300 words

Pandemic Infl uenza Planning 823

P. Edward French Mississippi State University

Eric S. Raymond University of Georgia

Eric S. Raymond is a doctoral student

in the Department of Political Science at the

University of Georgia. His research interests

include American politics and institutions,

local government, urban policies, homeland

security, and emergency management.

E-mail: [email protected]

Th e possibility of an infl uenza pandemic occurring within the next two decades is very real; the role of local governments in comprehensive preparation for this global threat is crucial. Th e federal government has provided broad guidelines for state and local offi cials who are ultimately responsible for emergency response and lifesaving services, vaccination and antiviral use, and the provision of other critical support. Much of this infl uenza pandemic preparedness has occurred under conditions of uncertainty, and these government actions may have unprecedented legal and ethical implications. Th is study evaluates the pandemic infl uenza policies of eight large U.S. cities to determine how Department of Health and Human Services recommendations with ethical and legal implications have been addressed. Th e authors fi nd that several important aspects of these guidelines are vague in many plans, and input from key stakeholders is inadequate.

The 1918 infl uenza pandemic killed more than 50 million people worldwide, with an estimat-ed 675,000 deaths in the United States alone during the outbreak (DHHS 2007). A pandemic of this proportion occurring today would extrapolate to 1.9 million deaths in the United States and 180 million to 369 million deaths globally if public health interventions are not instigated (Osterholm 2005). Th e impact on cities, states, the nation, and the global community would be devastating. Experts note that there have been between 10 and 13 infl uenza pan- demics in the world since the early 1700s, and they estimate that a pandemic will occur every 30 to 50 years (Knapp 2006). Th e last one occurred in 1968. Based on this information, the probability of another pandemic within the next quarter century is very real. Th e likelihood of its arrival means that emergency plans coordinating federal, state, and local responses must be in place. Th e role of local governments in the planning and implementation processes is paramount.

Planning for this health threat, however, can present numerous obstacles. Whether a pandemic will be caused by avian infl uenza or another virus is diffi cult

to predict. While the federal government has stock- piled vaccine against the H5N1 strain, which is the most likely viral source, this vaccine has been shown to produce the desired level of antibody needed to reduce the risk of contracting infl uenza in only 45 percent of healthy adults in a clinical study (Progress Report 2007). Also, pandemics occur in waves and endure for at least 18 months. Government offi cials must be prepared to face the fi rst wave with- out an eff ective vaccine and with a limited amount of antiviral medications. Experts note that the imple- mentation of nonpharmaceutical interventions during this time period is perhaps the most crucial element in limiting the eff ects and dissemination of a deadly virus (Grinberg 2007). Such interventions may include hospital infection control, decreased social mixing and increased social distance, isolation and quarantine, and international travel and border controls.

A myriad of ethical issues will arise with the next infl uenza pandemic. Some of the decisions regarding these matters will be unprecedented. While banning public outings, closing public schools, and ask- ing employees to stay at home may be troublesome measures for local public offi cials to undertake, the decisions regarding the allocation of limited resources such as vaccines and antivirals, the imposition of restrictive measures on the public such as isolation and quarantines, and the level of risk that the public workforce should be expected to face while assisting individuals infected with the infl uenza virus are much more formidable (Scanlon 2004; Upshur et al. 2007). While the federal government will provide only broad guidelines for state and local government actors, specifi c decisions regarding vaccination at the local level, maintenance of emergency response and lifesav- ing services, and provision of other critical needs may have unprecedented legal and ethical implications. Whether the next pandemic starts in the United States or abroad, it will only be a matter of time before local government offi cials see their fi rst case. Extensive pandemic infl uenza preparedness is crucial, and much of this preparedness has occurred under

P. Edward French is an assistant

professor in the Department of Political

Science and Public Administration

at Mississippi State University. He is

the coauthor of three books and has

published in numerous academic journals.

His teaching and research interests

encompass local government administra-

tion, including human resource issues,

risk management, and selected topics in

public management and policy.

E-mail: [email protected]

Pandemic Infl uenza Planning: An Extraordinary Ethical Dilemma for Local Government Offi cials

Tough Public Policy Choices Confronting America

current conditions of uncertainty. Th ese proposed interventions must take into account global interest and fundamental human rights if the American and international communities are expected to support restrictions that have the potential to impact individual civil liberties and national and world trade, travel, and economies.

The Potential Pandemic Strain: H5N1 An epidemic occurs when the population in a specifi c area is af- fected by the outbreak of a contagious disease. When this epidemic broadens its geographic area to include a region, nation, or the entire world, a pandemic occurs. According to public health experts, the avian fl u should be considered a permanent pandemic threat. At the present time, the spread of highly pathogenic Infl uenza A virus subtype H5N1 has mainly been confi ned to animal popu- lations. Th is virus is currently endemic in the bird populations of Southeast Asia, and outbreaks have occurred in Africa, Europe, and the Middle East (Gostin and Berkman 2007). Two of the three essential prerequisites for an infl uenza pandemic of this strain have been met on numerous occasions: (1) the identifi cation of a novel strain in animal populations, and (2) viral replication causing the disease in humans (Gostin 2004). However, even though human-to-human transmission of avian infl uenza has occurred, the transmission has yet to be highly effi cient; thus, the third prerequisite of a pandemic has not been fulfi lled to this date. Th e H5N1 strain is suffi ciently diff erent from ordinary seasonal fl u that individuals have little immunity to this virus.1 Th is strain usu- ally aff ects the tissues of the lower respiratory tract, resulting in the accumulation of large amounts of fl uid in the lungs (Miller 2006). Death may result within 24 to 48 hours. Th e federal government drafted its pandemic infl uenza plan in 2005, after the H5N1 avian infl uenza virus had been documented in 16 countries. Since that time, presence of the virus has been noted in 60 countries, and ap- proximately 300 people worldwide have been infected (Gostin and Berkman 2007). Of these infected individuals, 60 percent have been killed by the virus. If this strain is able to mutate into a form that is easily transmissible between humans, the stage for a global pandem- ic will be set. Th e mortality rate will depend on how many people become infected, the virulence of the virus, and the eff ectiveness of emergency preparedness plans.

