Interim Pre-pandemic Planning Guidance:

Community Strategy for Pandemic Influenza 

Mitigation in the United States—

Early, Targeted, Layered Use of Nonpharmaceutical Interventions

DEPARTMENT OF DEFENSE

UNITED STATES OF AMERICA

DEPARTMENT OF TRANSPORTATION

UN ED STATES OF AMERICA

IT
Interim Pre-Pandemic Planning Guidance:

Community Strategy for Pandemic Influenza Mitigation in the United States—

Early, Targeted, Layered Use of Nonpharmaceutical Interventions

February 2007
	 	 Executive Summary

	 	 Introduction

	 	 Rationale for Proposed Nonpharmaceutical Interventions

	 	 Pre-pandemic Planning: the Pandemic Severity Index

	 	 Use of Nonpharmaceutical Interventions by Severity Category

	 	 Triggers for Initiating Use of Nonpharmaceutical Interventions

	 	 Duration of Implementation of Nonpharmaceutical Interventions

	 	 Critical Issues for the Use of Nonpharmaceutical Interventions

	 	 Assessment of the Public on Feasibility of Implementation and Adherence

	 	 Planning to Minimize Consequences of Community Mitigation Strategy

	 Testing and Exercising Community Mitigation Interventions

	 	 Research Needs

	 	 Conclusions	

	 	 References

	 	 Appendices

Appendix 1. 	 Glossary of Terms

	 Appendix 2. 	 Interim Guidance Development Process

	 Appendix 3. 	 WHO Phases of a Pandemic/U.S. Government Stages of a Pandemic

	 Appendix 4. 	 Pandemic Influenza Community Mitigation Interim

	 	 	 Planning Guide for Businesses and Other Employers

	 Appendix 5. 	 Pandemic Influenza Community Mitigation Interim

	 	 	 Planning Guide for Childcare Programs

	 Appendix 6. 	 Pandemic Influenza Community Mitigation Interim

	 	 	 Planning Guide for Elementary and Secondary Schools

	 Appendix 7. 	 Pandemic Influenza Community Mitigation Interim

	 	 	 Planning Guide for Colleges and Universities

	 Appendix 8. 	 Pandemic Influenza Community Mitigation Interim

	 	 	 Planning Guide for Faith-based and Community Organizations

	 Appendix 9. 	 Pandemic Influenza Community Mitigation Interim Planning Guide

	 	 	 for Individuals and Families

Contents

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Executive Summary

I

Purpose

This document provides interim planning

guidance for State, territorial, tribal, and local

communities that focuses on several measures

other than vaccination and drug treatment that

might be useful during an influenza pandemic

to reduce its harm. Communities, individuals

and families, employers, schools, and other

organizations will be asked to plan for the use

of these interventions to help limit the spread of

a pandemic, prevent disease and death, lessen

the impact on the economy, and keep society

functioning. This interim guidance introduces

a Pandemic Severity Index to characterize

the severity of a pandemic, provides planning

recommendations for specific interventions

that communities may use for a given level of

pandemic severity, and suggests when these

measures should be started and how long they

should be used. The interim guidance will be

updated when significant new information about

the usefulness and feasibility of these approaches

emerges.

Introduction

The Centers for Disease Control and Prevention,

U.S. Department of Health and Human Services

in collaboration with other Federal agencies and

partners in the public health, education, business,

healthcare, and private sectors, has developed

this interim planning guidance on the use of

nonpharmaceutical interventions to mitigate

an influenza pandemic. These measures may

serve as one component of a comprehensive

community mitigation strategy that includes

both pharmaceutical and nonpharmaceutical

measures, and this interim guidance includes

initial discussion of a potential strategy for

combining the use of antiviral medications

with these interventions. This guidance will be

updated as new information becomes available

that better defines the epidemiology of influenza

transmission, the effectiveness of control

measures, and the social, ethical, economic, and

logistical costs of mitigation strategies. Over

time, exercises at the local, State, regional, and

Federal level will help define the feasibility of

these recommendations and ways to overcome

barriers to successful implementation.

The goals of the Federal Government’s response

to pandemic influenza are to limit the spread of a

pandemic; mitigate disease, suffering, and death;

and sustain infrastructure and lessen the impact

on the economy and the functioning of society. 

Without mitigating interventions, even a less

severe pandemic would likely result in dramatic

increases in the number of hospitalizations

and deaths. In addition, an unmitigated

severe pandemic would likely overwhelm

our nation’s critical healthcare services and

impose significant stress on our nation’s critical

infrastructure. This guidance introduces, for

the first time, a Pandemic Severity Index in

which the case fatality ratio (the proportion of

deaths among clinically ill persons) serves as

the critical driver for categorizing the severity

of a pandemic. The severity index is designed

to enable better prediction of the impact of a

pandemic and to provide local decision-makers

with recommendations that are matched to the

severity of future influenza pandemics.

7
8

Community Mitigation Guidance

It is highly unlikely that the most effective tool

for mitigating a pandemic (i.e., a well-matched

pandemic strain vaccine) will be available

when a pandemic begins. This means that we

must be prepared to face the first wave of the

next pandemic without vaccine and potentially

without sufficient quantities of influenza antiviral

medications. In addition, it is not known if

influenza antiviral medications will be effective

against a future pandemic strain. During a

pandemic, decisions about how to protect the

public before an effective vaccine is available

need to be based on scientific data, ethical

considerations, consideration of the public’s

perspective of the protective measures and

their impact on society, and common sense. 

Evidence to determine the best strategies for

protecting people during a pandemic is very

limited. Retrospective data from past influenza

pandemics and the conclusions drawn from those

data need to be examined and analyzed within

the context of modern society. Few of those

conclusions may be completely generalizable;

however, they can inform contemporary planning

assumptions. When these assumptions are

integrated into the current mathematical models,

the limitations need to be recognized, as they

were in a recent Institute of Medicine report

(Institute of Medicine. Modeling Community

Containment for Pandemic Influenza. A

Letter Report. Washington, DC.: The National

Academies Press; 2006).

The pandemic mitigation framework that is

proposed is based upon an early, targeted,

layered application of multiple partially

effective nonpharmaceutical measures. It is

recommended that the measures be initiated

early before explosive growth of the epidemic

and, in the case of severe pandemics, that they

be maintained consistently during an epidemic

wave in a community. The pandemic mitigation

interventions described in this document include:

1.	 Isolation and treatment (as appropriate)

with influenza antiviral medications of all

persons with confirmed or probable pandemic

influenza. Isolation may occur in the home or

healthcare setting, depending on the severity

of an individual’s illness and /or the current

capacity of the healthcare infrastructure.

2.	 Voluntary home quarantine of

members of households with confirmed or

probable influenza case(s) and consideration

of combining this intervention with the

prophylactic use of antiviral medications,

providing sufficient quantities of effective

medications exist and that a feasible means of

distributing them is in place. 

3.	 Dismissal of students from school

(including public and private schools as well

as colleges and universities) and school-based

activities and closure of childcare programs,

coupled with protecting children and teenagers

through social distancing in the community

to achieve reductions of out-of-school social

contacts and community mixing.

4.	 Use of social distancing measures

to reduce contact between adults in the

community and workplace, including, for

example, cancellation of large public gatherings

and alteration of workplace environments

and schedules to decrease social density and

preserve a healthy workplace to the greatest

extent possible without disrupting essential

services. Enable institution of workplace leave

policies that align incentives and facilitate

adherence with the nonpharmaceutical

interventions (NPIs) outlined above.

All such community-based strategies should be

used in combination with individual infection

control measures, such as hand washing and

cough etiquette.

Implementing these interventions in a timely

and coordinated fashion will require advance

planning. Communities must be prepared for the

cascading second- and third-order consequences

of the interventions, such as increased

workplace absenteeism related to child-minding

responsibilities if schools dismiss students and

childcare programs close. 
9

Community Mitigation Guidance

Decisions about what tools should be used

during a pandemic should be based on the

observed severity of the event, its impact on

specific subpopulations, the expected benefit

of the interventions, the feasibility of success

in modern society, the direct and indirect costs,

and the consequences on critical infrastructure,

healthcare delivery, and society. The most

controversial elements (e.g., prolonged dismissal

of students from schools and closure of childcare

programs) are not likely to be needed in less

severe pandemics, but these steps may save lives

during severe pandemics. Just as communities

plan and prepare for mitigating the effect of

severe natural disasters (e.g., hurricanes), they

should plan and prepare for mitigating the effect

of a severe pandemic.

Rationale for Proposed

Nonpharmaceutical Interventions

The use of NPIs for mitigating a communitywide epidemic has three major goals: 1) delay

the exponential growth in incident cases and

shift the epidemic curve to the right in order

to “buy time” for production and distribution

of a well-matched pandemic strain vaccine, 2)

decrease the epidemic peak, and 3) reduce the

total number of incident cases, thus reducing

community morbidity and mortality. Ultimately,

reducing the number of persons infected is a

primary goal of pandemic planning. NPIs may

help reduce influenza transmission by reducing

contact between sick and uninfected persons,

thereby reducing the number of infected persons. 

Reducing the number of persons infected will,

in turn, lessen the need for healthcare services

and minimize the impact of a pandemic on the

economy and society. The surge of need for

medical care that would occur following a poorly

mitigated severe pandemic can be addressed

only partially by increasing capacity within

hospitals and other care settings.Reshaping

the demand for healthcare services by using

NPIs is an important component of the overall

mitigation strategy. In practice, this means

reducing the burdens on the medical and public

health infrastructure by decreasing demand for

medical services at the peak of the epidemic and

throughout the epidemic wave; by spreading the

aggregate demand over a longer time; and, to the

extent possible, by reducing net demand through

reduction in patient numbers and case severity.

No intervention short of mass vaccination of

the public will dramatically reduce transmission

when used in isolation.Mathematical modeling

of pandemic influenza scenarios in the United

States, however, suggests that pandemic

mitigation strategies utilizing multiple NPIs

may decrease transmission substantially and that

even greater reductions may be achieved

when such measures are combined with the

targeted use of antiviral medications for

treatment and prophylaxis.Recent preliminary

analyses of cities affected by the 1918 pandemic

show a highly significant association between the

early use of multiple NPIs and reductions in peak

and overall death rates.The rational targeting

and layering of interventions, especially if these

can be implemented before local epidemics

have demonstrated exponential growth, provide

hope that the effects of a severe pandemic can

be mitigated.It will be critical to target those at

the nexus of transmission and to layer multiple

interventions together to reduce transmission to

the greatest extent possible.

Pre-Pandemic Planning: 

the Pandemic Severity Index

This guidance introduces, for the first time,

a Pandemic Severity Index, which uses case

fatality ratio as the critical driver for categorizing

the severity of a pandemic (Figure A, abstracted

and reprinted here from Figure 4 in the main

text). The index is designed to enable estimation

of the severity of a pandemic on a population

level to allow better forecasting of the impact of

a pandemic and to enable recommendations to be

made on the use of mitigation interventions that

are matched to the severity of future influenza

pandemics. 
10

Community Mitigation Guidance

Future pandemics will be assigned to one of

five discrete categories of increasing severity

(Category 1 to Category 5). The Pandemic

Severity Index provides communities a tool

for scenario-based contingency planning to

guide local pre-pandemic preparedness efforts. 

Accordingly, communities facing the imminent

arrival of pandemic disease will be able to use

the pandemic severity assessment to define which

pandemic mitigation interventions are indicated

for implementation.

Use of Nonpharmaceutical

Interventions by Severity Category

This interim guidance proposes a

community mitigation strategy that matches

recommendations on planning for use of selected

NPIs to categories of severity of an influenza

pandemic. These planning recommendations

are made on the basis of an assessment

of the possible benefit to be derived from

implementation of these measures weighed

against the cascading second- and third-order

consequences that may arise from their use. 

Cascading second- and third-order consequences

are chains of effects that may arise because of the

intervention and may require additional planning

and intervention to mitigate. The term generally

refers to foreseeable unintended consequences

of intervention. For example, dismissal of

students from school may lead to the secondorder effect of workplace absenteeism for child

minding. Subsequent workplace absenteeism

and loss of household income could be especially

problematic for individuals and families living

at or near subsistence levels. Workplace

absenteeism could also lead to disruption of the

delivery of goods and services essential to the

viability of the community. 

For Category 4 or Category 5 pandemics, a

planning recommendation is made for use

of all listed NPIs (Table A, abstracted and

reprinted here from Table 2. in the main text). 

In addition, planning for dismissal of students

from schools and school-based activities and

closure of childcare programs, in combination

with means to reduce out-of-school social

contacts and community mixing for these

children, should encompass up to 12 weeks of

intervention in the most severe scenarios. This

approach to pre-pandemic planning will provide

a baseline of readiness for community response. 

Recommendations for use of these measures

for pandemics of lesser severity may include a

subset of these same interventions and potentially

for shorter durations, as in the case of social

distancing measures for children.

Projected

Number of Deaths*

US Population, 2006

Assumes 30% Illness Rate and Unmitigated 

Pandemic Without Interventions

Case 

Fatality 

Ratio

Figure A. Pandemic Severity Index

≥ ≥

*
11

Community Mitigation Guidance

For Category 2 and Category 3 pandemics,

planning for voluntary isolation of ill persons

is recommended; however, other mitigation

measures (e.g., voluntary quarantine of

household members and social distancing

measures for children and adults) should be

implemented only if local decision-makers

determine their use is warranted due to

characteristics of the pandemic within their

community. Pre-pandemic planning for the

use of mitigation strategies within these two

Pandemic Severity Index categories should

be done with a focus on a duration of 4 weeks

or less, distinct from the longer timeframe

recommended for the more severe Category

4 and Category 5 pandemics. For Category 1

pandemics, voluntary isolation of ill persons

is generally the only community-wide

recommendation, although local communities

may choose to tailor their response to Category

1-3 pandemics by applying NPIs on the

basis of local epidemiologic parameters, risk

assessment, availability of countermeasures,

and consideration of local healthcare surge

capacity. Thus, from a pre-pandemic planning

perspective for Category 1, 2, and 3 pandemics,

capabilities for both assessing local public

health capacity and healthcare surge, delivering

countermeasures, and implementing these

measures in full and in combination should be

assessed.

Triggers for Initiating Use of 

Nonpharmaceutical Interventions

The timing of initiation of various NPIs will

influence their effectiveness. Implementing

these measures prior to the pandemic may

result in economic and social hardship without

public health benefit and over time, may

result in “intervention fatigue” and erosion of

public adherence. Conversely, implementing

these interventions after extensive spread of

pandemic influenza illness in a community may

limit the public health benefits of employing

these measures. Identifying the optimal time

for initiation of these interventions will be

challenging because implementation needs to be

early enough to preclude the initial steep upslope

in case numbers and long enough to cover the

peak of the anticipated epidemic curve while

avoiding intervention fatigue.

This guidance suggests that the primary

activation trigger for initiating interventions be

the arrival and transmission of pandemic virus. 

This trigger is best defined by a laboratoryconfirmed cluster of infection with a novel

influenza virus and evidence of community

transmission (i.e., epidemiologically linked cases

from more than one household). 

Defining the proper geospatial-temporal

boundary for this cluster is complex and should

recognize that our connectedness as communities

goes beyond spatial proximity and includes ease,

speed, and volume of travel between geopolitical

jurisdictions (e.g., despite the physical distance,

Hong Kong, London, and New York City may be

more epidemiologically linked to each other than

they are to their proximate rural provinces/areas). 

