New US pandemic plan stresses local self-reliance

May 3, 2006 (CIDRAP News) – The White House today released a lengthy new plan describing how the government intends to cope with an influenza pandemic, but officials continued to stress their standard message that states and communities will have to rely mainly on themselves in that situation, with the federal government in an advisory role.

"Rarely will the solution itself to the practical problem faced in a community come from inside the beltway," said Frances Townsend, President Bush's homeland security advisor, at a press briefing introducing the 228-page plan, titled National Strategy for Pandemic Influenza: Implementation Plan.

"Local communities will have to address the medical and non-medical effects of the pandemic with available resources," the document says. "This means that it is essential for communities, tribes, states, and regions to have plans in place to support the full spectrum of their needs over the course of weeks or months, and for the Federal Government to provide clear guidance on the manner in which these needs can be met."

The new plan is a follow-up to the HHS Pandemic Influenza Plan, released by the Department of Health and Human Services (HHS) last November. That document focused largely on HHS's efforts to procure vaccines and antiviral drugs to blunt the impact of a pandemic. At the same time, President Bush released his general strategy for pandemic flu preparedness and asked Congress for $7.1 billion to fund it.

The latest plan is intended to explain the steps that agencies throughout the federal government will take to deal with a pandemic. The document says it spells out more than 300 actions the government will take, and it also attempts to outline what's expected from non-federal players in pandemic preparedness. Townsend said federal agencies have drafted individual plans, which are to be released in coming weeks.

In the news briefing, Townsend said the H5N1 avian flu virus may reach birds in the United States this year, but she sought to reassure. "If the H5N1 virus appears in birds, it will not signal the start of a pandemic and will not necessarily represent a risk to the poultry population," she said.

But if the virus does lead to a pandemic, it could, in the worst case, infect up to 30% of the population and kill up to 2 million people, the plan states. It predicts that up to 40% of school-aged children could get sick and that work absenteeism in community outbreaks could peak at 40%.

But Townsend said good planning would prevent chaos even in that kind of crisis. "Do I think that's going to result in chaos? No, and that's the whole point of doing a national preparedness plan," she said. "The whole purpose of planning and preparation is to mitigate uncertainty, take the fear out of it so there's no chaos."

Under questioning, Townsend reinforced the plan's message that it won't be possible to keep a pandemic originating elsewhere in the world from invading the United States, but border restrictions might delay it a little.

"We don't expect a tight shutdown of borders would actually stop it from arriving here," she said. "When you look at border restrictions, there's a period of time very early on when they may be effective not in stopping the arrival of the virus, but buying us time, and allowing individuals and communities to get better prepared."

The report speaks of possible travel restrictions within the country, but Townsend refused to suggest what might trigger such measures or what they might look like. "It's difficult to answer that in hypotheticals; it'll depend on where it [the virus] comes from and how contagious it is," she said.

The report divides planning and response efforts into eight areas, with corresponding chapters: federal government planning, federal government response, international efforts, transportation and borders, protecting human health, protecting animal health, law enforcement and public safety, and institutions. The plan also has an appendix with advice for schools, the business sector, families, and individuals. Some highlights from selected chapters follow.

Coordinating the federal response
In a pandemic, HHS will "lead federal health and medical response efforts and will be the principal federal spokesperson for public health issues," while coordinating closely with the Department of Homeland Security (DHS) on public messages, the plan says.

An interagency group composed of senior decision-makers from across the government will develop strategic policy and coordinate domestic responses to the pandemic, the document states. The group will be "chaired by the White House."

Protecting human health
The federal government predicts that without containment measures, the number of cases of pandemic flu would double every 3 days. That estimate underscores the importance of good surveillance and prompt response.

The best way to contain a pandemic is by vaccinating people, the plan says. The government is trying to develop sufficient amounts of existing, or pre-pandemic, H5N1 vaccine to immunize 20 million people, as well as to create a vaccine-manufacturing surge capacity to make enough pandemic vaccine for all Americans within 6 months of a pandemic's start. The government has only a few million doses of pre-pandemic vaccine now.

In addition, the government aims to stockpile 81 million treatment courses of antiviral drugs. That includes 75 million courses to be shared with the states and 6 million courses reserved for use in efforts to contain initial outbreaks.

Primary prevention of a pandemic will include vaccination, early detection and treatment with antivirals, and infection control measures. Case tracking and contact tracing in the early stages of a pandemic may be useful in order to isolate the sick and request voluntary quarantine of their contacts, the plan says. However, it adds that the usefulness of quarantining contacts to contain flu is "not fully defined."

