This post originally appeared on NACCHO’s Essential Elements of Local Public Health blog.

On September 12-14, the Centers for Disease Control and Prevention (CDC) conducted a pandemic influenza functional exercise in response to a fictional influenza pandemic with federal, state, local, and non-governmental partners. The National Association of County & City Health Officials (NACCHO) and local health departments were among those that participated in the exercise. The exercise was an important opportunity for partners to help the CDC and their own organizations practice responding to and better prepare for future influenza pandemics. The exercise just so happened to also align with the 100th anniversary of the 1918 influenza pandemic. Below are reflections on the exercise from Lilly Kan, Senior Director for Infectious Disease and Informatics, who represented NACCHO during the exercise.

Tell us a little about the context for this exercise. What was the setting for the outbreak? Who was at the table? What partners were involved?

The setting for the outbreak was a fictional novel influenza virus that was highly transmissible with high morbidity. At the start of the exercise on September 12, the high-level scenario was as follows:

• More than 17,000+ cases of the novel influenza virus infection had been identified in the United States and worldwide
• 47 states had reported lab-confirmed virus infections
• The World Health Organization had declared an influenza pandemic the week prior
• The CDC Emergency Operations Center had been activated for 35 days

A key objective of the exercise was to coordinate with partners on pandemic preparedness and response. Federal partners participating in the exercise included several agencies within the Department of Health and Human Services (e.g., Office of the Assistant Secretary for Preparedness and Response, Food and Drug Administration, Indian Health Service) and other departments such as the Department of Veterans Affairs, Department of Agriculture, and Department of Labor. The majority of state and local partners were from health departments. One represented a local fire department. Associations and private partners represented sectors including public health, banks, pharmacies, the parcel delivery service industry, and foundations. Individuals from public health agencies in other countries also attended to observe the exercise.

How were local health departments represented? What was their role?

During the exercise, there was substantial attention toward gaining a better understanding of the challenges and needs state and local jurisdictions were facing during this fictional influenza pandemic. There were opportunities to pose questions specific to local health departments and report on their circumstances by teleconference and e-mail to the CDC. Local health department exercise participants delivered injects throughout the exercise, which were messages sent to the CDC that contained their question or described a situation they were facing. The CDC had also involved local health departments, NACCHO, and other partners in two meetings preceding the exercise to develop the injects and create and more realistic scenario. These injects made this fictional influenza pandemic more realistic and prompted the CDC to respond and act as they would during an actual pandemic.

What strategies were employed to contain the outbreak?

The strategies employed during the outbreak reflected those in the Community Mitigation Guidelines to Prevent Pandemic Influenza – United States, 2017. These strategies included non-pharmaceutical interventions such as school closures, social distancing, and using face masks. Other interventions included use of antivirals (in this scenario, the virus was resistant to some but not all drugs) and vaccines. While a vaccine for this pandemic virus was not yet available to the public at the time, there was supply of influenza vaccine in the Strategic National Stockpile. This vaccine was not matched to the pandemic virus but could be used as a priming dose.

How did partnerships and coordination affect the outcome of this exercise?

Partnerships among stakeholders, and between stakeholders and CDC, helped to ensure that critical information was reaching the right people more quickly. For instance, some examples about spot antiviral shortages had reached some partners who then helped inform others. Coordination also helped to ensure that CDC was issuing recommendations and guidance with a better understanding of the barriers and facilitators that state and local jurisdictions may face in implementing them. In one instance, the CDC engaged several partners to discuss its approach to prioritizing the limited amount of stockpiled influenza vaccine that was available. This was an important opportunity for partners to offer feedback that challenged or concurred with the approach. The outcome of this discussion was that the partners agreed with the CDC’s decision and provided additional perspectives that helped the CDC and each other to better anticipate the practical challenges of implementation.

What role did surveillance and access to data play in the exercise?

Exercise planners took great care in developing a realistic scenario, complete with surveillance and lab data that the CDC had to act on. Since the exercise started more than a month into the fictional pandemic, surveillance and access to data was crucial. As with any outbreak, CDC, along with its partners, used the data to inform its prevention and control measures and generate models on the evolution on the pandemic. The exercise also addressed how CDC and its partners could most efficiently and effectively issue and test for and confirm the presence of the pandemic virus in individuals.

What did the group learn about information-sharing during the outbreak response?

One lesson learned was the opportunity and responsibility that organizations, as partners, have in ensuring and considering whether the right individuals are part of the right conversations to receive critical information. During the exercise, participants were mindful of and proactive about engaging fellow partners in scheduled discussions if the partner organization could benefit from hearing directly about a particular topic. On the other hand, there are always consequences with being too inclusive and hindering information exchange and discussion of sensitive and targeted topics.

What were some of the challenges in going through this exercise? What gaps in preparedness emerged?

During the exercise, some of the participants delivering injects received either delayed responses or no communication at all to their reports, questions, or requests. One reason for this gap was due to user or technical difficulty with the web-based platform the exercise participants were using. While some of these difficulties were related to the platform set-up specifically for the exercise, it was an important reminder to prepare for the difficulties that may emerge when using technology to facilitate communication and information sharing during an actual influenza pandemic. Other reasons for the delay or lack of response were the inherent complexity of the question or response and the time it took for various groups within CDC’s pandemic influenza incident management structure to process and follow up. One matter that remains a perpetual gap in preparedness is the ability for responders to surge in their capacity. One theme that emerged in several instances during the exercise was that responders were overwhelmed. While strong organization and processes can help to address some of the burden responders face during an influenza pandemic, there are still inherent challenges in ramping up staff capacity and resiliency to respond to a pandemic, particularly if responders are at high risk of becoming ill themselves.

What were some of the major takeaways or key successes?

The focus of this exercise was to test the systems and processes the CDC has in place, such as its incident management structure, to respond to an influenza pandemic in coordination with partners. A key success was CDC’s ability to implement its incident management structure and leverage it to respond to and address the challenges and needs posed in the injects. Some subcomponents and staff within CDC’s incident management structure that have been involved in other public health responses, such as the Ebola or Zika virus outbreaks, were particularly well-equipped to rapidly make decisions, act on, and engage partners in the fictional pandemic influenza response. While the exercise overall was inclusive of local perspectives, some responses to injects were state-focused and less reflective of the needs and challenges that occur at the local level. This circumstance highlighted the continuing opportunities that NACCHO, local health departments, CDC, and other partners have to collectively assure that those needs and challenges are adequately recognized and addressed.

During the exercise, some challenges specifically related to the fictional influenza pandemic were implementation of school closures and vaccination of priority groups. Several state and local participants expressed the consequences of implementing school closures such as increased congregation in other public settings, lack of access to free or reduce meals for children in greatest need, and challenges parents face in arranging childcare, particularly in low-income households. Similarly, participants recognized several practical challenges with vaccinating target populations, such as providing clear and consistent public communication regarding the decision and rationale for prioritizing certain groups, establishing closed points of dispensing, and managing individuals seeking vaccination but do not fall within the target groups. While the exercise was not intended to resolve these ongoing challenges, these takeaways offer important areas to for the CDC and partners to continue addressing in preparation for a future influenza pandemic.