ESF-8 Pandemic Influenza Playbook

[Working Draft]

Disclaimer

This ESF 8 Pandemic Influenza Playbook provides guidance for Executive-level decision makers within the Department of Health and Human Services (HHS), specifically the HHS Secretary and HHS Assistant Secretary for Preparedness and Response.  This Playbook is not intended to be an instruction of how to implement ESF 8 missions at the operational or tactical level. 

This Playbook is a work in progress. Simultaneous planning processes and evolving policy decisions may result in some sections not reflecting current HHS or interagency plans or policies, thus the Playbook will require ongoing updates.  The HHS Office of the Assistant Secretary for Preparedness and Response (ASPR) is responsible for managing this process.  The date in the footer of all pages in the Playbook reveals the last time the document was updated. 

In addition to periodic updates, the response concepts articulated in this Playbook will need to be integrated with regional, State, local, and Tribal planning to improve the ability of ESF 8 response assets to act in concert with other efforts during an event when no one organization is able to complete a mission on its own.  Future iterations of this Playbook will describe this philosophy in more detail. 

Introduction

Purpose

The purpose of this playbook is to assist the Secretary of Health and Human Services (HHS) and the Assistant Secretary for Preparedness and Response (ASPR) in monitoring and directing pandemic response activities in response to a severe influenza pandemic. It also provides an overall summary of key decision points and action steps intended to support the participation of all Emergency Support Function-8 (ESF-8) agencies in pandemic influenza preparations and responses.

Playbook Structure

The playbook follows the seven USG Stages of Response (0-6), and tiers decisions and actions according to those stages, their related containment, and/or control strategies.  Categories of actions include the following:

• Planning and Coordination
• International Containment
• Vaccines and Antivirals
• Domestic Surveillance, Laboratory Measures, and Disease Investigation
• Healthcare Infrastructure
• Ports of Entry Operations
• External Communications

This ESF 8 Pandemic Influenza playbook is prepared in accordance with the National Response Framework and associated federal authorities and documents. It is prepared in six major sections including;  a hypothetical but plausible scenario; a relevant concept of operations (CONOPS); a playbook consisting of a table of operational actions and issues; a compendium of playbook decision papers (designed to provide planners and responsible officials with suggested actions at critical decision point junctures) and briefing papers (designed to provide guidance and action steps toward the implementation of  mitigating strategies); Essential Elements of Information associated with the action steps and issues; and finally a section on the Pre-Scripted Statements of Work (PSSWs) designed to call attention to the interagency coordinating activities. Finally, a list of acronyms is provided.  Definitions of playbook terms are provide below to acquaint planners with the context of this playbook.   

• Scenario:  The pandemic influenza scenario is an account or synopsis of a projected series of events and situations. Scenario development is used in policy planning within the Department of Health and Human Services in an effort to set the conditions for conventional thought on how the department would approach, plan for, and possibly test strategies against uncertain future developments. The purpose of the pandemic influenza scenario is to help understand different ways that future events could unfold. This scenario should not be used to forecast future events but rather is offered a plausible story line to account of possible future events leading toward pandemic influenza as depicted in National Planning Scenario #3 Biological Disease Outbreak– Pandemic Influenza.
• CONOPs:  The Concept of Operations (CONOPs) evolves from a vision of actions and events and is a description (or graphic depiction) of how a set of capabilities may be employed to achieve desired objectives or a particular end state for a pandemic influenza scenario. CONOPs take into account the steps and procedures that may be found in a local, State, Territory, Tribe, Region and Federal response plans for pandemic influenza. CONOPs incorporate the synchronized activities and capabilities under consideration and add the resource management details of how and where resources may be applied to achieve desired mitigating outcomes. The CONOPs of this playbook does not describe how to conduct preparedness activities but merely serves as a discussion point for Federal, Regional, Tribe, Territory, State and local planners to use as a baseline for a coordinated preparedness effort.
• Action/Issues:  This section refers to the actions and issues associated with each phase of the event, further segmented by functional activity.  Functional Activities include; Planning and Coordination, Surveillance, Healthcare Infrastructure, and Communications/Outreach. The actions steps and issues are the heart of this document and not only outline the steps necessary to achieve interagency coordination effects for the pandemic response but also assigns lead and supporting government agency responsibilities.
• Decision Papers:  The Decision Papers are a collection of issues and recommended actions that require specified critical decisions on the part of the Secretary, Department of Health and Human Services or other Federal agencies.  The contents of the briefing decision papers are the result of coordinated insights provided by interagency subject matter experts (SMEs) and are intended as a support to decision-making.  The format includes the recommended Lead and Supporting Agencies, Discussion Points and Recommendations for action.
• Briefing Papers:  Briefing papers represent a coordinated view on specified activities and actions. They are designed to provide the reader with background information and professional insights on mitigating strategies to achieve positive outcomes in a pandemic influenza  response.  The contents of the briefing papers are the result of coordinated insights provided by interagency subject matter experts (SMEs).  The format includes the recommended Lead and Supporting Agencies, Discussion Points and a Summary.
• Essential Elements of Information (EEI):  EEI are those critical items of information needed to accurately respond to circumstances surrounding an event. EEI provide decision makers at all levels of authority insight into how and where resources should be applied to achieve maximum benefit to the general population in easing suffering or protecting infrastructure. In this playbook, information requirements are derived as they relate to the preparedness and response activities for pandemic influenza. For instance, critical information on the case fatality rate may have an effect on how HHS and health departments manage the pandemic.
• Pre-Scripted Statements of Work for ESF #8 (PSSWs):  PSSWs are defined as those coordinated critical tasks that must be performed with or by other departments and agencies in the federal government.  Representative departments and agencies are supporting entities within ESF #8.  ESF #8 federal supporting agencies include: the Departments of Agriculture, Defense, Energy, Homeland Security, Interior, Justice, Labor, State, Transportation, Veterans Affairs, and agencies including Environmental Protection, General Services Administration, U.S. Agency for International Development, U.S. Postal Service, and the American Red Cross.

