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Public health is in danger of losing its edge, thanks to federal funding cuts to the Public Health Emergency Preparedness (PHEP) and the Cities Readiness Initiatives grants created to support state and local health departments in preparing for, and dealing with, different public health emergencies, like a flu pandemic, or terrorist attack, like an anthrax attack. According to a recent post by Raphael Barishansky on the Emergency Management blog, Funding Cuts Threaten Public Health Preparedness, the National Association of County and City Health Officials (NACCHO) said that 55% of the nation’s local health departments (LHDs) reduced at least one public health preparedness program between July 2010 and June 2011, with 20% of those programs focusing on emergency preparedness.
According to a 2010 NACCHO report, LHDs have responded to infectious disease (26%), natural disaster (23%), foodborne outbreak (21%), chemical spills or releases (9%), and exposure to a potential biological agent (5%). Our concern is that local and state health departments, and by extension, the public they serve, will be hurt by these budget cuts. Hold joint training exercises with nearby health departments, rather than each LHD holding their own training event, pool your resources and have a training event.
Lighthouse Readiness Group can help public health and other government agencies develop plans and strategies for dealing with reduced budgets and dwindling funds. Frank KrizFrank has been with Lighthouse Readiness Group (LRG) in Plainfield, IN since 2010, and currently serves as a Consultant, Level II Instructor.
Planning for and responding to the range of possible consequences following the emergence of a novel influenza A virus is complex. Significant progress has been made toward developing pandemic plans, as well as preparedness and response frameworks, during the past decade. In November 2005, the president of the United States released a national strategy for pandemic influenza (9), and the associated implementation plan was released in May 2006 (10). The resulting document (Proposal for the Use of Intervals, Triggers, and Actions in CDC Pandemic Influenza Planning, 2008) was revised, published as an appendix to the U.S. The revised framework also incorporates the recently developed Influenza Risk Assessment Tool (IRAT) (12) and Pandemic Severity Assessment Framework (PSAF) (13).
In 2013, WHO released interim guidance for pandemic influenza risk management, which includes restructured WHO phases (14). The framework described in this report is a revision of the 2008 CDC interim guidance (11) to 1) update the novel influenza virus pandemic intervals as the basis for U.S.
The framework was reviewed for accuracy, feasibility, and clarity by several stakeholders, including representatives of the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the Association of Public Health Laboratories, the Council of State and Territorial Epidemiologists, and the National Public Health Information Coalition.
For the purposes of responding to novel influenza viruses and potential pandemics, the six intervals (investigation, recognition, initiation, acceleration, deceleration, and preparation) represent events that occur along a hypothetical pandemic curve (Figure). For state and local planning, the intervals describe the progression of the pandemic within communities and provide a detailed framework for defining when to respond with various actions and interventions at any point in a pandemic. To define the intervals, the relationship between the timing of the broad WHO phases and the more detailed planning intervals was examined (Figure). The investigation interval is initiated by the identification and investigation of a novel influenza A infection in humans or animals anywhere in the world that is judged by subject-matter experts to have potential implications for human health (Appendix [Table 1]). The recognition interval is initiated when increasing numbers of human cases or clusters of novel influenza A infection are identified anywhere in the world, and the virus characteristics indicate an increased potential for ongoing human-to-human transmission (Appendix [Table 2]).
The initiation interval begins when human cases of a pandemic influenza virus infection are confirmed anywhere in the world with demonstrated efficient and sustained human-to-human transmission (Appendix [Table 3]).
The acceleration interval is indicated by a consistently increasing rate of pandemic influenza cases identified in the United States, indicating established transmission (Appendix [Table 4]). The deceleration interval is indicated by a consistently decreasing rate of pandemic influenza cases in the United States (Appendix [Table 5]). The preparation interval is characterized by low pandemic influenza activity, although outbreaks might continue to occur in certain jurisdictions (Appendix [Table 6]).
Decisions about appropriate actions require information regarding the real or potential impact of the novel virus on public health. Although data needed to make decisions might be limited during the earliest intervals, delaying action might weaken the effectiveness of the response.
