Topic Collection Cover Page

Influenza Epidemic/ Pandemic
Topic Collection
October 10, 2019

Topic Collection: Influenza Epidemic/ Pandemic

In 2009, the world watched as the pandemic influenza A (H1N1) virus circulated the globe. Many emergency departments, clinics, and physician offices were filled with symptomatic patients and the “worried well” as public health and emergency management agencies modified plans to respond to the evolving pandemic by delivering risk communications to the public, establishing mass vaccination clinics, and distributing personal protective equipment (PPE) and other supplies to protect worker safety. Since that time, the healthcare system has been incorporating lessons learned from the 2009 H1N1 response into continued pandemic influenza planning efforts. New technology in detection, advances in treatment, improved PPE and containment equipment, updated protocols on how to deal with highly infectious diseases, and experience responding to seasonal influenza outbreaks and other large-scale infectious disease outbreaks have all contributed to a more robust capability to respond to the next pandemic. The threats have also grown – an increasing number of novel influenza viruses have demonstrated the ability to occasionally infect humans. The resources included in this Topic Collection can help healthcare professionals and emergency medical planners prepare for the next influenza epidemic or pandemic. It is important to note how important strong healthcare coalitions with tiered response strategies and coordinated incident management are to an effective pandemic influenza response.

ASPR TRACIE has developed several additional Topic Collections with content relevant to specific aspects of epidemic and pandemic influenza planning; they are listed below.

Alternate Care Sites

Crisis Standards of Care

Disaster Ethics

Fatality Management

Healthcare-Related Disaster Legal/Regulatory/Federal Policy

Hospital Surge Capacity and Immediate Bed Availability

Medical Countermeasure

Non-Pharmaceutical Interventions

Pharmacy

Resource Management

Responder Safety and Health

Virtual Medical Care

 

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category. 

Must Reads


American Academy of Family Physicians. (2015). Pandemic Influenza - Clinical Considerations.
This document provides an overview of clinical considerations for pandemic influenza, including sections on immunization, surveillance, reporting, prevention, diagnosis, testing indications and types, treatment, and isolation and quarantine. It also includes information on limiting transmission when managing patients at home.
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Appiah, G., Chaves, S., Kirley, P., et al. (2017). Increased Antiviral Treatment Among Hospitalized Children and Adults with Laboratory-Confirmed Influenza, 2010-2015. Clinical Infectious Diseases. 64(3):364-367.
The authors analyzed surveillance data of hospitalized patients from the 2010-11 through the 2014-15 influenza seasons to determine the use of antiviral treatment. They found that antiviral treatment of hospitalized influenza patients increased from 72% in the 2010-11 season to 89% in the 2014-15 season. They also found that 45% of patients admitted within two days of illness onset, when the clinical benefit of antiviral treatment is known to be greatest, did not receive antiviral treatment on their day of admission.
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ASPR TRACIE. (2017). Avian Influenza (Including Asian H7N9): Resources at Your Fingertips. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This document provides healthcare system and public health preparedness professionals, emergency managers, and other stakeholders with resources and information to consider when improving their readiness for potential human infections with avian influenza A viruses.
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ASPR TRACIE. (2017). EMS Infectious Disease Playbook. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This playbook synthesizes multiple sources of information in a single planning document addressing the full spectrum of infectious agents to create a concise reference resource for emergency medical services (EMS) agencies developing their service policies. The information can be incorporated into agency standard operating procedures and reviewed by the EMS medical director.
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  • Tracy Miller Is there any way to order a printed and bound version?
    8/9/2018 5:16:09 PM
ASPR TRACIE. (2019). Healthcare Coalition Influenza Pandemic Checklist. U.S Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This planning tool is intended to assist health care coalitions and their partners in assessing their preparedness for an influenza pandemic. It may also be used to orient the response as a pandemic begins. This checklist can help healthcare coalitions assess, create, and improve their pandemic preparedness and response plans.
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Bessesen, M., Adams, J., Radonovich, L., and Anderson, J. (2015). Disinfection of Reusable Elastomeric Respirators by Health Care Workers: A Feasibility Study and Development of Standard Operating Procedures. American Journal of Infection Control. 43(6): 629-634.
This article describes a Department of Veterans Affairs feasibility study on the ability of personnel to safely disinfect respirators under pandemic conditions by following standard operating procedures.
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Bui, C., Chughtai, A., Adam, D., and MacIntyre, C. (2017). An Overview of the Epidemiology and Emergence of Influenza A Infection in Humans Over Time. Archives of Public Health. 75:15.
The authors reviewed the epidemiology and emergence of all influenza A serotypes known to cause human infection. They found an increase in recent years in the emergence of avian influenza viruses causing infections in humans and suggest a variety of measures to prevent the emergence of zoonotic disease.
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Centers for Disease Control and Prevention. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). U.S. Department of Health and Human Services.
This document provides infection control guidelines for healthcare settings across the continuum of care. It is intended to inform the development, implementation, and evaluation of infection control and prevention programs in healthcare settings.
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Centers for Disease Control and Prevention. (2016). Influenza Risk Assessment Tool (IRAT). U.S. Department of Health and Human Services.
This tool was developed by the Centers for Disease Control and Prevention and other influenza experts to assess the risk of a human pandemic emerging from influenza A viruses currently circulating in animals. The IRAT uses 10 weighted evaluation criteria to assess the risk of both emergence and public health impact and to classify each virus as low, moderate, or high risk.
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Centers for Disease Control and Prevention. (2016). Pandemic Influenza Triage Tools. U.S. Department of Health and Human Services.
This toolkit consists of a Pandemic Influenza Triage Algorithm to triage patients with influenza-like illness, a Community Site-of Care Tool to determine the appropriate care site for patients based on the Pandemic Influenza Triage Algorithm, and the Community Healthcare Decision Pathway to assess resource and medical surge to determine appropriate care sites.
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Centers for Disease Control and Prevention. (2019). How is Pandemic Flu Different from Seasonal Flu? U.S. Department of Health and Human Services.
This webpage lists commonly-asked questions about influenza and contrasts answers for seasonal influenza with pandemic influenza.
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Chest Care of the Critically Ill and Injured During Pandemics and Disasters Panel. (2014). Care of the Critically Ill and Injured During Pandemics and Disasters: Chest Consensus Statement. Chest Journal. 146(4), Supplement:p1S-41S, e1S-e177s.
This supplement to Chest Journal includes several articles composing a consensus statement of the American College of Chest Physicians on the care of the critically ill and injured during pandemics and disasters. Individual articles focus on the following: Introduction and Executive Summary; Methodology; Surge Capacity Principles; Surge Capacity Logistics; Evacuation of the ICU; Triage; Special Populations; System-Level Planning, Coordination, and Communication; Business and Continuity of Operations; Engagement and Education; Legal Preparedness; Ethical Considerations; and Infrastructure and Capacity Building and Response, Recovery, and Research in Resource-Poor Settings.
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Fain, B., Viswanathan, K., and Altevogt, B. (2012). Public Engagement on Facilitating Access to Antiviral Medications and Information in an Influenza Pandemic - Workshop Series Summary. The National Academies of Sciences, Engineering, and Medicine.
This report summarizes a series of workshops on the public’s perception of how to facilitate access to antiviral medication and treatment during an influenza pandemic.
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Holloway, R., Rasmussen, S., Zaza, S., et al. (2014). Updated Preparedness and Response Framework for Influenza Pandemics. Morbidity and Mortality Weekly Report. 63(RR06):1-9.
This article describes the Centers for Disease Control and Prevention’s revised framework for pandemic influenza preparedness and response. The authors describe the six intervals along the pandemic curve and eight domains used to organize efforts within each interval.
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Infectious Diseases Society of America. (2016). ID-Focused Hospital Efficiency Improvement Program.
This guide for infectious disease physician executives identifies service lines and related metrics to mitigate infectious disease-related issues. The guide addresses four areas: infection prevention and control; antimicrobial stewardship; outpatient parenteral antimicrobial therapy hospital admission/readmission avoidance; and bio-security, bio-preparedness, and emerging infectious diseases.
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Kao, H., Ko, H., Guo, P., et al. (2017). Taiwan's Experience in Hospital Preparedness and Response for Emerging Infectious Diseases. Health Security. 15(2):175-184.
The authors describe Taiwan’s Communicable Disease Control Medical Network, which was established after the 2003 SARS outbreak, and discuss its performance during the 2009 H1N1 influenza pandemic and the West African Ebola outbreak. They discuss similarities with the tiered response system established in the U.S. for Ebola, identify strengths as the establishment of a command system with well-prepared hospitals and trained personnel, and note the challenges of maintaining funding, clarifying the role of local public health authorities, and incentivizing the participation of frontline clinical staff.
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Los Angeles County Emergency Medical Services Agency. (2010). Recommended Actions for Hospitals to Prepare for and Respond to Pandemic Influenza.
This document provides guidelines to hospitals to prepare for an influenza pandemic. It includes a summary of recommended actions and their triggers, checklists, sample response guides, general background information, and links to additional resources.
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New York City Department of Health and Mental Hygiene. (n.d.). Mystery Patient Drill Toolkit. (Accessed 7/5/2019.)
This toolkit is intended for use by hospital emergency departments, and tests how long it takes for a potential patient with a highly infectious disease to be identified and for staff to begin exposure mitigation procedures; how long it takes for a patient to be transferred to an isolation room; and the capability of the facility to make notifications internally and to the health department. The Toolkit includes scenarios for Ebola Virus Disease, Middle East Respiratory Syndrome, and Measles, but may be modified to suit healthcare facilities of any nature and any type of disease outbreak.
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Noah, D. and Noah, J. (2013). Adapting Global Influenza Management Strategies to Address Emerging Viruses. American Journal of Physiology - Lung Cellular and Molecular Physiology. 305(2):L108-L117.
The authors provide an overview of influenza and discuss epidemiology and surveillance, perspectives on vaccines and antivirals, and research opportunities related to universal vaccine, alternate vaccine production strategies, novel antiviral development, and continued transmission studies.
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Occupational Safety and Health Administration. (2014). Protecting Workers During a Pandemic. U.S. Department of Labor.
This fact sheet provides guidance on workplace practices related to pandemic influenza.
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Qualls, N., Levitt, A., Kanade, N., et al. (2017). Community Mitigation Guidelines to Prevent Pandemic Influenza - United States, 2017. Morbidity and Mortality Weekly Report. 66(1):1-34.
These guidelines update Centers for Disease Control and Prevention recommendations on the use of non-pharmaceutical interventions to slow the spread of infectious respiratory diseases, including influenza.
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Reed, C., Biggerstaff, M., Finelli, L., et al. (2013). Novel Framework for Assessing Epidemiologic Effects of Influenza Epidemics and Pandemics. Emerging Infectious Diseases. 19(1):85-91.
This article describes the Centers for Disease Control and Prevention’s framework for classifying pandemic severity. The authors describe the four-step process used to develop the framework and how it can be used for an initial assessment in the early stages of a pandemic and a refined assessment once additional data become available.
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The authors review influenza pandemics throughout history to describe the changing knowledge of the virus and efforts to manage outbreaks. Given the unpredictable nature of when the next pandemic will occur, they encourage continued surveillance, coordination, and resource planning to mitigate risks.
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Smith, L., D'Antoni, D., Jain, V., et al. (2016). A Systematic Review of Factors Affecting Intended and Actual Adherence with Antiviral Medication as Treatment or Prophylaxis in Seasonal and Pandemic Flu. Influenza and Other Respiratory Viruses. 10(6):462-478.
The authors reviewed literature published through 2015 to identify factors influencing adherence to antivirals as prophylaxis or treatment for influenza, both seasonal and pandemic. The incidence of adverse side effects was the most common predictor of actual and intended adherence. Other predictive factors include knowledge about influenza risk factors, risk perceptions on the severity of and vulnerability to the outbreak, and beliefs about side effects or effectiveness of pharmaceuticals. These findings can inform both conversations between providers and individual patients and the development of public risk communication campaigns.
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This report examines early lessons learned by the healthcare system from the response to the 2009 H1N1 pandemic and highlights ongoing concerns about overall U.S. preparedness for potential outbreaks.
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U.S. Department of Health and Human Services. (2017). Pandemic Influenza Plan: 2017 Update.
This updated plan builds upon the 2005 Pandemic Influenza Plan and its subsequent updates, focusing on the seven domains of: surveillance, epidemiology, and laboratory activities; community mitigation measures; medical countermeasures; health care system preparedness and response activities; communications and public outreach; scientific infrastructure and preparedness; and domestic and international response policy, incident management, and global partnerships and capacity building.
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This document provides recommendations, best practices and principles for infection prevention and control for acute respiratory infections in health care, particularly those that present as epidemics or pandemics. It includes information on PPE and aerosol-generating procedures. There are also summaries of literature and research reviews on physical interventions for infection control; risk of transmission from aerosol-generating procedures; and effectiveness of vaccination of health care workers to protect patients.
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Antiviral Treatment


