Appendix: CDC Intervals for a Novel Influenza A Virus Pandemic: State/Local and Federal Indicators, Decisions, and Actions

Incident management

• Review state/local response plans.
• Coordinate activities and response plans with state animal health officials, as appropriate.
• Review and exercise all aspects of influenza response.

• CDC and the World Health Organization (WHO) convene international experts to implement the Influenza Risk Assessment Tool* to assess the risk for emergence of the novel virus, as well as the potential impact of the virus.
• If the United States is affected, report human cases to WHO (per the 2005 International Health Regulations).
• If the United States is affected, report animal cases to the World Organization for Animal Health (OIE) as required by OIE standards.
• Identify priority preparedness activities and accelerate progress.
• Consider activation of emergency operations centers.

Surveillance and epidemiology

• Maintain and enhance influenza and respiratory virus surveillance systems as needed.
• Implement case-based investigation of novel influenza infections in humans and animals.
• Assess contacts of ill persons to determine human-to-human transmission and risk factors for infection.
• Report cases according to the Nationally Notifiable Diseases Surveillance System.
• If only animal cases are identified, assess human exposures and risks for infection.†
• Coordinate activities with state animal health representatives as appropriate.
• Identify whether state or federal assistance is required to support surveillance systems, field investigation, laboratory, and animal control resources.

• Support international investigation efforts.
• If the United States is affected, support state and local investigation efforts.
• Coordinate activities with animal health officials.
• Maintain and enhance national surveillance for animal and human cases as needed.
• Update guidance for surveillance measures as relevant to the situation.

Laboratory

• Assess and optimize laboratory capacity to detect and characterize influenza cases.
• Coordinate activities with state/local veterinary diagnostic laboratories.
• Share viruses with CDC and the U.S. Department of Agriculture (USDA).
• Identify whether state or federal assistance is required to support laboratory activities.

• Support international efforts to characterize the virus, including antiviral resistance profiles.
• If the United States is affected, conduct laboratory confirmation of cases and monitor virus for transmission characteristics and resistance.
• Develop and distribute test kits to states and other countries if indicated.
• Identify genetic and antigenic relationship of virus to available vaccine candidates and to stockpiled vaccine.
• Initiate actions to isolate virus; prepare candidate vaccine viruses for use in vaccine development.
• Update select agent regulations and biosafety guidelines as appropriate for the situation.

Community mitigation

• Emphasize the importance of personal protective measures (e.g., voluntary isolation by staying home when ill, respiratory etiquette, and hand hygiene) in limiting spread of influenza.
• If human-to-human transmission is suspected, consider recommending isolation of ill persons and voluntary quarantine of close contacts (e.g., household members).
• Enhance all usual influenza pandemic preparedness activities with schools and businesses.

• Promote community mitigation preparedness activities, especially voluntary home isolation of ill persons, respiratory etiquette, hand hygiene, and infection control.
• Review all guidance documents and update as needed for the situation (e.g., recommendations on community mitigation measures and other nonpharmaceutical interventions designed to slow the spread of the virus in the community or within certain populations and settings at high risk for infection).
• Provide guidance for border health and travelers' health activities as appropriate for the situation.
• Evaluate the need to implement border controls, travel advisories, or both; conduct travel volume and pattern analyses.

Medical care and countermeasures

• Advise health-care providers statewide to promptly diagnose influenza and promptly treat ill persons.
• Based on current recommendations, implement infection-control practices; distribute health advisory notices with information on case definitions and infection-control measures to hospitals and outpatient care centers.
• If human-to-human transmission is suspected, monitor and assist with early access to postexposure chemoprophylaxis for case contacts per current recommendations.
• Review all guidance documents, update as needed for the situation, and communicate with key stakeholders.
• Conduct all usual influenza pandemic preparedness activities with health-care facilities.

• Review all guidance documents and update as needed for the situation (e.g., comprehensive medical care and countermeasure guidance for policy makers, clinicians, health-care organizations, employers, and public health); disseminate guidance for diagnosis and treatment of ill persons and infection-control measures to states and professional organizations.
• Consider which immediate steps are needed to establish medical countermeasure stockpiles (e.g., antivirals, respiratory protective devices, ventilators, and Emergency Use Authorizations).