CDC developed two risk assessment tools for the decision-making framework, IRAT (12) and PSAF (13). When a novel influenza A virus is identified in humans but is not circulating widely in the human population, it is important to evaluate 1) the risk that the virus will develop efficient and sustained human-to-human transmission and 2) the risk that the virus will substantially affect public health. Once a novel influenza virus has emerged and is circulating in human populations, the risk posed by the pandemic can be assessed. PSAF is based on transmissibility and clinical severity parameters and uses different scales for initial assessments in an emerging pandemic, and for later, more refined assessments.
The use of transmission-defined intervals and tools such as IRAT and PSAF to assess risks and potential impact provides information that can guide decision-making and actions across different jurisdictions and levels of government and help inform appropriate risk communication strategies. The updated influenza pandemic framework provides six intervals and indicators for public health decision-making and actions during the progression of a novel influenza A virus from emergence through pandemic. Because the resources and demographics among different regions and states in the United States vary widely, defining detailed indicators that address every potential situation is impossible. This framework is designed to assist with decision-making but does not diminish or replace the role of scientific expertise, particularly as a novel influenza outbreak unfolds. This report is based, in part, on contributions by subject-matter experts who represented professional societies, including the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the Association of Public Health Laboratories, the Council of State and Territorial Epidemiologists, and the National Public Health Information Coalition, as well as federal agencies including the U.S.
Alternate Text:This figure includes a hypothetical influenza outbreak curve and the corresponding preparedness and response framework for novel influenza A virus pandemics with the World Health Organization (WHO) phases and CDC intervals. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. This conversion might result in character translation or format errors in the HTML version. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Also, 53% of them have had to furlough employees or reduce staff hours because of budget cuts.
They affect how well public health departments create, train, and execute different strategies during an emergency or disaster. This does not include weather-related emergencies, like hurricanes and snowstorms, and the related health emergencies they bring. While we have found our friends and colleagues in the public health sector to be resourceful and hard-working, there is only so much that can be done without money.
There’s no need to reinvent the wheel for every county when creating a new disaster response plan.
He has over 20 years of emergency management experience at the state and local level and has participated in 11 Presidential declared disasters. On the basis of experience from recent influenza responses, CDC has updated its framework to describe influenza pandemic progression using six intervals (two prepandemic and four pandemic intervals) and eight domains. Department of Health and Human Services pandemic influenza operational plan (11), and used during the 2009 H1N1 pandemic to describe progression of the pandemic and to help guide the response.
IRAT makes an assessment of potential pandemic risk for a novel virus on the basis of the likelihood of emergence and the public health impact if it were to emerge.
Modeled epidemic or pandemic curves also can be used to describe potential events over time.

Pandemic curves differ by duration and intensity depending on many factors, including the geographic area in which they occur, the season of their emergence, and related population dynamics. These actions should be proportionate to the transmissibility and severity of the emerging virus. In addition to the relationship to the WHO phases, the intervals are characterized by specific transmission-related indicators (Table) and by the types of response activities that should occur within each interval (Appendix). For example, identification of a novel influenza A virus does not necessitate progression to the next interval (the recognition interval) if the virus does not demonstrate the potential for ongoing transmission. Public health actions concentrate on control of the outbreak, with a focus on potential use of case-based control measures, including treatment and isolation of ill persons and voluntary quarantine of contacts.
The definition of efficient and sustained transmission is established during an event based on the epidemiologic characteristics of the emerging virus.
Consideration of immediate initiation of appropriate community mitigation measures such as school and child-care facility closures and social distancing (16) in addition to the efficient management of public health resources (including medical countermeasures and vaccines, if available) are of primary importance in this interval (17) and are guided by PSAF results. During this interval, planning for appropriate suspension of community mitigation measures and recovery begins.
Within each interval, certain actions can be determined for state, local, and federal governments. Therefore, estimating the likelihood of risks, particularly the risks of transmissibility, severity, and antiviral resistance, is critical (12,13,22). Both are designed to be used during the initial intervals when data are limited, to allow for iterative updates as new information becomes available and to accommodate various potential scenarios.
