Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations (CMG-EVAL)

Form Approved

OMB No. 0920-0879

Expiration Date 01/31/2021

Pandemic Influenza: Assessing the Feasibility and Acceptability of Implementing the 2017 Community Mitigation Guidelines and Recommendations

Attachment C: Instrument word version

Introduction to the Project and the Tool

Dear Colleague:

On April 21, 2017, the US Department of Health and Human Services (HHS) and its Centers for Disease Control and Prevention (CDC) released the Community Mitigation Guidelines to Prevent Pandemic Influenza – United States, 2017 (https://www.cdc.gov/mmwr/volumes/66/rr/pdfs/rr6601.pdf). The guidelines serve as a pre-pandemic planning tool for state, territorial, and local public health officials and include updated recommendations on the use of non-pharmaceutical interventions (NPIs) in community settings, in a layered or phased approach starting at the earliest stages of a pandemic.

NPIs reserved for influenza pandemics include personal protective measures such as voluntary home quarantine of exposed household members and use of face masks in community settings when ill. They also include community measures such as temporary closures or dismissals of childcare facilities and K-12 schools as well as other social distancing measures that increase the physical space between people (e.g., limiting face-to-face contact in workplaces by replacing in-person meetings with teleconferences, or postponing or canceling mass gatherings).

Purpose and Relevance

This project is designed to assess the feasibility and acceptability of implementing the recommended NPIs in your jurisdiction. This online assessment tool will capture the responses related to your jurisdiction, which will be compiled with responses from other jurisdictions to help CDC to

• Identify issues raised by public health officials with respect to the feasibility and acceptability of implementing NPIs during severe influenza pandemics.

• Highlight expressed barriers to implementing NPIs in community settings by public health officials.

• Update sections of the 2017 Community Mitigation Guidelines, as needed, to enhance the usefulness of the guidelines for pre-pandemic planning.

This information also may give public health officials insight into how they can strengthen their pre-pandemic strategic planning and preparedness by identifying gaps and barriers as well as areas in which communication and education may need to be enhanced in their jurisdictions.

Instructions on the Tool

Please respond to the questions in your role as a state, territorial, or local public health official, and from the perspective of the communities within your jurisdiction. For questions where others in your agency might be more appropriate to respond (e.g., emergency preparedness coordinator, influenza epidemiologist, infectious disease surveillance coordinator), please feel free to consult those colleagues, but submit only one assessment for your jurisdiction. Please do not forward this assessment tool to another individual or jurisdiction.

Please note that several questions in Section II of this assessment tool refer specifically to the 2017 Community Mitigation Guidelines; therefore, accessing and reviewing the resources identified in Section II (i.e., the boxes, figures, and tables) beforehand may be helpful. You can access the 2017 guidelines here: https://www.cdc.gov/mmwr/volumes/66/rr/pdfs/rr6601.pdf.

Once you begin completing the assessment, you can exit out of it by closing the tab and return to it at a later time without losing your responses. To save responses entered on the current page, you must first click the “next” button before exiting the assessment—as responses are saved page by page as you progress through the assessment.

Your participation is voluntary. You can opt not to participate, or to refuse to answer any question, or to withdraw from participation at any time without loss of any services or support from HHS or CDC.

We will report only the aggregated responses of all the participating jurisdictions. The results of this assessment should provide information of benefit to your agency’s pre-pandemic strategic planning and preparedness efforts. Completing this assessment tool is expected to take up to 90 minutes.

If you have any questions about the project, this assessment tool, or your participation, please contact The MayaTech Corporation [NACCHO], which is helping CDC with this effort, at [email protected] [[email protected]] or Dr. Noreen Qualls, the CDC Project Co-Lead, at [email protected]. Thank you, in advance, for your participation and valuable input.

We kindly request the completion and submission of this assessment by [DATE].

By clicking the link below, you are consenting to participate in this assessment. Please consult with colleagues in your agency, as appropriate, but only submit one assessment. Please do not forward the assessment.