Appiah, G., Chaves, S., Kirley, P., et al. (2017). Increased Antiviral Treatment Among Hospitalized Children and Adults with Laboratory-Confirmed Influenza, 2010-2015. Clinical Infectious Diseases. 64(3):364-367.
The authors analyzed surveillance data of hospitalized patients from the 2010-11 through the 2014-15 influenza seasons to determine the use of antiviral treatment. They found that antiviral treatment of hospitalized influenza patients increased from 72% in the 2010-11 season to 89% in the 2014-15 season. They also found that 45% of patients admitted within two days of illness onset, when the clinical benefit of antiviral treatment is known to be greatest, did not receive antiviral treatment on their day of admission.
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* Centers for Disease Control and Prevention. (2011). Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report. 60(RR01):1-24.
This report provides recommendations for treatment and chemoprophylaxis of influenza virus infection. The authors identify populations at greater risk of complications, identify major changes from previous recommendations, describe the mechanism of virus transmission and the clinical signs and symptoms of disease, outline the role of laboratory diagnostics, and provide information on the four approved influenza antiviral agents, including their usage, dosage, adverse events, drug interactions, and possible emergency use authorization.
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Centers for Disease Control and Prevention. (2018). Influenza Antiviral Medications: Summary for Clinicians. U.S. Department of Health and Human Services.
This document provides information on antiviral medications recommended for treatment and chemoprophylaxis of influenza, summarizes influenza antiviral treatment recommendations, identifies treatment considerations for patients hospitalized with suspected or confirmed influenza, describes diagnostic testing for influenza, lists recommended dosage and duration of various antiviral agents for pediatric and adult populations, discusses chemoprophylaxis, and highlights special considerations.
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Dobson, J., Whitley, R., Pocock, S., and Monto, A. (2015). Oseltamivir Treatment for Influenza in Adults: A Meta-Analysis of Randomised Controlled Trials. The Lancet. 385(9979):1729-1737.
The authors reviewed individual patient data from nine clinical trials comparing oseltamivir with a placebo as a treatment for seasonal influenza in adults. They found that oseltamivir reduced the time to symptom alleviation, the risk of lower respiratory tract complications, and risk of hospitalization, but increased the risk of nausea and vomiting.
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* Fain, B., Viswanathan, K., and Altevogt, B. (2012). Public Engagement on Facilitating Access to Antiviral Medications and Information in an Influenza Pandemic - Workshop Series Summary. The National Academies of Sciences, Engineering, and Medicine.
This report summarizes a series of workshops on the public’s perception of how to facilitate access to antiviral medication and treatment during an influenza pandemic.
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Heneghan, C., Onakpoya, I., Jones, M., et al. (2016). Neuraminidase Inhibitors for Influenza: A Systematic Review and Meta-Analysis of Regulatory and Mortality Data. Health Technology Assessment. 20(42):1-242.
The authors reviewed regulatory information from 46 trials of oseltamivir and zanamivir for influenza in adults and children. They found that oseltamivir and zanamivir reduce the time to symptom improvement in adults with influenza-like illness. Neither oseltamivir nor zanamivir was found to reduce influenza complications, hospitalizations, or deaths. Oseltamivir increases the risk of nausea, vomiting, and psychiatric events in adults and vomiting in children, but may reduce the risk of diarrhea and cardiac events in adults. The authors found a minimal preventive effect of using oseltamivir or zanamivir as prophylaxis.
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Hurt, A. and Kelly, H. (2016). Debate Regarding Oseltamivir Use for Seasonal and Pandemic Influenza. Emerging Infectious Diseases. 22(6):949-955.
The authors discuss the debate about whether oseltamivir should be stockpiled for an influenza pandemic based on its performance in the treatment of relatively mild illness during seasonal influenza outbreaks.
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Jefferson, T., Jones, M., Doshi, P., et al. (2014). Neuraminidase Inhibitors for Preventing and Treating Influenza in Adults and Children. Cochrane Database of Systematic Reviews.
The authors reviewed available data from randomized, placebo-controlled trials on adults and children with confirmed or suspected exposure to naturally-occurring influenza to determine the effects of neuraminidase inhibitors. They found that two commonly-stockpiled neuraminidase inhibitors – oseltamivir and zanamivir – reduce the time to alleviation of symptoms in adults and that prophylactic use of either drug reduces the risk of developing symptomatic influenza. Neither drug reduced the time to alleviation of symptoms in asthmatic children, and oseltamivir use increased the risk of nausea, vomiting, psychiatric effects, and renal events in adults and vomiting in children.
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Lehnert, R., Pletz, M., Reuss, A., and Schaberg, T. (2016). Antiviral Medications in Seasonal and Pandemic Influenza. Deutsches Arzteblatt International. 113(47):799-807.
This systematic review of randomized and controlled trials and other relevant literature concludes that the benefits of antiviral drugs outweigh their risks. The article summarizes existing public health recommendations and examines research on antiviral prophylaxis and treatment. The authors encourage clinicians to consider the risk profile of patients in some at-risk populations and note the need for additional research on those populations and on the use of antivirals for highly pathogenic influenza viruses.
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Smith, L., D'Antoni, D., Jain, V., et al. (2016). A Systematic Review of Factors Affecting Intended and Actual Adherence with Antiviral Medication as Treatment or Prophylaxis in Seasonal and Pandemic Flu. Influenza and Other Respiratory Viruses. 10(6):462-478.
The authors reviewed literature published through 2015 to identify factors influencing adherence to antivirals as prophylaxis or treatment for influenza, both seasonal and pandemic. The incidence of adverse side effects was the most common predictor of actual and intended adherence. Other predictive factors include knowledge about influenza risk factors, risk perceptions on the severity of and vulnerability to the outbreak, and beliefs about side effects or effectiveness of pharmaceuticals. These findings can inform both conversations between providers and individual patients and the development of public risk communication campaigns.
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Wester, A. and Shetty, A. (2016). Peramivir Injection in the Treatment of Acute Influenza: A Review of the Literature. Infection and Drug Resistance. 9:201-214.
The authors review the literature on the use of peramivir for acute influenza treatment. They found that it is effective against a variety of influenza A and B subtypes and that its injectable form may be favorable for treating critically ill, hospitalized patients. While they found positive results in observational studies in pregnant women, pediatric patients, patients receiving continuous renal replacement therapy, and patients undergoing extracorporeal membrane oxygenation, there is a lack of clinical trials demonstrating the efficacy of peramivir in these populations.
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Education, Training, and Exercises


Federal Emergency Management Agency, Center for Domestic Preparedness. (n.d.). Barrier Precautions and Controls for Highly Infectious Disease. (Accessed 9/30/19.)
This is a four-day course for emergency medical services, healthcare, and public health professionals who may triage, transport, and treat those with a highly infectious disease. Training includes guided discussions of best practices, demonstrations, practical experiences, and exercises.
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These guidelines are intended as a quick reference for just-in-time training and set up of the types of mechanical ventilators included in the Strategic National Stockpile. The guidelines may be used by clinicians with a baseline knowledge of pulmonary physiology and the concepts of ventilation, but who may not be familiar with the stockpiled ventilators or who may not routinely care for children on ventilators.
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The authors studied the feasibility and effectiveness of an interactive, computer-assisted training course designed to build resilience to the stresses of working during a pandemic. They measured confidence in support and training; pandemic-related self-efficacy; coping style; and interpersonal problems, before and after training, and found that the course was associated with improvement in each variable, with the “medium” duration course providing the greatest benefit. The course is free and may be accessed at https://www.msh-healthyminds.com/sv/.
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* New York City Department of Health and Mental Hygiene. (n.d.). Mystery Patient Drill Toolkit. (Accessed 7/5/2019.)
This toolkit is intended for use by hospital emergency departments, and tests how long it takes for a potential patient with a highly infectious disease to be identified and for staff to begin exposure mitigation procedures; how long it takes for a patient to be transferred to an isolation room; and the capability of the facility to make notifications internally and to the health department. The Toolkit includes scenarios for Ebola Virus Disease, Middle East Respiratory Syndrome, and Measles, but may be modified to suit healthcare facilities of any nature and any type of disease outbreak.
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* The Society for Healthcare Epidemiology of America. (2017). Outbreak Response Training Program (ORTP).
This webpage contains links to four free toolkits that were developed to provide healthcare providers immediate access to key infectious disease outbreak information and resources. The toolkits contain guidance on incident management, emerging pathogens, horizontal strategies, communication, negotiation, and implementation. Each toolkit contains checklists, guidance documents, case studies, and fillable tables to meet the planning and response needs prior to or during an infectious disease outbreak.
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Epidemiology and Surveillance