In 2007, as part of the interim guidance for community mitigation strategies, the Pandemic Severity Index was introduced as a tool to define the severity of a future influenza pandemic. The initial assessment, performed early in the outbreak when epidemiologic data are limited, uses a dichotomous scale of low-moderate versus moderate-high transmissibility and severity. A list of some of the key decisions and options for action that are triggered by progression through each interval are described (Appendix). Certain indicators might not be scalable to all levels of government, and others do not have corresponding actions from every participant group. An effective pandemic response is based on numerous assumptions and actions that must be continuously reassessed with accumulated data as the pandemic progresses. Department of Health and Human Services, the Food and Drug Administration, the National Institutes of Health, the Biomedical Advanced Research and Development Authority, and CDC.
Antigenic and genetic characteristics of swine-origin 2009 A(H1N1) influenza viruses circulating in humans.
Global epidemiology of human infections with highly pathogenic avian influenza A (H5N1) viruses. WHO global influenza preparedness plan: the role of WHO and recommendations for national measures before and during pandemics. Selecting nonpharmaceutical strategies to minimize influenza spread: the 2009 influenza A (H1N1) pandemic and beyond. The four WHO phases include the interpandemic, alert, pandemic, and transitions phases, and the CDC intervals include the prepandemic intervals (investigation and recognition) and the pandemic intervals (initiation, acceleration, deceleration, and preparation). Joe is versed in the education of Incident Command and Tactical instruction and is a Paramedic and a HAZMAT Technician.
This updated framework can be used for influenza pandemic planning and serves as recommendations for risk assessment, decision-making, and action in the United States. Use of this updated framework is anticipated to improve pandemic preparedness and response in the United States.
Furthermore, novel influenza A viruses, even when transmissible in a closed setting, do not always result in a pandemic, such as the 1976 influenza A(H1N1) outbreak in Fort Dix, New Jersey, and the 2011–2013 H3N2v outbreak in the United States (3,6).
Six phases were used to describe the evolving risk of efficient human-to-human transmission as a basis for defining a pandemic. This report provides an update to the 2008 framework to reflect experiences with 2009 H1N1 and recent responses to localized outbreaks of novel influenza A viruses.
WHO uses the phases to describe evolving situations pertaining to the circulation of novel influenza viruses. Using these models for forecasting purposes might be particularly valuable for anticipating conditions and identifying actions that might flatten or otherwise attenuate the epidemic or pandemic curve. The WHO pandemic influenza phases, which can be used to describe and communicate worldwide disease progression, provide a general view of the emerging epidemiologic situation essentially by aggregating epidemic curves from around the world. The intervals are further stratified into eight domains so that the trajectory of planning and response activities for any one domain can be more easily followed.
The public health impact of novel influenza virus strains can differ substantially, both in geographic spread and mortality. Similarly, after the preparation interval, subsequent waves of outbreaks will prompt federal, state, and local public health officials to reenter the acceleration, deceleration, and preparation intervals.
After recognition of a case of novel influenza infection in a human, as occurred with the H7N9 and H3N2v viruses, animal investigations subsequently identified circulation of influenza viruses in birds and swine, respectively, and identified the reservoir of these previously unrecognized novel influenza viruses. For example, efficient transmission could be defined as a household or an institutional attack rate of ?20% in more than two communities, and sustained could be defined as transmission of virus for three or more generations in more than one cluster. Isolation and treatment of ill persons and voluntary quarantine of contacts continue as key mitigation measures.
State or local health officials might rescind community mitigation measures in certain regions within their jurisdiction when no new cases are occurring or are occurring infrequently. Because this interval can last from weeks to months, planning and preparation for a subsequent pandemic wave should reflect this variability. Each indicator also initiates a set of important decisions that affect actions in the current and subsequent intervals. In addition, certain actions, such as the decision to produce a pandemic vaccine, require extensive preparation or time to implement, mandating that decision-making be initiated and completed as early as possible before the intervals when those actions need to occur and usually long before adequate data are available to support the need for those actions with certainty. Once completed, results of both tools are communicated to federal, state, and local decision-makers to guide public health actions (Appendix). Therefore, the indicator for the investigation interval, which is a newly identified influenza A virus in animals or identification of a novel influenza A virus recovered from humans, can serve as an initial trigger to conduct IRAT scoring.
