Pandemic Influenza Scenario

Scenario 3: Biological Disease Outbreak – Pandemic Influenza

Casualties	At a 15% attack rate: 87,000 fatalities; 300,000 hospitalizations
Infrastructure Damage	None
Evacuations/Displaced Persons	No evacuation required; shelter-in-place or quarantine instructions given to certain highly affected areas
Contamination	Isolation of exposed persons
Economic Impact	$87 to $203 billion
Potential for Multiple Events	Yes, would be worldwide nearly simultaneously
Recovery Timeline	Several months

Scenario Overview: General Description –

Influenza pandemics have occurred every 10 to 60 years, with three occurring in the twentieth century (1918, 1957-1958, and 1967-1968). Influenza pandemics occur when there is a notable genetic change (termed genetic shift) in the circulating strain of influenza. Because of this genetic shift, a large portion of the human population is entirely vulnerable to infection from the new pandemic strain. This scenario hypothetically relates what could happen during the next influenza pandemic without an effective preplanned response.

Detailed Scenario –

In late February, an outbreak of unusually severe respiratory illness is identified in a small village overseas. At least twenty-five cases have occurred, affecting all age groups. Twenty patients have required hospitalization at the local provincial hospital, five of whom have died from fulminating pneumonia and acute respiratory failure. Surveillance in surrounding areas is increased, and new cases begin to be identified throughout the province. Specimens collected from some patients located in the continent where the original outbreak occurred are sent to the World Health Organization (WHO) Reference Center for Influenza at the Centers for Disease Control and Prevention (CDC) in Atlanta.

The CDC determines that the isolates are from a subtype never before isolated from humans. Isolates of the new strain, collected from patients in various overseas locales, are sent to the Food and Drug Administration (FDA) to begin work on producing a reference strain for vaccine production, and influenza vaccine manufacturers are placed on alert. The novel influenza virus begins to make headlines in every major newspaper, and becomes the lead story on major news networks. Key U.S. Government officials are briefed on a daily basis and surveillance is intensified throughout many countries, including the United States. (State health departments begin to set-up/start-up influenza surveillance systems.)

Over the next 2 months, March and April, outbreaks begin to appear in areas even more geographically separated. Although cases are reported in all age groups, young adults appear to be the most severely affected, and case-fatality rates approach 5%. The public is very concerned because a vaccine is not yet available and supplies of antiviral drugs are severely limited. Several weeks later, the CDC reports that the virus has been isolated from ill airline passengers (arriving from overseas) in four major U.S. cities. States and local areas are asked to intensify influenza surveillance activities, and vaccine manufacturers are requested to go into full production.

A few more weeks pass. In June and July, focal outbreaks begin to be reported throughout the United States. By late September, there is widespread occurrence of cases caused by the pandemic influenza strain. Rates of absenteeism in schools and businesses begin to rise. Phones at physicians’ offices and health departments begin to ring constantly. Police departments, local utility companies, and mass transit authorities begin to have severe personnel shortages, resulting in severe disruption of routine services. Hospitals and outpatient clinics become severely short-staffed when the majority of physicians, nurses, and other healthcare workers become ill. Elderly patients with chronic, unstable medical conditions hesitate to leave their homes for fear of becoming seriously ill with influenza. Intensive care units at local hospitals become overwhelmed, and soon there are widespread shortages of mechanical ventilators for treatment of patients with pneumonia. Family members are distraught and outraged when loved ones die within a matter of a few days. Further deterioration in health and other essential community services occurs over the next 6 to 8 weeks as the illness sweeps across the Country. The peak of cases occurs in late October, but a “second wave” occurs in January and February.