In order to balance connectedness and optimal

timing, it is proposed that the geopolitical trigger

be defined as the cluster of cases occurring

within a U.S. State or proximate epidemiological

region (e.g., a metropolitan area that spans more

than one State’s boundary). It is acknowledged

that this definition of “region” is open to

interpretation; however, it offers flexibility

to State and local decision-makers while

underscoring the need for regional coordination

in pre-pandemic planning. 

From a pre-pandemic planning perspective,

the steps between recognition of a pandemic

threat and the decision to activate a response are

critical to successful implementation. Thus, a

key component is the development of scenariospecific contingency plans for pandemic

response that identify key personnel, critical

resources, and processes. To emphasize the

importance of this concept, the guidance section

on triggers introduces the terminology of Alert, 
12

Community Mitigation Guidance

Generally Not Recommended = Unless there is a compelling rationale

for specific populations or jurisdictions, measures are generally not

recommended for entire populations as the consequences may outweigh

the benefits.

Consider = Important to consider these alternatives as part of a prudent

planning strategy, considering characteristics of the pandemic, such as agespecific illness rate, geographic distribution, and the magnitude of adverse

consequences. These factors may vary globally, nationally, and locally.

Recommended = Generally recommended as an important component of

the planning strategy. *

All these interventions should be used in combination with other infection

control measures, including hand hygiene, cough etiquette, and personal

protective equipment such as face masks. Additional information on

infection control measures is available at www.pandemicflu.gov. †

This intervention may be combined with the treatment of sick individuals

using antiviral medications and with vaccine campaigns, if supplies are

available.

§

Many sick individuals who are not critically ill may be managed safely at

home.

¶

The contribution made by contact with asymptomatically infected

individuals to disease transmission is unclear. Household members in

homes with ill persons may be at increased risk of contracting pandemic

disease from an ill household member. These household members may

have asymptomatic illness and may be able to shed influenza virus that

promotes community disease transmission. Therefore, household members

of homes with sick individuals would be advised to stay home. **To facilitate compliance and decrease risk of household transmission,

this intervention may be combined with provision of antiviral medications

to household contacts, depending on drug availability, feasibility of

distribution, and effectiveness; policy recommendations for antiviral

prophylaxis are addressed in a separate guidance document. ††Consider short-term implementation of this measure—that is, less than 4

weeks.

§§Plan for prolonged implementation of this measure—that is, 1 to 3

months; actual duration may vary depending on transmission in the

community as the pandemic wave is expected to last 6-8 weeks.

Table A. Summary of the Community Mitigation Strategy by Pandemic Severity
13

Community Mitigation Guidance

Standby, and Activate, which reflect key steps

in escalation of response action. Alert includes

notification of critical systems and personnel

of their impending activation, Standby includes

initiation of decision-making processes for

imminent activation, including mobilization

of resources and personnel, and Activate refers

to implementation of the specified pandemic

mitigation measures. Pre-pandemic planning

for use of these interventions should be directed

to lessening the transition time between Alert,

Standby, and Activate. The speed of transmission

may drive the amount of time decision-makers

are allotted in each mode, as does the amount of

time it takes to fully implement the intervention

once a decision is made to Activate.

For the most severe pandemics (Categories 4

and 5), Alert is implemented during WHO Phase

5/U.S. Government Stage 2 (confirmed human

outbreak overseas), and Standby is initiated

during WHO Phase 6/ U.S. Government Stage

3 (widespread human outbreaks in multiple

locations overseas). Standby is maintained

through Stage 4 (first human case in North

America), with the exception of the State or

region in which a cluster of laboratory-confirmed

human pandemic influenza cases with evidence

of community transmission is identified. The

recommendation for that State or region is to

Activate the appropriate NPIs when identification

of a cluster with community transmission

is made. Other States or regions Activate

appropriate interventions when they identify

laboratory-confirmed human pandemic influenza

case clusters with evidence of community

transmission in their jurisdictions.

For Category 1, 2, and 3 pandemics, Alert is

declared during U.S. Government Stage 3, with

step-wise progression by States and regions to

Standby based on U.S. Government declaration

of Stage 4 and the identification of the first

human pandemic influenza case(s) in the United

States. Progression to Activate by a given

State or region occurs when that State or region

identifies a cluster of laboratory-confirmed

human pandemic influenza cases, with evidence

of community transmission in their jurisdiction.

Duration of Implementation of

Nonpharmaceutical Interventions

It is important to emphasize that as long as

susceptible individuals are present in large

numbers, disease spread may continue. 

Immunity to infection with a pandemic

strain can only occur after natural infection

or immunization with an effective vaccine. 

Preliminary analysis of historical data from

selected U.S. cities during the 1918 pandemic

suggests that duration of implementation is

significantly associated with overall mortality

rates. Stopping or limiting the intensity of

interventions while pandemic virus was still

circulating within the community was temporally

associated with increases in mortality due to

pneumonia and influenza in many communities. 

It is recommended for planning purposes

that communities be prepared to maintain

interventions for up to 12 weeks, especially

in the case of Category 4 or Category 5

pandemics, where recrudescent epidemics may

have significant impact. However, for less

severe pandemics (Category 2 or 3), a shorter

period of implementation may be adequate for

achieving public health benefit. This planning

recommendation acknowledges the uncertainty

around duration of circulation of pandemic

virus in a given community and the potential

for recrudescent disease when use of NPIs is

limited or stopped, unless population immunity is

achieved.

Critical Issues for the Use of

Nonpharmaceutical Interventions

A number of outstanding issues should be

addressed to optimize the planning for use

of these measures. These issues include

the establishment of sensitive and timely

surveillance, the planning and conducting of

multi-level exercises to evaluate the feasibility

of implementation, and the identification

and establishment of appropriate monitoring
14

Community Mitigation Guidance

and evaluation systems. Policy guidance in

development regarding the use of antiviral

medications for prophylaxis, community and

workplace-specific use of personal protective

equipment, and safe home management of ill

persons must be prioritized as part of future

components of the overall community mitigation

strategy. In addition, generating appropriate

risk communication content/materials and an

effective means for delivery, soliciting active

community support and involvement in strategic

planning decisions, and assisting individuals and

families in addressing their own preparedness

needs are critical factors in achieving success.

Assessment of the Public on Feasibility 

of Implementation and Compliance

A Harvard School of Public Health public

opinion poll on community mitigation

interventions, conducted with a nationally

representative sample of adults over the age

of 18 years in the United States in September

and October 2006, indicated that most

respondents were willing to follow public health

recommendations for the use of NPIs, but it also

uncovered financial and other concerns. More

information on “Pandemic Influenza and the

Public: Survey Findings” is available at www.

keystone.org/Public_Policy/Pandemic_control.

html.

The Public Engagement Project on Community

Control Measures for Pandemic Influenza

(see link at www.keystone.org/Public_Policy/

Pandemic_control.html), carried out in October

and November 2006, found that approximately

two-thirds of both citizens and stakeholders

supported all the nonpharmaceutical measures. 

Nearly half of the citizens and stakeholders

supported implementation when pandemic

influenza first strikes the United States, and

approximately one-third of the public supported

implementation when influenza first strikes in

their State.

Although the findings from the poll and public

engagement project reported high levels of

willingness to follow pandemic mitigation

recommendations, it is uncertain how the public

might react when a pandemic occurs. These

results need to be interpreted with caution in

advance of a severe pandemic that could cause

prolonged disruption of daily life and widespread

illness in a community. Issues such as the ability

to stay home if ill, job security, and income

protection were repeatedly cited as factors

critical to ensuring compliance with these NPI

measures.

Planning to Minimize Consequences of 

Community Mitigation Strategy

It is recognized that implementing certain NPIs

will have an impact on the daily activities and

lives of individuals and society. For example,

some individuals will need to stay home to mind

children or because of exposure to ill family

members, and for some children, there will

be an interruption in their education or their

access to school meal programs. These impacts

will arise in addition to the direct impacts of

the pandemic itself. Communities should

undertake appropriate planning to address both

the consequences of these interventions and

direct effects of the pandemic. In addition,

communities should pre-identify those for

whom these measures may be most difficult

to implement, such as vulnerable populations

and persons at risk (e.g., people who live alone

or are poor/working poor, elderly [particularly

those who are homebound], homeless, recent

immigrants, disabled, institutionalized, or

incarcerated). To facilitate preparedness and

to reduce untoward consequences from these

interventions, Pandemic Influenza Community

Mitigation Interim Planning Guides have been

included (see Appendices 4-9) to provide broad

planning guidance tailored for businesses and

other employers, childcare programs, elementary

and secondary schools, colleges and universities,

faith-based and community organizations,

and individuals and families. It is also critical
15

Community Mitigation Guidance

for communities to begin planning their risk

communication strategies. This includes public

engagement and messages to help individuals,

families, employers, and many other stakeholders

to prepare.

The U.S. Government recognizes the significant

challenges and social costs that would be

imposed by the coordinated application of the

measures described above. It is important to

bear in mind, however, that if the experience of

the 1918 pandemic is relevant, social distancing

and other NPI strategies would, in all likelihood,

be implemented in most communities at some

point during a pandemic. The potential exists

for such interventions to be implemented in

an uncoordinated, untimely, and inconsistent

manner that would impose economic and social

costs similar to those imposed by strategically

implemented interventions but with dramatically

reduced effectiveness. The development of clear

interim pre-pandemic guidance for planning

that outlines a coordinated strategy, based

upon the best scientific evidence available,

offers communities the best chance to secure

the benefits that such strategies may provide. 

As States and local communities exercise the

potential tools for responding to a pandemic,

more will be learned about the practical

realities of their implementation. Interim

recommendations will be updated accordingly.

Testing and Exercising Community

Mitigation Interventions

Since few communities have experienced

disasters on the scale of a severe pandemic, drills

and exercises are critical in testing the efficacy

of plans. A severe pandemic would challenge

all facets of governmental and community

functions. Advance planning is necessary to

ensure a coordinated communications strategy

and the continuity of essential services. Realistic

exercises considering the effect of these proposed

interventions and the cascading second- and

third-order consequences will identify planning

and resource shortfalls.

Research Needs

It is recognized that additional research is

needed to validate the proposed interventions,

assess their effectiveness, and identify adverse

consequences. This research will be conducted

as soon as practicable and will be used in

providing updated guidance as required. A

proposed research agenda is outlined within this

document.

Conclusions

Planning and preparedness for implementing

mitigation strategies during a pandemic are

complex tasks requiring participation by all

levels of government and all segments of society. 

Community-level intervention strategies will

call for specific actions by individuals, families,

employers, schools, and other organizations. 

Building a foundation of community and

individual and family preparedness and

developing and delivering effective risk

communication for the public in advance of a

pandemic are critical. If embraced earnestly,

these efforts will result in enhanced ability to

respond not only to pandemic influenza but also

to multiple other hazards and threats. While

the challenge is formidable, the consequences

of facing a severe pandemic unprepared will be

intolerable. This interim pre-pandemic planning

guidance is put forth as a step in our commitment

to address the challenge of mitigating a pandemic

by building and enhancing community resiliency.
A severe pandemic in a fully susceptible

population, such as the 1918 pandemic or one of

even greater severity, with limited quantities of

antiviral medications and pre-pandemic vaccine

represents a worst-case scenario for pandemic

planning and preparedness.1However, because

pandemics are unpredictable in terms of timing,

onset, and severity, communities must plan and

prepare for the spectrum of pandemic severity

that could occur. The purpose of this document

is to provide interim planning guidance for

what are believed currently to be the most

effective combinations of pharmaceutical and

nonpharmaceutical interventions (NPIs) for

mitigating the impact of an influenza pandemic

across a wide range of severity scenarios. 

The community strategy for pandemic influenza

mitigation supports the goals of the Federal

Government’s response to pandemic influenza to

limit the spread of a pandemic; mitigate disease,

suffering, and death; and sustain infrastructure

and lessen the impact to the economy and the

functioning of society.2In a pandemic, the

overarching public health imperative must be

to reduce morbidity and mortality. From a

public health perspective, if we fail to protect

human health we are likely to fail in our goals of

preserving societal function and mitigating the

social and economic consequences of a severe

pandemic.3-8

A severe pandemic could overwhelm acute care

services in the United States and challenge our

nation’s healthcare system.9-11 To preserve as

many lives as possible, it is essential to keep the

healthcare system functioning and to deliver the

best care possible.12 The projected peak demand

Introduction

II

for healthcare services, including intensive

care unit (ICU) admissions and the number of

individuals requiring mechanical ventilation,

would vastly exceed current inventories of

physical assets (emergency services capacity,

inpatient beds, ICU beds, and ventilators) and

numbers of healthcare professionals (nurses

and physicians). The most prudent approach,

therefore, would appear to be to expand medical

surge capacity as much as possible while

reducing the anticipated demand for services by

limiting disease transmission. Delaying a rapid

upswing of cases and lowering the epidemic peak

to the extent possible would allow a better match

between the number of ill persons requiring

hospitalization and the nation’s capacity to

provide medical care for such people

(see Figure 1). 

The primary strategies for combating influenza

are 1) vaccination, 2) treatment of infected

individuals and prophylaxis of exposed

individuals with influenza antiviral medications,

and 3) implementation of infection control

and social distancing measures.5, 7, 8, 13, 14 The

single most effective intervention will be

vaccination. However, it is highly unlikely that

a well-matched vaccine will be available when

a pandemic begins unless a vaccine with broad

cross-protection is developed.15-18 With current

vaccine technology, pandemic strain vaccine

would not become available for at least 4 to 6

months after the start of a pandemic, although

this lag time may be reduced in the future. 

Furthermore, once an effective pandemic vaccine

is developed and being produced, it is likely that

amounts will be limited due to the production

process and will not be sufficient to cover the

17
18

Community Mitigation Guidance

entire population. Pre-pandemic vaccine may

be available at the onset of a pandemic, but there

is no guarantee that it will be effective against

the emerging pandemic strain. Even if a prepandemic vaccine did prove to be effective,

projected stockpiles of such a vaccine would

be sufficient for only a fraction of the U.S.

population.

These realities mean that we must be prepared

to face the first wave of the next pandemic

without vaccine—the best countermeasure—and

potentially without sufficient quantities of

influenza antiviral medications.19 In addition, it

is not known if influenza antiviral medications

will be effective against a future pandemic

strain. During a pandemic, decisions about how

to protect the public before an effective vaccine

is available need to be based on scientific data,

ethical considerations, consideration of the

public’s perspective of the protective measures

and their impact on society, and common sense. 

Evidence to determine the best strategies for

protecting people during a pandemic is very

limited. Retrospective data from past epidemics

and the conclusions drawn from those data need

to be examined and analyzed within the context

of modern society. Few of those conclusions

may be completely generalizable; however, they

can inform contemporary planning assumptions. 

When these assumptions are integrated into the

current mathematical models, the limitations

need to be recognized, as they were in a recent

Institute of Medicine report.20

This document provides interim pre-pandemic

planning guidance for the selection and timing

of selected NPIs and recommendations for their

use matched to the severity of a future influenza

pandemic. While it is not possible, prior to

Figure 1. 
19

Community Mitigation Guidance

emergence, to predict with certainty the severity

of a pandemic, early and rapid characterization

of the pandemic virus and initial clusters of

human cases may give insight into its potential

severity and determine the initial public health

response. The main determinant of a pandemic’s

severity is its associated mortality.21-27 This

may be defined by case fatality ratio or excess

mortality rate—key epidemiological parameters

that may be available shortly after the emergence

of a pandemic strain from investigations of initial

outbreaks or from more routine surveillance data. 

