Pandemic Influenza Preparedness in Maryland: Improving Readiness Through a Tabletop Exercise

Transcription

1 BIOSECURITY AND BIOTERRORISM: BIODEFENSE STRATEGY, PRACTICE, AND SCIENCE Volume 3, Number 1, 2005 Mary Ann Liebert, Inc. Pandemic Influenza Preparedness in Maryland: Improving Readiness Through a Tabletop Exercise JEAN LIN TAYLOR, BRENDA J. ROUP, DAVID BLYTHE, GREG K. REED, TIFFANY A. TATE, and KRISTINE A. MOORE In February 1999, the Maryland Department of Health and Mental Hygiene initiated pandemic influenza planning for the state of Maryland. This process involved several major steps, including the development of the Maryland Pandemic Influenza Preparedness Plan, and culminated in a highlevel tabletop exercise to test the plan in April During the tabletop exercise, participants were presented with nine different fictitious scripts encompassing a single scenario. They were asked to respond to the information presented in each script, discuss organization-specific questions posed by the exercise facilitator, and make decisions regarding action steps that their organization would take in response to the various issues raised. The exercise identified a number of important gaps that need to be addressed, including (1) additional surge capacity specific to a pandemic, (2) greater understanding of the realities and implications of pandemic influenza among elected officials and decisionmakers, (3) coordination of pandemic influenza planning with the existing emergency response infrastructure coupled with additional training in incident command, (4) further steps to operationalize several aspects of the Maryland Pandemic Influenza Preparedness Plan, and (5) additional federal guidance. istory repeats itself; that s one of the things Hthat s wrong with history, according to Clarence Darrow. Public health officials are bracing for the next influenza pandemic, which, if history repeats itself in this context, could parallel the dramatic loss of life and social disruption that characterized the great pandemic of Recent experience with H5N1 avian influenza virus in Asia has highlighted concerns about the emergence of a novel influenza strain that is capable of spreading easily from person-to-person and causing serious illness in humans across the age spectrum. 4,5 These features, along with limited immunity to the novel strain in the human population, would set the stage for a new global influenza pandemic. Conservative estimates of the toll of a future influenza pandemic in the United States predict 89, ,000 deaths, 314, ,000 hospitalizations, million outpatient visits, and million additional illnesses. 6 However, projections based on mortality data from the 1918 pandemic yield a much higher potential death toll and suggest that more than 1.7 million people in the U.S. alone could die over a 1- to 2- year period. As the prospects for a new pandemic increase, and with the release in August 2004 of the draft U.S. Pandemic Influenza Preparedness and Response Plan, 7 in- Jean Lin Taylor, DrPH, is Epidemiologist; Brenda J. Roup, PhD, RN, CIC, is Nurse Consultant, Infection Control; David Blythe, MD, MPH, is State Epidemiologist; and Greg K. Reed, MPA, is Program Manager, Center for Immunization, all at the Maryland Department of Health and Mental Hygiene, Baltimore. Tiffany A. Tate, MHS, is Executive Director, Maryland Partnership for Prevention, Baltimore. Kristine A. Moore, MD, MPH, is Medical Director, Center for Infectious Disease Research and Policy, University of Minnesota, Minneapolis. 61

2 62 fluenza pandemic preparedness planning efforts are becoming more relevant and timely in the public health arena. The Department of Health and Human Services (DHHS) (including the Centers for Disease Control and Prevention [CDC]), the Association of State and Territorial Health Officers (ASTHO), and the Council for State and Territorial Epidemiologists (CSTE) have encouraged state health departments to develop state pandemic influenza preparedness plans through a collaborative process of engaging key partners and stakeholders Tabletop exercises also have been recommended as a way to augment and assess preparedness planning activities. 7,9 This article reviews the pandemic influenza planning process in Maryland, including experience in conducting a tabletop exercise, and highlights lessons learned and recommendations for improving readiness. This is the first published report to detail the process of pandemic influenza planning at the state level. OVERVIEW OF PLANNING PROCESS IN MARYLAND TAYLOR ET AL. The tabletop exercise was held in April 2004, as the culmination of a planning process that began in February 1999 when the Maryland Department of Health and Mental Hygiene (DHMH) embarked on pandemic influenza planning in the state. From the start, the planning process included five major steps: Step 1. Various individuals and groups were identified and assembled, each with a