*Pandemic Phases, Triggers, and Response*
Defining Triggers to Initiate a Timely Response During a Pandemic
By: Fairplay
September/December 2006

  • Pandemic Phases, Triggers, and Response
    1. Introduction
    2. This document was created to capture thoughts and research that define a set of triggers used to initiate appropriate and timely responses during a pandemic. If you want to jump directly to the conclusions, go directly to section 1.5 Recommended Response.

      1. How to Use This Document
      2. This document will be the most benefit if used as a workbook. Use it to help assess your pandemic preparedness.

      3. Organization

    There is a section that provides an overview of the existing WHO pandemic phase definitions, why they are important, and a brief discussion on the speed that a pandemic is expected to develop. The remaining sections describe the thought behind establishing triggers and responses.

    Each of these remaining sections is grouped logically to simplify planning. Each section contains:

    Goals are established at the beginning to establish a well defined target. Recommendations are provided followed by the rationale. Worksheets are provided to help assess if the goals have been met.

        1. How To Use The Worksheets

    The worksheets are intended to provoke thoughts on how to improve preparedness. There is no right or wrong answer. The totals are not intended to provide an absolute "score", but instead are intended to provide a "yardstick" to measure the level of current preparedness so that areas needing improvement can be addressed. For each row, put a 1 under Yes or No column. Add up the totals for the Yes and No columns. Work towards a goal of 100% preparedness.

      1. Pandemic Phase Definitions
        1. Goals
        2. Understand the definition of the phases used to communicate the status of a pandemic.

        3. Recommendations
        4. Review the Pandemic Phase Definitions table.

        5. Rationale
        6. In order to communicate effectively it is essential that everyone is using the same terminology when discussing the status of a pandemic. You should know something about the various phases of a pandemic and be alert when there is a change being discussed. Remember you donít have to memorize all of this information; you just need to know where to find it when a question arises. When you get a Rubicon Alert on your cell phone that the pandemic is at Phase 5 you will know what that means and what to do.

        7. Pandemic Phase Definitions

        Phase

        WHO Definition

        One

        Low risk of human cases.

        Two

        Higher risk of human cases.

        Three

        No or very little limited human to human transmission.

        Four

        Evidence of increased human to human transmission.

        Five

        Evidence of significant human to human transmission.

        Six

        Efficient and sustained human transmission.

      2. How Fast Will It Spread
        1. Goals
        2. Understand the rapid speed at which a pandemic may spread, what the experts are saying, and what computer simulations are projecting. Understand that the infection will come in waves and there may be brief times between waves that may be safer than other times during a pandemic.

        3. Recommendations

    Los Alamos National Laboratory created a simulation showing how H5N1 could spread across the US. The infection is started when 10 infected individuals arrive in Los Angeles. By day 50, infection has spread across the US to most major cities. This is one wave and peaks at about day 90. By day 120, the infection is subsiding in Los Angeles, where it started and still active in more remote areas. On the next page are screenshots of the simulation at 50, 90, and 120 days. The colors on the maps represent infection rates as follows:

    Watch the computer simulation. It will open your eyes, it opened mine!

    Los Alamos National Laboratory Pandemic Flu Model link describes the simulation and has a link to run it:

    http://www.lanl.gov/news/index.php?fuseaction=home.story&story_id=8171

     

        1. Rationale
        2. It is important to fully realize how fast an evolved influenza virus could spread. . This is particularly noteworthy if you have family members that are remote and plan to return home during a pandemic or if you plan to bug out or relocate to weather a pandemic. Governments have stated the possibility that travel restrictions and quarantines may be used to slow the spread of infection. It is unclear how and when travel restrictions may be implemented. Avoiding getting caught in route with limited supplies would suggest that an early response is desirable if your plans include relocation.

           

        3. Phase Worksheet

    Pandemic Phase Definitions Questions

    Yes

    No

    Do you have a general idea of the pandemic phases?

       

    Experts believe there will be multiple waves of infection.

       

    Experts believe each wave may last 2-3 months.

       

    There may be brief periods between waves that infection is less likely.

       

    Experts estimate that the total pandemic could last 18-24 months or longer.

