Controlling a pandemic outbreak is a multi-disciplinary and whole-of-society endeavor, and the leadership and management structure must reflect that. Activating an Emergency Operations Center, as would occur in a natural disaster or other homeland security crisis, is a best practice used in previous large-scale novel outbreaks. The EOC should host a whole-of-community incident management structure, drawing on existing local emergency response plans and capacities where possible. Using an EOC enables a community to streamline communication, planning, decision-making, and operational coordination across a wide range of community leaders and stakeholders, including communication and alignment with higher-level (state/federal) EOC processes and decision cycles. The EOC should also have liaisons to, or representatives from, other levels of government, public health officials, civil society, religious leaders, the business community, academia, and others.

PRIORITY ACTIONS

• Activate local Emergency Operations Center and connect to state/federal EOCs
• Designate an empowered Incident Manager
• Organize EOC functional units/teams around major operational priorities
• Establish liaisons to key government partners (state, federal) and community stakeholders

OPERATIONAL REQUIREMENTS

Has the Emergency Operations Center (EOC) been activated and has the whole-of-community incident management structure been established? [1] [2] [3]

Have functional teams in the EOC been organized around defined operational priorities (such as the key actions identified in this guide)? [2] [3]

Does the EOC have designated liaisons with all relevant government, community, and private sector stakeholders, including: [1] [2] [3]

1. Other state, local, and federal officials involved in the response?
2. Healthcare coalitions, including hospitals, public health, EMS and other key elements of the health and medical sector?
3. Civil society groups, religious institutions, and other community leaders?
4. Appropriate representation from all departments and agencies?

Has the EOC identified the critical workers/sectors in the community (healthcare, utilities, transport, food supply, etc.)?

Is there a process to maintain the health and wellbeing of personnel assigned to work in the EOC? [4]

1. As quarantines and self-isolation requirements expand, is there a clear process for transitioning to a virtual EOC for non-essential personnel who still need to be engaged, as well as identifying alternates for those who may be infected?

Has a response coordinator been designated and do they have the authority to: [2] [3]

1. Bring issues directly to leadership for rapid resolution?
2. Link with scientific and health experts to provide guidance based on the latest research?

Is there a Continuity of Government plan to ensure continued essential services? (Example Here)

1. Do essential businesses such as healthcare facilities or facilities serving vulnerable populations have continuity plans to ensure continued service?
ADDITIONAL CONSIDERATIONS

A pandemic control strategy is grounded in understanding ongoing transmission risk in the community so that the disease can be effectively controlled and contained. This will require continuous disease surveillance, diagnostic testing, contact tracing, isolation, and reporting systems that ensure up-to-date information on local spread is available to inform strategy-setting and daily tactical decision-making. This may be difficult where limited testing supplies and/or shortages of personal protective equipment prevent sufficient testing. Scaling up and sustaining local access to testing will be critical as additional laboratory capacity comes online. If diagnostic testing is limited, as a stop-gap, communities can enhance syndromic surveillance and other dynamic surveillance tools, along with contact tracing, to gauge disease activity within the community. Effective testing and contact tracing will require a combination of rapid testing capability, interoperable tools for quickly collecting and analyzing contract tracing data, deployment and management of contact tracing teams, and the provision of adequate capacity and incentives for the effective quarantine of contacts and isolation of infected persons. Contact tracing and testing must also be deployed in concert with other elements of a long term plan to contain and maintain control of community transmission. Other components include iterative cycles of social distancing measures –such as canceling mass gatherings, school closures, incentives for teleworking -- and expansion of health care capacity to meet the need.