While vaccination will be one of the most cost-eff ective interven- tions, a pandemic infl uenza vaccine most likely would not be available for at least six months. Th is six-month period results from the time needed to collect the virus, decipher its genetic makeup, develop a prototypic vaccine, and manufacture the fi nal vaccine product, which must be evaluated by the Food and Drug Adminis- tration for use (Fauci 2006; Lister 2005). Currently, worldwide vac- cination production is limited to only nine facilities. Th e existence of this small number of manufacturing facilities reduces production capabilities to an estimated 300 million to 424 million trivalent fl u vaccines in the event of a pandemic outbreak (Emanuel and Wertheimer 2007; Lister 2005). Th is situation has left government offi cials with few options but to develop carefully planned vaccina- tion distribution policies in order to maximize both the distribution

of the vaccine and its eff ectiveness (Emanuel and Wertheimer 2007), and to develop emergency preparedness plans that incorporate other public health interventions focused on limiting the wide spread of the pandemic virus.

Emergency Management Framework Th ere are few natural disasters that have the capacity to signifi cantly disrupt the economic and social underpinnings of society. Hurri-

canes, major earthquakes, and even volcanic eruptions are certainly capable of decimating towns or regions of the country. Th ese natural occurrences pale in comparison, however, to the level of social, political, and economic disruption that a public health emergency such as an infl uenza pandemic would cre- ate. In fact, “an infl uenza pandemic has the potential to cause more deaths and illness than any other public health threat” (Milgrim 2007, 13). In the United States alone, current estimates predict an economic impact of $70 billion to $200 billion, 314,000 to 734,000 hospitalizations, and total deaths between 89,000 to 207,000 persons, depending on the severity of the viral strain (Haber et al. 2007;

Lister 2005; Luke and Subbarao 2006).

A recent poll found that 87 percent of Americans are unprepared for a public health crisis such as an infectious disease epidemic or food-born illness outbreak (Late 2007). While few disasters will off er advance notice, with proper planning and preparation, local offi cials and residents of a stricken area can reduce the unknowns that confound a normal response. Th e ultimate goal for residents is to reduce their own vulnerability, while the objective of municipal offi cials is to protect the public while minimizing interruptions to the operations of their governments (French, Goodman, and Stanley 2008). Emergency management requires much more than a rapid response to an emergency situation, and entails four phases that are common to all disasters: mitigation, preparedness, response, and re- covery (Petak 1985; Waugh 1994; Waugh and Streib 2006). Mitiga- tion includes evaluation of the risk presented by a potential disaster and attempts to minimize or eliminate these hazardous conditions. International eff orts to mitigate the possibility of pandemic infl u- enza from the H5N1 strain have included work to contain avian fl u outbreaks among poultry and concentrated eff orts to improve the laboratory diagnosis at the onset of an outbreak. Th e international community has also established early-warning networks in more than 75 countries and off ered logistical and fi nancial support to countries that have been hardest hit by this virus (Progress Report 2007). Preparedness plans of the U.S. government call for stockpil- ing enough vaccine to inoculate approximately 3 million Americans against the H5N1 virus and 16 million doses of antiviral drugs for treatment of exposed individuals. However, this stockpiling may be of little or no use, as the H5N1 strain tends to mutate, or the pandemic may be caused by a diff erent virus.

Emergency management eff orts frequently cross jurisdictional boundaries and often require the coordination of federal, state, and local responsibilities and authority (Waugh 1994). Th e National Strategy for Pandemic Infl uenza, which was issued by President

Th ere are few natural disasters that have the capacity to signifi cantly disrupt

the economic and social underpinnings of society.… natural occurrences pale in

comparison, however, to the level of social, political, and economic disruption that a public health emergency such as an infl uenza

pandemic would create.

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Pandemic Infl uenza Planning 825

George W. Bush on November 1, 2005, outlines the responsibilities that individuals, industry, state and local governments, and the fed- eral government have in preparing for and responding to a pandem- ic. Th e U.S. Department of Health and Human Services (DHHS) serves as the federal government’s primary agency for response to a disease outbreak, while state, local, and tribal governments are responsible for detecting and responding to disease outbreaks, in addition to implementing activities to reduce the health, social, and economic consequences of an outbreak (DHHS 2007). Response and recovery in the event of a pandemic infl uenza outbreak require the collaboration and cooperation of these three levels of govern- ment. Also, businesses, community-based organizations, and faith- based organizations must have continuity of operations plans in the event of an infl uenza pandemic. Individuals and communities who are well prepared will fair better than those who are unprepared.

