“Although pandemics occur infrequently, planning and preparing for a pandemic is important to ensure an effective response. Planning for and responding to a pandemic is complex and pandemics can affect everyone in a community. Therefore, public health officials, health care professionals, researchers and scientists in the United States and across the world are working together to plan and prepare for possible pandemics. Many resources are available to help international, national, state and local governments, public health and health care professionals, corporations, and communities develop pandemic preparedness plans and strengthen their capabilities to respond to different pandemic scenarios”
( Fig. 16.1 ).
The Continuum of Pandemic Phases With Indicative World Health Organization Actions
Pandemic Planning and Preparedness
Emergency preparedness and pandemic planning are continuous processes that require a commitment of resources including time, funding, and personnel, as well as political will ( Fig. 16.2 ). This is an evolving space with increasing information to guide stakeholders to work together to plan and implement priority actions when needed.
Every sovereign national state has the obligation to develop a strategy for a pandemic response and ensure its own emergency preparedness planning (International Health Regulations clearly describe responsibilities), which is a continuous effort. Nevertheless, epidemic and pandemic planning is a multinational and multisectoral endeavor requiring coordination among governments and international partners to address public health risks.
A pandemic transcends common public health boundaries and affects all sectors. Societies and economies are impacted in multiple ways, which can increase poverty and instability. The Sendai Framework for Disaster Risk Reduction may be used to (1) understand disaster risk, (2) strengthen crisis management, (3) guide risk-reduction investment, and (4) enhance preparedness; it includes biological hazards such as epidemics and pandemics to help reduce mortality, increase early warning, and promote the safety of health facilities and hospitals.
Epidemic risk indicators need to include refugees and migrants living in overcrowded camps, especially in or near areas with emerging epidemics. For example, recent migrations from East Africa to Yemen were associated with a cholera outbreak facilitated by several risk factors.
Epidemic planning must be grounded on evidence-based outbreak response, lessons learned, and preparedness exercises.
As the World Health Organization (WHO) emphasizes: “No single agency or organization can prepare for a pandemic on its own. Inadequate or uncoordinated preparedness of interdependent public and private organizations will reduce the ability of the health sector to respond during a pandemic. A concerted and collaborative effort is required by government ministries, businesses and civil society to sustain essential infrastructure and mitigate impacts of pandemic influenza on health, the economy and the functioning of society.”
Pandemic preparedness plans at national or international level address five key interconnected areas: (1) strategic planning, which requires political commitment to implement into action, (2) subnational planning to create actionable plans and a defined, established network, (3) testing those plans through exercises and proofs of concept, (4) implementing the knowledge in training and emergency response, and (5) continuously analyzing and evaluating processes to feed best practices and learn.
WHO. A strategic framework for emergency preparedness. Available at: www-who-int.easyaccess2.lib.cuhk.edu.hk/ihr/publications/9789241511827/en/.
Preparation of the Responders—Individuals and Teams
Responders to a pandemic or other humanitarian event frequently come together as rapidly formed multidisciplinary teams from different countries and cultures. Working effectively as a team can be challenging in a familiar environment with usual partners, let alone after arrival in a new environment with rapid introductions to new colleagues. As humanitarian responses frequently involve large numbers of national and international actors, coordination and collaboration can be challenging. Failures to work effectively together with a united vision and agreed path can lead to duplication of efforts or gaps in coverage. However, if different organizations align too closely to improve coordination, there is the risk of losing options and innovation. Finding a balance to improve effectiveness and efficiency while retaining the ability to debate and explore avenues of response can be challenging. In the deployed situation, although external assistance may be required and requested, it is also important to remember that every person sent to a situation needs logistical support. Hence, coordinating inbound personnel is required not just to ensure the right skills are being imported, but also to adequately support additional staff without stressing an already fragile situation.
Individual and team effectiveness are optimized by:
Being prepared and field-ready by attending appropriate deployment training and managing expectations for accommodation and support.
Seeking terms of reference ahead of deployment to ensure a good match with your skill set.
Upon arrival, checking in with the team and identifying partners with whom you will be working (and learning their roles). Identifying and addressing overlaps and gaps.
Being adaptable because of the dynamic nature of the environment. Focusing on the outcomes and considering alternative methods to achieve them.