INSERT “BEGIN ASSESSMENT” BUTTON

1. BACKGROUND INFORMATION ON RESPONDENT AND JURISDICTION(S)

In this section, we request some brief background information about you and your jurisdiction.

1. What is your jurisdiction size?

__Fewer than 10,000

__10,000 to 49,999

__50,000 to 499,999

__500,000+

2. At which level of government is your agency?

__State (skips to Q4)

__Territory (skips to Q4)

__Local—single county

__Local—multicounty, but not state-level

__Local—single city

__Local—multicity, but not county-level

__Other: please specify __________

3. Does your (local) health department operate autonomously?

___Yes

___No, shared with state

___No, governed by state only

3. Please indicate your role/position:

__State public health official

__Territorial public health official

__Local public health official

__Disaster/emergency preparedness coordinator

__Epidemiologist

__Planner

__Policy analyst

__Public information officer/communications specialist

__Other: please specify __________

1. STATUS OF PRE-PANDEMIC PLANNING IN YOUR JURISDICTION

In this section, we would like to get information about your jurisdiction’s progress in planning for an influenza pandemic and incorporating the HHS/CDC Community Mitigation Guidelines to Prevent Pandemic Influenza – United States, 2017 (hereafter referred to as the 2017 Community Mitigation Guidelines or the 2017 guidelines) (https://www.cdc.gov/mmwr/volumes/66/rr/pdfs/rr6601.pdf).

5. Are you aware of the updated HHS/CDC Community Mitigation Guidelines to Prevent Pandemic Influenza – United States, 2017?

__Yes

__No

6. Have you read the 2017 Community Mitigation Guidelines?

__Yes

__No

7. Have you incorporated the updated guidelines into your pandemic influenza preparedness plan?

__Completed

__In progress

__Do not know / Not sure (skips to Q11)

__Not started: Please explain the reason: __________ (skips to Q11)

In addition to updating the NPI recommendations, the 2017 guidelines

• Summarize lessons learned from the 2009 H1N1 pandemic response (described in Box 1, pages 4-7).

• Replace the Pandemic Severity Index with the Pandemic Severity Assessment Framework (PSAF) (described in Figure 3, page 12; Figure 4, page 13; Tables 5 & 6, page 29).

• Provide planning scenarios to put the NPI recommendations into context (described in Figure 5, page 15; Figure 6, page 20; Table 9, page 31; Table 10, page 32).

For each of the following new elements in the guidelines, please indicate (in Questions 8-10 below) if you have used them in your jurisdiction’s pre-pandemic planning:

8. Lessons Learned from 2009 H1N1 Pandemic Response?

__Yes (skips to an item with a dialog box for free text that asks: In what ways? _____)

__No, but planning to use

__No, have no plans to use

__Do not know / Not sure

9. Pandemic Severity Assessment Framework (PSAF)?

__Yes (skips to an item with a dialog box for free text that asks: In what ways? _____)

__No, but planning to use

__No, have no plans to use

__Do not know / Not sure

10. Planning Scenarios?

__Yes (skips to an item with a dialog box for free text that asks: In what ways? _____)

__No, but planning to use

__No, have no plans to use

__Do not know / Not sure

In thinking about the plans your jurisdiction has in place to address pandemic influenza, please answer the following questions:

11. For each of the following items related to pre-pandemic planning, please indicate your jurisdiction’s progress/status:

What is the status of the:	Completed	In progress	Not started	Do not know	Not applicable
a. Pandemic influenza preparedness plan or annex	If checked—In what year?
b. Operational plan for pandemic influenza response as an integral element of the overall state/local emergency response plan	If checked—In what year?
c. Integration of local, state, regional, and/ or territorial plans across jurisdictional boundaries	If checked—In what year?
d. Communications plan for informing, engaging, and mobilizing the community during an influenza pandemic	If checked—In what year?

