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BY: SCOTT SANTIBAÑEZ, MD

Church-Related Groups Will Be Vital Partners in Getting Ready for an Influenza Pandemic

Dr. Santibañez is commander, Department of Health and Human Services, U.S. Public Health Service and Centers for Disease Control and Prevention, Atlanta.

Ask people about pandemic influenza and you'll likely hear a variety of responses ranging from those who don't believe it is a real problem to those who envision a doomsday scenario. The truth is that it is prudent to plan for a pandemic occurrence. Faith-based and community-based organizations (FBCOs) are essential partners both in preparations for an influenza pandemic and in protecting the public's health and safety should one occur. In this article, I hope to help readers understand that the threat of pandemic influenza is real and to actively engage them in preparing for a severe occurrence.

What Are the Influenza Types?
There are three main categories of influenza: seasonal, avian, and pandemic. Each year, usually during the winter months, seasonal influenza affects from 5 percent to 20 percent of the U.S. population. About 225,000 people are hospitalized annually by seasonal flu and 36,000 people die from it. The best way for a person to protect him- or herself against this illness is to get an annual vaccine inoculation.

Avian influenza is found mostly in birds. Infection of humans is very rare. However, avian influenza viruses do sometimes develop an ability to infect humans and to spread readily from person to person. When this occurs, avian influenza viruses can cause influenza pandemics in humans.

What is Pandemic Influenza?
An influenza pandemic occurs when a new strain of influenza virus — one against which humans possess little or no natural immunity — emerges and has the ability to cause illness in humans and efficiently pass from person to person. The symptoms — fever, cough, and muscle pain — are similar to those seen with seasonal influenza, but, in a severe pandemic, 30 percent or more of the population gets sick and more people suffer from complications or even die. A severe pandemic influenza virus would likely spread around the world in a matter of months.

Influenza pandemics occurred three times in the past century and ranged considerably in severity. For example:

• The 1918 influenza pandemic caused from 20 million to 50 million deaths worldwide.
• The 1957 influenza pandemic caused from one million to two million deaths.
• The 1968 influenza pandemic caused from 700,000 to one million deaths.

A severe pandemic could change daily life by, for example, limiting travel and public gatherings, disrupting businesses, and requiring children to be dismissed from schools. Most significantly, such an event could cause increased sickness and death. It is estimated that 90 million Americans could become ill and nearly two million die in a severe pandemic. During even a less severe pandemic, 30 percent of the population or more would get sick and thousands of hospitalizations and deaths would occur.

Currently, there is no human influenza pandemic in the United States or overseas. However, leading public health experts at the Centers for Disease Control and Prevention (CDC) and elsewhere agree that the question is when rather than if the next one will occur. Moreover, it is not possible to know in advance how severe the next pandemic will be. Therefore, it is important to plan and prepare for a severe pandemic. If our country prepares now, we will be able to better withstand the impact of a pandemic and to help limit the spread of illness.

The United States is working with the World Health Organization and with other countries to strengthen the detection and tracking of new influenza viruses. Scientists are closely watching the avian influenza virus H5N1 and other avian influenza viruses. The H5N1 virus has spread widely throughout bird populations across Asia, Africa, Europe, and the Middle East. It has infected both long-range migratory birds and domesticated birds, including ducks and chickens. Accordingly, it is commonly referred to as "bird flu."

Since 1997, this virus has affected more than 300 people worldwide, with more than half of those infected dying from the illness. Fortunately, so far, animal-to-human transmission has been inefficient and human-to-human transmission extremely rare. Health officials are watching for mutations in the H5N1 virus that would increase their ability to spread easily among humans.

Preventing the Spread of an Influenza Pandemic
Once a pandemic begins, it is unlikely that its spread could be stopped. However, slowing its spread would provide more time to produce, distribute, and administer a vaccine and also prevent it from overwhelming the nation's health care system. When an influenza pandemic starts, public health officials will determine its likely severity and recommend responsive actions at all levels of society, according to CDC's Community Strategy for Pandemic Influenza Mitigation in the United States, a publication outlining a strategy for dealing with a pandemic at the community level.¹

Influenza viruses spread when infected people cough, sneeze, or talk, sending droplets and very small sprays into the air — and thus into contact with other people. These viruses also spread when people touch contaminated objects and then put their hands to their own noses, mouths, or eyes. To prevent spreading influenza, and respiratory infections in general, people should cover their coughs and sneezes with their hands and wash their hands frequently.

