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Pandemic-Ready Planning

A pandemic avian flu is overdue, say experts, but your campus leaders can have a crisis management strategy ready.

By Al Rickard

A few weeks later, the media begin to report the first U.S. cases of avian flu. Absenteeism in schools and businesses quickly spikes. Coverage of the virus’s rampant spread dominates front-page and top-of-the-hour news spots. Widespread panic erupts when people discover that supplies of antiviral drugs are severely limited and a suitable vaccine is not yet available.

Three months into the pandemic, police departments, local utility companies, and mass transit authorities experience significant personnel shortages that result in major disruption of routine services. Hospitals and outpatient clinics are critically short-staffed, as doctors, nurses, and other health-care workers become ill or are afraid to come to work. Fearing infection, people with chronic medical conditions rarely leave home. Intensive care units at local hospitals are overwhelmed, and soon the supply of ventilators for the treatment of flu patients runs out.

Over the next 6 to 8 weeks, health-care and other essential community services deteriorate further as the pandemic sweeps across the world.

Framework for Fighting Flu

The “Blueprint for Pandemic Flu Preparedness Planning for Colleges and Universities” was excerpted and revised from the “World Health Organization (WHO) Checklist for Influenza Pandemic Preparedness Planning.” Representatives from 10 colleges, universities, and university systems joined risk management experts to develop this framework outlining recommended preparedness efforts.

The blueprint includes a comprehensive checklist to guide colleges and universities in establishing a planning framework for their particular campuses. It includes key areas such as command and control, risk assessment, a response plan based on pandemic phase, communications, and legal and ethical implications.

Planning sections include the following:

  • implementation, testing, and revision of the plan;
  • monitoring incidence and prevalence;
  • infection control;
  • public health measures, such as social distancing, quarantine, and travel restrictions; and
  • maintaining essential services, including decisions to stay open rather than to close the campus.

Each section includes a short introduction, poses several critical questions, and outlines a checklist of planning activities.

The following sample checklist illustrates the format:

Completed In Progress Not Started  
     

1. Consider and identify liability issues in the event that the institution fails to respond appropriately to a pandemic outbreak.

     

2. Identify the advantages and disadvantages of declaring a state-of-emergency on campus during a pandemic.

     

3. Identify liability issues related to the institution’s failure to provide adequate level of care to students.

Institutions can also use the checklist format to review specific plans related to the following campus operations:

  • business and finance,
  • student health center,
  • food services,
  • admissions/registrar/financial aid,
  • academic affairs,
  • human resources,
  • student housing services,
  • physical plant and facilities,
  • international studies and foreign operations,
  • counseling, and
  • campus security.

To access the blueprint, go to www.ajg.com/highereducation; click on the “Resources” tab.

This frightening scenario is outlined in the “Blueprint for Pandemic Flu Preparedness Planning for Colleges and Universities,” a document published in 2006 by Arthur J. Gallagher Risk Management Services Inc., with the guidance of a panel of college and university risk management executives (see sidebar, “Framework for Fighting Flu” for further details).

Human-to-human transmission of the H5N1 (avian flu) virus is already suspected. This raises the likelihood that the virus is continuing to mutate in ways that could make a potential pandemic a reality. Experts are nearly unanimous in predicting that it is a matter of “when” and not “if” a pandemic will occur. And, the mandate for colleges and universities to be prepared for such a challenge is every bit as urgent as it is for governments, companies, or other institutions.

Those who worked on the blueprint’s description of a pandemic’s effects put it this way: “The impact on college or university operations may include unprecedented demands on student health services, relocation of students in residence halls, the establishment of quarantine sites, debilitating sickness among staff and faculty causing severe reductions in the workforce, essential services hampered and perhaps unavailable, and significant loss of tuition revenues from closure of the institution, and non-returning students.”

Clearly, such stark warnings demand the attention of chief business officers and other leaders across campus, who need to act in concert to plot out containment strategies.

Expert Warnings

“We are overdue for a pandemic,” warns Anita Barkin, director of student health services, Carnegie Mellon University, Pittsburgh. Barkin is chair of the Pandemic Planning Task Force for the American College Health Association. She notes that the most recent pandemics were in 1957 (Asian flu) and 1968 (Hong Kong flu). While these events were serious, the more devastating pandemic occurred in 1918, when the Spanish flu ravaged the globe. The virus killed 50 million people worldwide, including 675,000 in the United States. Few people alive today recall this event, making it much harder to deliver the message about how serious a pandemic can be. Interestingly, in 2004, National Geographic reported that the 1918 Spanish flu (so named because it was first widely reported in Spanish newspapers) also originated in birds.

