Description
read/skim through these three passages( uploaded below). Now, please share your thoughts about these short answer questions from the end of the activity. You only need to write a sentence or two for each question:
Did the U.S. government fail to recognize the potential of COVID-19?
Did public health officials effectively contain the spread of COVID-19 in the United States, in your state, or in your community?
What items in the “Pandemic Playbook” would have enabled a better initial response?
Were travel bans effective?
Was medical screening a success?
Why does the United States lead the world in the most reported cases and deaths for COVID-19 given that it represents only 4.3% of the world population?
Did we rapidly identify cases and perform contact tracing?
The U.S. federal government’s plans and procedures dictated that the Department of Health and Human Services would be the Lead Federal Agency (LFA) for a pandemic. This was transferred to FEMA on March 19th—why?Well, we’ve heard PLENTY from the media and politicians on our state of
preparedness for this COVID-19 breakout. Now I want to hear from you.
1
First reports from China – January 12, 2020
Setting:
The Invisible
Enemy
Emerges &
Invades
First case in U.S. – January 20, 2020
First hot spot in U.S. – Seattle – February 29, 2020
COVID-19 gains entry through multiple international
gateways from Asia and Europe
U.S. has more cases and deaths than any other
country
https://www.worldometers.info/coronavirus/#countries
Here is the progression cycle for this pandemic in the United States:
1. The first reports from China came out on January 12, 2020
2. The first case was reported on January 20
3. The first hot spot broke out in Seattle on February 29
4. Then it started to become a really scary thing as it gained entry through multiple
gateways from Asia and Europe
5. Now, the U.S. has more cases … and deaths .. than any other country.
2
Did we follow the plan?
• Look through the Pandemic
Playbook
• Did we fail to recognize the
potential of COVID-19?
• What items in the Playbook would
have enabled a better initial
response?
Here is the U.S. Government Pandemic Playbook. Please take a look at it and answer
these two questions:
• Did we fail to recognize the potential of COVID-19?
• What items in the Playbook would have enabled a better initial response?
3
What
mitigation
measures have
been
implemented?
Did we prevent
or contain the
spread of
COVID-19 in the
U.S., this state
or this county?
Were travel
bans effective?
Was medical
screening a
success?
Did we rapidly
identify cases
and perform
contact tracing?
Let me know your thoughts on these topics.
4
Pandemic Response
Terminal Learning Objective
Identify the response actions of various emergency services disciplines as they relate to caring
for victims of a pandemic.
Enabling Objectives
❖ List priorities for the response phase
❖ List key emergency services that come into play during a pandemic event
❖ Describe actions taken by first responders in a pandemic.
❖ Describe actions taken by healthcare workers in a pandemic.
❖ Identify measures used to protect and care for first responders and healthcare
workers.
❖ Describe actions used to manage fatalities in a pandemic.
Welcome to fourth and final lesson in this series! This lesson will focus on the response phase of
a pandemic event. Who are the main players? What do they do? What issues surround them as
they work the front lines of this slow-motion disaster.
Note that the overarching objective is for you to identify the response actions of various
emergency services disciplines as they relate to caring for victims of a pandemic. There are
several enabling objectives that we will cover so that we can obtain that understanding.
Introduction
Here is an interesting quote from Emperor Augustus Caesar. He was the ruler credited for the
creation of the Roman Empire: “festina lente” Which translated from Latin means “Make haste
slowly.”
“Festina lente”
Make haste slowly.
Augustus Caesar
Augustus Caesar was such an immense figure in history that the month of August was named in
his honor. After the assassination of his uncle, Julius Caesar, he helped defeat the assassins then
made himself the sole ruler of Rome. He replaced the decaying remnants of the Roman Republic
with new institutions that gave him essentially total power and became the Roman Empire. He
ruled for 40 years, and for two centuries afterwards the Empire’s heartland saw unprecedented
peace and prosperity, even as its armies brutally expanded its territory.
Throughout his long reign Augustus had one motto. He emphasized it to his generals and thought
it so important that he had coins minted with an image symbolizing it: festina lente. It is believed
that the emperor’s thought was that the best way to get something done is to do it right the first
time. Especially when you are feeling the crunch, take your time (Life of Caesar, 2016).
I designed this lesson to enable you to get an understanding for how communities must respond
to a pandemic event. There are many pieces, or agencies, that play a prominent role in the
response. We will cover the major players and give a few honorable mentions.
The Response Phase
What is the Response Phase and what are its priorities? Normally, for many natural disaster
events and some technological hazard events, the response period when we respond to the
incident may only last a few days or weeks. So, for instance, let us compare a tornado response
to a pandemic response.
A tornado rips through a community in minutes. When the winds calm down, the first responders
come out and rush to the scene. The objective is initially search and rescue. Dig survivors out
of the rubble, get them onto ambulances and into the healthcare system for lifesaving treatment.
Search and rescue actions may go on for hours or days. Normally, a 72-hour period is when most
survivors will be recovered. Beyond that, the chances of survival are very small.
The number one priority of any response is always Life and Safety (Lindell, Perry and Prater,
2006). The primary goal of first responders is to save lives and keep people safe. Typically, the
second priority in most incident responses is to stabilize the incident. Here, we are referring to
shutting off natural gas leaks and disabling power to a badly damaged building. The first
responders are trying desperately to prevent more harm and injury and death if they can.
Next, we would seek to protect property through fire suppression and placing tarps over
damaged roofs. Finally, responders would seek to preserve the environment. If hazardous
materials are being released, first responders will stop the leak or contain the spill. Often, those
materials may be immediately dangerous to life and health (IDLH). If that is the case, the priority
for life and safety will move these actions up on the priority list.
