A Guide for Public Transportation Pandemic Planning and Response (2014)

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4C H A P T E R 1 How to Use this Document NCHRP Report 769: A Guide for Public Transportation Pandemic Planning and Response has been developed to provide support to transportation organizations as they prepare for pandemics and other infectious diseases. While primarily intended for small urban and rural transportation orga- nizations, this guide can be used by all types and sizes of transportation agencies and organizations that may have achieved different levels of pre- paredness for pandemics. A pandemic can be described as a global disease outbreak. For example, when a new influenza virus emerges, flu pandemic can occur. (See http:// www.cdc.gov/flu/avianflu/influenza-a-virus-subtypes.htm for informa- tion on types of influenza viruses.) Depending on the characteristics of the disease, it may spread easily, there is little or no immunity to the disease, no vaccine is available, and there is a high rate of people getting sick and/or dying. This guide relies on this basic definition of pandemic (i.e., the disease is novel, easily spread, there is little or no immunity, and there is no vaccine). Pandemics cause significant absenteeism, change patterns of commerce, have limited immediate medical solutions and interrupt supply chains— all of which can have devastating effects on the operations and long-term sustainability of small transportation organizations. This guide provides information that small and rural transportation sys- tems can use for good decision making, actions, and outcomes for a global pandemic, which is also useful for seasonal flu and other disease outbreaks. The guide and its tools are intended to be used by rural and small urban transit organization planners, plan- ning committees, and administrative personnel, and can also be used by systems of any size. It provides information, tools, tips, and guidance on where to find up-to-date recommendations from federal agencies and other resources prior to and during a pandemic. It is valuable both for those who read from start to finish and those who are looking for specific resources. The guide will assist transportation agencies in internal planning and working with allied organizations to: • Enhance their ability to address pandemics in particular; • Improve their approach to minimize the impact of all infectious diseases; and • Improve overall emergency management capabilities. During an actual pandemic, there will likely be a lot of information available through the media, social media, and from the CDC and local public health agencies. Federal, state, and regional Introduction This chapter provides an overview of pandemics and their impacts to transportation organizations. Exhibits in this Chapter 1 Size of Agency and Level of Emergency Management Experience 2 Example of Additional Resources Placed Throughout Guide 3 Document Organization 4 Pandemic Impacts to Transportation Organizations 5 Seasonal Flu versus Pandemic Influenza 6 How Pandemics are Unique 7 Sample Pandemic Activation Matrix

Introduction 5 transportation organizations may also provide information and guidance. Transportation agen- cies that do not develop an understanding of pandemics and take specific preparedness actions (policy and operational) will likely struggle to respond safely and effectively in a timely manner. This document has been designed for use based on the objectives described below. Allow Different Sized Transportation Agencies to Use the Guide in Targeted Ways Many of the issues remain the same regardless of the size of the community and transporta- tion agency. What changes with community size is the scope of the challenges and the resources to address planning issues. Exhibit 1 provides guidance on how to use this document depend- ing on the organization size and emergency management experience level. Serve as a Centralized Resource Rather than Regurgitating Other Guidance Documents There is a wealth of information available from various resources to assist transportation agencies in general disaster preparedness and provide general information on pandemic pre- paredness. Over time, additional valuable information and guidance becomes available from varied sources. This guide is designed to bridge that gap and provide pandemic preparedness guidance specifically for transportation agencies. Rather than replicating resources, this guide provides references to other documents available in the public domain that can provide additional information on specific topics. These are placed throughout the guide; Exhibit 2 is an example of what these look like. Provide Guidance to Both Policy Makers and Emergency Planners in a Single Document Most disasters that cause major impacts to the transportation system are caused by severe weather or geological factors. In contrast, a pandemic’s cause is invisible; disease-causing organ- isms that travel from person to person (sometimes through an intermediary host) create impacts EMERGENCY MANAGEMENT EXPERIENCE Low High SI ZE O F TR AN SP O RT AT IO N AG EN CY Large Users are encouraged to read the enre document and access resources listed to provide a basis and context for developing organizaonal emergency management programs for pandemics and "all hazards." Users are encouraged to review the informaon on pandemics if current planning efforts do not address infecous diseases. Small The checklist and planning tools are best used in conjuncon with the text and cited resources as references for addressing emergency management as well as infecous disease planning. The checklists and planning tools can be used to guide discussion and measure progress on effecve pandemic planning. Exhibit 1. Size of agency and level of emergency management experience.