Responders often deploy individually through mechanisms such as the Global Outbreak Alert and Response Network (GOARN) or other country-registered rosters, such as UK-MED. However, in addition to rosters to fill individual billets, mechanisms exist to deploy preformed teamed. Emergency medical teams (EMTs) are an important part of the global health workforce, with a historical focus on trauma and surgery. More recently, EMTs have evolved to provide support in outbreak response. EMTs provide time-limited surge clinical capacity for affected populations. The WHO has developed a global verification system for EMTs to ensure that deployed teams meet the minimum required standards to provide quality of care that is appropriate for the context. This enables a country, when affected by a disaster or other emergency, to call on teams that have been classified at a predefined capability level.
Deployers must seek to integrate local staff—nurses, doctors, medical students, other healthcare workers—into the response team. This creates opportunities to increase local capability and capacity, a critical legacy after the event has ended. This also helps countries more effectively lead future disaster responses, even if they request external assistance.
The Sphere Handbook (2018) guidelines provide a holistic approach to reducing public health risks, prevent disease transmission, and control disease outbreaks. Implementing hygiene standards and ensuring access to safe water help prevent outbreaks in communities. Adherence to those standards resulted in very few cholera cases in the crowded internally displaced person camps despite nearby outbreaks in Haiti (2011) and South Sudan (2014).
GOARN has created “Go.Data” to assist outbreak investigations; it facilitates field data collection during public health emergencies and has been successfully used in several African nations. This tool supports national public health surveillance systems which may be disrupted in crises ( Fig. 16.3 ). Go.Data collects digital data, facilitates contact follow-up, helps visualize chains of transmission including secure data exchange, and analyzes and communicates in real-time to enable better decision-making for emergency public health and outbreak responders.
The Health Cluster Handbook , currently under revision, provides several planning considerations and assessments, which include other tools such as the WHO’s Early Warning, Alert, and Response System (EWARS) and initial assessment reports from different organizations.
Active Learning Network for Accountability and Performance (ALNAP), a global network of nongovernmental organizations (NGOs), United Nations (UN) agencies, members of the Red Cross/Crescent Movement, donors, academics, networks, and consultants, hosts a library of evaluations of humanitarian action, making available knowledge and evidence from previous responses to assist future responses and responders. See: www.alnap.org/about
OpenWHO is the WHO’s interactive, web-based knowledge transfer platform and provides online courses on response to health emergencies. OpenWHO also serves as a forum for the sharing of public health expertise and discussion on key issues. See: openwho.org
RedR Australia is an international humanitarian response agency that provides training for potential field workers. RedR Australia also manages a roster of deployable technical specialists. See: www.redr.org.au/training-courses/our-courses/
GOARN is a WHO network of over 250 technical institutions and networks globally that respond to acute public health events with the deployment of staff and resources to affected countries. GOARN is coordinated by an operational support team based at the WHO headquarters in Geneva and is governed by a steering committee. See: extranet-who-int.easyaccess2.lib.cuhk.edu.hk/goarn/
UK-MED is a UK-based registered charity that trains experienced doctors, nurses, paramedics, midwives, and other health professionals to respond to disasters around the world and to work with local emergency medical teams with a view to building their resilience to future threats. See: www.uk-med.org
Scope Out the Health System Capacity and Location
Humanitarian disasters often affect already-stressed health systems with capacity gaps and endemic health challenges. However, underresourced institutions and facilities can become invaluable pillars in an outbreak response when provided support. Deployed infection prevention and control (IPC) teams should work with host institutions to help appropriate IPC. Host staff should be provided supplementary skill training if needed to ensure they are prepared to safely work in the environment. For example, during the 2014 to 2015 Ebola outbreak in West Africa, healthcare workers were provided with targeted relevant training in IPC to protect their health and ability to care for others.
An example of epidemic mapping during a complex emergency is Haiti in 2010. The nation’s largest cell phone provider was able to anonymously track the movements of several million of mobile phones to inform their customers if they entered a cholera-contaminated area and simultaneously provide them advice on how to protect themselves. The methodology behind this “Flowminder” can be used to slow spread during the opening phases of an epidemic when the outbreak is potentially limited to a small area. Mapping and tracking health facility staffing, bed numbers, available services, and medical supply chain help determine capacity during a disaster response.