During a severe influenza pandemic, large public gatherings may be canceled and work schedules may be changed to reduce the spread of disease. Community-level actions to mitigate the virus spread would include the following:

• Asking ill people to voluntarily remain at home and not go to work or into the community for seven to 10 days, or until they are well and can no longer spread the infection to others (voluntary isolation).
• Asking members of households in which a person is ill to voluntarily remain at home for about seven days (voluntary quarantine).
• Treating ill individuals and members of their households with influenza antiviral medications.
• Dismissing students from public and private schools, colleges and universities, school-based activities, and child care programs for up to 12 weeks.
• Reducing out-of-school social contacts and community mixing by closing malls and movie theaters.
• Reducing contact among adults in the community and workplace by, for example, canceling large public gatherings, religious services, and social events. This could also include temporarily rearranging workplace environments and schedules to avoid bringing large numbers of people mixing together at the same time.

The Role of FBCOs
During a severe influenza pandemic, people from communities around the world will be asked to voluntarily avoid gathering together, to limit the virus' spread. People will be asked to stay at home if they are sick and to minimize contact with others. The U.S. government cannot prepare for or respond to a severe pandemic alone. During such a crisis, there may be an insufficient number of doctors, nurses, hospital beds, or other countermeasures to go around. Many — if not most — communities will be affected, and as many as 40 percent of workers may be unable to work because of illness or a need to care for ill family members. FBCOs will be essential partners in helping to ensure that people in need are provided for and that care is given in a way that minimizes stigma and other negative social responses. The following are areas in which FBCOs can make important contributions.

Food and Water Persons who are ill may need to stay at home for an extended period; so may their family members and other household contacts. These people will need access to food and water. The federal government recommends that individuals and families consider stockpiling a two-week supply of nonperishable food and water. People with more resources can consider obtaining supplies to support themselves and one or two other families. FBCOs can also help with food distribution through local food banks and meals-on-wheels programs adapted so as to limit face-to-face contact.

Child Care During a severe influenza pandemic, schools may be dismissed to help contain the spread of disease. If so, pupils could continue studying at home, with lessons being delivered via computer. Children and teenagers should also avoid gathering in the community, at shopping malls and other places.

Many churches operate child care centers, mothers-morning-out programs, and child care drop-off services. These may close during a pandemic. Such centers should plan in advance how they will inform parents and staff members of a closing.

Church members, co-workers, friends, families, and neighbors can work together to provide care for small groups of infants and young children. To minimize child-to-child contact, children should be cared for in separate rooms, allowed to play only in well-ventilated rooms, and encouraged to play outdoors (with supervision). People planning child care during a pandemic should plan to have available the equipment they will need to teach and entertain children at home.

Communication During a pandemic, FBCOs can play a vital role in maintaining community morale and cohesion, especially if worship services and other community assemblies are canceled. More than ever, people will need to be able to communicate with loved ones and receive timely information.

Research has shown that people are likely to turn to their religious and community organizations for reliable information during a health emergency. Such organizations should make sure that people can access them by way of the Internet, telephone, and e-mail, and that they are provided with contact information. Of course, not everyone will have access to Internet-based communications, but lack of this technology should not stop organizations from planning how to communicate during an emergency. Phone trees, mailed newsletters, and prerecorded messages on designated call-in phone numbers are ways that organizations can communicate with people who have no Internet access.

FBCOs can work with state and local health departments to help ensure that timely and accurate information is available to community members in ways that are nontechnical, easily understood, and presented in the context of shared values and honored traditions.

Work Cross-training of staff and volunteers can help to ensure that essential jobs will be covered if people must miss work during a severe pandemic. FBCOs should have up-to-date contact information for staff, volunteers, members, or clients. This information should include the names of family members; addresses; home, work, and cell phone numbers; e-mail addresses; and emergency contacts.

In planning their budgets, FBCOs should consider influenza pandemics among the unforeseen emergencies — such as fires and natural disasters — that can potentially cause financial deficits.

