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Volume 30, Issue 3

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Tuesday, 30 June 2009 15:17

Planning for the Fall – The H1N1 Pandemic

Written by  Regina Phelps, CEM, RN, BSN, MPA
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The events of the end of April were almost surreal. The country, the world had slipped into a lull. Pandemic fatigue had set in and we were well on to the next disaster de jour. Suddenly, a respiratory illness began to spread like wildfire from Mexico, taking everyone by surprise. Our eyes had been facing east to Asia and the Middle East, expecting H5N1. A new novel influenza virus had developed literally right under our nose.


The goal of this paper is to look at three things:

  1. The current status of the threat (understanding that this changes daily).
  2. Why you should care about this.
  3. What you can do when you don’t have much time left to plan.


The total number of reported H1N1 cases doesn’t really tell the story. Cases reported by the World Health Organization (WHO) or the Centers for Disease Control (CDC) are only those cases that have been documented by laboratory analysis. There are thousands of cases worldwide that are not counted in WHO or CDC numbers. Many of these are individuals who have become ill with a mild illness, treated themselves as they normally do, and recover without any difficulty.

The impact to the U.S. health care system has been significant in a country that has all but lost its ability to handle any surge in most city hospitals. Ask yourself this: Today, in your community, how many additional patients could local hospitals and emergency departments take without breaking under the burden? What if they have a number of sick staff as well, and have even less capacity than normal?


There are two compelling reasons why you should care about this:

  1. No one knows what is going to happen, no one. Anything from mild to severe disease is possible.
  2. There will not be a “silver” medical bullet.

Really? No one knows what is going to happen? Unfortunately, that’s true. It is very hard for the public to understand this important aspect of the pandemic flu story. No one knows what the virus will do. It is capable of mutating and changing on a daily basis. Currently, the illness is mild, but that could change suddenly. Historically, in 1918, the first wave of the flu was very mild. It returned in the fall to be a major killer.

Secondly, there will be no immediate medical solution for the illness. Vaccines are the best option, and it will take from six to nine months once the seed vaccine has been created. It will then be rationed by governments around the world as they see fit, based on the best thinking at the time. There will not be enough for most of us, and the second wave will likely conclude in the Northern Hemisphere with many of us not yet vaccinated. Additionally, the vaccine will likely require two shots to be effective, further contributing to the shortage. The good news is that antivirals are helpful. If taken once you have become ill, they will likely reduce the number of days you are ill as well as reduce the severity of the illness.

You should care about the pandemic issue as a individual, a family member, a person in your community, a company, a nation, and a world. It is in everyone’s best interest for us to be as prepared as we possibly can.


First of all, you don’t have much time. The official flu season in the Northern Hemisphere begins October 1. I recommend that you put a very large calendar on your wall as a reminder of the passage of time. With a limited amount of time, stay focused on these six issues:

  1. Categorization of staff.
  2. Education and communication.
  3. Cleaning protocols.
  4. Social distancing.
  5. Personal Protective Equipment (PPE).
  6. Medical management.

1. Categorization of staff

This is a critical aspect of any pandemic plan, but is also helpful in your overall BCP program. It entails the categorization of employees into one of two basic “buckets” according to mission-critical or non-mission-critical functions. This categorization is essential for future identification of necessary resources, including acquisition of PPE and training. Within each of those categories there are two sub-categories.

  • Mission-critical functions and staff:
    • Category One – Those who perform a mission-critical activity and must be on-site to perform the work.
    • Category Two – Those who perform a mission-critical activity and may work remotely.
  • Non-mission-critical functions and staff:
    • Category Three – Those who perform an activity that is not mission-critical but could also “backfill” the Category One and Two staff.
    • Category Four – Those who perform an activity that is not mission-critical and cannot be performed via remote access (e.g., mail room clerk or shipping attendant).

Making It Safe for Category One Staff

The big issue here is how to protect the staff who must be at work. If you can’t make it safe for them to be at work, they may not elect to come.  Some of the measures that will be used with this group are:

  • Social distancing.
  • Extensive workplace cleaning.
  • Masks.
  • Shift work and flex scheduling.
  • Limit face time.
  • Institute a no-handshaking policy.
  • Cross-training.

Connecting the Category Two Staff

Category Two staff are mission critical, but can work remotely. There are two parts to the work-from-home solution:

  1. The things you control – Equipment, company systems, and network.
  2. The things you don’t – Telecommunications and the “last mile.” A December 2007 DHS study (DHS, Pandemic Influenza Impact on Communications Networks Study, December 2007) notes clearly that at times of high absenteeism, the remote work solution might not work.

Key strategies for Category Two staff include:

  • Identify equipment needed to support remote work and amount of bandwidth the company needs to meet projected demands.
  • Identify alternative work options for call center environments.
  • Increase capacity and number of conference call bridges and provide training on how to use remote meeting technology.
  • Train staff to provide sufficient Help Desk support to remote staff.
  • Exercise the strategy by requiring Category Two staff to work from home one day a month to “work out the bugs.”

What about Category Three and Four Staff?

Those employees identified as Category Three and Four (not mission critical and will not be working) bring up issues of employment policies, pay, and benefits. Get the best possible human resources and communications advice. Bring in outside experts if necessary to develop policies.

  • Develop pay and benefit policies now. Consult with your labor attorneys to be clear about what you can – and cannot – do.
  • Will you extend medical or family leave to accommodate Category Three and Four staff? If so, for how long?

2. Education and communication

One critically important pillar to any pandemic program is education and communication. The two go together hand-in-hand.