6 A Guide for Public Transportation Pandemic Planning and Response on transportation that are human related rather than structural. As such, pandemics can create serious ethical, logistical, and operational challenges that are best addressed in advance by the organization and community policy makers, emergency planners, and department managers. This guide has been developed to aid individuals in all these roles simultaneously. Issues that must be resolved at a policy level are highlighted in the following areas: • Chapter 3: Decision Making and Partnerships (see page 18). • Decision Making and Partnership Planning Tool (see page 44). Organize the Document to Minimize Narrative and Maximize Tools For a planning guide to be useful it must include a combination of narrative and hands-on tools for its users. The first chapter is primarily narrative as it provides background on what a pandemic is and what it means to an agency. Subsequent chapters provide basic narrative to describe the content area; provide a series of tables, diagrams, tools, and checklists; and direct users to additional resources. Tools and checklists are referenced in each chapter but are shown in full at the end of the document. Likewise, complete references to the additional resources identified in each chapter are included at the end of the document. Exhibit 3 summarizes how each chapter balances narrative with tools and checklists What Is Important to Know About Pandemics? Pandemics are just one of the many calamities with which humans may be confronted. Unlike hurricanes, earthquakes, and industrial accidents, which are localized and damage infrastructure, pandemics are global and do not cause physical damage to infrastructure. Rather than one geographical area responding and other areas lending aid, many communities will have to respond to a pandemic at the same time, so resources may not be able to be shifted. Widespread absenteeism and challenges in containing the disease will disrupt how communities work, socialize, and travel. Rural and small urban transportation organizations may be especially hard hit with dramatic worker absenteeism, ongoing and additional need for services, disruptions from their supply Exhibit 2. Example of additional resources placed throughout guide.

Introduction 7 chain, and a confused and scared public. Preparing for pandemics focuses less on more common mitigation and emergency preparedness activities such as hardening structures, learning how to use new equipment, or practicing response to a mass casualty trauma incident. Rather, the focus is on planning through complex and sometimes controversial issues related to workforce, safety, services, and public communication. Urban transportation agencies, with more resources and staff than their rural and suburban counterparts, may seem to be better positioned for pandemic planning. However, rural and suburban organizations typically offer a more targeted set of services. Planning effectively for pandemics can be time consuming and challenging, but can help planners and their transporta- tion organizations prepare for all highly infectious diseases and other types of disasters since the focus is on the continuity of operations planning, staffing, crisis communications, and safety. For small urban and rural transportation organizations, this means targeting their specific set of services and developing plans to address the results of a pandemic. While there have been numerous outbreaks over the millennia, the most notable pandemics in history are the Black Death (bubonic plague) in the 14th Century and the 1918 Spanish Flu. Other diseases that have caused widespread morbidity and mortality (the rates of disease and death) include smallpox, malaria, HIV/AIDS, cholera, and typhus. Vaccines and treatments have been developed for many of these widespread killers. However, over time diseases may evolve, medications may become less effective, or new diseases may emerge. Exhibit 3. Document organization. Contents Chapter Objective Tools Checklist Additional Resources Chapter 1: Introduction Provides an overview of pandemics and their impacts to transportation organizations. X Chapter 2: How Prepared Is an Organization for a Pandemic? Provides an overview of all hazards emergency management and provides tools designed to help transportation organizations identify their vulnerabilities to pandemics and begin to address them. X X Chapter 3: Decision Making and Partnerships Discusses the importance of decision making and coordinating with like and allied organizations prior to and during an emergency. X X Chapter 4: Preventing the Spread of Disease Discusses the public health disaster containment strategies and how transportation organizations can adopt and adapt them internally. X X Chapter 5: Providing Services During a Pandemic Outlines the process for defining essential functions and determining how services may be utilized differently. X X Chapter 6: Workforce Outlines the process for identifying and addressing potential workforce challenges during a pandemic. X X Chapter 7: Crisis and Emergency Risk Communication Outlines the actions all transportation organizations should take in order to prepare for the demands of communications during a pandemic. X X

