Washington State: Suggested Principles for Supporting the Health, Safety and Security of Aging or Disabled During a Pandemic Flu Outbreak

English: A collection of pictograms. Three of ...

One of this project’s objectives is to find and aggregate best practices from around the country. Dr. Marc Roberts a Professor of Economy, Department of Health Policy Management, Harvard University, contacted us with information about his team’s work with Washington State, specifically for vulnerable populations during pandemic flu. They developed “Suggested Guiding Principles for Supporting the Health, Safety, and Security of Aging or Disabled Washingtonians During a Pandemic Influenza Outbreak.” We have quoted and included the guiding principles below.  Even though they were written with Washington State as the intended audience, they are broad enough to be adopted by any State with minor tweaking.

Principle #1: Planning for pandemic influenza in Washington State should support the Department of Health, first responders, and all medical professionals to take all appropriate measures to ensure equal access for aging people and people with disabilities by:

    • Providing the same range, quality or standard of care or emergency response as provided to other Washingtonians;
    • Providing the healthcare and emergency response needed by persons with disabilities specifically because of their disabilities, and services designed to minimize and prevent further disabilities;
    •  Providing these services and supports as close as possible to people’s own communities, including in rural areas;
    • Making an equal effort to secure informed consent from aging people and people with disabilities, as other Washingtonians regarding the provision of treatment;
    •  Prevent  denial of health care,  health services,  food, fluids on the basis of age, perceived disability, or disability.

Principle #2: Planning a public health, emergency, and medical response to pandemic influenza in Washington State must be comprehensive, community based, and coordinated at the regional level.

Principle #3:Planning for pandemic influenza in Washington State, should recognize that Washingtonians who are aging or who have disabilities, have the right to the highest attainable standard of health without discrimination on the basis of age, perceived disability, or disability.

Principle #4:The aim of planning for pandemic influenza in Washington State should be to keep the health care system functioning and to deliver acceptable quality of care to preserve as many lives as possible.

Principle #5: If those infected by pandemic influenza are facing quarantine, aging people and people with disabilities should be given the same opportunities to preserve the integrity of their family units as other Washingtonians.

Principle #6To the greatest extent possible Planning for pandemic influenza in Washington State should prioritize the communication of clear information, using  accessible modes and formats before, during, and after the outbreak.

Principle #7To the greatest extent possible aging people and people with disabilities, should not be separated from the support people, adaptive equipment, or working animals which contribute to their ability to follow the instructions necessary to be healthy, safe, and secure.

Although these principles don’t specifically address transportation, principle #2, which mentions comprehensive planning, certainly would include it.

We want to hear from you, does your State or organization have anything similar?

Wanted: Pandemic Transportation Plan Best Practices!

The Transportation Research Board National Cooperative Highway Research Program is currently conducting a study that will result in a Guide to Public Transportation Pandemic Planning–specifically intended for use by small urban and rural communities.

The project team is currently administering a survey in order to:

  • identify candidates for more in-depth interviews; and
  • identify  emerging and model practices relevant to pandemic planning.

The project team hopes to reach a broad range of participants, including practitioners in state departments of transportation, emergency management agencies, public health agencies and healthcare organizations, academics, public transportation/transit agencies, or in other types of organizations that provide transportation services (private businesses, nonprofit agencies, schools and faith-based organizations).

This survey should only take 10-15 minutes to complete.

For more information, please contact Kim Fletcher, principal investigator, kimlochfletcher@comcast.net; or Shanika Amarakoon, project manager, Shanika_Amarakoon@abtassoc.com.

Please share this post with anyone you know whom could provide valuable insight into practices related to pandemic planning.  

Thank you in advance for your participation. 

H5N1: Time to Dust off Your Plans?

Post by: Kim Stephens


H5N1 (Photo credit: Wikipedia)

Although H5N1 has received much media attention lately, the virus is not being ignored by public health officials around the globe.

Military and Aerospace Electronics online magazine states:

“Evidently the U.S. government is taking the threat of a global bird flu pandemic very seriously, as the U.S. Department of Health and Human Services (HHS) has awarded five contracts collectively worth as much as $25.36 billion for medical countermeasures to the H5N1 avian influenza virus.