1. FEASIBILITY AND ACCEPTABILITY OF IMPLEMENTING NPI RECOMMENDATIONS IN YOUR JURISDICTION

The 2017 Community Mitigation Guidelines include two categories of NPIs – those recommended at all times and those reserved for influenza pandemics. NPIs recommended at all times, and in all settings, include voluntary home isolation of ill persons; respiratory etiquette; hand hygiene; and environmental surface cleaning. As indicated in the 2017 guidelines, in the event of a severe, very severe, or extreme influenza pandemic (as opposed to a mild or moderate pandemic), the following will apply:

• CDC will provide guidance around NPIs, but implementing them will be a state, territorial, and local responsibility.

• CDC might not recommend the implementation of NPIs uniformly across the nation at the same time.

• If epidemiologic data suggest sustained human-to-human transmission and indicate high transmissibility of the novel influenza virus combined with severe disease outcomes (high clinical severity), CDC might recommend the following NPIs reserved for use only during influenza pandemics:

  • voluntary home quarantine of exposed household members;

  • use of face masks in community settings when ill;

  • preemptive, coordinated school closures or dismissals; and

  • social distancing measures at schools, workplaces, and mass gatherings.

In the following sections, please rate the feasibility and acceptability of implementing the four NPIs listed above (NPIs reserved for use only during influenza pandemics) and describe the barriers to implementation in your jurisdiction. For this assessment, these definitions apply:

• Feasibility – the extent (rated as “high”, “moderately high”, “moderately low”, or “low”) to which the NPI recommendation is capable of being implemented in a severe pandemic in your jurisdiction.

• Acceptability – the extent (rated as “high”, “moderately high”, “moderately low”, or “low”) to which community stakeholders and partners are willing to comply with the implementation of the NPI recommendation in a severe pandemic in your jurisdiction.

• Barriers – factors that may make difficult or impede the implementation of the NPI recommendation in a severe pandemic in your jurisdiction.

• Pandemic scenarios include “mild to moderate” like the 2009 H1N1 pandemic; “moderate to severe” like the 1968 H3N2 pandemic; “severe” like the 1957 H2N2 pandemic; and “very severe to extreme” like the 1918 H1N1 pandemic (see Table 9, page 31).

1. VOLUNTARY HOME QUARANTINE

Please read this CDC NPI recommendation and then respond to the questions that follow (see page 14: https://www.c dc.gov/mmwr/volumes/66/rr/pdfs/rr6601.pdf).

Voluntary home quarantine: CDC might recommend voluntary home quarantine of exposed household members as a personal protective measure during severe, very severe, or extreme influenza pandemics in combination with other personal protective measures such as respiratory etiquette and hand hygiene. If a member of the household is symptomatic with confirmed or probable pandemic influenza, then all members of the household should stay home for up to 3 days (the estimated incubation period for seasonal influenza) starting from their initial contact with the ill person, to monitor for influenza symptoms.

Note: Voluntary home quarantine is most practical when implemented very early in a pandemic and on a limited geographic scale, once there is evidence of the emergence of pandemic influenza in the community. Voluntary home quarantine of exposed household members might help reduce the chance of transmitting the influenza virus to others outside of the household at school and at work.

12. To what extent will the recommendation for voluntary home quarantine of exposed, non-ill household members be feasible to implement in your jurisdiction?

__High feasibility (skips to Q14)

__Moderately high feasibility (skips to Q14)

__Moderately low feasibility

__Low feasibility

__Do not know / Not sure (skips to Q14)

13. Please explain your reason for the Moderately Low or Low feasibility response selected in Question 12 and describe the barriers preventing high feasibility in your jurisdiction.

14. To what extent will the recommendation for voluntary home quarantine of exposed, non-ill household members be acceptable to stakeholders (including your agency) in your jurisdiction?

__High acceptability (skips to Section B)

__Moderately high acceptability (skips to Section B)

__Moderately low acceptability

__Low acceptability

__Do not know / Not sure (skips to Section B)

15. Please explain your reason for the Moderately Low or Low acceptability response selected in Question 14 and describe the barriers preventing high acceptability in your jurisdiction.

2. 
   