The Model for Infl uenza Preparedness Th e DHHS has developed a pandemic infl uenza plan that provides the framework for the federal government’s planning and response to the pandemic infl uenza threat. Th is strategic plan identifi es key response actions, the roles and responsibilities of DHHS agencies and offi ces, and recommendations on the use of vaccines and anti- viral drugs. Th e national plan also includes public health guidance for state and local partners that details how health departments and other local and state government agencies can prevent, mitigate, respond to, and recover from an infl uenza pandemic. Plans at the local level can be tailored to the needs of the specifi c local commu- nity. However, common eff orts of these plans should include community preparedness and leadership, infl uenza surveillance, infection control, vaccine and antiviral drug distribu- tion and use, public health communication, and public workforce support. In the event of a pandemic, local government offi cials have considerable responsibility, and they must be well prepared to meet a very broad spectrum of public health needs.

Implementation of pandemic preparedness plans will have signifi - cant legal and ethical implications. Th e extent of the hardships that will occur, including disruptions to trade, travel, economics, and personal liberty, are consequences of a public health strategy that has been developed under conditions of scientifi c and political uncertainty. No one can predict with certainty when the next pan- demic will take place; however, for this threat to become a reality, it requires only that the H5N1 virus mutate into a form that can be easily transmitted from one person to another. As a result, decision makers at all levels of government need to attempt to balance indi- vidual freedoms with the common good in order to minimize the human and economic harm that will result when another pandemic infl uenza outbreak occurs.

Ethical Concerns Emergency management has evolved into a collaborative, dynamic, and fl exible response that requires intergovernmental, multiorgani- zational, and intersectoral cooperation (Waugh and Streib 2006). While a national strategy for pandemic preparedness will focus on slowing the entry of the virus into the United States, local gov- ernment offi cials will be responsible for implementing plans that

address public health interventions and maintenance of the infra- structure of the community. Th e degree of hardship imposed by the next infl uenza pandemic will be signifi cantly related to the quality of local government preparedness. While this planning occurs under several conditions of uncertainty, including the timing, virulence, and scope of the future outbreak, local preparation requires a public health strategy that considers both the legal and ethical implications of its implementation. Th e development of policy with respect to ethics and the implementation of policy in an ethical manner have become increasingly important for government in rebuilding public trust and ensuring that government offi cials and employees respond to situations in ways that are legally and morally standard (West et al. 1998).

Th erapeutic countermeasures and public health interventions are the foundation of most plans, and these measures have the po- tential to create fi nancial, political, and legal issues that must take into account economic interests and fundamental human rights in their resolution. Local government offi cials are faced with the task of weighing the advantages and disadvantages of their pandemic infl uenza plans. Responsibility and accountability to the public require that administrators and policy makers evaluate the potential risk associated with policies and practices (Hall and Jennings 2008). Ethical decision making, a fundamental basis of the democratic ad- ministration of policy, requires that considerable attention be given to the values and principles that guide the choices government lead- ers and employees make (Bowman and Knox 2008; Menzel 1993).

Th ey must consider the underlying values of each step and the potential consequences. Responsible risk taking requires that offi cials have respect for the democratic processes and legal responsibility of the task at hand and be committed to ethical decision making (Berman and West 1998). For example, the allocation of vaccines and antiviral therapy requires complex decision making that has several ethical dimensions. Th e governments of most developed countries now recommend

that vaccinations be given to high-risk populations as a strategy for addressing seasonal infl uenza, and mass vaccination could be imple- mented in the event of a severe outbreak (Gostin 2004). However, the H5N1 strain is not a human pandemic virus. While the U.S. government has stockpiled vaccine against the current avian fl u H5N1 strain, it is diffi cult to predict whether this strain will cause the next human pandemic. Regardless of which virus causes this health crisis, six months from its onset will be needed to develop the targeted vaccine.

As the vaccine becomes available, local government offi cials must implement a vaccine distribution prioritization policy that addresses the fair allocation of limited vaccines and antiviral medications. In a 2002 meeting of public health offi cials from 46 states, repre- sentatives attempted to determine which factors were of greatest importance—reducing deaths, reducing disease, limiting impact, ensuring essential services, or implementing equitable distribution of a vaccine—in the event of an infl uenza pandemic; the partici- pants were hopelessly divided (Davis 2005). Local government offi cials must decide how to equitably balance the treatment of those individuals infected with the virus with the need to maintain

In the event of a pandemic, local government offi cials have considerable responsibility, and they must be well prepared to meet a very broad spectrum of

public health needs.

essential services provided by health care workers and fi rst respond- ers while preventing further spread of the virus to political leaders and other members of the population (Gostin 2004). Although the DHHS has published recommended guidelines for this policy, most state and local governments have tailored their vaccination distribu- tion prioritization policies to their own preparedness plans. Many of these plans do follow the DHHS guidelines, which eff ectively have created a tiered system of eight groups, dividing higher-priority groups from others (DHHS 2005; Lister 2005). Th e fi rst tier con- sists of “health care service” providers; the second tier of “medically high risk” individuals; the third and fi fth tiers of “medically at-risk groups”; the fourth, sixth, and seventh tiers of people engaged in the “preservation of social function,” and the eighth tier of the “lowest medical risk” (DHHS 2005). Th is prioritization policy considers medically high-risk and at-risk individuals to be of higher priority, based on their position within the system, than individuals who would ensure the preservation of social continuance. Ethical and legal concerns arise from these prioritizations and also from the imposition of vaccinations or treatment on individuals in society who oppose such interventions. Local government offi cials must be conscientious of the personal values of these individuals while pre- venting harm to the overall community. While public health offi cials do have the legal authority to compel vaccination and treatment, there must be a reasonable relationship between the public health intervention and the demonstrable threat to the community (Gostin and Berkman 2007).