Planning Considerations: Geographical Considerations/Description –

The two most important geographic considerations for pandemic influenza are that it occurs almost everywhere and that it moves extremely rapidly. For example, in 1918, well before the advent of commercial passenger aviation, pandemic influenza spread across the United States within a 6- to 8-week period. Appendix 3-A illustrates the speed and global distribution of the 1957-1958 influenza pandemic. It may seem that, with large-scale international air travel, pandemic influenza may move faster than suggested by the timeline in Appendix 3-A. However, in the Appendix 3-A example, there are only 3 to 4 months between the April outbreaks in Far Eastern cities, such as Hong Kong, and the June-July outbreaks that are beginning to occur in the United States. Faster spread is possible, but the net result will still be the same: most people will not be vaccinated ahead of the pandemic (see the following section, Timeline/Event Dynamics). The earlier the pandemic arrives, the smaller the number of persons who will have been vaccinated. If there are any problems associated with vaccine production (see the section, Assumptions), then it is possible that no one will have been vaccinated ahead of the pandemic arriving in the United States.

The implication of these two time-and-space facts is that few, if any, medical personnel, medical equipment, or similar resources will be available for redistribution. In the United States, State, city, and local governments, as well as healthcare systems, essentially will have to cope using already existing resources. Obviously, available medical supplies, such as vaccines and drugs, will be distributed as available. But healthcare systems will not, for example, be able to “borrow” additional health personnel from the neighboring city or State.

On an international level, countries without resources (predominately developing countries) will likely request aid from the United States and other developed countries. However, current limitations regarding vaccine manufacturing, drug production and stockpiling – and limited stocks of relevant medical equipment – will make it extremely difficult, if not impossible, to simultaneously meet all national and international demands for medical supplies. Likely, there will be notable international political ramifications of this inability to meet even a portion of the requests from developing countries for relevant aid.

Timeline/Event Dynamics –

When planning and preparing for the next influenza pandemic, there are two equally important timelines. One describes the spread of the influenza pandemic and the other describes the effort to develop, test, produce, and distribute an effective vaccine. The following two appendices provide illustrations of each of these timelines:

• Appendix 3-A outlines the emergence and spread of the disease. This appendix and the previous brief narrative description provide an example of how the disease might spread.
• Appendix 3-B outlines the time needed to produce a pandemic influenza vaccine using currently available technologies. This appendix also provides the timeline for the production of the “standard” influenza vaccine in 1997.

Together, these two timelines show that the disease will likely arrive in the United States before people can be vaccinated. It is possible that, given potential problems with the current technology used to produce influenza vaccines (see the section, Assumptions), the pandemic could arrive before public health officials can vaccinate a “significant” number of people. The implication of this is that, as part of any pandemic influenza preparation and response plan, there must be a mechanism for allocating the vaccine among the population (i.e., a method for deciding who will be at the “head of the line”).

Assumptions –

• A vaccine that is effective against the pandemic influenza strain can be produced. However, for a variety of technical reasons directly related to how the vaccine is currently produced, it is quite possible that there could be a notable delay in producing sufficient amounts of the vaccine. Even without a delay, technical problems with production could result in lower yields of vaccine material, causing fewer doses to be produced in the initial production runs.
• Most of this vaccine will not be ready before the pandemic arrives (see the earlier section, Timeline/Event Dynamics). Currently, annual production capacity in the United States is about 90 million doses of three-strain, inactivated influenza vaccine – this does not include the new, attenuated, live-virus vaccine. During a pandemic, production will probably focus on producing a single-strain vaccine, implying that approximately 270 million doses can be produced.
• Estimates of influenza-related deaths, hospitalizations, outpatients, and ill individuals who self-care are made using a wide variety of sources from a number of influenza epidemic years (see CDC website). Fatalities caused by the 1918 influenza pandemic were excluded from the fatality rates because the 1918 pandemic represents an extreme. (The 1918-1919 influenza pandemic caused more than 500,000 deaths in the United States and more than 20 million fatalities worldwide. The 1957-1958 pandemic caused 70,000 fatalities in the United States; and the 1968-1969 pandemic caused 34,000 fatalities in the United Sates.) Advances in medicine may help prevent a repeat of the 1918 fatality rate. The result of this assumption is that the estimates of impact provided can be described as the “conservative, lower end” of estimates of possible impact.
• Estimates of the impact of pandemic influenza are made for a range of gross attack rates (percentage of clinical influenza illness cases per population). For each assumed gross attack, there are ranges of possible health outcomes.
• Estimates are given in totals, after the fact, and before the application of any systematic and effective, large-scale response. Influenza spreads among societies in a different pattern every year. Before the event, it is very difficult to accurately estimate what person-group (e.g., age, gender, risk status) will be the first affected by the next influenza pandemic and where it will occur.