Figure 1. Lesson 4 focuses on pandemic response. We will relate all response phase
actions to the COVID-19 pandemic. Image courtesy of Shutterstock.
https://www.shutterstock.com/image-vector/coronavirus-covid19-graphical-designelement-illustrating-1687661971
So, what about a pandemic response? I believe that we all have firsthand experience due to
COVID-19 (Figure 1) and have come to know that a pandemic response will last months to
years. It ebbs and flows – but it goes on and on. We still have life and safety concerns in a
pandemic response. You have survivors and victims to deal with. Why create more in the
process? Response is dangerous business. You are putting first responders, healthcare providers
and others in harm’s way when you conduct search and rescue and other response actions.
Responder and Receiver Safety
Always have safety on your mind. We must provide our first responders and healthcare
professionals (receivers) with Personal Protective Equipment (PPE) to shield them from injury
and infection. We also rely on protocols, procedures, and best practices to operate in an unsafe
environment. For a pandemic, the World Health Organization and Centers for Disease Control
and Prevention are the agencies we look to for these important guidelines.
We conduct training aimed at giving them the knowledge and skills to do their job safely and
efficiently. Does all of this make a difference? Yes, a tremendous difference. Finally, there are
government regulations that mandate safety considerations. For COVID-19 in the workplace, we
have OSHA 3990 designed to give us guidelines for making the workplace safe (OSHA 3990,
2020).
First Responder Agencies Involved in Pandemic Response
In this lesson we will cover the four primary first responder agencies you find engaged in all
response no matter the disaster. They are 9-1-1 Call Centers, Police, Fire, and Emergency
Medical Services (EMS).
Figure 2. 9-1-1 Call Center concept diagram. Image courtesy of
Shutterstock.https://www.shutterstock.com/image-vector/emergency-call-911-conceptdesign-flat-606493412
9-1-1 Emergencies
9-1-1 emergency call centers take requests for emergency assistance from citizens. In turn, they
collect information and dispatch police, fire, and EMS to the scene of the emergency (Figure 2).
When you are in the midst of a pandemic, other emergencies do not stop. There are car accidents,
lawlessness, house fires, and heart attacks to respond to. The toll of a pandemic adds to the daily
burden on these services. In some cases, it nearly brings them to the point of breaking. An
example of this is EMS. Paramedics and EMTs have experienced an unprecedented demand on
their services. More about that later.
Police
What role do law enforcement organizations play in a pandemic? Well, the answer to that
depends on what public health measures are in play and how they are being enforced. Law
enforcement organizations are busy with the day-to-day emergencies that occur within their
jurisdictions. As previously mentioned, car accidents occur, and acts of lawlessness are no less
common during a pandemic. Some state and federal orders and restrictions require strict
enforcement. Travel bans, business closures, and sometimes quarantine must be enforced by law
enforcement officers with arrest authority (Figure 3).
Figure 3. Law enforcement officers seen here checking travel authorization documents
during the COVID-19 pandemic. These check points are necessary to prevent
unnecessary travel aimed at limiting the spread of infection. Image courtesy of
Shutterstock. https://www.shutterstock.com/image-photo/municipal-police-protectivemasks-due-coronavirus-1676078338
Mandatory mask orders are commonplace, but difficult to enforce. This measure is one that has
become politically charged. As such, many people refuse to comply with the order. Occasionally,
there may be confrontations in public over this issue, which may call for police to intervene and
remove persons that refuse to comply with the order or resort to violence in their insistence that
this mandatory mask order tramples on their human rights. Quarantine laws at the federal, state,
and local level may be enforced by public health officials with assistance from law enforcement.
This is rare, but a possibility all the same.
Fire and Emergency Medical Services
Fire departments are also focused on their traditional role during a pandemic. Responding to
fires, automobile accidents, and hazardous materials incidents are the top priority for firefighters.
However, many fire departments also respond to medical emergencies with a fire rescue unit
(Figure 4). In those instances, emergency medical technicians (EMT) and paramedics respond
with a fire-rescue truck that is enabled with trauma life support equipment and capabilities.
These highly trained medical personnel make use of the appropriate level of PPE (Figure 5). It
should be noted here that there are publicly- and privately- owned EMS units.
Figure 4.A long line of Fire Department of New York ambulances staging for emergency
medical calls. https://www.shutterstock.com/image-photo/new-york-ny-usa-march-291701721414
Figure 5. A firefighter dresses out in PPE before going on a medical emergency call.
Image courtesy of Shutterstock. https://www.shutterstock.com/image-photo/firefighterwhite-protective-tyvek-style-suit-1717115371
Healthcare Systems
Naturally, with the number of infections increasing exponentially, healthcare systems can be
easily overwhelmed by a pandemic. We have seen the devastating effects of COVID-19 in the
United States, India, Spain, the United Kingdom, France, and Italy. Hospitals have been
overwhelmed in these hotspot areas. We hear the daily news reports from the fall and winter of
2020 telling us just how bad it is getting and wonder how much more can they take.
It begins in small clinics that see the mild cases and the worried well. More severe cases make
their way to the local Emergency Room (ER) via ambulance or personal vehicle. An ER must be
ready to receive and treat them rapidly. More severe cases must be seen first. A process known
as triage is used to determine who needs care immediately.
Beyond the hospitals we can have augmentation through several different means. The first is
healthcare coalitions. They have been established to handle mass casualty incidents at the
community or regional level (HHS, n.d.). These are medical entities working together to meet the
needs of the community. Alternate care sites may be established. During the 1918 Spanish Flu,
many communities across the United States constructed flu hospitals or tent cities. In the modern
era, alternate sites have been established for COVID-19. This facet of medical surge will be
covered in depth in Lesson 5.
Figure 6. An alternate care site established in Lombardi, Italy to treat COVID-19
patients. Image courtesy of Shutterstock. https://www.shutterstock.com/imagephoto/lombardia-italy-february-26-2020-empty-1654878436
Finally, the National Disaster Medical System (NDMS) and Department of Defense (DOD) have
medical teams that can be deployed to areas that need medical assistance beyond what the
community can support. A Disaster Medical Assistance Team (DMAT) and a Disaster Mortuary
Team (DMORT) are two examples of this capability.