Vaccine

• Evaluate all usual influenza pandemic preparedness activities, including a review and update of vaccine distribution and administration plans, process for rapid contract negotiation and staffing, mechanisms to identify and provide vaccine and document vaccination for critical infrastructure personnel and other possible priority groups for vaccination, and plans and staffing for mass vaccination clinics and points of dispensing.
• Review all guidance documents, update as needed for the situation, and communicate to key stakeholders.

• Evaluate whether findings from the Influenza Risk Assessment Tool and other information support initiation of development of vaccine candidates, manufacturing, vaccine stockpiling, or all of these.
• Evaluate capability to make pandemic vaccine available with federal agencies and industry partners (e.g., activation of plans to develop, manufacture, and clinically evaluate pandemic vaccine).
• Review all guidance documents, and update as needed using available data (e.g., vaccine allocation, distribution, prioritization, and administration, including monitoring vaccine adverse events).
• Evaluate local and state preparedness level for a large vaccination campaign.

Risk communication

• Frequently update clinicians and veterinarians through the state health alert network.
• Share information with key federal and local partners, such as animal and human health public affairs officers and other agencies or organizations.
• Disseminate timely and relevant messages to the public as appropriate.
• Work with CDC, USDA, and the Food and Drug Administration (FDA) to disseminate messages regarding food safety concerns as appropriate.

• Disseminate relevant and timely messages in coordination with other key partner audiences, including local and federal agencies, the National Public Health Information Coalition, and USDA.
• Work with FDA and USDA to disseminate messages regarding food safety concerns as appropriate.

Incident management

• Continue or initiate actions described for the investigation interval for all domains.
• Consider activation of the state/local emergency operations center.
• Forecast future resource needs for a potential response.

• Continue or initiate actions described for the investigation interval for all domains.
• Review all decisions previously made during the investigation interval to ensure they continue to be relevant to the emerging situation.
• Repeat the Influenza Risk Assessment Tool, as indicated by new findings, to assess risk for emergence of the novel virus, as well as the potential impact.
• Formulate and prioritize research needs (e.g., scientific preparedness).
• Forecast future resource needs for a potential response.
• Consider using the Pandemic Severity Assessment Framework* if sufficient data are available.
• Convene group of U.S. Department of Health and Human Services leaders regularly to address policy issues and make national-level policy decisions; expand interagency and intergovernmental coordination.
• Consider determination of a potential public health emergency.
• Consider activation of emergency operations centers.

Surveillance and epidemiology

• Conduct enhanced novel influenza A surveillance.
• Continue case-based investigation and control using standard methods.
• Report cases according to the Nationally Notifiable Diseases Surveillance System.
• If animal cases are identified, expand implementation of joint investigation plan with state agriculture officials.

• Conduct enhanced novel influenza A surveillance for cases nationwide.
• Refine criteria for reporting and investigating cases.
• Provide technical assistance as needed.
• Evaluate the need for border controls for animals or products if appropriate.
• Consider whether use of a vaccine for animals is an acceptable option.

Laboratory

• Confirm all suspected cases at a public health laboratory.
• Prepare specimen triage plans and implement surge plans if needed.

• Continue to monitor the virus for transmission characteristics and antiviral resistance.
• Evaluate virus susceptibility to potential late-stage development therapeutic options as a mitigation plan for drug shortages or drug resistance to already-approved therapeutics.
• Stockpile diagnostic test kits and ancillary reagents; continue to distribute to state public health laboratories as needed.
• Assess the performance of commercial rapid influenza diagnostic tests for detecting emerging novel influenza A.

Community mitigation

• Prepare for implementation of community mitigation measures, in addition to voluntary home isolation of ill persons, respiratory etiquette, hand hygiene, and infection control. These might include voluntary home quarantine of contacts, use of face masks, temporary closure of child care facilities and schools, and social distancing measures.

