1. Skelton, Adam G. PhD, MPH

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The Threat and Potential Impact of Pandemic Influenza

According to infectious disease experts at the US Department of Health and Human Services (DHHS), the US Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and other respected agencies, the specter of an influenza pandemic is great.1-6 With the increase in global transport and increased travel into and out of primarily agrarian societies, the emergence of new, particularly, virulent strains of influenza virus, the likelihood of these viruses to mutate to enable human-to-human transmission, the paradoxical effect of human autoimmune response to influenza, urbanization and overcrowded conditions enhancing transmissibility, an increasingly compromised human-animal barrier, an aging population in industrialized countries, the lack of a vaccine for many emerging strains of influenza and the lack of the ability to quickly produce influenza vaccine, the presence of other ongoing pandemics such as acquired immunodeficiency syndrome and tuberculosis, and pandemics due to emerging influenza virus's are likely to break out and quickly take hold around the world.


The severity of the next pandemic cannot be predicted with certainty, but modeling studies suggest that its effect in the United States could be severe. Meltzer and colleagues7 have developed a model for estimating the economic impact of influenza. In the absence of any control measures (pharmaceutical, nonpharmaceutical, or medical), this model estimated (in 1999 numbers, based on data from the 1968 influenza pandemic) that in the United States a "medium level" pandemic could cause 89,000 to 207,000 deaths, between 314,000 and 734,000 hospitalizations, 18 to 42 million outpatient visits, and another 20 to 47 million people with the illness but who do not seek care. With a projected attack rate of between 15% and 35%, the economic impact could range from $82.8 billion to $193.3 billion.*,7 This estimate includes the costs of inpatient and outpatient medical care, prescription and nonprescription medications, and days lost from work for the affected individual. It probably significantly underestimates the true economic impact because it does not include days lost from work due to caring for a family member; the cost of replacement workers; lost business revenue due to business closures; slow or eliminated sales; supply, manufacturing, and distribution problems; the cost of business processes reengineering; the cost of nonpharmaceutical interventions; and uninsured losses. The CDC has developed a software application based on Meltzer's work called FluAid Version 2.0 to facilitate the modeling of influenza.8 FluAid is designed to assist state-level and local-level planners in preparing for influenza pandemics by providing estimates of potential impact specific to their locality and could likely be easily modified to reflect economic losses suffered by the business community at the hands of an influenza pandemic.


Economic Impact of Pandemic Influenza on the US Business Community

The private sector would bear an inordinate amount of the burden of an influenza outbreak of significant size or duration. This is because it would not only suffer revenue losses but also pay the majority of the healthcare costs resulting from an influenza pandemic. A chilling economic scenario is presented by BMO Nesbitt Burns Research,9,10 in which economists concluded that the economic and societal effects of an influenza pandemic would be severe "comparable to the Great Depression of the 1930s." This is because business is dependent on the health of its employees, its suppliers, its inventories, its supply chains, its manufacturing capabilities, its strategic partners, and its customers. If these are compromised, business is severely impacted. This economic burden is reflected in the form of lost productivity, lost sales, human resource casualties, and healthcare claims. The authors of the BMO study urge that businesses and consumers join the public health establishment in preparedness and response planning and pandemic intervention, although the exact structure for this interaction is not specified.


The ERISA Industry Committee was recently surveyed on their perspectives of the threat of an influenza pandemic and ways to reduce the impact of such a pandemic.11 According to the results of this nonscientific survey, representatives of US companies are very concerned about pandemic influenza and believe it is a real threat to the nation, but few believe their companies are adequately prepared to protect themselves in the event of an outbreak. Other findings include:


* Fifty-seven percent of respondents believed that a pandemic influenza presents a real threat to the United States, while 9 percent disagreed, and 33 percent were undecided.


* Fifty-two percent of respondents said their company is very concerned about a pandemic influenza outbreak, while 26 percent said they were not very concerned, and 32 percent were undecided.