       

    You can still get influenza at the most remote location.

       

    Experts say that hygiene, social distancing, and quarantine are the best available tactics to slow a pandemic.

       

    Totals

       

     

     

     

     

      1. Triggers and Responses
        1. Goals

    Understand the importance of having defined triggers and responses.

    Define triggers that allow a response in time to:

    1. Avoid infection
    2. Avoid spreading the infection
    3. Survive the infection
    4. Survive the aftermath

        1. Recommendations
        2. Plan the timing of a response based that can be realistically supported by existing capabilities.

        3. Rationale
        4. A trigger is an observable event. A response is your reaction to that trigger. All triggers are the same for everyone. All responses are the same for everyone. What is different is the timing of when you respond. This is an important concept that will simplify your planning. It also establishes a common language and terminology for the Rubicon membership that will help us communicate our status effectively with one another in different geographic areas.

          There may be little time to respond when sustained human transmission occurs. It is POSSIBLE that sustained human transmission evolves initially at a location much closer than the other side of the globe, in which case there may only be days or hours to respond. This is a guide, individual and families should make their own decisions about how to respond. These decisions will be difficult and should be discussed and decided in advance. Waiting for as long as possible without endangering members will help us keep jobs, insurance, stay in touch with loved ones, and care for our homes for as long as is safe to do so.

          It is therefore very important to have a well defined plan of response based on a set of observable triggers. These triggers initiate a response in order to react in time to reduce the opportunity of infection. The triggers are well defined. Each response should be discussed and agreed to as appropriate by your family before the pandemic begins. Without such a detailed plan, valuable time will be lost deciding what to do instead of responding.

          The primary objective is to avoid infection. This plan contains many aspects on how to prepare and how to develop habits that are not only desirable during a pandemic but many are healthy habits that should be practiced as standard operating procedures all the time. Many responses are also applicable to other threats such as biological, nuclear, or natural. The time that you spend discussing triggers and responses with your family will be time well spent in improving your preparedness efforts. Knowing when to respond is as important as knowing how to respond. Each member of your family should know what is expected of them so everyone can work together more effectively.

          If infection has occurred it is important to avoid spreading the infection. Those not infected will be required to care for those that are ill. Home care may be necessary and/or desirable if hospitals and clinics are at capacity. Prevention and survival will be dependant on rapid response to quickly changing conditions.

          The triggers are the same for everyone. The responses are the same for everyone. When a response is executed determines your level of risk. Each Rubie has different conditions that affect capabilities. For example: your family, where they are physically located, your health, your job, and your financial priorities all may affect the timing of a response. The timing of a response for a couple that is retired, well prepared, with no mortgage may be different than the timing of a response for a family with children, only partially prepared, paying a mortgage, with children living at home, and other children attending a university in another city. The responses are the same but the timing may be different based on individual capabilities.

          You have invested time and money in material preparations that will be of little value if you do not have a plan and the capability to respond with timing reflecting your risk tolerance. Timing will be critical to use these preparations during what will likely be a rapidly changing environment as a pandemic develops.

        5. Trigger Simplification

    An analysis of triggers suggested that the large number of triggers could be simplified to the following:

    People today are highly mobile; therefore, it is prudent to afford yourself the highest margin of safety permissible given your personal circumstances without reacting too early as a pandemic develops.

     

      1. Recommended Response
        1. Goal
        2. Minimize infection risk by timely response.

        3. Recommendations
        4. Trigger

          Response

          NOW

          Hygiene

          Monitor

          Response plan defined

          Preparations complete

          Human sustained, remote

          Alert Family

          Human cases, national

          Assemble Family

          Limit travel

          Human cases, regional

          Operate Positive Pressure (FIAC)

          Quarantine

          Decontaminate

          Wear Mask Outside

          Animal cases, regional

          Animal controls

          Human cases, local

          Lock down

          Human cases, in house

          Isolate

          Use antiviral

           

            1. Rationale

        A response initiated too early will waste valuable resources that may be in short supply. A response too late increases the risk of infection.

        Attention now should be on evaluating and completing your preparations including reviewing plans to identify and improve weak areas.

