Human Pandemic – How Will Nutrition Assistance Programs Respond?

Food and Nutrition Service Stakeholders Meeting
December 8, 2006 - Meeting Summary

Background

Currently, the Avian Influenza (AI) outbreak affects only birds. Of the few avian influenza virus subtypes that have crossed the species barrier to directly infect humans, H5N1 has caused the highest human morbidity and mortality. So far, the spread of H5N1 virus from person to person has been suspected in only one case, and was not conclusively proven. Nonetheless, because all influenza viruses have the ability to change, scientists are concerned that H5N1 virus one day may be able to infect humans and spread easily from one person to another.

On Nov. 1, 2005, President Bush released the National Strategy for Pandemic Influenza, a comprehensive approach to addressing the threat of pandemic influenza. The Strategy outlines how the U.S. government is preparing for, and how it will detect and respond to a pandemic. On May 3, 2006, the Homeland Security Council released the Implementation Plan for the National Strategy for Pandemic Influenza, which integrates planning across all levels of government to ensure that planning and response actions are complementary, compatible and coordinated.

Both of these documents emphasize the need for communities to be self-sufficient and able to deal with the outbreak of a pandemic. Political leaders, government service personnel, employers, school leaders, healthcare leaders, faith-based and community organizations, businesses, families and the media all must be accurately informed, engaged, and actively involved.

The Department of Health and Human Services (DHHS) Pandemic Planning Update Report notes that the pandemic will not spread in a predictable manner, but will likely affect counties and communities simultaneously around the globe. Local leaders and health officials will determine how to deliver emergency services and food assistance and when to encourage individuals to practice social distancing and avoid congregate settings. They also will determine the length of time schools are closed and what other roles schools may assume, such as conversion to secondary hospitals.

To assist States and communities with preparedness planning, Congress allocated $350 million in fiscal year 2006. Governors were asked to establish comprehensive and credible preparedness and response plans. Many States held pandemic planning summits this past year to develop such plans.

FNS Program Challenges during a Pandemic

The Food and Nutrition Service (FNS) nutrition assistance programs must be prepared to assist communities and needy families in this time of crisis. However, all of the Federal nutrition programs assume some face-to-face contact in order to deliver benefits. Although some programs are more dependent on congregate settings than others, social distancing may create challenges in the delivery of benefits for all the nutrition programs.

	The Food Stamp Program (FSP) may continue operations seamlessly for current participants even if social distancing is recommended. For example, EBT cards can be mailed to recipients; benefits can be electronically posted to these cards; and periods of eligibility may possibly be extended under disaster authority.
	Similarly, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) may continue operations seamlessly for current participants. WIC food instruments can be set up for multi-month issuances and WIC food instruments can be mailed to recipients.
	Both FSP and WIC may face challenges in enrolling new participants who lose income because of social distancing, illness or workplace closures. Both also rely on the retail food industry for food delivery and store operations, which FNS has no authority over, or means to ensure, their continuity of operation.
	The Emergency Food Assistance Program (TEFAP), the Commodity Supplemental Food Program (CSFP) and the Food Distribution Program on Indian Reservations (FDPIR), rely on the congregation of individuals to provide benefits either through congregate feeding or by relying on the congregation of workers to prepare meals or food packages. While the congregate feeding offered by TEFAP soup kitchens may be limited or cease, TEFAP, CSFP and FDPIR household food package distribution can continue to the extent workers and volunteers are available.
	The Child Nutrition programs, including the National School Lunch Program (NSLP), School Breakfast Program (SBP), Child and Adult Care Food Program (CACFP) and Summer Food Service Program (SFSP) offer federally reimbursable meals in a congregate setting. In a pandemic situation, if schools, child care centers, family day care homes, parks and community centers are closed and/or public congregation is discouraged, the Child Nutrition programs, as presently designed, would not be operational.
	As part of its Disaster Program, FNS provides commodities for both congregate feeding and household distribution in response to Presidentially-declared disasters. In a Presidentially-declared disaster, replacement of commodities distributed at the local level is guaranteed by FNS. Without a Presidential disaster declaration, the pandemic would be considered a “situation of distress” in which case FNS can approve distribution of commodities, but will replace commodities used only to the extent that FNS disaster funds are available (currently $500,000 annually).