Assuming that medical advances and vaccine development will mitigate the impact of a pandemic as serious as 1918 may be wishful thinking. Vaccines for new or mutated viruses can’t be developed overnight. Even when medicines become available, supplies will likely be limited. This could make the risk of death, at least during the first wave of a pandemic, extremely high.

Barkin notes that people may be able to transmit the flu virus up to 72 hours before they experience symptoms, allowing an outbreak to “sneak up” on a college or university. By the time the first person gets sick, hundreds or even thousands of others on campus could already be infected.

“With airline travel and other rapid modes of transportation, the flu can spread very quickly in today’s world,” says Barkin. “In 1918 that wasn’t true—trains were the main mode of transportation, [but the flu] still spread across the country in four weeks.”

Be Prepared

The preparedness blueprint points to the importance of self-reliance and preparation. It repeats the message that Health and Human Services Secretary Mike Leavitt has hammered home in many speeches: People can expect little help from the federal government, and they need to get their emergency plans in order.

“Avian flu, when it occurs, will severely test the best-laid plans…and many companies are not making any plans at all,” Leavitt says. “We are overdue and ill-prepared. Local communities are going to have to take the lead. Those expecting the federal government to ride in and come to their rescue are going to be sorely disappointed.”

At the same time, he adds, “Let’s acknowledge that anything we say before a pandemic occurs feels like an exaggeration, feels alarmist. But anything said afterward shows a lack of preparation.”

The Legal Imperative for Preparation

“Failure to produce a pandemic response plan may create liability for the institution, particularly given the amount of warning and guidance offered by governmental officials and the encouragement to develop such a plan.” This language from the “Blueprint for Pandemic Preparedness Planning for Colleges and Universities” reinforces the importance of developing a deliberate plan for dealing with a pandemic.

Indeed, a number of legal reasons underscore the need for proper planning, including directives contained in the Occupational Safety and Health Administration General Duty Clause and the Homeland Security Presidential Directive Number 5 (February 28, 2003), which maps out the National Incident Management System (NIMS).

The OSHA General Duty Clause states that employers—including colleges and universities—have an obligation to provide a safe work environment for employees. While the clause does not extend directly to students, certainly higher education institutions have a strong moral obligation to provide students with a safe learning and living environment.

The Department of Homeland Security (DHS) requires all public entities (including state universities and community colleges) to comply with NIMS, which is a highly structured top-down management system developed jointly by DHS and the Federal Emergency Management Agency (FEMA). The system also assigns common definitions to words and phrases that are typically used in emergencies to avoid miscommunication during crisis situations.

“Agencies in California, including some colleges and universities, have been using the equivalent of the NIMS system for years,” says John Watson, executive director, Higher Education Practice Group, Arthur J. Gallagher Risk Management Services, Inc. “Whoever steps into the structure knows their responsibilities and understands what all the terms mean. They can also have confidence that others have the same understanding.”

The blueprint also notes, “During a pandemic, governmental bodies may find it necessary to overrule existing legislation or individual human rights. Examples include the enforcement of quarantine (overruling individual freedom of movement), use of privately owned buildings for hospitals, off-license use of drugs, and compulsory vaccination or implementation of emergency shifts in essential services. These decisions need a legal framework to ensure transparent assessment and justification of the measures that are being considered.”

Thomas P. Fuller, an industrial hygiene associate with Tech Environmental and a consultant to the University of Boston Medical Center, has given many talks on pandemic planning and is amazed at the lack of planning by most organizations.

He is a member of the Pandemic Planning Task Force of the American Industrial Hygiene Association (AIHA), an organization of professionals who anticipate health and safety issues and design solutions to prevent them.

“When I talk to people at large companies,” Fuller reports, “they say they will just shut down. The actual pandemic may or may not dictate that this is the best response. Planning should be graded to the actual event.”

In a recent forum he led on pandemic planning, Fuller found that only 5 of the 150 people attending had written pandemic preparedness plans. Even those who have created plans have not vetted them sufficiently.

