NGA's pandemic primer says the states have a long way to go in planning for flu

States have made progress in planning for the public health aspects of coping with a major flu pandemic, but have a long way to go in thinking through many of the other aspects. That's a conclusion drawn by the National Governors Association (NGA) Center for Best Practices in its study Preparing for a Pandemic Influenza: A Primer for Governors and Senior State Officials.

Center for Best Practices senior policy analyst Chris Logan tells State Health Watch that, to date, states have focused primarily on public health preparedness and medical preparedness, addressing issues such as surge capacity, alternative treatment sites, and the need for additional staff.

"Now states need to focus on the nonmedical aspects," he says, "such as continuity of operations and maintaining existing services. For instance, it's necessary to think through how to maintain essential police, fire, sanitary, and wastewater services when up to 40% of the people who normally work in those areas are unable to come to work because they are sick."

Meanwhile, the Centers for Disease Control and Prevention said the national pandemic influenza plan should be revised to provide states with more concrete information they could use in their planning process.

Mr. Logan says the NGA primer calls for comprehensive planning that involves government agencies, businesses, and individuals, each of whom will have a role to play in responding to a pandemic outbreak.

"The impact of a pandemic will be felt most acutely at the state and local levels," said NGA vice chair Janet Napolitano, governor of Arizona. "Strong state leadership will be crucial. This document will help governors and state officials understand their unique roles in the development of an effective response plan and the challenges they face."

Outlined in the document are four key principles to guide governors in their ongoing efforts to shape effective response plans:

  • The effects of a pandemic flu will be broad, deep, and simultaneous, and states must focus resources to ensure continuation of essential services;
  • Medical response capability in a pandemic will be limited, strained, and potentially depleted during a pandemic;
  • Government must work closely with the private sector to ensure critical operations and services are maintained;
  • A pandemic will force many key decisions to be made in a dynamic environment of shifting events and partnerships must be built now and tested to ensure appropriate and rapid action.

All social sectors will be affected

"Pandemic planning involves more than stockpiling pharmaceuticals and planning for surges of patients at hospitals," the primer says. "A severe pandemic will affect all sectors of society: high rates of worker absenteeism could affect the operations of water treatment facilities and power plants; efforts to slow or stop the spread of the disease could limit the availability of food, cause schools to be closed for significant periods of time, and cause economic hardships for state and local governments, business owners, and individuals; and government efforts to manage the public's response could be complicated by the myriad sources of information—including the Internet—on which people rely for guidance."

According to the report, state and local officials must address not just the immediate outbreak of influenza, but also the time between the pandemic waves, and the possibility that the worst effects may occur in a second or third wave. It may take more than a year to complete the likely three phases of the disease. During each time between outbreaks, it says, there will be an opportunity to recover and prepare for a future outbreak, but that opportunity will come during a time of considerable stress for the public and an exhausted responder community.

"After a pandemic wave is over, it can be expected that many people will have lost friends or relatives, suffer from fatigue, or have financial losses as a result of the interruption of business," the report explains. "State governments or other state or local authorities will need to address these concerns while also preparing to respond to the next wave of the disease. A key priority will be ensuring that government operations continue. Each agency must develop a list of service priorities and then develop plans for meeting those priorities."

Effective plans, the report says, must answer these questions:

  • Is there recognition of the potential human, social, and economic impact of a pandemic within the state and region?
  • Are there public and private sector commitments to prepare for such an event?
  • Is there a strategy on how to involve the community in the planning process?
  • Have ethical aspects of policy decisions been considered? Is there a leading ethical framework that can be used during the response to an outbreak to balance individual and population rights?
  • Is a legal framework in place for the state pandemic plan? Does this framework include contingencies for health care delivery and the maintenance of essential services, and for the implementation of public health measures?
  • Has the state prioritized countermeasure allocation before an outbreak? Can the state update this prioritization immediately after the outbreak begins based on the at-risk populations, available supplies, and characteristics of the virus?
  • Does the state have an effective communications plan and strategy? Are all the key state personnel aware of their roles and responsibilities in the communication plan? Does the state have backup plans in the event that one or more functions fail due to infrastructure or manpower losses during the epidemic?