The authors describe a method for predicting the likely impact of an emerging influenza pandemic based on an analysis of data at the household level collected from the first few hundred cases.
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Bui, C., Chughtai, A., Adam, D., and MacIntyre, C. (2017). An Overview of the Epidemiology and Emergence of Influenza A Infection in Humans Over Time. Archives of Public Health. 75:15.
The authors reviewed the epidemiology and emergence of all influenza A serotypes known to cause human infection. They found an increase in recent years in the emergence of avian influenza viruses causing infections in humans and suggest a variety of measures to prevent the emergence of zoonotic disease.
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* Centers for Disease Control and Prevention. (2016). Influenza Risk Assessment Tool (IRAT). U.S. Department of Health and Human Services.
This tool was developed by the Centers for Disease Control and Prevention and other influenza experts to assess the risk of a human pandemic emerging from influenza A viruses currently circulating in animals. The IRAT uses 10 weighted evaluation criteria to assess the risk of both emergence and public health impact and to classify each virus as low, moderate, or high risk.
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* Holloway, R., Rasmussen, S., Zaza, S., et al. (2014). Updated Preparedness and Response Framework for Influenza Pandemics. Morbidity and Mortality Weekly Report. 63(RR06):1-9.
This article describes the Centers for Disease Control and Prevention’s revised framework for pandemic influenza preparedness and response. The authors describe the six intervals along the pandemic curve and eight domains used to organize efforts within each interval.
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* Noah, D. and Noah, J. (2013). Adapting Global Influenza Management Strategies to Address Emerging Viruses. American Journal of Physiology - Lung Cellular and Molecular Physiology. 305(2):L108-L117.
The authors provide an overview of influenza and discuss epidemiology and surveillance, perspectives on vaccines and antivirals, and research opportunities related to universal vaccine, alternate vaccine production strategies, novel antiviral development, and continued transmission studies.
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The authors review influenza pandemics throughout history to describe the changing knowledge of the virus and efforts to manage outbreaks. Given the unpredictable nature of when the next pandemic will occur, they encourage continued surveillance, coordination, and resource planning to mitigate risks.
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Using electronic medical claims data from 2003 to 2010, the authors found that influenza-like illness indicators accurately reflected weekly fluctuations in influenza activity. They suggest that electronic medical claims data can supplement surveillance systems and can be used to provide situational awareness, refine influenza transmission models, and support future pandemic responses.
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General Information


American Academy of Family Physicians. (2015). Pandemic Influenza - Clinical Considerations.
This document provides an overview of clinical considerations for pandemic influenza, including sections on immunization, surveillance, reporting, prevention, diagnosis, testing indications and types, treatment, and isolation and quarantine. It also includes information on limiting transmission when managing patients at home.
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* ASPR TRACIE. (2017). Avian Influenza (Including Asian H7N9): Resources at Your Fingertips. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This document provides healthcare system and public health preparedness professionals, emergency managers, and other stakeholders with resources and information to consider when improving their readiness for potential human infections with avian influenza A viruses.
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Centers for Disease Control and Prevention. (2018). Past Pandemics. U.S. Department of Health and Human Services.
This webpage summarizes the four global pandemics that occurred in the past century and includes links to additional resources on each.
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Centers for Disease Control and Prevention. (2019). How is Pandemic Flu Different from Seasonal Flu? U.S. Department of Health and Human Services.
This webpage lists commonly-asked questions about influenza and contrasts answers for seasonal influenza with pandemic influenza.
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Chest Care of the Critically Ill and Injured During Pandemics and Disasters Panel. (2014). Care of the Critically Ill and Injured During Pandemics and Disasters: Chest Consensus Statement. Chest Journal. 146(4), Supplement:p1S-41S, e1S-e177s.
This supplement to Chest Journal includes several articles composing a consensus statement of the American College of Chest Physicians on the care of the critically ill and injured during pandemics and disasters. Individual articles focus on the following: Introduction and Executive Summary; Methodology; Surge Capacity Principles; Surge Capacity Logistics; Evacuation of the ICU; Triage; Special Populations; System-Level Planning, Coordination, and Communication; Business and Continuity of Operations; Engagement and Education; Legal Preparedness; Ethical Considerations; and Infrastructure and Capacity Building and Response, Recovery, and Research in Resource-Poor Settings.
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Ghebrehewet, S., MacPherson, P., and Ho, A. (2016). Influenza. BMJ. 355.
This web page provides basic information on influenza, including what it is, what the symptoms are, how it is diagnosed and treated, and how epidemics and pandemics occur.
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Iskander, J., Strikas, R., Gensheimer, K., et al. (2013). Pandemic Influenza Planning, United States, 1978-2008. Emerging Infectious Disease. 19(6):879-885.
This article provides a chronology and describes the evolution of pandemic planning since the 1970s.
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Kash, J. and Taubenberger, J. (2015). The Role of Viral, Host, and Secondary Bacterial Factors in Influenza Pathogenesis. The American Journal of Pathology. 185(6):1528-1536.
The authors provide an overview of influenza and describe the viral, host, and bacterial factors that contribute to more severe illness, complications, and mortality.
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Mina, M. and Klugman, K. (2014). The Role of Influenza in the Severity and Transmission of Respiratory Bacterial Disease. Lancet Respiratory Medicine. 2(9):750-763.
The authors review influenza and respiratory bacterial co-infections, describing the historic understanding of such co-infections, disease dynamics and mechanisms, and prevention and treatment strategies.
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National Academies of Sciences, Engineering, and Medicine. (2017). Preparing Airports for Communicable Diseases on Arriving Flights. The National Academies Press.
The authors review current disease preparedness and response practices at airports in the U.S. and Canada with a focus on coordination with public health officers and partners. The emphasize that while larger (international) airports are more likely to face these challenges, the lessons in this document are applicable to the aviation sector as a whole, including smaller airports (which may be the final destination of some travelers with communicable diseases).
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* Noah, D. and Noah, J. (2013). Adapting Global Influenza Management Strategies to Address Emerging Viruses. American Journal of Physiology - Lung Cellular and Molecular Physiology. 305(2):L108-L117.
The authors provide an overview of influenza and discuss epidemiology and surveillance, perspectives on vaccines and antivirals, and research opportunities related to universal vaccine, alternate vaccine production strategies, novel antiviral development, and continued transmission studies.
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Reed, C., Biggerstaff, M., Finelli, L., et al. (2013). Novel Framework for Assessing Epidemiologic Effects of Influenza Epidemics and Pandemics. Emerging Infectious Diseases. 19(1):85-91.
This article describes the Centers for Disease Control and Prevention’s framework for classifying pandemic severity. The authors describe the four-step process used to develop the framework and how it can be used for an initial assessment in the early stages of a pandemic and a refined assessment once additional data become available.
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The authors review influenza pandemics throughout history to describe the changing knowledge of the virus and efforts to manage outbreaks. Given the unpredictable nature of when the next pandemic will occur, they encourage continued surveillance, coordination, and resource planning to mitigate risks.
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Guidance


* ASPR TRACIE. (2017). Avian Influenza (Including Asian H7N9): Resources at Your Fingertips. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This document provides healthcare system and public health preparedness professionals, emergency managers, and other stakeholders with resources and information to consider when improving their readiness for potential human infections with avian influenza A viruses.
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This webpage provides guidance on avian influenza A (H7N9), Asian H5N1, and newly detected avian influenza H5 viruses in the U.S.
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Centers for Disease Control and Prevention. (2019). Interim Guidance for Clinicians on Human Infections with Variant Influenza Viruses. U.S. Department of Health and Human Services.
This document provides interim guidance for clinicians on how to identify, diagnose, report, and manage suspect cases of exposure to variant influenza viruses.
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Centers for Disease Control and Prevention. (2019). Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities. U.S. Department of Health and Human Services.
This webpage provides guidance to long-term care facilities on preventing transmission of influenza through vaccination, testing, infection control, antiviral treatment, and antiviral chemoprophylaxis.
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This document provides guidance for emergency departments and outpatient clinics to develop screening and isolation protocols for patients possibly infected with a highly communicable disease of public health concern. The document focuses on initial patient identification, initial infection control measures, notification and patient evaluation, and identification and management of exposed persons.
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The Center for Health Policy, Columbia University School of Nursing. (2008). Adapting Standards of Care under Extreme Conditions: Guidance for Professionals during Disasters, Pandemics, and Other Extreme Emergencies. American Nurses Association.
This policy paper is intended for professionals in a care giver or service provider role. It includes guidance on ethical principles in emergency care, meeting usual care expectations, and recommendations for emergency event care.
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Based on extensive federal interagency coordination and stakeholder input, the guidance in this document can help those who work in healthcare facilities, medical transportation operations, and laboratories better understand infectious waste and how to manage it.
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This is a summary of a guidance document based on extensive federal interagency coordination and stakeholder input and designed to help those who work in healthcare facilities, medical transportation operations, and laboratories better understand infectious waste and how to manage it. Access the full report at https://www.phmsa.dot.gov/sites/phmsa.dot.gov/files/docs/transporting-infectious-substances/6821/cat-waste-planning-guidance-final-2019-08.pdf.
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Guidelines