There is ample reason to take the threat of an H5N1 bird flu pandemic seriously, too. Over the last decade there have been 608 confirmed cases of H5N1 in humans, according to the World Health Organization (WHO) in Geneva. Of those, 359 died; that’s nearly a 70 percent mortality rate.

Of those confirmed cases of H5N1 and their resulting deaths, most have been in Indonesia, Vietnam, and Egypt. No cases have been reported in the U.S. — yet.”

Is H5N1 on your radar yet?

Thanks to the LinkedIn Group “Pandemic/Health Crisis Group for Business and Industry” for altering me to this article.

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Research on Pandemic Planning: Summary of Findings

An AATA bus, with the blue-roofed Blake Transi...

An AATA bus, with the blue-roofed Blake Transit Center in the background. (Photo credit: Wikipedia)

Our team, which is working on developing a guidebook for small urban and rural communities for transportation planning during a pandemic, first conducted a literature review to identify the current domestic and international research. The team evaluated the research based on its applicability, conclusiveness of findings, and usefulness for pandemic planning for U.S. public transportation. Of note, only 5 of the documents directly addressed small urban or rural transit agencies.

Below we highlight of few of the findings.


In general, many of the reviewed documents discussed:

  • the importance of using social distancing measures during a pandemic event;
  • promoting public awareness and effective risk communication on pandemic preparedness and response, and;
  • effectively communicating and coordinating across types of agencies and organizations (e.g., public health, transportation, emergency management, etc.) at multiple levels (i.e., local, state, and/or federal).

There were a few stand-out guides:

  • Arizona Pandemic Influenza Operational Plan (2008) includes:
    • detailed steps for pandemic response across all state government functions;
    • coordination between agencies;
    • specific response strategies for public awareness, include distributing educational materials to passengers and providing guidance to employees who must travel.
  • King County Metro system’s (in Seattle, Washington) pandemic plan includes:
    • social distancing measures,
    • emphasis on services to special needs groups,
    • and instructions for employees on workspace sanitization.

Find a summary of all of the State and local plans we reviewed in the tab above or click here: http://pandemictransportation.wordpress.com/state-and-local-pandemic-plans/.

We have also included the research documents we reviewed in this blog site. Each document includes a brief summary, a sentence or two about the best practices the document provides,  identification of any gaps or opportunities, and a hyperlink to the document itself.

Let us know if we missed anything!

Schools and Pandemic Planning–Many are Unprepared

Post by: Kim Stephens

English: A 2010 Girardin MB-II school bus belo...

English: A 2010 Girardin MB-II school bus belonging to Boston Public Schools. (Photo credit: Wikipedia)

The All Hazards/Pandemics Preparedness and Response Bulletin is an email sent out weekly with content curated by Andre La Prarie of the Public Health Agency of Canada. Today, this article, Many Schools Unprepared For Next Pandemicstruck me as interesting since it has a tangential relation to transportation: we tend to assume that school buses are a possible alternative if  transportation needs exceed a cities capability during a crisis. However, based on this journal article and study, most of the surveyed schools were not keeping updated  general pandemic plans.

Many Schools Unprepared For Next Pandemic
Biosecurity researchers surveyed approximately 2,000 school nurses at elementary, middle, and high schools about their preparations for pandemics, like swine flu or SARS, and published their results on Thursday in the American Journal of Infection Control.
The results showed that since the swine flu pandemic in 2009, less than half of schools had updated their crisis plans or had developed a plan to address biological events. Only a third of schools had instructed children on how to protect themselves from infection, only a third had stockpiled personal protective equipment, and only half of schools coordinated their relief plans with local and regional agencies.

Almost no schools ever ran school disaster exercises that included infectious disease scenarios. And nearly one in four schools had no staff members who were trained in the disaster plan.

Are school buses part of your plan?

Health Map Outbreak Visualization Tool

Post by: Kim Stephens

We wanted to bring your attention to a pandemic visualization tool called “HealthMap.”

HealthMap, a team of researchers, epidemiologists and software developers at Children’s Hospital Boston founded in 2006, is an established global leader in utilizing online informal sources for disease outbreak monitoring and real-time surveillance of emerging public health threats. The freely available Web site ‘healthmap.org’ and mobile app ‘Outbreaks Near Me’ deliver real-time intelligence on a broad range of emerging infectious diseases for a diverse audience including libraries, local health departments, governments, and international travelers.