A key education topic is hand and cough hygiene. Not only are hand hygiene practices the simplest things to do, they are the most effective and most recommended by all agencies and medical experts. Staff must be educated about thorough hand washing (for 20 seconds, using warm water and soap), to avoid touching their faces, and proper cough and sneeze etiquette (always cough or sneeze into your elbow or shoulder, ideally into fabric). A very amusing and thoughtfully designed video is called “Why don’t we do it in our sleeves?” Available at http://www.coughsafe.com/media.html.

One excellent resource is the new education program in the UK entitled, “Catch It, Bin It, Kill It.” There are posters, a very captivating video, and also children’s coloring books and songs, all available through the National Health Service.

It is also important area to teach overall employee preparedness for other hazards. This is critical for your overall company readiness. The outreach should include preparedness information about the hazards of your particular area, in addition to pandemic planning.


How quickly did you communicate with your employees when this all began in April 2009? Prompt, effective, and efficient communication can make the difference between what is viewed as a thoughtful and timely response, and one that is perceived as sloppy and hurried. This requires your communications team to develop pre-approved template communication materials now, and to develop lists of all identified key stakeholders.

3. Cleaning protocols

Respiratory illnesses are spread by droplet nuclei, and our hands carry bacteria and viruses to our faces, where we can then breathe them into our lungs. This makes extensive cleaning of all commonly touched surfaces absolutely essential. During a pandemic, however, janitorial staff is likely to be in short supply. The solution will be a combination of well-trained janitorial staff, and employees cleaning their own areas.


  • Develop and/or refine procedures for facility cleaning
  • Identify which cleaning agents will be used – products should have both anti-bacterial and antiviral properties.

4. Social distancing

Social distancing is a technique used to minimize close contact among persons in public places, such as work sites and public areas. It involves keeping people three to six feet apart. This can be a challenge in some work environments. Assess your situation daily. Be sure to include this social distancing information in your pandemic staff education.

Some social distancing options include:

  • Split teams into different work locations.
  • Stagger shift changes.
  • Prohibit face-to-face meetings. Use technology solutions: telephones, video conferencing, and web meetings.
  • Avoid unnecessary travel.
  • Contrary to non-pandemic situations, advise your employees to avoid public transportation and drive to work. Or allow a version of “flex time” that will work for you, with employee work hours shifted earlier or later to avoid rush-hour crowds on public transport.
  • Introduce staggered lunchtimes to minimize numbers of employees in lunchrooms at any one time.
  • Advise employees not to congregate in break rooms or smoke-break areas where people normally socialize. If they do, advise them to keep three to six feet from their colleagues.
  • Discourage or prohibit hand shaking and hugging.
  • Close company gyms, childcare centers, and recreation areas.
  • In areas where workstations may be shared (such as call centers), provide each worker with his or her own keyboard and headset or phone. Remind employees not to share their equipment and to clean all work surfaces before beginning work.

In work settings where social distancing is not possible, the introduction of personal protective equipment (such as masks) may make the difference between your business being open or closed.

5. Personal Protective Equipment

In a pandemic event, there will likely be work that must be performed, but staff cannot be separated by a minimum of six feet. In these instances, personal protective equipment (PPE) will be required. The U.S. Department of Health and Human Services and the Centers for Disease Control have issued interim guidance on the use of facemasks and respirators. Make a point of checking their websites on a regular basis to ensure that you have the most current guidance.

PPE program questions to address:

  • When will the PPE be distributed?
  • Who will develop the training needed to support use of PPE?
  • Who will deliver initial and refresher training?
  • Who will develop a security plan so that the supplies of PPE are secure during the pandemic?

6. Medical Management

Medical management during a pandemic includes three areas:

  1. Medical advice.
  2. Flu vaccine program – both seasonal and pandemic.
  3. Antivirals.

Where will you find qualified medical advice during a pandemic? Sources that you might normally go to, such as local Departments of Public Health, may be overwhelmed. Consider a contract with “virtual medical support” for advice as necessary.

The CDC is strongly encouraging a seasonal flu shot this year so that everyone will be protected against our “usual” seasonal flu (H3N2). Then, if someone gets a flu during the next pandemic wave, you could assume it was the pandemic strain. Having a seasonal flu program in place also provides another plus: you will have the process in place when a pandemic vaccine becomes available. Vaccines take six to eight months to develop and prepare, and initially, supplies will be very limited.

Antivirals are the only pharmacological option for potentially preventing, shortening, or reducing the severity of illness. Offering employees antivirals as part of a prevention or treatment strategy could be a cost-effective way of improving chances that critical staff can come to work, reducing worker absenteeism and bolstering employees' and customers’ confidence in your company. Questions to consider:

  • Will antivirals be used as a strategic response to a pandemic? If yes, does that include distribution to employee families?
  • When and how would the medications be ordered?
  • Where will antivirals be stored?
  • When will they be distributed?
  • How will employees be educated about their use and storage?

These questions and your answers to them are crucial. In the absence of a readily available, effective vaccine – which will take months to produce and will have limited availability – antiviral drugs may be the best pharmaceutical hope for mitigating disease and preventing death.


Thankfully, it is not often that you get to put the work that you do everyday into practice. We are in one of those professions where people pray that they will never have to use what has been worked so hard to develop. As the famous Cecil De Mille was noted for saying, “Get ready for your close up.” Our time, perhaps, has come.

Regina Phelps, RN, CEM, BSN, MPA is an internationally recognized expert in the field of emergency management and contingency planning.  She is the founder of Emergency Management & Safety Solutions (www.ems-solutionsinc.com). With over 27 years of experience, she has provided consultation and speaking services to clients in four continents. Ms. Phelps first began speaking on the pandemic threat at the Fall World Conference in San Diego in 2003 and has written hundreds of pandemic plans and conducted over 250 pandemic exercises since that time.

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