These guidelines review data on handwashing and hand antisepsis in healthcare settings and provide recommendations for the promotion of hand hygiene practices and the reduction of pathogen transmission in healthcare settings.
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Centers for Disease Control and Prevention. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). U.S. Department of Health and Human Services.
This document provides infection control guidelines for healthcare settings across the continuum of care. It is intended to inform the development, implementation, and evaluation of infection control and prevention programs in healthcare settings.
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* Centers for Disease Control and Prevention. (2011). Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report. 60(RR01):1-24.
This report provides recommendations for treatment and chemoprophylaxis of influenza virus infection. The authors identify populations at greater risk of complications, identify major changes from previous recommendations, describe the mechanism of virus transmission and the clinical signs and symptoms of disease, outline the role of laboratory diagnostics, and provide information on the four approved influenza antiviral agents, including their usage, dosage, adverse events, drug interactions, and possible emergency use authorization.
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This webpage provides background information on the reliability and interpretation of rapid influenza diagnostic test results, guidance on how to minimize false results, lists details about available testing methods, and describes characteristics of rapid influenza diagnostic tests.
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* Centers for Disease Control and Prevention. (2017). Vaccine Recommendations and Guidelines of the ACIP. U.S. Department of Health and Human Services.
This webpage includes links to current and archived influenza vaccine recommendations from the Advisory Committee on Immunization Practices.
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Centers for Disease Control and Prevention. (2018). Information for Clinicians on Rapid Diagnostic Testing for Influenza. U.S. Department of Health and Human Services.
This webpage provides background information on the reliability and interpretation of rapid influenza diagnostic test results, guidance on how to minimize false results, lists details about available testing methods, and describes characteristics of rapid influenza diagnostic tests.
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Centers for Disease Control and Prevention. (2018). Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. U.S. Department of Health and Human Services.
This webpage defines healthcare settings and healthcare personnel, discusses modes of influenza transmission and fundamental elements of prevention; and outlines 13 recommended prevention strategies.
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These guidelines are intended as a quick reference for just-in-time training and set up of the types of mechanical ventilators included in the Strategic National Stockpile. The guidelines may be used by clinicians with a baseline knowledge of pulmonary physiology and the concepts of ventilation, but who may not be familiar with the stockpiled ventilators or who may not routinely care for children on ventilators.
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Infectious Diseases Society of America. (2016). ID-Focused Hospital Efficiency Improvement Program.
This guide for infectious disease physician executives identifies service lines and related metrics to mitigate infectious disease-related issues. The guide addresses four areas: infection prevention and control; antimicrobial stewardship; outpatient parenteral antimicrobial therapy hospital admission/readmission avoidance; and bio-security, bio-preparedness, and emerging infectious diseases.
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Kulkarni, T., Sharma., N., and Diaz-Guzman, E. (2016). Extracorporeal Membrane Oxygenation in Adults: A Practical Guide for Internists. Cleveland Clinic Journal of Medicine. 83(5):373-384.
The authors review current evidence and indications for ECMO. They describe what it is, who could benefit, how to do it, and what the complications are. ECMO was used extensively during the H1N1 pandemic, and the guide has implications on decisions for its use during future influenza pandemics.
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This protocol developed by an expert panel is based on a literature review and the experience of Polish treatment centers with extensive use of veno-venous extracorporeal membrane oxygenation (ECMO). The protocol is intended to improve treatment outcomes, expand access to ECMO where appropriate, and to avoid the use of ECMO in situations when it is unlikely to be beneficial.
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* Los Angeles County Emergency Medical Services Agency. (2009). Recommended Actions for EMS Providers to Prepare For and Respond to Pandemic Influenza.
This document provides pandemic influenza guidelines for emergency medical services responders and management, recommended actions during each pandemic period, and additional resources, such as infection control information, employee health considerations, and patient assessment tools.
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* Los Angeles County Emergency Medical Services Agency. (2010). Recommended Actions for Hospitals to Prepare for and Respond to Pandemic Influenza.
This document provides guidelines to hospitals to prepare for an influenza pandemic. It includes a summary of recommended actions and their triggers, checklists, sample response guides, general background information, and links to additional resources.
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* Qualls, N., Levitt, A., Kanade, N., et al. (2017). Community Mitigation Guidelines to Prevent Pandemic Influenza - United States, 2017. Morbidity and Mortality Weekly Report. 66(1):1-34.
These guidelines update Centers for Disease Control and Prevention recommendations on the use of non-pharmaceutical interventions to slow the spread of infectious respiratory diseases, including influenza.
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Vemula, S., Zhao, J., Liu, J., et al. (2016). Current Approaches for Diagnosis of Influenza Virus Infections in Humans. Viruses. 8(4).
This article describes the various approaches currently available to diagnose human influenza infections. The authors discuss advantages and limitations of the various approaches, such as sensitivity and specificity of the tests, cost-effectiveness, and ease to perform.
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Wijetunge, G. and Oliver, A. (2009). State EMS System Pandemic Influenza Preparedness: A Report of the FICEMS. Federal Interagency Committee on EMS.
This report reviews gaps in influenza pandemic preparedness among emergency medical services and 911 systems and outlines five strategies to address these gaps.
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This document provides recommendations, best practices and principles for infection prevention and control for acute respiratory infections in health care, particularly those that present as epidemics or pandemics. It includes information on PPE and aerosol-generating procedures. There are also summaries of literature and research reviews on physical interventions for infection control; risk of transmission from aerosol-generating procedures; and effectiveness of vaccination of health care workers to protect patients.
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Lessons Learned


Kao, H., Ko, H., Guo, P., et al. (2017). Taiwan's Experience in Hospital Preparedness and Response for Emerging Infectious Diseases. Health Security. 15(2):175-184.
The authors describe Taiwan’s Communicable Disease Control Medical Network, which was established after the 2003 SARS outbreak, and discuss its performance during the 2009 H1N1 influenza pandemic and the West African Ebola outbreak. They discuss similarities with the tiered response system established in the U.S. for Ebola, identify strengths as the establishment of a command system with well-prepared hospitals and trained personnel, and note the challenges of maintaining funding, clarifying the role of local public health authorities, and incentivizing the participation of frontline clinical staff.
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This case study describes the collaboration between the Palm Beach County (FL) Health Department and the medical and hospital community, responding partners, and community pharmacies that facilitated a mass influenza vaccination campaign during the H1N1 influenza outbreak in 2009. The partnership enabled information and vaccines to flow from the health department to hundreds of area supermarkets and community pharmacies and their in-store health clinics, ensuring the public had access to credible and timely influenza information.
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Office of the Assistant Secretary for Preparedness and Response. (2012). An HHS Retrospective on the 2009 H1N1 Influenza Pandemic to Advance All Hazards Preparedness. U.S. Department of Health and Human Services.
The authors share lessons learned from the 2009 influenza pandemic, grouped into the following categories: surveillance, mitigation measures, vaccination, and communications and education.
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* Patel, A., D’Alessandro, M., Ireland, K., et al. (2017). Personal Protective Equipment Supply Chain: Lessons Learned from Recent Public Health Emergency Responses. (Abstract only.) Health Security. 15(3):244-252.
The authors describe lessons learned from the 2009 H1N1 influenza pandemic and the 2014 Ebola virus epidemic related to the commercial supply chain of pharmaceutical and other healthcare products. They discuss how these lessons learned could inform readiness for future emergencies from a personal protective equipment supply chain and system perspective.
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Paules, C. Eisinger, R., Marston, H., and Fauci, A. (2017). What Recent History Has Taught Us About Responding to Emerging Infectious Disease Threats. (Abstract only.) Annals of Internal Medicine. 167(11):805-811.
The authors share lessons learned from recent outbreaks that can be incorporated into planning efforts for future public health emergencies.
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This report examines early lessons learned by the healthcare system from the response to the 2009 H1N1 pandemic and highlights ongoing concerns about overall U.S. preparedness for potential outbreaks.
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The U.S. Government Accountability Office was charged with 1) determining how the Homeland Security Council and the responsible Federal agencies were monitoring the progress and completion of the Implementation Plan for the National Strategy for Pandemic Influenza, and 2) assessing the extent to which selected action items have been completed.
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Non-Pharmaceutical Strategies


Barrios, L., Koonin, L., Kohl, K., and Cetron, M. (2012). Selecting Nonpharmaceutical Strategies to Minimize Influenza Spread: The 2009 Influenza A (H1N1) Pandemic and Beyond. Public Health Reports. 127(6):565-571.
The authors describe the development of guidance on non-pharmaceutical strategies to minimize the spread of the 2009 influenza A (H1N1) pandemic. They recommend a framework to be used by state and local health officials when collaborating with stakeholders including educational officials and large employers to select which non-pharmaceutical measures to use during a future pandemic.
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Hatchett, R., Mecher, C., and Lipsitch, M. (2007). Public Health Interventions and Epidemic Intensity During the 1918 Influenza Pandemic. Proceedings of the National Academy of Sciences of the United States of America. 104(18):7582-7587.
The authors examined 19 categories of public health responses in 17 cities during the first 16 weeks of the 1918 influenza pandemic to determine their effectiveness. They found that early interventions were most effective in lowering peak death rates and that early closures of schools, churches, and theatres were associated with lower peak excess death rates.
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Martinez, D. and Das, T. (2014). Design of Non-Pharmaceutical Intervention Strategies for Pandemic Influenza Outbreaks. BMC Public Health. 14(1328).
The authors modeled various non-pharmaceutical interventions, social behaviors, and their interactions on outcome measures such as numbers of contacts, infections, and deaths to simulate the effects of the strategies on pandemic influenza outbreaks with varying levels of virus transmissibility.
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* Noah, D. and Noah, J. (2013). Adapting Global Influenza Management Strategies to Address Emerging Viruses. American Journal of Physiology - Lung Cellular and Molecular Physiology. 305(2):L108-L117.
The authors provide an overview of influenza and discuss epidemiology and surveillance, perspectives on vaccines and antivirals, and research opportunities related to universal vaccine, alternate vaccine production strategies, novel antiviral development, and continued transmission studies.
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* Qualls, N., Levitt, A., Kanade, N., et al. (2017). Community Mitigation Guidelines to Prevent Pandemic Influenza - United States, 2017. Morbidity and Mortality Weekly Report. 66(1):1-34.
These guidelines update Centers for Disease Control and Prevention recommendations on the use of non-pharmaceutical interventions to slow the spread of infectious respiratory diseases, including influenza.
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* Saunders-Hastings, P., Quinn Hayes, B., Smith, R., and Krewski, D. (2017). Modelling Community-Control Strategies to Protect Hospital Resources During An Influenza Pandemic in Ottawa, Canada. PLoS One. 12(6).
The authors modeled the effects on hospital capacity in one city of various strategies to control an influenza pandemic. They calculated ranges bounded by no interventions and all interventions for the attack rate, peak acute care hospital capacity, peak intensive care unit capacity, and mortality along with estimated economic burdens. They found vaccination, isolation, and personal protective measures to be the most effective strategies. However, all interventions decreased in effectiveness as transmissibility increased and as the outbreak progressed.
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This study reviews existing systematic reviews and meta-analyses on pandemic influenza interventions including vaccines, antivirals, personal protective measures, school closures, and traditional Chinese medicine. Pandemic influenza vaccine was found to be protective against infection, but the authors found insufficient evidence for the effectiveness of each of the other interventions in isolation and hypothesized that a combination of interventions would be most effective.
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* Torner, N., Soldevila, N., Garcia, J., et al. (2015). Effectiveness of Non-Pharmaceutical Measures in Preventing Pediatric Influenza: A Case-Control Study. BMC Public Health. 15(543).
In this case-control study of illnesses during the 2009-10 and 2010-11 seasons, the authors evaluated the effectiveness of frequency of hand washing, alcohol-based hand sanitizer use, and hand washing after touching contaminated surfaces. Hand washing more than five times per day was the only statistically significant protective factor. Among the school-age 5-17 year old group, both hand washing more than five times per day and hand washing after touching contaminated surfaces had a negative association for influenza infection.
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Zhang, Q. and Wang, D. (2015). Assessing the Role of Voluntary Self-Isolation in the Control of Pandemic Influenza Using a Household Epidemic Model. International Journal of Environmental Research and Public Health. 12(8):9750-9767.
The authors modeled the effect of voluntary self-isolation when distribution of antivirals is delayed and found that it reduced the transmission of pandemic influenza. Voluntary self-isolation is more effective the closer in time to symptom onset it is implemented and loses effectiveness as the proportion of asymptomatic infections increases.
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Pediatric Issues