specific role (Figure 1). Step 2. The Core Work Group promoted awareness of the need for advance planning and undertook a number of activities to secure buy-in from a wide variety of organizations in the public and private sectors. This effort began with a series of meetings and presentations to executivelevel staff at DHMH and then to senior personnel in Maryland s emergency management and emergency medical agencies. At the same time, through official memoranda the Group informed Maryland s 24 local health departments, hospitals, and long-term care facilities about the importance of advance planning for pandemic influenza. The Group held two conferences to educate and engage additional potential partners and stakeholders, including those in public health, emergency management, social services, education, law enforcement, public safety, the medical community, health maintenance organizations, transportation, communication and media, local military installations, public utilities, religious organizations, and major employers and businesses. Members of the group also interviewed with local public television and print media, the latter of which produced a full feature article in a popular maazine. 11 Step 3. The Core Work Group developed a draft Mary- FIGURE 1. PANDEMIC INFLUENZA PLANNING IN MARYLAND: PROJECT ORGANIZATION

3 PANDEMIC INFLUENZA PREPAREDNESS IN MARYLAND 63 land Pandemic Influenza Preparedness Plan (hereinafter referred to as the Plan) based on interim guidance from CDC 12 and additional research. Step 4. Comments on the Plan were solicited from local health departments and from a wide array of partners and stakeholders from private and public agencies. The comments from all of these groups resulted in revisions to the Plan. Step 5. A senior-level tabletop exercise was conducted on April 28, 2004, to test the Maryland Pandemic Influenza Preparedness Plan; this exercise is the major focus of this report. The exercise represented a collaborative effort between DHMH, the Maryland Partnership for Prevention, and a group of outside consultants. Its objectives were to: (1) evaluate selected operational aspects of the Plan; (2) assess whether strategies are in place for effective and rapid communication; (3) clarify roles and responsibilities (including the leadership structure); (4) identify risk communication messages and key issues in developing a coordinated public information plan; and (5) assess the decision-making process among government agencies, elected officials, and other systems involved in the pandemic influenza response. TABLETOP EXERCISE FORMAT The tabletop exercise conducted in April 2004 began with two brief introductory presentations to equip all participants with adequate background information. The exercise lasted 4 hours (as a matter of practicality, given participants schedules) and was divided into a series of nine fictional scripts of a single scenario. Following the presentation of each script, participants were asked to respond to the information presented, discuss organization-specific questions posed by the facilitator, and make decisions regarding action steps that their organization would take in response to the script. Given the limited time, the exercise was designed to cover overall roles and responsibilities across agencies and to deal with operational planning issues at a high-level. As a result, the exercise was not able to assess detailed operational aspects of response or to probe deeply into agency-specific issues. Exercise Participants, Consultants, and Observers Forty people participated in the tabletop exercise, including senior-level professionals with decision-making authority from local and state governments as well as private organizations (Figure 2). Each participant was allowed to bring up to two additional experts for consultation on an as-needed basis. These consultants, as well as FIGURE 2. others who were invited to observe the exercise, had no direct role in the discussions. A total of 150 people participated in, consulted in, or observed the exercise. Exercise Assumptions PARTICIPANTS IN THE TABLETOP EXERCISE Key assumptions of the overall scenario for the exercise included the following: A novel H5N1 avian influenza strain will emerge with the following key features: (1) it causes severe disease in humans, (2) the global human population does not have preexisting immunity to the strain, and (3) it is capable of moving rapidly through person-to-person spread. Vaccine against the novel H5N1 strain will not be available until approximately 4 months after the pandemic arrives in the United States. Vaccine will be made available in batches as it is produced and will initially be released only in the public health sector; therefore, state officials will need to implement a priority system for vaccination of the state s population. Two doses of vaccine will be required to develop immunity to the novel H5N1 strain.

