Local Government Influenza Pandemic Planning

By Richard DiPentima

Editor’s Note: As this publication was going to press, the World Health Organization released information regarding several cases of avian flu in Turkey. On January 13, the state Department of Health and Human Services announced that New Hampshire will receive $813,384 in federal funding to assist with the development of pandemic plans at the state and local level. This funding is part of $100 million distributed nationally.

Over the past few months there has been a great deal of discussion and concern about the potential for an influenza pandemic developing. The reason for this concern has been the spread of the so-called bird flu in poultry and wild migratory fowl to many parts of the globe, especially Asia. Also of great concern has been the small, but growing number of human cases of avian influenza in Asia with a fatality rate exceeding 50 percent of those known to have contracted the disease. As of December 23, 2005, there have been 141 human cases identified with 73 deaths. All of these cases have occurred in Asian countries. While almost all of these human cases have been linked to contact with ill domestic poultry, there is concern that possible human-to-human transmission of the virus may have occurred in close family contacts.

What is an influenza pandemic?
A pandemic is defined as a worldwide spread of a disease or disease causing agent that is new to the human population and for which we have little or no natural immunity. With regard to influenza, this is known as a novel influenza virus strain. In recent history there have been three influenza pandemics: the 1918 “Spanish Flu," and the pandemics in 1957 and 1968. While the 1957 and 1968 pandemics were relatively minor, the “Spanish Flu" killed over 50 million people worldwide.

In the case of avian influenza, or “bird flu," the concern is that the current virus affecting birds is one that most humans have no immunity against, and that it may mutate or change in a way that will allow the virus to be easily transmitted from human to human. If such an event were to occur, millions of people across the globe could become ill and many could die, depending on the severity of the novel virus strain, and the absence of an effective vaccine and sufficient doses of effective antiviral drugs. Because an effective vaccine cannot be produced until the particular virus strain is known, adequate supplies of a vaccine may not be available for 4 to 6 months into a pandemic. Sufficient antiviral drugs may also not be available due to manufacturing limitations, and there is some concern that the circulating virus may develop resistance to these drugs. For these reasons, it is imperative for local governments to plan now for what many agree—based on history—is an inevitable epidemic.

What can cities and towns do now to plan for a possible pandemic?
Considering this scenario, New Hampshire cities and towns should plan for the potential economic, social and infrastructure disruption that could result. It is understood that most towns and small cities in New Hampshire lack a public health infrastructure at the regional or county level to coordinate influenza pandemic planning. Furthermore, the state Influenza Pandemic Plan can only be effective with the cooperation and assistance from local communities. Since, during a pandemic, each community will be facing the same problems, reliance on outside assistance may be a luxury not available to towns as with many other natural disasters. The following provides a basic overview to help communities begin the planning process.

Step 1 – Define clear roles and responsibilities
The first step for a community is to begin to identify clear roles and responsibilities among local officials, including the health officer, selectman, fire chief, police chief, town administrator, school superintendent, highway supervisor, water and sewage plant operators, among others. Establish an incident command structure within the community in order to assure good communication and clear lines of authority. Everyone should know what their role is and whom they report to. One individual should be identified as the spokesperson for the jurisdiction.

Step 2 – Establish collaborations and formal mutual aid agreements
It is essential that community resources vital to addressing a public health emergency be identified and brought into the planning process early. These may include the local home health agency, visiting nurse association, hospital, clinic, ambulance service, nursing homes, mental health providers and mortuary services. A local advisory committee consisting of these partners and key local government officials should be established and meet regularly during the planning process. Identify the gaps that exist in your local emergency response structure and begin to communicate with surrounding town or city governments to explore mutual aid agreements and sharing of resources. While individual small towns may not be in a position to address all of the issues and needs alone, now is the time to develop the collaborations and partnerships with surrounding communities and the private sector to jointly develop regional plans. For years local police and fire departments have established mutual aid agreements to assist in large emergencies. These same types of agreements should be considered with regard to providing necessary public health support during a flu pandemic or other large public health emergency. This is especially important during a pandemic when state limited resources may not be available to assist every local community.

Step 3 – Identify vital community servicesEach community must identify critical services that must be maintained during a pandemic, assuming the possibility that 30 percent of the town work force may be absent from work at any given time. This level of absenteeism could extend for a period of weeks or months depending on the nature of the pandemic’s course. Local governments must assess if sufficient numbers of employees are trained to maintain critical infrastructure operations such as police and fire dispatch, water and sewer plant operations, snow plowing, communications, and other operations. If not, consider training additional staff to create redundancy with regard to these critical tasks. Sharing of resources with surrounding communities through mutual aid agreements may also provide some redundancy in critical areas as well.