Mission Areas Activated – Prevention/Deterrence:

With the current state of technology and knowledge, it is impossible to prevent or deter an influenza pandemic. Other prevention and protection activities that can occur in the pre-pandemic years include increasing the use of annual influenza vaccinations. Increased annual, non-pandemic demand may increase the capacity for influenza vaccine production that will be available during an influenza pandemic year. There is a great deal of potential for increasing demand. Currently, a large percentage of high-risk individuals do not get annual influenza vaccinations. For example, less than 20% of high-risk children currently receive an annual influenza vaccination.

Increasing surveillance capacity, particularly in terms of the types of data collected, will help increase understanding of who becomes ill and the consequences of such illnesses (see the following section, Emergency Assessment/Diagnosis). Increasing international surveillance capacity also will improve the “early warning system” for early identification of a virus with pandemic potential and allow maximum time to develop a suitable vaccine.

Other pre-pandemic prevention activities include investing in the research and development of new methods for producing influenza vaccines and researching new types of vaccines. However, there is no certainty regarding the success of such projects. Even if such research and development were to result in new vaccines that could be produced faster, it is uncertain when such vaccines would be available.

Preparedness:

Pre-pandemic preparedness activities largely refer to the capacity to deal with the impact (see the section, Emergency Management/Response). Another possible pre-pandemic activity is the stockpiling of influenza antiviral drugs. Antiviral drugs for influenza consist of two classes: adamantanes (amantadine and rimantadine) and neuraminidase inhibitors (zanamivir and oseltamivir). However, the amount of drugs stockpiled will depend on selected goals. The question is whether such drugs should be used primarily for treatment or extensively for prophylaxis (until sufficient vaccine is available). A large-scale use of influenza antiviral drugs for prophylaxis will potentially require an enormous stockpile. Furthermore, one of the older and cheaper drugs (amantadine) has side effects related to the central nervous system that prevent it from widespread use as a prophylactic among workers (e.g., its use could cause accidents). Additionally, widespread use of these two classes of antiviral drugs for treatment of ill people could cause antiviral-resistant strains of pandemic influenza to begin to circulate, which would limit the effective lifespan of these drugs. (Antiviral resistance appears to be much less of a problem with neuraminidase inhibitors.)

Another planning problem is that some of the benefits of using antiviral drugs are not well known/documented. This is particularly true in the case of using the neuraminidase inhibitors prophylactically

Emergency Assessment/Diagnosis:

Assessment of the rate of spread and the outcome of illnesses depends upon the surveillance system. Currently, there are four elements to U.S. nationwide influenza surveillance. As happens every influenza season, all of these elements will be activated with the occurrence of a pandemic influenza. However, none of these elements allow for a measurement of the attack rate (i.e., the proportion of the population that becomes clinically ill), nor does it identify what person-group becomes ill (e.g., age, gender, risk status). This will hamper the optimal allocation of scarce resources.

Emergency Management/Response:

The effectiveness of emergency management during a pandemic will depend on the degree of pre-pandemic planning and preparation. Such preparedness includes Federal, State, and local public health and other government units creating pandemic influenza plans. Such plans ideally should contain clear guidelines on setting priorities for the use of scarce resources (e.g., vaccines, drugs, hospital beds, mechanical ventilators). The National Vaccine Program Office (NVPO) website (http://www.hhs.gov/nvpo/) has some guidelines for developing such documents However, approximately thirty-eight States have yet to complete such a plan. The U.S. Federal Government plan is currently under review.

