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Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness (PHEP) program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Chapter 8. Influenza Pandemic Case Study

Authors: Members of all writing teams contributed to this chapter.

Previous chapters highlighted important issues, concepts and strategies that need to be taken into consideration when preparing mass casualty event (MCE) response plans. This final chapter of the guide pulls much of that information together and applies it to a specific MCE case study: the hypothetical scenario of an influenza pandemic. This chapter provides an overview of the myriad challenges community planners need to consider when faced with the allocation of scarce resources as a result of a worldwide outbreak of influenza.


Preceding chapters of this report have discussed a broad range of issues that planners need to consider when developing their MCE preparedness and response plans. This chapter distills that information into a specific case study planning exercise. Specifically, the discussion in this chapter explores the implications of planning for a hypothetical MCE: that of an influenza pandemic. None has been "mitigated" to date.

An influenza pandemic would fall under the category of a developing impact MCE discussed in the introduction of this guide. A pandemic poses daunting challenges for planners in that it will occur in many areas simultaneously; there will not be a single disaster "site." Indeed, a pandemic will affect a large part of the population across the world and across all age groups, including the health care and emergency response workforce. The magnitude of the pandemic's impact will be felt in the large numbers of patients who quickly overwhelm hospitals and emergency departments and necessitate the allocation of scarce resources.

The National Strategy for Pandemic Influenza Implementation Plan puts the bulk of the planning and coordination responsibility on States and localities rather than the Federal Government. The ubiquitous nature of an influenza pandemic requires such shared responsibility. State and local health authorities and community planners, therefore, represent the front lines of pandemic preparedness response planning efforts.

The National Strategy for Pandemic Influenza Implementation Plan is available at (PDF Help).

The Department of Health and Human Services Pandemic Influenza Plan is available at (PDF Help).

Consistent with the messages from the other chapters of this guide, planners need to create their pandemic preparedness plans now, practice and exercise the plans and revise them when necessary. The range of issues that planners need to consider as they prepare for an event likely to place overwhelming demand not only on each community's health care system, but on essential services as well, is indeed staggering.

While an important component of all disaster responses, clear communications with the public assumes even greater prominence in pandemics. Effective and coordinated risk communication, domestically and internationally, before and during a pandemic, is essential to helping the public understand the rationale for recommended protective actions and in accepting the prioritization of scarce resources.

Communications activities include the identification of credible spokespersons at all levels of government to effectively coordinate and communicate helpful, informative messages in a timely manner. In the pre-pandemic period, for example, the public can be educated about infection control behaviors and the specific actions individuals likely will be asked to take during a pandemic, such as self-isolation and protection of others, if they themselves become ill with the flu.

Preparedness activities that planners need to consider include using available communications tools (see box) to develop messages to address the difficult topics discussed in this guide, including decisions regarding the uses of scarce resources and caring for the sick at home.

The National Governors Association (NGA) primer for Governors and Senior State Officials, Preparing for a Pandemic Influenza notes that "Managing during a pandemic—with considerable loss of staff, depleted resources, a struggling economy and a nervous public—will be a considerable challenge to local and State leadership."

The NGA primer is available at Exit Disclaimer

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Risk Communications Tools for Planners

Activities are underway to develop training modules to assist communities prepare for all public health crises. Training guides, publications, and other risk communications documents are available at

Given the range of issues to be considered and the potential scope of the pandemic's impact, communities are encouraged to identify what resources will be needed, what processes and systems need to be put in place and to prepare their plans now to help mitigate the impact of a pandemic; decrease the amount of infection; and, by extension, reduce hospitalizations and deaths.

The first sections of this chapter set the stage for our hypothetical case study with an overview discussion of influenza and the implications of a pandemic. The succeeding sections of the chapter focus on the key concepts and strategies that planners need to consider when faced with the challenge of planning for a potential flu pandemic and the requisite allocation of scarce resources.

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Not all influenza strains are alike. Avian influenza, for example, a strain that occurs naturally among birds, differs markedly from what we know as the seasonal human influenza that claims an average of 36,000 lives annually in the United States (Table 8.1).

