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In 2006, the North Carolina Division of Public Health (NC DPH) required all 85 local health departments (LHDs) in North Carolina to develop a pandemic influenza plan. Because few LHDs had experience in developing such plans, NC DPH engaged in a unique partnership with an academic center, the North Carolina Center for Public Health Preparedness (NCCPHP), to provide technical assistance to local planners. This article describes the technical assistance program implemented by NCCPHP, the use of technical assistance by local planners, subsequent completeness of local pandemic influenza plans, and lessons learned throughout the program. We discuss selected topic areas (surveillance, vaccine/antiviral, and vulnerable populations) observed within local pandemic influenza plans to highlight the variability in planning approaches and identify potential opportunities for state and local standardization.
An ongoing avian influenza outbreak and the 2009 H1N1 human influenza pandemic have spurred planning at the federal, state, and local levels.1–3 State and local planning is critical for an influenza pandemic, when federal resources may be limited or completely unavailable.4 All 50 states have published pandemic plans that have been reviewed by the Centers for Disease Control and Prevention (CDC) and others.5,6 However, little has been published about local health department (LHD) pandemic influenza planning. CDC and the National Association of County and City Health Officials (NACCHO) each developed guidance for local pandemic influenza planning, but, to our knowledge, no critical review of LHD pandemic influenza plans exists.7,8 Further, although some studies have addressed specific issues related to local planning, little has been written about the process of local planning from a public health perspective.9,10
Since 2005, the North Carolina Division of Public Health (NC DPH) has promoted pandemic influenza planning at the state and local level. North Carolina has a decentralized public health system, with its 85 LHDs exerting significant local influence and receiving funding from NC DPH to conduct certain public health activities. NC DPH utilized Public Health Emergency Preparedness Cooperative Agreement funds to support this project.
In 2006, NC DPH required that LHDs develop a local pandemic influenza plan. NC DPH partnered with the North Carolina Center for Public Health Preparedness (NCCPHP) in the North Carolina Institute for Public Health at The University of North Carolina at Chapel Hill's Gillings School of Global Public Health to provide technical assistance to LHD planners from September 2006 to August 2007. The desired outcome of the technical assistance program was for all 85 LHDs to produce a complete pandemic influenza plan addressing key topic areas such as surveillance, vaccine, antivirals, and disease containment. Plans were due on March 31, 2007.
To begin the technical assistance program, NCCPHP and NC DPH created a checklist of plan components, or Essential Elements, to guide plan writing and to facilitate review of plans (http://nccphp.sph.unc.edu/LHDplanning/2007EssentialElements.pdf). The checklist was developed using the North Carolina Pandemic Influenza Plan and local planning guidance from NACCHO.8,11 It included 40 items in 10 topic areas: introduction, command and control, surveillance, laboratory diagnostics, vaccine, antiviral, disease containment, emergency response, communication, and continuity of operations. Each topic area had between two and five elements. Some elements were designated as required for plans to be approved by NC DPH; other elements were strongly recommended but not required. NC DPH reviewed and approved the checklist before it was disseminated to local planners prior to rollout of the technical assistance program.
The technical assistance program had six components: individual assistance, a statewide planning workshop, regional meetings, an online course, an online resource center, and an e-mail listserv. We conducted brief surveys of LHD planners before and after the program to determine LHD planning needs and assess participation in the program.
We provided assistance to local planners through telephone and e-mail consultation and face-to-face meetings. Assistance included explanation of checklist elements and suggestions of activities to address them, discussion of local planning challenges, and review and feedback on draft plans. Individual technical assistance was offered to local planners before and after the March 2007 planning deadline.
In response to expressed need from local planners, NCCPHP held a statewide one-day planning workshop in early March 2007. The workshop included oral presentations on specific planning topics by subject-matter experts, breakout sessions addressing planning challenges, and a panel discussion with local planners. In addition, we distributed excerpts of plans that successfully addressed the Essential Elements.
North Carolina is divided into seven Public Health Regional Surveillance Teams (PHRSTs), which facilitate regional emergency planning and response. The PHRSTs organize regional meetings of local preparedness coordinators, which NCCPHP attended upon request. At the meetings, NCCPHP presented information about planning topics included in the Essential Elements checklist. Meetings varied from intensive pandemic influenza planning sessions to brief updates on the latest guidance.
In collaboration with NC DPH, NCCPHP developed and offered an online pandemic influenza course twice during the technical assistance program, from September through November 2006 and again from January through March 2007.12 Course participants viewed presentations, completed homework assignments, and posted comments to online discussion boards.
The final two components of the technical assistance program were an online resource center and an e-mail listserv. The resource center was designed as a one-stop source for planning guidance; examples of pandemic plans from other jurisdictions; and pandemic influenza literature, presentations, and educational material. The listserv was used to share information about planning resources as it became available.