PRIORITY ACTIONS

• Does the community have clear plans, with metrics, for implementing, continuing, adjusting, or lifting social distancing measures incorporate benchmarks based on surveillance, testing, and contact tracing?
• Track influenza-like-illness (ILI) and COVID-19-like illness (CLI)
• Develop a protocol for broad diagnostic testing in the community. If tests are limited, include all symptomatic persons, close contacts, healthcare workers, first responders, essential service providers, and other at-risk individuals
• Develop a protocol for regular testing of healthcare workers, first responders and critical infrastructure employees
• Develop sentinel surveillance and testing sites in at-risk locations serving older individuals, lower-income individuals, racial and ethnic minorities including Native Americans
• Link COVID-19 testing and surveillance data to the local EOC
• Identify, hire, and train contact tracing workforce
• Develop a plan for follow up on positive tests including recommendations for isolation and treatment
• Identify and deploy a unified platform for entering cases and integrating any other technologies and data collected for contact tracing
• Identify capacity for quarantine and isolation of all contacts for positive and symptomatic cases, including for those who should be separated from other household contacts and those who are currently in long-term care settings, prisons, or are currently homeless
• Conduct and document formal risk assessment based on current level and trajectory of COVID-19 spread in the community

OPERATIONAL REQUIREMENTS

Does the community have clear plans, with metrics, for implementing, continuing, adjusting, or lifting social distancing measures incorporate benchmarks based on surveillance, testing, and contact tracing? [1] [2] [3]

Surveillance: Is the community conducting active surveillance for COVID-19? Has a comprehensive surveillance system been implemented to monitor new cases in the community? [4]

Does the EOC have an accurate real-time picture of the trajectory of the outbreak within the community? [5] [6]

Are health care providers in the area analyzing syndromic data on Influenza-Like Illnesses and Severe Acute Respiratory Illnesses as a proxy for COVID19?

Widespread, Rapid Testing: Can testing in your community fully meet medical demand and wider public demand? [7] [8] [9] [10] [11]

Is testing widely available for all those who need it, including all with symptoms, at high-risk, and those who are close contacts of infected persons? [12] [13]

1. Are test results returned rapidly (24 hours)?

Is same-day, point-of-care testing available for all patients exhibiting COVID-19 symptoms? Including: [14] [15]

1. Hospitalized patients?
2. Health care workers, first responders, essential service providers, and others in at-risk settings such as long-term care facilities?
3. People who have had contact with infected persons (positive test or symptomatic person)?
4. Symptomatic persons in outpatient settings (such as doctors’ offices)?

Are sufficient test kits available?

Have an overview of the supply chain for test kits, laboratory capacity to conduct testing, supplies (e.g. nasal swabs, test reagents) been conducted?

1. Is there a plan and a specific timeline to fill identified gaps?

Is guidance available for how to follow-up with and treat those who test positive? [15] [16] [17]

1. Is there a reporting structure to ensure medical providers are rapidly notified of results and have a clear plan to communicate to patients?
2. Is data being reported up the chain from health care facilities/testing sites to local health officials? From local officials to both State and/or Federal officials?

Are sentinel testing sites operating in locations serving older individuals, lower-income individuals, racial and ethnic minorities including Native Americans? [18]

Has serological testing been incorporated to begin to determine how many people may have been exposed? [19]

Have laboratory testing priorities been established and are they being implemented? [20]

1. Is there a lag time for receiving laboratory and clinical data? Have actions been identified and implemented to reduce the lag?

Are there localized trade-offs between using scarce PPE for testing vs. treatment or other priorities? [21]

Contact Tracing: Is the public health workforce conducting contact tracing and monitoring of close contacts for confirmed cases? [17] [22] [23] [24] [25] [26] [27] [28] [29]

Has a cadre of contact tracers been hired, trained, and deployed with the ability to trace most cases in the community? [20]

1. Has long-term funding been identified for contact tracing staff?

Do training materials and implementation plans for contact tracers include actions and requirements associated with:

1. Testing?
2. Investigation and elicitation?
3. Tracing?
4. Quarantine or isolation?
5. Follow-up?

Is there a system in place to support data collection and tracking of contact tracing efforts available to the tracing teams?

1. If technological or data collection tools are being used, have security requirements been defined and are protocols in place to ensure privacy and security of the data?
2. Is there a system in place to support data collection and tracking of contact tracing efforts available to the tracing teams?