Many churches and related organizations rely on community giving to support their activities. In their planning for a possible pandemic, such organizations will want to develop ways — through the mail, Internet, or some other means — to enable people to make contributions even if they must stay at home for an extended period.

Some jobs can be done at home. Organizations can use the mail, e-mail, or telephone to relay work assignments and other communications to homebound staff members and volunteers. For those jobs that cannot be done from home, flexible work hours and schedules (e.g., staggered shifts) can be set up to limit the number of people who must gather at the workplace at one time.

Caring for the Sick
Clinicians deal with influenza by treating its symptoms, treating other infections that may afflict a patient sick with influenza, and addressing any other medical conditions the person might have, such as heart disease or diabetes. FBCOs can help their neighbors, staff, volunteers, members, or clients keep their own up-to-date list of medical conditions and medications. People should periodically check their supply of regular prescription and over-the-counter drugs to ensure that they have a sufficient supply should an emergency occur. People who become ill after traveling during a pandemic should seek health care and inform their provider of the places where they have traveled.

Antiviral medications may reduce influenza symptoms and shorten the time of illness if they are begun within 48 hours of the onset of symptoms. During the course of an influenza pandemic, the CDC and other laboratories will test pandemic strains to determine whether antiviral medications are useful against these strains. Once medications are available, FBCOs can work with state and local health departments to help ensure that medical treatments are provided and distributed equitably.

Facilities
Some religious schools have already arranged with county health departments to turn their buildings into vaccination clinics, antiviral distribution centers, triage centers, hospitals, or morgues during a severe pandemic. FBCOs should work with state and local health departments to determine other ways their facilities might be used in a crisis — as, for example, temporary care facilities or central distribution sites for food, water, supplies, or medicine.

Spiritual and Emotional Care
During a pandemic event, FBCOs can play a vital role by providing counseling and other means of reducing stress. In such an event, staff members and volunteers may be asked to provide support to ill persons, family members, and others — including congregational leaders, who will be under increased stress themselves. Philosophical and theological questions may arise about why innocent people suffer. Those who have lost loved ones may need support working through the grieving process.

FBCOs should consider developing an existing mental health or counseling hotline (or publicizing existing hotlines) that people in the community can call during a pandemic or other emergency. They should also work with community leaders to ensure that materials concerning disasters (and coping with disasters) are both culturally and ethnically sensitive and available in a variety of languages. Trusted community leaders can help reduce any stigma attached to using mental health resources by fostering a safe environment in which it is OK to talk about and deal with stress.

FBCO staff members may be called upon to provide support to emergency responders. Although the work of emergency responders can be personally rewarding, it can also potentially affect the responders in harmful ways. The stress, long hours, ambiguous roles, and extensive exposure to human suffering involved in such work can adversely affect even the most seasoned of professionals.

Vulnerable Populations
Groups already vulnerable to ill health may be even more at risk during a severe influenza pandemic because of both the illness itself and the burdens associated with containment efforts.² The CDC's Pandemic Influenza Working Group on Vulnerable Populations says these groups are at high risk for exposure, complications, and death, and may need assistance in preparing for a pandemic and responding to it because of social or medical disadvantages.

Vulnerable population types will vary from community to community, but are likely to include people with disabilities or chronic diseases (such as HIV/AIDS, tuberculosis, or hepatitis), pregnant women, prison inmates, homeless persons, immigrants, refugees (especially those with limited proficiency in the English language), poor people, single-parent families, public housing residents, migrant and farm workers (and other low-wage workers), and members of racial and ethnic minorities (including members of Indian tribes). Several populations will be of special interest to FBCOs.

People Who Rely on Public or Church-Related Assistance
FBCO staffers should get to know which of their neighbors, co-workers, employees, volunteers, members, or clients are likely to need extra assistance due to economic hardships while sheltering at home during a severe influenza pandemic. Some religious organizations have a great deal of experience in working with underserved communities. For example, those that provide homeless shelters and apartment complexes for low-income senior citizens are already planning to provide housing for the poor and developing sanitary practices to reduce the spread of infection within these facilities. Plans are also being made on how to assist those who live alone, single parents, and children who might become orphaned during a pandemic. FBCOs that do not now provide such services might want to help provide them in a pandemic by working with more experienced organizations.