4 64 Availability of antiviral agents will be limited and have minimal overall impact. Approximately 30% of the Maryland population will contract influenza during the first wave of the pandemic (an estimated 1,500,000 cases). A case-fatality rate of approximately 1.2% (18,000 deaths) among those who contract influenza during the first wave will occur. (This takes into consideration the recent experience with H5N1 influenza in Asia.) OVERVIEW OF EXERCISE SCRIPTS TAYLOR ET AL. A short summary of each of the nine scripts, along with selected questions posed by the facilitator (in italics), follow. (Note: The original scripts have been modified slightly to be more consistent with recent federal estimates of vaccine production during a pandemic.) July 28, 2004 September 1, WHO officials issue an influenza pandemic alert and related travel advisories. The H5N1 influenza outbreak that spread across live poultry markets in Asia during early 2004 has been brought under control, and no human cases have been detected in recent weeks. However, on July 28 WHO confirms that 7 new human cases of H5N1 influenza have been recognized in Hanoi, Vietnam, and 4 of the 7 people have died. By the end of August, 207 cases of the novel strain are recognized in Hong Kong and Vietnam; most are clearly the result of person-to-person transmission. Because of the growing concern about the pandemic potential of this novel H5N1 strain, on September 1 WHO issues an influenza pandemic alert and travel advisories for Vietnam and Hong Kong. In conjunction with this alert, CDC recommends that people returning to the U.S. from Vietnam and Hong Kong be placed on a 5-day fever watch. CDC also recommends that any returning travelers with influenza-like illness be placed in immediate isolation. Have inventories been conducted to assess existing capacity for emergency departments, hospital beds, ICU beds, ventilators, and numbers of health-care providers available to see outpatients? Who is responsible for implementing evaluation and follow-up for travelers arriving at the airport, and how will this be accomplished? What are the legal issues related to implementing isolation for travelers with influenza-like illness? September 2, 2004 September 30, WHO officials declare the onset of an influenza pandemic. By late September, outbreaks of human H5N1 influenza are reported from throughout China as well as from Japan, the Philippines, South Korea, Malaysia, Singapore, Mongolia, Indonesia, and Australia. Because of the rapid spread of this novel H5N1 strain, on September 30 WHO officials declare the onset of an influenza pandemic. At the end of September, CDC informs state health departments that a vaccine against the novel H5N1 strain will not be available for distribution until at least the end of January Once WHO has declared a pandemic, what steps will local public health agencies be expected to take? What steps will DHMH take to establish surveillance for illness caused by the novel H5N1 strain? What will be the initial risk communication messages to the public? Who will be in charge of communications with the public and who will be the main spokespersons? October 1, 2004 October 31, The pandemic arrives in Maryland. On October 10, an explosive outbreak of H5N1 is reported among a group of 40 soldiers who had just returned to Fort Meade from a tour of duty in South Korea. The soldiers had entered the U.S. 2 days earlier through Baltimore/Washington International Airport (BWI). At the time of reentry, none of the soldiers admitted to influenza-like symptoms; however, public health officials later learn that several of the soldiers were symptomatic when they passed through the airport. All 40 of the soldiers become ill, and 4 die over the next 2 days. Between October 15 and October 31, 44 additional cases of H5N1 influenza are confirmed in Maryland. At what point or under what conditions would the Maryland Emergency Operations Center be activated? Under what conditions would a public health emergency be declared? How will DHMH monitor and allocate state health department resources during the pandemic response? How will any stockpiles of antiviral agents be allocated and who will make those decisions? November 1, 2004 November 10, School outbreaks of H5N1 influenza are recognized. On November 1, CDC warns that the pandemic could be severe in the U.S., with illness rates of up to 30% of the population and a much higher than expected mortality rate, particularly among children and healthy young adults. Given the extreme virulence of this strain, CDC estimates that overall mortality rates among those who develop influenza could be as high as 1 2%. On November 4, 2004, an outbreak of H5N1 influenza is reported at Johns Hopkins University following the return of a group of students from the Johns Hopkins affiliate center in Nanjing, China. At least 16 students are ill, and several have been hospitalized; 2 deaths have occurred in previously healthy students. By November 10, H5N1 outbreaks are recognized in a number of schools in the Baltimore area, and several school-aged children have died. Many parents are refusing to send their children to school. How will decisions be made regarding closing universities, schools, and daycare centers? What additional steps will be recommended to minimize community transmission? How will these recommendations be enforced? November 10, 2004 November 30, Health-care staffing and bed shortages become a serious problem. By late November, the state laboratory at DHMH has