Quarantine and Isolation: Are there housing options available for those requiring quarantine, but who cannot be at home? [30] [31]

Is there a plan in place to follow up with inbound travelers to assess their COVID-19 status and to provide guidance on self-isolation or quarantine, as needed? [32] [33]

Have public messaging and communication efforts been updated to include contact tracing and testing guidance? [34] [35] [27] [29]
ADDITIONAL CONSIDERATIONS

Slowing and limiting transmission within a community is central to reducing the near-term human cost of the outbreak and ensuring that hospitals will be able to maintain lifesaving and life sustaining care. It can also be highly disruptive, as social distancing measures must become more aggressive in proportion to the exponential spread of the virus. Determinations on the best means of limiting transmission should follow national and state guidance, in addition to considering local risk factors. In general, distancing practices during the early phases of an outbreak should be calibrated to be more aggressive than what observable local conditions might intuitively suggest. Once transmission rates within the community have decreased and the burden on the healthcare system has stabilized or declined, it will become possible to consider incrementally relaxing the range of distancing measures put in place. To avoid increases in community transmission following the lifting of social distancing measures, the “re-opening” of communities must be done in a phased manner with communities achieving specific sets of criteria before moving to the next phase. See below for definitions for the phases of incremental lifting of social distancing measures as well as criteria that should be met before progressing to the next phase of re-opening.

PRIORITY ACTIONS

• Clearly outline local social distancing guidelines to the community, implement, and maintain them
• Establish criteria for essential and non-essential activities
• Assess and mitigate secondary impact of social distancing measures
• Develop plans for gradually relaxing social distancing efforts when criteria are met

OPERATIONAL REQUIREMENTS

Does the community have defined thresholds for when to impose or lift measures for social distancing, including stay-at-home orders, non-essential business closures, and curfews? [1] [2]

Has community leadership issued guidance on self-isolation and quarantine, including how, when, and where to seek help? [3]

1. Have standards for quarantine and isolation release been established and communicated?

Have small businesses and corporations been engaged as partners in the response effort? [4]

1. Have concerns about providing paid sick leave and/or work from home policies to discourage disease spread?
2. Has messaging with businesses been coordinated in the area regarding measures to slow spread in the community?
3. Is there a plan to exclude employees with high-risk exposures from work or mitigate transmission potential if allowed to return to duty?

Has school leadership (public and private) been engaged on the following: [5]

1. Establishing clear criteria for when to recommend cancelling schools and for how long?
2. Maintaining clear and open lines of communication with school and district leadership?
3. Developing and testing remote teaching and learning methods in case they are needed?
4. Putting mechanisms in place to care for children who need additional resources and to incentivize all children to stay at home, if school is cancelled?
5. Providing low-income families with meals?
6. Addressing similar requirements for cancellations of aftercare and extracurricular activities provided by the school(s) or district(s)?

Is there a plan to incentivize interventions that can slow community spread of disease?

1. Is there a process in place for addressing noncompliance (e.g., fines, criminal charges, etc.)?

Does the EOC have a list of all upcoming major conferences, sporting events, concerts, rallies, or other events where large numbers of people may gather? [6]

1. Has the community established guidance criteria or official limitations on gatherings consistent with current public health guidance (as of this date it is 10 people or above)?

Have health officials conducted a risk assessment for these events?

Have community leaders encouraged the public to adhere to best practices to reduce transmission including: [7]

1. Proper hand washing?
2. Avoiding close contact?
3. Staying home if sick?
4. Covering coughs and sneezes?
5. Wearing face coverings in public?
6. Cleaning and disinfecting?

Once community transmission begins to sustainably decrease, is there a plan for reopening and reintegrating the community following the relaxation of stay-at-home orders? Does the plan consider the criteria and phasing approach recommended in this guide?

Have the steps to manage future community transmission events been identified? [8]

1. What resources are available for expanding health care and/or fortifying the health care system?
2. What sort of plans and procedures can be put in place to prevent diseases from spreading in the community?
3. Has the community convened an accounting of lessons learned, pulling in the various sectors that were involved or should have been involved? This could include public and private entities.
ADDITIONAL CONSIDERATIONS

COVID-19 poses extreme risks to older populations and those with complicating health conditions. Each local context is unique and each local EOC should create a commonly agreed upon and regularly reassessed list of particularly vulnerable populations and sites (examples included below). Attention must be paid to the needs of these populations and the facilities where they may reside or gather. Reducing transmission among these groups through targeted support measures can help protect them, while also alleviating pressure on healthcare systems.