People Who Are Vulnerable because of Disabilities
FBCO staffers should also get to know of neighbors, co-workers, employees, volunteers, members, or clients who have disabilities, especially those who live alone or have health problems. When planning, FBCO staffers should remember to account for colleagues and volunteers who might be unavailable during a crisis because they need to stay home to care for disabled family members.

Partnerships
Government, communities, and individuals must work together to prepare for and respond to an influenza pandemic. A FBCO does not need to do everything by itself. Rather, it should be one part of a community, local, regional, and national collaborative effort. One of the most important things that a FBCO can do is get to know and work with its state and local health departments. It should also work with elected officials, emergency responders, law enforcement agencies, health care systems, schools, businesses, and other FBCOs.

State and local officials are developing, testing, improving plans for pandemic influenza and, should one occur, will lead the response in their areas. The U.S. Department of Health and Human Services and other federal agencies help support state and local pandemic preparedness and response planning by providing funding and advice.³

Many hospital and health care systems, law enforcement and emergency- responder agencies, schools, and businesses are also actively preparing for an influenza pandemic. For example, hospitals are planning how to deal with large numbers of people who become ill simultaneously. Businesses are planning how to continue operating during an emergency. However, many such organizations may be unaware that a FBCO could offer valuable resources to their communities during a pandemic. FBCOs should identify these potential partners and meet with them to learn about their planning and to educate them about the FBCO's plans and capabilities. FBCOs might begin by partnering with other religious and local neighborhood organizations. They should develop collaborative efforts to keep the partner organizations running during an emergency.

State and local government can help such partner organizations coordinate their work with other pandemic preparedness efforts. For example, the Catholic Diocese of Davenport, Iowa, participates in influenza pandemic planning sessions with the local public health department, the state department of education, and the Iowa Catholic Conference. Scott County, Iowa, has arranged with the diocese to use Davenport's Catholic high school for triage, medical, and (if necessary) morgue services during a pandemic. Moreover, a member of the diocesan staff serves on the Iowa Department of Public Health's Contingency Ethics Committee, which is developing a guide to aid ethical decision making during a pandemic.

"The Right Thing to Do"
The CDC and other leading public health organizations say the threat of an influenza pandemic is real — valid enough to warrant prudent preparedness planning. If such an event occurs, FBCOs will be key partners in protecting the public's health and safety. The individual and collective leadership of such organizations is essential in encouraging people to prepare now for an influenza pandemic.

"The most important reason we are doing this is because this is about human lives," says Sr. Patricia A. Talone, RSM, Ph.D., CHA's vice president, mission services. "This is a moral imperative; we don't have a choice with it. We are doing this not because of the money, not because of the safety, but because this is the right thing to do."⁴

The findings and conclusions in this article are those of the author and do not necessarily represent the views of the funding agency.

Acknowledgements
The author would like to thank the following people for their help: Deacon Francis L. Agnoli, MD, MDiv, director of liturgy, St. Ambrose University and the Diocese of Davenport; Richard Dixon, MD, associate director for science, Division of Partnerships and Strategic Alliances, CDC/CCHIS/NCHM; Lisa Koonin, MN, MPH, chief, Private Partnerships Branch, Division of Partnerships and Strategic Alliances, CDC/CCHIS/NCHM; Stephanie Marshall, MSW, director of pandemic communications, Office of the Assistant Secretary for Public Affairs, U.S. Department of Health and Human Services; Dan Rutz, MPH, acting director, Division of Partnerships and Strategic Alliances, CDC/CCHIS/NCHM; Sr. Patricia A. Talone, RSM, Ph.D., vice president, mission services, Catholic Health Association.

NOTES

1. Centers for Disease Control and Prevention, Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States — Early, Targeted, Layered Use of Nonpharmaceutical Interventions, Atlanta, February 2007 (www.pandemicflu.gov/plan/community/community_mitigation.pdf).
2. S. L. Cutter, B. J. Boruff, and W. L. Shirley, "Social Vulnerability to Environmental Hazards," Social Science Quarterly, vol. 84, no. 2, June 2003, pp. 242-261.
3. U.S. Department of Health and Human Services, HHS Pandemic Influenza Plan, Washington, DC, 2005 (www.hhs.gov/pandemicflu/plan/); U.S. Homeland Security Council, National Strategy for Pandemic Influenza Implementation Plan, Washington, DC, 2006 (www.whitehouse.gov/homeland/nspi_implementation.pdf).
4. U.S. Department of Health and Human Services, "Pandemic Influenza Leadership Forum — Media Briefing," July 13, 2007 (www.pandemicflu.gov/news/leadershipmediabrief.html).