   Please read this CDC NPI recommendation and then respond to the questions that follow (see pages 14-15: https://www.c dc.gov/mmwr/volumes/66/rr/pdfs/rr6601.pdf).

   
   
   

   Use of face masks by ill persons: CDC might recommend the use of face masks by ill persons as a source control measure during severe, very severe, or extreme influenza pandemics when crowded community settings cannot be avoided (e.g., when adults and children with influenza symptoms seek medical attention) or when ill persons are in close contact with others (e.g., when symptomatic persons share common spaces with other household members or symptomatic postpartum women care for and nurse their infants).

   
   

   Note: Disposable surgical, medical, and dental procedure masks are used widely in health care settings to prevent exposure to respiratory infections. Some evidence indicates that face mask use by ill persons at home or out in public might protect others from infection.

   
   
   

   USE OF FACE MASKS BY ILL PERSONS

16. To what extent will the recommendation for use of face masks by ill persons be feasible to implement in your jurisdiction (assuming supplies are sufficient)?

__High feasibility (skips to Q18)

__Moderately high feasibility (skips to Q18)

__Moderately low feasibility

__Low feasibility

__Do not know / Not sure (skips to Q18)

17. Please explain your reason for the Moderately Low or Low feasibility response selected in Question 16 and describe the barriers preventing high feasibility in your jurisdiction.

18. To what extent will the recommendation for use of face masks by ill persons be acceptable to stakeholders (including your agency) in your jurisdiction?

__High acceptability (skips to Section C)

__Moderately high acceptability (skips to Section C)

__Moderately low acceptability

__Low acceptability

__Do not know / Not sure (skips to Section C)

19. Please explain your reason for the Moderately Low or Low acceptability response selected in Question 18 and describe the barriers preventing high acceptability in your jurisdiction.

Please read this CDC NPI recommendation and then respond to the questions that follow (see pages 16-17: https://www.c dc.gov/mmwr/volumes/66/rr/pdfs/rr6601.pdf).

• School closures and dismissals: CDC might recommend the use of preemptive, coordinated school closures and dismissals during severe, very severe, or extreme influenza pandemics. This recommendation is in accord with the conclusions of the US Community Preventive Services Task Force (https://www.thecommunityguide.org/findings/emergency-preparedness-and-response-school-dismissals-reduce-transmission-pandemic-influenza), which makes the following recommendations:

  • The task force recommends preemptive, coordinated school dismissals during a severe influenza pandemic.

  • The task force found insufficient evidence to recommend for or against preemptive, coordinated school dismissals during a mild or moderate influenza pandemic. In these instances, jurisdictions should make decisions that balance local benefits and potential harms.

Note: School closure means closing a school and sending all students and staff members home, whereas during a school dismissal, a school might stay open for staff members while the children stay home. Preemptive, coordinated school closures and dismissals might be implemented for childcare facilities, K-12 schools, and institutions of higher education during the earliest stages of a pandemic, before many students and staff members become ill. Community preparedness ahead of a pandemic is essential to determine who needs to weigh-in on closing local schools (e.g., local childcare licensing organization, board of education), and to address potential secondary consequences of school closures that could affect their feasibility and acceptance (e.g., loss of ancillary school services such as free/subsidized school meals, school-based healthcare, and after-school services for children with disabilities).

C. SCHOOL CLOSURES AND DISMISSALS

Childcare Facilities

20. To what extent will the recommendation for temporary childcare facility closures or dismissals be feasible to implement in your jurisdiction?

__High feasibility (skips to Q22)

__Moderately high feasibility (skips to Q22)

__Moderately low feasibility

__Low feasibility

__Do not know / Not sure (skips to Q22)

21. Please explain your reason for the Moderately Low or Low feasibility response selected in Question 20 and describe the barriers preventing high feasibility in your jurisdiction.

22. To what extent will the recommendation for temporary childcare facility closures or dismissals be acceptable to stakeholders (including your agency) in your jurisdiction?