Meeting Purpose

A stakeholders’ meeting on pandemic planning for the Food and Nutrition Service (FNS) nutrition assistance programs was held on December 8, 2006 from 9:00 a.m. to 12:30 p.m. at FNS Headquarters in Alexandria, Virginia. Seventeen stakeholder groups attended as well as Senior Officials from FNS and other USDA agencies (see Attachment A for attendees). The purpose of the meeting was to exchange information and stimulate development of Federal, State and local pandemic planning related to nutrition assistance. It provided an opportunity for dialogue between Federal officials and stakeholders on human pandemic. To that end, meeting participants were asked to come prepared to discuss the following topics:

	What plans are being developed at the State and local level to address community nutrition assistance needs during a pandemic?
	Are communities looking at specific solutions for children, elderly or families as a whole?
	What program adaptations are needed to respond to social distancing, voluntary quarantines, and possible disruption of the normal food supply?
	How will food be supplied and delivered through commercial markets?
	Will current program flexibilities/waiver authority be sufficient or will new flexibilities need to be considered?

Meeting Proceedings

Opening Remarks – Roberto Salazar, Administrator, Food and Nutrition Service

Two things that are very important to FNS are communication and partnerships. FNS wants everyone at the table in order to make informed decisions and effectively tackle tough issues. With that in mind, stakeholders were invited to this meeting to help FNS do two things:

1. First, to develop a common understanding of the issue, underlying assumptions and major strategies that are being discussed. This is extremely important because forums and meetings are being held around the country on pandemic planning. Assumptions are sometimes being made about FNS programs without our representation at the table. It is critical that we work together on viable solutions.

2. The second reason for meeting is to begin to address the questions posed in the letter of invitation. The invited speakers will help to partially answer some of the questions. We will then look to all meeting participants to help answer the questions on administering our nutrition assistance programs during a pandemic.

FNS has done some initial thinking on how our nutrition assistance programs might operate during a human pandemic. These thoughts are reflected in the background paper that was provided to you in preparation for this meeting. But this was merely a beginning, because we knew that we needed to hear from our stakeholders on how our programs might work and what, if any, adaptations might be necessary.

FNS senior managers and our other USDA colleagues are attending this meeting to learn from each other what is being planned at the Federal, State, and community level and how our nutrition assistance programs might fit into the changing environment created by a pandemic. No idea is wrong, wild or crazy for the purposes of discussion. FNS is very appreciative of the time and effort of stakeholders to participant in this stakeholders meeting.

Presentations on Pandemic Planning

National Perspective (.ppt) – Carter Mecher, MD, Homeland Security Council

Dr. Mecher provided an overview of pandemic influenza, including definition of terms, historical perspective and current national strategies and planning. He emphasized that not all pandemic flu variations are avian in origin.

If the 1918 influenza outbreak occurred today the effect could be:

	90 million ill (1/3 of general population, but 40% of kids)
	45 million require outpatient care (50% of infected)
	9.9 million require hospitalization (3 x current bed capacity)
	1.485 million in ICU (100,000 ICU beds available now)
	1.903 million deaths (2% of infected)

Interventions must be implemented immediately, not in the middle of an outbreak, in order to have a significant effect. Local and State agencies must act quickly and decisively at the first sign of an outbreak. Community-based interventions are expected to:

	Delay outbreak peak while vaccine is developed. One person generally infects two others, so the disease load will increase geometrically (daily doubling of disease load) without intervention.
	Decompress peak burden on hospitals.
	Diminish overall cases and health impacts.

Transmission of the influenza comes when large and small droplets/particles from an infected individual are carried in the air through sneezing or coughing to others nearby or when infected individuals touch their mucous membranes (eyes, nose, mouth) and then touch objects that others touch. Strategies to fight spread of infections include:

	Vaccine – however, vaccine will not be available for some months into pandemic. Developing and manufacturing vaccine time-consuming and will only cover 25% of population.
	Infection control –
	-- hand washing, sneezing etiquette    -- environmental cleaning with usual cleaners at home and office        (antibacterial products not needed)
	Social distancing –
	-- Isolation - sick individuals stay home    -- Voluntary home quarantine – seemingly uninfected members of households with        sick members stay home    -- School closure – necessary because of the high density of school classrooms        and school busses    -- Children and teens kept from congregating    -- Cancellation of mass gatherings - businesses should prepare work-from-        home capabilities    -- Distancing at places where people must gather – increase distance between        people/workstations and decrease the number of contacts (telephone meetings,        even within buildings)

No one preventive measure will be wholly successful. Agencies must be prepared to implement multiple interventions to cover inadequacies in any given intervention. The economic impact of social distancing is likely to be large, due to disruption of business, with a disproportionate impact on vulnerable (elderly, young, poor) populations.