The Healthcare Facility
During a pandemic, healthcare facilities are “ground zero” for the response. The pandemic event
will change the day-to-day routines of a hospital and stress its capacity to the fullest. This puts a
financial strain on the system and leads to shortages in staff, supplies, and space. To compensate
for this, hospitals and healthcare systems have strategies for medical surge. This will also be
covered in Lesson 5. Hospitals will establish special wards to care for these highly infectious
patients. Those that are most acutely ill will need to be moved to an Intensive Care Unit or
facility where they can get the highest level of care and the best chance for survival.
So, what goes on inside a hospital Intensive Care Unit during a pandemic like COVID-19? Let
us look inside the Harborview Medical Center Intensive Care Unit at the University of
Washington (video above). You probably noticed that the healthcare providers working in the
hospital with infected patients were wearing quite a bit of PPE. This is essential. It would be
criminal to put these professionals in harm’s way without some form of shielding. They wear
two layers of gloves, a protective mask (ideally an N95 or better) to protect their airway, a shield
for splash protection, a disposable gown, and booties to protect their clothes. All of these must be
provided by their employers to protect them.
Healthcare professionals also need training to know how to put it on (donning) their PPE, how
to work in it safely, and most importantly how to remove it (doffing). Why is doffing
emphasized here? Well, work with an infected patient for an hour and consider how many
infectious particles are on the surfaces of your gloves, gown, mask, and face shield. You must be
extremely careful when you doff this equipment. In fact, it should be done with a step-by-step
process with an observer guiding you through it and making sure you don’t contaminate yourself
when shedding this dirty PPE. In most hospitals, this is part of their Standard Operating
Procedure.
Figure 7. First responders doffing their PPE are assisted by a team of co-workers. This is
done in accordance with a set procedure. Image courtesy of Shutterstock.
https://www.shutterstock.com/image-photo/change-rescuers-comes-out-zone-infection1668414559
Some PPE is not disposable, so it must be decontaminated before it’s used again. There are many
ways to do this. This can be accomplished through chemical disinfection, heat, with and without
pressure, and ultraviolet (UV-C) light exposure (REF). When supply of N95 masks were short
for COVID-19, we had to find ways to decontaminate them so that we get multiple uses. They
were not intended to be used in this way, but sometimes you must play the cards you’re dealt.
The same principles for disinfection of equipment can be used in buildings and vehicles. These
processes can be both laborious and expensive. Also, substances used for chemical disinfection
can be corrosive and harmful to skin and the respiratory tract. Be sure to read the Material Safety
Data Sheet for any chemicals that are used.
The Role of Public Health in Pandemic
What do Public Health agencies and professional do during a pandemic? Public health has a
heavy lift during a pandemic. All their other programs must be scaled back and it’s all hands on
deck for the pandemic plunge. With an emerging disease threat, public health agencies like the
CDC will have to establish guidelines and protocols for a wide variety of things:
To get a sense for the broad scope and variety of guidelines and information that have been
created for COVID-19, go to the CDC COVID-19 webpage. This is a tremendous repository for
information on the number of cases, the number of tests performed and the number of deaths.
This information must also be analyzed for troubling trends or to guide response efforts.
Figure 8. Public health nurse sampling a patient at a COVID-19 drive-through testing
site in the United Kingdom. Image courtesy of Shutterstock.
https://www.shutterstock.com/image-photo/medical-uk-nhs-worker-performingdrivethru-1723264393
Public health agencies will develop initial diagnostic criteria and tests to identify case patients.
The importance of testing during a pandemic cannot be overstated. Testing thousands of people
daily has become a major priority for public health agencies. So much so, that drive through
testing sites have become commonplace in communities large and small all over the world
(Figure 8). The results of these tests will have to be communicated to the doctors that ordered
them. In addition, positive cases require follow up by a public health official who will collect
information to see who has been exposed to those cases. This is called Contact Tracing. Patients
who are positive must be put into isolation. People that were directly exposed to that patient will
need to be in quarantine. Public health agencies are supported by powerful public health laws
that enable them to operate in the best interest of community health.
A Note here: Isolation is a medical procedure or measure supported by procedures and protocols.
Quarantine is a public health measure supported by laws.
The Role of the Emergency Management Agency in Pandemic
Every State, county and many cities have an Emergency Management Agency. The role of an
EMA during pandemics is the subject of much discussion. In some jurisdictions, the local EMA
is doing very little during the pandemic response phase. In others it plays a prominent role. But,
as we like to say in the world of response and emergency management …. All response is local.
Figure 9. The Federal Emergency Management Agency (FEMA) is the Lead Federal
Agency (LFA) for the COVID-19 pandemic response. This is role that they inherited
from the Department of Health and Human Services (HHS). Image courtesy of
Shutterstock. https://www.shutterstock.com/image-photo/washington-dc-january-262019-fema-1295805778
In my experience, a local EMA has an important role to fulfill during a pandemic. They can act
as the hub for a Unified Command made up of local response agencies, regional public health
and hospital incident command. This triad served the county where I reside, Calhoun County,
Alabama, since the initial wave of the COVID-19 pandemic and continues to function at a high
level many months later.
It begins by forming a Task Force with several key functions: Collaborative Planning, Training,
Resourcing (logistics) and Medical Operations. This will enable the community to get off to a
good start. In a pandemic, that is critical.