In September 2006, prior to the technical assistance program, we conducted a baseline survey of LHD planners to assess technical assistance needs. A similar follow-up survey was conducted in April 2007 to assess progress toward planning goals and to determine if technical assistance needs were met. Both surveys were administered via a Web-based data-collection tool. Because the follow-up survey included individual identifiers, we administered a separate anonymous evaluation survey to assess satisfaction with the technical assistance program. The survey was determined not to constitute human subjects research as defined under federal regulations and, therefore, did not require Institutional Review Board approval.
NCCPHP and NC DPH reviewed plans using the Essential Elements checklist. The review was a stepwise process (Figure 1). In the Tier 1 review, NCCPHP assessed whether each plan contained a minimum number of items from each topic area of the checklist. Each item was scored as 0 (item not present), 1 (item present but could be expanded), or 2 (item present and well addressed). A score of 1 or 2 was sufficient to indicate the item was satisfied. Plans that did not include the minimum number of items were returned to the LHD with suggested improvements. Plans that passed Tier 1 were sent to subject-matter experts at NC DPH for further review. Primary criteria for passing the Tier 2 review were accuracy, consistency with the North Carolina Pandemic Influenza Plan, and compliance with state contracts. LHDs whose plans did not meet Tier 2 were referred back to NCCPHP for additional technical assistance or were contacted directly by NC DPH staff to address gaps. When a plan passed Tier 2, NCCPHP and NC DPH leaders sent an official letter to the local health director indicating approval of the plan.
Nearly all respondents to the follow-up survey (71 of 79, 90%) participated in one or more components of the technical assistance program (Table). Most LHDs (61 of 79, 77%) had face-to-face meetings with NCCPHP staff.
Thirty-four participants representing 28 LHDs attended the statewide workshop. Of the 22 attendees completing evaluations (65% response rate), all rated the workshop as “very useful” (73%) or “moderately useful” (27%). All participants planned to use information provided at the workshop to improve their pandemic influenza plans. Fifty-eight public health workers from 49 LHDs completed the online course. Of the 54 students who completed the post-course evaluation, 15 (28%) reported they were confident in their abilities to write or contribute to their pandemic influenza plan prior to the course, but 40 (74%) felt confident in their pandemic flu planning abilities after completing the course. Additionally, 34 students (63%) reported they had edited or planned to edit their pandemic flu plan based on new information provided during the course.
The response rate for the baseline and follow-up surveys was 93% (79 of 85 LHDs). At baseline, LHDs requested guidance on plan structure (60%) and content (54%), examples of promising practices from other counties (65%), and review of draft plans (67%). For all types of assistance except examples of promising practices, the number of agencies receiving each type of assistance at follow-up exceeded the number of agencies requesting it at baseline.
The response rate for the evaluation survey was 75% (64 of 85 LHDs). When asked, “Overall, how satisfied were you with the technical assistance provided by NCCPHP for pandemic influenza planning?” the vast majority of LHDs indicated they were “very satisfied” (n=46, 72%) or “somewhat satisfied” (n=14, 22%). Most planners (n=44, 69%) reported that the technical assistance helped them to address planning barriers.
Eighty-three of 85 LHDs (98%) submitted a pandemic influenza plan by the March 31, 2007, deadline. Sixty of the 83 submitted plans (72%) did not pass Tier 1 review on first submission and were returned to the planners with suggestions for improvement. Several plans were submitted multiple times before addressing the minimum requirements for Tier 1 approval.
In final plans resubmitted after revision, most LHDs (n=80, 96%,) addressed all 10 topic areas in the Essential Elements checklist; a few (n=7, 8%) addressed all 40 items within the 10 topic areas. Completeness varied by topic area (Figure 2). Only 16 plans (19%) addressed all items in the antiviral section, while 79 plans (95%) addressed all items in the communications section.
Overall, the strongest sections of plans noted in the Tier 2 process included command and control and communications. For example, several plans included press release templates and other pre-drafted messages in the communications section. In certain topic areas, we observed wide variability in the specificity and accuracy of plans across LHDs. There were four topics with notable variation and inaccuracies: surveillance, vaccine, antiviral, and vulnerable populations—a cross-cutting topic area.
In the surveillance section, planners were asked to address five items: (1) sentinel surveillance programs and plans for enhanced surveillance for novel influenza, (2) reporting of novel influenza from providers to LHDs, (3) reporting from LHDs to NC DPH, (4) case investigation, and (5) monitoring of local morbidity and mortality. We observed inaccuracies regarding reporting of novel influenza, and definition and timing of enhanced surveillance. While most plans addressed reporting of influenza, some incorrectly noted that novel influenza is not reportable. Although seasonal influenza is not reportable (except for pediatric deaths), novel influenza is part of the National Notifiable Diseases Surveillance System and must be reported immediately. We provided feedback about reporting requirements to local planners. Several plans neglected to define “enhanced surveillance,” and several noted that enhanced surveillance would begin with the first documented case of pandemic influenza in the county or neighboring counties. In fact, at the time, enhanced surveillance included screening travelers from H5N1-infected areas and should already have been occurring due to the World Health Organization's phase 3 pandemic alert.