Emergency management will have to deal with scarce resources (including vaccine and probably influenza antiviral drugs) without assuming that there will be a great deal of re-allocation of resources around the Country (see the earlier section, Geographic Considerations/Description).

Hazard Mitigation:

The success of any hazard mitigation will depend on how well scarce resources are distributed. Even if resources, such as vaccines, are distributed as optimally as possible, there will still be a large number of clinically ill persons (see Table 3-1 and Appendix 3-C). The number of ill persons will overburden the healthcare system. Essential public services (other than healthcare services) also may be compromised as workers in those service areas become ill. The degree of mitigation of the chaos caused by such illnesses will depend on the amount of available vaccine and antiviral drugs (see the earlier section, Prevention/Deterrence) as well as the effectiveness of communication of information to the public.

Recent public health emergencies, such as the anthrax-letter attacks in October 2001 and the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic, have clearly demonstrated that the public’s response depends, in part, on the following factors:

• The type of public health information provided
• The perceived and actual reliability and scientific “soundness” of such information
• The source of the information
• The timeliness of the information

Other factors also will influence public response and the overall success of hazard mitigation activities.

Evacuation/Shelter:

Evacuations will most likely have no meaningful effect on the spread of disease, and probably will be counter-productive (i.e., they will merely move a group of people likely to require services and healthcare to another site that is already overburdened or soon to be overburdened). Quarantine has not typically been used with much success to stop the spread of influenza. This is because influenza can be spread before an infected person becomes symptomatic, and it has a relatively short incubation period (i.e., 2 to 4 days).

Victim Care:

Victim care will rely, in part, on the use of available antiviral drugs for treatment. The amount of antiviral drugs available will depend on the amount stockpiled (see the earlier section, Preparedness, for additional comments regarding the stockpiling of influenza antiviral drugs). Public protection will rely primarily on the use of this stockpile to prevent the disease. Many victims may require hospitalization, especially those experiencing influenza-related breathing difficulty. However, hospital beds and medical equipment, such as mechanical ventilators, will likely be in short supply (see the following section, Secondary Hazards/Events).

Other, non-critically ill victims will require rest and recuperation. Their symptoms may perhaps be alleviated with over-the-counter medications.

There is also a need to plan to deal with the large number of fatalities (see Table 3-1 and Appendix 3-C) that will occur in a relatively short period of time. Mortuary and burial services may become over-extended, causing delays in funeral services; this, in turn, will heighten the anguish of bereaved families.

Since this is an international incident, the U.S. Department of State’s Bureau of Consular Affairs will need to be involved in order to assist foreign populations residing in the United States, foreign nationals in the United States, or U.S. citizens exposed or ill abroad.

Investigation/Apprehension:

For pandemic influenza, investigation is really disease surveillance. The current influenza surveillance system, described in the Emergency Assessment/Diagnosis section, has distinct limitations.

Implications: Secondary Hazards/Events –

The greatest secondary hazard will be the problems caused by shortages of medical supplies (e.g., vaccines and antiviral drugs), equipment (e.g., mechanical ventilators), hospital beds, and a shortage of healthcare workers. Having a detailed system for allocating resources potentially can reduce such difficulties. This system ideally should be in place well before an influenza pandemic actually occurs.

Of particular concern is the real likelihood that healthcare systems, particularly hospitals, will be overwhelmed. The only method of mitigating such an impact is to have one or more plans in place that effectively allocate scarce hospital-based resources among incoming patients. This will require incoming patients to be triaged according to need, availability of resources, and expected outcomes caused by allocating given resources to a particular patient. In effect, hospital staff and patients will have to accept a standard of care, appropriate to the situation existent during an influenza pandemic. For example, nurse-to-bed ratios will have to be decreased, meaning that each nurse will have to look after more occupied beds. Patients might not be given all of the treatment, such as mechanical ventilation, that they and their physicians would normally expect.