Other factors, such as efficiency of transmission,

are important for consideration as well.

The Centers for Disease Control and Prevention

(CDC) developed this guidance with input from

other Federal agencies, key stakeholders, and

partners, including a working group of public

health officials and other stakeholders (see

Appendix 2, Interim Guidance Development

Process). A community mitigation framework

is proposed that is based upon an early, targeted,

layered mitigation strategy involving the directed

application of multiple partially effective

nonpharmaceutical measures initiated early and

maintained consistently during an epidemic

wave.20, 28-33 These interventions include the

following:

1.	 Isolation and treatment (as appropriate)

with influenza antiviral medications of all

persons with confirmed or probable pandemic

influenza. Isolation may occur in the home or

healthcare setting, depending on the severity

of an individual’s illness and /or the current

capacity of the healthcare infrastructure.

2.	 Voluntary home quarantine of

members of households with confirmed or

probable influenza case(s) and consideration

of combining this intervention with the

prophylactic use of antiviral medications,

providing sufficient quantities of effective

medications exist and that a feasible means of

distributing them is in place. 

3.	 Dismissal of students from school

(including public and private schools as well

as colleges and universities) and school-based

activities and closure of childcare programs,

coupled with protecting children and teenagers

through social distancing in the community

to achieve reductions of out-of-school social

contacts and community mixing.

4.	 Use of social distancing measures to

reduce contact among adults in the community

and workplace, including, for example,

cancellation of large public gatherings and

alteration of workplace environments and

schedules to decrease social density and preserve

a healthy workplace to the greatest extent

possible without disrupting essential services.

Enable institution of workplace leave policies

that align incentives and facilitate adherence

with the nonpharmaceutical interventions (NPIs)

outlined above.

The effectiveness of individual infection control

measures (e.g., cough etiquette, hand hygiene)

and the role of surgical masks or respirators in

preventing the transmission of influenza are

currently unknown. However, cough etiquette

and hand hygiene will be recommended

universally, and the use of surgical masks and

respirators may be appropriate in certain settings

(specific community face mask and respirator

use guidance is forthcoming as is guidance for

workplaces and will be available on

www.pandemicflu.gov).

Decisions about what tools should be used

during a pandemic should be based on the

observed severity of the event, its impact on

specific subpopulations, the expected benefit

of the interventions, the feasibility of success

in modern society, the direct and indirect costs,

and the consequences on critical infrastructure,

healthcare delivery, and society. The most

controversial elements (e.g., prolonged dismissal

of students from schools and closure of childcare

programs) are not likely to be needed in less

severe pandemics, but these steps may save lives
20

Community Mitigation Guidance

during severe pandemics. Just as communities

plan and prepare for mitigating the effect of

severe natural disasters (e.g., hurricanes), they

should plan and prepare for mitigating the effect

of a severe pandemic.

The U.S. Government recognizes the significant

challenges and social costs that would be

imposed by the coordinated application of the

measures described above. 2, 10, 34 It is important

to bear in mind, however, that if the experience

of the 1918 pandemic is relevant, social

distancing and other NPI strategies would, in all

likelihood, be implemented in most communities

at some point during a pandemic. The potential

exists for such interventions to be implemented

in an uncoordinated, untimely, and inconsistent

manner that would impose economic and social

costs similar to those imposed by strategically

implemented interventions but with dramatically

reduced effectiveness. The development of clear

interim pre-pandemic guidance for planning

that outlines a coordinated strategy, based

upon the best scientific evidence available,

offers communities the best chance to secure

the benefits that such strategies may provide. 

As States and local communities exercise the

potential tools for responding to a pandemic,

more will be learned about the practical

realities of their implementation. Interim

recommendations will be updated accordingly.

This document serves as interim public health

planning guidance for State, local, territorial,

and tribal jurisdictions developing plans for

using community mitigation interventions in

response to a potential influenza pandemic in the

United States. Given the paucity of evidence for

the effectiveness of some of the interventions

and the potential socioeconomic implications,

some interventions may draw considerable

disagreement and criticism.20 Some interventions

that may be highly useful tools in the framework

of a disease control strategy will need to be

applied judiciously to balance socioeconomic

realities of community functioning. CDC

will regularly review this document and, as

appropriate, issue updates based on the results

from various ongoing historical, epidemiological,

and field studies. Response guidance will

need to remain flexible and likely will require

modification during a pandemic as information

becomes available and it can be determined

if ongoing pandemic mitigation measures are

useful for mitigating the impact of the pandemic. 

Pandemic planners need to develop requirements

for community-level data collection during a

pandemic and develop and test a tool or process

for accurate real-time and post-wave evaluation

of pandemic mitigation measures, with

guidelines for modifications.

Communities will need to prepare in advance if

they are to accomplish the rapid and coordinated

introduction of the measures described while

mitigating the potentially significant cascading

second- and third-order consequences of the

interventions themselves. Cascading secondand third-order consequences are chains of

effects that may arise because of the intervention

and may require additional planning and

intervention to mitigate. The terms generally

refer to foreseeable unintended consequences of

intervention. For example, dismissal of students

from school classrooms may lead to the secondorder effect of workplace absenteeism for child

minding. Subsequent workplace absenteeism

and loss of household income could be especially

problematic for individuals and families living

at or near subsistence levels. Workplace

absenteeism could also lead to disruption of

the delivery of goods and services essential to

the viability of the community. If communities

are not prepared for these untoward effects, the

ability of the public to comply with the proposed

measures and, thus, the ability of the measures to

reduce suffering and death may be compromised. 

Federal, State, local, territorial, and tribal

governments and the private sector all have

important and interdependent roles in preparing

for, responding to, and recovering from a

pandemic. To maintain public confidence and to

enlist the support of private citizens in disease
21

Community Mitigation Guidance

mitigation efforts, public officials at all levels

of government must provide unambiguous

and consistent guidance that is useful for

planning and can assist all segments of society

to recognize and understand the degree to

which their collective actions will shape the

course of a pandemic. The potential success of

community mitigation interventions is dependent

upon building a foundation of community and

individual and family preparedness. To facilitate

preparedness, Pandemic Influenza Community

Mitigation Interim Planning Guides have been

included as appendices to provide broad but

tailored planning guidance for businesses and

other employers, childcare programs, elementary

and secondary schools, colleges and universities,

faith-based and community organizations, and

individuals and families (see Appendices 4-9). 

See also the Department of Homeland Security’s

Pandemic Influenza Preparedness, Response and 

Recovery Guide for Critical Infrastructure and 

Key Resources (available at www.pandemicflu.

gov/plan/pdf/cikrpandemicinfluenzaguide.pdf). 

U.S. and Global Preparedness Planning

The suggested strategies contained in this

document are aligned with the World Health

Organization (WHO) phases of a pandemic.35 

WHO has defined six phases, occurring before

and during a pandemic, that are linked to the

characteristics of a new influenza virus and its

spread through the population (see Appendix 2. 

WHO Phases of a Pandemic/U.S. Government

Stages of a Pandemic). This document

specifically provides pre-pandemic planning

guidance for the use of NPIs in WHO Phase 6. 

These phases are described below:

Inter-Pandemic Period 

Phase 1: No new influenza virus subtypes have

been detected in humans. An influenza virus

subtype that has caused human infection may be

present in animals. If present in animals, the risk

of human disease is considered to be low.

Phase 2: No new influenza virus subtypes

have been detected in humans. However, a

circulating animal influenza virus subtype poses

a substantial risk of human disease.

Pandemic Alert Period

Phase 3: Human infection(s) with a new

subtype, but no human-to-human spread, or at

most rare instances of spread to a close contact.

Phase 4: Small cluster(s) with limited humanto-human transmission but spread is highly

localized, suggesting that the virus is not well

adapted to humans.

Phase 5: Larger cluster(s) but human-to-human

spread still localized, suggesting that the virus

is becoming increasingly better adapted to

humans, but may not yet be fully transmissible

(substantial pandemic risk).

Pandemic Period

Phase 6: Pandemic phase: increased and

sustained transmission in general population.

The WHO phases provide succinct statements

about the global risk for a pandemic and provide

benchmarks against which to measure global

response capabilities. However, to describe the

U.S. Government’s approach to the pandemic

response, it is more useful to characterize the

stages of an outbreak in terms of the immediate

and specific threat a pandemic virus poses to the

U.S. population.2The following stages provide

a framework for Federal Government actions:

Stage 0: New Domestic Animal Outbreak in AtRisk Country

Stage 1: Suspected Human Outbreak Overseas

Stage 2: Confirmed Human Outbreak Overseas

Stage 3: Widespread Human Outbreaks in

Multiple Locations Overseas

Stage 4: First Human Case in North America

Stage 5: Spread throughout United States

Stage 6: Recovery and Preparation for

Subsequent Waves
22

Community Mitigation Guidance

Using the Federal Government’s approach,

this document provides pre-pandemic planning

guidance from Stages 3 through 5 for step-wise

escalation of activity, from pre-implementation

preparedness, through active preparation for

initiation of NPIs, to actual use.
Rationale for Proposed

Nonpharmaceutical Interventions

III

The three major goals of mitigating a

community-wide epidemic through NPIs are 1)

delay the exponential increase in incident cases

and shift the epidemic curve to the right in order

to “buy time” for production and distribution

of a well-matched pandemic strain vaccine, 2)

decrease the epidemic peak, and 3) reduce the

total number of incident cases and, thus, reduce

morbidity and mortality in the community

(Figure 1). These three major goals of epidemic

mitigation may all be accomplished by focusing

on the single goal of saving lives by reducing

transmission. NPIs may help reduce influenza

transmission by reducing contact between sick

persons and uninfected persons, thereby reducing

the number of infected persons. Reducing the

number of persons infected will also lessen

the need for healthcare services and minimize

the impact of a pandemic on the economy

and society. The surge of need for medical

care associated with a poorly mitigated severe

pandemic can be only partially addressed by

increasing capacity within hospitals

and other care settings. Thus, reshaping the

demand for healthcare services by using NPIs is

an important component of the overall strategy

for mitigating a severe pandemic 

Principles of Disease Transmission

Decreasing the Basic Reproductive number, R0

The basic reproductive number, R0, is the

average number of new infections that a typical

infectious person will produce during the

course of his/her infection in a fully susceptible

population in the absence of interventions.36-38 

R0 is not an intrinsic property of the infectious

agent but is rather an epidemic characteristic

of the agent acting within a specific host within

a given milieu. For any given duration of

infection and contact structure, R0 provides a

measure of the transmissibility of an infectious

agent. Alterations in the pathogen, the host,

or the contact networks can result in changes

in R0 and thus in the shape of the epidemic

curve. Generally speaking, as R0 increases,

epidemics have a sharper rise in the case curve,

a higher peak illness rate (clinical attack rate),

a shorter duration, and a higher percentage of

the population infected before the effects of

herd immunity begin to exert an influence (in

homogeneous contact networks, herd immunity

effects should dominate when the percentage of

the population infected or otherwise rendered

immune is equivalent to 1 – 1/ R0). Rt is the

change in the reproductive number at a given

point in time. Thus, as shown in Figure 2,

decreasing Rt by decreasing host susceptibility

(through vaccination or the implementation

of individual infection control measures) or

reducing transmission by diminishing the number

of opportunities for exposure and transmission

(through the implementation of communitywide NPIs) will achieve the three major goals of

epidemic mitigation.39 Mathematical modeling

of pandemic influenza scenarios in the United

States suggests that pandemic mitigation

strategies utilizing NPIs separately and in

combination with medical countermeasures may

decrease the Rt.

20, 28-31, 40 This potential to reduce

Rt is the rationale for employing early, targeted,

and layered community-level NPIs as key

components of the public health response.

23
24

Community Mitigation Guidance

Influenza: Infectiousness and Transmissibility

Assuming the pandemic influenza strain will

have transmission dynamics comparable

to those for seasonal influenza and recent

pandemic influenza strains, the infection control

challenges posed will be considerable. Factors

responsible for these challenges include 1) a

short incubation period (average of 2 days,

range 1-4 days); 2) the onset of viral shedding

(and presumably of infectiousness) prior to the

onset of symptoms; and 3) the lack of specific

clinical signs and symptoms that can reliably

discriminate influenza infections from other

causes of respiratory illness.41, 42 Although the

hallmarks of a pandemic strain will not be known

until emergence, patients with influenza may

shed virus prior to the onset of clinical symptoms

and may be infectious on the day before illness

onset. Most people infected with influenza

develop symptomatic illness (temperature of

100.4° F or greater, plus cough or sore throat),

and the amount of virus they shed correlates with

their temperature; however, as many as one-third

to one-half of those who are infected may either

have very mild or asymptomatic infection. This

possibility is important because even seemingly

healthy individuals with influenza infection

as well as those with mild symptoms who are

not recognized as having influenza could be

infectious to others. 

Source: Lewis, 2006

Figure 2. 
25

Community Mitigation Guidance

Early, Targeted

Implementation of Interventions

The potential for significant transmission

of pandemic influenza by asymptomatic

or minimally symptomatic individuals to

their contacts suggests that efforts to limit

community transmission that rely on targeting

only symptomatic individuals would result in

diminished ability to mitigate the effects of a

pandemic. Additionally, the short intergeneration

time of influenza disease suggests that household

members living with an ill individual (who are

thus at increased risk of infection with pandemic

virus) would need to be identified rapidly and

targeted for appropriate intervention to limit

community spread.20, 28-31, 40 Recent estimates

have suggested that while the reproductive

number for most strains of influenza is less

than 2, the intergeneration time may be as little

as 2.6 days. These parameters predict that in

the absence of disease mitigation measures,

the number of cases of epidemic influenza

will double about every 3 days, or about a

tenfold increase every 1-2 weeks. Given the

potential for exponential growth of a pandemic,

it is reasonable to expect that the timing of

interventions will be critical. Planning for

community response that is predicated on

reactive implementation of these measures may

limit overall effectiveness. Measures instituted

earlier in a pandemic would be expected to be

more effective than the same measures instituted

after a pandemic is well established. Although

subject to many limitations, mathematical

models that explored potential source mitigation

strategies that make use of vaccine, antiviral

medications, and other infection control and

social distancing measures for use in an influenza

outbreak identified critical time thresholds for

success.20, 28, 31 These results suggest that the

effectiveness of pandemic mitigation strategies

will erode rapidly as the cumulative illness rate

prior to implementation climbs above 1 percent

of the population in an affected area. Thus, prepandemic, scenario-based contingency planning

for the early, targeted use of NPIs likely provides

the greatest potential for an effective public

health response.

To summarize, isolation of ill individuals will

reduce the onward transmission of disease

after such individuals are identified. However,

influenza is a disease in which infected persons

may shed virus prior to onset of symptoms and

thus are potentially infectious for approximately

1 day before becoming symptomatic. In

addition, not all infected individuals will be

identified because mild or asymptomatic cases

may be relatively common. Isolation strategies

are thus, at best, a partial solution. Similarly,

voluntary quarantine of members of households

with ill persons will facilitate the termination of

transmission chains, but quarantine strategies

are limited to the extent that they can be

implemented only after cases are identified. 