PRIORITY ACTIONS

• Establish a comprehensive list of facilities that house high-risk populations (assisted living facilities, seniors’ communities, prisons, detention centers, etc.)
• Assess facilities’ infection prevention and hygiene practices and supply needs
• Address identified vulnerabilities (PPE, training, infection control practices, visitors, staffing levels, etc.)
• Establish guidance to minimize exposure of high risk groups (such as limiting outside visit to high-risk facilities)
• Focus on the particular needs of marginalized populations, including the homeless and undocumented migrants

OPERATIONAL REQUIREMENTS

Has a comprehensive list been compiled of high-risk populations and sites where they congregate, including:

1. Homeless populations? [1] [2]
2. Long-term care facilities?
3. Other elder homes and communities? [3]
4. Home-care resources?
5. Prisons? [4]
6. Shelters?
7. Places of worship?
[5]
8. Undocumented populations?
[6] [7]
9. Other high-density housing where high-risk populations may reside?

Have those facilities’ infection prevention and hygiene practices been assessed and verified?

Do these facilities currently have the capacity and appropriate protocol for timely reporting infectious diseases?

Have high-risk facilities received guidance and site-visits to ensure compliance with policies for infection prevention, to include sufficient access to PPE?

1. Have regulatory authorities been involved in the assessments of these facilities?

Has visitor access been restricted to facilities with high-risk groups?

Are there additional strategies to protect the safety and well-being of high-risk and underserved populations?
ADDITIONAL CONSIDERATIONS

The mortality risk posed by COVID-19 can grow substantially if a health system becomes overwhelmed with critical cases. . Experiences from China, Italy, New York, and elsewhere have demonstrated that COVID-19 cases can overwhelm health facilities and crowd out other critical medical needs. Identifying creative means of surging overall medical capacity as well as expanding critical care capacity will be urgent as case counts grow. Urgent action should be taken to minimize the risk of transmission within health settings (nosocomial transmission). Telehealth consultations, including the use of telemedicine oversight of critically ill patients in the emergency department and intensive care units, should be considered as an option to triage cases as well as manage patient care.

PRIORITY ACTIONS

• Track hospital occupancy rates (overall and critical care) in real time and project future occupancy requirements based on trend
• Ensure hospitals have activated emergency plans and initiated measures to reduce elective or non-urgent medical activities
• Track PPE availability at critical facilities
• Identify alternate PPE purchasing and manufacturing sources
• Initiate plans for surge expansion of critical treatment capacity
• Work with health officials to establish clear criteria to prioritize patients for care and establish referral systems for severe cases
• Initiate plans to separate screening and intake of potential COVID-19 cases from general health care intake
• Track exposure and infections of health workers and assess impact on system capacity
• Initiate plans to screen employees daily for signs and symptoms of illness
• Establish daily operational communication to discuss current case volume (suspected and confirmed), assess hospital census, and staffing needs

OPERATIONAL REQUIREMENTS

Are healthcare facilities in the community able to provide care to all those who need it? [1]

1. Is there a process in place to continually assess the level of demand on hospitals and understand the risk of those facilities becoming overwhelmed? Does this process feed into a state or federal plan to access and allocate PPE to your community? Are there alternate, quality-controlled, procurement or manufacturing options available (see resources below)?
2. Do your local healthcare facilities have a current emergency operations plans and has it been shared with the EOC?
3. Do healthcare and EMS providers in your area have sufficient PPE on hand to meet immediate needs? Projected needs?
4. Are telehealth capabilities available and supported by internet connections?

Following laboratory-confirmation of SARS-CoV-2 (COVID-19) in patients or employees, has an exposure and contact-tracing review been performed? Have those exposed been notified and have employees with high-risk exposures been considered for exclusion from work for 14 days? [2]

1. Are priority testing capabilities available for healthcare workers?

Have alternate sites of care been established with surge capabilities for five to ten times the normal number of pneumonia and influenza admissions at peak flu season? [3]

Have facilities rescheduled and reprioritized non-emergency care?

Have treatment centers established separate triage lines for patients with influenza-like illness and/or upper respiratory infection?