• Review all guidance documents and update as needed for the situation (e.g., recommendations on community mitigation measures and other nonpharmaceutical interventions designed to slow the spread of the virus in the community or within certain populations and settings at high risk for infection).
• Provide updated guidance for border health and travelers' health activities, including travel health notices, as appropriate for the situation.
• Evaluate and implement required border control measures (entry, exit, or both) as appropriate for the situation; continue to conduct travel volume and pattern analysis.

Medical care and countermeasures

• Consider implementation of voluntary contact chemoprophylaxis based on current recommendations.
• Educate clinicians about recommended treatment, prophylaxis, and infection-control guidelines.
• Initiate contact with coordinators of the local or regional (or both) Strategic National Stockpile (SNS) regarding the potential receipt and distribution of SNS countermeasures, as appropriate.
• Assess impact on medical care facilities; Identify whether medical resources are sufficient to manage ill persons and conduct case-based control efforts; determine if federal assistance is required.

• Update and release guidance documents as needed for the situation (e.g., comprehensive medical care, infection-control, and countermeasure guidance for policy makers, clinicians, health-care organizations, employers, and public health officials).
• Review options for provision of mass health care with scarce resources.
• Consider development of prioritization procedures for materials that could be in short supply.
• Continue with regulatory readiness steps (e.g., Emergency Use Authorizations [EUAs] for countermeasures).
• Evaluate whether transmission and severity assessments merit deployment of SNS countermeasures or other therapeutics under EUA.
• Evaluate whether SNS inventories require replenishment.

Vaccine

• Prepare for vaccine availability and vaccine campaign; refine vaccine distribution and administration plans if a campaign will be initiated, including mass vaccination initiatives and coordination with pharmacies and other groups, as appropriate.
• Consider enrolling adult, obstetrical, and pediatric health-care providers, including pharmacies, to promote vaccine access to persons in all indicated age and risk groups and ability to identify and vaccinate critical infrastructure personnel.
• Ensure that all identified vaccinators are authorized, and review policies and procedures regarding identification, authorization and training of nontraditional vaccinators.
• Confirm vaccine providers have access to the immunization information system (IIS) or alternative systems.
• Review capacity and capabilities of IIS for use by vaccine providers and in mass vaccination clinics for the required dosing schedule anticipated (1 or 2 doses with or without adjuvant).

• Establish the decision framework for initiating a national vaccine campaign.
• Evaluate implementation of vaccine manufacturing for distribution as appropriate.
• Develop and provide technical support and guidance to state, local, tribal, and territorial and private sector partners in preparation for and during a potential pandemic vaccination response in the United States.
• Engage the Advisory Committee on Immunization Practices regarding vaccination recommendations.
• Implement systems to monitor vaccine distribution to end-user providers of CDC's vaccine distribution system.
• Establish or update systems to monitor and assess pandemic vaccine adverse events, coverage, and effectiveness.
• Consider which vaccine policies need to be developed or updated to support a vaccination response.

Risk communication

• Develop or update a media relations and outreach plan.
• Disseminate risk communication messages, including what is known, what is not known, and what is being done by public health officials.
• Disseminate messages for travelers, as well as community mitigation messages, when to seek care, and how to care for ill persons at home as appropriate.
• Conduct briefings with local, regional, and state response partners, businesses, tribes, and health-care facilities on the potential for escalation, response actions underway, and preparedness steps that partners should consider.
• Work with CDC, the U.S. Department of Agriculture, and the Food and Drug Administration to disseminate messages to address food safety concerns as appropriate.

• Develop or update a media relations and outreach plan; disseminate risk communication messages.
• Disseminate messages for travelers, as well as community mitigation messages, when to seek care, and how to care for ill at home as appropriate.
• Collaborate, coordinate, and engage with partners and stakeholders.

* Source: Reed C, Biggerstaff M, Finelli L, et al. Novel framework for assessing epidemiologic effects of influenza epidemics and pandemics. Emerg Infect Dis 2013;19:85–91.

Incident management

• Continue or initiate actions described for the recognition interval.
• Consider activation of state/local emergency operations center.
• Consider declaring a public health emergency.

• Continue or initiate actions described for the recognition interval.
• Consider declaring a public health emergency.