“Many organizations have not thought of how to phase their shutdowns and what ‘essential people’ will need to remain working,” Fuller says. “A lot of times the emergency planning person has done a plan and assumes it will be easy to roll out. Planning cannot be done in a vacuum—it has to be vetted across campus with all departments, so that [staff] know what they will need to do and are ready to do it.”

Fuller notes that one key preparation that the Boston University Medical Center has made is its six-month supply of N95 air-purifying respirator masks, which are recommended by the U.S. Centers for Disease Control and Prevention for employees who perform high-risk duties. These masks filter out particles smaller than the droplets created during talking, coughing, and sneezing that usually transmit flu viruses.

The medical center uses these on a regular basis for infection control. However, N95 masks must be fitted to each person to be fully effective, so this limits how widely they could be used in a pandemic.

“It’s hard to say if this is cost-effective,” says Fuller, who is also the Infection Control Project team leader on the AIHA Healthcare Working Group. “Masks have a shelf life of a few years. Also, you may end up with a disease that is transmitted through surface contact, and then the N95 masks won’t do any good.”

Controlling the Campus

In the event of a pandemic, how can college and university authorities control the campus and ensure that both employees and students are complying with instructions, which could include quarantines in dormitories?

Barkin says the answer for Carnegie Mellon University is simple: “If the virus looks like it did in 1918, the young and healthy people most at risk are the ones on our campuses. It is critical for us to call this early and get students home or with relatives and friends. We will not have the manpower to handle the number of people who will become ill. Residence halls could become incubators for spreading the virus. It would spread like wildfire. It is really important that we use good judgment and get students home.”

However, she recognizes that the global nature of higher education, including the presence of international students on campus, means that some students may not be able to get home.

“Those students will have to be cared for,” she says. “We have to provide shelter and food. You can look at some creative ways to do that. We know that the burden will fall on student affairs and residence life staffs. In a pandemic, if you are looking at 35 percent absenteeism, that will be even harder. But we will not be having classes, so is there a way you can reassign people from areas that are not in operation to assist with residence life issues? Human resources staffs will have to determine what you can and can’t do. These are tricky issues but you need to start these conversations now.”

Time-Tailored Responses

Pandemics do not occur in a linear fashion, making planning even more difficult. Epidemiologists warn that pandemics typically occur in three distinct waves, each requiring a different response.

In 1918, for example, the Spanish flu pandemic occurred in three waves that were about six months apart. The second and third waves were much worse than the first, presumably because the viral strain continued to mutate and become more virulent.

But the timing of the waves is not predictable.

In 1957, the second wave of the Asian flu pandemic started three months after the first; and in 1968, the second wave of the Hong Kong flu pandemic began one year later.

With current technologies, it is estimated that it will take at least five or six months before vaccines based on a new influenza strain can be produced on a large scale.

Complicating matters is the fact that pandemics typically occur in three waves at unpredictable intervals. (See sidebar “Time-Tailored Responses” for details.)

After dealing with the first cycle of the pandemic, it may not be clear what to do, Barkin observes. “The variability of the waves and the level of virulence will help determine the response. Potentially you may have to repeat the scenario. The colleges and university leaders I have spoken with are grappling with what to do with just one wave, let alone others. After we have the first wave, we will need a debriefing to see what we did right and wrong and what we can do better. This will allow us to refine procedures and protocols. If you look at 1918, schools that opened before 12 weeks [of continuous closure] experienced a resurgence of the illness. Ideally, you would close for more than 12 weeks to be safe, but most higher education people are talking about closing for 8 weeks at most.”

Adding to the Prepping Package

Virtually every college and university has some type of institution emergency or crisis management plan. It makes sense to incorporate pandemic-control strategies to this master plan. In some cases, the framework for addressing pandemic priorities can even provide additional guidance for responding to other crises. Here are some examples.

Yale University. Peter Reinhardt, director of environmental health and safety, Yale University, New Haven, Connecticut, says the pandemic response plan at his institution is definitely part of the overall emergency strategy. He has involved his staff, including industrial hygienists, who are experts in identifying and preventing health and safety risks, in developing emergency measures. One aspect was to assess the personal protective equipment that may be required during a pandemic. As a result, Yale—similar to Boston University Medical Center—has stockpiled thousands of N95 respirator masks, as well as some surgical masks that may be needed. Since N95 masks must be fitted, the university has implemented policies as to who would receive masks. The equipment will be fit-tested on a regular basis.