Are specific plans in place to:

1. Expand critical care/ICU capacity/extracorporeal membrane oxygenation, including additional ventilator capacity?
2. Provide prescription medications for two to three months for all patients, eliminating co-pay penalties and insurance restrictions?
3. Offer mail-order or other remote refill mechanisms?
4. Triage patients to preserve hospital resources for those most acutely ill?
5. Utilize the electronic medical record system for proactive infection control measures such as triggers for isolation precautions based off screening questions or tests being performed?
6. Cohort inpatient units for suspected or confirmed COVID-19 patients?
7. Govern crisis standards of care plans focused on the decisions that will govern scarce resource allocation?
8. Surge healthcare workforce, including in the event that medical staff are infected?
9. Develop processes for emergency credentialing of providers (doctors and nurses)?
10. Provide rapid training to bolster medical surge capacity?
11. Sustain corpse management, avoid morgue overflow, expedite issuance of death certificates, and meet resource requirements, including medical examiner capacity?
12. Safely manage waste?
13. Provide wellness and mental health support in times of crisis?
14. Provide family support resources to healthcare workers to avoid staff distraction?

Are facilities continually reassessing:

1. Occupancy rates?
2. PPE supply and predicted usage rates?
3. Critical care capacity?
4. Ventilator and oxygen capacity?
5. Thresholds for triggering/expanding crisis standards of care plans?
ADDITIONAL CONSIDERATIONS

Public officials have an obligation to accurately and transparently relay risk information, even (or perhaps especially) when it is alarming. Community trust can make or break an outbreak response, because the effectiveness of social distancing and other interventions hinges on community compliance. Risk communication should follow best practices to mobilize informed action rather than inducing panic. A set of Critical Information Requirements (CIRs) for leaders/decision makers should be set by an EOC, updated daily, and help feed a set of Public Information Requirements (PIRs) that should be communicated to affected populations in ways that are easily accessible by all.

PRIORITY ACTIONS

• Establish a regular briefing rhythm to inform community leaders and members
• Provide balanced and measured information; explicitly communicate uncertainty; do not sugar-coat bad news or over-promise potential progress
• Engage with community, business, religious, and other civil society leaders to equip them to be credible sources of information for their stakeholders

OPERATIONAL REQUIREMENTS

Is community leadership regularly and effectively communicating with various sectors of your government and non-governmental organizations (policy, education, etc.) to discuss ongoing activities? [1]

Is community leadership communicating with the people who live and work in your community on a routine basis?

1. Have the most effective communication methods been identified?
2. Can critical communications reach everyone?
3. Is there an emergency alert systems in place and tested?
4. Is there an effective way to dispel disinformation or misinformation?

Have trusted spokespeople been identified and assigned to relay important, fact-based messages to the community? [2]

Have continuity of communications plans been reviewed for the EOC and first responders in the event that mobile communications are disrupted/crash?

Has a set of critical information requirements for leaders and decision makers been established? Does it help feed public information requirements easily accessible online?
ADDITIONAL CONSIDERATIONS

Pandemic outbreaks can cause enormous social and economic disruption. These disruptions are damaging in their own right but can be particularly problematic if they create economic disincentives to cooperating with social distancing measures. Mitigating these disruptions can help to reduce the human cost of the outbreak, beyond the immediate toll of the disease itself. Leaders should also pay careful attention to the impact that both the outbreak itself, and the measures to control it, may have on vulnerable populations.

PRIORITY ACTIONS

• Establish mechanisms to address impacts of the pandemic on vulnerable populations (e.g. food insecure families reliant on school lunch programs)
• Assess and mitigate impact of social distancing measures on key workforce sectors (health care, public services, etc.)
• Assess second-order impacts of social distancing measures on the local economy
• Assess impact of business closures on local tax revenues and advocate for state/federal support to ensure continuity of government operations
• Identify and work to mitigate economic disincentives to social distancing measures

OPERATIONAL REQUIREMENTS

Do you have a strategy in place to ensure medications are available to those that need them? [1]

In the event of a stay-at-home social distancing order, is the community able to provide the necessary resources (e.g., food, medical care, other necessities) to the affected populations? [2]
ADDITIONAL CONSIDERATIONS