Health Cluster Guide: www-who-int.easyaccess2.lib.cuhk.edu.hk/hac/network/global_health_cluster
Strengthening Laboratory Support
Public health laboratories and pathology services are critical. Without the ability to provide laboratory testing of clinical samples, illnesses may be misdiagnosed and diseases newly circulating in a community may be missed. Under the 2005 International Health Regulations, member states are required to strengthen their ability to detect, assess, respond to, and report public health events. Detection of public health events requires credible and accessible laboratory services capable of providing reliable results in a timely manner.
However, in many low- and middle-income countries, laboratories remain underresourced. Many laboratories lack the capacity to do the necessary testing for endemic infectious diseases, let alone novel or rapidly expanding ones.
If one does not already exist, creation of a quality management system that complies with the requirements of the international quality standard (ISO 15189) represents a meaningful form of support. The WHO provides a range of tools developed in collaboration with the US Centers for Disease Control and Prevention (CDC) and the Clinical and Laboratory Standards Institute (CLSI) to support laboratories, suitable for low-, middle-, and upper-income countries, and includes an assessment tool, a quality manual handbook and template, and a laboratory quality implementation tool. This last tool is a website that provides a stepwise plan for laboratories to implement a quality management system in compliance with ISO 15189. These resources are free and available, some in multiple languages, at: www-who-int.easyaccess2.lib.cuhk.edu.hk/ihr/capacity-strengthening/laboratory-improvement/en/.
Improving laboratory capacity during a public health event often involves supporting and expanding the capacities of existing laboratories, reinforcing sample transport systems for testing in reference laboratories, and potentially establishing mobile laboratories provided by international partners.
During crises, countries need to increase diagnostic testing capacity to evaluate probable cases but should also, when possible, include sentinel surveillance for asymptomatic cases. For many low- and middle-income countries, this requires assistance from major clinical diagnostic companies to produce reagents and testing kits at a large scale. Supply chains need to be agreed upon, funded, and operational. When public health events occur simultaneously in multiple countries, supply chains are at higher risk of disruption. Stakeholders should work during noncritical periods to build sustainable testing programs that are less vulnerable during stress.
Rapid point-of-care tests can be very useful, especially for countries with limited formal lab capacity. However, sensitivity and specificity parameters need to be well understood and appropriate to provide meaningful information.
For more information from WHO on diagnostic test selection:
For more information on laboratory quality management, regulation, biosafety, policy, and strategy: www-who-int.easyaccess2.lib.cuhk.edu.hk/in-vitro-diagnostic/en/
For an overview of requirements for establishing good quality public health laboratory services, consider reading:
Establishment of Public Health Laboratories in South East Asia, available at: apps-who-int.easyaccess2.lib.cuhk.edu.hk/iris/handle/10665/274288
Laboratory Professionals in Africa: The Backbone of Quality Diagnostics, available at: documents.worldbank.org.easyaccess2.lib.cuhk.edu.hk/curated/en/419941468010480283/Laboratory-professionals-in-Africa-the-backbone-of-quality-diagnostics
For information on rapid malaria diagnostic tests, refer to:
Crisis Communication and Social Mobilization
“The right message at the right time from the right person can save lives.” Barbara Reynolds, CDC Senior Crisis and Risk Communication Advisor.
The six key principles for effective crisis communication to build trust, rapport, and cooperation with the public (Crisis and Emergency Risk Communication [CERC], CDC) are:
Be first: communicating information quickly is crucial to engage members of the public with you as the source of information.
Be right: ensure credibility by delivering accurate information, including expressing what is not known and how these knowledge gaps are being addressed.
Be credible: always seek to be honest and truthful. Use recognized, respected people and provide clear messaging.
Express empathy: acknowledge the challenges that members of the public are facing.
Promote action: engage the community in meaningful actions. Utilize social mobilization to promote their sense of control over their situation.
Show respect: being respectful builds promotes cooperation with the public.
A related and equally important element of outbreak response is social mobilization. Social mobilization is the process of bringing together societal influences to raise awareness of a healthcare issue. Social mobilization becomes particularly important during outbreak response and can be a powerful tool to create necessary changes in societal behaviors. Good social mobilization empowers communities and their social networks to address and adjust behaviors and to be proactively involved in the outbreak response. Good social messaging can be used to instill in the community feelings of trust and respect for healthcare workers and to generate support for the response.
Some elements to consider when planning social mobilization activities include:
Engage with religious leaders and build space for respectful dialogue around cultural beliefs. Find ways to incorporate scientifically valid messaging while respecting the importance of cultural beliefs and practices.