Surveillance and epidemiology

• If affected, continue enhanced surveillance; conduct case investigation and response.
• If unaffected, prepare for investigation and response.
• Consider surveillance for influenza hospitalizations and deaths if not already a component of state-based influenza surveillance.

• Deploy federal responders to states that were initially affected as appropriate.
• Conduct analyses and field studies; disseminate data regarding transmission, treatment, and prognosis.

Laboratory

• Continue to confirm all suspected cases at a public health laboratory, resources permitting; prepare a plan for limiting testing using surveillance criteria.

• Remove select agent status and U.S. Department of Agriculture regulations for the novel influenza virus strain.
• Continue monitoring virus characteristics to identify changes in virulence, transmission, or antiviral resistance markers.

Community mitigation

• Consider implementing appropriate community mitigation measures* in selected affected locations or institutions as indicated by the results of the Pandemic Severity Assessment Framework.

• Maintain situation-appropriate border and travelers' health measures.
• Evaluate recommendations for appropriate community mitigation measures.

Medical care and countermeasures

• Monitor the surge in health-care needs and assess whether assistance is needed to mitigate the surge.
• Review and prepare to deploy a mortuary surge (mass mortality) plan.
• Consider deployment of state/local caches.
• Consider implementation of voluntary quarantine of contacts and chemoprophylaxis of exposed persons based on current recommendations.

• Initiate targeted studies of the clinical course of the illness, treatment responses, and disease transmission.
• Monitor the health-care surge and stress on the health-care system, including provision of key medical resources and tools, as needed.
• Consider deployment of Strategic National Stockpile antiviral drugs and other material reserves.

Vaccine

• Implement stockpiled pandemic vaccination campaigns if a stockpiled pandemic vaccine is available, appropriate for the emerging virus, and the U.S. government has made the decision to do so.
• Update the state distribution plan based on CDC prioritization guidelines, estimated state allocation of vaccine, and epidemiology of pandemic influenza in the state.

• Provide technical support and guidance to state, local, tribal, and territorial (SLTT) and private sector partners in preparation for and during a potential pandemic vaccination response in the United States.
• Implement and monitor vaccine distribution as appropriate.
• Monitor and assess pandemic vaccine adverse events, coverage, and effectiveness.
• Work with the Advisory Committee on Immunization Practices and others to refine policies for vaccine use and prioritization.

Risk communication

• Disseminate updated risk messages, including providing anticipatory guidance or information on what might be expected.
• Share information regarding antivirals and the possibility of implementation of community mitigation measures as appropriate.
• Continue to provide regular updates to key partners, stakeholders, elected officials, and the media.

• Disseminate updated risk messages, including providing anticipatory guidance or information on what might be expected.
• Share information regarding antivirals and the possibility of implementation of community mitigation measures as appropriate.
• Continue to coordinate and provide regular updates to key partners, stakeholders, elected officials, and the media.

Incident management

• Continue or initiate actions described for the initiation interval.
• Maintain processes to monitor effectiveness of response.

• Continue or initiate actions described for the initiation interval.
• Maintain processes to monitor effectiveness of response.

Surveillance and epidemiology

• If affected, transition surveillance from individual case confirmation to severe disease and syndromic surveillance as appropriate.
• If unaffected, continue individual case confirmation.
• Monitor for changes in epidemiology.

• Maintain enhanced surveillance.
• When appropriate, transition surveillance to severe disease and syndromic surveillance.

Laboratory

• Provide laboratory confirmation of only a sample of cases as required for virologic surveillance.
• Implement revised specimen submission protocol per CDC guidance as appropriate.

• Continue monitoring virus characteristics to identify changes in virulence, transmission, or antiviral resistance markers.
• Transition to virologic testing of a sample of viruses submitted from states.
• Distribute to state public health laboratories recommendations that outline revised specimen submission protocol as needed.

Community mitigation

• Consider activating (if not already implemented) or expanding (if already implemented) appropriate community mitigation measures for affected communities (such as temporary closure of child care facilities and schools, school and workplace social distancing measures, and postponement or cancellation of mass gatherings).
• Monitor effectiveness of community mitigation measures.
• Monitor adverse impact of community mitigation measures on society, and coordinate with local response agencies to address the impact if possible.