In the vaccine and antiviral sections, planners were asked to identify priority groups, estimate number of doses needed, describe receipt and storage, and identify private stockpiles (antiviral only). We observed difficulties in the estimation and interpretation of vaccine and antiviral priority groups. The majority of plans incorporated federal recommendations for prioritization of vaccines and antiviral medications during a pandemic, but several plans prioritized other groups. For example, one plan prioritized family members of health department personnel to receive antivirals as a strategy to minimize absenteeism among health department staff. Such a strategy might be effective if antivirals were plentiful, but would not be feasible if supply was limited. NC DPH provided feedback that plans should include language indicating the county would follow federal antiviral prioritization guidelines if required by the state health director through an emergency order. Local planners also had difficulty estimating the number of people within specific tier groups in their county. In some counties, planners had difficulty accessing the data to determine how many individuals would be considered essential personnel for pandemic response and who would, therefore, be prioritized for antiviral and/or vaccine countermeasures. Other planners were hesitant to spend time on this issue as priority groups could change prior to a pandemic event.
Three items in the Essential Elements checklist addressed the needs of at-risk, or vulnerable, groups: (1) plans for disease containment relative to vulnerable groups, (2) support for vulnerable groups during emergency response activities, and (3) communication incorporating the needs of people with limited English proficiency and other vulnerable groups. The most common problem relative to these items was a lack of specificity. While most plans included a list of vulnerable groups and some agencies serving them, fewer plans included specific actions that might lessen the impact of a pandemic on such groups. In feedback to local planners, NCCPHP encouraged consideration of specific issues relative to vulnerable populations that might be addressed by the LHD or agency partners and next steps to address those issues. Some plans included specific actions, such as defining groups at risk in the area, developing message maps in multiple languages, and educating homeless service providers about infection control.
Partnering with a Center for Public Health Preparedness provided increased capacity to serve all 85 LHDs in a timely manner. State-level planners contributed subject-matter expertise, and NCCPHP added technical expertise, as well as an additional workforce to assist with planning efforts.
The NCCPHP technical assistance program for pandemic influenza planning incorporated multiple methods, both in-person and distance-based, to reach a diverse population of LHD planners in a wide geographic area. Overall, the program was well received by local planners and NC DPH partners. The six components—individual assistance, statewide and regional workshops, online course, online resource center, and e-mail listserv—complemented each other and met different needs.
Individual assistance through in-person visits and plan review was the core component of the program. Three NCCPHP staff members traveled throughout North Carolina visiting individual LHDs. These face-to-face meetings were crucial to conveying the importance of pandemic influenza planning, providing examples of items in the Essential Elements checklist, and -serving as an incentive for plan writing. Most importantly, they were an opportunity to establish rapport between NCCPHP staff and local planners. However, the individual assistance component of the technical assistance program required significant resources from NCCPHP. Reviewing plans and providing individual feedback was the most time-consuming task from April 2007 to September 2007. However, based on the high proportion of plans that did not pass Tier 1 review upon initial submission (72%), review and feedback from NCCPHP was responsible, in part, for submission of more complete plans to NC DPH. By screening plans before sending them to NC DPH, NCCPHP effectively lessened the burden of plan review for NC DPH and assured that all plans met a baseline level of competence and standardization. While the fact that most plans did not meet Tier 1 review criteria upon initial submission could be perceived as negatively reflecting on our technical assistance activities, this finding was to be expected given that LHDs were encouraged to share draft plans early in the process, in many cases before individually based technical assistance interventions began.
Recognizing that in-person visits to all 85 LHDs might not be feasible in the short time frame, we developed and used other methods of engaging local planners. The statewide workshop and regional mini-workshops provided updates on topics such as working with schools and planning for vulnerable populations. In addition to presenting information relevant to local planning, the workshops had the added benefit of creating a sense of community among local planners. The importance of such collateral outcomes should not be overlooked, especially for planners struggling to balance competing demands on their time. The challenges of planning, especially working with a wide range of community partners, may be easier to address when planners can share strategies and provide support. To leverage the power of resource sharing, examples of promising practices identified in LHD plans during the review process were distributed at the workshops and were well received by local planners.