In the event of a local outbreak of infl uenza caused by a pandemic strain, local government entities must be able to investigate and con- tain potential or known cases. Civil confi nement may be required to separate infected or exposed individuals from the healthy popula- tion. Local offi cials may fi nd it necessary to implement various levels of movement restriction within their jurisdiction. While isolation and quarantine are judicially sanctioned, an individual’s entitlement to civil liberties becomes a concern. Isolation or quarantine must take place in a humane and habitable environment, and compen- sation for work and other essential activities are to be considered (Gostin 2004). Th e usefulness of isolation and quarantine measures depends a great deal on when the measures are initiated. Beyond the technical aspects of quarantine measures, however, there also are issues of civil liberties infringement and which level of government should have the power to enforce the quarantines.

A 2003 report to the Centers for Disease Control and Prevention on quarantine and isolation lessons learned from SARS (severe acute respiratory syndrome) revealed some interesting points concerning these issues. Th is report reviewed the expan- sive and intrusive (although eff ective) meas- ures used by many Asian countries, including China and Singapore, to contain the disease. Th ese measures included mandatory closure of schools, child care facilities, markets, and public transportation; restrictions on travel; and the cordoning off of entire sections of towns (Rothstein et al. 2003). Th ese coun- tries enforced the usage of electronic cameras in homes to ensure that individuals did not break the quarantine, and individuals were re-

quired to take their temperature in front of the camera several times a day. Government offi cials also used telephone calls as another measure to ensure that individuals did not break the quarantine. Finally, both law enforcement offi cials and the military were used to enforce these measures, and for anyone who did break the quaran- tine, an electronic tag was placed around their ankle (Rothstein et al. 2003). Clearly, such actions, if attempted in the United States, would face many social, cultural and political challenges.

In addition to quarantine measures, local government offi cials may fi nd it necessary to restrict social mixing and increase social distance during a declared state of emergency for an infl uenza pandemic. Businesses or schools may need to close, and public meetings may be suspended. Also, voluntary social distancing would allow individuals to avoid exposure. Civic activities, large gatherings, and mass transportation systems would be aff ected as local authorities intervene to avert spread of the infl uenza virus at the earliest stage. Th e importance of public cooperation in the enforcement of these measures does have historical precedence. A study was conducted of seven U.S. communities that implemented signifi cant social isola- tion measures during the second wave of the deadly 1918 infl uenza pandemic. Th e authors of this study reviewed nearly 300 federal, state, and local documents, as well as more than 1,400 periodicals and medical journals published between 1918 and 1920 (Markel et al. 2006). Based on this extensive review of these documents, they found that public cooperation played a major role in the successful- ness of the quarantine measures. Specifi cally, “protective seques- tration, if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved, and contin- ued for the lengthy time period in which the area is at risk, stands the best chance of guarding against infection” (Markel et al. 2006, 1963). Ultimately, if government offi cials expect the American pub- lic to accept social distancing measures, they must understand that social, political, and cultural factors will play a predominant role.

In the event of an infl uenza pandemic, careful attention to these social, political, and cultural factors will be required if government offi cials expect the American public to “buy in” to the potentially extensive restrictions that could be placed on civil liberties. Th e quality of democracy and its administration is rooted in ethical de- cision making (Bowman and Knox 2008). Public health interven- tions that are intended to address the pandemic spread of H5N1 infl uenza have created ethical and legal questions whose answers require the delicate balance of personal liberty with restrictions

that could severely impact national and world trade, travel, and economics. Ethical decision making during this health crisis should be focused on the best patient and public health outcomes with respect to the unique circum- stances created by an avian infl uenza pan- demic (Upshur et al. 2007). In addition, local government offi cials must address these issues with community stakeholders and solicit input from all members of their localities. If local government authority and accountabil- ity in policy decisions are addressed before the onset of a pandemic, the individuals aff ected, both directly and indirectly, by public health interventions will be more familiar with and

If local government authority and accountability in policy

decisions are addressed before the onset of a pandemic, the

individuals aff ected, both directly and indirectly, by

public health interventions will be more familiar with and understanding of the purpose

and challenges of the pandemic infl uenza plan.

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Pandemic Infl uenza Planning 827

understanding of the purpose and challenges of the pandemic infl uenza plan. Educating the public regarding these objectives and the actions that local government authorities have taken to safeguard their individual rights is essential to maintaining the trust that citizen members have placed in their local political and administrative leaders.