8 A Guide for Public Transportation Pandemic Planning and Response The diseases that may become pandemics often have one or more of the following origins and characteristics: • Currently in existence but not widespread (e.g., Ebola); • Novel diseases: – Current diseases that go through significant changes (known as shift) and become more dangerous (e.g., Avian influenza) – New diseases that were previously unknown (e.g., SARS, MERS-CoV) • Populations may have little or no resistance or immunity to these diseases; and • No vaccine or pharmacological intervention is currently available. Transportation organizations will be both directly and indirectly impacted by a pandemic occurring within their community with the effects potentially lasting from weeks to extended periods (see Exhibit 4). Case Study: Pandemic Influenza Pandemic influenza is an example of a disease, but not the only disease, that this guide can help address. Recognizing the ongoing concern regarding various types of non-seasonal influenza that emerge periodically, this section will help those engaged in infectious disease planning. (A highly virulent influenza outbreak would test any organization; thus, using influenza as a model for pandemic planning is appropriate.) Exhibit 5 summarizes the differences between a seasonal flu and pandemic influenza. Pandemic influenza will likely include a more severe version of seasonal flu symptoms such as a fever of 100°F or higher, cough, sore throat, runny or stuffy nose, headaches, body aches, chills, and fatigue. More common in children are the added symptoms of nausea, vomiting, and/or diarrhea, although adults may also suffer from these symptoms, depending on the virus strain and individual. Rates of serious illness, hospitalization, and deaths will depend on the specific virus. It is impossible to predict which risk groups are most likely to see more severe and fatal infections, but they are likely to include infants, the elderly, pregnant women, and persons with chronic Exhibit 4. Pandemic impacts to transportation organizations. Characteristics of a Pandemic Impact to Transportation Organization Widespread workforce shortages Significant absenteeism amongst employees Disruption to supply chain Lack of resources/mutual aid support from surrounding communities and like organizations Change in required services and operations Confusion and fear amongst public and employees Increased need for public information about services, changes to procedures, restrictions Coordination of messages with other local agencies Safety concerns regarding sick passengers and their impact on the workforce Implementation of public health strategies to limit transmittal of the disease (e.g., social distancing, personal protection) Challenges implementing containment and control strategies Increased need of scarce personal protection supplies (e.g., gloves, masks, hand sanitizer)

Introduction 9 or immunosuppressive medical conditions. Sometimes, as in the 1918 influenza pandemic, the virus hits young healthy adults. Pandemic influenza, much like the seasonal flu, can be a highly contagious virus spread from person to person through coughing, sneezing, talking, and breathing. The virus can land on surfaces (called fomites) including skin and then be transmitted to others through physical contact such as shaking hands. For transportation organizations with even robust emergency management programs in place, addressing the needs of a pandemic will require a shift in thinking. Most potential threats and vulnerabilities that emergency management focuses on are very different in their nature than a pandemic. Many of the planning assumptions normally incorporated into plans and efforts will be different. It is important to understand how pandemics are different from other hazards such as tornados, earthquakes, and mass casualties. (See Exhibit 6.) Pandemics threaten to overwhelm routine capabilities and disrupt essential services and operations both domestically and internationally. The best place for transportation agencies to begin preparing for pandemic influenza is to understand what an outbreak would look like and how it varies from other hazards. Why a Pandemic Plan Is Needed Unless there is an outbreak of a highly infectious disease that originates in an organization’s community, there will generally be a period of time where events unfold and the disease is dis- tant (known as a “rising tide”). Taking a measured and tiered approach to response is generally Exhibit 5. Seasonal flu versus pandemic influenza. Adapted from http://www. flu.gov/pandemic/about/index.html Seasonal Flu Pandemic Influenza Happens annually and usually peaks in January or February. Rarely happens (three times in 20th century). Usually some immunity built up from previous exposure. People have little or no immunity because they have no previous exposure to the virus. Usually only people at high risk, not healthy adults, are at risk of serious complications. Healthy people may be at increased risk for serious complications. Health care providers and hospitals can usually meet public and patient needs. Health care providers and hospitals may be overwhelmed. Vaccine available for annual flu season. Vaccine probably would not be available in the early stages of a pandemic. Adequate supplies of antivirals are usually available. Antivirals may be in limited supply and may not be effective. Seasonal flu–associated deaths in the United States over 30 years ending in 2007 have ranged from about 3,000 per season to about 49,000 per season. Number of deaths could be high (the U.S. death toll during the 1918 pandemic was approximately 675,000). The virulence of the disease and effectiveness of medical support measures is unknown. Symptoms include fever, cough, runny nose, and muscle pain. Symptoms may be more severe. Usually causes minor impact on the general public, some schools may close and sick people are encouraged to stay home. May cause major impact on the general public, such as widespread travel restrictions and school or business closings. Manageable impact on domestic and world economy. Potential for severe impact on domestic and world economy.

