When the pandemic is on our doorstep, is it too late to prepare?

(CIDRAP Source Weekly Briefing) – What will the first days of the pandemic look like?

Imagine that the virulent H5N1 influenza virus has begun spreading from human to human in an Asian country. Your employees—like the rest of the world—are watching the situation unfold, and you must react. What do you do and when do you do it?

Just as it's impossible to predict the pandemic's origin, when it will hit the United States, the virulence of the strain, and the number of waves, it's impossible to pinpoint the precise moment when businesses should enact their pandemic preparedness plans. What businesses can do is stock up now on supplies and prepare the messages they will need to deliver to minimize business disruption and mobilize employees.

Speak the truth—then brace yourself

The keys to optimizing these messages, experts say, are to start now, prepare to tell the truth, and expect backlash—no matter how perfectly timed you expect your response to be. Timing is such a delicate matter, because, although you will know that the virus has become efficient at transmitting from human to human, you will likely not know how severe the first wave of the pandemic will be for a week or 2. Further, it may be many months before the second wave starts and its severity becomes apparent.

"We are preparing all sorts of actions to take to protect ourselves from a pandemic before we have any drugs that will work, or vaccines," says John Barry, author of The Great Influenza, a book about the 1918 pandemic. "The question is 'When do you pull the trigger on them?' You can only do that one time, because the public is going to get inattentive."

Whichever way a company chooses to go—mobilizing its pandemic plan early just in case the strain is deadly or taking a wait-and-see approach—it will be criticized, says risk-communication expert Peter Sandman. "There will be no way to know whether you're right or wrong," he says. "It will be about deciding which way of being wrong is worse. And you're going to have to make that decision in the context of other companies' doing radically different things and, having made that choice, you're going to have to be able to explain it."

Every explanation, Sandman adds, should include the information that you may be wrong. "If you're moving into crisis mode, admit it'll look like an over-reaction if the pandemic turns out mild," he says. "If you're waiting to find out, admit you'll have lost precious prep time if it turns out bad."

Businesses will also experience the impact of pandemic plans enacted by other organizations facing similarly agonizing decisions in the first, uncertain days. One example is school closings, which will dramatically increase worker absenteeism, Barry says. It's unclear who—government, individual school administrators, or parents—will initiate the closings and when.

If schools are closed too early and no cases of pandemic influenza occur in the community, parents may want to send their kids back to school and be reluctant to accept closings when it might in fact be helpful. "At what point do you decide to close schools if there's a mild first wave?" Barry asks. "It's hard enough if you have a virulent first wave, because if you delay closing schools, there's no point in doing it at all, because the virus will have the opportunity to circulate."

Will the panic button be pushed?

No one knows where the pandemic will begin, but the highest number of opportunities for the virus to jump species appears to be in Asia, regardless of whether the causative organism is H5N1 or another influenza strain. "We're obviously concerned about Asia," Barry says, "but that's only because of the density of population and the close contact between people and birds."

No matter where it starts, you won't be able to miss it, says Reuters Health and Science Editor Maggie Fox, who predicts that the US Department of Health and Human Services would begin holding press conferences and issuing advisories as consumer groups clamor for word on which groups of people would receive vaccinations once they became available. "I would imagine Congress would try to hold a hearing on what kind of responses should be happening," says Fox, who is based in Washington, DC. "President Bush would probably try to hold a news conference on what was happening and what should be done."

She predicts that travel industry would experience the impact, but that the public response in the United States would be fairly muted if the pandemic began offshore. "I don't think Americans have come to grips with bird flu and what it would mean," she says. "It's a different kind of threat."

As hospitals brace for the first cases, they likely will cancel elective procedures and try to increase surge capacity, which may mean that some patients may be discharged sooner than they would under normal circumstances.

Barry believes border closings are unlikely and would prevent any chance of getting necessary supplies. "I think closing borders doesn't make any sense, because I don't think it would be effective enough, and I think the disruption in trade would be enormous." In contrast, Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, Minneapolis, cautions that, however unwise border closings may be, they are a likely response from governments under intense pressure to do everything they can to stop the virus from reaching their shores.

Helen Branswell, medical reporter for the Canadian Press in Toronto, forecasts that people might immediately begin some subtle social-distancing measures. "I wouldn't be surprised if people stopped using the communal cup in churches or if people stopped shaking hands in Catholic services or if people started putting a piece of cloth between them and the elevator button," she says.

She also thinks that people, feeling powerless to stop the pandemic, will try to exert some control over their situation. "I think that one of the things we would see would be panic-buying of foodstuffs and pharmaceuticals—over-the-counter drugs—probably people trying to get into the doctor to see if they can get prescriptions for antivirals," she says.

Many people will shift into a panic mode even if no cases have yet shown up in the United States, Osterholm says. "The audiovisual media will begin to show shots of what's happening elsewhere, and they'll feed into the mentality that the pandemic is now here," he says.

People are likely to buy whatever they can get because they don't know when it will become available again, Osterholm says. Our "just-in-time" delivery system leaves us little surge capacity to restock behind the surge buying, and many critical items may not get restocked for the duration of the pandemic.

Businesses such as pharmacies and companies that sell masks and N-95 respirator masks need to prepare now for when people demand their products and slip into panic mode when they can't get them, he says. And businesses that plan to use these items need to stock up now, because they simply won't be available when the pandemic is imminent.

Osterholm is concerned that the public will react similarly to the way it did on the night of Sep 11, 2001, when people lined up at gas stations, even though there was no reason to believe that gas would become unavailable. "Anticipate this kind of reaction now," he says. "Know that if you wait until this event happens before you start moving forward with your pandemic plans that it's possible you will not have access to the items that you hope to stockpile."

Sandman points out that it's inevitable—and even healthy—for people to take premature precautions. "It's part of what we call the 'adjustment reaction,'" he says. "It's a kind of rehearsal that helps people get ready emotionally as well as logistically. So tell them it's too soon to start wearing masks, but don't tell them they're fools to want to."

Real and present danger

When the pandemic begins, it's essential that employees understand that the threat is real and imminent, Sandman says. "Tell people that this is not last year's warning," he says. "Last year, we warned that a pandemic will come someday. Now we are warning that a pandemic is on its way right now, and it's H5N1. What we don't know yet is how severe it's going to be."

It's important to tell employees that the pandemic may or may not be horrible so they are prepared for either eventuality, Sandman says. Let them know that the pandemic has not yet arrived, so it's pointless to try to evacuate or to wear masks. At the same time, validate their feelings of fear and helplessness. "When you validate those feelings, people can bear the feelings better," he says. "It's a very good time to remind people that almost everybody will survive."

It's also a good time to remind employees that if they get the flu during the first wave, they will be immune to it during the second wave of infection. "Say 'think of whether you want to help, think about how you're going to handle things if you have the flu and get better.' Your goal is to get people thinking that they may be heading into a really hard time, and to get them thinking that they will probably get through it alive. And you want to recruit much-needed volunteers for later."

An organization that has identified employees who want to volunteer to return to work after they recover will be much better able to function, Sandman says. These employees should be asked to identify their skills and then, if their job is routine, to be cross-trained to do essential jobs.

Employees are much more likely to return to work if they have been assigned an emergency duty station and know others are counting on them to show up. "If you're a company that didn't do it [before the pandemic], you've got a window in which you can assign people an emergency duty station," he says.

Businesses that are underprepared for this task have plenty of company. Two large multinational organizations declined to be interviewed for this article because their preparedness plans are incomplete. But there is still time. The bottom line, Sandman says, is to not wait until the pandemic hits: "They're not going to know much in the first few days of a pandemic that they don't know right now."

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