CDC Learns from Katrina, Plans for Pandemic

Lessons from storm benefit preparation for deadly global virus

Hurricane Katrina was more than a test of CDC's hurricane response—it was a test of its resilience in the face of overwhelming chaos and destruction. CDC did not flinch. CDC fulfilled its public health mission when put to the test. CDC also did not flinch when it was time to learn the lessons this historic natural disaster could teach it to prepare for one still on the horizon—pandemic influenza. A mile-wide swirling wind storm may seem very different from a microscopic virus; but to CDC's professionals, that storm provided a "road map" through which the agency can gauge and improve its performance and achieve its urgent mission during the next emergency.

—Julie Gerberding, MD, MPH, Director of CDC

What CDC learned in its response to Hurricane Katrina—arguably the worst weather disaster ever to hit the United States—is helping CDC prepare for the world's worst potential infectious-disease emergency: pandemic influenza.

A lesson like no other

By September 2005, CDC had many hurricane responses under its belt, but nothing to rival the public-health upheaval wreaked by the deadly winds and flooding of Hurricane Katrina. The lessons CDC learned about its emergency response capabilities when stretched to the wall during Katrina are invaluable. CDC has taken those lessons to heart because it must now prepare to face a yet unknown influenza virus that could travel the globe in weeks, kill as many as 2-million Americans, and cause great harm to our economy.

As awful as the devastation of Hurricane Katrina was, it has helped CDC better organize for emergency public health response. As each phase of the Katrina disaster unfolded in 2005, nearly every element of CDC was involved in supporting the Secretary's HHS [the Department of Health and Human Services] response. CDC helped with health issues that involved:

infectious disease detection, prevention, and outbreak control in shelters and in affected communities,
injury prevention for displaced people and rescue workers
environmental health and safety monitoring of homes, water quality, and shelters
rebuilding public health infrastructure,
school health, and
worker and responder safety recommendations and monitoring.

Nearly 700 CDC experts responded side by side with state and local public health professionals every step of the way—working to prevent illness, injury and death—and re-establish safe living and working environments. Many hundreds more of its committed professionals remained at CDC to provide support to field teams and coordinate the response as the focus of health concerns evolved from the dire and immediate to the chronic and longer-term.

In the general sea of Federal incompetence that we saw in New Orleans and along the Gulf Coast the CDC really stood out as an agency that represents what the Federal Government should be, and we thank you for that.
—Rep. Sherrod Brown (Ohio)
Sep. 22, 2005
View the complete transcript of the Sep. 22, 2005 Congressional testimony of Julie Gerberding, MD, MPH, Director of CDC
(2.66 MB/12 pages)

Through this effort, infectious disease outbreaks were averted or quickly controlled, hospitals were resupplied with critical medicines and medical staff, evacuees had better health monitoring and vaccinations, dedicated rescue workers and volunteers had environmental health guidance they needed, and affected community members, who remained or returned, were warned about potential rebuilding injuries, dangers of mold, and carbon monoxide poisoning.

Even amidst CDC's swift and effective response and the thousands of person-hours the agency applied to helping hard-hit states and states sheltering evacuees, things behind the scenes did not go perfectly. As it has done after every major public health emergency response—including after 9-11 and the anthrax mail incident—CDC took an honest and open look at its own performance. The agency examined why things happened the way they happened, to then fix what was in its power to fix.

"Of course, not everything went without complication or misstep—it rarely does in the midst of enormous natural disasters. Disasters, by their very nature, are chaotic," said Richard Besser, MD, Director, Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER).

Besser, who on his first day on the job as the head of COTPER found himself leading the response to Hurricane Katrina in the CDC Director's Emergency Response Operation Center (DEOC), continued, "But what we've seen through our internal assessment is that the lion's share of the agency's response was extremely proactive and comprehensively addressed the incredible public health needs engendered by this storm."

Literally, while CDC's Hurricane Katrina response was still ongoing, it started to look for emergency response areas that needed improvement, and with a sense of urgency it set about correcting them. "Thinking we had only a few months before the next hurricane season, we felt a real urgency to refine our existing Hurricane Operations Plan based on the lessons learned from the 2005 season," said Phil Navin, Director, Division of Emergency Operations, COTPER. "Our plan refinement was done in coordination with HHS and other federal and state agencies."

During Hurricane Katrina, many factors contributed to CDC's ability to respond in a swift, effective, coordinated manner. In a nutshell, the "can-do" attitude of leadership and staff and willingness to learn and adapt as the operation unfolded were agency strengths during and after the crisis. "CDC has been praised by Admiral Allen and other senior federal officials for its exemplary operational response, but there are still issues that worked against our ability to provide the best possible response," says Phillip Navin. "A year later, we've addressed nearly all of them and are now applying these lessons to pandemic influenza preparedness."

