Pandemic Influenza Concept of Operations

The United States will apply all instruments of national power, in the public sector, at the Federal, state and local levels of government; in the private sector and at the level of the individual to prevent, protect against and respond to the threat of pandemic, with the intent of (1) stopping, slowing or otherwise limiting the spread of a pandemic to the United States; (2) limiting the domestic spread of a pandemic, and mitigating disease, suffering and death; (3) sustaining infrastructure and mitigating impact to the economy and the functioning of society.

The World Health Organization (WHO) has provided succinct statements about the global risk of a pandemic and benchmarks to measure global response capabilities. When describing the U.S. government’s (USG) approach to the pandemic response, it is additionally useful to characterize the stages of an outbreak in terms of the immediate and specific threat a pandemic virus poses to the U.S. population.  The following seven U.S. stages provide a framework for USG actions:

• Stage 0:  New Domestic Animal Outbreak in “At-Risk-Country”
• Stage 1:  Suspected Human Outbreak Overseas
• Stage 2:  Confirmed Human Outbreak Overseas
• Stage 3:  Widespread Human Outbreaks in Multiple Locations Overseas
• Stage 4   First Human Case in North America
• Stage 5:  Spread throughout United States
• Stage 6:  Recovery and Preparation for Subsequent Waves

Summary of HHS and ESF-8 Objectives During a Severe Influenza Pandemic

Stage 0: New Domestic Animal Outbreak in At-Risk Country (WHO Phase 1, 2, or 3)

A human pandemic influenza virus could emerge outside the United States or within our borders. Because of the potential for an HPAI virus, including the current HPAI H5N1, to become a pandemic strain, many international animal health initiatives are being implemented to assist affected countries with their response to disease outbreaks in poultry. Control of threatening viruses among animals is a critical element of the strategy to reduce the level of human exposure, a key risk factor for infection and, therefore, emergence of a pandemic strain.

Objectives

• Leverage international and domestic surveillance systems and monitor for reoccurrence of avian disease.
• Track avian outbreaks until control/resolution.
• Develop and exercise pandemic influenza response strategies and plans. 

Stage 1: Suspected Human Outbreak Overseas (WHO Phase 3)

There are many ways in which suspicious clusters of illness may be identified, including through reporting to the WHO, news reporting, clinical results in regional laboratories, or through informal channels. It is incumbent upon the international community to take rapid action to ascertain the facts on the ground, irrespective of the manner in which the reporting occurs. The steps taken here and at subsequent stages will be closely coordinated with international partners and multilateral organizations such as the WHO.

Objectives

• Rapidly investigate and confirm or refute reports of human-to-human transmission.
• Initiate coordination mechanisms and operational plans that will be necessary if outbreak is confirmed.

Stage 2: Confirmed Human Outbreak Overseas (WHO Phase 4 or 5)

The WHO confirms sustained human-to-human transmission of a novel influenza virus. Confirmation could also come directly from an affected nation or through HHS scientists operating in the affected region.

Objectives

• Support international requests for containment response to limit the pandemic severity and potential for geographic spread.
• Enhance domestic public health and medical preparedness in anticipation of the arrival of cases in the U.S.

Stage 3: Widespread Human Outbreaks in Multiple Locations Overseas (WHO Phase 6)

The occurrence of widespread outbreaks suggests that efforts are unlikely to be successful in containing the emerging pandemic. The U.S. domestic preparedness and response posture will reflect a concerted effort to delay the onset of outbreaks within the United States and to prepare for the eventual identification of cases within the U.S.

Objectives

• Delay the emergence of pandemic influenza in the U.S. and North American populations through risk based border interventions.
• Leverage domestic surveillance systems to ensure the earliest warning possible of the first case(s) in the United States.
• Continue to prepare the United States for the potential onset of the pandemic.