Figure 10. The Incident Command System (ICS) is a fundamental aspect of incident
response. The use of ICS has been mandated by the National Incident Management
System (NIMS). The Incident Commander (IC) leads and is assisted by a Command
Staff, a General Staff, and Subject Matter Experts. Image courtesy of Shutterstock.
https://www.shutterstock.com/image-photo/metal-sign-emergency-operations-center1382805905
Local and state EMAs can assist public health in orchestrating the response, manage crisis
communications and act as a clearing house for resources. All of this is very helpful. I have
found that collaboration is the key to success. To facilitate collaboration and mission focus the
Department of Homeland Security (DHS) developed the National Incident Management System
(NIMS). A major component of NIMS is the Incident Command System (ICS), which has been
established as a uniform way of managing incidents at all levels of government in the United
States (Figure 10). To receive federal funding for their programs, all emergency management
agencies and response organizations must be NIMS compliant.
The Incident Commander (IC) takes the lead with the assistance of four primary functions:
Planning, Operations, Logistics, and Finance/Administration. The ICS is scalable and designed
in such a way that it meshes with higher levels of government, which facilitates coordination in a
well-established and consistent manner.
Volunteers Active in Disaster (VOAD)
No discussion on response or recovery should be without mention of VOAD. Volunteer
Organizations Active in Disaster is one of the most helpful components in the wake of disaster.
Their goal is to help us take care of survivors with food, shelter, clothing, essential supplies and
even cash (Figure 11).
Figure 11. Volunteers Active in Disaster (VOAD) are an essential part of any disaster
response and recovery effort. They bring compassionate care and much needed supplies.
We would not be able to do as well as we do in the wake of disaster without them.
https://www.shutterstock.com/image-photo/coronavirus-pandemic-epidemic-volunteersoldier-brought-1683496741
In the area where I reside, the United Way orchestrates VOAD. They are joined by the American
Red Cross, many church groups and a long list of other non-governmental organizations and
non-profits. Many communities also have a Community Emergency Response Team made up of
local volunteers. This precious team is trained and certified to participate in response activities.
Most are led by the local EMA.
Government could not do it alone. There are too few people in government to take care of
survivors compassionately and efficiently. Government is too slow and bureaucratic to get that
job done. Every first responder and emergency manager who has ever experienced a disaster is
forever grateful for VOAD and all it brings to the table.
Stress Management
Disasters and pandemics are stressful. They are on the front lines. The Activity following this
lesson focuses on Stress on the Front Lines and asks the question: How do they do it?
Day after day they work on the front lines. They perform difficult duties over long hours with the
risk of infected themselves through the performance of their duty. Well, as we have seen, many
of these front-line workers have or will have Post-traumatic Stress Disorder (PTSD).
Figure 12. Medical treatment provided during the COVID-19 pandemic is very stressful.
Healthcare professionals may be suffering from PTSD due seeing their co-workers and
many of their patients succumbing to the disease. Long hours and difficult conditions
take a toll on these heroes. https://www.shutterstock.com/image-photo/doctor-ppe-suituniform-has-stress-1687243240
Professionals and volunteers working on the front lines of this pandemic need stress management
and/or psychological first aid. That must be planned and programmed at the local level. Many
states have regional Critical Incident Stress Management (CISM) teams available to help with
this. However, individual agencies and their leaders must do their best to help their peers and
subordinates. It is the trait of a good leader – take care of your people. They are risking their
lives! Tell them you appreciate that every day.
The short news clip above from ABC News discusses the stress that Emergency Medical
Services personnel experience during the COVID-19 pandemic. At the time of this broadcast, it
was just ramping up in New York City. The toll on EMTs and paramedics has been enormous.
Fatality Management
The last, but often forgotten piece of pandemic planning and response is fatality management or
“caring for the dead.” Tens of thousands of people die due to a pandemic. The stress and strain of
the increase in need for mortuary services has been realized across the world.
We have social norms that should not be compromised when it comes to paying our respects to
the dearly departed and allowing their family and friends to grieve for them in the best way
possible. However, there are many considerations for handling the remains and arranging funeral
services. In many large metropolitan areas cold storage units have been placed in hospital
parking lots to accommodate the many dead that have overwhelmed the system.
This is an area of response that needs some professionals with special expertise. We must do all
we can to treat this area of response with great respect and selfless service. We owe the victims
nothing less.
Conclusion
Pandemic response is a multifaceted, complex endeavor. It differs from all other types of
incidents in that it can go on for more than a year. The top priority for response to all types of
incidents is life and safety. Typically, this is followed by incident stabilization, protection of
property, and preservation of the environment. Agencies and systems involved in pandemic
response are numerous. In this lesson, we covered 9-1-1 Call Centers, police, fire, EMS, public
health, healthcare systems, emergency management, VOAD, and CISM.
First responders and healthcare professionals need to protect themselves while caring for the
victims of a pandemic. This is done using PPE, training, and the application of procedures and
protocols. Finally, we covered stress and fatality management and how important these pieces
are in the response.
References
Life of Caesar. Episode 47. Festina Lente. December 2016. https://lifeofcaesar.com/life-ofaugustus-47-festina-lente/ Retrieved 16 November 2020.
Lindell, M. K., Perry, R. W., Prater, C., Nicholson, W. C., United States., & United States.
(2006). Fundamentals of emergency management. Washington, D.C.: FEMA.
Occupational Safety and Health Administration. Guidance on Preparing Workplaces for COVID19. 3990-03-2020. March 2020. https://www.osha.gov/Publications/OSHA3990.pdf. Retrieved
16 November 2020
United States. Department of Health and Human Services. n.d. HPP In Your State.
https://www.phe.gov/Preparedness/planning/hpp/Pages/find-hc-coalition.aspx Retrieved 15
November 2020.
Pandemic Preparedness & Mitigation
Here are the Learning Objectives for this lesson.
Terminal Learning Objective
❖ List measures used to prepare for and mitigate against a pandemic threat.
Enabling Objectives
❖ List the four phases of the Emergency Management Cycle.
❖ Identify the purpose of the Preparedness Phase of Emergency Management.