      2. Evaluate Your Capabilities
        1. EVALUATE YOUR INFORMATION SOURCES
          1. Goals
          2. Develop your information sources so you will know when to pull the trigger.

          3. Recommendations
          4. Use the worksheet to improve your awareness and improve your sources of reliable information.

          5. Rationale
          6. Early detection is dependant upon the quality and availability of information from many sources including: news reporting, government agencies, internet blogs, and certainly the Rubicon. Keep in mind that once a pandemic starts events will happen rapidly. Reliable information will likely become increasingly suspect, containing a chaotic mix of rumors and facts. Government agencies may even attempt to suppress information to reduce panic and may not have reliable information depending on how broken the "system" becomes because of the pandemicís disruption.

            Think about the people that you know that work in various places and jobs that can be sources of reliable first hand information. It is likely that EMTs, LEOs, and hospital workers are going to be aware of a pandemicís effects before it becomes common knowledge. The homeless, people in long term care facilities, and inmates are likely going to show signs of a pandemicís impact first because of their proximity and exposure to other people. Also school children, college students, and people living on military installations or on campus type grounds are at higher risk for infection.

            Make use of your available sources of information and share what you know with the Rubicon. You will think of other people to cultivate as sources of information. Now before a pandemic starts is the time to develop your information gathering capabilities and develop habits to help you monitor a pandemic when it occurs.

          7. Information Sources Worksheet

          Information Sources

          Yes

          No

          I read the newspaper every day.

             

          I watch the news on TV or radio every day.

             

          I get my news from the Rubicon.

             

          I work or have friends that are health care professionals.

             

          I work or have friends that are first responders (EMTs, LEOs).

             

          I work or have friends that work in a long term care facility or nursing home.

             

          I visit NBII wildlife disease maps.

          http://wildlifedisease.nbii.gov/diseaseresource.jsp?disease=Avian%20Influenza&section=Maps&pagemode=submit

             

          I visit CIDRAP.

          http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/index.html

             

          I visit WHO.

          http://www.who.int/csr/disease/avian_influenza/en/

             

          I visit CDC.

          http://www.cdc.gov/flu/avian/outbreaks/current.htm

             

          I visit H5N1 News and Resources for timely information about Avian Flu.

          http://crofsblogs.typepad.com/h5n1/

             

          I rely on FluWiki news aggregators and blogs.

          http://www.fluwikie.com/pmwiki.php?n=Resources.Resources

             

          I visit The Microbiology Information portal for my news.

          http://www.microbes.info/news/bird_flu.php

             

          Total score

             

           

        2. Evaluate your Capability to Reduce Exposure
          1. Goals
          2. Identify ways to reduce exposure.

          3. Recommendations
          4. Use the worksheet to identify areas for improvement. For example: now is the time to try working from home (if that is a possibility).

          5. Rationale
          6. Until an effective vaccine is available; hygiene, social distancing, and quarantine are the best tactics to reduce chances of exposure and infection. Each trip beyond the confines of your positive pressure protection represents increased risk of exposure and infection.

          7. Job, Health, and Finance Worksheet

          Health, Job, and Finance Questions

          Yes

          No

          Do you have the option of receiving your supply of required medication via the mail instead of visiting the pharmacy? Your spouse? Your children?

             

          Do you have a relationship with your Doctor that would allow you to conduct your business on the telephone and reduce or avoid office visits? Your spouse? Your children?

             

          If you rely on employer-provided health insurance for a health condition or medication, do you have a plan for coverage if you lose your job?

             

          Does your employer have a disaster or pandemic plan?

             

          Do you know how your employer will manage absenteeism during a disaster or pandemic?

             

          Can you work from home?

             

          Have you tried working from home?

             

          Do you have accrued vacation or paid time off?

             

          Does your employer have a temporary leave of absence program?

             

          Do you have any disability insurance? Short-term or long-term?

             

          Do you have unemployment insurance?

             

          Do you have a short-term emergency cash reserve? Enough to operate your household for 6 to 12 months?

             

          Do you have barter-able goods and services? Do you have a barter network? Are you a successful barter or a newbie?