5 PANDEMIC INFLUENZA PREPAREDNESS IN MARYLAND 65 confirmed more than 800 isolates of H5N1 influenza in Maryland; more than 500 deaths caused by suspected or confirmed influenza have been reported. Hospitals are reporting high numbers of admissions for influenza, and staffing shortages are occurring at several hospitals because of illness in employees. A number of deaths have occurred in health-care workers who had provided care to influenza patients. These reports have received extensive media coverage and have added to concerns among hospital employees. In some locations, employees are refusing to come to work, which has further exacerbated staffing shortages. The public has become aware that several hospital pharmacies are still reserving small amounts of antiviral agents for prophylaxis and treatment of health-care providers (particularly physicians). The public is outraged that vaccine is not yet available and that health-care providers are hoarding antiviral agents. How will hospital admissions be monitored to assess influenza morbidity and mortality? How will transmission in health-care facilities be minimized? What considerations will be given to establishing influenza facilities? Are there plans in place to provide surge capacity for clinical care? Are systems in place to provide mental health support to family members of victims and others adversely affected by the epidemic? December 1, 2004 January 1, Critical infrastructure shortages occur. By mid-december, essentially all states are reporting heavy pandemic influenza activity. Maryland has experienced more than 6,000 deaths due to the novel H5N1 strain, many in healthy young adults. BWI, Dulles, and Reagan National airports are nearly shut down because of a shortage of air traffic controllers and flight cancellations. Most daycare centers in the state have closed because of staffing shortages. Local public health agencies and DHMH are experiencing severe staffing shortages. EMS, fire, police, and other public service agencies also are experiencing severe staffing shortages; public transportation has had to be sharply curtailed because of absenteeism. How will DHMH and local public health agencies maintain essential public health services during the pandemic in light of staffing shortages? How will bodies be managed when morgue capacity has been exceeded? January 15, 2005 January 31, H5N1 influenza vaccine becomes available in Maryland. In early January, CDC decides that the initial batches of H5N1 vaccine will be released through the public sector only. By mid-january, Maryland has experienced more than 12,000 influenza deaths. Mortality rates in some nursing homes have exceeded 30% of the entire facility. On January 15, states are informed that CDC intends to release the first batch of H5N1 influenza vaccine on January 20. Because the population has no preexisting immunity, CDC recommends that people receive 2 doses of vaccine 1 month apart. On January 20, Maryland receives 200,000 doses, and decisions for prioritizing the initial vaccinations need to be made. Hospitals and vaccination clinics are quickly overwhelmed by people who are demanding to be vaccinated. Small riots break out in several areas, and security is a major concern. How will decisions be made to prioritize vaccinations? How will vaccine be distributed to priority groups? How will DHMH monitor availability and coordinate distribution and delivery of public sector vaccines? What will be the risk communication messages to the public around prioritization of the initial vaccination doses? How will public order be maintained once vaccine becomes available? February 1, 2005 April 30, More H5N1 influenza vaccine arrives in Maryland. On February 1, Maryland receives an additional 200,000 doses of H5N1 vaccine and then continues to receive about 200,000 doses every 2 weeks. A high level of pandemic influenza activity continues through mid-february, and by the end of February, nearly 16,000 influenza deaths have occurred in Maryland. How will vaccine be deployed over the next several months? April 30, 2005, and beyond. Recovery from the initial pandemic wave and planning for additional waves. By late May, CDC declares that the first wave of the pandemic is over. Approximately 18,000 influenza deaths have occurred in Maryland during the first pandemic wave. Once the pandemic is over, how will DHMH and local health departments assess capacity to resume normal public health functions? Are systems in place to track public health and health-care system costs during an emergency? LESSONS FROM THE TABLETOP EXERCISE The experience of conducting the tabletop exercise revealed several lessons and suggested ways to improve Maryland s readiness for an influenza pandemic. In addition, a number of detailed and specific issues related to the Plan were identified throughout the exercise. The exercise also provided implications for others involved in preparedness activities beyond pandemic influenza planners in Maryland. The major lessons learned are outlined below; these lessons are based on comments made by participants during the exercise as well as in the written evaluations, and they reflect the observations and conclusions of the authors of this report. Participants realized that Maryland needs to continue to build surge capacity specific to the challenges of an influenza pandemic. The exercise demonstrated to participants that pandemic influenza could overwhelm existing public health, clinical, and community resources. While some participants were well aware of the potential