Consequently, only a percentage of transmission

chains will be interrupted in this fashion. Given

the very short generation times (time between

a primary and secondary case) observed with

influenza and the fact that peak infectiousness

occurs around the time of symptom onset,

the identification of cases and simultaneous

implementation of isolation and quarantine

must occur very rapidly or the efficacy of these

strategies will erode significantly.

Antiviral Therapy/Prophylaxis

Four approved influenza antiviral agents are

available in the United States: amantadine,

rimantadine, zanamivir, and oseltamivir. The

role of influenza antiviral medications as therapy

for symptomatic individuals is primarily to

improve individual outcomes not to limit the

further transmission of disease; although, recent

clinical trials have demonstrated that prophylaxis

of household contacts of symptomatic

individuals with neuraminidase inhibitors can

reduce household transmission. 43-48

Current antiviral medication stockpiles are

thought to be inadequate to support antiviral

prophylaxis of members of households with

ill individuals.49, 50 Moreover, the feasibility
26

Community Mitigation Guidance

of rapidly (within 48 hours after exposure)

providing these medications to ill individuals and

those who live in household with ill individuals

has not been tested and mechanisms to support

such distribution need to be developed. As with

the use of antiviral medications for treatment,

concerns exist regarding the emergence of

resistance if the use of antiviral medications

for prophylaxis is widespread.51, 52 Although

mathematical models illustrate the additive

effects that antiviral prophylaxis offers in

reducing disease transmission, these challenges

must be addressed to make this a realistic

measure for implementation during a pandemic.20 

Future updates of this guidance will address

feasibility concerns and incorporate any new

recommendations regarding use of antiviral

prophylaxis for members of households with ill

individuals.

Targeting Interventions by Exploiting 

Heterogeneities in Disease Transmission 

Our social connectedness provides a disease

transmission network for a pandemic to

spread.50, 53-58 Variation exists with respect to

individual social connectedness and contribution

to disease transmission. Such a distribution

is characteristic of a “scale-free” network. A

scale-free network is one in which connectivity

between nodes follows a distribution in which

there are a few highly connected nodes among a

larger number of less connected nodes. Air travel

provides an example of this concept. In this

example, a relatively small number of large hub

airports are highly connected with large numbers

of originating and connecting flights from a much

larger number of small regional airports with a

limited number of flights and far lesser degree of

connectedness to other airports. Because of the

differences in connectivity, the closure of a major

hub airport, compared with closure of a small

regional airport, would have a disproportionately

greater effect on air travel. Given the variation

of social connectedness and its contribution to

the formation of disease transmission networks,

it is useful to identify the nodes of high

connectivity since eliminating transmission at

these nodes could most effectively reduce disease

transmission.

Social Density

One measure for decreasing transmission of an

influenza virus is by increasing the distances

among people in work, community, and school

settings.31, 50, 59 Schools and pre-schools represent

the most socially dense of these environments. 

Social density is greatest in pre-school

classrooms, with guidelines for occupancy

density specifying 35-50 square feet per

child.60, 61 Published criteria for classroom size

based upon the number of students and one

teacher recommend an elementary school and

high school classroom density of 49 and 64

square feet per person, respectively.62 There is

more space per person in work and healthcare

settings, with high variability from one setting

to another; for example, occupancy density in

hospitals is about 190 square feet per person.63 

Office buildings and large retail buildings have

an average occupational density of 390-470

square feet per person.64, 65 Homes represent

the least socially dense environment (median

occupancy density of 734 square feet per person

in single-family homes).66

Public transportation, including subways and

transit buses, represents another socially dense

environment. There were on average 32.8

million unlinked passenger trips each weekday

for all public transportation across the United

States in 2004—nearly 20 million of which were

by bus.67 More than half these 32.8 million

passenger trips are work related (54 percent)

and about 15 percent of these trips are school

related.68 Each day, 144,000 public transit

vehicles, including 81,000 buses, are in use.

More than half the children attending school

(K-12) in the United States travel on a school

bus—that equates to an estimated 58 million

person trips daily (to school and back home).69 

The number of schoolchildren traveling via

school bus and via public transportation during

a school day is twice the number of people
27

Community Mitigation Guidance

taking all public transportation in the United

States in terms of number of trips and number of

individuals during a weekday.

Targeting Schools, Childcare, and Children

Biological, social, and maturational factors make

children especially important in the transmission

of influenza. Children without pre-existing

immunity to circulating influenza viruses are

more susceptible than adults to infection and,

compared with adults, are responsible for more

secondary transmission within households.70, 71 

Compared with adults, children usually shed

more influenza virus, and they shed virus for

a longer period. They also are not skilled in

handling their secretions, and they are in close

proximity with many other children for most

of the day at school. Schools, in particular,

clearly serve as amplification points of seasonal

community influenza epidemics, and children are

thought to play a significant role in introducing

and transmitting influenza virus within their

households.20, 27, 70-76, 78 A recent clinical trial

demonstrated that removing a comparatively

modest number of school children from

the transmission pool through vaccination

(vaccinating 47 percent of students with a live

attenuated vaccine whose efficacy was found in

a separate trial to be no greater than 57 percent)

resulted in significant reductions in influenzarelated outcomes in households of children

(whether vaccinated or unvaccinated) attending

intervention schools. 77 

Therefore, given the disproportionate

contribution of children to disease transmission

and epidemic amplification, targeting their

social networks both within and outside of

schools would be expected to disproportionately

disrupt influenza spread. Given that children

and teens are together at school for a significant

portion of the day, dismissal of students from

school could effectively disrupt a significant

portion of influenza transmission within these

age groups. There is evidence to suggest that

school closure can in fact interrupt influenza

spread. While the applicability to a U.S.

pandemic experience is not clear, nationwide

school closure in Israel during an influenza

epidemic resulted in significant decreases in

the diagnoses of respiratory infections (42

percent), visits to physicians (28 percent) and

emergency departments (28 percent), and

medication purchases (35 percent).56 The New

York City Department of Health and Mental

Hygiene recently examined the impact of routine

school breaks (e.g., winter break) on emergency

department visits for influenza-like illness from

2001 to 2006. Emergency department visits for

complaints of febrile illness among school-age

children (aged 5 to 17 years) typically declined

starting 2-3 days after a school break began,

remained static during the school break, and

then increased within several days after school

recommenced. A similar pattern was not seen in

the adult age group.78

Dismissal of students from schools could

eliminate a potential amplifier of transmission. 

However, re-congregation and social mixing

of children at alternate settings could offset

gains associated with disruption of their social

networks in schools. For this reason, dismissal

of students from schools and, to the extent

possible, protecting children and teenagers

through social distancing in the community,

to include reductions of out-of-school social

contacts and community mixing, are proposed

as a bundled strategy for disrupting their social

networks and, thus, the associated disease

transmission pathways for this age group.79 

Targeting Adults—Social Distancing

at Work and in the Community

Eliminating schools as a focus of epidemic

amplification and reducing the social contacts for

children and teens outside the home will change

the locations and dynamics of influenza virus

transmission. The social compartments within

which the majority of disease transmission will

likely take place will be the home and workplace,

and adults will play a more important role in

sustaining transmission chains.20, 53, 73 Disrupting

adult-to-adult transmission will offer additional
28

Community Mitigation Guidance

opportunities to suppress epidemic spread. The

adoption by individuals of infection control

measures, such as hand hygiene and cough

etiquette, in the community and workplace will

be strongly encouraged. 

In addition, adults may further decrease their risk

of infection by practicing social distancing and

minimizing their non-essential social contacts

and exposure to socially dense environments. 

Low-cost and sustainable social distancing

strategies can be adopted by individuals

within their community (e.g., going to the

grocery store once a week rather than every

other day, avoiding large public gatherings)

and at their workplace (e.g., spacing people

farther apart in the workplace, teleworking

when feasible, substituting teleconferences

for meetings) for the duration of a community

outbreak. Employers will be encouraged to

establish liberal/unscheduled leave policies,

under which employees may use available

paid or unpaid leave without receiving prior

supervisory approval so that workers who are

ill or have ill family members are excused from

their responsibilities until their or their family

members’symptoms have resolved. In this way,

the amount of disease transmission that occurs

in the workplace can be minimized, making the

workplace a safer environment for other workers.

Healthcare workers may be prime candidates

for targeted antiviral prophylaxis once

supplies of the drugs are adequate to support

this use. Moreover, beyond the healthcare

arena, employers who operate or contract for

occupational medical services could consider

a cache of antiviral drugs in anticipation of a

pandemic and provide prophylactic regimens to

employees who work in critical infrastructure

businesses, occupy business-critical roles, or

hold jobs that put them at repeated high risk of

exposure to the pandemic virus. This use of

antiviral drugs may be considered for inclusion

in a comprehensive pandemic influenza response

and may be coupled with NPIs. Strategies

ensuring workplace safety will increase worker

confidence and may discourage unnecessary

absenteeism.

Value of Partially Effective

Layered Interventions

Pandemic mitigation strategies generally include

1) case containment measures, such as voluntary

case isolation, voluntary quarantine of members

of households with ill persons, and antiviral

treatment/prophylaxis; 2) social distancing

measures, such as dismissal of students from

classrooms and social distancing of adults in the

community and at work; and 3) infection control

measures, including hand hygiene and cough

etiquette. Each of these interventions may be

only partially effective in limiting transmission

when implemented alone.

To determine the usefulness of these partially

effective measures alone and in combination,

mathematical models were developed to

assess these types of interventions within the

context of contemporary social networks. The

“Models of Infectious Disease Agents Study”

(MIDAS), funded by the National Institutes

of Health, has been developing agent-based

computer simulations of pandemic influenza

outbreaks with various epidemic parameters,

strategies for using medical countermeasures,

and patterns of implementation of communitybased interventions (case isolation, household

quarantine, child and adult social distancing

through school or workplace closure or

restrictions, and restrictions ontravel).20, 28-30, 32, 39,

40

Mathematical modeling conducted by MIDAS

participants demonstrates general consistency

in outcome for NPIs and suggests the following

within the context of the model assumptions:

•	 Interventions implemented in combination,

even with less than complete levels of

public adherence, are effective in reducing

transmission of pandemic influenza virus,

particularly for lower values of R0.

•	 School closure and generic social distancing

are important components of a community
29

Community Mitigation Guidance

mitigation strategy because schools and

workplaces are significant compartments for

transmission.

•	 Simultaneous implementation of multiple

tools that target different compartments

for transmission is important in limiting

transmission because removing one source of

transmission may simply make other sources

relatively more important.

•	 Timely intervention may reduce the total

number of persons infected with pandemic

influenza.

Each of the models generally suggest that a

combination of targeted antiviral medications and

NPIs can delay and flatten the epidemic peak, but

the degree to which they reduce the overall size

of the epidemic varies. Delay of the epidemic

peak is critically important because it allows

additional time for vaccine development and

antiviral production. However, these models are

not validated with empiric data and are subject to

many limitations.20 

Supporting evidence for the role of combinations

of NPIs in limiting transmission can also be

found in the preliminary results from several

historical analyses.20 One statistical model being

developed based on analysis of historical data

for the use of various combinations of selected

NPIs in U.S. cities during the 1918 pandemic

demonstrates a significant association between

early implementation of these measures by cities

and reductions in peak death rate.80, 81

Taken together, these strands of evidence are

consistent with the hypothesis that there may

be benefit in limiting or slowing the community

transmission of a pandemic virus by the use of

combinations of partially effective NPIs. At the

present time, this hypothesis remains unproven,

and more work is needed before its validity can

be established.
Appropriate matching of the intensity of

intervention to the severity of a pandemic is

important to maximize the available public

health benefit that may result from using an early,

targeted, and layered strategy while minimizing

untoward secondary effects. To assist prepandemic planning, this interim guidance

introduces the concept of a Pandemic Severity

Index based primarily on case fatality ratio 23-27,

a measurement that is useful in estimating the

severity of a pandemic on a population level and

which may be available early in a pandemic for

small clusters and outbreaks. Excess mortality

rate may also be available early and may

supplement and inform the determination of the

Pandemic Severity Index.82 Pandemic severity

is described within five discrete categories of

increasing severity (Category 1 to Category 5). 

Other epidemiologic features that

are relevant in overall analysis of mitigation

plans include total illness rate, age-specific

illness and mortality rates, the reproductive

number, intergeneration time, and incubation

period. However, it is unlikely that estimates

will be available for most of these parameters

during the early stages of a pandemic; thus, they

are not as useful from a planning perspective. 

The Pandemic Severity Index provides

U.S. communities a tool for scenario-based

contingency planning to guide pre-pandemic

planning efforts. Upon declaration by WHO of

having entered the Pandemic Period (Phase 6)

and further determination of U.S. Government

Stage 3, 4, or 5, the CDC’s Director shall

designate the category of the emerging pandemic

based on the Pandemic Severity Index and

Pre-pandemic Planning:

The Pandemic Severity Index

IV

consideration of other available information. 

Pending this announcement, communities

facing the imminent arrival of pandemic

disease will be able to define which pandemic

mitigation interventions are most indicated for

implementation based on the level of pandemic

severity. 

Multiple parameters may ultimately provide a

more complete characterization of a pandemic. 

The age-specific and total illness and mortality

rates, reproductive number, intergeneration time,

and incubation period as well as population

structure and healthcare infrastructure are

important factors in determining pandemic

impact. Although many factors may influence

the outcome of an event, it is reasonable to

maintain a single criterion for classification of

severity for the purposes of guiding contingency

planning. If additional epidemiologic

characteristics become well established during

the course of the next pandemic through

collection and analysis of surveillance data,

then local jurisdictions may develop a subset of

scenarios, depending upon, for example, agespecific mortality rates. 

Table 1 provides a categorization of pandemic

severity by case fatality ratio—the key

measurement in determining the Pandemic

Severity Index—and excess mortality rate. In

addition, Table 1 displays ranges of illness

rates with potential numbers of U.S. deaths per

category, with recent U.S. pandemic experience

and U.S. seasonal influenza to provide historical

context. Figure 3a plots prior U.S. pandemics

from the last century and a severe annual

31
32

Community Mitigation Guidance

influenza season based on case fatality ratio and

illness rate and demonstrates the great variability

in pandemics based on these parameters

(and the clear distinctiveness of pandemics

from even a severe annual influenza season). 

Figure 3b demonstrates that the primary factor

determining pandemic severity is case fatality

ratio. Incremental increases in case fatality

ratio result in proportionally greater mortality

in comparison to increasing illness rates, which

result in proportionally much smaller increases in

mortality. Figure 4 provides a graphic depiction

of the U.S. Pandemic Severity Index by case

fatality ratio, with ranges of projected U.S.

deaths at a constant 30 percent illness rate and

without mitigation by any intervention.

Data on case fatality ratio and excess mortality

in the early course of the next pandemic will

be collected during outbreak investigations

of initial clusters of human cases, and public

health officials may make use of existing

influenza surveillance systems once widespread

transmission starts. However, it is possible

that at the onset of an emerging pandemic, very

limited information about cases and deaths will

be known. Efforts now to develop decision

algorithms based on partial data and efforts to

improve global surveillance systems for influenza

are needed.