A recent Harvard School of Public Health survey on the likelihood the public will follow health department recommendations revealed the following:

	All household members will stay home 7-10 days if individual in home is sick - 85%
	Individuals will stay home if they are sick -94%
	Able to arrange child care if schools closed 1 month - 93%
	Able to arrange child care if schools closed 3 months - 86%
	Would avoid mass gatherings - 79-93%
	Of the 25% of those surveyed whose children received free school lunch, having no school lunch would be a major problem for 13%, minor problem for 21%, no problem for remainder.

To fully respond to pandemic flu, pandemic planners have to consider households’ faith and social needs, individual and family concerns, and school and work life. Organizations must engage with leadership in all of these spheres of life using imagination and demonstrating resilience.

Questions and answers

Food Retailer Perspective (.ppt) – Jennifer Hatcher, Food Marketing Institute

The Food Marketing Institute (FMI) is highly involved in discussions around pandemic flu and they feel that much of what has already been achieved in preparing for or responding to other disasters could be applied to pandemic influenza. Advance preparation is the most essential part of a good response to a pandemic. FMI has a number of resources available on pandemic/disaster preparedness:

	Consumer brochure – communicates with customers on basics of avian influenza, including the safety of poultry purchases.
	Planning Guide on FMI website. Addresses business continuity, dealing with consumers and employees, communications, and more. Retailers must be ready for dramatic shifts in consumer behavior, including fewer, larger shopping trips, spikes in purchases for certain products (like antibacterial agents), increased demand for self-checkout, stockpiling, and internet and phone orders. Retailers are prepared to perform internet and phone orders/food reservations, but not to conduct financial transactions with EBT cards, due to security concerns/need for improved technology. They are also prepared to deliver parking lot sales, where retailers would preassemble food boxes and allow clients to purchases them at a “drive-thru” style concession, which would reduce human contact. Drive-thru transactions would also help reduce the load of the virus in stores, keeping them clean.
	Lessons learned during 9/11 – a document for planning for disaster recovery.
	Electronic Benefits and Services Council – Guide to Disasters – features best practices at the local, State, Federal, and advocacy level.

In order to respond effectively in a disaster, FMI needs several considerations from the Federal government:

	Inclusion as part of the critical infrastructure, allowing for easier, faster communication, and priority access to fuel and cash.
	Designation as a first responder – would allow them access to closed roads for transporting/receiving food.

Questions and Answers

State Perspective (.ppt) – Kris Eide, Minnesota Homeland Security and Emergency Management Department of Public Safety Presentation

Kris Eide discussed Minnesota (MN)’s planning and preparedness for a human pandemic. She stressed the importance of having plans for those who are sick and those who aren’t sick because if 40% of workforce is out, 60% is still there. Every organization needs a good continuity of operations plan (COOP). The level of readiness of program managers may depend on what department within State government they reside. Pandemic funding in 2006 was provided to public health agencies, which may have implied that it is a public health issue only.

MN developed a supplement for Pandemic Planning to their State Emergency Plan in order to be all-inclusive of State departments and agencies. It provides for a strategy to stop the spread of disease as soon as possible with a combined State/local and Federal response. A planning guide is being sent to all State agencies that is based strategies on World Health Organization’s phases and separates bird flu and pandemic planning.

MN is the number one turkey producer in the country; therefore, it has developed a very good biosecurity system. It has in place a specialized team in addition to Government to make decisions in the event of a pandemic. MN will request disaster declaration from the White House as soon as pandemic begins.

In order to be effective, pandemic plans need to be robust and flexible. MN’s plan includes service continuation “Priority Service Levels” in order to determine what are the most critical levels of service to citizens.