While these viruses usually do not infect humans, a lethal strain of avian influenza known as H5N1 did appear among humans in Hong Kong in 1997, sending 18 people to the hospital and killing 6 people. The H5N1 strain reappeared in Hong Kong in 2003, killing one person. Since that time, the virus has extended its geographic reach to other nations in Asia, Europe, and the Middle East. According to the World Health Organization, more than 50 percent of the people that have been infected with the virus to date have died.

What is particularly troubling to experts is the knowledge that all influenza viruses are capable of mutating. If the current strain circulating were to gain the capacity to spread easily from person to person, a worldwide influenza pandemic could ensue. While no one can tell if this may happen, experts are concerned about—and are monitoring closely—the evolving H5N1 virus situation in Asia, Africa, and Europe in preparation for a possible pandemic.

Despite the uncertainty about whether or when a pandemic will hit, we do have prior experience with pandemics. Over the course of the last century, the world witnessed three pandemics: the "Spanish influenza" of 1918, which resulted in a worldwide death toll of more than 50 million lives; the "Asian influenza" in 1957, which resulted in one-to-two million deaths worldwide; and the "Hong Kong influenza" in 1968, with 700,000 deaths worldwide.

Given the significant growth in not only the human population but animal populations as well since the last pandemic, the current environment may be even more conducive for the reassortment between animal and human influenza strains leading to a novel influenza virus that spreads between people and could cause a pandemic.

The sharp increase in worldwide travel over the past 40 years would fuel the rapid spread of the virus even further. Since viruses such as avian flu are not usually transmitted to humans, there is little or no immune protection against them, so most people are susceptible. The supply of antiviral drugs may be inadequate and the development of a vaccine will take a significant amount of time. Moreover, there may be a shortage of supplies, equipment, and hospital beds to cope with a pandemic.

Potential shortages of ventilators could be particularly problematic. In the case of such a pandemic, hospitals may not have an adequate supply of reserve ventilators required to treat patients suffering from acute respiratory failure. The Centers for Disease Control and Prevention (CDC) has a reserve supply of thousands of mechanical ventilators under the Strategic National Stockpile, and is planning to procure additional ventilators in 2007. To help prepare for a potential pandemic, the American Association for Respiratory Care (AARC) has issued the following guidelines and recommendations.

Key AARC Ventilator Capacity Recommendations

  • Increase human resources to assist respiratory therapists and physicians and have easy-to-use ventilators available in the event the respiratory therapists on the hospital staffs cannot handle the volume and noncritical care professionals must be enlisted.
  • Extend ventilator capacity for any mass casualty response, expanding the Strategic National Stockpiling Program by 5,000 to 10,000 ventilators. Additional ancillary supplies for ventilator use also should be stockpiled.*
  • Develop a distribution plan for ventilators at both the local and national levels.
  • Intubation (placing a breathing tube down the windpipe) is recommended for patients suffering acute respiratory failure during a pandemic flu, because ventilation by mask may increase the risk for infection to staff and other patients.
  • Prepare for a power outage: each medical center should identify emergency power sources for electricity and compressed gas.

The guidance document is available at Exit Disclaimer

* The Department of Health and Human Services (HHS) has since allocated $25 million toward ventilator procurements.

The impact of the pandemic will be felt in the closing of schools and businesses, with high worker absenteeism as employees remain at home either due to their own illness or to care for a sick family member.

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Current State of U.S. Emergency Medicine and Disaster Preparedness

Pandemic response planning efforts will not take place in a vacuum; planners need to be aware of the overall environment in which any disaster preparedness effort will operate. Unfortunately, planners will not be working necessarily from a position of strength in terms of the current state of emergency health care and disaster preparedness in the United States.

"It became evident to me that [emergency preparedness] was a major part of my responsibility. [September 11] has created a need for an even deeper inspection of our readiness throughout the country. The people of Salina, Kansas weren't really worried about terrorists coming to their town, but they have reason to be concerned about a [flu] pandemic."