HealthMap brings together disparate data sources, including online news aggregators, eyewitness reports, expert-curated discussions and validated official reports, to achieve a unified and comprehensive view of the current global state of infectious diseases and their effect on human and animal health. Through an automated process, updating 24/7/365, the system monitors, organizes, integrates, filters, visualizes and disseminates online information about emerging diseases in nine languages, facilitating early detection of global public health threats.

The recent outbreak of West Nile virus in Ohio can serve as an example of what people would see when using this visualization tool. When there is an outbreak, the location is marked with a color-coded pin that changes color and size based on the activity level. The colors are yellow, orange or red–with a red pin indicating the highest level of activity.

When the user clicks on the pin, they are able to see where the data came from, including local news reports. Each news report is then summarized as well as hyperlinked.

Users can also share the reports via their social networks, as well as rate the report.

Play around with the tool and leave a comment about how you think this might help your community planners.

H3N2 Virus–In the News

Post by: Kim Stephens

Entrance to the Ohio State Fair and Expo in Co...

Entrance to the Ohio State Fair and Expo in Columbus (Photo credit: Wikipedia)

On August 3 the CDC issued a health advisory based on an “Increase in Influenza A H3N2v Virus Infections in Three U.S. States.” According to CBS News “HealthPop” blog:

None of the cases have been tied to human-to-human transmission and all 12 of the new patients had close contact with swine prior to getting sick. The two other new cases occurred in Hawaii and Indiana.

From the advisory:

“Multiple infections with variant* influenza A (H3N2v) viruses have been identified in 3 states in recent weeks. From July 12 through August 3, 2012, 16 cases of H3N2v were reported and confirmed by CDC. This virus was first detected in humans in July 2011. It has also been isolated in U.S. swine in many U.S. states. Since July 12, 2011, there have been 29 cases of H3N2v virus infection, including the 16 cases occurring in the last three weeks.  All 29 cases were infected with H3N2v viruses that contain the matrix (M) gene from the influenza A (H1N1)pdm09 virus…”

See full advisory here: advisory.

Canada Studies How to Strengthen Collaboration Between Public Health, Health Care and Emergency Management

Post by: Kim Stephens

This new report by the Centre for Emergency Preparedness and Response (CEPR) Public Health Agency of Canada (PHAC) does not address transportation issues specifically, but it does capture the best practices and common challenges of how to collaborate and coordinate public health, health care and emergency management. EN-2012-EPR-Forum-Report-Final-July-2012. The content is based on a summary of the finding from a forum on the topic that was held in January of 2012:

During the Forum, 31 leading experts from Canada, the United States, Japan and Germany, shared their expertise and best practices through a variety of panel discussions and presentations. As the Forum progressed, five overarching themes emergency: collaboration and coordination, communication, information sharing, psychosocial considerations, and planning for the future.

Addressing the Fears of Direct Contact

Post by: Paul Penn

English: Map showing the position of the distr...

In an article on CNN.com 8/1/12 regarding two additional deaths from the Ebola outbreak in Uganda was the following paragraph:

Market day was canceled Wednesday after Uganda’s president warned people not to gather in large groups. Drivers of taxi motorbikes called boda-boda have become reluctant to take on passengers and there have been rumors that public transportation will be banned.

Ebola stands out in the pantheon of diseases in the mind’s eye of the public due to its rapid spread, lack of effective treatment (other than supportive), high mortality rate, disturbing symptoms (including hemorrhaging from body orifices [absent in this outbreak]), communicableness, and notoriety from various print and film depictions (The Hot Zone, Outbreak, Contagion [actually based on Nipah Virus]).  However, from an epidemiological standpoint Ebola is spread by direct contact with body fluids and relatively easy to contain.

This is useful as an extreme example of the public’s reaction to perceived threats. I am reminded of a federal epidemiological physician at a National Disaster Medical System conference who, when recounting his dispatch to Asia following the SARS outbreak, somewhat facetiously advised against purchasing a first class ticket to an outbreak location since there were full rows of vacant seats to stretch out upon.