* American Academy of Pediatrics. (2013). Pediatric Preparedness Resource Kit.
This resource kit was designed to address issues that occurred during 2009 H1N1 planning and allows for pediatricians, public health leaders, and other pediatric care providers to assess what is already happening in their community or state, and help determine what needs to be done before an emergency or disaster. It promotes collaborative discussions and decision making about pediatric preparedness planning at the local and state level and encourages integration of pediatric providers into disaster planning. It also contains a link to the Joint Policy Statement—Guidelines for Care of Children in the Emergency Department, as well as a Preparedness Checklist for Pediatric Practices and guidance for prioritizing vaccination during pandemics.
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* Centers for Disease Control and Prevention. (2010). Coordinating Pediatric Medical Care During an Influenza Pandemic: Hospital Workbook. U.S. Department of Health and Human Services.
This workbook was designed to assist hospitals in coordinating the care of pediatric patients during an influenza pandemic. The workbook guides hospitals in thinking about needed actions to inform their preparedness planning.
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These guidelines are intended as a quick reference for just-in-time training and set up of the types of mechanical ventilators included in the Strategic National Stockpile. The guidelines may be used by clinicians with a baseline knowledge of pulmonary physiology and the concepts of ventilation, but who may not be familiar with the stockpiled ventilators or who may not routinely care for children on ventilators.
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Shakib, J., Korgenski, K., Presson, A., et al. (2017). Influenza in Infants Born to Women Vaccinated During Pregnancy. Pediatrics. 137(6).
This cohort study to compare influenza outcomes of infants less than 6 months of age born to vaccinated and unvaccinated women included more than 245,000 women who delivered nearly 250,000 infants in a single health system between December 2005 and March 2014. The authors found that while only 10% of pregnant women were vaccinated during the overall course of the study, the proportion steadily increased to 52% in the final season. They also found a 64% reduction in influenza-like illness health encounters, a 70% reduction in laboratory-confirmed influenza, and an 81% reduction in hospitalization with laboratory-confirmed influenza in infants born to women who reported being vaccinated during pregnancy and 97% of laboratory-confirmed influenza in infants less than 6 month occurred in those born to women who did not report being vaccinated during pregnancy.
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* Torner, N., Soldevila, N., Garcia, J., et al. (2015). Effectiveness of Non-Pharmaceutical Measures in Preventing Pediatric Influenza: A Case-Control Study. BMC Public Health. 15(543).
In this case-control study of illnesses during the 2009-10 and 2010-11 seasons, the authors evaluated the effectiveness of frequency of hand washing, alcohol-based hand sanitizer use, and hand washing after touching contaminated surfaces. Hand washing more than five times per day was the only statistically significant protective factor. Among the school-age 5-17 year old group, both hand washing more than five times per day and hand washing after touching contaminated surfaces had a negative association for influenza infection.
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Personal Protective Equipment and Worker Safety


Bessesen, M., Adams, J., Radonovich, L., and Anderson, J. (2015). Disinfection of Reusable Elastomeric Respirators by Health Care Workers: A Feasibility Study and Development of Standard Operating Procedures. American Journal of Infection Control. 43(6): 629-634.
This article describes a Department of Veterans Affairs feasibility study on the ability of personnel to safely disinfect respirators under pandemic conditions by following standard operating procedures.
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Centers for Disease Control and Prevention. (2019). Influenza Vaccination Information for Health Care Workers. U.S. Department of Health and Human Services.
This web page provides questions and answers to illustrate the importance of influenza vaccination among healthcare workers to not only protect vaccinated personnel but also to reduce transmission of influenza in healthcare settings.
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The authors examined existing policies and guidelines from the Centers for Disease Control and Prevention, the World Health Organization, three high-income countries, and six low/middle-income countries on mask and respirator use for influenza, SARS, and tuberculosis. They found significant variation in choice of products, applications, and specifications. They encourage joint evaluation of evidence and development of a uniform policy to reduce confusion in healthcare settings.
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Fisher, E. and Shaffer, R. (2014). Commentary Considerations for Recommending Extended Use and Limited Reuse of Filtering Facepiece Respirators in Health Care Settings. Journal of Occupational and Environmental Hygiene. 11(8):D115-D128.
This article reviews scientific findings on the extended use or reuse of filtering facepiece respirators in healthcare settings. The authors discuss considerations for routine events versus during public health emergencies. The authors express a preference for extended use over reuse and suggest that future recommendations consider new cautions and limitations.
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The author provides an overview on occupational exposure to emerging infectious diseases in the healthcare industry and the history and use of isolation gowns as personal protective equipment (PPE). As the second-most used type of PPE, the author discusses properties affecting gown performance and factors influencing their design and development.
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Larson, E. and Liverman, C., eds. (2011). Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel: Update 2010. The National Academies of Sciences, Engineering, and Medicine.
This report was updated following the 2009 H1N1 pandemic to assess current knowledge on personal protective equipment, research progress, and future efforts to protect healthcare personnel.
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Lindsley, W., Martin, S., Thewlis, R., et al. (2015). Effects of Ultraviolet Germicidal Irradiation (UVGI) on N95 Respirator Filtration Performance and Structural Integrity. Journal of Occupational and Environmental Hygiene. 12(8):509-517.
The authors exposed material coupons and straps from four models of N95 filtering facepiece respirators to a range of doses of ultraviolet germicidal irradiation to test particle penetration, flow resistance, bursting strengths of coupon layers, and breaking strength of straps. They found small effects on filtration performance and almost no effect on flow resistance, but a reduction in the strength of respirator materials of more than 90% in some models and a 20-51% reduction in breaking strength of straps. The authors suggest that ultraviolet germicidal irradiation is a possible method to disinfect respirators for reuse, but the respirator model used should first be tested to determine the maximum number of disinfection cycles and the dose required to inactivate the specific pathogen.
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Liverman, C., Domnitz, S., and McCoy, M. (2015). The Use and Effectiveness of Powered Air Purifying Respirators in Health Care: Workshop Summary. The National Academies of Sciences, Engineering, and Medicine.
This report summarizes the proceedings of a workshop examining the current state of practice on the use of powered air purifying respirators in healthcare settings and research on their use and effectiveness.
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National Academies of Sciences, Engineering, and Medicine. (2018). Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. The National Academies Press.
This report examines strategies for and pros and cons related to stockpiling and reusing elastomeric respirators during an influenza pandemic or other large aerosol-transmissible outbreak.
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National Institute for Occupational Safety and Health. (2015). NIOSH Personal Protective Equipment Information (PPE-Info). Centers for Disease Control and Prevention.
This website compiles standards information for personal protective equipment from the U.S. government, American National Standards Institute-accredited standard development organizations, and the International Organization for Standardization. Users can search the database by fields including the category of personal protective equipment, hazard type, standard type, and standard organization.
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National Institute for Occupational Safety and Health. (2018). Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings. Centers for Disease Control and Prevention.
This guidance for professionals who manage respiratory protection programs for healthcare facilities provides recommendations on extended use and reuse of N95 filtering facepiece respirators. It also explains the risks associated with extended use and reuse.
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Occupational Safety and Health Administration. (n.d.). Respiratory Protection Standards. (Accessed 10/3/2019.) U.S. Department of Labor.
This webpage contains standards on respirators, respiratory protection, and the medical evaluation program.
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Occupational Safety and Health Administration. (2009). Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers. U.S. Department of Labor.
This document provides an overview of infection control and other standards appropriate for pandemic influenza.
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Occupational Safety and Health Administration. (2014). Protecting Workers During a Pandemic. U.S. Department of Labor.
This fact sheet provides guidance on workplace practices related to pandemic influenza.
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* Patel, A., D’Alessandro, M., Ireland, K., et al. (2017). Personal Protective Equipment Supply Chain: Lessons Learned from Recent Public Health Emergency Responses. (Abstract only.) Health Security. 15(3):244-252.
The authors describe lessons learned from the 2009 H1N1 influenza pandemic and the 2014 Ebola virus epidemic related to the commercial supply chain of pharmaceutical and other healthcare products. They discuss how these lessons learned could inform readiness for future emergencies from a personal protective equipment supply chain and system perspective.
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Pillai, S., Beekmann, S., Babcock, H., et al. (2015). Clinician Beliefs and Attitudes Regarding Use of Respiratory Protective Devices and Surgical Masks for Influenza. Health Security. 13(4):274-280.
The authors described a survey of infectious disease physicians to learn their perspectives on influenza transmission, personal protective equipment preferences, respirator supplies, barriers to expanded use of respirators, and respirator conservation strategies. Among the findings, respondents widely agreed with recommendations to use surgical masks during seasonal influenza outbreaks. They slightly favored N95 respirators during mild severity pandemics, but two-thirds preferred N95 respirators over surgical masks during a high mortality pandemic. They also preferred extended use or reuse of disposable N95 respirators over elastomeric or powered air-purifying respirators in the event of a respirator shortage.
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This meta-analysis examined the effectiveness of hand hygiene, respiratory etiquette, and use of facemasks in reducing the risk of pandemic influenza transmission. The authors did not find data on the effectiveness of respiratory etiquette, but found that hand hygiene was statistically significant and wearing a face mask was suggestive of preventing infection.
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Smith, J., MacDougall, C., Johnstone, J., et al. (2016). Effectiveness of N95 Respirators Versus Surgical Masks in Protecting Health Care Workers from Acute Respiratory Infection: A Systematic Review and Meta-Analysis. Canadian Medical Association Journal. 188(8):567-574.
The authors conducted a meta-analysis of both clinical studies and surrogate exposure studies comparing N95 respirators to surgical masks to prevent transmission of acute respiratory infections. While the surrogate studies suggested a protective advantage of N95 respirators over surgical masks, the meta-analysis showed insufficient data to definitely determine whether N95 respirators are more protective.
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Plans, Tools, and Templates: EMS


ASPR TRACIE. (2017). EMS Infectious Disease Playbook. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This playbook synthesizes multiple sources of information in a single planning document addressing the full spectrum of infectious agents to create a concise reference resource for emergency medical services (EMS) agencies developing their service policies. The information can be incorporated into agency standard operating procedures and reviewed by the EMS medical director.
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  • Tracy Miller Is there any way to order a printed and bound version?
    8/9/2018 5:16:09 PM
* ASPR TRACIE. (2019). Healthcare Coalition Influenza Pandemic Checklist. U.S Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This planning tool is intended to assist health care coalitions and their partners in assessing their preparedness for an influenza pandemic. It may also be used to orient the response as a pandemic begins. This checklist can help healthcare coalitions assess, create, and improve their pandemic preparedness and response plans.
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Centers for Disease Control and Prevention. (2006). Emergency Medical Service and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist. U.S. Department of Health and Human Services.
This planning checklist is intended to assist emergency medical services and other transport providers assess and improve their influenza pandemic preparedness.
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* Los Angeles County Emergency Medical Services Agency. (2009). Recommended Actions for EMS Providers to Prepare For and Respond to Pandemic Influenza.
This document provides pandemic influenza guidelines for emergency medical services responders and management, recommended actions during each pandemic period, and additional resources, such as infection control information, employee health considerations, and patient assessment tools.
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Plans, Tools, and Templates: Hospitals