The USG Stages are highlighted in blue, while the U.S. response strategies are highlighted in purple. It is assumed that actions are continous, from one Stage to the next, and are not repeated in subsequent sections, unless otherwise noted.  The order of actions within each stage is not listed chronologically as many actions will be undertaken simultaneously.

Pandemic Influenza Overview

The Disease

Influenza pandemics occur unpredictably, with three occurring in the past century (1918-1919, 1957-1958 and 1968-1969). Influenza pandemics may occur when a new influenza A virus subtype emerges and causes infection in people (termed “genetic shift”).  If this new virus subtype spreads efficiently between people it can cause a pandemic.  Rates of influenza illness, as well as its severity, are likely to be high because most, if not all, of the human population will be susceptible, having had no prior exposure and, thus, no immunity to this new influenza subtype.  In addition, persons not generally at high risk may develop severe or fatal disease. 

Experience with influenza pandemics during the 20^th century varied markedly: in the United States the 1918 pandemic caused over 500,000 deaths; the 1957 pandemic caused about 70,000 deaths; and the 1968 pandemic caused about 34,000 deaths. The pandemics arrived in “waves.” Each wave lasted approximately three months with spring, fall and winter waves in 1918-19 and fall and winter waves in 1957-58.  A pandemic impacts on health, society and economic functions, and pandemic response activities will differ quantitatively and qualitatively for moderate and severe pandemic scenarios.  Optimal preparedness requires considering responses for both moderate and severe pandemics.  The scenario to be presented here (based on the one used in the Catastrophic Assessment Task Force/CATF exercise of December 2005) will be similar in severity to that of the 1918 pandemic. No predictions can be made on the relative likelihood of a more or less severe pandemic occurring.

Table 1: Projected Number of Episodes of Illness, Healthcare Utilization, and Death Associated with Moderate and Severe Pandemic Influenza Scenarios*

* Estimates based on extrapolation from past pandemics in the United States.   Note that these estimates do not include the potential impact of interventions not available during the 20th century pandemics.

** At the present time, there are only 60,000 ICU beds in the United States, with an average utilization rate of around 85%, resulting in an available surplus of only 9000 beds.

The Threat

The current outbreak of disease caused by the H5N1 strain of the influenza A virus in Asia, Europe, and Africa poses an unprecedented threat to wild birds and poultry and carries the potential for the emergence of a human pandemic strain of influenza virus. 

Avian influenza (AI) is an infectious disease of birds caused by type A strains of influenza virus.  These viruses are naturally found in certain species of waterfowl and shorebirds; such birds are considered to be the natural reservoirs of all AI viruses.  AI viruses are classified on the basis of two proteins, hemagglutinin (H) and neuraminidase (N), found on the surface of the virus.  Specific viral subtypes have one of 16 different H proteins and one of 9 different N proteins, resulting in 144 possible combinations or subtypes based on this classification scheme.

All birds are thought to be susceptible to AI virus infection.  AI viruses are further classified as either highly pathogenic AI (HPAI) or low pathogenic AI (LPAI) based on the genetic features of the virus and the severity of disease in poultry.  While most AI viruses are LPAI and usually result in mild or symptomatic infections, HPAI viruses are associated with very high morbidity and mortality rates in poultry of up to 90 to 100 percent.

Since 2003, the occurrence of HPAI, subtype Asian H5N1, has raised concern regarding the potential impact on the United States’ human health, domestic poultry, and wild bird populations. Numerous routes exist for the introduction of the virus into the United States, including legal and illegal movement of domestic or wild birds, movement of infected travelers, contaminated products, acts of bioterrorism, and the migration of infected wild birds. 

All type A influenza viruses are genetically labile and constantly change as they replicate in the infected hosts, which can be either humans or animals.  As a result of these changes, the existing strain of virus is replaced by a new antigenic variant in a process referred to as “antigenic drift.”  Influenza mixes with other viruses (reassortment), resulting in a novel subtype in a process known as “antigenic shift.”  Historically, antigenic shift has resulted in human pandemics that cause significant mortality.

It is thought that during 1995 and 1996, antigenic drift occurred in an AI virus of wild birds, allowing the virus to infect chickens in China.  This development was followed by reassortment into the HPAI virus subtype Asian H5N1.  Since that time, this highly pathogenic H5N1 has been circulating in Asian poultry and domestic fowl, resulting in significant mortality in these species.  Asian H5N1 likely underwent further antigenic drift and shift, allowing infection in additional species of birds as well as in mammals and humans.  More recently, this virus moved back into wild birds, resulting in significant mortality of species such as bar-headed geese, brown-headed gulls, black-headed gulls, ruddy shelducks, and great cormorants in China during April 2005.