The document lists several other methods to reduce the spread of the virus:

Social distancing measures, such as advising people to stay at least 3 feet apart
Using more telecommuting or teleconferencing for work
Closing schools
Canceling non-essential public gatherings
Restricting long-distance travel
"Snow-day restrictions"—suggestions or mandates by community authorities that everyone stay home for two incubation periods (about 4 days for typical flu viruses)

The plan says the likely effectiveness of school closures and snow-day restrictions is not yet known.

In addition, geographic quarantine, imposed by force, if necessary, may be used to stop or slow the spread of flu from an infected community to an uninfected community. "Even if such efforts prove unsuccessful, delaying the spread of the disease could provide the federal government with valuable time to activate the domestic response," the plan states.

The plan also emphasizes the importance of expanding healthcare surge capacity. Rationing of scarce supplies, including ventilators and intensive hospital care, is to be expected, it says. Effective home-based care could be an option to reduce demand for hospital rooms. Protecting human health also means planning for behavioral health and ways to support populations to reduce psychological distress.

Transportation and borders
The United States has 317 ports of entry, and about 1.1 million people pass through them on a typical day, according to the plan. Moreover, Americans are highly mobile, taking about 1.1 billion trips per day.

Although policies affecting the nation's ports of entry and transportation system will influence the spread of a pandemic flu virus, even the most extreme action—closing the borders—would not stop the virus or decrease the ultimate number of cases or deaths, says the plan. It would, however, have "significant negative social, economic, and foreign policy consequences."

Slowing the virus's spread while minimizing the social and economic consequences, then, is the goal. This would buy time to continue preparations and take preventive actions, such as transporting vaccines and antivirals to an outbreak area.

The transportation system's complexities and its importance for public safety, health, and the economy require "extraordinary cooperation between the varied and diverse elements of the sector," says the plan. Critical transportation services will need to be sustained to keep communities functioning and to allow delivery of emergency supplies and resources. For example, planning must be done for delivery of chlorine for water supplies, gasoline, food, and drugs and other medical supplies.

The plan points out that while individual travel will likely decrease as a pandemic spreads, a surge may occur early in an outbreak area as people try to return home, help others, or relocate.

The federal government will have a key role "to provide clear criteria to guide and inform State and local actions and to conduct outreach with State, community and tribal entities to communicate a cohesive national strategy for maintaining movement of essential critical goods and services, while encouraging limitation of non-essential transportation."

Federal support for emergency transportation will come through activation of the "National Response Plan and Emergency Support Function #1." Even so, the plan acknowledges that a pandemic will pose a greater challenge than natural disasters do in this regard, because multiple urban areas will be affected simultaneously and for a longer time.

Cargo entry into the United States, except for live animals and animal products, would pose little risk of spreading flu and could continue, the plan says. Protective measures for workers may be necessary, as may actions such as confining crews and using strict transmission prevention protocols to lower the risk of transmission to or by cargo workers.

Continental rather than national containment will be stressed in a pandemic, and treaty commitments and other agreements with Canada and Mexico will be respected, says the plan. It predicts that mass migration from Central America or Mexico could occur if the virus affects those areas first, likely leading to the need for the Department of Homeland Security to deal with a large increase in illegal aliens.

Protecting workers, ensuring continuity
The implementation plan recommends that government agencies and the private sector expect absenteeism of 40% for 2 weeks during a pandemic’s peak, with fewer employees missing work before and after that period. Some preparedness recommendations for employers and their employees:

Identify essential functions and personnel beforehand. Consider cross-training to ensure vital functions continue. Protect and ensure the ready availability of key electronic and hard copy documents.
Delegate authority beforehand for key decisions, and establish an order of succession in case leaders are incapacitated.
Consider alternate operating facilities and preparing personnel for an announced relocation of essential functions. Such relocation steps may include telecommuting components or other “social distancing” steps.
Implement measures to protect personnel, which include frequent hand-washing, limiting travel to affected areas, maintaining 3 feet of personal space, replacing face-to-face meetings with teleconferences, posting infection-control guidelines, cleaning frequently touched surfaces like keyboards daily, and, possibly, wearing face masks.
Emphasize communication measures that minimize person-to-person contact.
Establish plans to resume normal operations quickly once a pandemic subsides.

Preparedness checklists for state, local, and tribal governments; private businesses; schools and universities; faith- or community-based organizations; and individuals and families can be found at the federal Web site dedicated to flu pandemic information (see link below).