Find it, Fix it, Foster it

Letter (1 of 2) to CDC Director Julie Gerberding from Dr. David Buhner, Department of Health and Human Services of Dallas County, Texas (9/27/2005) (71 KB/2 pages)
Letter (2 of 2) to CDC Director Julie Gerberding from Dr. David Buhner, Department of Health and Human Services of Dallas County, Texas (9/27/2005) (39 KB/1 page)
Letter to CDC Director Julie Gerberding from Dr. William Moyer, Professor and Head of the Department of Large Animal Medicine & Surgery, College of Veterinary Medicine, Texas A&M University (9/27/2005) (47 KB/1 page)
E-mail to the faculty, staff and students of Texas A&M Univeristy from University President Robert Gates (9/28/2005) (260 KB/5 pages)
Letter to CDC Director Julie Gerberding from Dr. Brian Amy, State Health Officer, Mississippi Department of Health (10/13/2005) (67 MB/2 pages)

After Katrina, no one was left out of the search for ways to improve CDC's emergency response—the assessment looked inward and outward. In a national response, CDC's role is to support the operational direction of the Secretary's Operation Center, so it was most important to assess how well that was accomplished in the context of the larger federal assessment. CDC staff, the Federal Emergency Management Agency, the National Emergency Management Association, public health agencies, private sector organizations, international observers (like the World Health Organization and the Pan American Health Organization), and other interested parties contributed input to the assessment. "The team drew upon emergency response documentation, previous performance assessments, and other relevant information," Besser noted. "Data were analyzed; common themes were identified; conclusions and recommendations were then determined."

The operational lessons from Katrina were grouped into five broad categories:

Mission Objectives and Deployment Assignment;
Organizational Structure and Incident Command System;
Information Flow and Management;
Public Health Practice; and
Training and Exercises.

Navin continued, "We took a multi-disciplinary approach to identifying both strengths and opportunities for improvement to CDC's all-hazards preparedness and response so immediate steps could be taken."

The assessment identified some simple and some complex areas for improvement. Corrective actions are nearly complete a year later (see Katrina Lessons table). An example of a relatively straightforward lesson learned was that CDC needed clear objectives from HHS for its Hurricane Katrina mission. "Success or failure in a situation like this depends, at least in part, on having and communicating the mission to staff so that they understand the plans, policies, and procedures in place to support this mission," Besser explained. "A clear, publicized Incident Action Plan (IAP) was not implemented, which led to confusion among our responders." While responders defaulted to what they believed to be the right course of action, a formal IAP would have supported an understanding of overall objectives and helped avoid confusion between states and CDC about deployed personnel and their mission assignments. Incident action plans are now the norm for CDC's emergency response.

In the midst of the operation, CDC learned that its operations organizational structure, developed in the context of less complicated disasters, was not adequate to support the best possible flow of information and lines of authority to federal response leaders in the field, state health officials, and leaders at HHS. During the Hurricane Katrina response, the DEOC reorganized to better support the new federal Incident Command Structure and now adheres to this structure and the use of Standard Operating Procedures (SOP). At the time, SOPs either did not exist, were in draft form, or were in conflict with those of other response organizations. Since Katrina, CDC has worked with HHS and other federal partners to develop playbooks and checklists and developed pre-scripted mission assignments for CDC assets. It has already initiated a comprehensive exercise program to see how this work can be optimized for a pandemic response.

CDC also found that its staff was willing to volunteer in record numbers to deploy for Katrina, but many employees lacked basic knowledge of emergency response operations. Among a group of 421 responders questioned, this was the first deployment for 51% of them. CDC is now making an unprecedented investment in training staff through its Corporate University, web-based training modules, exercises, and simulations.

Some lessons learned were more complex. For example, Katrina itself presented unique public health challenges, especially how to meet short-to-intermediate needs of incoming evacuees and "expatriate" citizens in other states. Also, as these vulnerable, displaced populations had chronic medical conditions, CDC recognized the need to address the expanding requirements for the Strategic National Stockpile in providing chronic and emergency medical supplies. The stockpile was originally designed to support provision of immediate medical care in the context of an emergency event like an explosion, and countermeasures like antimicrobials in the case of a bioterrorist attack. In the Katrina operation, the SNS was asked to support a new mission—provision of the ongoing needs for routine medications, intravenous supplies, and other materials needed to deliver healthcare to sheltered people and others who lost access to their routine services. "Not being able to provide the right medication to the right individuals can pose additional health risks and worsen chronic diseases," says Dr. Besser. "Shelters simply did not have the medications they needed to treat exacerbations of chronic disease, which are a primary health problem." Similarly, in the areas impacted by the storm, the approach to shelter assessment and surveillance appeared more suited to developing country situations where the main health issues are infectious, rather than chronic, diseases. Therefore, CDC identified a need to clarify public health's role in domestic sheltering.