MN Department of Health which administers the WIC Program has posed the following as challenges:

	How to maintain program
	How to determine eligibility
	Flexibility needed to provide grocers with a list of alternative food items which could be WIC approved a rapid notification to food stores of approved list of alternate foods needs to be developed.
	Working with Public Safety on the possibility of a single application for all types of public assistance be developed
	Possibility of issuing larger quantities and stockpiling of food MN Department of Human Services has encouraged planning:
	Continue payments to nursing homes during pandemic to support ongoing services
	Sponsored 7 regional food shelf conferences. Issues included:
	-- Role of food banks in a pandemic? -- Waiver requests from USDA to curtail face-to-face interviews for food support     program. -- Option of more food supplies provided in advance (blizzard food baskets) -- Ability of food banks to supply pre-made foods (frozen and ready-to-heat) -- Provision of homemade meals ready to eat (MREs) – have prisons create ahead of     time.

MN Department of Education Challenge if schools are closed:

	Training at the same time of planning with little lead time and no real experience with this scenario
	Use of school kitchens to prepare meals to be delivered by school buses by volunteer agencies with the recognition that there is an issue with home delivery because of restrictions to congregate settings in USDA programs, funding availability and nutritional soundness of meals
	Use of possible waivers on requirements for temperatures (and related food safety issues, serving sizes, storage, nutrition standards, and handling
	Menu planning ahead to make sure to use existing food inventories
	Development of different delivery mechanisms

MN is working with the private sector to develop a Business Ops Center in Emergency Management Center. It is coordinating with regional businesses to provide services while keeping employees working, including General Mills, ConAgra and Cargill. It is in the best interest of the companies to provide services and be a venue for education as it would most likely reduce the number of workers absent during a pandemic.

MN also is developing a Statewide Public Information Campaign with a memorable “brand” which motivates public to prepare. It has hired PR firm to figure out how to change ideas, utilizing a strategy that convinces the public that emergency preparedness begins at home.

Questions and Answers

Community Perspective - Laurie Willshire, American Red Cross

The American Red Cross provides relief to victims of disaster and helps people prevent, prepare for, and respond to emergencies. Red Cross provides services through its chapters located across the country; about 97% of Red Cross workers who provide service are volunteers. The local response during emergencies is very critical. In response to a pandemic, Red Cross will provide public education, as well as feeding and bulk distribution. Since disasters (natural and otherwise) will continue during a pandemic, Red Cross chapters will need to be prepared to respond to those as well as the pandemic. Red Cross has been providing guidance to its chapters for over a year, and now has a unit at its national headquarters with staff dedicated to full-time pandemic planning and preparedness.

Some of the challenges that the Red Cross could face during a pandemic include:

	Decreased availability of workers due to illness or travel restrictions; this will also make it difficult, if not impossible, to send workers from other areas to respond.
	Normal service delivery options may not be appropriate (such as congregate feeding or sheltering), so alternatives must be identified
	Decreased availability of resources needed to provide service delivery

As part of general pandemic preparedness activities, Red Cross chapters are:

	Establishing pandemic Continuity of Operations Plans, including succession planning and cross-training.
	Working with local authorities (e.g., emergency management, public health) and community organizations to identify appropriate and realistic roles and responsibilities during a pandemic.
	Taking steps to ensure the safety of their workers.

Specific to feeding, Red Cross chapters are:

	Working with vendors to increase access to food and supplies.
	Increasing their reliance on packaged meals, including ready to eat and shelf stable items.
	Exploring relationships with food service operations, such as meals on wheels, feeding kitchens, and school cafeterias.
	Working with local community groups, such as food banks, professional organizations, and faith based groups, to expand the chapter capacity to assemble and distribute food supplies.
	Developing plans for bulk distribution of food and food supplies.

Additional feeing guidance will be provided to chapters in the near future.

Red Cross also offers pandemic preparedness education. The Pandemic Flu Public Information Series: Are You Prepared? is an educational presentation that is now available; a leader’s kit, which includes a DVD, brochure, CD-ROM, and leader’s guide, was made available to meeting attendees.