—Michael O. Leavitt
Secretary U.S. Department of Health and Human Services

According to a recently issued Institute of Medicine report, Hospital-based Emergency Care: At the Breaking Point, the U.S. emergency medical care system is seriously unprepared for a national crisis such as a pandemic or terrorist attack. The report concluded that our current emergency medical system is already strained to the breaking point and suffers from inadequate funding along with weak communications and coordination across levels and geographic areas, with little if any surge capacity to deal with a disaster of the magnitude of a flu pandemic or other crisis.

It is within this context that every community must address the daunting task of developing a pandemic preparedness response plan. Given the current state of emergency medicine, it is important to reemphasize the key message of the earlier chapters of this guide: advance planning is critical.

Many hospitals are already operating at or over capacity. Because major hospitals and emergency departments are already crowded with patients and even may be boarding large numbers of inpatients, there is little or no surge capacity to absorb a large influx of patients from an MCE.

Hospital-Based Emergency Care: At the Breaking Point.
Institute of Medicine, June 2006.

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Setting the Stage: Progression of a Hypothetical Flu Pandemic

For the purposes of this case study, the Expert MCE Working Group devised a hypothetical pandemic scenario that can be grouped into four periods.

  1. Pre-pandemic Period. The pre-pandemic period is the period in which we currently find ourselves. A limited number of human cases of avian flu H5N1 have occurred in persons having close contact with infected birds or poultry, and only limited human to human transmission has occurred. This is the period in which the bulk of the planning effort should be completed. Indeed, the discussions throughout this planning guide have emphasized the importance of advance planning for an MCE; it is precisely here in this early pre-pandemic alert period that most of the advance planning for a potential flu pandemic needs to take place.
  2. Initial Pandemic Alert: No Cases in U.S. The next period in our hypothetical case study involves the confirmation of an outbreak of sustained human-to-human transmission of a strain of H5N1 in a small village in Thailand. The World Health Organization then commits 3 million courses of Tamiflu to the region and requests additional donations from industrialized nations with stockpiles. Thailand also requests additional countermeasures directly from the United States. Other Southeast Asian countries subsequently institute restrictions on movement to protect their populations and prevent the disease from spreading further. By the end of the first phase, there are 446 cases of the disease and 18 deaths in Southeast Asia.
  3. Pandemic Alert: Global Spread and First Confirmed Cases in U.S. The next period of our pandemic scenario sees the H5N1 virus spreading beyond Southeast Asia to major municipalities, countries, and regions worldwide, with sustained human-to-human transmission. The number of reported infections rises to 158,487 cases worldwide and 6,318 deaths. This period ends with the appearance of the first flu case from the H5N1 virus in the United States.
  4. Pandemic Period: Widespread U.S. Pandemic. The final period of our hypothetical pandemic scenario, the pandemic period, involves increased attention to the worsening conditions in the United States, where millions are infected and 2 percent of those infected ultimately die from the disease. Workplace absenteeism and disruption in trade and travel begin to take a large toll on world economies. Shortages of medical supplies, staff members, and facilities complicate treatment of the ill. Over the course of a 7 week period, the number of cases in the United States rises from 90 to nearly 5 million and the number of deaths increases from 1 to nearly 100,000.

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Pandemic Flu Case Study: Important Concepts, Strategies, and Actions for Planners

The following sections detail important concepts, strategies, and actions that planners need to incorporate into their preparedness planning. The information is arranged according to the three periods of our hypothetical case study described above. Within each period of the pandemic, we highlight the important concepts to be considered as well as the strategies and actions to be taken within the prehospital, hospital, and alternative care site (ACS) sectors.

As noted earlier in this guide, the home will be particularly relevant in the case of a flu pandemic. Planners must emphasize the importance of the home as a "safe haven" and consider the use of primary care vans to go out into localities to provide services so that people may remain in their homes. At the same time, planners need to recognize the vital role of primary care providers in deciding which patients may remain at home and which patients need to go to the hospital. In the case of a flu pandemic, primary care providers may be the first medical personnel contacted. Moreover, the ambulatory care system will be a critical element of a system to keep the hospitals from being overwhelmed during a pandemic.