The online components of the technical assistance program allowed planners to receive education on pandemic influenza preparedness topics without the expense of travel. The online course attracted a majority of LHD planners, many of whom had never previously enrolled in an online course. Those who participated in the course received instruction on such topics as pandemic impact modeling, novel influenza virus surveillance, non-pharmaceutical interventions, and incident command systems. While much of this content was intended to help inform planners about what needed to be addressed in local plans, no specific instructions on how to write a pandemic influenza plan were provided. Because many preparedness coordinators do not have a background in planning, an online course offered by NCCPHP in 2008–2009 specifically addressed planning.
Many local planners took advantage of the resource center and listserv. The primary advantage of these methods is efficiency—it is possible to provide information to all local planners throughout the state easily. This was advantageous for quickly disseminating new guidance, such as the community mitigation guidance released by CDC midway through the technical assistance program.13 It also provided the only electronic forum for sharing LHD plans across the state. For example, one LHD had a comprehensive mass fatality plan and was willing to circulate it to other LHDs in the state through the listserv.
Our qualitative review of plans highlights the variability that exists in local plans and illustrates some of the challenges faced in providing technical assistance. While some observed variability was clearly the natural result of differing local circumstances (e.g., unique demographics or geography), other variability may underscore the need for more education at the local level or a more clearly stated state policy. It was clear that LHD plans mirrored the state plan in many sections. For example, at the time of this project, planning for vulnerable populations and mass fatalities was still under development in the state pandemic influenza response plan. These sections were underdeveloped in most local plans as well.
Review of LHD plans provided needed insight for NC DPH planners. For example, many local plans included misinformation regarding transmission of influenza viruses and infection-control practices to reduce transmission. State-level planners could take areas of misinformation and turn them into learning opportunities during subsequent workshops and presentations across the state. For larger issues, such as a lack of understanding of various state agencies' roles, state planners could revise specific sections of the state pandemic influenza response to clarify roles and responsibilities during a pandemic.
Throughout the process, we sought a balance between providing guidance that was too general versus too prescriptive. One example is vaccine priority groups. We recommended using the federal priority group guidelines tailored to local circumstances (e.g., prioritization of vaccine-manufacturing employees in counties with vaccine plants) but ended up with some plans that cited groups not included on the federal list. If we had provided LHDs with a structured planning template, we could have minimized the amount of plan variability. However, we did not want to shortcut the planning process, which has intrinsic value beyond the production of a written plan. Indeed, many LHDs created new multi-agency planning entities to develop a structured process for creating their pandemic influenza plans, which have continued functioning, planning for other public health threats.
In some cases, it was difficult to determine the extent of actual LHD planning through review of the plans. For example, many LHDs cited partnerships with local agencies to manage aspects of the response in their plans (e.g., social service agencies to provide support to vulnerable populations). Yet, our analysis of LHD plans did not include verification to confirm that local partner agencies were aware of their roles as stated in LHD plans. Additional studies would seek to prospectively monitor multi-agency planning at the local level, as a process evaluation might identify outcome measures that are better predictors of preparedness than could be obtained through a review of plans.
The purpose of the project was to obtain complete plans from all 85 North Carolina LHDs. Of course, the ultimate goal of writing plans is to be well prepared for an influenza pandemic. A written plan is one proxy to indicate preparedness. At best, a written plan accurately reflects actual planning and can serve as an operational guide before, during, and after a pandemic event. However, in some cases, a plan may not represent true organizational or community preparedness. Our outcome measure—plan completeness—is not adequate to distinguish between these types of plans. Determining actual preparedness would require alternative measures, such as conducting in-depth interviews with community partners or observing performance during an exercise.
Participation in technical assistance programs offered by NCCPHP was not compulsory. LHDs that had a high level of participation in NCCPHP programs are likely to be different from those that developed their plans without such services. This selection bias makes it difficult to measure the overall impact of our technical assistance program. Some LHDs were particularly reliant on NCCPHP for planning assistance. While these high-participation LHDs were more likely to be successful in developing an approved plan, they required significantly more NCCPHP staff time than other LHDs.
The technical assistance program provided support for LHD planners, ensured that all local plans addressed a minimum number of elements in key topic areas, and lessened the burden of plan review for NC DPH. The multifaceted approach, including in-person and distance-learning components, was designed to appeal to local planners with a range of needs. Future projects may use a similar approach with an additional emphasis on measuring preparedness outcomes.
The authors thank Cathy Chow from the Centers for Disease Control and Prevention (CDC), Office of Public Health Preparedness and Response for her assistance in the review and editing of the article. The authors also thank Ann-Marie Meyer and Emily Eidenier for their assistance with data analysis, and Lindsay Tallon for providing technical assistance to local health departments.
This article was supported by Cooperative Agreement #U90/CCU424255 from CDC and #01559-07 from the North Carolina Division of Public Health (NC DPH). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of CDC or NC DPH.