             

          Do you bank on-line? Can you conduct your financial affairs without leaving your home? Can you pay common bills on-line? Can you wire transfer on-line? Can you access your account and make payments by telephone?

             

          Totals

             

           

        3. Evaluate Your Preparations
          1. Goals
          2. Determine level of preparedness and prioritize needed improvements.

          3. Recommendations
          4. Use the worksheet to evaluate your preparedness and identify areas that need improvement.

            There are many good articles in the Rubicon and an abundance of Rubicon experts available on the boards to help answer these questions. Avoid becoming overwhelmed. Instead take each row in the worksheet and evaluate an answer based on your circumstances. If you really donít know the answer, take the time to determine an informed response based on FNV. For example: you may have bought a few N100 masks. Do you have enough? How did you determine that number? How long will they last? This worksheet is intended to break things down into "bite sized" manageable pieces.

          5. Rationale
          6. You canít fix what you donít know is broken.

          7. Preparations Worksheet

        Preparations Questions

        Yes

        No

        Do you have adequate food storage for a wave that may last 2-3 months?

           

        Do you have adequate food storage for a pandemic that may last 18-24 months?

           

        Do you have adequate supplies of PPE (including masks, tyvek suits, etc.)?

           

        Do you have the means to isolate a family member that becomes ill?

           

        Do you have adequate supplies to care for a family member that becomes ill?

           

        Do you have adequate over the counter medications?

           

        Do you have adequate cleaning and disinfectant supplies?

           

        Do you have the means to quarantine arrivals that may be infected?

           

        Do you have the means to decontaminate mail? Money?

           

        Do you have an alternative source of electricity?

           

        Do you have an alternative source for heat?

           

        Do you have an alternative way to cool?

           

        Do you have a security system?

           

        Do you have a water supply?

           

        Do you have a positive pressure system (FIAC, etc)?

           

        Do you have the means to decontaminate when reentering the confines of your positive pressure protection?

           

        Do you have alternative communication capabilities (HAM, CB, etc.)?

           

        Do you have "things to do" for entertainment to avoid cabin fever?

           

        Do you have a plan to deal with the bodies of dead family members?

           

        Totals

           
      3. Definitions
        1. Terminology
        1. Trigger Definitions

    The initial list of triggers was identified:

    1. Animal cases, remote.
    2. Human cases, remote.
    3. Human clusters, remote.
    4. Human sustained, remote.
    5. Animal cases, national.
    6. Human cases national.
    7. Human clusters, national.
    8. Human sustained, national.
    9. Animal cases, regional.
    10. Human cases, regional.
    11. Human sustained, regional.
    12. Human cases, regional.
    13. Animal cases, local.
    14. Human cases, local
    15. Human clusters, local.
    16. Human sustained, local.

     

    1 - 3, 5 were eliminated because they have already occurred. 6, 7, 8 were collapsed into a single trigger; Human cases, national to simplify. 10, 11, 12 were collapsed into a single trigger; Human cases, regional to simplify. 13 was eliminated because it was felt to represent a delayed response with unacceptable risk. 14, 15, 16 were collapsed into a single trigger; Human cases, local.

     

        1. Response Definitions

    The initial following responses were identified:

    1. Hygiene
    2. Monitor
    3. Alert Family
    4. Wear mask outside
    5. Animal Control
    6. Stay home
    7. Use antiviral (post exposure or preventive)
    8. Bug Out
    9. Assemble Family
    10. Quarantine
    11. Operate positive pressure system (FIAC)
    12. Decontaminate
    13. Isolate infection
    14. Use antiviral (illness treatment)

     

    7 was eliminated based on conversation with medical professionals and high cost that was better spent on other preparations.

      1. References

     

    Pandemic Reference Guides

    http://www.pandemicreferenceguides.com/

    Los Alamos National Laboratory Pandemic Flu Simulation

    http://www.lanl.gov/news/images/avianflu.shtml

    Los Alamos National Laboratory Pandemic Flu Model

    http://www.lanl.gov/news/index.php?fuseaction=home.story&story_id=8171

    University of Maryland Pandemic Plan

    http://www.umd.edu/emergencypreparedness/pandemic_flu/pdfs/AvianFlu_S.pdf


    Fairplay



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