Following Katrina and to contribute to clarifying public health's role, HHS and CDC's National Center for Chronic Disease Prevention and Health Promotion have worked together to resolve this issue. A draft action guide focusing on emergency care for people with chronic diseases has been developed, and a CDC work group with multiple external partners has formed to continue improvements. CDC's National Center for Environmental Health has held multiple meetings with Federal Emergency Management Agency (FEMA) regions and is working with states to coordinate the Emergency Mutual Aid Compact, in which states join together for inter-state relief activities in emergency situations. The Division of Bioterrorism Response Program is leading the deployment coordination requirements group and has standardized disaster surveillance forms.

Table: Examples of Hurricane Katrina Lessons Learned that Lead to Corrective Actions
Katrina Lesson Learned	Corrective Action
Missing mission statement and clear objectives	Incident Action Plan and Mission Statement standardized
Lines of authority confused	Standard Operating Procedures written and exercised; Incident Management System staffing standardized in the DEOC
Inadequate support staff to support experts	Support staff integrated into deployed teams
Procurement and Grants Office overtaxed	PGO developing surge-capacity plan
Financial Management Office overtaxed	FMO developing surge-capacity plan
Partner/stakeholder communication spotty	CDC developed partner database and protocol and identified a "partner desk" in the DEOC
HQ Briefing documents cumbersome	Briefing template standardized
CDC staff lacked understanding of the nature and demands of emergency deployments	Deployment training for staff institutionalized based on U.S. Forest Service "Red Card" training
Collaboration with federal partners spotty	Now play books, checklists in place
SNS role too restrictive for Katrina disaster	CDC is assessing expansion of SNS formulary
Responder resilience not fully addressed	CDC expanded existing responder resilience program
Cross-cutting agency roles unclear	All agency elements defining roles for natural disaster response

From Katrina to Pandemic

While the lessons from Hurricane Katrina have helped CDC prepare for future hurricanes, it also crystallized vital emergency response concepts that are critical to preparing to respond to pandemic influenza. The crisis most likely to directly involve the greatest number of persons in the United States is a major respiratory-transmitted infectious disease outbreak such as pandemic influenza. Over 12 to 18 months, a pandemic outbreak may come and go in waves in a community, each of which can last for six to eight weeks. An especially severe influenza pandemic could lead to high levels of:

illness,
death,
social disruption, and
economic loss.

Everyday life would be disrupted because so many people in so many places could become seriously ill at the same time. Impacts can range from school and business closings to the interruption of basic services such as public transportation and food delivery.

During a pandemic, a substantial percentage of the world's population will require some form of medical care. Health care facilities could be overwhelmed, creating a shortage of hospital staff, beds, ventilators and other supplies. Surge capacity at non-traditional sites such as schools may need to be created to cope with demand. The need for vaccine is likely to outstrip supply and the supply of antiviral drugs is also likely to be inadequate early in a pandemic. Difficult decisions will need to be made regarding who gets antiviral drugs and vaccines.

These are the realities CDC's emergency response is focused on today and tangible additions to pandemic preparedness planning have come from the agency's experiences in Hurricane Katrina. For example, Katrina solidified for CDC that it had to structure its emergency response under the Incident Management System (IMS) to provide stability and continuity. With a long-term, large-scale event like a pandemic, where turnover among staff will be high, the stability of this structure will be critical and the pandemic preparedness group is now also using IMS.

CDC learned from Katrina that it had to pre-identify its resources, material and personnel. During the last year, CDC has cataloged more than 1,800 possible requirements to be filled for a disaster; of these, 100 are related to international deployments for situations like pandemic influenza. In addition, a truly tangible lesson from Katrina taken directly to pandemic influenza preparedness was the addition of a Vulnerable Populations Workgroup to CDC's pandemic influenza task force.

During Katrina, CDC found that the well-being of those responding and their families also needed more attention. Agency staff along the Gulf Coast encountered situations that were both physically and emotionally challenging. CDC recognized the impact of responder resilience on overall agency operations and performance, not only on those that deploy. This represented a shift in CDC organizational dynamics. These lessons are invaluable as CDC prepares its agency for pandemic influenza response, where the well-being of families will be a concern while CDC staff are deployed. In addition, many may need strong psychological support to manage the magnitude and length of a pandemic response. Ensuring the staff can work, find respite, and quickly return to work will be critical.

Each disaster brings its own unique twists and new challenges. Yet a violent storm can help CDC change and prepare for a deadly virus—because the one constant for CDC in every emergency response is the urgent need to prevent illness, injury, and death and protect the well-being of every one touched by that disaster.

As for those who experienced Katrina and its aftermath in person, however, change of a deeply personal nature has already come. "Seeing human suffering firsthand is life-changing and more than humbling," recalled Kristin Uhde, PhD, MPH, who was deployed to Mississippi as an Epidemic Intelligence Service Officer, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases. "Even more so is seeing the people who suffer do so with a grateful and happy heart." She and her team carried out injury surveillance at coastal healthcare facilities. "While we were in a clinic collecting data, we met a lady who survived the storm by floating on a soccer ball while her friend hung from the rafters in a gymnasium," Dr. Uhde added. "Although these people were suffering so much, they were so grateful for any help anyone could provide..." Lessons learned, indeed.