Case Studies Th e DHHS has developed a state and local pandemic infl uenza planning checklist based on the Federal Pandemic Infl uenza Plan that identifi es important activities that are recommended for inclu- sion in state and local plans. Th is checklist is divided into 10 areas, outlining key aspects for state and local jurisdictions preparedness in the event of a disease outbreak.2 Th e authors have identifi ed several of the recommendations included in the checklist that have ethical implications for local community stakeholders. Th ese guidelines were found under the areas of community preparedness leader- ship and networking, vaccine distribution and use, antiviral drug distribution and use, community disease control and prevention, public health communications, and workforce support. Th e authors considered these areas to have the potential to create political, legal, and fi nancial issues that must take into account economic interest and fundamental human rights in their resolution.3 Th e following table outlines key recommendations by the DHHS that are used in this study.

Th e pandemic infl uenza policies of eight large cities across the United States were evaluated to determine whether and how these recommendations have been incorporated into local government preparedness plans. Th e municipalities evaluated in this study in- clude Austin/Travis County, Texas; Boston, Massachusetts; Cleve- land/Cuyahoga County, Ohio; Kansas City, Missouri; Louisville, Kentucky; Memphis, Tennessee; Seattle/King County, Washington; and Tulsa/Tulsa County, Oklahoma. Each of these eight cities falls into the top 100 cities according to the 2000 population classifi ca- tion of the U.S. Census Bureau (2000). Also, at least one city from each of the four census regions is represented.4 Th e preparedness plans for these localities varied in length from 21 pages to 336 pages. Some of the plans were very detailed in their preparations for pandemic infl uenza, while other plans were generalized and noted that specifi c details would be developed as the community pro- gressed through the pandemic phases.

Discussion of Findings Th e unique circumstances and uncertainty created by an infl uenza pandemic require considerable planning by local government of- fi cials with signifi cant input from community stakeholders. Th e DHHS places substan- tial emphasis on community preparedness, leadership, and networking that includes all relevant stakeholders in the locality—govern- ment, public health, emergency response, education, business, faith-based organiza- tions, and private citizens. Th is action helps to ensure that the pandemic infl uenza plan is responsive to the community’s needs and that local government offi cials and employees are prepared to address the unprecedented issues that may arise from a pandemic. Th e pan-

demic infl uenza plans of only half the communities reviewed in this analysis referred directly to a pandemic preparedness coordinating committee representing relevant stakeholders. Th e City of Mem- phis/Shelby County Health Department actually noted community input obtained during a series of stakeholder meetings with leaders, including elected and appointed offi cials, emergency responders, health and medical providers, media, service and human need pro- viders, schools and education community, and business and industry (Memphis/Shelby County Health Department 2007). Th e other plans did not mention specifi c consultation with other community stakeholders in their initial development.

Community preparedness leadership and networking also require that accountability and responsibility, capabilities, and resources for key stakeholders engaged in planning and executing specifi c components of the plan be delegated. All eight preparedness plans addressed this issue and specifi cally identifi ed the legal authorities responsible for case identifi cation, isolation, quarantine, movement restriction, and other health service requirements. In addition, these eight plans included detailed communication operational sections that addressed how information during the pandemic phases would be communicated to public and private sector audiences. Only four of the plans, however, identifi ed state and local law enforcement personnel who would be responsible for maintaining public order and implementing control measures. Also, several of the plans did not address the provision of psychosocial support services for local community members aff ected by containment procedures, and several failed to create a demographic profi le of the community that included special needs populations and language minorities to ensure that the needs of these residents were addressed in the operational plan.

In regard to vaccine and antiviral drug distribution and use, all eight plans incorporated state-based plans for distribution, use, and monitoring. Most of the plans also noted specifi c guidelines for the procurement, storage, security, distribution, and monitoring of actions to ensure access to the treatments during a pandemic. Specifi c references by six of the plans were made to procedures for tracking the number and priority of vaccine recipients, the training requirements of involved personnel, and the distribution plan for specifi c locations in the community. However, only two of the plans actually included information for citizens in advance about where they would be vaccinated. Th e needs of vulnerable and hard-to-reach populations were addressed in the operational plans of six of these localities. Yet contingency planning for the use of unlicensed antivi- ral drugs that might be administered under investigational new drug

or emergency use guidelines was only included in two of these plans.

Several of the DHHS guidelines regarding community disease control and prevention and public health communications were implemented in all of these plans. Operational plans for the investigation and containment of potential cases, including isolation, quaran- tine, and enforcement of these measures, were outlined in each of the eight communities’ plans. Almost all of these plans included guide- lines for utilizing various levels of movement

Public health communication details for all plans included

planning and coordination of emergency communication

activities with private industry, education, and nonprofi t

partners and regular review, exercise, and updates of these

plans.