The fears of passengers and workers worried about contracting an infectious disease by direct contact are real whether or not the risk is commensurate with the perception.  In the current world of social media where rumors can be given instant gravitas by members of the general public, transit systems must be able to respond precipitously and effectively with facts and a multi-tiered approach to reach and influence identified audiences. Otherwise they might see their normally crowded vehicles empty and staff unwilling to report to work. What used to be called “rumor control” in emergency public information is now referred to as “rapid response.”

The isolation ward of Gulu Municipal Hospital,...

The isolation ward of Gulu Municipal Hospital, Gulu, Uganda, during an outbreak of Ebola hemorrhagic fever in October 2000 (Photo credit: Wikipedia)

In a July 31, 2012 article on Yahoo.com:

 “Ebola outbreak! What you need to know,” screamed a headline in the daily New Vision newspaper. In Kampala — a chaotic city of around 1.5 million people with densely populated slums and bustling markets — the message of caution appears to be getting through to the public. They are telling us about it over the radio,” says Boniface Ongwang, a motorcycle taxi driver.

“You are not supposed to touch others or drink local water. In public places don’t hold someone’s hand, just wave at them.” Ongwang, 28, says that for the moment he is confident that Kampala remains more or less safe, but he has told his wife to keep his baby daughter at home.

“If you do not have to, there is no need to move around in busy places,” he said. Residents said they would feel more secure if they were able to avoid taking the crowded and dilapidated minibuses that zoom around town but many do not have a choice.

“If I could I would avoid taking public transport,” 35-year-old Wangalwa Ojambo told AFP while waiting at a bus stop on the outskirts of the city.

The responsibility to tackle perceptions is not only that of the transit systems but must be coordinated with emergency management, public and acute health, political leadership, and social and faith organizations.

Framing Perceptions

Taxis in Kampala, Uganda

Taxis in Kampala, Uganda (Photo credit: Wikipedia)

How people react to events can be visceral.   The reactions are exacerbated when the unknowns and impacts are high.  The consequences of a tornado, fire, and flood are usually evident and able to be grasped.  Diseases and chemical releases are much more difficult to “put one’s arms around.”  Expect heightened concerns in events where the universe is less defined.

Being prepared with facts will make a big difference.  Knowing what you don’t know is another component to incorporate as appropriate.

It should be noted that some cases, especially where the disease may be airborne or spread via indirect contact, that avoiding crowded settings is advised.  Here appropriate personal protection and behaviors can minimize the spread of disease.  Transit systems must be cognizant of those circumstances and be able to address those challenges “head-on.” Effective planning and coordination with allied multi-disciplinary organizations to develop messages and means of dissemination are key to addressing the fears, both real and imagined. This can be accomplished by keeping the following concepts in the forefront:

Regarding Risk Communication (as articulated by Barbara Reynolds at CDC including CDC Crisis and Emergency Risk Communication Pandemic Influenza August 2006 Revised October 2007, Crisis and Emergency Risk Communication coursebook (Reynolds, Galdo, Sokler, 2002), and the Crisis and Emergency Risk Communication: By Leaders for Leaders coursebook (Reynolds, 2004) the operative phrases are:

  • Be First
  • Be Right
  • Be Credible
Mobile phones are enabling African countries t...

Mobile phones are enabling African countries to leapfrog generations of communications technology as they spread rapidly. Usable with attribution and link to: FutureAtlas.com (Photo credit: Wikipedia)

At the Advanced Public Information Officer for Health and Hospitals course that I teach at the Center for Domestic Preparedness Noble Training Facility, the approach incorporates the Risk Communication component and the mantra of emergency public information which is:

Get the:

  • Right information to the
  • Right people at the
  • Right time in the
  • Right format so that they can make the
  • Right decisions

In the International Journal of Mass Emergencies and Disasters March 2006, Vol. 24, No. 1, pp. 45-75 Public Perceptions About Trust in Emergency Risk Communication: Qualitative Research Findings (Wray et al) the

“Perceptions of trust are highly relevant to the development of effective communication strategies concerning potential bioterrorism threats. A variety of implications emerge from this analysis for developing messages that promote trust. These implications are organized around three categories: Considerations prior to an attack, agency integration in dealing with an attack, and emergency response communication.”

Prior to an Attack

 Adequacy of Resources for Emergency Response: Members of the public have the impression that there are inadequate resources in the areas of equipment, personnel, training, and planning for emergency response. It is important for local agencies to make clear the extent of their preparedness.