Another important secondary hazard is the disruption that will occur in society. Institutions, such as schools and workplaces, may close because a large proportion of students or employees are ill. A large array of essential services may be limited because workers are off work due to pandemic influenza. Travel between cities and countries may be sharply reduced, not only due to fewer staff personnel available to operate the transportation system, but because fewer people will want to or be able to travel.

Fatalities/Injuries –

Estimates of impact are provided in Table 3-1 (see the last three bullets in the Assumptions section). The estimates are for impact before any effective, large-scale interventions are applied.

Table 3-1. Mean estimates (5^th, 95^th percentiles) of the impact of the next influenza pandemic in the United States without any large-scale and/or effective interventions

Additional scenarios/estimates can be generated for virtually any population level using the CDC’s Flu-Aid program, which is a free software program designed to help State and local public health officials plan, prepare, and practice for the next influenza pandemic. The program is available at http://www2a.cdc.gov/od/fluaid.

There are patients who, due to pre-existing medical complications, are at high risk for having influenza-related adverse health outcomes. These pre-existing conditions include emphysema, asthma, diabetes, autoimmune diseases, immune system deficiencies (e.g., AIDS), and chronic heart disease. Approximately 15% of the entire population has one or more of these conditions. However, some 84% of all fatalities will occur among those with these high-risk conditions.

Similar to the experience of the three influenza pandemics in the twentieth century, approximately 60% of the fatalities will occur among those less than 65 years of age. In non-pandemic years, approximately 80% (or more) of all influenza-related fatalities occur among those over the age of sixty-five.

As described in the section, Secondary Hazards/Events, the healthcare system will most likely be rapidly overwhelmed and standards of patient care at all levels may be altered according to the existing conditions.. It is unknown what the exact impact this alteration in quality of healthcare will have on estimated fatalities and hospitalizations.

Property Damage –

Property damage is unlikely, except to the extent that pandemic influenza-related absence from work may cause maintenance-related failures and/or accidents.

Service Disruption –

Service disruption could be severe, depending upon the pattern of which persons become ill, when they become ill, and for how long they are ill. It is probably “safe” to assume that, even if healthcare workers are among the first to receive vaccinations and/or treatment, the healthcare system will be severely stressed, if not overwhelmed.

The workloads of essential service personnel and first responders are also likely to be severely strained, due to both influenza-related emergency calls and the number of workers who fall ill to influenza. Beyond the “traditional” definition of essential services (e.g., fire, water, electricity, phone systems), severe disruptions could occur if large numbers of transportation workers are simultaneously off work due to influenza-related illnesses. Again, the exact extent of such disruptions will depend on the pattern of which persons become ill, when they become ill, and for how long they are ill.

Economic Impact –

Using the previous estimates provided regarding the numbers of fatalities, hospitalizations, etc., it has been estimated that the economic impact, in 2004 U.S. dollars, will range from $87 billion (15% gross attack rate) to $203 billion (35% gross attack rate). These estimates do not include any estimate due to economic disruption; however, they do include a value for time lost from work.

These impact estimates can be used to consider the economic cost-benefits (net returns) of vaccinating various age and risk groups.

Long-Term Health Issues –

Many people recovering from severe influenza-related illnesses may need care and convalescence for several months after the pandemic has ended. Costs for such care are not included in the economic impact.estimates.

 Planning Assumptions  (There are facts contained within the assumptions)

1.      Scenario

2.      Virus Characteristics

3.      Community Mitigation Impact

4.      Healthcare Impact

5.      Countermeasure

6.      Operational

7.      Mental Health/Public Health

 

1.      Scenario

1.1.            Efficient and sustained person-to-person transmission signals an imminent pandemic. 

1.2.            The pandemic virus will originate outside North America.

1.3.            Within one month of the first confirmed case in the United States, pandemic influenza will have spread throughout the nation.