To facilitate risk communication, the index had five categories similar to the hurricane severity scale, ranging in severity from category 1 (moderate severity) to category 5 (most severe) and was based on a hypothetical 30% attack rate and ranges of case-fatality ratios associated with a particular novel influenza virus (16). The later assessment, performed when more reliable data are available, is more refined, using a 5-point scale for transmissibility and a 7-point scale for clinical severity.
Planning and response efforts for recent novel influenza A viruses and pandemics have been organized into eight domains to ensure that subject-matter expertise is properly applied to all aspects of the event.
Although the actual shape of a future epidemic curve cannot be accurately predicted and might be modified by interventions, the use of an idealized curve permits generally applicable intervals to be defined. However, the proposed intervals, triggers for decision-making, and actions are meant to be flexible enough to allow for the implementation of local, state, and federal actions appropriate to jurisdiction-specific conditions. The content of this framework is intended to support and organize planning and response efforts at the federal, state, and local levels.

As a Consultant, Gary provides training in hazardous materials and incident command, including hospital decontamination in the form of classroom facilitation, on-site and hands-on training, post-scenario evaluation, and recommendation. The WHO phases are distinct from declarations of either a public health emergency of international concern (15) or a pandemic and are not specifically aligned with national risk management decisions. The CDC intervals serve as additional points of reference to provide a common orientation and clearer epidemiologic picture of what is taking place and when to intervene. For example, the 2009 H1N1 outbreak was caused by a highly transmissible novel influenza virus that emerged in North America and resulted in a pandemic (2), whereas the H3N2v virus, which also emerged in North America, caused approximately 300 cases in humans and limited outbreaks involving domestic animal-to-human transmission (3). The duration of each pandemic interval might vary from weeks to months depending on the characteristics of the virus and the public health response. CDC conducts an IRAT assessment during the investigation interval to characterize the potential for emergence, and if the virus does emerge, the severity of human infection (12). Historical analyses and mathematical modeling indicate that early institution of combined, concurrent community mitigation measures might maximize reduction of disease transmission and subsequent mortality in the affected areas (18–21).
A pandemic is declared ended when evidence indicates that influenza, worldwide, is transitioning to seasonal patterns of transmission (8).
These decisions can range from formal generation and analysis of options to more informal but equally important discussions among subject-matter experts, pandemic response leaders, and various stakeholders (Appendix). These 10 elements fall into three categories: 1) attributes that pertain to the biologic properties of the virus (four elements), 2) attributes of the population (three elements), and 3) attributes of the ecology and epidemiology of the virus (three elements) (12).
Experiences from the 2009 H1N1 pandemic identified that early data on the less severe but highly transmissible characteristics of the virus in the community were limited. After available data are assessed on these scales, the overall results are plotted with the measures of transmissibility along a y-axis and the measures of severity along an x-axis and compared with referent points such as previous pandemics or particularly severe influenza seasons (13). The decisions and actions are further stratified into these domains so that the trajectory of planning and response activities for any one domain can be more easily followed. The concept of describing intervals of a pandemic can be applied to a single outbreak occurring in an individual state or a community, or information from multiple outbreaks can be aggregated to describe the situation at the national level. The use of common concepts is critical for tracking the course of the pandemic, for communication, and for implementing timely, coordinated response efforts. In this role, he trains and tests hospital plans in Hospital Incident Command System (HICS), assists in the creation of customized plans for specific needs and is the lead consultant for evacuation training and exercises. These intervals serve as a reference for public health decision-making by federal, state, and local health authorities in the United States during an influenza pandemic and are not meant to be prescriptive or comprehensive. Preparedness and response frameworks provide a common basis for planning across different jurisdictions and ensure transparency in decisions made and actions taken. After a novel virus has achieved efficient and sustained transmission, PSAF can be used to characterize the potential impact of a pandemic relative to previous influenza epidemic and pandemic experiences.