Stage 4: First Human Case in North America (WHO Phase 6)

The identification of the first case anywhere in North America signals that for practical purposes it will be impossible to prevent the disease spreading to the United States. However, continuing efforts to delay the arrival or further seeding of the virus in the U.S. may afford local and State governments and the private sector time for last minute preparations before widespread outbreaks within the U.S. 

Objectives

• Delay the emergence of pandemic influenza in the U.S. (if no cases in the U.S.)
• Coordinate with affected localities to attempt to contain the first outbreaks within the U.S. (if cases in the U.S.)
• Continue efforts to prepare the United States for the potential onset of the pandemic

Stage 5: Spread throughout United States (WHO Phase 6)

The emergence of human cases in multiple locations around the country will portend a progressive increase in case load on communities and a resulting impact on all institutions, including those supporting critical infrastructure.  At any one time in the subsequent months, multiple States will be actively and simultaneously involved in response and mitigation activities.

Objectives

• Support timely and consistent implementation of community-based mitigation measures across the U.S.
• Preserve ability of HHS to perform essential Departmental functions, including the functionality of critical HHS healthcare workers.
• Support State and Territory responses, to the extent possible, to mitigate illness, suffering, and death.

Stage 6: Recovery and Preparation for Subsequent Waves (WHO Phase 6 or 5)

While a pandemic may impact the Nation for several months or over a year, a given community can expect to be affected by a pandemic over the course of 8 to 12 weeks. Subsequent waves have been the norm in previous pandemics therefore it will be important for communities to begin reconstituting themselves as soon as possible in order to mitigate persistent secondary and tertiary impacts of the outbreak.

Objectives

• Support the return of the public health and healthcare sectors to the highest level of functioning as soon as possible.
• Respond to subsequent waves as appropriate, consistent with – and incorporating the lessons learned from – successful actions taken during the first pandemic wave.

Federal responsibilities include the following:

• Lead departments have been identified for the public health and medical response (Department of Health and Human Services), veterinary response (Department of Agriculture), international activities (Department of State) and the overall domestic incident management and Federal coordination (Department of Homeland Security). Each department is responsible for coordination of all efforts within its authorized mission.
• Advancing international preparedness, surveillance, response and containment activities.
• Supporting the establishment of countermeasure stockpiles and production capacity by:
  • Facilitating the development of sufficient domestic production capacity for vaccines, antiviral drugs, diagnostics and personal protective equipment to support domestic needs, and encouraging the development of production capacity around the world;
  • Advancing the science necessary to produce effective vaccines, therapeutics and diagnostics; and
  • Stockpiling and coordinating the distribution of necessary countermeasures, in concert with states and other entities.
• Ensuring that federal departments and agencies, including federal health carehealthcare systems, have developed and exercised preparedness and response plans that take into account the potential impact of a pandemic on the federal workforce, and are configured to support state, local and private sector efforts as appropriate.
• Facilitating state and local planning through funding and guidance.
• Providing guidance to private industry and the public at large on preparedness and response planning, in conjunction with states and communities.

While the Federal government plays a critical role in preparedness and response to a pandemic, the success of these measures is predicated on actions taken at the individual level and in states and communities.

Local/State Responsibilities

Local communities are on the front lines of an influenza pandemic response and will face many challenges in maintaining continuity of society in the face of widespread illness and increased demand on most essential government services. State and local responsibilities include the following:

• Ensuring that all reasonable measures are taken to limit the spread of an outbreak within and beyond the community’s borders.
• Establishing comprehensive and credible preparedness and response plans that are exercised on a regular basis.
• Integrating non-health entities in the planning for a pandemic including law enforcement, utilities, city services and political leadership.
• Establishing state and community-based stockpiles and distribution systems to support a timely and comprehensive pandemic response.
• Identifying key spokespersons for the community, ensuring that they are educated in risk communication, and creating coordinated crisis communications plans.
• Providing public education campaigns on pandemic influenza.