❖ Identify the goals and activities of Pandemic Preparedness and planning.
❖ Describe what you can do to prepare yourself and your family for a pandemic.
❖ Identify measures used to mitigate the pandemic threat.
Note that the overarching objective is for you to list measures used to prepare for and mitigate a
pandemic threat. There are five enabling objectives covered so that you can obtain that
understanding.
In the text box is an interesting quote from Benjamin Franklin. It is one of my favorites. Here he
“If you fail to plan, you are planning to fail.”
Benjamin Franklin
was telling us how important it is to have a plan for future efforts. If not, you are not planning to
succeed. That quote has been restated by many great leaders and others. I find it to be so true
when it comes to natural disasters, major incidents, and pandemic events.
When it comes to the threat of a pandemic, you must have a detailed plan. That plan can be the
key to success. Or, if you do not have a plan or fail to follow your plan, you are destined to fail.
Your views on this topic may very well be shaped by where you get your news from. We live in
a politically charged and divided society. Public health should not be politicized, but it has been
and that is really a shame. What we do to prepare for and mitigate a pandemic should have
nothing to do with your political preferences.
COVID-19 has been a terrible experience for the United States. We lead the world in the number
of cases and deaths. This is an amazing statement given that our nation only accounts for about
4% of the world population. So, did we fail to plan? Or did we fail to follow a plan? Does it
really matter? The activity at the end of this lesson will try to get you to think objectively, not
politically, about this.
I designed the framework for these lessons using the same framework that emergency managers
and public health officials use to manage catastrophic events and disasters. Specifically, they use
the concepts of Comprehensive Emergency Management and the Emergency Management cycle
to divide their time and apportion their activities.
This lesson was specifically designed to give you an introduction into pandemic preparedness
and mitigation. As such, we are covering the following:
•
The Emergency Management Cycle
•
The purpose and goals of Preparedness & Mitigation
•
How individuals, agencies and communities prepare for a pandemic
•
Measures that can be implemented to mitigate the impact of a pandemic event
Comprehensive Emergency Management
We will cover two of the phases of the Emergency Management Cycle; Preparedness and
Mitigation. We will define those phases, cover their goals and objectives, and learn what
activities and measures occur in each. We will go from the general nature of disaster to the
specifics of a pandemic event.
Figure 1. Comprehensive Emergency Management is often looked at in four distinct
phases: Mitigation, Preparedness, Response, and Recovery. The figure above provides
some examples of actions typical for each of the four phases.
https://www.shutterstock.com/image-illustration/emergency-management-process635046212
There are four phases to the Emergency Management cycle (Figure 1). Preparedness, Response,
Recovery and Mitigation. Typically, before an event occurs, we mitigate to lessen the impact of
that event and we prepare for that event. Then, if the event occurs, we must respond. When the
response has concluded, we must then recover from that event.
In terms of a pandemic: We can Prepare for it; respond to it; recover from it; and, mitigate to
lessen the impact. Pandemics are slow motion disasters. I often say that it is like a train off in the
far distance. You can hear the whistle. You might even be able to see the headlight. But it comes
at us slowly and with tremendous momentum. Its passing takes a very long time. Months to
years. Sometimes decades to end.
Let us consider another natural disaster – a hurricane. If you live in a coastal area and have a
history of hurricanes, your Emergency Management Agency (EMA) has addressed this in their
Hazard Mitigation Plan. They have detailed plans for mitigating (or lessening) the damage from
a hurricane. More about this later. They will spend a great deal of time preparing for one. When
it occurs, they will respond to it over the course of a few days. Then, they may spend months to
years recovering from it. A pandemic event is similar, but they don’t happen as frequently, so
preparedness and mitigation efforts are long-term investments. The response can go on for many
months to a few years. Recovery from a pandemic may take decades.
Figure 2. Pandemic preparedness can be viewed in several ways and includes many
facets. This figure from the CDC indicates that personal preparedness, pandemic
planning, policy and partnerships, and a well-defined public health response are primary
attributes of pandemic preparedness.
https://www.cdc.gov/cpr/npm/npm2018.htm
Pandemic Preparedness
What is the purpose of preparedness? In a light-hearted way of looking at things, I often say that
the purpose of preparedness is to have a good disaster. All disasters are bad, really. The
definition of a disaster is that this is an incident that will overwhelm a community’s ability to
respond. Without preparedness activities you are pretty much guaranteed to have a bad disaster.
But preparedness can make the experience a much better. With proper attention to preparedness
there will be far less death, suffering, and loss.
There are many things that go on in the Preparedness cycle. Here we are educating ourselves and
the public. The more we know, the better prepared we will be for the event. Well, that is, if
people are listening. It is hard to get someone’s attention these days. More about that later.
First responders and front line medical professionals require a good training program to hone
their skills for dealing with those that become sick and may even die. Planning is one of the
biggest aspects of Preparedness. There is no substitute for a good plan. It is essential that all
agencies and entities plan for a pandemic. Those that do not are likely to fare poorly during that
event.
We can also spend some time and money stockpiling resources that we know we are going to
need for the event. This can be done at all levels of government and within individual healthcare
facilities and systems.
So, now that everyone has been properly informed, you have adequate resources and facilities,
and a good plan, what is next? The plan must be tested. This is the purpose of a good exercise.
My suggestion to all EM and medical planners is to force the plan to fail and see what can be
learned about the gaps in planning or critical resources.
Figure 3. Pandemic planning at all levels is critical for an effective response. It begins at
the National level and cascades down from there. Seen in this figure are two prime
examples of pandemic planning at the national level. On the left is the National Strategy
for Pandemic Influenza (2005) and the updated federal Pandemic Influenza Plan (2017).
Both are excellent documents that should be part of every pandemic planner’s digital
library.