* Sixty-one percent of respondents said they are not confident that their company is prepared to manage a pandemic influenza outbreak should it occur, while 16 percent were confident, and 24 percent were undecided.


* Seventy-three percent said their company could use help in understanding what it should do to plan for a pandemic influenza outbreak, while 14 percent disagreed, and 13 percent were undecided.While respondents to the survey believed their company is concerned and that a pandemic would be a threat to the nation as a whole, they were less certain that it would adversely affect their business and whether there was anything they could do about it:


* Thirty-nine percent of respondents believed that an influenza pandemic would adversely affect their business, while 17 percent said it would not, and 44 percent were undecided.


* Sixty-eight percent of respondents said their company has not adequately planned ways to protect itself from a pandemic influenza outbreak, while 12 percent said they are adequately prepared, and 20 percent were undecided.


* Thirty-nine percent of respondents believed that there was not much a company could do to protect it from the adverse effects of an influenza pandemic, while 39 percent disagreed with that statement, and 21 percent were undecided.When asked about potential options for coping with pandemic influenza:


* Sixty percent of respondents agreed that allowing employees to telecommuting would be an effective way to address an outbreak, while 11 percent disagreed, and 29 percent were undecided.


* Sixty-four percent of respondents said they were undecided on whether they would waive sick leave restrictions in order to encourage sick employees to stay at home, while 27 percent said they would waive the restrictions, and 10 percent said they would not.



"Major employers are concerned at the destructive potential of disasters and pandemics, and want to protect their workers," said Edwina Rogers, vice president for Health Policy of the ERISA Industry Committee. "If the private sector experiences that kind of crisis without proper planning, there could be major implications for the US economy."


The recently released HHS Pandemic Influenza Plan12 has precious little to say about the role or responsibilities of the business community in pandemic influenza planning, preparedness, and response. The business community is mentioned in Supplement 10 (Public Health Communications) in a section about business continuity planning. This section simply states, "Engage business leaders in continuity planning," though it does not mention what continuity planning is, what will be the result or business continuity planning, or how this will be done in concert with local, state, or federal planning efforts. The plan advocates the conduct of "business roundtables" and/or "town hall meetings" to facilitate this planning.


The National Strategy for Pandemic Influenza, released by the Homeland Security Council in November 2005,13 states that "it is essential that the US private sector be engaged in all preparedness and response activities for a pandemic." This strategy briefly outlines the responsibilities of the private sector to include:


* Establishing an ethic of infection control in the workplace that is reinforced during the annual influenza season to include, if possible, options for working offsite while ill, systems to reduce infection transmission, and worker education.


* Establishing contingency systems to maintain delivery of essential goods and services during times of significant and sustained worker absenteeism.


* Where possible, establishing mechanisms to allow workers to provide services from home if public health officials advise against nonessential travel outside the home.


* Establishing partnerships with other members of the sector to provide mutual support and maintenance of essential services during a pandemic.



The CDC's National Center for Health Marketing, Division of Partnerships and Strategic Alliances, is currently exploring ways to operationalize these directives through the development of checklists and other guidance aimed at the business community as well as sponsoring business roundtables and systematic data collection initiatives. However, the private sector has been aggressively pursuing its own initiatives to minimize the impact of an influenza pandemic on its employees and lines of business through business continuity planning, the development of partnerships to assure value chains, and engaging experts to provide guidance in disaster preparedness.


The threat to the personal well-being of employees, their families, and strategic business partners would be reason enough to become involved in influenza preparedness. But the economic impact on large businesses of such a crisis can also be serious and long-term.7,9,10,14 As with any other public health threat, the development of planning, preparedness, and response capabilities is critical to the minimization of risk, threat, vulnerability, and impact.15 The balance of this article will focus on activities to reduce the economic impact of pandemic influenza on business.