1.4.            Pandemic spread in the U.S. will occur in waves with 60 days from first case to peak.

1.5.            Urban areas will be affected first.

1.6.            In an affected community, a pandemic outbreak will last about 6 to 8 weeks.  A community that is effectively using community mitigation measures, including non-pharmaceutical interventions, may experience a longer pandemic outbreak, lasting between 6 and 12 weeks.

1.7.            Multiple waves (periods during which community outbreaks occur across the country) of illness could occur with each wave lasting 2-3 months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty.

 

2.      Virus Characteristics

2.1.            Susceptibility to the pandemic influenza virus will be universal.

2.2.            The clinical disease attack rate will be 30 percent in the overall population during the pandemic.  Illness rates will be highest among school-aged children (about 40 percent) and decline with age.  Among working adults, an average of 20 percent will become ill during a community outbreak.

2.3.            Some people will become infected, but not develop clinically significant symptoms.  Asymptomatic or minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection.

2.4.            Rates of serious illness, hospitalization, and deaths will depend on the virulence of the pandemic virus and differ by an order of magnitude between more and less severe scenarios. Risk groups for severe and fatal infection are likely to include infants, the elderly, pregnant women, and persons with chronic or immunosuppressive medical conditions.

2.5.            In previous pandemics, about half of those who became ill sought care.  With the availability of effective treatment, this proportion may be higher in the next pandemic.

2.6.            Persons who become ill may shed virus and can transmit infection for one-half to one day before the onset of illness.  Viral shedding and the risk of transmission will be greatest during the first two days of illness.  Children will play a major role in transmission of infection as their illness rates are likely to be higher, they shed more virus over a longer period of time, and they control their secretions less well.

2.7.            On average, infected persons will transmit infection to approximately two other people.

2.8.            The typical incubation period (interval between infection and onset of symptoms) for influenza is approximately two days.

2.9.            Contact tracing, contact monitoring, and quarantine of close contacts may be effective in special situations during the earliest stages of a pandemic.  However, the usefulness of these measures will be limited by the short incubation period of influenza and the ability of asymptomatic persons to transmit infection.

 

3.      Community Mitigation Impact

3.1.            Rates of absenteeism will depend on the severity of the pandemic.  In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members and fear of infection may reach 40 percent during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak. 

3.2.            Certain community mitigation measures (e.g. dismissing students from school, voluntary quarantine of household contacts of infected individuals) are likely to increase rates of absenteeism.

3.3.            Worker absenteeism will increase the likelihood of sudden and potentially significant gaps in public services and safety.

 

4.      Healthcare Impacts

4.1.            Of those who become ill with influenza, 50% will seek outpatient medical care. With the availability of effective antiviral drugs for treatment, this proportion may be higher in the next pandemic.

4.2.            A significant number of non-citizens as well as uninsured U. S. citizens will require medical and public health intervention. However, non-citizens may be unlikely to come forward for treatment for fear of deportation from the U.S. 

4.3.            Depletion of medical supplies and pharmaceuticals and difficulties in re-supply will significantly stress the Nation’s industrial base and ability to rapidly meet national resource requirements.

 

5.      Countermeasures

5.1.            Pandemic vaccine will not be available until 4-6 months after the pandemic virus has emerged.

5.2.            The pandemic influenza virus will be susceptible to antiviral drugs which are currently stockpiled

5.3.            Pre-pandemic vaccine will provide some amount of protection against the pandemic virus.

5.4.            It will be necessary to provide prophylaxis and/or vaccination with pre-pandemic vaccine to protect deployed HHS responders and mission essential personnel.