Table 1. Pandemic Severity Index by Epidemiological Characteristics 
33

Community Mitigation Guidance

Figure 3A. Projected Mortality* of a Modern Influenza Pandemic Compared with that of

20th Century Pandemics (1918, 1957, 1968)

Figure 3B. Pandemic Severity Categories as Determined by Differences in Case Fatality Ratio 
34

Community Mitigation Guidance

Projected

Number of Deaths*

US Population, 2006

Assumes 30% Illness Rate and Unmitigated 

Pandemic Without Interventions

Case 

Fatality 

Ratio

Figure 4. Pandemic Severity Index

≥ ≥

*
This section provides interim pre-pandemic

planning recommendations for use of pandemic

mitigation interventions to limit community

transmission. These planning recommendations

are likely to evolve as more information about

their effectiveness and feasibility becomes

available. To minimize economic and social

costs, it will be important to judiciously match

interventions to the pandemic severity level. 

However, at the time of an emerging pandemic,

depending on the location of the first detected

cases, there may be scant information about

the number of cases and deaths resulting from

infection with the virus. Although surveillance

efforts may initially only detect the “herald”

cases, public health officials may choose to err on

the side of caution and implement interventions

based on currently available data and iteratively

adjust as more accurate and complete data

become available. These pandemic mitigation

measures include the following:

1.	 Isolation and treatment (as appropriate)

with influenza antiviral medications of all

persons with confirmed or probable pandemic

influenza. Isolation may occur in the home or

healthcare setting, depending on the severity

of an individual’s illness and /or the current

capacity of the healthcare infrastructure.

2.	 Voluntary home quarantine of

members of households with confirmed or

probable influenza case(s) and consideration

of combining this intervention with the

prophylactic use of antiviral medications,

providing sufficient quantities of effective

medications exist and that a feasible means of

distributing them is in place. 

Use of Nonpharmaceutical Interventions

by Pandemic Severity Category

V

3.	 Dismissal of students from school

(including public and private schools as well

as colleges and universities) and school-based

activities and closure of childcare programs,

coupled with protecting children and teenagers

through social distancing in the community

to achieve reductions of out-of-school social

contacts and community mixing.

4.	 Use of social distancing measures to

reduce contact between adults in the community

and workplace, including, for example,

cancellation of large public gatherings and

alteration of workplace environments and

schedules to decrease social density and

preserve a healthy workplace to the greatest

extent possible without disrupting essential

services. Enable institution of workplace leave

policies that align incentives and facilitate

adherence with the nonpharmaceutical

interventions (NPIs)

outlined above.

Planning for use of these NPIs is based on the

Pandemic Severity Index, which may allow

more appropriate matching of the interventions

to the magnitude of the pandemic. These

recommendations are summarized in Table 2. All

interventions should be combined with infection

control practices, such as good hand hygiene and

cough etiquette. In addition, the use of personal

protective equipment, such as surgical masks or

respirators, may be appropriate in some cases,

and guidance on community face mask and

respirator use will be forthcoming. Guidance

on infection control measures, including those

for workplaces, may be accessed at www.

pandemicflu.gov.

35
36

Community Mitigation Guidance

Table 2. Summary of the Community Mitigation Strategy by Pandemic Severity 

Generally Not Recommended = Unless there is a compelling rationale for

specific populations or jurisdictions, measures are generally not recommended for entire populations as the consequences may outweigh the

benefits.

Consider = Important to consider these alternatives as part of a prudent

planning strategy, considering characteristics of the pandemic, such as agespecific illness rate, geographic distribution, and the magnitude of adverse

consequences. These factors may vary globally, nationally, and locally.

Recommended = Generally recommended as an important component of

the planning strategy.

*All these interventions should be used in combination with other infection

control measures, including hand hygiene, cough etiquette, and personal

protective equipment such as face masks. Additional information on infection control measures is available at www.pandemicflu.gov.

†This intervention may be combined with the treatment of sick individuals

using antiviral medications and with vaccine campaigns, if supplies are

available

§Many sick individuals who are not critically ill may be managed safely

at home

¶The contribution made by contact with asymptomatically infected individuals to disease transmission is unclear. Household members in homes

with ill persons may be at increased risk of contracting pandemic disease

from an ill household member. These household members may have

asymptomatic illness and may be able to shed influenza virus that promotes

community disease transmission. Therefore, household members of homes

with sick individuals would be advised to stay home.

**To facilitate compliance and decrease risk of household transmission,

this intervention may be combined with provision of antiviral medications to household contacts, depending on drug availability, feasibility

of distribution, and effectiveness; policy recommendations for antiviral

prophylaxis are addressed in a separate guidance document.

††Consider short-term implementation of this measure—that is, less than

4 weeks.

§§Plan for prolonged implementation of this measure—that is, 1 to 3

months; actual duration may vary depending on transmission in the community as the pandemic wave is expected to last 6-8 weeks.
37

Community Mitigation Guidance

For Category 4 or Category 5 pandemics, a

planning recommendation is made for use of

all listed NPIs (Table 2). In addition, planning

for dismissal of students from schools and

school-based activities and closure of childcare

programs, in combination with means to reduce

out-of-school social contacts and community

mixing for these children, should encompass up

to 12 weeks of intervention in the most severe

scenarios. This approach to pre-pandemic

planning will provide a baseline of readiness for

community response even if the actual response

is shorter. Recommendations for use of these

measures for pandemics of lesser severity may

include a subset of these same interventions and,

possibly, suggestions that they be used for shorter

durations, as in the case of the social distancing

measures for children.

For Category 2 or Category 3 pandemics,

planning for voluntary isolation of ill persons

is recommended, whereas other measures

(voluntary quarantine of household contacts,

social distancing measures for children

and adults) are to be implemented only if

local decision-makers have determined

that characteristics of the pandemic in their

community warrant these additional mitigation

measures. However, within these categories,

pre-pandemic planning for social distancing

measures for children should be undertaken

with a focus on a duration of 4 weeks or

less, distinct from the longer timeframe

recommended for pandemics with a greater

Pandemic Severity Index. For Category 1

pandemics, only voluntary isolation of ill

persons is recommended on a community-wide

basis, although local communities may still

choose to tailor their response to Category 1-3

pandemics differently by applying NPIs on the

basis of local epidemiologic parameters, risk

assessment, availability of countermeasures,

and consideration of local healthcare surge

capacity. Thus, from a pre-pandemic planning

perspective for Category 1, 2, and 3 pandemics,

capabilities for both assessing local public

health capacity and healthcare surge, delivering

countermeasures, and implementing these

measures in full and in combination should be

assessed.

Nonpharmaceutical Interventions

Voluntary Isolation of Ill Persons

The goal of this intervention is to reduce

transmission by reducing contact between

persons who are ill and those who are not. Ill

individuals not requiring hospitalization would

be requested to remain at home voluntarily for

the infectious period, approximately 7-10 days

after symptom onset. This would usually be in

their homes, but could be in a home of a friend

or relative. Voluntary isolation of ill children and

adults at home is predicated on the assumption

that many ill individuals who are not critically ill

can, and will need to be cared for in the home. 

In addition, this intervention may be combined

with the use of influenza antiviral medications

for treatment (as appropriate), as long as such

medications are effective and sufficient in

quantity and that feasible plans and protocols for

distribution are in place.

Requirements for success include prompt

recognition of illness, appropriate use of hygiene

and infection control practices in the home

setting (specific guidance is forthcoming and

will be available on www.pandemicflu.gov);

measures to promote voluntary compliance

(e.g., timely and effective risk communications);

commitment of employers to support the

recommendation that ill employees stay home;

and support for the financial, social, physical, and

mental health needs of patients and caregivers. 

In addition, ill individuals and their household

members need clear, concise information about

how to care for an ill individual in the home and

when and where to seek medical care. Special

consideration should be made for persons who

live alone, as many of these individuals may be

unable to care for themselves if ill.
38

Community Mitigation Guidance

Voluntary Quarantine of Household Members of 

Ill Persons

The goal of this intervention is to reduce

community transmission from members of

households in which there is a person ill with

pandemic influenza. Members of households in

which there is an ill person may be at increased

risk of becoming infected with a pandemic

influenza virus. As determined on the basis of

known characteristics of influenza, a significant

proportion of these persons may shed virus

and present a risk of infecting others in the

community despite having asymptomatic or

only minimally symptomatic illness that is not

recognized as pandemic influenza disease. Thus,

members of households with ill individuals may

be recommended to stay home for an incubation

period, 7 days (voluntary quarantine) following

the time of symptom onset in the household

member. If other family members become ill

during this period, the recommendation is to

extend the time of voluntary home quarantine

for another incubation period, 7 days from

the time that the last family member becomes

ill. In addition, consideration may be given

to combining this intervention with provision

of influenza antiviral medication to persons in

quarantine if such medications are effective and

sufficient in quantity and if a feasible means of

distributing them is in place.

Requirements for success of this intervention

include the prompt and accurate identification

of an ill person in the household, voluntary

compliance with quarantine by household

members, commitment of employers to support

the recommendation that employees living

in a household with an ill individual stay

home, the ability to provide needed support to

households that are under voluntary quarantine,

and guidance for infection control in the home. 

Additionally, adherence to ethical principals

in use of quarantine during pandemics, along

with proactive anti-stigma measures should be

assured.83, 84

Child Social Distancing

The goal of these interventions is to protect

children and to decrease transmission among

children in dense classroom and non-school

settings and, thus, to decrease introduction

into households and the community at large. 

Social distancing interventions for children

include dismissal of students from classrooms

and closure of childcare programs, coupled

with protecting children and teenagers through

social distancing in the community to achieve

reductions of out-of-school social contacts and

community mixing. Childcare facilities and

schools represent an important point of epidemic

amplification, while the children themselves, for

reasons cited above, are thought to be efficient

transmitters of disease in any setting. The

common sense desire of parents to protect their

children by limiting their contacts with others

during a severe pandemic is congruent with

public health priorities, and parents should be

advised that they could protect their children

by reducing their social contacts as much as

possible. 

However, it is acknowledged that maintaining the

strict confinement of children during a pandemic

would raise significant problems for many

families and may cause psychosocial stress to

children and adolescents. These considerations

must be weighed against the severity of a given

pandemic virus to the community at large and

to children in particular. Risk of introduction

of an infection into a group and subsequent

transmission among group members is directly

related to the functional number of individuals

in the group. Although the available evidence

currently does not permit the specification of

a “safe” group size, activities that recreate the

typical density and numbers of children in school

classrooms are clearly to be avoided. Gatherings

of children that are comparable to family-size

units may be acceptable and could be important

in facilitating social interaction and play

behaviors for children and promoting emotional

and psychosocial stability.
39

Community Mitigation Guidance

A recent study of children between the ages of

25 and 36 months found that children in group

care with six or more children were 2.2 times as

likely to have an upper respiratory tract illness

as children reared at home or in small-group

care (defined as fewer than six children).85 If a

recommendation for social distancing of children

is advised during a pandemic and families must

nevertheless group their children for pragmatic

reasons, it is recommended that group sizes be

held to a minimum and that mixing between

such groups be minimized (e.g., children should

not move from group to group or have extended

social contacts outside the designated group). 

Requirements for success of these interventions

include consistent implementation among

all schools in a region being affected by an

outbreak of pandemic influenza, community and

parental commitment to keeping children from

congregating out of school, alternative options

for the education and social interaction of the

children, clear legal authorities for decisions to

dismiss students from classes and identification

of the decision-makers, and support for parents

and adolescents who need to stay home from

work. Interim recommendations for prepandemic planning for this intervention include a

three-tiered strategy: 1) no dismissal of students

from schools or closure of childcare facilities

in a Category 1 pandemic, 2) short-term (up

to 4 weeks) dismissal of students and closure

of childcare facilities during a Category 2 or

Category 3 pandemic, and 3) prolonged (up to

12 weeks) dismissal of students and closure of

childcare facilities during a severe influenza

pandemic (Category 4 or Category 5). The

conceptual thinking behind this recommendation

is developed more fully in Section VII, Duration 

of Implementation of Nonpharmaceutical 

Interventions.

Colleges and universities present unique

challenges in terms of pre-pandemic planning

because many aspects of student life and activity

encompass factors that are common to both

the child school environment (e.g., classroom/

dormitory density) and the adult sphere (e.g.,

commuting longer distances for university

attendance and participating in activities and

behaviors associated with an older student

population). Questions remain with regard to the

optimal strategy for managing this population

during the early stages of an influenza pandemic.

The number of college students in the United

States is significant. There are approximately 17

million college students attending both 2- and 4-

year universities 86, a large number of whom live

away from home.87 Of the 8.3 million students

attending public or private 4-year colleges and

universities, less than 20 percent live at home

with their parents.

At the onset of a pandemic, many parents may

want their children who are attending college

or university to return home from school. 

Immediately following the announcement of

an outbreak, colleges and universities should

prepare to manage or assist large numbers of

students departing school and returning home

within a short time span. Where possible,

policies should be explored that are aligned with

the travel of large numbers of students to reunite

with family and the significant motivations

behind this behavior. Pre-pandemic planning to

identify those students likely to return home and

those who may require assistance for imminent

travel may allow more effective management of

the situation. In addition, planning should be

considered for those students who may be unable

to return home during a pandemic.

Adult Social Distancing

Social distancing measures for adults include

provisions for both workplaces and the

community and may play an important role in

slowing or limiting community transmission

pressure. The goals of workplace measures are

to reduce transmission within the workplace and

thus into the community at large, to ensure a safe

working environment and promote confidence
40

Community Mitigation Guidance

in the workplace, and to maintain business

continuity, especially for critical infrastructure. 

Workplace measures such as encouragement

of telework and other alternatives to in-person

meetings may be important in reducing social

contacts and the accompanying increased risk of

transmission. Similarly, modifications to work

schedules, such as staggered shifts, may also

reduce transmission risk. 

Within the community, the goals of these

interventions are to reduce community

transmission pressures and thus slow or limit

transmission. Cancellation or postponement

of large gatherings, such as concerts or theatre

showings, may reduce transmission risk. 

Modifications to mass transit policies/ridership

to decrease passenger density may also reduce

transmission risk, but such changes may require

running additional trains and buses, which

may be challenging due to transit employee

absenteeism, equipment availability, and the

transit authority’s financial ability to operate

nearly empty train cars or buses.

Requirements for success of these various

measures include the commitment of employers

to providing options and making changes in

work environments to reduce contacts while

maintaining operations; whereas, within

communities, the support of political and

business leaders as well as public support is

critical.
The timing of initiation of various NPIs will

influence their effectiveness. Implementing

these measures prior to the pandemic may result

in economic and social hardship without public

health benefit and may result in compliance

fatigue. Conversely, implementing these

interventions after extensive spread of a

pandemic influenza strain may limit the public

health benefits of an early, targeted, and layered

mitigation strategy. Identifying the optimal

time for initiation of these interventions will be

challenging, as implementation likely needs

to be early enough to preclude the initial steep

upslope in case numbers and long enough to

cover the peak of the anticipated epidemic curve

while avoiding intervention fatigue. In this

document, the use of these measures is aligned

with declaration by WHO of having entered the

Pandemic Period Phase 6 and a U.S. Government

declaration of Stage 3, 4, or 5.

Case fatality ratio and excess mortality rates

may be used as a measure of the potential

severity of a pandemic and, thus, suggest the

appropriate nonpharmaceutical tools; however,

mortality estimates alone are not suitable trigger

points for action. This guidance suggests

the primary activation trigger for initiating

interventions be the arrival and transmission

of pandemic virus. This trigger is best defined

by a laboratory-confirmed cluster of infection

with a novel influenza virus and evidence of

community transmission (i.e., epidemiologically

linked cases from more than one household). 