__High acceptability (skips to Q24)

__Moderately high acceptability (skips to Q24)

__Moderately low acceptability

__Low acceptability

__Do not know / Not sure (skips to Q24)

23. Please explain your reason for the Moderately Low or Low acceptability response selected in Question 22 and describe the barriers preventing high acceptability in your jurisdiction.

K-12 Schools

Implementation of preemptive, coordinated school closures and dismissals during an evolving influenza pandemic might have one or more of the following three public health objectives:

• Objective 1: To gain time for an initial assessment of transmissibility and clinical severity of the pandemic virus in the very early stage of its circulation in humans (closures for up to 2 weeks).

• Objective 2: To slow down the spread of the pandemic virus in areas that are beginning to experience local outbreaks and thereby allow time for the local health care system to prepare additional resources for responding to increased demand for health care services (closures up to 6 weeks).

• Objective 3: To allow time for pandemic vaccine production and distribution (closures up to 6 months).

Please refer to these objectives when responding to the following questions:

24. To what extent will the recommendation for preemptive K-12 school closures or dismissals be feasible to implement in your jurisdiction in order to accomplish the stated public health objectives?

If the duration of closures or dismissals is:	Please rate the feasibility for your jurisdiction
	High	Moderately high	Moderately low	Low	Do not know / Not sure
Objective 1: Up to 2 weeks
Objective 2: Up to 6 weeks
Objective 3: Up to 6 months

24d. Please list the number of the objective(s) for which Moderately Low or Low feasibility was selected and describe the reasons and barriers.

25. To what extent will the recommendation for preemptive K-12 school closures or dismissals be acceptable to stakeholders (including your agency) in your jurisdiction in order to accomplish the stated public health objectives?

If the duration of closures or dismissals is:	Please rate the acceptability for your jurisdiction
	High	Moderately high	Moderately low	Low	Do not know / Not sure
Objective 1: Up to 2 weeks
Objective 2: Up to 6 weeks
Objective 3: Up to 6 months

25d. Please list the number of the objective(s) for which Moderately Low or Low acceptability was selected and describe the reasons and barriers.

Institutions of Higher Education (IHE: Colleges and Universities)

26. To what extent will the recommendation for temporary IHE closures or dismissals be feasible to implement in your jurisdiction?

__High feasibility (skips to Q28)

__Moderately high feasibility (skips to Q28)

__Moderately low feasibility

__Low feasibility

__Do not know / Not sure (skips to Q28)

27. Please explain your reason for the Moderately Low or Low feasibility response selected in Question 26 and describe the barriers preventing high feasibility in your jurisdiction.

28. To what extent will the recommendation for temporary IHE closures or dismissals be acceptable to stakeholders (including your agency) in your jurisdiction?

__High acceptability (skips to Section D)

__Moderately high acceptability (skips to Section D)

__Moderately low acceptability

__Low acceptability

__Do not know / Not sure (skips to Section D)

29. Please explain your reason for the Moderately Low or Low acceptability response selected in Question 28 and describe the barriers preventing high acceptability in your jurisdiction.

Please read this CDC NPI recommendation and then respond to the questions that follow (see pages 17-18: https://www.cdc.gov/mmwr/volumes/66/rr/pdfs/rr6601.pdf).

Social distancing measures: Even though the evidence base for the effectiveness of some of these measures is limited, CDC might recommend the simultaneous use of multiple social distancing measures to help reduce the spread of influenza in community settings (e.g., schools, workplaces, and mass gatherings) during severe, very severe, or extreme influenza pandemics while minimizing the secondary consequences of the measures. Social distancing measures include the following:

• Increasing the distance to at least 3 feet between persons when possible might reduce person-to-person transmission. This applies to apparently healthy persons without symptoms. In the event of a very severe or extreme pandemic, this recommended minimal distance between people might be increased.

• Persons in community settings who show symptoms consistent with influenza and who might be infected with (probable) pandemic influenza should be separated from well persons as soon as practical, be sent home, and practice voluntary home isolation.