Planning Concepts Common to All

Some of the preparatory steps for dealing with widespread influenza infection vary based on campus type, location, consistency, and size. Certain other planning concepts and approaches, however, will be common to all institutions. Those activities include the following:

  • Evaluate your constituencies. Institutions need to look at two major groups—employees and students—and plan accordingly for each of them. Within the employee group, consider subsets, such as administration, faculty, maintenance, and service workers, and “essential” employees. Each will need direction in terms of work schedules, evacuation plans, and other related actions.
  • Set up stages and timelines. Structure the plan in segments to be implemented at each wave of a pandemic. Include optional responses based on the virulence of the flu strain and the advice of health professionals.
  • Communicate internally. Set up an efficient campuswide communication system for all constituencies, including employees and students. This will ensure that they can be notified quickly of any action steps or instructions should the pandemic plan be implemented. This type of communication system—already in place at many institutions to address other types of emergencies—can be modified to include pandemic-related messages.
  • Communicate externally. Set up communication links and contact points with local hospitals, health agencies, and first responders. Also, communicate with other nearby colleges and universities to find out what they are doing.
  • Be flexible. No one can predict how a pandemic will unfold or how serious it will be. Flexibility in planning—and the willingness to change plans if needed to protect people—is vital.
  • Err on the side of caution. If a pandemic is closing in on your community, don’t wait until it hits your institution to take action. Cancel classes, shut down nonessential functions, and send students home to their families. One university that serves mostly in-state students has decided to close when a case of avian flu hits within a 500-mile radius of the campus.
  • Test the plan. Conduct simulation exercises to test the plan’s effectiveness. By including key players in this activity, you can emphasize the importance of the plan, gain buy-in from key participants, identify weak points, and make updates and corrections as needed.

Many health agencies indicate that, during the first wave of a pandemic, the goal will simply be to slow the spread of the virus by quarantining, restricting group activities, and closing schools and offices.

Yale also has significant clinical research operations, some of which would have to continue operating during a pandemic to support the medical care needed by campus patients. “Industrial hygienists and our environmental health and safety staff,” says Reinhardt, “understand laboratory operations and the hazardous materials they contain—better than any other department on campus. So, we help laboratories plan for emergencies, and [explain] how to keep them safe and operating.”

He adds that the focus on pandemic response has resulted in even more planning for other types of campus emergencies. “We are strengthening our incident command structure,” Reinhardt explains, “deciding on how to get information to students and ways to update our continuity of operations plans. For example, a communications system that would work for a violent situation on campus would also work for a pandemic. There are also many similarities in planning for a pandemic and for other types of biological hazards. In either scenario, we would work closely with state and local health departments and local hospitals to understand their capacities, monitor the diseases, and track patients.”

Carnegie Mellon University. “We are planning for a 1918 scenario,” says Barkin. “We have evidence of how the Spanish flu affected people. Mortality was quite high in otherwise healthy people. In other pandemics, mortality was highest among the elderly, frail, and very young. But, the 1918 virus affected young and healthy people who should have been able to handle it. That makes it a worrisome possibility.”

Considering the 1918 experience, says Barkin, “Trying to keep the university open is foolish. Families will want their children to be home, and students will want to go there. The only responsible action is to get students home as soon as possible. Taking a risk and sending people home prematurely,” Barkin says, “is better than being late.”

Carnegie Mellon University’s pandemic plan is outlined as an appendix in the blueprint document, “Avian Flu Response by Phases: Level 1, Level 2, and Level 3.” These levels are based on the following potential developments:

  • Level 1: Pre-event planning: Very limited human-to-human transmission of avian flu.
  • Level 2: Sustained cases of human-to-human transmission of a highly virulent strain of avian flu, with cases appearing anywhere in the world in cities having an international airport.
  • Level 3: Confirmed case(s) of avian flu in Pittsburgh (where Carnegie Mellon University is located) or the surrounding metropolitan area.

The plan details the responsibilities of each campus office for each of the three levels. “We are continually looking at updating the triggers for each level,” Barkin explains. “We would recommend sending people home at Level 2, with temporary closing of buildings and suspension of on-campus activities. Of course, executive management would ultimately make this decision.”

For the business office, much of the response to a serious flu outbreak has to do with risk management. For Level 1, the plan calls for (1) identifying risk exposures for which insurance can and cannot be obtained, including associated financial impact; (2) identifying steps that must be taken to monitor and protect insurance coverage; and (3) benchmarking risk management response and insurance coverage options with peer universities. If Level 2 is triggered, the business office communicates with insurance carriers on evolving campus issues. And, at Level 3, an assessment of actual risk and related insurance-claim issues becomes a necessity.