Other factors that will inform decision-making

by public health officials include the average

number of new infections that a typical

infectious person will produce during the

Triggers for Initiating Use of

Nonpharmaceutical Interventions

VI

course of his/her infection (R0) and the illness

rate. For the recommendations in this interim

guidance, trigger points for action assume an

R0 of 1.5-2.0 and an illness rate of 20 percent

for adults and 40 percent for children. In this

context, in all categories of pandemic severity,

it is recommended that State health authorities

activate appropriate interventions (as described

in Table 2) when a laboratory-confirmed human

pandemic influenza case cluster is reported in

their State or region (as appropriate) and there is

evidence of community transmission. 

Defining the proper geospatial-temporal

boundary for this cluster is complex and should

recognize that our connectedness as communities

goes beyond spatial proximity and includes ease,

speed, and volume of travel between geopolitical

jurisdictions (e.g., despite the physical distance,

Hong Kong, London, and New York City may

be more epidemiologically linked to each other

than they are to their proximate rural provinces/

areas). In this document in order to balance

connectedness and the optimal timing referenced

above, it is proposed that the geopolitical trigger

be defined as the cluster of cases occurring

within a U.S. State or proximate epidemiological

region (e.g., a metropolitan area that spans more

than one State’s boundary). It is acknowledged

this definition of region is open to interpretation;

however, it offers flexibility to State and local

decision-makers while underscoring the need for

regional coordination in pre-pandemic planning. 

From a pre-pandemic planning perspective, the

steps between recognition of pandemic threat

and the decision to activate a response are

critical to successful implementation. Thus, a

41
42

Community Mitigation Guidance

key component is the development of scenariospecific contingency plans for pandemic

response that identify key personnel, critical

resources, and processes. To emphasize the

importance of this concept, this guidance section

on triggers introduces the terminology of Alert, 

Standby, and Activate, which reflect key steps

in escalation of response action. Alert includes

notification of critical systems and personnel

of their impending activation, Standby includes

initiation of decision-making processes for

imminent activation, including mobilization

of resources and personnel, and Activate refers

to implementation of the specified pandemic

mitigation measures. Pre-pandemic planning

for use of these interventions should be directed

to lessening the transition time between Alert,

Standby, and Activate. The speed of transmission

may drive the amount of time decision-makers

are allotted in each mode, as does the amount of

time it takes to truly implement the intervention

once a decision is made to activate.

These triggers for implementation of NPIs will

be most useful early in a pandemic and are

summarized in Table 3. This table provides

recommendations arrayed by Pandemic Severity

Index and U.S. Government Stage for step-wise

escalation of action from Alert, to Standby, to

Activate.

Table 3. Triggers for Implementation of Mitigation Strategy by Pandemic Severity Index and

 U.S. Government Stages 

Alert: Notification of critical systems and personnel of their impending

activation.

Standby: Initiate decision-making processes for imminent activation,

including mobilization of resources and personnel.

Activate: Implementation of the community mitigation strategy.

*Widespread human outbreaks in multiple locations overseas.

†First human case in North America.

§Spread throughout the United States.

¶Recommendations for regional planning acknowledge the tight

linkages that may exist between cities and metropolitan areas that are not

encompassed within state boundaries.

**Standby applies. However, Alert actions for Category 4 and 5 should

occur during WHO Phase 5, which corresponds to U.S. Government Stage

2.

††Standby/Activate Standby applies unless the laboratory-confirmed case

cluster and community transmission occurs within a given jurisdiction, in

which case that jurisdiction should proceed directly to Activate community

interventions defined in Table 2.
43

Community Mitigation Guidance

For the most severe pandemics (Categories 4

and 5), Alert is implemented during WHO Phase

5/U.S. Government Stage 2 (confirmed human

outbreak overseas), and Standby is initiated

during WHO Phase 6/U.S. Government Stage

3 (widespread human outbreaks in multiple

locations overseas). Standby is maintained

through Stage 4 (first human case in North

America), with the exception of the State or

region in which a laboratory-confirmed human

pandemic influenza case cluster with evidence

of community transmission is identified. The

recommendation for that State or region is to

Activate the appropriate NPIs as defined in

Table 2 when identification of a cluster and

community transmission is made. Other States

or regions Activate appropriate interventions

when they identify laboratory-confirmed human

pandemic influenza case clusters with evidence

of community transmission in their jurisdictions.

For Category 1, 2, and 3 pandemics, Alert

is declared during U.S. Government Stage

3, with step-wise progression by States and

regions to Standby based on U.S. Government

declaration of Stage 4 and the identification of

the first human pandemic influenza case(s) in

the United States. Progression to Activate by a

given State or region occurs when that State or

region identifies a laboratory-confirmed human

pandemic influenza case cluster with evidence of

community transmission.

Determining the likely time frames for

progression through Alert, Standby, and Activate

postures is difficult. Predicting this progression

would involve knowing 1) the speed at which the

pandemic is progressing and 2) the segments of

the population most likely to have severe illness. 

These two factors are dependent on a complex

interaction of multiple factors, including but not

limited to the novelty of the virus, efficiency of

transmission, seasonal effects, and the use of

countermeasures. Thus it is not possible to use

these two factors to forecast progression prior to

recognition and characterization of a pandemic

outbreak, and predictions within the context of

an initial outbreak investigation are subject to

significant limitations. Therefore, from a prepandemic planning perspective and given the

potential for exponential spread of pandemic

disease, it is prudent to plan for a process of rapid

implementation of the recommended measures.

Once the pandemic strain is established in

the United States, it may not be necessary for

States to wait for documented pandemic strain

infections in their jurisdictions to guide their

implementation of interventions, especially for a

strain that is associated with a high case fatality

ratio or excess mortality rate. When a pandemic

has demonstrated spread to several regions

within the United States, less direct measures of

influenza circulation (e.g., increases in influenzalike illness, hospitalization rates, or other locally

available data demonstrating an increase above

expected rates of respiratory illness) may be used

to trigger implementation; however, such indirect

measures may play a more prominent role in

pandemics within the lower Pandemic Severity

Index categories.

Once WHO has declared that the world has

entered Pandemic Phase 5 (substantial pandemic

risk), CDC will frequently provide guidance on

the Pandemic Severity Index. These assessments

of pandemic severity will be based on the most

recent data available, whether obtained from the

United States or from other countries, and may

use case fatality ratio data, excess mortality data,

or other data, whether available from outbreak

investigations or from existing surveillance.
Preliminary analysis of historical data from

selected U.S. cities during the 1918 pandemic

suggests that duration of implementation of

NPI’s is significantly associated with overall

mortality rates. Stopping or limiting the intensity

of interventions while pandemic virus was still

circulating within the community was temporally

associated with recrudescent increases in

mortality due to pneumonia and influenza

in some communities.20, 81 Total duration of

implementation for the measures specified in

this guidance will depend on the severity of the

pandemic and the total duration of the pandemic

wave in the community, which may average

about 6-8 weeks in individual communities. 

However, because early implementation

of pandemic mitigation interventions may

reduce the virus’s basic reproductive number,

a mitigated pandemic wave may have lower

amplitude but longer wavelength than an

unmitigated pandemic wave (see Figure 2). 

Communities should therefore be prepared to

maintain these measures for up to 12 weeks in a

Category 4 or 5 pandemic.

It is important to emphasize that as long as

susceptible individuals are present in large

numbers, spread may continue. Immunity to

infection with a pandemic strain can only occur

after natural infection or immunization with an

effective vaccine. The significant determinants

for movement of a pandemic wave through a

community are immunity and herd effect, and

there is likely to be a residual pool of susceptible

individuals in the community at all times. Thus,

while NPIs may limit or slow community

transmission, persisting pandemic virus

circulating in a community with a susceptible

population is a risk factor for re-emergence of the

Duration of Implementation of

Nonpharmaceutical Interventions

VII

pandemic. Monitoring of excess mortality, case

fatality ratios, or other surrogate markers over

time will be important for determining both the

optimal duration of implementation and the need

for resumption of these measures. 

While the decisions to stop or limit the intensity

of implementation are crucial factors in

pandemic response, this document is primarily

oriented to providing pre-pandemic planning

guidance. It is recommended for planning

purposes that a total duration of 12 weeks for

implementation of these measures be considered,

particularly with regard to severe pandemics of

Category 4 or 5 in which recrudescent disease

may have significant impact. However, for

less severe pandemics, a shorter period of

implementation may be adequate to achieving

public health benefit.

This guidance recommends a three-tiered

strategy for planning with respect to the

duration of dismissal of children from schools,

colleges and universities, and childcare

programs (Table 2):

•	 No dismissal of students from schools or

closure of childcare facilities in a Category 1

pandemic

•	 Short-term (up to 4 weeks) dismissal of

students and closure of childcare facilities

during a Category 2 or Category 3 pandemic

•	 Prolonged (up to 12 weeks) dismissal of

students and closure of childcare facilities

during a severe influenza pandemic (Category

4 or Category 5 pandemic)

45
46

Community Mitigation Guidance

This planning recommendation acknowledges the

uncertainty around the length of time a pandemic

virus will circulate in a given community and around

the potential for recrudescent disease when use of

NPIs is limited or stopped. When dismissals and

closures are indicated for the most severe pandemics,

thoughtful pre-planning for their prolonged duration

may allow continued use of this intervention.
A number of outstanding issues should be

addressed to optimize the planning for use

of these measures. These issues include

the establishment of sensitive and timely

surveillance, the planning and conducting of

multi-level exercises to evaluate the feasibility

of implementation, and the identification

and establishment of appropriate monitoring

and evaluation systems. Policy guidance in

development regarding the use of antiviral

medications for prophylaxis, community and

workplace-specific use of personal protective

equipment, and safe home management of ill

persons must be fast-tracked and prioritized as

part of future versions of the overall community

mitigation strategy. As well, developing

appropriate and effective risk communication

content and a means for its effective delivery,

soliciting active community support and

involvement in strategic planning decisions, and

assisting individuals and families in identifying

their own preparedness needs are critical

community factors in achieving success.

Establishing and maintaining sensitive and

timely surveillance at national, State, and local

levels is critical. Achieving this goal will require

enhancing the capability of local physicians

and public health authorities to rapidly identify

suspect cases of pandemic influenza. This

increased capability may be facilitated by the

development of point-of-care testing and the

appropriate laboratory capacity and ability

to transmit specimens and data to reference

laboratories.

In addition, establishing protocols for notification

of Federal authorities and establishing

effective reporting and feedback systems to

ensure information is shared appropriately

with State and local decision-makers is a key

requirement. Within this framework, focused

support of established systems, such as the 121

Cities Mortality Reporting System 88, and the

establishment of electronic mortality records

may facilitate the rapid robust reporting of data

elements to support the timely and appropriate

implementation of NPIs. Similarly, establishing

surveillance systems to monitor trends in

disease in a community and to provide guidance

on adjusting implementation of interventions

and determining appropriate durations for

intervention are critical components for

implementation and will provide valuable data

for decision-making around lifting interventions.

Critical issues remain with regard to ensuring

both timely implementation and appropriate

layering of interventions. Preliminary analysis

of historical data and mathematical modeling

suggest that the early, coordinated application

of multiple interventions may be more effective

in reducing transmission than the use of a single

intervention. Multi-level exercises to evaluate

the feasibility of implementation and identify

critical enablers for use of these measures

are required. In addition, early planning for

appropriate monitoring and evaluation systems

to provide assessment of the effectiveness of all

proposed pandemic influenza interventions is

needed. Policies and plans are required to ensure

the availability of rapid diagnostic testing to

distinguish influenza-like illness due to seasonal

influenza strains and other respiratory pathogens

from illnesses due to pandemic influenza strains. 

Accurate ascertainment of pandemic influenza

Critical Issues for the Use of

Nonpharmaceutical Interventions

VIII

47
48

Community Mitigation Guidance

cases is needed early during the course of a pandemic

to minimize unnecessary application of mitigation

interventions and in later stages of the pandemic to

ascertain persisting community transmission.

Policies and planning for distribution of antiviral

medications for treatment (and prophylaxis) needs

to account for local capabilities, availability of the

antiviral medications, and systems for distribution

that could leverage the combined capabilities of

public health organizations, the private sector,

community organizations, and local governments. 

As well, guidance for community- and workplacespecific use of personal protective equipment is

required, as are policies and planning to support their

use.

Clear and consistent guidance is required for planning

for home care of ill individuals, such as when and

where to seek medical care, how to safely care for an

ill individual at home, and how to minimize disease

transmission in the household. In addition, guidance

is required for appropriate use of community

resources, such as home healthcare services,

telephone care, the 9-1-1 emergency telephone

system, emergency medical services, and triage

services (nurse-advice lines, self-care guidance, and

at-home monitoring systems) that could be deployed

to provide resources for home care. 

Community engagement is another critical issue for

successful implementation and includes building a

foundation of community preparedness to ensure

compliance with pandemic mitigation measures. 

Community planners should use media and trusted

sources in communities to 1) explain the concepts of

pandemic preparedness, 2) explain what individuals

and families can do to be better prepared, and 3)

disseminate clear information about what the public

may be asked to do in the case of a pandemic. In

addition, developing and delivering effective

risk communications in advance of and during a

pandemic to guide the public in following official

recommendations and to minimize fear and panic will

be crucial to maintaining public trust.
A Harvard School of Public Health public

opinion poll was conducted with a nationally

representative sample of adults over the age

of 18 years in the United States in SeptemberOctober 2006 to explore the public’s willingness

to adhere to community mitigation strategies. 

A majority of the almost 1,700 respondents

reported their willingness to follow public

health recommendations for the use of NPIs, but

this poll also uncovered serious financial and

other concerns.89 The respondents were first

read a scenario about an outbreak of pandemic

influenza that spreads rapidly among humans

and causes severe illness. They were then asked

how they would respond to and be affected by

the circumstances that would arise from such an

outbreak.90

Recognizing that their lives would be disrupted,

most participants expressed willingness to limit

contact with others at the workplace and in public

places. More than three-fourths of respondents

said they would cooperate if public health

officials recommended that for 1 month they

curtail various activities of their daily lives, such

as using public transportation, going to the mall,

and going to church/religious services. However,

the poll respondents were not asked if they would

be willing to follow those recommendations for

longer periods in the case of a severe pandemic.

More than nine in ten (94 percent) said they

would stay at home away from other people for

7-10 days if they had pandemic influenza. Nearly

three-fourths (73 percent) said they would have

someone to take care of them at home if they

became ill with pandemic influenza and had to

remain at home for seven to ten days. However,

Assessment of the Public on Feasibility

of Implementation and Adherence

IX

about one in four (24 percent) said they would

not have someone to take care of them.

In addition, 85 percent of the respondents said

they and all members of their household would

stay at home for seven to ten days if another

member of their household was ill. However,

about three-fourths (76 percent) said they would

be worried that if they stayed at home with a

household member who was ill from pandemic

influenza, they themselves would become ill

from the disease. A substantial proportion of

the public believed that they or a household

member would be likely to experience various

problems, such as losing pay, being unable to get

the healthcare or prescription drugs they need, or

being unable to get care for an older person or a

person with a disability, if they stayed at home

for 7-10 days and avoided contact with anyone

outside their household.