Make Training and New Resources Known: Educating the public about preparedness training regimens and new resources may help increase public confidence in government preparedness. When local members of emergency services receive training for a terrorist attack, the news media can be engaged to get this information out.

Emphasize Planning for Underserved Areas: Members of the public in both inner city and rural areas perceive that they will get short shrift in an emergency. Government planning and resource allocation must anticipate and meet the particular needs of these areas, and must inform the public that this is happening.

Rebuild Trust by Building New Public Experience: Past experience clearly plays a role in the level of public trust in the government. Government officials need to be aware that their actionsin other areas can influence trust during emergency situations. Officials acting in a reckless or poor manner can have long lasting effects on trust in government and consequently on the effectiveness of government efforts to respond to emergencies. While it is impossible to provide everyone with a positive experience with the government, improving experiences with the public can begin to recover trust in government by providing the public with positive experiences on which to base their opinions.

Agency Integration in Dealing with an Attack

FEMA - 43659 - Center for Domestic Preparednes...

FEMA – 43659 – Center for Domestic Preparedness building (Photo credit: Wikipedia

Integration of Local Agencies for Emergency Response: The results indicate that the general public trusts local agencies for information in an emergency, and give their information greater credibility. Therefore, federal and state agency crisis communication planners must strive to integrate and prepare local agencies and officials for primary roles as communicators during emergencies.

Integrate Community Organizations in Emergency Response: Local hospitals and other services were mentioned as trusted groups and need to be included in the process of planning and preparing for emergencies. These organizations can make substantial contributions in communication during emergencies, and must be prepared for inclusion in this role.

Integrate Federal Agencies and National Organizations: CDC, American Red Cross and FEMA in Emergency Response

Communication:The high level of trust for these agencies indicates that they should be at the forefront of informational efforts during and after emergencies.

Emergency Response Communication

Communication and Design

Communication and Design (Photo credit: Alex Osterwalder)

Convey Full Disclosure in Emergency Response Communication. Short of jeopardizing national security during or after a terrorist attack, government officials should divulge all information to which they have access. Where complete information is not available, officials should offer an honest “don’t know” and promise to follow up with information once it is at hand. Full disclosure will enhance the assurances of honesty and contribute to the likelihood that members of the public will adhere to public agency warning messages, thereby reducing morbidity and mortality.

Provide Action Steps to Empower the Public. Finally, the focus group participants universally demanded action steps for how to respond and stay safe in the case of emergencies. This information is critical in promoting open, honest communication between the public and government agencies. Not only does it give the government a chance to rebuild trust by new experiences with the public but it also may provide the public with a better sense of awareness and capability to deal with emergency situations.

Convey Dedication and Caring in Emergency Response. As learned in the case of Mayor Guiliani’s crisis communication efforts following the World Trade Center Attacks (Mullin 2003), an active, engaged leadership with daily media presence can do a great deal to provide direction and simultaneously inspire public confidence.

Planning Transportation for People with Access and Functional Needs in a Pandemic

Post by: Raymond E. Glazier, Ph.D.

This is the internationally recognized symbol ...

Public transit systems in small cities and rural areas, if they exist at all (forty percent of rural counties are without), already face serious challenges: budget cuts and layoffs because of the weak economy, long distances because of low population density, and vulnerable user populations because non-metro counties, especially in the South, have larger proportions of the poor, the elderly, and persons with disabilities.  In fact, poverty, age, and disability often coincide.  So providing transportation to vulnerable populations in an influenza pandemic scenario, and that scenario is inevitable, would seem to be the makings of a Perfect Storm.  But ‘it ain’t necessarily so.’

An influenza pandemic is a situation in which there is widespread and spreading infection with a new influenza virus to which we don’t have any natural immunity.  The rapid spread, significant mortality, and subsequent waves of illness of a pandemic cause far greater damage and human suffering than typical, more limited occurrences of influenza.  Persons at immediate, serious risk of death from infection include the elderly and many persons with disabilities, who may have weakened immune systems; most will require transportation to receive inoculation, or in some cases immediate medical treatment.  Travel demand will therefore be unusually high in very difficult service provision circumstances, including staff reduction due to illness with the influenza virus or absenteeism because staff is fearful of contracting it through daily contact with many riders.