10 A Guide for Public Transportation Pandemic Planning and Response Exhibit 6. How pandemics are unique. (continued) Most Disasters Why Pandemics are Different Impact to Transportation Organization Most disasters strike a specific geographical area (e.g., tornado, extreme weather, blackout) while sparing surrounding areas, which then often provide assistance. Pandemics are global and local. When a pandemic emerges, expect it to spread around the world. Some countries or regions may try to delay the pandemic’s arrival through border closings and travel restrictions. Expect that the pandemic will hit both globally and locally at the same time or in geographical waves. Whatever challenges are faced by communities and transportation systems will likely be shared by many others, leading to a lack of mutual aid and shortage of transportation, medical, and safety supplies. o Transportation organizations will likely not benefit from mutual aid as nearby agencies will probably be experiencing similar issues. Worker absenteeism may occur initially but not extend past a week or two. Dramatic worker absenteeism will have broad and deep impacts. In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members, and fear of infection may reach 30% or more during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak. Certain public health measures (closing schools, isolation, quarantining household contacts of infected individuals) are likely to increase rates of absenteeism. The high level of absenteeism will have a direct effect on the transportation organization’s workforce and also impact vendors, supply chains, infrastructure, and society as a whole. The assumption when planning for most major disasters is that there will be damage to structures and/or critical infrastructure (e.g., hurricane, fire, and floods) with injuries as a secondary impact. Significant impact without structural damage. Pandemics are a public health emergency where the primary impact is the health of individuals within a population. o Pandemics cause no damage to structures or equipment. Organizations must be prepared for significant workforce challenges which, depending on rates of disease and death, can also require long term recovery strategies. Pandemics may require routine and periodic disinfection of vehicles and equipment. The assumption when normally planning for a disaster is that the response time will usually be anywhere from a few hours to a week. Response to the disaster is typically rapid. Response time is in months, not hours or days. Organizations often have foreknowledge of potential impact by the disease. Planning for workforce shortages that may last a week is very different than shortages that may last for months. o Epidemics require different thinking as they are expected to last six to eight weeks in affected communities. Multiple waves (periods during which community outbreaks occur across the country) of illness are likely to occur. o Each wave may last two to three months when the communities and their residents are already compromised. Healthcare providers and hospitals can usually meet the needs required by infectious diseases such as the seasonal flu. The healthcare system will be overloaded for months without the benefit of mutual aid between facilities. With little or no immunity to a pandemic microorganism, infection and illness rates will soar, sending more people to the hospital than hospitals have the beds, staff, ventilators, or supplies to effectively provide care. Death rates may be high depending on the number of people infected, the strength of the virus, the underlying characteristics and vulnerability of affected populations, and the effectiveness of preventive and supportive measures.