American College of Emergency Physicians. (n.d.). National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza. (Accessed 10/3/2019.)
This plan can help healthcare providers manage an H1N1 outbreak or other large scale epidemic or pandemic. Developed during the 2009 H1N1 pandemic, it provides a checklist/template for hospital preparedness.
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ASPR TRACIE. (2019). Considerations for the Use of Temporary Care Surge Sites for Managing Seasonal Patient Surge. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This document describes the major considerations healthcare facility emergency planners must account for when determining patient surge management solutions for longer-duration events, such as weeks to months of managing seasonal illness surge. The term "surge site" is used to describe a non-patient care area either inside the walls of the facility or a site immediately adjacent such as a tent, trailer, or other mobile and temporary facility.
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* ASPR TRACIE. (2019). Healthcare Coalition Influenza Pandemic Checklist. U.S Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This planning tool is intended to assist health care coalitions and their partners in assessing their preparedness for an influenza pandemic. It may also be used to orient the response as a pandemic begins. This checklist can help healthcare coalitions assess, create, and improve their pandemic preparedness and response plans.
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Centers for Disease Control and Prevention. (n.d.). Hospital 2009 H1N1 Pandemic Influenza Readiness Review Checklist. (Accessed 10/3/2019.) U.S. Department of Health and Human Services.
This checklist can help hospital staff with decision making and influenza plan development.
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Centers for Disease Control and Prevention. (2007). Hospital Pandemic Influenza Planning Checklist. U.S. Department of Health and Human Services.
This checklist is intended to assist hospitals in evaluating current pandemic influenza plans or developing new ones.
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* Centers for Disease Control and Prevention. (2010). Coordinating Pediatric Medical Care During an Influenza Pandemic: Hospital Workbook. U.S. Department of Health and Human Services.
This workbook was designed to assist hospitals in coordinating the care of pediatric patients during an influenza pandemic. The workbook guides hospitals in thinking about needed actions to inform their preparedness planning.
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Centers for Disease Control and Prevention. (2013). Hospital Discussion Guide for Pandemic Influenza Planning. U.S. Department of Health and Human Services.
This guide is intended to assist community hospitals in identifying issues with response capabilities and resource availability during an influenza pandemic as well as to develop strategies to address them.
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Centers for Disease Control and Prevention. (2016). Pandemic Influenza Triage Tools. U.S. Department of Health and Human Services.
This toolkit consists of a Pandemic Influenza Triage Algorithm to triage patients with influenza-like illness, a Community Site-of Care Tool to determine the appropriate care site for patients based on the Pandemic Influenza Triage Algorithm, and the Community Healthcare Decision Pathway to assess resource and medical surge to determine appropriate care sites.
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* Los Angeles County Emergency Medical Services Agency. (2010). Recommended Actions for Hospitals to Prepare for and Respond to Pandemic Influenza.
This document provides guidelines to hospitals to prepare for an influenza pandemic. It includes a summary of recommended actions and their triggers, checklists, sample response guides, general background information, and links to additional resources.
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Minnesota Department of Health, Association for Professionals in Infection Control and Epidemiology - Minnesota, and Health Care Coalitions of Minnesota. (n.d.). High Consequence Infectious Disease (HCID) Toolbox for Frontline Health Care Facilities. (Accessed 7/11/2019.)
This toolbox includes a variety of resources to assist frontline facilities in their readiness activities related to patients with high consequence infectious diseases. Included are planning and training tools, exercise templates, and the components (e.g., screening guide, checklists, posters) to create a readiness binder.
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* New York City Department of Health and Mental Hygiene. (n.d.). Mystery Patient Drill Toolkit. (Accessed 7/5/2019.)
This toolkit is intended for use by hospital emergency departments, and tests how long it takes for a potential patient with a highly infectious disease to be identified and for staff to begin exposure mitigation procedures; how long it takes for a patient to be transferred to an isolation room; and the capability of the facility to make notifications internally and to the health department. The Toolkit includes scenarios for Ebola Virus Disease, Middle East Respiratory Syndrome, and Measles, but may be modified to suit healthcare facilities of any nature and any type of disease outbreak.
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New York City Health + Hospitals. (2019). Frontline Hospital Planning Guide: Special Pathogens.
This planning guide from New York City Health + Hospitals provides high-level planning information for frontline hospital multidisciplinary teams to support planning and training for the initial care of suspected special pathogen patients while determining whether and when they will be transferred to another facility for further assessment and treatment.
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* The Society for Healthcare Epidemiology of America. (2017). Outbreak Response Training Program (ORTP).
This webpage contains links to four free toolkits that were developed to provide healthcare providers immediate access to key infectious disease outbreak information and resources. The toolkits contain guidance on incident management, emerging pathogens, horizontal strategies, communication, negotiation, and implementation. Each toolkit contains checklists, guidance documents, case studies, and fillable tables to meet the planning and response needs prior to or during an infectious disease outbreak.
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Plans, Tools, and Templates: Long Term Care/Assisted Living/Home Health


Anderson, E. and Montgomery, J. (2010). Pandemic Influenza Workbook for Long Term Care Providers. California Association of Health Facilities.
This state-specific report provides guidance to long-term providers on what actions to take to protect the health and safety of the staff and residents in their facilities in the event of a pandemic influenza outbreak (e.g., vaccines/antivirals, PPE use, staff impact and augmented supply management). It may be used to develop a hazard-specific Pandemic Influenza Plan Annex to a facility’s Emergency Operations Plan.
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Centers for Disease Control and Prevention. (2006). Home Health Care Services Pandemic Influenza Planning Checklist. U.S. Department of Health and Human Services.
This checklist can help public and private healthcare organizations assess and better their pandemic influenza preparedness and planning.
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Centers for Disease Control and Prevention. (2016). A Toolkit for Long-Term Care Employers: Increasing Influenza Vaccination among Health Care Personnel in Long-Term Care Settings. U.S. Department of Health and Human Services.
This toolkit has sub links in three areas: staff vaccinations; increasing coverage and other vaccine-related information. It is intended to inform long-term care facilities and their owners about the importance of influenza vaccination among their workforce.
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Centers for Disease Control and Prevention. (2016). Long-Term, Home Health, and Hospice Care Planning Guide for Public Health Emergencies. U.S. Department of Health and Human Services.
This planning guide is geared towards long-term care, homecare, and hospice providers and is comprised of six sections: situational awareness, continuity of operations, facility or agency operations, crisis standards of care, staffing, and fatality management.
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Centers for Disease Control and Prevention. (2018). Menu of State Long-Term Care Facility Influenza Vaccination Laws. U.S. Department of Health and Human Services.
This resource identifies state statutes or regulations that require long term care facilities to assess the influenza vaccination status of personnel or patients, to offer or require influenza vaccination among personnel or patients, or require unvaccinated personnel to wear surgical masks during influenza season.
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This tool is intended to assist nursing facilities in developing their pandemic preparedness and response plans. It consists of several modules, which are to be used as a guide to facilitate discussion and to ensure that key points related to a specific topic, such as human resources, are identified and addressed in the planning process. It also includes sample policies and procedures and a module on ethics/values.
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Plans, Tools, and Templates: Modeling Tools


Centers for Disease Control and Prevention. (2016). CommunityFlu 2.0. U.S. Department of Health and Human Services.
This free, downloadable software allows users to simulate the effects of various interventions – including vaccination, school closure, facemasks, and patient isolation – on the spread of an influenza pandemic.
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Centers for Disease Control and Prevention. (2016). FluAid 2.0. U.S. Department of Health and Human Services.
This free, downloadable software allows planners to estimate the effects of an influenza pandemic on their community in terms of hospitalizations, outpatient visits, and deaths.
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Centers for Disease Control and Prevention. (2016). FluLabSurge 1.0. U.S. Department of Health and Human Services.
This free, downloadable software allows laboratory directors and emergency planners to estimate the daily number of specimens expected to be received for testing and the laboratory’s testing capacity during each pandemic stage.
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Centers for Disease Control and Prevention. (2016). FluSurge 2.0. U.S. Department of Health and Human Services.
This free, downloadable spreadsheet allows hospital administrators and emergency planners to estimate hospitalizations and deaths during an influenza pandemic and to compare existing hospital capacity to expected numbers of patients needing hospitalization, intensive care, and ventilator support.
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Centers for Disease Control and Prevention. (2016). FluWorkLoss 1.0. U.S. Department of Health and Human Services.
This free, downloadable spreadsheet allows emergency planners to estimate the number of days lost from work during an influenza pandemic.
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Plans, Tools, and Templates: Other


* ASPR TRACIE. (2019). Healthcare Coalition Influenza Pandemic Checklist. U.S Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This planning tool is intended to assist health care coalitions and their partners in assessing their preparedness for an influenza pandemic. It may also be used to orient the response as a pandemic begins. This checklist can help healthcare coalitions assess, create, and improve their pandemic preparedness and response plans.
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Centers for Disease Control and Prevention. (2005). Business Pandemic Influenza Planning Checklist. U.S. Department of Health and Human Services.
This checklist identifies actions that businesses can take to plan for pandemic influenza.
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* Centers for Disease Control and Prevention. (2016). Influenza Risk Assessment Tool (IRAT). U.S. Department of Health and Human Services.
This tool was developed by the Centers for Disease Control and Prevention and other influenza experts to assess the risk of a human pandemic emerging from influenza A viruses currently circulating in animals. The IRAT uses 10 weighted evaluation criteria to assess the risk of both emergence and public health impact and to classify each virus as low, moderate, or high risk.
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* Holloway, R., Rasmussen, S., Zaza, S., et al. (2014). Updated Preparedness and Response Framework for Influenza Pandemics. Morbidity and Mortality Weekly Report. 63(RR06):1-9.
This article describes the Centers for Disease Control and Prevention’s revised framework for pandemic influenza preparedness and response. The authors describe the six intervals along the pandemic curve and eight domains used to organize efforts within each interval.
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Office of the Assistant Secretary for Preparedness and Response. (2005). National Strategy for Pandemic Influenza. U.S. Department of Health and Human Services.
The National Strategy for Pandemic Influenza provides strategies to stop, slow or limit the spread of a pandemic to the United States; limit the domestic spread of a pandemic, and mitigate disease, suffering and death; and sustain infrastructure and minimize economic and societal impacts. It aims to do so through preparedness and communication; surveillance and detection; and response and containment.
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Office of the Assistant Secretary for Preparedness and Response. (2019). National Health Security Strategy. U.S. Department of Health and Human Services.
The goal of the National Health Security Strategy (NHSS) is to strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from disasters and emergencies. This webpage includes links to the full text of the plan, an overview, the NHSS Implementation Plan, the NHSS Evaluation of Progress, and an NHSS Archive.
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San Francisco Department of Public Health. (2011). Infectious Disease Emergency Response Plan.
This plan contains the following sections: command, plans section (by unit), operations section, logistics, and finance. Four annexes that focus on different threats are included, as are sample forms and other appendices.
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Santa Clara County Public Health Department. (n.d.). Home Care Guide: Providing Care at Home during Pandemic Flu. (Accessed 10/3/2019.) Center for Infectious Disease Research and Policy.
This guide can help people create a plan for and recognize the signs of influenza and care for themselves or others sick with the virus. It is available in several languages.
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U.S. Department of Health and Human Services. (2017). Pandemic Influenza Plan: 2017 Update.
This updated plan builds upon the 2005 Pandemic Influenza Plan and its subsequent updates, focusing on the seven domains of: surveillance, epidemiology, and laboratory activities; community mitigation measures; medical countermeasures; health care system preparedness and response activities; communications and public outreach; scientific infrastructure and preparedness; and domestic and international response policy, incident management, and global partnerships and capacity building.
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University of Minnesota, Center for Infectious Disease Research and Policy. (2009). Doing Business During an Influenza Pandemic: A Toolkit for Organizations of All Sizes.
This toolkit is intended to provide business leaders that are new to pandemic planning with information regarding high-priority Human Resources (HR) issues related to business operations during influenza pandemic. While some of the links in the presentation are outdated, the presentation provides a valuable overview of issues and tasks.
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Plans, Tools, and Templates: Physician Offices