Organization, planning, and training can prevent a threat from becoming a disaster.  Flexibility and ‘thinking outside the box’ are of over-arching importance in all three aspects.  In fact, non-metro transportation systems have some distinct advantages: a) Given the difficult constraints under which they operate, nimble creativity has been a survival instinct for many small city and rural systems; b) They know their ridership in a much more ‘up close and personal’ sense than do the very impersonal urban mass transit systems; c) Pandemics usually spread out from urban centers to less densely populated areas, giving non-metro providers greater notice that a flu pandemic is in progress.


Bus Display

Bus Display (Photo credit: WSDOT)

Although there are only about 1200 rural public transportation systems in the nation, the nation’s elderly and persons with disabilities are served by 3700 specialized transportation systems that received Section 5310 federal funding for capital investments like equipment purchases; many are operated by local human service agencies, including a good number in non-metro areas. Because of the Title II provisions of the Americans with Disabilities Act (ADA), public transportation systems should have lift-equipped vehicle fleets or paratransit service with specially equipped vehicles to serve passengers who use wheelchairs or other mobility devices.

It is important to build and sustain relationships with other service providers – Paralyzed Veterans of America and other disability-specific service organizations, local human service providers that may have a transport service, taxi companies, school bus vendors (schools will probably be closed, freeing up buses and drivers), ambulance services, fire and rescue departments – and other community organizations like Independent Living Centers which serve persons with diverse disabilities, senior centers, other human service agencies, local public health departments, school departments, religious institutions  (services are likely to be suspended).  Local emergency management should coordinate among all these actors to prepare a pandemic response, including the transportation component.  All component entities may require disability awareness training in advance of a crisis that has transportation implications, as most public emergencies do.


Having a strategic contingency plan is also of paramount importance to the community and its transportation needs.  Transportation workers, who come in contact with many persons each day, are at greater risk for infection than most people in a pandemic situation that makes their services even more crucial.  A key part of advance planning for a pandemic is making arrangements for their early inoculation, once a vaccine becomes available.  Transportation personnel should be in line with health care providers, first responders, and utility workers for first available doses of vaccine.  Recruitment of volunteer drivers and driver aides, as needed to cover absenteeism should be part of the plan; the plan should include their advance training and indemnification.

Planners need to know the size and characteristics of the at-risk population in the catchment area – the elderly, the indigent (hence carless), and persons with disabilities – net of double-counting.   Special route plans can be prepared and regularly updated to provide transportation of all at-risk persons to their closest healthcare facility (hospital or clinic) for inoculation or treatment.  Persons with disabilities, as well as their advocates must be at the table as planning participants, and all seniors and persons with disabilities should be informed about pandemic plans.  The emergency planning motto is “Nobody left behind.”


English: Training Français : Formation Transportation providers at all levels require training that makes them aware of the needs and constraints of persons with disabilities of all types and all ages.  Local Centers for Independent Living and disability advocacy organizations can help train workers, including volunteers on treating individuals with disabilities with respect and dignity in a way that is not patronizing: When and how to help, recognizing disabilities, how to act / how not to act, what to say / what not to say, disability etiquette, treating people like people.

Most passengers are seen at their worst in a difficult time like a pandemic; people are confused, anxious, fearful, stressed to the max; persons with disabilities and the elderly are feeling especially vulnerable.  Everyone must be aware of the specific functional needs of at-risk individuals:

  • Maintaining Independence: Individuals who need supports that enable them to be independent in daily activities must not lose touch with these supports during the course of an emergency or a disaster situation.
  • Communication: Individuals who have limitations that interfere with the receipt of and response to information (blind / low vision, Deaf / hard of hearing) will need information provided in methods and media they can understand and use.
  • Supports: Before, during, and after an emergency, individuals may become disconnected from caregivers, family, or friends and be unable to cope in a new environment.  Service animals like guide dogs and service monkeys, in addition to personal care assistants must always be permitted to accompany the individual who needs them.
  • Medical Care: Individuals must not become separated from their medical support systems used to manage their conditions; this incudes prescription drugs and access to provider networks connected to their particular insurance coverage.

Related Resources -

Is your organization planning for this? Please let us know.


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