Work with community elders to establish engagement with communities.
Consider the education sector in particular schools. Children absorb information and take it home to their families.
Use social media such as Instagram and Twitter, in addition to television and radio, to provide health messages in line with national public health recommendations. This can reach many more members of the community than might otherwise be reached using only official websites and traditional media.
The CERC (CDC) program provides trainings, tools, and resources to help health communicators, emergency responders, and leaders of organizations communicate effectively during emergencies. Available at: emergency.cdc.gov/cerc/index.asp
CDC’s CERC Manual: emergency.cdc.gov/cerc/manual/
WHO Guideline for Emergency Risk Communication: www-who-int.easyaccess2.lib.cuhk.edu.hk/risk-communication/guidance/download/en/
Risk Communication and Community Engagement (RCCE): reliefweb.int/report/world/risk-communication-and-community-engagement-rcce-action-plan-guidance-covid-19
Predeployment Considerations: Suggested Packing Items
Deploying as part of a rapid response team often entails many unknowns. Situation reports may not provide useful information for packing. Reaching out to those already in the country can help gauge what resources will be available and what might need to be brought.
Although one should be as prepared as possible, packing lightly facilitates agility, especially if it is carried on, versus checked luggage, which is vulnerable to delay or becoming lost.
If you can bring supplies for colleagues, endeavor to do so—this can mean at minimum a morale boost, and may also have significant operational impact. Also consider bringing useful supplies for the local population. Seek advice from colleagues in the country before doing this and be mindful of what you bring in—local staff should know best what to recommend and how to distribute the items without creating unintended issues.
The following items may be useful you in a deployed setting:
10 m of rope with a pegs/clothes pins (useful as washing line or for securing items)
Small external speaker
Silk or cotton liner in the event that you are unexpectedly billeted in a location where bed linen is not provided
Head lamp with new batteries
Door stop (for extra security or in the event that there is no working lock on your door)
First aid kit with thermometer (with new batteries) and clear safety glasses
1 L (32 oz) clear water bottle and water purification tablets and/or small water filter—this can reduce plastic waste as well as consumption of community safe drinking water, which may be in limited supply for the local population.
Appropriate power adapter
Duct tape (good for making repairs to damaged luggage or tarpaulins)
Buff headband or similar—can be a neck warmer, eye shield for sleeping, or backup mask for decreasing respiratory transmission of pathogens
Reading device or books. Taking books means that you can share with others or opt to leave them behind to form a small library.
Watch—a “smart” watch can provide a lot of information but will require charging and may be expensive if damaged or lost. Alternatively, a simple splashproof analog watch with date and time (e.g., a Swatch) will be robust enough for most situations and will not require reliable power.
Partnering With the Local Workforce
There are several reasons to seek to employ the local workforce to advance pandemic goals. First, visiting emergency personnel create additional logistical demands. Second, local personnel best understand their culture and history and typically are able to gain trust more quickly with patients. Third, local citizens will have to manage the situation long after the visiting team has departed. Contact tracing is especially well-suited for this aim. It is resource-intensive, but during disruptive events like pandemics, there will likely be a ready supply of trainable individuals who are highly motivated to effect change.
Prioritize real estate for quarantine, especially for isolation patients in camp settings
Define your plan for expansion in advance and walk through the implications
Prioritize case definition and criteria, as well as testing protocols
Maintain good version control of data and latest guidance/tools for data collection
Begin intersectoral discussions early on, as soon as you realize a situation is heading toward a possible epidemic
Standardize contact tracing protocols
Decide early on who has what authority, especially for managing quarantine versus isolation issues
Understand operational needs of community—what needs to go on, and how can this be accommodated.
Clear communication—work closely with public affairs and media
Low threshold for protective measures
Maintain communication with frontline medical leaders
Lead with confidence, balance, compassion, and equanimity
Build relationships ahead of time
Medical personnel lead by example
Clear communication with outside populations regarding expectations for movement into and out of your area
When facing crises such as pandemics, many people—including leaders—move through the five stages of grief. Logic and data alone are not always adequate to persuade, but must still always be involved in communication.
Saavedra L, Knox-Clarke P. Working together in the field for effective humanitarian response. ALNAP Working Paper. London: ALNAP/ODI [Online]; 2015. Available at: www.alnap.org/system/files/content/resource/files/main/alnap-30-am-paper-working-together.pdf .