Table 1 Key Recommendations for Pandemic Infl uenza Planning

Specifi c Activity

Community prepared- ness leadership and networking

Establish a Pandemic Preparedness Coordinating Committee representing all relevant stakeholders

Delineate accountability and responsibility, capabilities, and resources for key stakeholders engaged in planning and executing specifi c com- ponents of the operational plan

Within every state, clarify which activities will be performed at a state, local, or coordinated level, and indicate what role the state will have in providing guidance and assistance

Ensure the existence of a demographic profi le of the community (including special needs populations and language minorities) and ensure that the needs of these populations are addressed in the operation plan

Address the provision of psychosocial support services for the community, including patients and their families, and those affected by com- munity containment procedures in the plan

Test the communication operational plan that addresses the needs of targeted public, private sector, government, public health, medical, and emergency network of communication personnel, including lead spokespersons and persons trained in emergency risk communication; and links to other communication networks

Identify for all stakeholders the legal authorities responsible for executing the operational plan, especially those authorities responsible for case identifi cation, isolation, quarantine, movement restriction, health care services, emergency care, and mutual aid

Identify the state and local law enforcement personnel who will maintain public order and help implement control measures

Vaccine distribution and use

Work with health care partners and other stakeholders to develop state-based plans for vaccine distribution, use, and monitoring

Exercise an operational plan that addresses the procurement, storage, security, distribution, and monitoring actions necessary to ensure ac- cess to this product during a pandemic

Ensure the operational plan delineates procedures for tracking the number and priority of vaccine recipients, where and by whom vaccina- tions will be given, a distribution plan for ensuring that vaccine and necessary equipment and supplies are available at all points of distribu- tion in the community, the security and logistical support for the points of distribution, and the training requirements for involved personnel

Address vaccine security issues, cold chain requirements, transport and storage issues, and biohazardous waste issues in the operational plan

Address the needs of vulnerable and hard-to-reach populations in the operational plan

Inform citizens in advance about where they will be vaccinated

Antiviral drug distribu- tion and use

Develop state-based plans for distribution and use of antiviral drugs during a pandemic through the Strategic National Stockpile

Test the operational plan that addresses the procurement, storage, security, distribution, and monitoring actions necessary to assure access to these treatments during a pandemic

Ensure the jurisdiction has a contingency plan if unlicensed antiviral drugs administered under Investigational New Drug or Emergency Use Authorization provisions are needed

Community disease control and prevention

Exercise the jurisdiction’s operational plan to investigate and contain potential cases or local outbreaks of infl uenza potentially caused by a novel or pandemic strain

Exercise the jurisdiction’s containment operational plan that delineates procedures for isolation and quarantine, the procedures and legal authorities for implementing and enforcing these containment measures and the methods that will be used to support, service, and monitor those affected by these containment measures in health care facilities, other residential facilities, homes, community facilities, and other settings

Ensure the jurisdiction has exercised the operational plan to implement various levels of movement restrictions within, to, and from the jurisdiction

Inform citizens in advance about what containment procedures may be used in the community

Public health commu- nications

Assess readiness to meet communications needs in preparation for an infl uenza pandemic, including regular review, exercise, and update of communications plans

Plan and coordinate emergency communication activities with private industry, education, and nonprofi t partners

Workforce support Develop a continuity of operations plan for essential health department services, including contingency planning for increasing the public health workforce in response to absenteeism among health department staff and stakeholder groups that have key responsibilities under a community’s response plan

Ensure availability of psychosocial support services for employees who participate in or provide support for the response to public health emergencies such as infl uenza pandemics

Develop workforce resilience programs and ensure readiness to deploy to maximize responders’ performance and personal resilience during a public health emergency

restrictions within, to, and from the jurisdiction, and more than half detailed how citizens would be informed of the containment proce- dures that may be used in community disease control and prevention eff orts. Public health communication details for all plans included planning and coordination of emergency communication activities

with private industry, education, and nonprofi t partners and regular review, exercise, and updates of these plans.

Most of the pandemic preparedness plans evaluated in this study had developed contingency plans for the provision of essential

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Pandemic Infl uenza Planning 829

health department services that addressed potential absenteeism among health department staff and stakeholder groups with key responsibilities in the community’s response plan. However, only the City of Memphis/Shelby County Health Department included the availability of psychosocial support services for employees who would participate either directly or indirectly in the public health emergency responses. Th is locality’s plan also provided for the development of workforce resilience programs aimed at enhancing and maximizing emergency responders’ performance during a public health emergency. None of the other seven preparedness plans made specifi c reference or provisions for these issues.

Conclusions and Implications Th e existing literature suggests that a future infl uenza pandemic is inevitable, and the severity of such a pandemic can only be miti- gated by the thoughtful planning of government offi cials and the respectful interpretation of past infl uenza statistics. Government offi cials must use available information and guidelines in order to develop policies that will maximize positive social and economic return in their communities while being sensitive to public concerns regarding factors that were considered during policy formulation. While the federal government has provided only broad guidelines for state and local government actors, specifi c decisions regarding vaccination, nonpharmaceutical interventions, and the maintenance of critical services during a pandemic may have unprecedented legal and ethical implications. In many cases, these interventions must take into account economic and global interests and fundamental human rights. Eff ective emergency management during an infl uenza pandemic entails mitigation, preparedness, response, and recovery as local government offi cials focus on protecting the public with mini- mal interruptions to their government functions. In many cases, these eff orts will require the coordination of federal, state, and local authorities; however, most of the responsibility for the development and implementation of these pandemic preparedness plans rests with local health departments. Th is consequence has the potential to be of great concern to city and town offi cials who will be directly involved with many of the nonpharmaceutical interventions.