When it comes to programs, let us start at the top and go down from there. At the National level
there must be extensive planning (Figure 3). In the George W. Bush administration, our nation’s
leaders were very focused on the threat of pandemic influenza. The 2005 National Strategy for
Pandemic Influenza was one of the most forward-looking documents I have ever come across. It
inspired me to want to learn more about pandemic threats. It laid the groundwork for the detailed
plans that followed. The most recent national-level Pandemic Influenza plan was published in
2017. It is an excellent, detailed document that has us prepared for that event.
On the subject of pandemic influenza
preparedness, the CDC created a short
video in 2018 to sell us on this idea.
Here, Dr. Anne Schuchat explains the
importance of being prepared for
pandemic flu. At the time, she was one
of the Deputy Directors at the CDC.
Preparing for Emerging Infectious
Disease Threats
Influenza is not SARS, MERS, or
COVID-19. We have imagined for a
very long time that other emerging
infectious disease (EID) threats will
not come in the form or fashion as a
novel version of the influenza virus. So, what about those other, off the wall threats that come
from some dark corner of nature?
Figure 4. Cover of the Pandemic Playbook. This was assembled by the Obama
Administration for federal agencies to follow in the event of a EID threat, such as SARSCoV-2.
That is what the Pandemic Playbook was created for. In Figure 4 you see the cover page of the
Playbook for Early Response to High Consequence Emerging Infectious Disease Threats and
Biological Incidents. This document was prepared by the National Security Council during the
Obama administration. The Pandemic Playbook is very detailed and easy to follow. It provides
guidelines and steps to follow when something like a highly-transmissible and novel virus
emerges and begins to spread across the globe. The premise of the Pandemic Playbook is that IF
you have early warning, you have about 3-6 weeks to act swiftly to implement these measures.
On the other hand, if you do not have early warning or fail to act swiftly, there is a strong
possibility that the EID threat will become widespread and extremely difficult to control.
Was the United States prepared for a global pandemic like COVID-19? Well, I’m certain that
question will be the subject of many After Action Reviews across many federal and state
agencies. However, in 2019 there was a national exercise named Crimson Contagion that sought
to make a pre-pandemic assessment of the nation’s readiness.
A report from ABC News summarizes the exercise’s draft After Action Review findings that
were leaked to the media (HHS, 2019).
Each agency, be they governmental or private, needs to have a Continuity of Operations Plan
(COOP). A COOP is needed for continuity of government and continuity of business. Disasters
happen! What will you do to continue to operate? Remember what old Ben Franklin said …… If
you fail to plan, you are planning to fail.
Figure 5. This poster jointly published by the Alabama Department of Public Health and
the Alabama Emergency Management Agency outlines a 10-step process. State and
federal governments provide plenty of advice for COOP planning of all kinds.
Some of the most important factors here is that the organization’s leader must believe in the
process and support the time and effort that go into this COOP process. If you do not have this
from the top, it is very unlikely that a functional plan will be derived. Planning takes input from
many people. We call them stakeholders. A stakeholder is anyone who can be affected by the
plan. Get them all involved! It is only through this that an organization will have a good COOP
that everyone is aware of and where you have buy-in for the plan.
Local jurisdictions, like a County or a City, will have a general Emergency Operations Plan, or
EOP. Normally, this plan will address the most likely causes of disaster for that jurisdiction. For
special disaster scenarios, like a pandemic or act of biological terrorism, there will be a
Pandemic or Infectious Diseases Annex in the back of the EOP.
I have reviewed many of these annexes. Since pandemic events can vary greatly in terms of the
infectious agent and the manner by which it’s transmitted, I find the creation of a Contingency
Plan, or CONPLAN, is the most beneficial way to tackle the pandemic threat.
Figure 6. The cover of the Jacksonville State University CONPLAN for COVID-19.
Image courtesy of author.
At Jacksonville State University we started drafting our CONPLAN at the end of January 2020
(Figure 6). A Task Force of key people was formed to provide input to the CONPLAN. The
CONPLAN starts by describing the setting for the pandemic threat (JSU, 2020). Then, the
Purpose of the CONPLAN was described in four bullets.
•
We described possible scenarios where COVID-19 might come to our campus.
•
We discussed the issues and challenges related to COVID-19.
•
We detailed our actions for COVID-19 for all four phases of the EM cycle.
•
We assigned responsibilities to specific individuals or units.
Figure 7. This is a scenario flow chart from JSU’s COVID-19 CONPLAN that describes
actions to be taken when a student presents to the Student Health Center with a flu-like
illness. Image courtesy of author.
One of the six scenarios detailed in our plan is shown in Figure 7. Here a student or employee of
the University feels sick and presents to the Student Health Center on campus. The flow chart
details what actions are taken as what we know about this potential case of COVID-19 as it goes
through the healthcare system. If the patient meets the case definition and a test is ordered, we
isolate the patient, take a sample, and test that sample for the presence of SARS-CoV-2.
The actions in our plan are driven by the concept of RAIN. Recognize the problem. Enable
uninfected people to Avoid it (through the use of Personal Protective Equipment). Isolate the
case from others. Notify the people that need to know.
Figure 8. This is the logo for the Pandemic Ready program. The program defines
preparedness and mitigation measures to be taken for the pandemic threat. Image
courtesy of the author.
Organizational Readiness is a mainstay of preparedness for any disaster and pandemic. I often
like to say that it is a concept in search of a process. For the pandemic problem, I created a
preparedness and mitigation program for our campus, which was named Pandemic Ready
(Figure 8). Initially, Pandemic Ready was designed as a tool for small businesses in our
community to prepare themselves for operating safely during the COVID-19 outbreak in the
region. The idea here is simple. Give people a tool to work through the complex problem of
infectious disease mitigation and business continuity.
Figure 9. Page 1 of the Pandemic Ready checklist for Jacksonville State University.
Image courtesy of the author.