Private Sector and Critical Infrastructure Entities

The private sector must be engaged in all preparedness and response activities for an influenza pandemic. Critical infrastructure entities also must be engaged in planning for a pandemic because of our society’s dependence upon their services. Roles and responsibilities of the U.S. private sector and critical infrastructure entities include the following:

• Establishing an ethic of infection control in the workplace that is reinforced during the annual influenza season through employee education and the development and exercise of methods to reduce infection transmission.
• Establishing contingency systems to maintain delivery of essential goods and services during times of significant and sustained worker absenteeism.
• Where possible, establishing mechanisms to allow workers to provide services from home if public health officials advise against non-essential travel outside the home.
• Establishing partnerships with other members of the sector to provide mutual support and maintenance of essential services during a pandemic.

Individuals and Families

The role of individuals and families in controlling a pandemic is critical and cannot be overstated. Modeling of the transmission of influenza vividly illustrates the impact of one individual’s behavior on the spread of disease, by showing that an infection carried by one person can be transmitted to tens or hundreds of others. For this reason, individual action is perhaps the most important element of pandemic preparedness and response.

While education on pandemic preparedness for the population should begin before a pandemic and is the responsibility of all levels of government and the private sector, responsibilities of the individual and families include:

• Taking precautions to prevent the spread of infection to others if an individual or a family member has symptoms of influenza.
• Being prepared to follow public health guidance that may include limitation of attendance at public gatherings and nonessential travel for several days or weeks.
• Keeping supplies of materials at home, as recommended by authorities, to support essential needs of the household for several days if necessary.

International Partners

The United States’ pandemic preparedness and response strategies rely on partnerships with the United Nations, and international public and private non-profit organizations. The international effort to contain and mitigate the effects of an outbreak of pandemic influenza is a central component of United States’ overall strategy. The timeliness and quality of the U.S. response and that of our international partners will play a determining role in the severity of a pandemic.

The International Partnership on Avian and Pandemic Influenza stands in support of multinational organizations. Members of the partnership have agreed that the following principles will guide their efforts:

• International cooperation to protect the lives and health of our people;
• Timely and sustained high-level global political leadership to combat avian and pandemic influenza;
• Transparency in reporting of influenza cases in humans and in animals caused by virus strains that have pandemic potential, to increase understanding and preparedness and especially to ensure rapid and timely response to potential outbreaks;
• Immediate sharing of epidemiological data and samples with the World Health Organization (WHO) and the international community to detect and characterize the nature and evolution of any outbreaks as quickly as possible, by utilizing, where appropriate, existing networks and mechanisms;
• Rapid reaction to address the first signs of accelerated transmission of H5N1 and other highly pathogenic influenza strains so that appropriate international and national resources can be brought to bear;
• Prevent and contain an incipient epidemic through capacity building and in-country collaboration with international partners;
• Work in a manner complementary to and supportive of expanded cooperation with and appropriate support of key multilateral organizations (including the WHO, Food and Agriculture Organization and World Organization for Animal Health);
• Timely coordination of bilateral and multilateral resource allocations; dedication of domestic resources (human and financial); improvements in public awareness; and development of economic and trade contingency plans;
• Increased coordination and harmonization of preparedness, prevention, response and containment activities among nations, complementing domestic and regional preparedness initiatives, and encouraging where appropriate the development of strategic regional initiatives; and

Actions based on the best available science. Through the Partnership and other bilateral and multilateral initiatives, we will promote these principles and support the development of an international capacity to prepare, detect and respond to

The government of a nation affected by a potentially pandemic influenza outbreak, which will:

• Be the lead entity responsible for preparing for, detecting, organizing and leading an assessment and containment response to,
• and requesting any needed assistance for a pandemic influenza outbreak within the nation’s borders.
• The World Health Organization, which will:
• When WHO assistance is requested, be the lead coordinator of international support to the affected nation, working in support
• to the affected nation and in coordination with regional organizations and other governments that may be able to assist upon
• request.
• Regional organizations, such as the Association of Southeast Asian Nations (ASEAN), which will:
• Facilitate and coordinate preparedness, assessment, and containment activities for the affected region as needed and requested,
• along with the affected nation, the World Health Organization, other governments including the USG that may receive requests
• for assistance, and other responding entities.

