peak/Established Transmission” Interval – Transmission is Established and Peak of the Pandemic Wave:  This interval encompasses the time period when there is extensive transmission in the community and the State has reached its greatest number of newly identified cases.  The ability to provide treatment when the healthcare system is overburdened will be particularly challenging.  To reduce the societal effects of the pandemic, available resources must be optimized to maintain the critical infrastructure and key resources in the face of widespread disease.  

Affected State – A State in which 1) >10% of specimens from patients with influenza-like illness submitted to the State public health laboratory are positive for the pandemic strain during a seven day period, or, 2) “regional” pandemic influenza activity is reported by the State Epidemiologist using CDC-defined criteria, or, 3) the healthcare system surge capacity has been exceeded.

• Continue/initiate actions as above (Acceleration)
• Manage health care surge
• Maintain critical infrastructure and key resources
• Laboratory confirmation of only a sample of cases as required for virologic surveillance
• Implement surveillance primarily for mortality and syndromic disease

Unaffected States – As transmission increases in the United States, States are likely to be in different intervals.  Thus, States should anticipate the actions needed for subsequent intervals and plan accordingly. 

“Deceleration” Interval – Deceleration of the Pandemic Wave:  During this interval, it is evident that the rates of pandemic infection are declining.  The decline provides an opportunity to begin planning for appropriate suspension of community mitigation activities and recovery.  State health officials may choose to rescind community mitigation intervention measures in selected regions within their jurisdiction, as appropriate; however mathematical models suggest that cessation of community mitigation measures are most effective when new cases are not occurring or occur very infrequently.³³ 

Affected State – A State where <10% of specimens from patients with influenza-like illness submitted to the State public health laboratory are positive for the pandemic strain for at least two consecutive weeks, or, the healthcare system capacity is below surge capacity.

• Continue/initiate actions as above (Peak/Established Transmission)
• Assess, plan for, and implement targeted cessation of community mitigation measures if appropriate
• Transition surveillance from syndromic to case-based monitoring and confirmation
• Initiate targeted cessation of surge capacity strategies
• Maintain aggressive infection control measures in the community

“Resolution” Interval – Resolution of the Pandemic Wave:  In this interval, pandemic cases are occurring only sporadically.  The primary actions to be taken during this interval include discontinuing all community mitigation interventions, facilitating the recovery of the public health and healthcare infrastructure, resuming enhanced surveillance protocols to detect possible subsequent waves, and preparing for next waves of infection should they occur.  

Affected State – A State where active virologic surveillance detects pandemic cases occurring sporadically.

• Continue/initiate actions as above (Deceleration)
• Rescind community mitigation interventions
• Continue case confirmation of selected cases to verify resolution of pandemic wave
• Resume enhanced virologic surveillance to detect emergence of increased transmission.
• Prepare for possible second wave
• Continue to promote community mitigation preparedness activities on standby for second wave
• Conduct after-action review for lessons learned
• Replenish stockpiles/caches as able