Note: The choice of social distancing measure depends on the severity of the pandemic. Examples include:

• For schools, dividing classes into smaller groups of students, or rearranging desks so students are spaced at least 3 feet from each other.

• For workplaces, offering telecommuting, replacing in-person meetings with telephone or video conferences, or staggering work hours.

• For mass gatherings (such as at concerts, places of worship, and sports events), modifying, postponing, or canceling large events.

D. SOCIAL DISTANCING AT SCHOOLS, WORKPLACES, AND MASS GATHERINGS

30. To what extent will the recommendation for social distancing be feasible to implement in your jurisdiction?

Social distancing measures at:	Please rate the feasibility for your jurisdiction
	High	Moderately high	Moderately low	Low	Do not know / Not sure
Schools
Workplaces
Mass gatherings

30d. Please list the specific setting(s) for which Moderately Low or Low feasibility was selected and describe the reasons and barriers.

31. To what extent will the recommendation for social distancing be acceptable to stakeholders (including your agency) in your jurisdiction?

Social distancing measures at:	Please rate the acceptability for your jurisdiction
	High	Moderately high	Moderately low	Low	Do not know / Not sure
Schools
Workplaces
Mass gatherings

31d. Please list the specific setting(s) for which Moderately Low or Low acceptability was selected and describe the reasons and barriers.

IV. POTENTIAL TRIGGERS TO ACTIVATE NPIs IN YOUR JURISDICTION

In the 2017 Community Mitigation Guidelines, CDC identified possible indicators (described in Table 3, page 28) that might provide information for triggering implementation of NPIs before the explosive growth of an influenza pandemic occurs.

32. Does your jurisdiction have the following influenza surveillance data?

Influenza surveillance data items	Please indicate the availability of these data for your jurisdiction
	Yes, in near real-time	Yes, but not in near real-time	No	Do not know / Not sure
Number of patient visits to outpatient health care providers for influenza-like illness (ILI) in jurisdiction
Estimated weekly level of geographic spread of influenza activity reported by local health department(s)
Proportion of respiratory specimens that test positive for influenza virus in jurisdiction
Absenteeism rates in jurisdiction due to ILI in childcare facilities, K-12 schools, or IHEs (reflects number of ILI cases)
Number of laboratory-confirmed influenza cases among students, teachers, and staff in jurisdiction
Number of influenza-associated hospitalizations in jurisdiction
Total number of deaths attributed to influenza in jurisdiction
Number of influenza-associated deaths among those <18 years old in jurisdiction

33. Please describe any other influenza surveillance data not listed here that you have available in your jurisdiction.

34. Please rate the usefulness of these influenza surveillance indicators for deciding when to trigger the activation of NPIs in your jurisdiction.

Activation triggers	Please rate the usefulness of this trigger in your jurisdiction
	Extremely useful	Very useful	Moderately useful	Slightly useful	Not at all useful	Do not know / Not sure	Not applicable (Do not have near real-time data)
Number of patient visits to outpatient health care providers for influenza-like illness (ILI) in jurisdiction
Estimated weekly level of geographic spread of influenza activity reported by local health department(s)
Proportion of respiratory specimens that test positive for influenza virus in jurisdiction
Absenteeism rates in jurisdiction due to ILI in childcare facilities, K-12 schools, or IHEs (reflects number of ILI cases)
Number of laboratory-confirmed influenza cases among students, teachers, and staff in jurisdiction
Number of influenza-associated hospitalizations in jurisdiction
Total number of deaths attributed to influenza in jurisdiction
Number of influenza-associated deaths among those <18 years old in jurisdiction

35. If you rated any of the triggers above as moderately useful, slightly useful, or not at all useful, please explain why.

36. Please describe any other triggers not listed here that you might use to activate NPIs in your jurisdiction.

37. Please use this space to provide any additional information or comments you would like to share on the feasibility/acceptability of or barriers to implementing NPIs in your jurisdiction.

Thank you for responding to this assessment. We appreciate your time and valuable input.

SUBMIT

CDC estimates the average public reporting burden for this collection of information as 90 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).