Private Sector Objectives of Planning, Preparedness, and Response

The objectives of pandemic influenza planning and preparedness from a business perspective are fourfold. First, businesses aim to protect their primary and secondary revenue streams, the products and/or services they sell, and their ability to sell them. This necessitates an understanding of how an influenza pandemic could adversely impact various lines of business as well as business enablers. The metric for this objective is lost revenue. Second, businesses aim to protect their employees. Employees are a critical resource to business and when they do not work or work inefficiently or ineffectively, business losses are incurred. The metrics for this objective are days of work lost due to illness, the costs of hiring and training new employees, and insurance costs for self-insured employers. Third, businesses aim to protect their clients and strategic partners. This involves determining how an influenza pandemic might impact clients and strategic partners and minimizing this impact. Strategic partners of note might include suppliers, manufacturers, distributors, regulators, etc. Finally, businesses aim to protect their employee's families in order to reduce revenue lost due to leave taken to care for a sick family member and insurance costs for self-insured employers. Metrics for this objective include days of work lost due to caring for an ill family member and healthcare claims paid for dependents.


Planning inevitably focuses initially on the "business case" for planning within the context of avoided costs. How much would a large business invest to reduce its risk of losing $300 million or even $100 million? In what should they invest to realize the greatest reduction of risk? How should investments be evaluated for effectiveness and efficiency? A structured planning process that focuses on "all hazards" risk reduction within the context of business continuity planning is a reasonable approach. Rather than planning for distinct events within this environment of uncertainty, it is helpful in planning for a range of scenarios with a fluid process to initialize and manage resources specific to the threat.


Private Sector Activities to Support Influenza Preparedness and Response

The private sector will accomplish these objectives through both internal and external means. Internally, businesses will plan to protect their lines of business and employees as strategic assets. Externally, businesses will organize and align themselves into coalitions in an attempt to influence the environment that influences pandemic influenza impact and burden.


There is a significant role for private businesses in influenza pandemic planning, preparedness, response, and evaluation. This is due to both their incentives to reduce their risk and adverse economic impact and their roles as "population aggregator," "health services purchaser," and "policy influencer." This complements, and in some areas supplants, the role of traditional organizations such as state and local health departments, the federal government, healthcare providers, and insurers and health plans. This role might take the form of the following activities:




* Develop organization-specific preparedness and response plans that follow standard guidelines. The Planning Guidance for State and Local Health Departments, part 2 of the 2005 HHS Pandemic Influenza Plan,12 can be easily modified to meet the requirements of business planning, preparedness, and response. The goal should be to identify the major components of a Pandemic Influenza Preparedness and Response Plan and assure that they are approached with a minimum level of variance. These components include establish command, control, and management procedures; develop a communications plan; establish and distribute travel restriction and quarantine policies; develop wellness capabilities; establish a priori response activities with health plans; and engage a preferred set of providers to assure care in the event of an outbreak. A private sector entity response plan should complement that of applicable local public health agencies and first responders. This planning stage is critical and implies implementing a strategic (as opposed to tactical) approach that involves attention to crucial internal resources (human resources, business process innovation, knowledge management, and data management) and external resources (customers, markets, strategic partners, and the public sector). If possible, relevant public sector agencies such as local health departments, state health departments, federal agencies such as the CDC, the Department of State, and the Department of Homeland Security, should be engaged during the planning process, as plans are completed and implemented. As most large businesses operate over a wide geographic area, it might be impractical to engage all relevant resources in the planning process. Therefore, the private sector might limit involvement to major public sector partners. This will maximize opportunities to harmonize activities while optimizing planning resources. It is very likely that the public sector will have limited resources to participate in integrated public-private sector planning and will best serve as "reviewer" or "subject matter expert."


* Develop and deliver structured information on pandemic influenza threats, prevention, care, and treatment, and what to do in the event of an outbreak to employees and their families during interpandemic periods. This communication can be through normal business channels such as e-mail, Web portals, or distributed through management channels, and should be sponsored by the highest levels of leadership and should be clear, consistent, and medically accurate. There is a critical opportunity to partner with relevant public sector resources to lend credibility to this information.