If schools and daycare were closed for 1

month, 93 percent of adults who have major

responsibility for children under age 5 who are

normally in daycare or for children 5 to 17 years

of age and who have at least one employed adult

in the household think they would be able to

arrange care so that at least one employed adult

in the household could go to work. Almost as

many (86 percent) believe they would be able to

do so if schools were closed for 3 months.

When asked about possible financial difficulties

due to missed work, a greater number of

respondents reported they would face financial

problems. While most employed people (74

percent) believed they could miss 7-10 days of

work without having serious financial problems,

49
50

Community Mitigation Guidance

one in four (25 percent) said they would face

such problems. A majority (57 percent) think

they would have serious financial problems if

they had to miss work for 1 month, and threefourths of respondents (76 percent) thought they

would have such problems if they were away

from work for 3 months.

The Public Engagement Project on Community

Control Measures Against a Severe Pandemic

of Influenza was carried out in October and

November 2006.91 Two to three representatives

from the organized stakeholder public were

chosen from approximately ten major sectors

likely to be affected by the measures (e.g.,

public health, education, private sector) to form

a 50-member national level panel. In addition,

a representative sample of approximately 260

citizens from the general public was recruited

from Seattle, Washington; Syracuse, New

York; Lincoln, Nebraska; and Atlanta, Georgia. 

Participants were presented with a scenario

describing a severe pandemic and asked to

consider their support for the use of the NPIs

outlined above. 

Approximately 95 percent or more of the

citizens and stakeholders supported encouraging

ill persons to stay at home, and the same high

percentage supported canceling large public

gatherings and altering work patterns for the

purpose of social distancing. A lower percentage

(83-84 percent) supported encouraging the

members of households with ill persons to

stay at home, and a similar percentage favored

closing schools and large day care facilities for

an extended period. Overall, approximately

two-thirds of both citizens and stakeholders (64-

70 percent) supported all of the interventions. 

Based on the scenario of a severe pandemic,

nearly half (44-48 percent) of the citizens and

stakeholders supported implementation of the

interventions when pandemic influenza first

strikes the United States, and approximately

one-third of the public supported implementation

when influenza first strikes in their State.

Although the findings from this poll and public

engagement activity reported high levels of

willingness to follow pandemic mitigation

recommendations, it is uncertain how the public

might react when a pandemic occurs. These

results need to be interpreted with caution

in advance of a severe pandemic that could

cause prolonged disruption of daily life and

widespread illness in a community. Adherence

rates may be higher during the early stages of a

pandemic and adherence fatigue may increase

in the later stages. These results may not be

able to predict how the public would respond

to a severe pandemic in their community nor

predict how the public will tolerate measures that

must be sustained for several months. Changes

in perceived risk from observed mortality and

morbidity during a pandemic relative to the

need for income and the level of community

and individual/family disruption caused by

the mitigation interventions may be major

determinants of changes in public adherence.
Pandemic mitigation interventions will pose

challenges for individuals and families,

employers (both public and private), and local

communities. Some cascading second- and thirdorder effects will arise as a consequence of the

use of NPIs. However, until a pandemic-strain

vaccine is widely available during a pandemic,

these interventions are key measures to reduce

disease transmission and protect the health of

Americans. The community mitigation strategy

emphasizes care in the home and underscores

the need for individual, family, and employer

preparedness. Adherence to these interventions

will test the resiliency of individuals, families,

and employers. 

The major areas of concern derive from the

recommendation to dismiss children from school

and closure of childcare programs. The concerns

include 1) the economic impact to families;

2) the potential disruption to all employers,

including businesses and governmental agencies;

3) access to essential goods and services; and 4)

the disruption of school-related services (e.g.,

school meal programs). Other interventions,

such as home isolation and voluntary home

quarantine of members of households with ill

persons, would also contribute to increased

absenteeism from work and affect both business

operations and employees. These issues are of

particular concern for vulnerable populations

who may be disproportionately impacted. 

However, these and other consequences may

occur in the absence of community-wide

interventions because of spontaneous action by

the public or as a result of closures of schools and

workplaces related to absenteeism of students

Planning to Minimize Consequences

of Community Mitigation Strategy

X

and employees. These consequences associated

with the pandemic mitigation interventions must

be weighed against the economic and social costs

of an unmitigated pandemic.

Many families already employ a number

of strategies to balance childcare and work

responsibilities. Pandemic mitigation

interventions, especially dismissal of students

from school classes and childcare programs, will

be even more challenging. These efforts will

require the active planning and engagement of all

sectors of society.

Impact of School Closure on the 

Workforce

Workplace absenteeism is the primary issue

underlying many of the concerns related to the

pandemic mitigation strategies. Absenteeism

for child minding could last as long as 12

weeks for a severe pandemic. The potential

loss of personal income or employment due to

absenteeism related to prolonged cancellation

of school classes and the need for child minding

can lead to financial insecurity, fear, and worry. 

Workplace absenteeism, if severe enough,

could also affect employers and contribute

to some workplaces reducing or closing

operations (either temporarily or permanently). 

Depending on the employers affected, this could

limit the availability of essential goods and

services provided by the private sector and the

government, interrupting critical business supply

chains and potentially threatening the ability

to sustain critical infrastructure. Workplace

absenteeism and the resulting interruption of

household income would test the resiliency

51
52

Community Mitigation Guidance

of all families and individuals but would

be particularly challenging for vulnerable

populations. The potential impact on society

underscores the need for preparedness of

individuals, families, businesses, organizations,

government agencies, and communities. 

There are 300 million Americans living in 116

million households in the United States.92 

Approximately one-third of U.S. households

(40 million) include children less than 18 years

of age. In slightly more than half of these

households (22 million), all adults present are

working. Five million of these households have

only a single working adult present. These

households with children and only one working

adult would be impacted disproportionately—

potentially requiring the single working adult

in the household to remain home to mind the

children if students were dismissed from schools

or childcare facilities were closed. 

Depending upon the age threshold assumed for

children requiring adult supervision, the impact

of dismissing students from school and closure

of childcare programs on working families would

vary. The number of households impacted could

range from 12.4 million (assuming children <13

years of age would require adult supervision) to

15.4 million (assuming children <15 years of age

would require full-time adult supervision).

The projected impact of these estimates,

however, does not fully account for the strategies

families already employ to care for their children

and remain in the workforce. Families with

all adults in the household working currently

utilize a number of strategies for child minding,

including the assistance of other family members,

such as grandparents and siblings, assistance

from separated/divorced spouses, children

minding themselves, staggered work/childminding shifts for parents, and parents working

from home. There are 60 million children under

the age of 15. Over half these children (32

million or 56 percent) have a working mother. 

Nearly one-third (29 percent) of these children

have a mother who works a non-day shift. 

Nearly one-third (29 percent) have a mother

working part time. Nearly one-third (30 percent)

of children under age 5 living with only their

father in the household were regularly cared for

by their mother while their father was working or

in school. One of seven (14 percent) school age

children, 5-14 years of age, living with only one

parent in the household were regularly cared for

by the other parent while their father or mother

was working or attending school.93

The Harvard School of Public Health public

opinion poll reported that 86 percent of families

with children under age 5 in childcare or

children 5-17 years of age would be able to

arrange for childcare to allow at least one adult

in the household to continue to work if classes

and childcare were cancelled for 3 months.89 

These findings, when applied to the overall

population, suggest that approximately one in

seven households with children attending school

or childcare would be unable to have at least one

adult continue to work during a prolonged period

of school and childcare cancellation. 

Impact of Voluntary Home Isolation

and Voluntary Home Quarantine 

The impacts of pandemic mitigation

interventions on workplace absenteeism are

overlapping. In contrast to possible prolonged

absenteeism for child minding, voluntary

home quarantine would require all household

members of an ill individual to remain home for

approximately 1 week (single-person households,

representing 27 percent of all U.S. households,

would not be impacted by this intervention). 

In addition, ill individuals would stay home

from work for a period of approximately 7-10

days. When estimating overall absenteeism, this

hierarchy suggests first considering the impact

of child minding, then illness, then quarantine.

For example, if a working single parent remains

home from work for 12 weeks to mind her

children, workplace absenteeism is unaffected

if one of her children becomes ill and the home
53

Community Mitigation Guidance

voluntarily quarantines itself (the adult will

remain absent from the workplace for 12 weeks

due to child minding).If a working adult living

in a household of two or more people becomes

ill and is absent due to illness, the additional

impact of absenteeism related to voluntary home

quarantine would only apply if there are other

non-ill working adults present in the household. 

Absenteeism due to illness is directly related to

the rate of clinical illness in the population. The

proposed community interventions attempt to

reduce disease transmission and illness rates. As

illness rates are reduced, absenteeism related

to illness and quarantine would be expected to

decline, whereas absenteeism related to child

minding would remain constant. 

The feasibility of following pandemic mitigation

interventions is of particular concern for

vulnerable populations (e.g., people who are

living alone, the poor or working poor, elderly,

[particularly those who are homebound],

homeless, recent immigrants, disabled,

institutionalized, or incarcerated). More than

31 million individuals in the United States

live alone (27 percent of all households) and

one-third of these individuals are age 65 years

or older.According to the Harvard School of

Public Health public opinion poll, 45 percent of

respondents living in one-adult households report

they would not have anyone to take care of them

in the event of a pandemic.90More than four in

ten respondents living in one-adult households

(45 percent) and about one-third of low-income

(36 percent), African-American (34 percent),

disabled (33 percent), or chronically ill (32

percent) adults said they would not have anyone

to take care of them if they were ill and had to

remain at home. Similarly among people age 65

or over, those who live in one-adult households

were far more likely (41 percent vs 15 percent)

than those who lived in two-adult households

with another person age 65 or over to say they

would have no one to take care of them.

Additionally, the millions of frail elderly

individuals who require life-sustaining supports

to remain in the community would need

additional consideration. Planning should

begin now to include solutions to address the

needs of the frail elderly. Of the approximately

45 million seniors (age 65 years and older)

currently in the United States, 5 percent, or

2.25 million are considered frail. Currently the

Elderly Nutrition Program provides meals for

approximately 3 million elderly participants,

including the frail elderly, in congregate settings,

or through volunteers who provide homebound

seniors with home-delivered meals. Participants

receive approximately half of their daily

nutritional needs from those meals. In addition,

other related community-based services, such

as transportation and healthcare, are critical

for seniors, particularly the frail elderly, who

receive this assistance in order to maintain

their independence.94, 95 Communities will

need to plan for how these vital supports can

continue both for this population as well as for

other groups with unique physical and mental

challenges in light of efforts to protect lives and

limit the spread of disease.

Strategies to Minimize Impact of 

Workplace Absenteeism

Solutions or strategies for minimizing the

impact of dismissal of students from school and

closure of childcare programs and workplace

absenteeism may include the following: 1)

employing child-minding strategies to permit

continued employment; 2) employing flexible

work arrangements to allow persons who are

minding children or in quarantine to continue to

work; 3) minimizing the impact on household

income through income replacement; and 4)

ensuring job security.

In contrast to the unpredictable nature of

workplace absenteeism related to illness

(unpredictability of who will be affected and

who will be absent from work), it may be easier

to forecast who is likely to be impacted by the

dismissal of students from school and/or the
54

Community Mitigation Guidance

closure of childcare. Accordingly, early planning

and preparedness by employers, communities,

individuals, and families is critical to minimizing

the impact of this intervention on families and

businesses. 

In a severe pandemic, parents would be advised

to protect their children by reducing out-ofschool social contacts and mixing with other

children.96 The safest arrangement would be to

limit contact to immediate family members and

for those family members to care for children

in the home. However, if this is not feasible,

families may be able to develop support systems

with co-workers, friends, families, or neighbors,

to meet ongoing childcare needs.For example,

they could prepare a plan in which two to three

families work together to supervise and provide

care for a small group of infants and young

children.

As was noted in the Harvard School of Public

Health public opinion poll, parents reported

that they would primarily depend upon family

members to assist with child minding (self/

family member in the home, 82 percent; children

caring for themselves, 6 percent; family member

outside the home, 5 percent; and combination, 5

percent). One of four households with children

under age 5 in childcare or children 5-17 years

of age estimated that they would be able to work

from home and care for their children. Students

returning home from colleges and universities

may also be available to assist with child

minding.90

More than half (57 percent) of private-sector

employees have access to paid sick leave.97 

More than three-fourths (77 percent) have paid

vacation leave, and 37 percent have paid personal

leave. Currently, leave policies would likely not

cover the extended time associated with child

minding. Expanded leave policies and use of

workplace flexibilities, including staggered shifts

and telework, would help employees balance

their work and family responsibilities during a

severe pandemic. Additional options to offset

the income loss for some employees meeting

specific requirements include provisions for

Unemployment Insurance. In addition, following

a “major disaster” declaration under the Stafford

Act, additional individual assistance, including

Disaster Unemployment Assistance, may become

available to eligible persons. The Family and

Medical Leave Act may also offer protections

in terms of job security for up to 12 weeks for

covered and eligible employees who have a

serious health condition or who are caring for a

family member with a serious health condition. 

In addition to employers expanding leave policies

and adopting workplace flexibilities, Federal,

State, local, tribal, and territorial officials should

review laws, regulations, and policies to identify

ways to help mitigate the economic impact of

a severe pandemic and implementation of the

pandemic mitigation measures on employers,

individuals, and families, especially vulnerable

populations. Clarity on such policies from

employers and the government will help workers

plan and prepare for the potential threat of a

severe pandemic and to plan and comply with the

pandemic mitigation intervention. Many of these

programs and policies would also be applicable if

no pandemic mitigation measures were in place

and absences were due to personal illness or the

need to care for an ill family member.

Interruption of School Meal Programs

An additional concern related to dismissal of

students is the interruption of services provided

by schools, including nutritional assistance

through the school meal programs. This would

alter the nature of services schools provide and

require that essential support services, including

nutritional assistance to vulnerable children, be

sustained though alternative arrangements. 

The National School Lunch Program operates in

more than 100,000 public and non-profit private

schools and residential childcare institutions 98,

and the School Breakfast Program operates
55

Community Mitigation Guidance

in approximately 80,000 schools 99. School

lunch and breakfast are free for students at or

below 130 percent of the poverty level and are

available at reduced price for students between

130 percent and 185 percent poverty level. Half

of the thirty million students that participate in

the School Lunch Program received free meals

in 2006. During the summer, a Summer Food

Service Program operates at more than 30,000

sites, providing breakfast, lunch and snacks to

children living in low-income areas; the program

served approximately 1.9 million total students in

2005.100

According to the Harvard School of Public

Health public opinion poll, 13 percent of

households with children receiving free school

meals reported that they would have a major

problem if schools were closed and meals

discontinued.90 Approximately 15 million

children currently receive free school meals;

thus, it is anticipated that about 2 million would

have a major problem associated with the

interruption of school meals.

Many of these households also depend upon

other Federal nutrition programs, including the

Food Stamp Program, the Special Supplemental

Nutrition Program for Women, Infants, and

Children, and the Child and Adult Care Food

Program, and community food pantries.

Strategies to Minimize the Impact of 

Interrupting School Meals

During a severe pandemic, it will be important

for individuals and families to plan to have extra

supplies on hand, as people may not be able

to get to a store, stores may be out of supplies,

and other services (e.g., community soup

kitchens and food pantries) may be disrupted. 

Communities and families with school-age

children who rely on school meal programs

should anticipate and plan as best they can for

a disruption of these services and school meal

programs for up to 12 weeks.