6 66 surge capacity needs during a pandemic, for others the exercise served to make this issue much more apparent. During the course of the exercise, participants realized that the surge capacity challenges posed in a pandemic are much different from other local and regional outbreaks, as many responders themselves will become ill with influenza, the response will need to be sustained over months rather than days or weeks, and regional and federal resources will be unavailable or severely limited. Several participants noted that current plans underestimate the scope of impact. Of the 69 evaluation forms completed by participants or observers, issues related to surge capacity were mentioned 20 (29%) times. One respondent wrote, Too many people are thinking of hightech business as usual responses. Another wrote, The degree of disorder in such a disaster is underrated.... Tables 1 and 2 further illustrate the serious potential health impact of pandemic influenza in Maryland, assuming a gross clinical attack rate of 15 35% (higher than typical influenza epidemics but similar to the rates for previous pandemics) and the absence of any interventions. 6,13,14 Table 2 illustrates the impact of an 8-week influenza pandemic with a 25% gross clinical attack rate. In this example, the demand on hospital resources peaked in week 5, with a maximum of 523 hospital admissions per day. During this week, an estimated 3,529 persons would be hospitalized, 741 would require use of an intensive care unit, and 370 would need mechanical ventilation. These numbers translate to 35% of all hospital beds, 69% of total ICU capacity, and 37% of all ventilators in Maryland, respectively. This example illustrates how the next influenza pandemic may overwhelm existing hospital resources in Maryland. Consequently, public health officials and hospital administrators must plan for surges in demand for hospital services during the next pandemic. Such surge capacity planning should include: TAYLOR ET AL. Examination of actual documented numbers of available staff and volunteer resources; Consideration of the need for consistent guidelines for managing employees who refuse to come to work; and Specific contingency plans for situations when surge capacity is exceeded (such as credentialing, special powers to compel, and emergency scope of practice guidelines, decentralized delivery of care [e.g., home care], and alternative sites of care). Participants noted that elected officials and decisionmakers (at the state and local levels) must have a clear understanding of the potential implications of an influenza pandemic and that additional efforts are needed to assure that such officials are adequately informed. Comments from elected officials and other community leaders during the exercise demonstrated that they had not previously appreciated the potential severity of an influenza pandemic. For example, when asked about the main lessons learned from the exercise, several participants responded with the following comments: The extent of the next influenza pandemic; the seriousness of the problem, Just how bad it could be! Scope of potential problems is larger than can be imagined and will require cooperation of all agencies in the state. In Maryland, while public health and emergency response officials have met in various settings, it was clear from the exercise that elected officials and political leaders require further engagement to inform and equip them to respond to the next influenza pandemic. As part of this process, leaders need to know in advance the types of decisions that will be required and the implications of available policy options. For example, issues that were raised during the exercise included the following: (1) What are the conditions and procedures for closing businesses and schools and suspending public meetings? (2) What re- TABLE 1. ESTIMATES OF THE HEALTH IMPACT OF PANDEMIC INFLUENZA ON MARYLAND Estimated range of persons affected a Percent of MD Health impact Number b population 11,12 Deaths 1,589 3, Hospitalizations 5,296 15, Outpatient visits 317, , Total infected 794,473 1,853, a The numbers reflect CDC estimates and do not necessarily reflect the higher mortality rates that could be seen with a highly virulent strain such as in the 1918 influenza pandemic and in the scenarios presented in this report. b Range is calculated using Maryland 2000 population from the U.S. Census Bureau: 5,296,486 (