Plans must stress communication, intergovernmental coordination, public education, health resources, curbing economic impacts, maintaining essential services, using appropriate legal authority to stop disease spread, and training, NGA says.

Respond to changing conditions

Because a pandemic will not present a single event or catastrophe, but rather a series of events to address over time, states' decision-making processes must be agile and responsive, the report stresses.

"For this reason," it says, "states, together with localities, the private sector, and neighboring states, must spend considerable time in testing plans and simulating events. Only through such exercises will there be an opportunity to explore contingencies and build relationships among those tasked with responding."

Mr. Logan tells State Health Watch that much of the planning has to look at interdependencies among various systems and activities. Thus, he says, planners have to consider what happens if the schools must close to ensure that children don't end up going to the mall to hang out. And they must consider the possible need for additional law enforcement resources if students are not in school.

"Once you start looking at it, it can become overwhelming," he says. "Everyone needs to be present to discuss and decide."

Mr. Logan says governments must realize the situation will change rapidly and they will need to be able to react quickly in response to changing situations.

He says it is not NGA's role to produce a template that all states could follow. The primer was written, he says, to raise questions and help state officials think through the many issues that are involved.

"What will be needed in California and Washington is very different from what will be needed in Wyoming and New Mexico," he says. "Everyone needs to think about the same kinds of things, and especially about how to preserve resilience."

States have an advantage, according to Mr. Logan, because they have done planning for other kinds of catastrophes and some of the issues are the same.

"One of the things we learned from Hurricane Katrina is that the things you rely on can disappear quickly," he says. "If you can ride out a pandemic, you're in pretty good shape for a number of other things. States probably have been thinking about many of the issues already in other contexts."

Long way to go in planning

American Public Health Association executive director Georges Benjamin, MD, FACP, who had been Secretary of Health and Mental Hygiene in Maryland, tells State Health Watch states' ability to respond to a pandemic is improving, but "we still have a long way to go."

He says there is a broad awareness in government about the issue today. Major companies are aware of some of the potential ramifications for them, he says, but smaller employers have not yet gotten their hands around the issues. The average person has heard something about flu pandemics on TV but that's all, and the low-income and disabled populations don't have it on their radar screens.

"States have made some plans," according to Dr. Benjamin, "but they're in varying degrees of completeness. And even the best plans have not been fully integrated into broader preparedness plans. They have not stood the test of real time. You have to drill and test plans to identify problems that need to be fixed."

He also is concerned that states have not engaged the public yet.

"It's clear the public won't do what we want them to do," he says, "and that leads to a mismatch between plans and what people actually do."

Dr. Benjamin agrees with Mr. Logan that the task can seem overwhelming, but says it can be managed if state officials take it one step at a time. Strategies states should consider, he says, include 1) building to the extent possible on the existing infrastructure; and 2) building a logistical system that works. He gives just one example of the kinds of logistical issues that need to be addressed—schools provide many functions in addition to educating children, such as providing one or more meals a day to children. If the schools close, some way must be found to continue mass feedings. Dr. Benjamin says there have been suggestions that school buses be used to follow their normal routes and deliver meals.

"But school bus drivers don't know anything about mass feeding and delivery routes," he says. "It might make more sense to involve those who are used to delivering in a community, such as FedEx and UPS, and team them up with people who are used to cooking for large numbers such as fast-food restaurants and other eating establishments."

Dr. Benjamin also believes states need to build their public health capacity holistically.

"Surge capacity comes from people who are already there but are doing other things," he says. "You need to be sure people know it's their responsibility to come to work and pick up a different task."

Download the NGA primer from Contact Mr. Logan at (202) 624-5379. American Public Health Association pandemic materials are available at Contact Dr. Benjamin at (202) 777-2742.