Sources of Additional Information

U.S. Department of Health and Human Services, The Faith-Based & Community Organizations Pandemic Influenza Preparedness Checklist, Washington, DC (www.pandemicflu.gov/plan /community/faithcomchecklist.html) provides an approach to pandemic planning by FBCOs. If a pandemic influenza event occurs, reliable, accurate, and timely information on the status and severity of the pandemic also will be posted at www.pandemicflu.gov.

Additional information is available from the Centers for Disease Control and Prevention (CDC) Hotline: 800-CDC-INFO (1-800-232-4636; TTY: 888-232-6348.). This line is available in English and Spanish, 24 hours a day, seven days a week. Or questions may be e-mailed to [email protected].

Information about related topics can be found at the following sources:

Seasonal influenza CDC (www.cdc.gov/flu/keyfacts.htm) and HHS (http://www.hhs.gov/flu/).

Avian Influenza CDC (www.cdc.gov/flu/avian).

Antiviral Medications HHS (www.pandemicflu.gov/vaccine/medantivirals.html).

Vaccines HHS (www.pandemicflu.gov/vaccine/vacresearch.html).

Washing Hands CDC (www.cdc.gov/cleanhands/).

Cough and Sneeze Etiquette CDC (www.cdc.gov/flu/protect/covercough.htm).

Guidance on Preparing Workplaces for an Influenza Pandemic The U.S. Department of Labor Occupational Safety and Health Administration provides guidance and recommendations on infection control in the workplace, including information on proper mask and respirator use (www.osha.gov/Publications/OSHA3327pandemic.pdf).

Health Recommendations for International Travel Visit CDC's Travelers' Health website (www.cdc.gov/travel) to educate yourself and others who may be traveling with you about any disease risks.

Prepandemic Planning
See the CDC's Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States — Early, Targeted, Layered Use of Nonpharmaceutical Interventions (www.pandemicflu.gov/plan/community/community_mitigation.pdf).

Creating a Pandemic Preparedness Movement
HHS is engaging influential leaders from the business, faith-based, civic, and health care sectors to help it spread the word about the critical need for individual preparedness. For more information on the campaign and how to get involved, visit www.pandemicflu.gov/plan/federal/forum.html.

Spiritual and Emotional Care
The National Voluntary Organizations Active in Disaster (National VOAD) has developed A Guide for Spiritual Care in Times of Disaster for Disaster Response Volunteers, First Responders and Disaster Planners (www.nvoad.org/articles/Light_Our_Way_LINKS.pdf). See also R. H. Gurwitch, et al., Building Community Resilience for Children and Families (www.nctsn.org/nctsn_assets/pdfs/edu_materials/BuildingCommunity_FINAL_02-12-07.pdf).

Disability Preparedness provides information on how people with disabilities, their family members and service providers can prepare for emergencies. The site also includes information for emergency planners and first responders to help them to better prepare for serving persons with disabilities (www.disabilitypreparedness.gov).

Ethical Considerations
The CDC offers guidance relevant to public health decision making during planning for and responding to pandemic influenza (www.cdc.gov/od/science/phec/guidelinesPanFlu.htm).

Information on Contacting Important Agencies in Your State
See HHS's Contact Information for State Departments of Agriculture, Wildlife, and Public Health (www.pandemicflu.gov/plan/states/statecontacts.html). See also HHS, Pandemic Influenza Planning Checklists for Home Health Care Services, Medical Offices and Clinics Checklist, Emergency Medical Services and Non-Emergent (Medical) Transport Organizations, Hospitals, Long-Term Care and Other Residential Facilities, and Health Insurers (www.pandemicflu.gov/plan/healthcare/index.html).

Copyright © 2007 by the Catholic Health Association of the United States
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