7 PANDEMIC INFLUENZA PREPAREDNESS IN MARYLAND 67 TABLE 2. IMPACT OF PANDEMIC INFLUENZA ON HOSPITAL RESOURCES IN MARYLAND BY WEEK a Pandemic week Category Hospital admissions 1,061 1,768 2,652 3,359 2,652 1,768 1,061 per week Peak daily hospital admissions Number of 1,061 1,768 2,652 3,359 3,529 3,249 2,514 1,658 hospitalized influenza patients Percent of overall 11.% 18.% 27.% 34.% 35.% 32.% 25.% 17.% hospital capacity Number of patients hospitalized in ICUs Percent of overall 15.% 31.% 48.% 64.% 69.% 67.% 53.% 37.% hospital ICU capacity Number of patients on ventilators Percent of overall 8.% 17.% 26.% 35.% 37.% 36.% 29.% 20.% ventilator capacity Number of influenza deaths Number of influenza deaths among hospitalized patients a Assuming an 8-week influenza pandemic with a 25% gross clinical attack rate; numbers are generated through FluSurge, a CDC modeling program. These figures are not to be considered predictions of what will actually occur during an influenza pandemic. Rather, they should be treated as estimates of what could happen. Number of licensed acute care hospital bed capacity as of July 1, 2003, was provided by the Maryland Health Care Commission. Total intensive care unit (ICU) bed capacity and ventilator capacity were provided by the Maryland 2003 Hospital Disaster Preparedness Survey, conducted by the Maryland Institute of Emergency Medical Services System (MIEMSS). strictions on travel and trade can be invoked in the event of a pandemic? (3) Would influenza vaccine or antiviral agents be commandeered from the private sector as a state asset during an influenza pandemic? (4) Although the governor has broad legal authority, additional clarity is needed to define what events during the course of a pandemic would trigger that authority. For instance, at what stage will a state public health emergency be declared? (5) A strategic process for decision-making is needed that (a) clearly articulates the specific roles of all persons involved in making decisions; (b) clearly articulates the specific roles of all persons involved in providing consultation and advice to decision-makers; (c) ensures that critical and timely information is available to decision-makers regarding the consequences of each decision; and (d) is widely shared in advance with all planning and response partners. Pandemic influenza planning needs to be further coordinated with the existing emergency response infrastructure, and additional training in incident command is needed. It was clear during the course of the exercise that although significant public health preparedness and all-hazards planning have been completed and response systems have been developed, those not directly involved in that planning and development may not be uniformly informed about and aware of the systems in place or in development. To address this issue, DHMH should continue to foster coordination between bioterrorism preparedness activities and influenza pandemic planning. Issues around lines of authority were mentioned in 17 (25%) of 69 evaluation forms that were submitted by participants and observers. Furthermore, during the exercise it was clear that the concept of incident command was new to a number of participants. In the evaluation forms, several people asked, Who takes the lead? One participant noted, We need to identify who the leader would be in a statewide pandemic is it the Secretary of Health, the State Epidemiologist, MEMA, or the Governor?

8 68 Such questions pointed out that a need exists for increased understanding of and comfort with the interdisciplinary use of incident command systems. More detailed operational planning is required to achieve an effective overall response. While the Maryland Pandemic Influenza Preparedness Plan is relatively comprehensive, a number of the activities outlined in the Plan still need to be operationalized further into response capabilities to assure an effective overall response. On the 69 evaluation forms, the need for additional operational planning was mentioned 25 (36%) times. One participant commented, [Maryland] needs much work on operational aspects of the plan, especially interagency and other partner interactions. Another participant stated a similar sentiment: [Maryland] needs to do more detailed planning and really turn our plan into a how to manual. Respondents noted particular activities that need to be operationalized, including processes for decision-making about closure of schools, agency roles and functions such as communication flow and decisionmaking, and staffing of alternative care sites, among others. Examples of specific operational documents that could be developed if resources allow include: (1) a resource inventory by county of sites that could be used for alternative mass care; (2) a protocol for distribution of public sector vaccine (once it becomes available), including identification of priority groups and strategies to reach them; (3) various pandemic planning guidance documents for schools and health-care facilities; (4) a surveillance protocol to monitor key parameters, such as deaths, in a timely fashion; and (5) a review of existing legal authorities in relation to a pandemic. State planning is not complete until plans are translated into policy decisions and concrete action steps that can be implemented at the local level, where most of the actual response will take place. The current Plan identifies a number of steps that local health departments should take to assure that they are prepared for a pandemic; however, more clarity is needed concerning how many health departments actually have followed through with these recommendations. In this regard, the exercise clearly demonstrated that additional oversight and guidance from DHMH to local health departments is needed. Activities that could be undertaken include providing a checklist of planning activities to local health departments, ensuring that each local health department has a written plan for mass distribution of influenza vaccine, and performing a survey of all local health departments about pandemic planning at the local level to identify gaps. Additional support is needed at the federal level. Many of the challenges encountered during an influenza pandemic would not be unique to Maryland; therefore, we believe that ongoing, strong federal leadership is needed to develop consistent policies across different jurisdictions. The recently released draft national Pandemic Influenza Preparedness and Response Plan provides essential guidance that can aid state and local communities in their pandemic planning efforts. 