American Academy of Family Physicians. (2015). Checklist to Prepare Physicians' Offices for Pandemic Influenza.
This checklist identifies universal early preparations, describes actions for areas with suspected or known pandemic influenza, outlines telephone and office triage, notes referral or transfer and waste disposal procedures, and lists required equipment and supplies for physician offices to consider when preparing for pandemic influenza.
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* American Academy of Pediatrics. (2013). Pediatric Preparedness Resource Kit.
This resource kit was designed to address issues that occurred during 2009 H1N1 planning and allows for pediatricians, public health leaders, and other pediatric care providers to assess what is already happening in their community or state, and help determine what needs to be done before an emergency or disaster. It promotes collaborative discussions and decision making about pediatric preparedness planning at the local and state level and encourages integration of pediatric providers into disaster planning. It also contains a link to the Joint Policy Statement—Guidelines for Care of Children in the Emergency Department, as well as a Preparedness Checklist for Pediatric Practices and guidance for prioritizing vaccination during pandemics.
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Centers for Disease Control and Prevention. (n.d.). Abbreviated Pandemic Influenza Plan Template for Primary Care Provider Offices: Guidance from Stakeholders. (Accessed 10/3/2019.) U.S. Department of Health and Human Services.
The planning tool, based on discussion during an August 2009 CDC-sponsored stakeholder meeting, identifies considerations in a wide range of subject areas that primary care office staff should keep in mind when developing their office pandemic plans.
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Centers for Disease Control and Prevention. (n.d.). Medical Office Telephone Evaluation of Patients with Possible Influenza. (Accessed 10/3/2019.) U.S. Department of Health and Human Services.
This flowchart can aid medical staff in triaging calls. The tool may identify high-risk patients for consideration of initiation of antiviral treatment prior to an office visit.
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Centers for Disease Control and Prevention. (n.d.). Pandemic Influenza Pediatric Office Plan Template: Product of a Pediatric Healthcare Response to Pandemic H1N1 Influenza Stakeholder Meeting. (Accessed 10/3/2019.) U.S. Department of Health and Human Services.
This template can assist pediatric medical offices in identifying needed modifications to current office practices and developing a pandemic influenza plan.
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Centers for Disease Control and Prevention. (2012). Medical Office Preparedness Planner: A Tool for Primary Care Provider Offices. U.S. Department of Health and Human Services.
This document was created to help primary care providers develop pandemic influenza response plans. It includes a monthly planning calendar, as well as a detailed plan template for practices to fill in.
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Research


Aoyagi, Y., Beck, C., Dingwall R., and Nguyen-Van-Tam, J. (2015). Healthcare Workers' Willingness to Work During an Influenza Pandemic: A Systematic Review and Meta-analysis. Influenza and Other Respiratory Viruses. 9(3):120-130.
The authors reviewed literature through to 2013 that discussed healthcare workers’ willingness to work during an influenza pandemic, and found that willingness to work ranged from 23.1% to 95.8%, depending on the context. Male gender, physicians and nurses, full-time employment, perceived personal safety, awareness of pandemic risk and clinical knowledge of influenza pandemics, role-specific knowledge, pandemic response training, and confidence in personal skills were statistically significantly associated with increased willingness. Childcare obligations were significantly associated with decreased willingness.
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Dawood, F., Iuliano, A., Reed, C., et al. (2012). Estimated Global Mortality Associated with the First 12 Months of 2009 Pandemic Influenza A H1N1 Virus Circulation: A Modelling Study. The Lancet Infectious Diseases. 12(9):687-695.
The authors estimated more than 200,000 respiratory deaths with more than 83,000 additional cardiovascular deaths worldwide associated with 2009 influenza A H1N1. This mortality estimate is 15 times higher than the number of reported laboratory-confirmed deaths.
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Hsieh, Y., Kelen, G., Dugas, A., et al. (2013). Emergency Physicians' Adherence to Center for Disease Control and Prevention Guidance During the 2009 Influenza A H1N1 Pandemic. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health. 14(2):191-199.
The authors reviewed all 339 patients with a clinical diagnosis of influenza at a single hospital emergency department from May 2008 to December 2009 to compare patient management pre and during the H1N1 pandemic and to test adherence to H1N1 guidance from the CDC and the American College of Emergency Physicians. They found similar rates of hospital admission, but different clinical presentation patterns during the pandemic period. Diagnostic testing practices were very good or excellent in adherence to guidelines, but suboptimal in antiviral prescription guideline adherence.
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Kunin, M., Engelhard, D., Thomas, S., et al. (2015). Challenges of the Pandemic Response in Primary Care During Pre-Vaccination Period: A Qualitative Study. Israel Journal of Health Policy Research. 4(32).
The authors interviewed 65 primary care physicians in Australia, Israel, and England about their experiences during the 2009 influenza pandemic. Physicians in all three countries perceived difficulties in translating pandemic policies and guidelines into practice. The researchers attributed this to knowledge barriers (high volume of information and lack of time to keep pace, multiple sources of information, guidelines not oriented to primary care), primary care physician doubts about some guidelines, and operational difficulties associated with providing personalized consultations to patients hearing media reporting on policy changes before physicians received official updates from health authorities.
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Lum, H., Mody, L., Levy, C., and Ginde, A. (2014). Pandemic Influenza Plans in Residential Care Facilities. Journal of the American Geriatrics Society. 62(7):1310-1316.
The authors conducted a nationally representative, cross-sectional survey of the pandemic influenza planning of 2,294 assisted living facilities and personal care homes. They found that more than half did not have a pandemic influenza plan. Facilities that were small, for-profit, and non-chain-affiliated were less likely to have a plan while those with higher staff vaccination rates were more likely to have a plan.
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Martin, V., Castilla, J., Godoy, P., et al. (2016). High Body Mass Index as a Risk Factor for Hospitalization Due to Influenza: A Case-Control Study. Archivos de Bronconeumologia. 52(6):299-307.
The authors conducted a case-control study to determine the association between body mass index and risk of hospitalization due to influenza. The researchers matched laboratory-confirmed hospitalized influenza patients with laboratory-confirmed outpatients and an outpatient control group during the 2009-10 and 2010-11 influenza seasons. They found an approximate five-fold increase in risk of hospitalization for those with a body mass index between 35 and 40 kg/m2 compared to those of normal weight. They also found significantly increased risk of hospitalization for those with a body mass index between 30 and 34.9 kg/m2 who are unvaccinated and under 65 years of age, underscoring the importance of influenza vaccination for these populations.
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Matias, G., Haguinet, F., Lustig, R., et al. (2016). Model Estimates of the Burden of Outpatient Visits Attributable to Influenza in the United States. BMC Infectious Diseases. 16:641.
The authors used statistical modeling on time series data from two medical claims databases to estimate outpatient visits for respiratory diagnoses and otitis media attributable to influenza. For those under age 65, the model estimated approximately 14.5 million outpatient visits for respiratory diagnoses attributable to influenza, with approximately 80% occurring in those age 5 to 49. They also found approximately 2.2 million outpatient visits for otitis media attributable to influenza, with 86% occurring in those under 18 years of age.
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Nguyen, J., Yang, W., Ito, K., et al. (2016). Seasonal Influenza Infections and Cardiovascular Disease Mortality. JAMA Cardiology. 1(3):274-281.
The authors analyzed vital statistics and emergency department visit data for cardiovascular deaths during non-pandemic influenza seasons from 2006 to 2012 in New York City. They found a 2.3% increase in cardiovascular disease mortality, a 2.4% increase in ischemic heart disease mortality, and a 5.5% increase in myocardial infarction mortality in those 65 years and older associated with an increase from the 25th to 75th percentiles in the number of influenza-related emergency department visits in the previous 21 days.
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Rodrigo, C., Leonardi-Bee, J., Nguyen-Van-Tam, J., and Lim, W. (2015). Effect of Corticosteroid Therapy on Influenza-Related Mortality: A Systematic Review and Meta-Analysis. The Journal of Infectious Diseases. 212(2):183-194.
The authors reviewed 16 observational studies and found that corticosteroid therapy for presumed influenza-associated complications is associated with increased mortality. The authors also noted that they were unable to identify any clinical trials on the issue, not all studies specified the indications for corticosteroid therapy, and that when doses were specified they were a higher daily dose than typically recommended.
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Shrestha, S., Swerdlow, D., Borse, R., et al. (2011). Estimating the Burden of 2009 Pandemic Influenza A (H1N1) in the United States (April 2009-April 2010). Clinical Infectious Diseases. 52(suppl_1):S75-S82.
The authors modeled the number of cases, hospitalizations, and deaths due to 2009 H1N1 to address likely underreporting and compared these estimates to those for seasonal influenza. They found that the rates of hospitalizations and deaths among those under 65 were higher than for seasonal influenza while the rates of hospitalization were 75 percent lower and deaths 81 percent lower among those 65 and older in comparison to seasonal influenza.
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Simonsen, K., Hunskaar, S., Sandvik, H., and Rortveit, G. (2013). Capacity and Adaptations of General Practice During an Influenza Pandemic. PLoS One.
This Norwegian study of general practice and primary care doctors on duty in out-of-hours services reviewed consultations for influenza-like illness during the 2009 pandemic in comparison to the 2008-2009 influenza season. In both seasons, the majority of consultations occurred in general practice, but there was a 5.5 fold increase in out-of-hours consultations during the pandemic year.
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Resource Allocation and Management