The Pandemic Ready program comes with a simple three-part checklist that the business owner
or supervisor completes (Figure 9). The requirements for the program are based upon guidelines
and best practices from government organizations like the CDC, OSHA and NIOSH. If the
supervisor needs an onsite consultation, they can request that. They can even order supplies from
the University stockpile by clicking on a link embedded in the form. Page 2 of the form provides
links to all the documents and websites that were used to assemble the checklist or to where they
can get further guidance. Once the supervisor or business owner has completed the checklist,
they present it for a compliance check. Pandemic Ready stickers are then issued for them to
display in offices, classrooms, or storefronts.
So, we have worked our way down from the top. National level to State level to Counties, Cities
and agencies. They all have processes to follow. But wait! There is more. What about Individual
and Family Preparedness?
In the event of a disaster, Federal, state, and local governments want their citizens to take care of
themselves for at least 72 hours. That said, what can you do to prepare for a disaster? First, you
need to understand the threat. By doing so you will know how it can affect you and how to keep
yourself safe. You will also know what sort of things to have on hand, so that you are not caught
empty handed when disaster strikes.
FEMA and CDC officials want you to know that simple preparedness measures are individual
and family responsibilities. If you do these things you will be a part of the solution, not
necessarily the problem. Also, through the empowerment of knowledge you can encourage
neighbors, friends, and family members to get onboard.
Figure 10. A CDC poster that addresses family preparedness in the wake of public health
emergency. Image courtesy of the CDC.
https://blogs.cdc.gov/publichealthmatters/files/2013/10/Emergency-kit-infographic_evensmaller.jpg
Figure 10 is a CDC poster aimed at getting you to prepare yourself and your family for a
pandemic. There are some very interesting facts in that CDC poster. A study showed that 60% of
respondents were not even aware of a threat or problem. If you’re not aware of it, how could you
be expected to prepare for it. Only 42% of people that took the survey said they believe that
preparing can help and give them confidence to survive. That means that 58% didn’t realize that.
Finally, as many of 43% of respondents said that they or a family member had personal
experiences with a disaster. This means the task we face is enormous. We have to make many
attempts to get through to people if we hope that we can expect individuals and families to
prepare themselves for disaster.
How do we get people to take preparedness seriously? In my opinion, you have to make it
personal! Let me give you an example. Let’s assume that we have the results of a study that
indicate vehicular accidents occur within 2 miles of the victim’s home. The study also provides
evidence that this has something to do with a lack of preparedness for family trips and the many
distractions that take place inside the vehicle as
drivers set out on a journey. So, here’s the scenario
…. The Smith family is about to pull out of town
for two weeks with the family camper in tow. A
checklist provided Mr. and Mrs. Smith with all the
necessary preparations for such a journey.
Unfortunately, Mr. Smith forgot to get some cash
for the road before leaving town. Instead, he heads
out for the bank so that he can make a quick trip to
the ATM. Sounds, okay. But let’s see how it turned
out. CLICK ON THE VIDEO >
Did I get your attention? Have I made it personal? Can you see yourself in this scenario?
Tornado, Flood, pandemic, etc. I use this video in some of my lectures to drive home the point
that you need to make people see themselves as possible victims of a disaster or incident to make
them prepare of take appropriate action for it.
Pandemic Mitigation
The purpose of Mitigation is to lessen the impact of a disaster. Mitigation measures might
include the prevention of a disaster or incident if it is possible and feasible. You cannot prevent a
hurricane or tornado, but you can do many things to lessen their impact. We often divide
mitigation measures into two broad categories: Structural and Non-structural (Islam and Ryan,
2016). For instance, if we have a good mitigation plan for a hurricane, we might pass legislation
to prevent people from building their homes in areas prone to excessive storm surge, or if they do
you could require them to build their homes on stilts or to be hardened from hurricane-force
winds. You could use federal funds to build or improve levees, which can lessen the impact of
storm surge.
Figure 12. The purpose of mitigation is to prevent or lessen the impact of a disaster. How
can this be applied to a pandemic situation? There are things we can do before, during,
and after a pandemic begins. Image courtesy of the author.
What mitigation measures can be done for pandemics? Is it possible to prevent a pandemic?
Could it be that we are already doing this with vaccines and medications that help us keep the
pandemic threat at bay? Yes, we do that now with polio, measles, diphtheria, typhoid, and
chicken pox. Think of the required vaccines every child must get before attending school. Those
measures are mitigation, and they keep us from having massive outbreaks – even pandemics.
Consider the eradication of smallpox. The smallpox vaccination program of the 1970s eradicated
that disease from the planet.
Then, there are things we do when there is a new threat. Let’s look at that in three different ways.
Before a pandemic begins, when it’s active, and when it’s over.
Figure 13. Pre-pandemic mitigation suggests that you do everything you can do now to
lessen the impact of an emerging infectious disease threat. Image courtesy of the author.
Pre-disaster mitigation is a very good thing! In the United States, it is the primary reason why the
Centers for Disease Control and Prevention exists. You do what you can do with the resources
that you have (Figure 13). Your primary goal should be preventing or containing the pandemic
threat. In mitigating the pandemic threat, you might require a certain vaccine or prophylactic
drug. For instance, healthcare workers are required to get the annual flu vaccine. Here,
surveillance systems help us track trends in infectious diseases. Typically, this is done as passive
syndromic surveillance – like reporting the number of Influenza-Like Illness (ILI).
We should describe trigger points in our pandemic plan. A trigger point is normally an event
described in a plan that necessitates a specific action. Think of a trigger point in this way: When
X occurs, we will do Y. Can you think of an example from the COVID-19 pandemic? What did
the U.S. do when COVID-19 cases in Europe became widespread? Well, we banned travel from
Europe. Presumably, this was in our COVID-19 pandemic plan. Finally, if you find yourself
leading in a pandemic, you should consider the creation of some Rainy-Day policies. Think
through the tough legal subjects so that you are ready to take those policies out of your top desk
drawer and implement them.