Step 4 – Plan for mass immunization and/or mass medication distribution clinics
Since, in all likelihood, a vaccine will not be available in sufficient quantities during the early phases of a pandemic, certain priority groups will be identified to receive vaccination initially. Once adequate supplies of vaccine become available, large community vaccination clinics may be necessary. Local communities should identify a location in their community at which a mass vaccination clinic could be held; it should be a location with adequate parking and interior space. In most cases, a school, church, community center or private club may be available for such an event. In addition, adequate medical and non-medical volunteers would be required to staff such a clinic. Outreach to the community to identify residents with medical training that could be available to assist should be part of the planning process. A list of needed supplies and equipment should be developed along with a floor plan for the operation of the clinic at the selected facility. Security for the vaccine and the clinic must be provided. The community should identify residents with special needs, such as those who are home-bound, and those with language or other communication needs, and develop a plan to deliver vaccine to these individuals. Communities should look at available transportation resources such as school buses, community organization buses, or other vehicles to assist in the effort.

Step 5 – Plan for community disease control and prevention measures
Another aspect of a pandemic, especially in the early phases, may involve the implementation of isolation and quarantine measures by the state to limit disease spread. Isolation refers to the separation of an ill person from the general population for as long as they are contagious, whereas quarantine is the separation of individuals exposed to the disease but not yet ill. In most cases, these measures will be undertaken on a voluntary basis, but in situations where an individual refuses to cooperate, the state may issue a legal order of isolation or quarantine. In such cases, local law enforcement officials may be required to issue and enforce such orders. Police officers should receive training on disease transmission and be fitted and trained on how to use protective equipment such as masks in preparation for such an event. For those individuals in isolation or quarantine in their homes, a system to follow-up on these people must be developed. Since these individuals will be restricted to their home for a number of days, there must be a system of delivering needed supplies, food and other essentials to them during this period of confinement. During an influenza pandemic, a state of emergency may be declared. Under such an emergency the state may issue orders to limit public gatherings, close schools and take other measures to increase social distancing to limit the spread of disease. Local officials will play important roles in enforcing such restrictions.

Step 6 – Review work policies and practices
Individual towns should begin now to review work policies. It may be necessary to establish or expand policies and tools that enable some employees to work from home to limit exposure to disease. Review sick leave policies to assure ill workers can take time off with pay. If possible, take action now to expand the services that your citizens can access by phone, mail and through the Internet, such as tax payments, auto registration and other services. This will decrease the number of people your staff will be exposed to during a pandemic.

An influenza pandemic has the potential to cause severe hardship and disruption of life as we know it for months. While to some degree we are at the mercy of the microbes, there still is a great deal we can do now to limit the impact. Providing for the health and safety of the people is first and foremost a responsibility of government. The leadership for this effort must come from our elected and appointed officials. The people will look to state and local officials for assistance, and they will rightfully hold us accountable for our success or failure.

Additional Resources

Department of Health and Human Services

The state Department of Health and Human Services (DHHS) Web site offers information specific to avian flu, as well as other public health issues. The site provides links to the state’s Influenza Pandemic Public Health Preparedness and Response Plan and related publications. For more information, visit www.dhhs.nh.gov/DHHS/CDCS/avian-flu.htm or call 603.271.4501.

New Hampshire Public Health Network
The New Hampshire Public Health Network (NHPHN) works to assure coordinated and comprehensive delivery of essential public health services and serves as a local liaison with state agencies involved in the public’s health and safety. NHPHN is comprised of community-based partnerships involving broad public health interests including local health departments and health officers, fire, police, emergency medical services, health care providers, social service agencies, schools, media and advocacy groups, and leaders in business, politics and faith working together to address complex public health issues. Currently there are 14 public health partnerships serving nearly 50 percent of New Hampshire towns and 70 percent of New Hampshire residents. For more information and a map of existing partnership areas, visit www.nhphn.org.

U.S. Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) Web site, www.cdc.gov, provides information on avian flu and other topics of national health concern. The CDC’s State and Local Government Influenza Planning Checklist (released in December 2005), as well as the new official federal Web site for pandemic flu, www.pandemicflu.gov, can also be accessed through the CDC Web site.