Ajao, A., Nystrom, S., Koonin, L., et al. (2015). Assessing the Capacity of the US Health Care System to Use Additional Mechanical Ventilators During a Large-Scale Public Health Emergency. Disaster Medicine and Public Health Preparedness. 9(6):634-641.
This study models the number of additional ventilators that could be absorbed by hospitals during the peak of an influenza pandemic.
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Bayram, J., Sauer, L., Catlett, C., et al. (2013). Critical Resources for Hospital Surge Capacity: An Expert Consensus Panel. PLoS Currents.
The authors convened an expert consensus panel representing health providers, administrators, emergency planners, and specialists, and asked them to review four disaster scenarios and prioritize 132 hospital resources. The number of hospital resources considered to be critical varied by scenario: 58 for the pandemic influenza scenario, 51 for radiation exposure, 41 for explosives, and 35 for nerve gas scenario.
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Carias, C., Rainisch, G., Shankar, M., et al. (2015). Potential Demand for Respirators and Surgical Masks During a Hypothetical Influenza Pandemic in the United States. Clinical Infectious Diseases. 60(suppl_1):S42-S51.
The authors modeled demand for N95 filtering facepiece respirators and surgical masks during an influenza pandemic under base case, intermediate demand, and maximum demand scenarios. Because the billions of respirators and masks required under all three scenarios would likely exceed supply, the authors suggest the consideration of other strategies, including extended use and reuse of respirators and the use of other types of respirators.
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* Fain, B., Viswanathan, K., and Altevogt, B. (2012). Public Engagement on Facilitating Access to Antiviral Medications and Information in an Influenza Pandemic - Workshop Series Summary. The National Academies of Sciences, Engineering, and Medicine.
This report summarizes a series of workshops on the public’s perception of how to facilitate access to antiviral medication and treatment during an influenza pandemic.
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Huang, H., Araz, O., Morton, D., et al. (2017). Stockpiling Ventilators for Influenza Pandemics. Emerging Infectious Diseases. 23(6).
The authors developed a model to determine the optimal local versus central storage allocation of mechanical ventilators based on risk and stockpiling cost. Using data from Texas under mild, moderate, and severe scenarios, they found while central stockpiles may be more cost-effective, they are only advisable when there is little correlation in peak demand among local areas and deployment from a central location is highly reliable.
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Koonin, L. and Hanfling, D. (2013). Broadening Access to Medical Care During a Severe Influenza Pandemic: The CDC Nurse Triage Line Project. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 11(1):75-80.
The authors describe the Centers for Disease Control and Prevention's Nurse Triage Line Project and its goals of using a coordinated network of nurse triage telephone lines during a pandemic to assess the health status of callers, help callers determine the most appropriate site for care, disseminate information, provide clinical advice, and provide access to antiviral medications for ill people, if appropriate.
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Meltzer, M. and Patel, A. (2017). Stockpiling Ventilators for Influenza Pandemics. Emerging Infectious Diseases. 23(6):914-921.
This commentary on Huang, H., Araz, O., Morton, D., et al.’s Stockpiling Ventilators for Influenza Pandemics offers context for the challenge of estimating surge demand for ventilators during a pandemic. The authors discuss the importance of models like the ones described in the article and identify its strengths and limitations.
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Meltzer, M., Patel, A., Ajao, A., et al. (2015). Estimates of the Demand for Mechanical Ventilation in the US During an Influenza Pandemic. Clinical Infectious Diseases. 60(suppl_1):S52-S57.
The authors created a spreadsheet model to explore potential demand for invasive mechanical ventilation during an influenza pandemic. They used four standardized pandemic scenarios, each with a low and high clinical severity. They found that the number of deaths prevented varied greatly by scenario and was influenced by the shape of the epidemic curve and the effectiveness of ventilation as well as the distribution of ventilators throughout the healthcare system along with trained staff and resources to support their use.
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O'Hagan, J., Wong, K., Campbell, A., et al. (2015). Estimating the United States Demand for Influenza Antivirals and the Effect on Severe Influenza Disease during a Potential Pandemic. Clinical Infectious Diseases. 60 (Suppl 1):S30-41.
Following the detection of a novel influenza strain A (H7N9), the authors modeled the use of antiviral treatment in the U.S. to mitigate severe disease across a range of hypothetical pandemic scenarios. The model included estimates of attack rate, healthcare-seeking behavior, prescription rates, and other related data. Based on these inputs, the total antiviral regimens estimated to be available in the U.S. (as of April 2013) were deemed sufficient to meet treatment needs for the scenarios considered.
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Spaulding, A., Radi, D., Macleod, H., et al. (2012). Design and Implementation of a Statewide Influenza Nurse Triage Line in Response to Pandemic H1N1 Influenza. Public Health Reports. 127(5): 532-540.
The Minnesota Department of Public Health developed several tools to support healthcare providers during the 2009 H1N1 influenza pandemic, including MN FluLine, a nurse triage line, that reached many rural and uninsured residents, and, according to the authors, may have prevented up to 11,000 in-person health-care encounters.
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The Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. (2011). Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency. Centers for Disease Control and Prevention.
This document, developed by an expert workgroup, provides a conceptual framework for planning efforts related to allocation of mechanical ventilators during a severe influenza pandemic. It supplements a document released by CDC in 2007, Ethical Guidelines in Pandemic Influenza. The document outlines key assumptions, describes routine versus emergency practice, and discusses principles guiding ventilator allocation, who should make allocation decisions, and other considerations.
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The authors designed a decision model to determine whether the benefits of stockpiling antivirals for an influenza pandemic outweigh the negative consequences of not stockpiling. They estimated both the cost-effectiveness benefits as well as the health benefits, which were measured as deaths averted by stockpiling. While they found that the probability of not using a stockpile was greater than using it, stockpiling was justified due to the catastrophic losses that would occur from a severe pandemic without it.
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Zaza, S., Koonin, L., Ajao, A., et al. (2016). A Conceptual Framework for Allocation of Federally Stockpiled Ventilators During Large-Scale Public Health Emergencies. (Registration required.) Health Security. 14(1):1-6.
The authors describe a conceptual framework for the distribution of ventilators stockpiled by the federal government during a large-scale emergency. They identify necessary planning steps to aid in the optimal allocation of ventilators to individual hospitals.
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Vaccines


Biggerstaff, M., Reed, C., Swerdlow, D., et al. (2015). Estimating the Potential Effects of a Vaccine Program Against an Emerging Influenza Pandemic, United States. Clinical Infectious Diseases. 60(suppl_1):S20-S29.
The authors modeled the effects of variables including the start time of a vaccination campaign, number of vaccine doses administered per week and allocation by age group, clinical attack rate, case hospitalization ratio, and case fatality ratio, on an influenza pandemic. The timing of the start of the vaccination campaign relative to the start of the pandemic had the greatest effect, with 141,000 to 2.2 million hospitalizations and 11,000 to 281,000 deaths prevented when the vaccination program started prior to the beginning of the pandemic.
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* Centers for Disease Control and Prevention. (2017). Vaccine Recommendations and Guidelines of the ACIP. U.S. Department of Health and Human Services.
This webpage includes links to current and archived influenza vaccine recommendations from the Advisory Committee on Immunization Practices.
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Centers for Disease Control and Prevention. (2018). Allocating and Targeting Pandemic Influenza Vaccine During an Influenza Pandemic. U.S. Department of Health and Human Services.
This document provides guidance on the allocation of influenza vaccine during the early stages of a pandemic when demand may exceed production capacity. It offers general principles on pandemic vaccination and a framework based on targeted groups and pandemic severity.
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  • Sheran Kaplan-Hicks This link is broken and does not provide access to this document.
    10/15/2019 12:32:50 PM
Fitzgerald, T., Kang, Y., Bridges, C., et al. (2016). Integrating Pharmacies into Public Health Program Planning for Pandemic Influenza Vaccine Response. Vaccine. 34(46):5643-5648.
The authors analyzed reporting data from immunization and public health preparedness programs to assess their pandemic planning with pharmacies. They found that most jurisdictions include pharmacies in their pandemic vaccine distribution plans, nearly half have a process to recruit pharmacists as vaccinators, and nearly a third have formal relationships established with pharmacies.
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Li, Z., Swann, J., and Keskinocak, P. (2018). Value of Inventory Information in Allocating a Limited Supply of Influenza Vaccine During a Pandemic. PLOS One. 13(10):e0206293.
The authors describe using a population-based allocation model versus a model based on population plus inventory demand to simulate the value of information on vaccine inventory levels during an influenza pandemic. They find that the population plus inventory approach may reduce the attack rate, decrease the amount of unused vaccine, and maintain or increase the percentage of the population vaccinated, suggesting that greater visibility of the vaccine supply chain would be beneficial.
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Manzoli, L., Ioannidis, J., Flacco, M., et al. (2012). Effectiveness and Harms of Seasonal and Pandemic Influenza Vaccines in Children, Adults and Elderly. Human Vaccines and Immunotherapeutics. 8(7):851-862.
The authors completed an umbrella review and reanalyzed data from 15 previously published meta-analyses to determine how different analyses and study selection criteria could explain differences in findings or interpretations. They found statistically significant efficacy and effectiveness – high for laboratory-confirmed cases in children and adults and modest for clinically-confirmed cases and for the elderly – of seasonal influenza vaccines. They identified a scarcity of data on the efficacy of live-attenuated vaccine in those less than two years old, suboptimal quality of harms data, and a lack of meta-analysis on the effect of H1N1 vaccination on clinical outcomes.
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Moulia, D., Dopson, S., Vagi, S., et al. (2017). Readiness to Vaccinate Critical Personnel during an Influenza Pandemic, United States, 2015. (Abstract only.) American Journal of Public Health. 107(10):1643-45.
The authors analyzed results from two surveys to assess readiness to vaccinate critical infrastructure personnel during an influenza pandemic. They found that less than half of responding public health preparedness programs had a plan to identify and vaccinate such workers and slightly more than a quarter of immunization programs knew the number of such personnel in their jurisdictions.
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* Noah, D. and Noah, J. (2013). Adapting Global Influenza Management Strategies to Address Emerging Viruses. American Journal of Physiology - Lung Cellular and Molecular Physiology. 305(2):L108-L117.
The authors provide an overview of influenza and discuss epidemiology and surveillance, perspectives on vaccines and antivirals, and research opportunities related to universal vaccine, alternate vaccine production strategies, novel antiviral development, and continued transmission studies.
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* Saunders-Hastings, P., Quinn Hayes, B., Smith, R., and Krewski, D. (2017). Modelling Community-Control Strategies to Protect Hospital Resources During An Influenza Pandemic in Ottawa, Canada. PLoS One. 12(6).
The authors modeled the effects on hospital capacity in one city of various strategies to control an influenza pandemic. They calculated ranges bounded by no interventions and all interventions for the attack rate, peak acute care hospital capacity, peak intensive care unit capacity, and mortality along with estimated economic burdens. They found vaccination, isolation, and personal protective measures to be the most effective strategies. However, all interventions decreased in effectiveness as transmissibility increased and as the outbreak progressed.
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This study reviews existing systematic reviews and meta-analyses on pandemic influenza interventions including vaccines, antivirals, personal protective measures, school closures, and traditional Chinese medicine. Pandemic influenza vaccine was found to be protective against infection, but the authors found insufficient evidence for the effectiveness of each of the other interventions in isolation and hypothesized that a combination of interventions would be most effective.
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Schwerzmann, J., Graitcer, S., Jester, B., et al. (2017). Evaluating the Impact of Pharmacies on Pandemic Influenza Vaccine Administration. (Abstract only.) Disaster Medicine and Public Health Preparedness. 11(5):587-593.
The authors developed a model to estimate the effects of vaccine administration in retail pharmacies. They estimated that nationwide capacity to administer vaccines would increase to 25 million doses per week when retail pharmacies were included and that the time to achieve 80% nationwide vaccination coverage could be reduced by seven weeks.
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Agencies and Organizations


Association of State and Territorial Health Officials. Pandemic Influenza.
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Centers for Disease Control and Prevention. Influenza.
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Centers for Disease Control and Prevention. Pandemic Influenza.
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Centers for Infectious Disease Research and Policy. Influenza.
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Centers for Infectious Disease Research and Policy. Pandemic Influenza.
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Infectious Diseases Society of America. Animal Influenza Viruses of Zoonotic Concern. Supplement of The Journal of Infectious Diseases.
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National Institute of Allergy and Infectious Diseases. Influenza.
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National Library of Medicine Disaster Information Management Research Center. Pandemic Influenza: Preparedness and Response.
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Office of the Assistant Secretary for Preparedness and Response. Influenza and Outbreaks.
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U.S. Department of Agriculture, Animal and Plant Health Inspection Service. Avian Influenza.
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U.S. Department of Agriculture, Animal and Plant Health Inspection Service. What is Influenza A Virus in Swine (IAV-S).
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U.S. Department of Labor, Occupational Safety and Health Administration. Pandemic Influenza.
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U.S. Department of Labor, Occupational Safety and Health Administration. Seasonal Influenza.
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World Health Organization. Influenza.
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