Pandemic Planning Resources

The attention paid to a potential pandemic has sparked the development of many planning resources.

  • The Department of Health and Human Services, the Centers for Disease Control, and the Department of Education have developed checklists that can help educational institutions prepare for a pandemic. Find resources at www.pandemicflu.gov, including a “Colleges and Universities Pandemic Influenza Planning Checklist.”
  • “Planning for a Pandemic,” a NACUBO webcast, is available for viewing at www.nacubo.org/x8435.xml.
  • The American Industrial Hygiene Association has created pandemic planning resources for workplaces at www.aiha.org. Click on “Pandemic” at the top tool bar.
  • Access the American College Health Association’s plan at www.acha.org.
  • Review the “Blueprint for Pandemic Flu Preparedness Planning for Colleges and Universities” by going to www.ajg.com/highereducation and clicking on the “Resources” tab.
  • Access the complete World Health Organization Web site on avian flu at www.who.int/csr/disease/avian_influenza/en/.
  • For more information on the National Incident Management System, go to www.fema.gov/emergency/nims/index.shtm.

“If it doesn’t look like a highly virulent strain,” says Barkin, “we would modify our plan accordingly and could, for example, hold off on closing the residence halls. In that type of situation, you could suspend classes for two weeks and keep people away from each other until the number of new cases declines. We could also have a scenario where a lot of faculty and maintenance people are sick, requiring us to suspend classes.”

Educating your population is critical, advises Barkin. Carnegie Mellon analyzed its student demographics, identifying the time zones of students’ homes and figured that those from the Eastern time zone would be able to get home within 48 hours. “That would leave us with 1,800 students to evacuate in the few days after that,” says Barkin.

For those who may not want to leave, recommends Barkin, make it clear to students that campus life will not be comfortable. “We are not going to operate dining facilities, for example, and food will be dropped off. We will paint a picture for students that underscores the seriousness of the situation and that we expect them to go home, if at all possible. Our goal will be to get as many students off campus as possible.”

Barkin notes, however, that the university is continuing to evaluate the decision-making process, since other factors come into play.

“For example, people have their careers invested in their research,” she notes. “We could lose all that intellectual capital if these operations were shut down.” Barkin explains that even if the university suspended classes, Carnegie Mellon might still be able to conduct research—if there are enough environmental health and safety people working to ensure that the labs are safe. If people in the labs could maintain social distancing, the university could try to maintain research operations. “We will try to continue to do some things that we consider critical,” says Barkin. “We will have to do some creative thinking.”

College of Southern Maryland. General Counsel Stephen Goldman reports that the pandemic planning process is underway at the College of Southern Maryland (CSM), a community college in La Plata. The college is using a combination of the National Incident Management System and the Incident Command System as a pilot program with some departments at the college. Goldman has high praise for the NIMS system and the planning framework it provides. (For more information, go to www.fema.gov/emergency/nims/index.shtm.)

He also attended a session at the NACUBO 2007 Annual Meeting in which the University of California–Berkeley presented its business continuity planning tool developed with a grant from FEMA. Offered at no charge, the online tool guides institutions through a systematic planning process. “We’ve used this tool,” says Goldman, “to improve pandemic planning—and overall planning—to make emergency response strategies as robust as possible.” (For more information on the UC–Berkeley tool, see “Business Continuity Planning Tool Available” in the November 2007 issue of Business Officer.)

Involving all departments at the college, CSM’s plan includes a series of stages to be activated depending on the seriousness of the situation. The college could close if the situation called for activation of responses indicated for the most severe stage of the pandemic.

Since the college does not have any student housing, that part of the planning process is simplified. “Like many other community colleges, we offer many of our courses online,” Goldman says. “To the extent possible, we would try to remain open and drive things with our online activities.”

He adds, “We started out developing a pandemic strategy alone and recognized that we needed to develop a plan for all contingencies. Even if there is not a pandemic,” Goldman says, “the related plan should be easily translatable to another kind of biological event. We realize, too, that the planning process is never over. There are always things we can learn and ideas that we can apply to improve it.”

Al Rickard, principal, Association Vision, Chantilly, Virginia, writes on higher education business topics for Business Officer.