Facilitated Discussion with All Stakeholders – Potential Flexibilities and Strategies Suggested By Stakeholders for Consideration for FNS Programs during a Pandemic

Food Stamp Program

Pre-approved State waiver package - During hurricanes there were many waivers done quickly. During a pandemic event, FNS should have off-the-shelf package to address consequences such as eligibility issues (face-to-face interviews, relocation of residents, and reliance on Internet). This package would be proactive, anticipating needs and providing approvals for program flexibilities instead of waiting for reports to be submitted to substantiate need for waivers.

Need to retain flexibility - The food stamp legislation allows for flexibility to assure that specific needs are addressed, which must be weighed against the development and application of a “cookie cutter” approach to planning.

Stockpiling – Provide a supplemental food benefit for stockpiling since low income families may not have the necessary resources. Explore the feasibility of preloading an EBT card with supplemental benefits that could not be accessed until an authorized date. Perhaps other government agencies might want to add benefits to EBT cards to allow stockpiling of non-food items needed such as masks.

Enrolling new households – Families that suddenly have income reduced or eliminated often turn first to food banks, so need to provide alternate access sites in communities, such as food banks, where families could apply for Food Stamps online.

Preparing families - Outreach and nutrition education efforts should include information on pandemic planning for individuals and families. Trusted messengers in communities need to be used to get the word out about preparing for a pandemic.

WIC

Continuation of Katrina-like Flexibilities – The flexibilities that were in place for Katrina such as extended certification periods, mailing of WIC vouchers, and expedited services for new applicants should be continued.

WIC as a First Responder – Explore the possibility of the WIC Program being considered a first responder in situations like pandemics and other emergencies.

Development of WIC Guidelines– The National WIC Association’s Task Force on Disaster Planning and FNS should work collaboratively to develop pandemic planning guidelines.

Stockpiling Infant Formula – Infant formula should be a consideration for the national Strategic Stockpile of Pharmaceuticals to assure adequate supplies will be available during a pandemic.

Breastfeeding Support – Work with CDC and other organizations on breastfeeding support and health messages to assist breastfeeding mothers.

Collaboration in State Plans – State WIC directors should be part of pandemic planning activities by working with their State Health Officer and be included in regional tabletop exercises that are being planned by States, the National Governors Association and other stakeholders.

Educating Participants – Some WIC programs are already providing participants with information on preparedness planning. Examples should be shared and included in WIC’s nutrition education efforts across the country.

Child Nutrition Programs (NSLP, SBP, CACFP, and SFSP)

Emergency Preparedness – Programs need to continue to emphasize the importance of food safety and mitigation strategies that reduce transmission of illness.

Reprogramming of Program Funds – If Child Nutrition Programs are not providing meals due to social distancing measures that close schools and childcare programs, reprogramming of funds into other nutrition assistance programs to replace those benefits to families should be considered.

Commodity Distribution Programs (TEFAP, CSFP, FDPIR, and Disaster Assistance)

Responding to Increased Demand for Commodities – Commodity distribution inventories could be rapidly depleted due to increased demand. In the absence of a Presidential declaration, there needs to be a mechanism to assure sufficient resources will be available to replace those inventories. The approximate $500,000 in disaster funding that FNS receives annually is unlikely to be adequate to meet anticipated need.

Closing Remarks– Roberto Salazar, Administrator, Food and Nutrition Service

It is important for FNS to know what State and local emergency response planners are considering to meet community nutrition assistance needs so that together creative solutions can be developed. The dialogue initiated with this meeting must continue across the country. Stakeholders should make it a priority for conference agendas that are being planned. Organizations with membership at the State and local level should encourage those members to include nutrition assistance programs and program managers in the pandemic planning process. Ideas and solutions that are generated from these activities need to be shared with FNS.

In terms of next steps, FNS will explore the efficacy and feasibility of suggestions provided by stakeholders. It will work with USDA as a whole to have an appropriate and comprehensive Departmental plan of action to address a human pandemic. USDA, in turn, will continue working with the White House and the Homeland Security Council to assure a coordinated and complete plan of action and response to a human pandemic. FNS is proud of the positive record that our nutrition programs have achieved working in partnership with program cooperators and public and private organizations across the country. It will continue to work with stakeholders to identify program strategies and flexibilities needed to respond to a pandemic.

Last updated: 01/08/2009