6 However, as the public health community addresses the complex challenges that a global pandemic would pose, DHHS (including CDC) should continue to work with state and local partners to refine a number of key issues raised in the current national Plan. Examples of these issues include: Further clarification of the level of federal purchase of influenza vaccine during a pandemic; Further clarification regarding federal purchase or stockpiling of antiviral agents; National guidelines on recommendations for use of antiviral agents during a pandemic; A federal determination of priority groups for vaccination (including recommendations for prioritization within priority groups); and Surveillance prototypes for monitoring health impact at the state and local levels during a pandemic. CONCLUSION This exercise was extremely valuable in bringing a diverse group of people to the table to discuss pandemic influenza. It served to engage the emergency response community and address the issues of incident command and how pandemic planning fits with the all hazards approach. The exercise also educated key partners and stakeholders, through an experiential approach, about the potential severe consequences of pandemic influenza, and it provided a forum to drill down beyond the current state plan and identify additional critical local planning activities that are needed. Instructive insights and lessons were gained from the exercise that should bolster further planning efforts in Maryland, not only for pandemic influenza, but also for bioterrorism and other public health disasters. ACKNOWLEDGMENTS TAYLOR ET AL. We thank Jeffrey Roche and Dale Rohn for their assistance in pandemic influenza planning. We thank Karen Black, John Healy, and Jill DeBoer for assisting in the tabletop exercise and Michael Osterholm for facilitating the tabletop exercise. We also thank Arlene Stephenson, Diane Matuszak, Lisa Kirk, John Krick, and Julie Casani for their critical review of this report. We are grateful to the participants of the tabletop exercise. The tabletop exercise was conducted in part through a grant from the Centers for Disease Control and Prevention.

9 PANDEMIC INFLUENZA PREPAREDNESS IN MARYLAND 69 REFERENCES 1. Cox NJ, Tamblyn SE, Tam T. Influenza pandemic planning. Vaccine 2003;21: Strikas RA, Wallace GS, Myers MG. Influenza pandemic preparedness action plan for the United States: 2002 update. Clin Infect Dis 2002;35: Trampuz A, Prabhu RM, Smith TF, Baddour LM. Avian influenza: a new pandemic threat? Mayo Clin Proc 2004; 79: Hien TT, Liem NT, Dung NT, et al. Avian Influenza A (H5N1) in 10 patients in Vietnam. New Engl J Med 2004; 350: Snacken R, Kendal AP, Haaheim LR, Wood JM. The next influenza pandemic: lessons from Hong Kong, Emerg Infect Dis 1999;5: Meltzer MI, Cox NJ, Fukuda K. The economic impact of pandemic influenza in the United States: priorities for prevention. Emerg Infect Dis 1999;5: United States Department of Health and Human Services. Pandemic influenza preparedness and response plan, August 26, Available at: pandemicplan. Accessed March 14, National Vaccine Program Office. Pandemic Influenza Home Page. Available at: index.html. Accessed March 14, Association of State and Territorial Health Officers. Preparedness Planning for State Health Officials, Nature s Terrorist Attack: Pandemic Influenza, November Available at: Influenza.pdf. Accessed March 14, Council for State and Territorial Epidemiologists. Influenza Pandemic Preparedness State Plans. Available at: cste.org/specialprojects/influenza%20pandemic%20state%2 0Plans/Influenza[%]20Pandemic%20Preparedness%20State %20Plans.htm. Accessed March 14, Granat D. Ready or not. Washingtonian September 2000; Patriarca PA, Strikas RA, Gensheimer KF, Cox NJ, Meltzer MI. Draft pandemic influenza planning guide for state and local officials, version 2.1. January Available at: Gellin B, Director, National Vaccine Program Office, Department of Health and Human Services. Presentation at Institutes of Medicine Workshop: Pandemic Influenza: Assessing Capabilities for Prevention and Response; June 16, 2004; Washington, DC. 14. Zhang X, Meltzer MI, Wortley P. FluSurge 1.0: A manual to assist state and local public health officials and hospital administrators in estimating the impact of an influenza pandemic on hospital surge capacity (Beta test version). Washington, DC: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; Address reprint requests to: Jean Taylor, DrPH Maryland Department of Health and Mental Hygiene 201 West Preston Street Baltimore, MD taylorj@dhmh.state.md.us