Finally, in addition to looking at the flu pandemic planning considerations in each health care setting, we also detail important palliative care-related issues to be considered.

Not all the material provided in this chapter will be appropriate to each community planner. Indeed, many of the concepts presented here will need to be tailored to the resources available and the systems that are in place in the specific community, locality, region, or State. It is hoped that planners can use this information to help fill in the gaps in their pandemic preparedness plans by answering the questions, "What do I do, and when do I do it?" This chapter aims to provide community planners with options to consider in terms of preparing for a potential flu pandemic.

This chapter presents a hypothetical case study, and the material provided, while extensive, is not exhaustive. Planners are encouraged to consult the wealth of excellent pandemic influenza planning documents for detailed information and recommended actions.

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Pandemic Preparedness Resources

A sample of the many valuable resources for community planners include:

State and local government pandemic planning and response avian and pandemic flu information can be found at

HHS Pandemic Influenza Plan:

CDC Pandemic Influenza information for Health Professionals:

World Health Organization materials on influenza preparedness: Exit Disclaimer

State health planning information from The Association of State and Territorial Health Officials: Exit Disclaimer

The National Governors Association Primer for Governors and Senior State Officials: Exit Disclaimer

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Pre-pandemic Period

This pre-pandemic period represents the period in which we currently find ourselves. This period is where most of the advance planning for a pandemic needs to take place. An overview of issues and activities that community planners need to consider is listed below.

I. General Coordination and Planning Issues

Command Structure
  • Determine the trigger for emergency health powers provision (see discussion of legal issues in Chapter 4 of this guide). Conduct discussions with hospital associations and local and State Public Health officials on when the trigger would be pulled on emergency health powers provisions and who makes that decision.
  • Develop continuity of government and leadership protocols  in the event that senior leadership becomes missing, incapacitated, or deceased.
  • Conduct regional exercises that are inclusive, use realistic scenarios, involve all responders, and embrace participation from agencies that are often not included.
  • Include local and State political representatives  using education and exercises to get them involved, committed, and supportive.
  • Consider the special needs population and children  in all planning scenarios.
  • Begin a public communication campaign. Focus the messaging campaign on managing expectations; and providing updates on the community plan for pandemic response, including community care sites. This communications campaign should be a joint effort by hospitals, hospital partners, and public health departments.
  • Emphasize prevention. Inform and educate the public about influenza. Provide advice and information on prevention and interventions to reduce virus transmission so that if and when the virus arrives the public is knowledgeable about reducing the spread of the virus.

II. Prehospital

  • Prepare universal precautions for every patient encounter.
  • Pre-plan community staging locations, which would be pre-designated sites that could be opened ahead of time for alternative care and EMS staging.
  • Locate transport assets in advance.

Planners are encouraged to consult the EMS planning checklist available at (PDF Help).

  • Arrange mutual aid agreements for acquisition and use of specialized assets. This would be accomplished by meeting with local and regional transportation authorities or businesses and agreeing by Memorandum of Understanding (MOU) on deployment, available assets, and staging locations (e.g., buses, other means of transports, staff augmentation). The MOU could be further enhanced by the development of a pre-event contractual agreement between the government and these institutions.
  • Evaluate triage models such as JUMPSTART, Israel, and SACO.
  • Develop and publicize call centers to minimize load on hospitals and clinics.

III. Hospital

Planners are encouraged to consult the detailed hospital pandemic preparedness checklist available at

  • The Hospital Planning Committee should complete all components of hospital pandemic influenza preparedness and response plans (multidisciplinary committee including a range of response partners).
    • Develop hospital guidance for flu pandemic control measures.
    • Work with other local hospitals, community organizations, State and local health departments to coordinate pandemic response actions.