In the interim guidance, WHO strongly advises countries to use local circumstances and information provided by the WHO global assessments to develop their own national risk assessments (13).
This framework is designed for decision-making by federal, state, and local health authorities and is not meant to be prescriptive or comprehensive. The intervals also might be valuable as a common reference point because they can be used to link the status of a pandemic with specific interventions.
Generally, identification of human cases of novel influenza A infection are reported to WHO in accordance with the International Health Regulations (15). If possible, PSAF results (13) should be used to ensure that actions are proportional to the severity of the disease caused by the virus. Like the 2009 H1N1 strain, pandemic strains might circulate for years after the pandemic, gradually taking on the behavior and transmission patterns of seasonal influenza viruses. A team of experts assigned to each particular element provides a risk score for the virus for that element. Consequently, the Pandemic Severity Index, which based severity solely on mortality, tended to overestimate severity because more severe cases are likely to be reported at the initiation of a pandemic.
As a Consultant, Mike provides training in Emergency Medical Services and Public Health Preparedness for hospitals and healthcare organizations throughout Indiana.
Sta[ read more ]Jay DotsonJay currently serves as a Consultant, Level II with Lighthouse Readiness Group in Plainfield, Indiana. This framework incorporates information from newly developed tools for pandemic planning and response, including the Influenza Risk Assessment Tool and the Pandemic Severity Assessment Framework, and has been aligned with the pandemic phases restructured in 2013 by the World Health Organization. The recent emergence of human disease caused by H3N2v in the United States (3) and H7N9 in China (5) has demonstrated the need to align existing documents and frameworks into one useful tool that can be used to guide ongoing planning and response efforts. The stages provided a general overview of the approach to a pandemic response; however, detailed pandemic response planning requires a greater level of specificity to determine federal, state, and local response actions during the course of a pandemic. State and local health authorities might even elect to implement interventions asynchronously within their jurisdictions by focusing early efforts on communities that are first affected. Building on those lessons, PSAF was developed to characterize the potential impact of a pandemic relative to previous influenza epidemic and pandemic experiences (13).
The tables are not meant to be prescriptive or comprehensive but rather to identify numerous priority issues that need to be addressed during each interval. Jay brings a wealth of knowledge to the organization from the law enforcement and hospital security perspectives. In addition, the stages framework presumed geographic spread from outside the United States into the United States. These experiences have provided opportunities to test the validity and usefulness of the intervals and the recommendations for public health actions triggered by each interval to ensure that they are applicable in a diverse range of scenarios. The results of this process can be used to decide whether and how to act and communicate concerns regarding both emergence and potential public health impact.
PSAF can be used early in a pandemic and assessments can be repeated as information changes. As a Consultant, Jason helps design, develop, and deliver training exercises and hazard management to multiple hospital and healthcare organizations throughout the State of Indiana. In 2007, CDC developed the CDC intervals, a common framework from which CDC and other federal, state, and local governments and agencies could plan and coordinate their pandemic response actions. Although IRAT focuses on risk of emergence and potential for impact if emergence occurs, PSAF focuses on epidemiologic parameters of transmissibility and severity after a virus has emerged with efficient and sustained transmission and requires a sufficient number of cases and clusters in humans to allow for the assessment to be completed. The six intervals of the updated framework are as follows: 1) investigation of cases of novel influenza, 2) recognition of increased potential for ongoing transmission, 3) initiation of a pandemic wave, 4) acceleration of a pandemic wave, 5) deceleration of a pandemic wave, and 6) preparation for future pandemic waves. This process has been used to assess recently emerging viruses such as H3N2v and H7N9 for vaccine development, manufacturing, and stockpile decisions. Depending on the number of cases, size of clusters, and the geographic location of outbreaks, the trigger for using PSAF might be as early in the pandemic as the recognition interval but is more likely to be triggered during the initiation interval and regularly updated as the pandemic progresses. After a novel virus has achieved efficient and sustained transmission, PSAF can then be used to characterize the potential impact of a pandemic relative to previous influenza epidemic and pandemic experiences.

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