5.4.1 Antivirals for use by HHS response personnel as force health protection have not been explicitly identified as of January 2009. Discussions on this policy are ongoing.

5.5.            Other Federal Departments and Agencies will be responsible for providing prophylaxis and and/or vaccination to their mission essential and deployed personnel.

5.5.1.        Antivirals for use by USG response personnel as force health protection are to be stockpiled by each respective department as of January 2009. Discussions on this preparedness aspect are ongoing.

5.6.            When the pandemic begins, some States, Territories and/or the District of Columbia will not have stockpiled enough antiviral drugs to support their populations.

5.7.            Some States, Territories and/or the District of Columbia will choose to use antiviral drug stockpiles for prophylaxis, in addition to treatment, and this will result in the need for communities to prioritize antiviral allocation. 

5.8.            Deployment of state allocated quantities of antivirals (44 million regimens) will be considered by HHS at US Stages 2 and 3 and will take place in a phased manner.   

5.9.            No more than 5% of the HHS SNS stockpile of antiviral regimens can be sent abroad to support international containment operations.

5.9.1.       Deployment of antivirals by HHS to support international and/or domestic containment efforts will come from the SNS Strategic Reserve

5.10.        HHS will consider deployment of industry-managed stockpiles of pre-pandemic vaccine at US Stages 2 and 3.

 

6.      Operational

6.1.            Initial responsibility for a domestic pandemic response will rest with State, Local, Territorial, and Tribal (SLTT) authorities, however the nature and scope of a pandemic may overwhelm their capabilities.

6.2.            The President will declare a major disaster or emergency under the Stafford Act when there are cases identified within the U.S. (Stage 4), however HHS does not anticipate receiving mission assignments for a majority of actions it will take to respond to the pandemic (e.g. border intervention activities, epidemiological investigations).

6.3.            ESF 8 assets will be initially available to lead USG efforts to contain the virus abroad, manage the deployment of medical countermeasures and support border interventions (US Stages 2-4). 

6.4.            At no point during a pandemic will ESF 8 assets be available to support requests for assistance from States, Territories and/or the District of Columbia that HHS normally receives during a focused public health/medical event (e.g. medical surge, field hospitals, support to countermeasure distribution and dispensing).  

6.5.            The NDMS patient movement and definitive care system will not be utilized by HHS for civilian use during a pandemic.

6.6.            Once US Stage 2 has been triggered, DHS/FEMA will establish 5 JFOs and activate their 6 Principle Federal Officials (one National, five Regional).

6.6.1.      HHS will follow by activating the 6 HHS Pandemic Influenza Senior Federal Officials (one National, five Regional).

6.6.2.      HHS will also activate and deploy 5 IRCTs to staff the JFOs and coordinate the ESF 8 response assets in the field, including the ESF 8 liaisons to each State and territory (fulfilled by current HHS/CDC Senior Management Officials and augmented by additional HHS personnel).

6.7.            U.S. international and domestic borders will remain open throughout the pandemic, although during US Stages 2 - 4, all international travelers entering the U.S. through aviation, land and maritime crossings will be assessed for risk (ill or exposed to pandemic virus), screened and possibly isolated or quarantined under Federal quarantine order.

6.8.            If there are cases of pandemic influenza in the U.S. while the rest of the globe remains relatively free of cases, the WHO will require the U.S. to screen all exiting international travelers to prevent exportation of the virus. 

6.9.            PHS Commissioned Corps personnel from other HHS agencies, as needed and as available, will be released to reinforce the ESF #8 response capability.

6.10.        Public Health Service (PHS) Commissioned Corps personnel serving in critical Operating Division positions will remain assigned and available to that Operating Division during an influenza pandemic.

 

7.      Mental Health/Public Health

7.1.            Increased public anxiety will cause increased psychogenic and stress-related illness compounding the strain on health facilities.

7.2.            Public anxiety related to pandemic will require effective risk communication and will require mental health and substance abuse services.