The hospital pandemic influenza planning committee may include representatives from the following departments:

  • Administration.
  • Legal counsel.
  • Infection control/hospital epidemiology.
  • Hospital disaster/emergency coordinator.
  • Risk management.
  • Facility engineering/physical plant/institutional safety.
  • Nursing administration.
  • Medical staff.
  • Intensive care.
  • Emergency Department.
  • Laboratory services.
  • Respiratory therapy.
  • Psychiatry.
  • Environmental services (housekeeping, laundry).
  • Public relations.
  • Security.
  • Materials management.
  • Education/training/Staff development.
  • Occupational health.
  • Diagnostic imaging.
  • Pharmacy.
  • Information technology.
  • Other members (infectious diseases, mental health, social work, critical care medicine, pathology, among others).
  • Representatives from State and local health departments and community partners such as EMS, local law enforcement, and community service agencies, among others.

Source: HHS Pandemic Influenza Plan at

  • Assess surge capacity (beds, ventilators, etc.) to meet expected increased needs during a pandemic.
  • Develop plan to expand staff capacity. Determine how the hospital will meet staffing needs during a pandemic.
  • Draw up preference list of supplemental providers:
    • Consider volunteers, ESAR VHP, CERTs, MRC, clinic staff, out-of-State licensed staff, military, retirees, non-health-care staff, among others.
    • Ensure policies are in place to test and manage deployment of nonhospital personnel at both the community and hospital levels.
    • Ensure that a plan for managing volunteers is in place.
  • Develop contingency plans for staff absences during a pandemic, particularly ER staff.
  • Initiate discussions of allocation of hospital resources during a pandemic; hospital administrators to meet with hospital ethics committee early on in planning process:
    • Establish hospital process for scarce resource allocation.
    • Develop communication process so community understands the rationale behind resource allocation policies.
  • Stockpile supplies and equipment:
    • PPE equipment (e.g., gloves, masks).
    • Estimate increased need for respiratory care equipment and develop strategy to acquire additional equipment if needed.
    • Consult with local and State health departments about access to the national stockpile during a pandemic.
  • Develop facility access guidelines:
    • Define "essential" and "non-essential" visitors and develop policies for restricting visitors during a pandemic (and mechanisms for enforcing the policies).
    • Plan to limit hospital entry to a few key entrances.
    • Plan for increased security needs during a pandemic.

IV. Alternative Care Sites

Planners are encouraged to consult the HHS Influenza Plan for Alternative Care Sites at

A major challenge for planners is that in contrast to hospitals and EMS, ACSs do not currently exist as operating medical care systems. In fact, in many communities, ACSs have not even been carefully considered as an option for patient care. Therefore, it is imperative that the planning process for ACSs begin as early in the initial pandemic planning process and include the following activities:

  • Define ownership, command, and control of ACS.
  • Perform site selection based on best estimates of need.
  • Decide on the scope of care to be provided in the ACS.
  • Establish functional requirements based on the level of care to be provided:
    • Acquire supplies, equipment, and pharmaceuticals (including communications equipment).
    • Perform staffing planning, taking into account absentee rates from potential sources of staff members.
  • Develop MOUs for operational support of the ACS.
    • Include housing for health care workers.
  • Develop policies of operation for the ACS, including:
    • Incident command.
    • Criteria for admission, discharge, and transfer.
    • Clinical roles and responsibilities.
    • Infection control.
    • Pharmacy and medication control.
    • Safety and security.
    • Housekeeping.
    • Food service.
    • Finances and documentation.
  • Develop a health care risk communication message, including criteria for seeking health care, such as postponement of non-emergency procedures or surgeries.
  • Develop criteria for hospital decompression.

V. Palliative Care

  • Hold planning discussions of limited treatment options due to scarce resources. In a situation of scarce resources, decisions will need to be made that typically would not be considered under usual circumstances. The standards of care and treatment decision options will be appropriate to the situation at the time the decision is made. Community planners need to be aware that:
    • It may not be possible always to save a life during a pandemic.
    • It is important to have these difficult discussions prior to the occurrence of a pandemic.
  • Establish and maintain standards of palliative care.  Ensure that standards of palliative care are published and available for consideration in pandemic planning efforts.
  • Provide education and training for palliative care responders  in basic preparedness for understanding, recognizing and establishing response actions in a pandemic flu situation.
    • Include instruction about self-protection and avoidance of the spread of disease.

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