* Identify critical human resources and plan to assure continuity among them. This involves segmenting and classifying resources into critical and noncritical jobs, cross-training where applicable, and developing and implementing a succession plan in order to assure continuity. Other human resources-related planning includes a revision and reaffirmation of sick day policies to assure that ill individuals do not come to work. In order for this planning to be successful, a comprehensive review and revision of human resources policies and procedures in compliance with federal and state regulations such as the Americans With Disabilities Act16 and the Family and Medical Leave Act17 as well as organized labor concerns should be involved.


* Engage internal wellness and benefits management resources as well as affiliated health plans and provider networks in order to assure that these partners understand the preparedness and response plan, their role in this plan, and essential activities relative to executing the plan. It is critical to leverage the position as major healthcare purchasers, even more influential when businesses organize into purchasing coalitions. Payers, and their affiliated provider networks, should be contractually obligated to support pandemic influenza preparedness and response activities. If possible, these resources should be involved in the planning process.




* Develop the infrastructure to respond to an influenza pandemic. This includes identifying a responsible person or a team, providing that person or team with the authority to enact the response plan (within a set of agreed-upon decision rules), committing a budget for "all hazards" risk reduction, developing a Web site or other communications hub that will be "switched on" and accessible by all employees, and developing contracts with partners to distribute and administer medications including seasonal vaccine, pandemic influenza vaccine (when and if it becomes available), antiviral medications, antibiotics, and nonpharmaceutical supplies. This also involves making any required investments in virtual workplace technologies and training.


* Participate in business coalitions of vaccine development, manufacturing, and distribution "sponsors." This type of coalition would leverage its purchasing and/or investment power to subsidize the cost of vaccine and antiviral development, assist in clinical trials, purchase vaccines and other medications once developed, and provide accurate demand forecasts for vaccine production planning. This activity would involve creating legal partnerships with like-minded organizations that result in significant pooled resources to augment the costs of these activities. The return for the investors would be guaranteed access to pharmaceuticals or a financial return based on sales of the vaccine. This tends to contradict the current process, whereby vaccine producers determine the number of doses of a particular vaccine that they will manufacture by estimating how many doses they will sell to providers or through established government purchasing agreements. This new approach would generate capital for influenza vaccine development and manufacturing and allow organizations to purchase the appropriate number of doses of medication for their employees, their families, and others as desired and assure that the medication be administered in an appropriate and timely manner through service contracts with providers. Direct contract with pharmaceutical firms eliminates the risk that providers bear as purchasers, facilitates cost savings thorough economies of scale, minimizes the variance between the estimated number of doses to be produced and the number of doses actually administered, and short circuits debates about reimbursement rates for vaccine administration.


* Develop contracts with payers and provider networks to provide services in a timely manner in the event of a pandemic. This likely involves modifying existing contracts and evaluating the performance that can be expected in the event of a pandemic. Health plans and affiliated provider networks must be engaged as early as possible in order to identify their role in any future pandemic scenario.


* Test and evaluate pandemic influenza plans through a structured tabletop or scenario-based exercises. The objectives of this activity are, according to the CDC, to raise awareness about the impact of pandemic influenza on the healthcare system or any other organizations that are planning to increase understanding regarding the roles and responsibilities of all response partners; to evaluate whether current plans adequately address anticipated events; to identify gaps in coordination between response partners and to determine partnering strategies; and to promote advance planning between response partners. The result of these exercises would be the advice regarding modifications in planning, preparedness, and response activities.




* Quickly and decisively execute pandemic influenza response plans that involve the implementation of corporate travel restrictions, initiation of administration of antiviral and antibiotic medications, dissemination of influenza educational materials, and authorization of flexible work arraignments where appropriate. This set of activities includes communicating with employees through pre-established channels, implementing technologies to facilitate telecommuting and teleconferencing, and engaging preexisting strategic partnerships. This response plan execution can be facilitated by structured decision-making aids such as automated rules, alerts, and reminders. Developing a leadership "dashboard" that presents updated relevant metrics is a helpful management process.