HINT FOR TTX IN MODULE 8 & 9. Your group’s planning activities should include detailed
trigger points and short rainy-day policies.
Figure 14. Mid-disaster mitigation measures for a pandemic like COVID-19. Image
courtesy of the author.
So, here we are …. the pandemic is upon us. We did not contain it. Now what? You must test,
test, test! If you cannot (or will not) identify the problem, you cannot solve it. One of the first
steps here is to create a case definition that describes the signs and symptoms for this specific
new disease. Once someone meets that definition, they become a Person Under Investigation
(PUI). In the diagnostic world, they are a Suspect case. Initial testing, like rule-out tests for
influenza and strep throat are performed. If those tests are negative, the patient’s diagnosis may
be elevated to the level of Probable or Presumptive Positive. Only a definitive test can make
them a Confirmed case (Pulia, et al., 2020). Those individuals must be directed to self-isolation.
After a presumptive positive or confirmed diagnosis, we need to determine who that patient may
have been in contact with. Contact Tracing is done by a Public Health professional to determine
who may have been exposed to the infected person. They have a right to know that they have
been exposed, and they need to be directed into quarantine for a period equal to the known
duration of the incubation period for that disease. For COVID-19, the period of quarantine is
now 10 days (initially it was 14) from the time that the person was exposed to that COVID-19
positive case patient. For Ebola Virus Disease (EVD), the incubation/quarantine period is 21
days.
Public health measures are designed to limit our mobility in society. We all have heard about,
and in some instances, may have been subjected to these measures over the past few months.
What were they designed to do? To flatten the curve! See Figure 15 for a full explanation of this
concept.
Figure 15. This graphic demonstrates the concept of Flatten the Curve and explains the
purpose of such a measure. Public health mitigation strategies are designed to limit the
spread of infection. Without such measures, the number of cases will quickly rise and
possibly overwhelm the healthcare system. The goal of such a strategy is to delay (or
prolong) the rise in cases so that the healthcare system can better manage the epidemic. In
essence, this gives us the best chance for favorable medical outcomes, which may lessen
the number of people that succumb to the disease.
So, let us now surmise we are in one of those post-peak periods or that the pandemic has
completely played out and determined to be over by the World Health Organization. We should
strongly consider post-pandemic mitigation strategies (Figure 16). Typically, with other natural
disasters, more federal money would be available for mitigation post-disaster than there will be
for a pandemic event. Why? Well, the thought is that if you are going to have to rebuild it, build
it back better and stronger. I do not know that will be the case with the COVID-19 pandemic.
State and federal governments might be broken from numerous economic stimulus packages and
lost revenues.
Figure 16. There are many things we can do in a post-pandemic period to mitigate for
subsequent waves of the pandemic or lessen the impact of the next pandemic threat. First,
apply lessons learned. What did we do wrong and how can we improve? Federal and state
resources need to be made available for rebuilding our communities and businesses in a
post-pandemic period. We should always give great support for new vaccines and
treatments. Image courtesy of the author.
However, we should see a good bit of funding when we are between waves (post-peak periods).
With COVID-19, the first wave in the Spring of 2020 did not produce a very high number of
cases. However, many businesses and schools were shuttered. The second wave in July and
August was worse. That would have been a good time to build a robust capacity for medical
treatment, testing, and contact tracing. This was also a good time to stockpile Personal Protective
Equipment (PPE) and medications needed to treat the patients. Regardless of the time frame, it is
always a great time to put maximum funding into the effort of creating a safe and effective
vaccine. Also, a specific treatment for any new pandemic threat needs to be supported. Some
great things can be realized in the post-pandemic period.
Conclusion
There are four phases in the Comprehensive Emergency Management cycle. They are
preparedness, mitigation, response, and recovery. This lesson focused on two of them:
preparedness and mitigation. The purpose of preparedness is to ensure that when a disaster
occurs everyone in the community is ready for that event. You are trying to have the best
outcome through your preparedness activities. This comes from information sharing, education,
planning, and exercises. The goal of mitigation is to prevent or lessen the impact of an incident.
Typically, this is viewed in two broad categories: structural and non-structural. Preparedness and
mitigation for pandemic events are very important functions of government. It starts at the
national level and trickles down to state, tribal, and local governments.
The United States has a very good pandemic plan for a novel strain of influenza. The United
States also has a Pandemic Playbook, which wasn’t followed for the COVID-19 outbreak. Early
warning can lead to containment strategies that can preclude widespread transmission of an
Emerging Infectious Disease threat.
Regardless of your role in the current or next pandemic, take time to prepare yourself and your
family. We should all stive to be part of the solution, not part of the problem. Pay close attention
to what public health officials are directing us to do. If we all did these things, the pandemic
experience would not be as poor as the one we have been through over the past two and a half
years.
References
Islam, T. and J. Ryan. Hazard Mitigation in Emergency Management. Publisher: Elsevier;
Boston, MA. ISBN-10: 0124201342; September 2015.
Jacksonville State University. Contingency Plan for Novel Coronavirus COVID-19. March 2020.
Pulia, M. S., O’Brien, T. P., Hou, P. C., Schuman, A., & Sambursky, R. (2020). Multi-tiered
screening and diagnosis strategy for COVID-19: a model for sustainable testing capacity in
response to pandemic. Annals of medicine, 52(5), 207–214.
https://doi.org/10.1080/07853890.2020.1763449
United States Department of Health and Human Services. Office of the Assistant Secretary for
Preparedness and Response. Crimson Contagion 2019 Functional Exercise Draft After Action
Report. October 2019. Accessed at https://int.nyt.com/data/documenthelper/6824-2019-10-keyfindings-and-after/05bd797500ea55be0724/optimized/full.pdf#page=1 Retrieved November 8,
2020.
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