Introduction 11 Exhibit 6. (Continued). Most Disasters Why Pandemics are Different Impact to Transportation Organization The disease may disproportionately impact healthcare workers, further reducing the availability of medical services. Modern medicine can normally address disaster caused medical issues immediately following a disaster. Inadequate medical interventions available. Pandemics require medicines and/or vaccines that may not be available in the early stages of a pandemic or effective. o Once a potential pandemic microorganism’s characteristics are identified, it will take considerable time (e.g., 6 8 months) before a vaccine could be widely available, if at all. o Many of those hospitalized with severe respiratory symptoms will require ventilators that are in limited supply despite emergency caches. Some communications systems may be operational during a disaster. Using the available communications systems and clear messages tailored to employees and customers will prevent confusion in the long term. The massive scope of a pandemic combined with rarely used disease containment strategies will make the need for consistent and accurate information essential. Transportation agencies will likely need to alter services that will require constant communication with employees as well as those who use the services. o Smaller transportation organizations may not have staff trained to deal with this time intensive activity. Traditional first responders (e.g., police, fire, search and rescue) normally take the lead in disaster response. Public health agencies are the lead response agency. The robustness of public health support services varies greatly around the nation. o The clear trend is that rural public health agencies have difficulty providing even the basics expected in a comprehensive public health program due to demographics, funding challenges, population density, existing chronic diseases, and long distances. While all disasters have a public health component, pandemics will clearly impact the ability of public health to prevent and treat widespread disease outbreaks. In many jurisdictions, the local public health department is tasked with operational responsibilities such as managing and staffing alternate care sites (ACS, places that provide medical care when hospitals are full) and points of distribution (POD, places to distribute medicine), which are often beyond locally available resources. People don’t need to be ‘policed’ on how they interact and congregate. Public health at the federal, state, and local levels has the power to require individuals to take specific actions to protect public health. In addition to providing medical care to those already afflicted with a pandemic disease, several strategies recommended or ordered by health departments will attempt to limit social interactions and disease spread in order to reduce illness and death. Many of the key disease containment strategies (e.g., isolation, quarantine, social distancing, closing places of assembly, and/or furloughing non essential workers) create challenges for transportation agencies whose workforce may work in close proximity to one another (e.g., cubicles) and interact directly with the public; and transports individuals positioned closely together. Modifying normal operations to create distance and the use of personal protective gear will alter how operations are run.

12 A Guide for Public Transportation Pandemic Planning and Response prudent. Having a plan that sets forth roles, responsibilities, and policies will help assure that organizations can make good decisions. Whether transportation organizations address a pandemic in the main emergency operations plan as an annex (recommended) or as a standalone plan (not recommended), the document should include an activation section that provides leadership with guidance on when to activate specific actions within the plan and make operational decisions. The following examples demonstrate a reasoned escalation to an infectious disease outbreak that has impacts on a transportation organization: • Standby/alert/monitoring. When an infectious disease outbreak occurs somewhere in the world that causes concern to public health officials, transportation agencies should take notice and follow events as they evolve. This may involve tracking developments (known as situational awareness) by monitoring media reports, public health alerts, and communications from state and federal transportation agencies. Emergency plans should be revisited, contact lists and agreements updated, perhaps a tabletop exercise planned, and active participation with local emergency management and public health functions should be reinforced. • Minor impact. Even if the disease has not been found within a jurisdiction, concerns about contracting a disease that has arrived in close proximity may disrupt ridership patterns, absenteeism may rise, supply chains may be interrupted, and mental health issues may increase. At this level, efforts should be made to ensure transition to the next level of impact. • Moderate impact. The disease has arrived. Riders and employees have contracted the disease. While the community and organization are impacted, day-to-day activities are still occurring with some modifications such as changes in routing, scheduling, and frequency. • Major impact. The community is deep within the throes of the outbreak. Staffing within the organization is problematic, ridership patterns are significantly different than normal, and providing service is challenging. Both full-time and part-time employees are impacted. • Catastrophic impact. Society has broken down to the point that basic food, clothing, shelter, and access to medicine are not readily available. Transportation organizations severely curtail or halt service. (Note: This guide does not address a catastrophic impact in detail.) Activation of different levels of response should be coordinated with local emergency management, public health, and regional/state transportation agencies. See Exhibit 7 for a description of the sample pandemic activation matrix available at the end of this Guide. Exhibit 7. Sample pandemic activation matrix. This tool is included on page 42 of Chapter 7. Purpose: Provide a sample activation matrix for a pandemic plan/annex. Directions: Customize the chart to a transportation organization and include the Activation Matrix in a pandemic plan/annex.