ESF-8 Incident Command and Management

• Under the National Response Framework, HHS is the lead federal agency for Emergency Support Function #8 (Public Health and Medical Services). Consistent with the HHS mission and its lead role in addressing an influenza pandemic, a large number of agencies and offices within the Department would be involved in activities related to pandemic influenza.   Lead departments have been identified for the public health and medical response (Department of Health and Human Services), veterinary response (Department of Agriculture), international activities (Department of State) and the overall domestic incident management and Federal coordination (Department of Homeland Security).  Each department is responsible for coordination of all efforts within its authorized mission.
• DHS has established five (5) Pandemic Influenza Regions (A-E) that each will be supported by a pre-designated Principal Federal Official (PFO).  There will be up to 10 Joint Field Offices stood up to manage Federal support to States and Territories in each pandemic region.  All 5 regional PFOs will be led by a National PFO working out of the DHS NOC.   DHS Secretary may activate the PFOs and JFOs beginning at USG Stage 2, in consultation with the Secretary of HHS/ASPR.  The current plan is:
  • At USG Stage 2 or as needed, activate the HHS EMG at headquarters with appropriate liaisons from within HHS and interagency ESF-8 partners.
  • Deploy pre-designated PI RECs to RRCC/JFO as ESF-8 liaisons and to lead public health and medical emergency activities in the region.
  • Deploy HHS PI Senior Health Officials (PI SHOs) to support the DHS PFOs Teams with public health and medical expertise, to facilitate HHS strategic decision making, and interface with State government senior health officials. 
  • Deploy small Incident Response Coordination Teams (IRCTs) to JFOs to coordinate ESF-8 deployed assets and manage the field response.  
  • As needed deploy additional ESF 8 representatives as liaisons to State Health Department EOCs and State Senior Health Official during the pandemic response.
  • Incident coordination, communication and information flow would work the same way as standard responses such as hurricane.   There will be fewer ESF-8 resources to manage in the field over an extended pandemic response period estimated at 12 -18 months, and many of the resources get deployed early in the pandemic response (e.g., surge personnel for screening at ports of entry, state allocations of antivirals and distribution of pre-pandemic vaccine, CDC teams for domestic surveillance, containment and disease control, and pandemic vaccine after 5 months).  
  • Much like a multi-event hurricane response the PI REC would perform as ESF-8 Lead at the JFO working in the unified command structure there along with the PI SHO, and the IRCT field response elements reporting up to the EMG headquarters. Requests for support would flow from States to the JFO in the Region up to the EMG and be sub-tasked to CDC DEOC, other OPDIV/StaffDiv and federal partner supporting agencies to execute the mission at the field level under the direction, command and control of the IRCT in the field.  CDC staff will be represented on the IRCT in the Operations Section, perhaps leading the Public Health Branch in the core mission areas such as epidemiological surveillance and laboratory support, border screening, SNS distribution, public information etc.   
  • Information flow for situational awareness and reporting will use standard channels.  The EMG battle rhythm, call schedule and situation updates will accommodate White House DRG, HSC, the NOC and DHS National PFO Team information requirements.  At a minimum, daily ESF-8 conference calls and twice daily situation reports through WEBEOC should be anticipated.   The SOC and EMG will define critical information requirements in advance and will require more frequent  information exchange with CDC DEOC.
  • During a pandemic response, the EMG and headquarters may have a larger strategic decision-making role in management of deployed resources due to equity concerns across States.  Challenging decisions will need to be made about how to distribute limited resources nationally (e.g., FMS, medical personnel support, and distribution of antivirals from the strategic reserve for domestic containment, ventilators, masks and respirators etc.)