• Maintain situation-appropriate border and travelers' health measures.
• Continue or initiate exit screening if appropriate.
• Provide, evaluate, and revise recommendations for use of community mitigation measures.
• Deploy federal responders or assist states in other ways to evaluate the effectiveness and potential adverse effects of community mitigation measures.

Medical care and countermeasures

• Monitor and respond to surge in health-care needs, including setting up alternative care sites.
• Educate clinicians and the public about the need for prompt treatment of ill persons.
• Review and prepare to deploy mortuary surge (or mass mortality) plan.
• Monitor antiviral use to identify possible shortages.
• Consider deployment of state/local caches.

• Monitor antiviral use, effectiveness, and adverse events.
• Advise on implementation of mitigation strategies for the surge in health-care needs (e.g., activation of alternative care sites and modalities and implementation of situation-appropriate standards of care).
• Monitor the health-care surge and stress on the health-care system, including provision of key medical resources and tools, as needed.
• Modify guidance documents based on situation as appropriate.
• Consider additional deployments of the Strategic National Stockpile antiviral drug reserve and other material.

Vaccine

• Implement vaccination campaigns if stockpiled pandemic or newly developed antigen-specific pandemic vaccine is available.
• Monitor vaccination coverage levels and adverse events.

• Implement vaccination campaigns if stockpiled pandemic or newly developed antigen-specific pandemic vaccine is available.
• Monitor vaccination coverage levels, adverse events, and vaccine effectiveness.

Risk communication

• Disseminate updated risk messages.
• Share updated information regarding vaccine.
• Continue to provide regular updates to partners, stakeholders, elected officials, and the media.

• Disseminate updated risk messages.
• Share updated information regarding vaccine.
• Continue to provide regular updates to partners, stakeholders, elected officials, and the media.

Incident management

Surveillance and epidemiology

Laboratory

Community mitigation

Medical care and countermeasures

Vaccine

Risk communication

Incident management

• Continue actions described for the deceleration interval as appropriate.
• Consider deactivation of the state/local emergency operations center.
• Prepare for subsequent waves.
• Create an after-action report to document lessons learned.
• Consider suspending the public health emergency declaration.

• Continue actions described for the deceleration interval as appropriate.
• Consider deactivation of the emergency operations center.
• Prepare for subsequent waves.
• Create an after-action report to document lessons learned.
• Consider suspending the public health emergency declaration.

Surveillance and epidemiology

• Continue case confirmation of selected cases to monitor progress of the pandemic and to detect acceleration to the next wave.
• Begin conducting routine interpandemic surveillance.

• Return to routine interpandemic surveillance.
• Evaluate and update ongoing research protocols as appropriate.

Laboratory

• Return to routine interpandemic virologic surveillance.
• Assess and optimize laboratory capacity.

• Return to routine interpandemic virologic testing.
• Continue monitoring for viral drift and genetic mutations indicating changes in severity, transmission, or antiviral resistance.

Community mitigation

• Modify community mitigation measures as necessary.
• Continue to promote community mitigation preparedness activities on standby for a subsequent wave.

• Provide assistance with cessation or modification of community mitigation measures.

Medical care and countermeasures

• Monitor medical surge trends.
• Replenish stockpiles or caches as able.
• Monitor antiviral dispensing and usage trends.

• Provide assistance with cessation of surge capacity strategies.
• Replenish stockpiles as able.
• Assist states/localities with replenishing stockpiles or caches of personal protective equipment, antivirals, and other materials.

Vaccine

• Participate in vaccine recovery as appropriate.
• Continue to vaccinate, with a focus on hard-to-reach populations, in anticipation of a subsequent wave.

• Begin vaccine recovery as appropriate.

Risk communication

• Disseminate updated risk messages, including information on measures to prepare for and respond to possible additional pandemic waves.

• Disseminate updated risk messages, including information on measures to prepare for and respond to possible additional pandemic waves.