Th e plans reviewed in this analysis illustrate the myriad of issues that will accompany the next infl uenza pandemic. Th ere are numer- ous ethical and legal implications regarding the allocation of vac- cines and antivirals, the imposition of restrictive measures such as isolation and quarantines, bans on public outings and assemblies, and the maintenance of emergency response and critical services in which leaders in public health positions may lack adequate prepara- tion and training. Only half of the plans included in this study actually mentioned the existence of a pandemic preparedness com- mittee representing all relevant stakeholders, and many segments of these plans are implemented with little or no input from the mayor, council, city manager, police chief, department heads, or other local government offi cials. Th e potential economic, political, and legal issues that will emerge with the next infl uenza pandemic require a plan that will be seen as both legitimate and in the best interest of all citizens. Local government offi cials are the fi rst and most signifi cant point of contact between citizens and their govern- ment, and their insight, knowledge, and expertise are crucial for policy decisions. In our democratic society, citizen members place their trust in political and administrative leaders who are expected to continually engage in ethical decision making. Ultimately, the

eff ectiveness of these pandemic infl uenza plans rests on convincing the American public that the preparation and implementation of these measures are focused on the best patient and public health outcomes while safeguarding their individual rights.

Notes 1. Seasonal fl u is caused by a virus that can be transmitted from

person to person and produces a respiratory illness. Individuals may have some immunity, and a vaccine is available for reducing transmission. Low pathogenic avian (or bird) fl u occurs commonly in the bird population and causes relatively few problems. Th e highly pathogenic H5N1 strain is fatal to domestic fowl, can be transmitted from birds to humans, and can cause death in individuals who become infected by the virus. Currently, a human vaccine is in very limited supply, and humans have no developed immunity to the H5N1 virus.

2. Th ese 10 areas include community preparedness leadership and networking, surveillance, public health and clinical laboratories, health care and public health partners, infection control and clinical guidelines, vaccine distribution and use, antiviral drug distribution and use, community disease control and prevention, public health communications, and workforce support (including psychosocial considerations and information needs).

3. Coincidentally, after this research was completed, the Centers for Disease Control and Prevention published its “Planning and Responding to Pandemic Infl uenza Ethical Considerations Checklist.” Th is checklist addresses many of the DHHS recommendations that were identifi ed in this study as having ethical implications for local community stakeholders. Th e ethical considerations provided by this additional tool, if implemented, should enhance the legitimacy of decision making for pandemic infl uenza planning at the local government level.

4. Th e eight cities included in this analysis are not considered by the authors to be a representative sample of all top-100 population municipalities from which statistical inferences could be made. Th ese cities were chosen based on their closeness in population and their respective locations across the United States. Th e pandemic preparedness plans of these eight cities were available online.

References Austin/Travis County Health and Human Services Department. 2006.

Preparedness and Response Plan for Pandemic Infl uenza. http:// www.ci.austin.tx.us/pandemicfl u/downloads/fl u_plan.pdf [accessed May 19, 2009].

Berman, Evan M., and Jonathan P. West. 1998. Responsible Risk-Taking. Public Administration Review 58(4): 346–52.

Boston Public Health Commission. 2007. Pandemic Infl uenza Plan. http://www.bphc.org/bphc/pdfs/panfl uplan_1206.pdf [accessed May 27, 2008].

Bowman, James B., and Claire Connolly Knox. 2008. Ethics in Government: No Matter How Long and Dark the Night. Public Administration Review 68(4): 627–39.

City of Memphis and Shelby County Health Department. 2007. Pandemic Infl uenza Response Plan. http://www.memphistn.gov/ framework.aspx?page=812 [accessed May 19, 2009].

Cleveland/Cuyahoga County. 2006. Cuyahoga County Pandemic Infl uenza Response Plan. www.ccbh.net/ccbh/export/sites/default/ CCBH/pdf/ESI_Docs/ESI_Cuyahoga_County_Pandemic_ Infl uenza_Respose_Plan.pdf [accessed May 19, 2009].

Davis, Mike. 2005. Th e Monster at Our Door: Th e Global Th reat of Avian Flu. New York: Owl Books. Emanuel, Ezekiel J., and Alan Wertheimer. 2007. Vaccine Prioritization during an Infl uenza Pandemic: Overview of Health and Human Services’ Response Plan

Concerning Vaccine Prioritization. Fairfax, VA: George Mason University Law School, Critical Infrastructure Protection Plan. http://cipp.gmu.edu/archive/ PandemicMonograph_1007.pdf [accessed May 19, 2009].

Fauci, Anthony S. 2006. Pandemic Infl uenza Th reat and Preparedness. Emerging Infectious Diseases 12(1): 73–77. French, P. Edward, Doug Goodman, and Rodney E. Stanley. 2008. Two Years Later: Hurricane Katrina Still Poses Signifi cant Human Resource Problems for Local

Governments. Public Personnel Management 37(1): 67–75. Gostin, Lawrence O. 2004. Pandemic Infl uenza: Public Health Preparedness for the Next Global Health Emergency. Journal of Law, Medicine and Ethics 32(4):

565–74. Gostin, Lawrence O., and Benjamin E. Berkman. 2007. Pandemic Infl uenza: Ethics, Law, and the Public’s Health. Administrative Law Review 59(1): 121–76. Grinberg, Maya. 2007. Learning from the 1918 Pandemic. Risk Management 54(8): 10. Haber, Michael J., David K. Shay, Xiaohong M. Davis, Rajan Patel, Eric Weintraub, Evan Orenstein, and William W. Th ompson. 2007. Eff ectiveness of