* Initiate existing relationships with aligned providers to assure vaccine availability and administration to employees and their families. Vaccines may be administered at places of business (plants, office buildings, etc) or at predetermined vaccine sites. Existing provider network relationships should be leveraged, however, if needed. Business should consider developing contracts with visiting nurse associations for on-site vaccine administration.


* To assure business continuity during an influenza pandemic, the human resources policies must reflect a strategic approach to pandemic response. Capabilities such as multitasking, cross-training, temporary worker augmentation, "buddy systems," and on-site risk reduction should be implemented.



The private sector had a limited role relative to industry input or guidance in the HHS Pandemic Influenza Plan12 that was released on November 1, 2005. However, there exists a great deal of opportunity and resources within the private sector to prepare and respond to an outbreak of pandemic influenza. The business community should be engaged to assist in creative thinking and innovation regarding the business models that drive vaccine demand forecasting, production, sale, distribution, and administration as well as other critical elements. This type of involvement is alluded to in Supplement 10 of the HHS Pandemic Influenza Plan12 and is described in the form of business roundtables. To be sure, the business community has more than financial and "business continuity" reasons for being involved. It should be reiterated that planning and preparedness is an investment and that engaging public or private partners in this preparedness and response planning can be extremely empowering for all parties involved. The process of public-private engagement to achieve the aim of pandemic influenza preparedness could involve the following tasks:


* Establish a basic level of understanding regarding the impact that an influenza pandemic could have on the US business community. This involves sharing with businesses the latest information about influenza (threat, vulnerability, risk, impact, etc) within a framework for action as well as sharing information about the current preparedness activities of the WHO, the DHHS, the CDC, states, local governments, other public agencies, and private, not-for-profit organizations such as the American Lung Association. This activity would also involve understanding investment models relative to pandemic influenza risk and impact reduction.


* Develop collaborative partnerships between businesses and between business and relevant public sector entities. These partnerships should be based on shared risk, identified incentives, and complementary values, and express ways that these organizations can become involved in pandemic influenza preparedness and response to the benefit of their business, business partners, and employees and their families. These partnerships are surprisingly difficult to develop and maintain, mostly due to a perceived variance in values. These partnerships should respect that public sector resources include scientific expertise and policy leverage while business resources include financial and in-kind resources, their position as population aggregators, influence over employees, and leverage over contracted providers and health plans. These partnerships should also respect the fact that public sector entities such as local and state health departments are severely under-funded and may not be able to dedicate appropriate resources to the partnership. One example of a partnership between businesses involves developing collaborations with vaccine manufacturers to assure timely access to vaccines, antiviral medications, antibiotics, and other medications in exchange for involvement in vaccine trials and access to distribution infrastructure. An example of a public-private partnership would be a blended community education program.


* Identify issues associated with influenza pandemic preparedness and response (vaccine development, vaccine distribution, economics, etc) and determine better practices to enable the development of planning guidelines similar to those developed for state and local health departments that will standardize preparedness and response planning. During this process, challenges associated with influenza pandemic planning, preparedness, response, and evaluation should be identified and prioritized.


* Lead the development of "preparedness coalitions," along the model of Business Executives for National Security or national business groups on health, that would assist pharmaceutical firms in the development of predictive demand models for vaccines, assist the CDC, the WHO, or states in the development of a comprehensive influenza/pneumonia surveillance system (including disease occurrence as well as vaccine administration surveillance) that leverages sick day data from timekeeping systems, or assist with leveraging resources to support response in the event of a pandemic.



For the range of reasons presented here, it behooves business to plan independently for the eminent influenza pandemic. It is also advised to align with other businesses and local, state, and federal public health agencies, as well as private public health organizations to leverage opportunities identified here (as well as others) in order to mitigate business risk represented by pandemic influenza.




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