Interventions to Reduce Contact Rates during a Simulated Infl uenza Pandemic. Emerging Infectious Diseases 13(4): 581–89. Hall, Jeremy L., and Edward T. Jennings, Jr. 2008. Taking Chances: Evaluating Risk as a Guide to Better Use of Best Practices. Public Administration Review 68(4):

695–708. Kansas City, Missouri, Health Department. 2008. Pandemic Infl uenza Preparedness Plan. http://www.kcmo.org/health.nsf/web/fl uplan [accessed May 19, 2009]. Knapp, Darrell. 2006. Avian Flu: Bracing for a Pandemic. Risk Management 53(7): 42–48. Late, Michele. 2007. APHA Poll: Americans are not Ready for Public Health Crises. Th e Nation’s Health 37(4): 1–3. Lister, Sarah A. 2005. Pandemic Infl uenza: Domestic Preparedness Eff orts. Washington, DC: Congressional Research Service. http://www.fas.org/sgp/crs/homesec/

RL33145.pdf [accessed May 19, 2009]. Louisville Metro Department of Public Health and Wellness. 2006. Pandemic Infl uenza and Highly Infectious Respiratory Disease Standard Operating Guide.

http://www.louisvilleky.gov/NR/rdonlyres/5596F977-6F11-4E35-BFFF-344A82EE77CA/0/LMHD_Pandemicinfl uenza_v10.pdf [accessed May 19, 2009]. Luke, Catherine J., and Kanta Subbarao. 2006. Vaccines for Pandemic Infl uenza. Emerging Infectious Diseases 12(1): 66–72. Markel, Howard, Alexandra M. Stern, J. Alexander Navarro, Joseph R. Michalsen, Arnold S. Monto, and Cleto DiGiovanni. 2006. Nonpharmaceutical Infl uenza

Mitigation Strategies, U.S. Communities, 1918–1920 Pandemic. Emerging Infectious Diseases 12(12): 1961–64 Menzel, Donald C. 1993. Ethics Induced Stress in the Local Government Workplace. Public Personnel Management 22(4): 523–37. Milgrim, Michelle. 2007. Vaccine Prioritization During an Infl uenza Pandemic. Fairfax, VA: George Mason University Law School, Critical Infrastructure

Protection Plan. http://cipp.gmu.edu/archive/PandemicMonograph_1007.pdf [accessed May 19, 2009]. Miller, Henry I. 2006. Dee-fense! Dee-fense! Preparing for Pandemic Flu. Issues in Science and Technology 22(4): 79–85. Osterholm, Michael T. 2005. Preparing for the Next Pandemic. Foreign Aff airs, July/August. Petak, William J. 1985. Emergency Management:

A Challenge to Public Administration. Special issue, Public Administration Review 45: 3–7. Progress Report on U.S. Pandemic Flu Preparations. 2007. Th e Nation’s Health 37(7): 8. Rothstein, Mark A., M. Gabriela Alcalde, Nanette R. Elster, Mary A. Majumder, Larry I. Palmer, and T. Howard Stone. 2003. Quarantine and Isolation: Lessons

Learned from SARS: A Report to the Centers for Disease Control and Prevention. http://www2a.cdc.gov/PHLP/docs/Quarantine-Isolation-Lessons-Learned- from-SARS.pdf [accessed May 19, 2009].

Scanlon, Joe. 2004. Lessons Learned or Lessons Forgotten: Th e Canadian Disaster Experience. Institute for Catastrophic Loss Reduction, Paper no. 1. http://www. iclr.org/pdf/research%20paper%2016%20-%20paper%201%20joe%20scanlon.doc.pdf [accessed May 19, 2009].

Seattle/King County Public Health. 2007. Pandemic Infl uenza Response Plan. http://www.metrokc.gov/health/pandemicfl u/plan/panfl u-response-plan.pdf [accessed May 19, 2009].

Tulsa Health Department. 2007. Pandemic Infl uenza Plan. http://www.tulsa-health.org/emergency-preparedness/pandemic-infl uenza-planning/ [accessed May 19, 2009].

Upshur, Ross E. G., Karen Faith, Jennifer L. Gibson, Alison K. Th ompson, C. Shawn Tracy, Kumanan Wilson, and Peter A. Singer. 2007. Ethics in an Epidemic: Ethical Considerations in Preparedness Planning for Pandemic Infl uenza. Health Law Review 16(1): 33–40.

U.S. Census Bureau. 2000. Top 100 Cities. http://www.census.gov/popest/geographic/estimates_geography.html [accessed July 4, 2008]. U.S. Department of Health and Human Services (DHHS). 2005. Pandemic Infl uenza Plan. http://www.hhs.gov/pandemicfl u/plan [accessed May 19, 2009]. ———. 2007. Pandemic Flu: General Information. www.pandemicfl u.gov/General/index.html [accessed May 19, 2009]. Waugh, William L., Jr. 1994. Regionalizing Emergency Management: Counties as State and Local Government. Public Administration Review 54(3): 253–58. Waugh, William L., Jr., and Gregory Streib. 2006. Collaboration and Leadership for Eff ective Emergency Management. Special issue, Public Administration Review

66: 131–40. West, Jonathan, Evan Berman, Stephen Bonczek, and Elizabeth Kellar. 1998. Frontiers in Ethics Training. Public Management 80(6): 4–6.

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