This may be particularly challenging for families

with children who already depend on a number

of these programs. The Federal Government is

working together with State and local emergency

response planners to find creative solutions to

meet nutrition assistance needs for vulnerable

populations.Local government and faith-based

and community leaders are being encouraged

to work closely with nutrition program

administrators at the local, State, and Federal

level to:

•	 Develop plans to address community nutrition

assistance needs during a pandemic

•	 Identify nutrition program adaptations needed

to respond to social distancing, voluntary

quarantines, and possible disruption of the

normal food supply

•	 Address challenges related to the supply and

delivery of food through commercial markets

•	 Identify current program flexibilities/

authorities and determine if others are needed

School Resources Available for 

Community Service

If students are dismissed from school but

schools remain open, school- and educationrelated assets, including school buildings, school

kitchens, school buses, and staff, may continue to

remain operational and potentially be of value to

the community in many other ways. In addition,

faculty and staff may be able to continue to

provide lessons and other services to students

by television, radio, mail, Internet, telephone,

or other media. Continued instruction is not

only important for maintaining learning but also

serves

as a strategy to engage students in a constructive

activity during the time that they are being asked

to remain at home.

Impact on Americans Living Abroad

Although this document primarily considers

a domestic influenza pandemic, it provides

guidance that is relevant to American

organizations and individuals based abroad. 
56

Community Mitigation Guidance

There are approximately 7 million American

citizens living overseas. About 3 million of

these are working abroad on behalf of more

than 50 Federal agencies, although the vast

majority are employees of the U.S. Department

of Defense and their dependents.101, 102 In

addition, there are 194 American Overseas

Schools that have students in all grades, the vast

majority of whom are children of U.S. citizens

working in government or for private companies

and contractors. Excluding the military,

approximately one-third of American households

overseas have children under 18 years of age,

and approximately half are households in which

both parents work.103 (“American households” in

this context is defined as households in which the

head of household is a U.S. citizen without dual

citizenship.) The impact of pandemic mitigation

measures on Americans overseas would be

similar to that in the United States, except that

there are very few extended family members

overseas to assist in childcare should schools

be closed. As a result, a decision to dismiss

students from school and close childcare could

result in increased workplace absenteeism. This

might be partially offset by the fact that singleparent households with children are less common

among Americans abroad than in the United

States.

During a pandemic, security for Americans

abroad could become an increased concern,

particularly in those countries that are unstable

or lack the capability to prevent lawlessness. In

such instances, the desire to close institutions,

such as schools or embassies, must be balanced

against the greater protection that can be

provided to American citizens who are gathered

in one place, rather than distributed in their

homes. Additionally, an estimated one-third (80

of 250) of U.S. diplomatic posts abroad have

undependable infrastructure for water, electricity,

and food availability, which may impair the

ability of people to adhere to NPIs.103

In consideration of these factors, many

Americans may wish to repatriate to the United

States at the outset of a pandemic, and this

should be considered in decisions to implement

closure of institutions and other NPIs in the

international setting.

Strategy to Reduce Impact

on Americans Living Abroad

Americans abroad should review pandemic

preparedness recommendations issued by

the U.S. Department of State and the U.S.

Department of Health and Human Services. 

Updated regional and country-specific

information is provided on www.pandemicflu.

gov, the CDC travel website (www.cdc.gov/

travel/), and the U.S. Department of State’s travel

site (www.travel.state.gov). In addition, two

million of the estimated 4.5 million non-military

affiliated Americans abroad are registered with

U.S. Embassies and Consulates, and are thus

able to receive warnings and announcements

from these diplomatic posts. Those preparing

to travel overseas can register for countryspecific announcements online at https://

travelregistration.State.gov/ibrs/.

Americans should not assume that international

transportation would be available during a

pandemic. As a result, Americans abroad

should identify local sources of healthcare and

prepare to “shelter-in-place” if necessary. In

those areas with potentially limited water and

food availability, Americans living abroad are

encouraged to maintain supplies of food and

water to last at least two and as long as 12 weeks. 

Additional recommendations for preparing for

a pandemic while abroad are available in the

State Department fact sheet How to Prepare for 

“Sheltering-In-Place,” which is available at

travel.State.gov/travel/tips/health/health_3096.

html.
Because pandemics occur rarely, drills and

exercises are required to test plans and to

maintain response proficiency. Such real-world

operational experience could yield invaluable

empirical evidence regarding how readily

particular pandemic mitigation measures might

be implemented and how well they might work

if applied on a larger scale and/or for longer

duration. Drills and exercises permit individuals

and organizations to carry out their normal

duties and relate to each other under unusual

circumstances in simulated environments that are

far less costly and threatening than real events.

Discussion-based exercises (e.g., tabletop

exercises) are a first step to help identify “gaps”

in the plans, policies, protocols, processes, and

procedures, included in planning for pandemic

mitigation interventions. Such gaps should

be filled before expensive, resource-intense,

operations-based drills and exercises are

conducted. For example, developing community

communications plans to notify the public about

the status of a pandemic, what protective actions

should be taken, and where to seek medical

advice during a pandemic, as well as planning for

distribution of antiviral medications, determining

the process for dismissal of students from

schools and closure of childcare facilities, and

planning for possible closure of mass gatherings

should be decided before conducting a full-scale

exercise. 

As responders practice the plan through

exercising, they learn which aspects of response

do not go “as planned.” After the exercise,

responders debrief (“hot wash”) and create

Testing and Exercising Community

Mitigation Interventions

XI

an after-action-report to describe corrective

actions to fix response problems, including

who is responsible for fixing what by when (a

“corrective action plan”). Proposed solutions

should be re-tested to ensure that they adequately

correct the response problem. 

In July 2006, CDC’s Coordinating Office

of Terrorism Preparedness and Emergency

Response provided supplemental guidance for

recipients of Federal funding through the Public 

Health Preparedness and Response Cooperative 

Agreement (Cooperative Agreement AA154)

specifically intended to foster developing and

exercising pandemic influenza plans. Specific

performance measures for testing and exercising

plans are listed in that guidance, which can

be accessed at www.bt.cdc.gov/planning/

coopagreement/pdf/phase2-panflu-guidance.pdf.

57
A comprehensive research agenda for pandemic

influenza is needed to improve the evidence

base of the proposed NPIs described in this

interim guidance. This agenda should include

conducting studies to gain more knowledge of

the epidemiology of influenza, the effectiveness

of community-based interventions, the use of

medical countermeasures that complement

community interventions, the modification

of existing mathematical modeling to include

adverse societal consequences, and the

development of new modeling frameworks to

assess the effectiveness of interventions.6, 13, 14,

19, 20, 104-108 Research to clarify or expand upon

these issues may be necessary during a pandemic

outbreak. Thus, planning for accelerated

Institutional Review Board approval in the

setting of a pandemic may facilitate important

research conducted in hospitals, public health

departments, and universities.

Key areas for further research

include the following:

•	 Enhancing epidemiologic and laboratory 

surveillance systems for influenza: Existing

influenza surveillance systems have gaps

in timeliness and completeness that will

hamper adequate functioning during a

pandemic. A high priority must be given to

the development of more timely surveillance

for laboratory-confirmed cases of human

infections with novel influenza A viruses,

methods to rapidly estimate the excess

mortality rate during a pandemic, better

use of existing electronic data sources, and

the development of platforms that can be

used to assess the effectiveness of pandemic

Research Needs

XII

interventions, including vaccines, antiviral

medications, and NPIs.

•	 Development of rapid diagnostics: The

development of sensitive and specific pointof-care rapid tests for influenza A subtypes

with pandemic potential may play an

important role in pandemic preparedness.

Laboratory diagnosis of influenza is critical

fortreatment, prophylaxis, surveillance,

vaccine development and efficacy, and

the timing of the initiation of pandemic

mitigation strategies. 

•	 Measurement of effectiveness of personal 

protective equipment (PPE, e.g., surgical 

masks and respirators) in community 

settings: Quantification of the effectiveness

of PPE for infection prevention, the ability

of community members to correctly use

PPE, the relative benefit of fit-testing for

respirator-use in community settings, the

utility of PPE for children and the elderly for

whom PPE is not currently designed, and the

relative contribution of PPE to safety in the

context of other NPIs should be undertaken.

•	 Determination of the trigger points for

implementation of NPIs: Infection with

influenza results in annual communitybased epidemics. While the historic data

from 1918 on use of NPIs indicate an

ecological relationship between timing and

effectiveness, additional prospective data

on timing of each of these measures will

usefully complement the value of historic

evidence. Studies of some of the NPIs can

be conducted during sporadic outbreaks of

seasonal influenza.

59
60

Community Mitigation Guidance

•	 Determination of markers to signal that it 

might be appropriate to end or lift pandemic 

mitigation interventions: Pandemic

mitigation measures may be employed in

communities until sufficient vaccine is

available to that population or until other

parameters are reached. Retrospective

and other studies could provide detailed

information regarding these predictive

factors.

•	 Advancing the knowledge base on 

pharmaceutical interventions: Antiviral

medications and vaccines are integral

components of pandemic mitigation

strategies. Availability and use of

medications can complement the

effectiveness of voluntary isolation and

quarantine and enhance compliance within

communities. Therefore, the capacity to

rapidly obtain data on antiviral and vaccine

effectiveness, the development of resistance,

and the assessment of distribution dynamics

is important to successful implementation of

pandemic mitigation strategies.

•	 Determination, through prospective field 

studies, of the effectiveness of interventions 

required to achieve reduced transmission: 

The evidence base for most of the

interventions currently suggested for use

is based on historic reviews, common

sense, and biological plausibility. Evidence

should be obtained through prospective

trials or observational studies conducted

during seasonal influenza outbreaks. 

Given the socioeconomic ramifications of

pandemic mitigation interventions such

as social distancing measures for children

and adults, adherence with prolonged use

of interventions is likely to be limited. 

Therefore, in addition to the assessment of

effectiveness, studies should also be done to

assess factors that promote compliance and

the optimal duration of interventions.

•	 Improved understanding of fundamental 

questions of influenza transmission and 

epidemiology: Prospective epidemiological

studies to address gaps in understanding of

influenza epidemiology and transmission and

the natural history of disease may guide the

application of NPIs in the community.

•	 Improved understanding of environmental 

factors that may influence influenza survival 

and transmissibility: Studies to elucidate

the impact of temperature, humidity,

radiation, seasonality, and other factors

and their relation to influenza transmission

in communities are needed to identify

complementary mitigation interventions.

•	 Improved measures of uncertainty with 

regard to parameter and model estimates 

for mathematical modeling of NPIs: 

Development of improved metrics of

uncertainty around interpretation of modeling

outputs may more appropriately guide

the incorporation of modeling results into

development of policy for community use of

these measures.

•	 Characterize and determine the potential 

psychosocial sequelae of voluntary home 

quarantine and social distancing strategies: 

Investigation of the use of home quarantine

and social distancing strategies in simulations

and in severe seasonal influenza outbreaks

could determine key issues that might arise

during a severe pandemic requiring long-term

social distancing strategies and might suggest

possible strategies to reduce untoward effects.

Studies that focus on incidences of school

closure that might be used for other disease

outbreaks might help to better understand

facilitators and barriers to adherence with

public health recommendations.

•	 Expanded parameter inputs for 

modeling the potential effectiveness of 

school and workplace interventions in 

mitigating an influenza pandemic: The

current mathematical models have been

prepared with a single option for each

of the interventions. For example, the

recommendation for dismissing students

from schools is absolute and does not

include options to partially implement
61

Community Mitigation Guidance

this intervention. Given the societal

consequences of this protective intervention,

as well as other measures, it is recommended

that models be further developed to

study a broader range of options for each

intervention.

•	 Appropriate modeling of effect of 

interventions to limit the impact of cascading 

second- and third-order consequences of the 

use of NPIs: The implementation challenges

and cascading consequences of both the

pandemic and of the interventions should

be considered in the mathematical models. 

For example, broader outcome measures

beyond influenza-related public health

outcomes might include costs and benefits of

intervention strategies.

• Development of process indicators: Given

the need to assess community-level response

capacity in any Incident of National

Significance, a research agenda related to

mitigation of pandemic influenza should

include development of tools to assess

ongoing response capacity. These tools

may include ways to assess adherence with

interventions and to determine factors that

influence adherence fatigue. Such tools

would be most useful for the implementing

jurisdictions in development of preparedness

plans and for evaluating the implementation

dynamics during a pandemic.
The goals of planning for an influenza pandemic

are to save lives and to reduce adverse personal,

social, and economic consequences of a

pandemic; however, it is recognized that even the

best plans may not completely protect everyone. 

Such planning must be done at the individual,

local, tribal, State, Federal, and international

levels, as well as by businesses and employers

and other organizations, in a coordinated manner. 

Interventions intended for mitigating a pandemic

pose challenges for individuals and families,

employers (both public and private), schools,

childcare programs, colleges and universities,

and local communities. Pre-pandemic, scenariobased planning offers an opportunity to better

understand and weigh the benefits of possible

interventions as well as identify strategies to

maximize the number of people protected while

reducing, to the greatest extent possible, the

adverse social, logistical, and economic effects of

proposed interventions.

The early use of combinations of NPIs that are

strategically targeted, layered, and implemented

in a coordinated manner across neighboring

jurisdictions and tailored to the severity of

the pandemic is a critical component of a

comprehensive strategy to reduce community

disease transmission and mitigate illness and

death. This guidance introduces, for the first

time, a Pandemic Severity Index in which case

fatality ratio serves as the critical driver for

categorizing the severity of a pandemic. The

severity index is designed to enable better

forecasting of the impact of a pandemic and

allows for fine-tuning the selection of the most

appropriate tools and interventions, balancing the

Conclusions

XIII

potential benefits against the expected costs and

risks. Decision-makers may find the Pandemic

Severity Index useful in a wide range of

pandemic planning scenarios beyond pandemic

mitigation, including, for example, in plans for

assessing the role for pre-pandemic vaccine or

estimating medical ventilator supply and other

healthcare surge requirements.

This planning guidance should be viewed as

the first iteration of a dynamic process that

will be revisited and refined on a regular basis

and informed by new knowledge gained from

research, exercises, and practical experience. 

The array of public health measures available

for pandemic mitigation is also evolving, and

future versions of this document will need to

incorporate the changing landscape. Some

critical priority issues for inclusion in subsequent

drafts are highlighted in actions being pursued

under the National Implementation Plan Action

Items. These include the role and further

development of point-of-care rapid influenza

diagnostics, antiviral medications, pre-pandemic

vaccines, face mask and respirator use in

community settings, and home-care infection

control management strategies. The development

of sensitive and specific diagnostic tests for

pandemic strains not only enables a more

efficient use of antiviral medication for treatment

and prophylaxis but also helps minimize the

need for isolation and quarantine for persons

with nonspecific respiratory infections. The

increasing availability of antiviral medications

will prompt new discussions about the role

of antiviral prophylaxis for households and

workers in critical infrastructure to further reduce

63
64

Community Mitigation Guidance

transmission potential and to provide incentives

to comply with voluntary home quarantine

recommendations and for healthcare and other

workers to report to work. Changes in the

technology and availability of personal protective

equipment will influence guidance on community

use of face masks and respirators. Guidance

for safe management of ill family members

in the household should serve to decrease the

risk of household transmission of influenza,

once again aligning incentives for compliance

and increasing the effectiveness of pandemic

mitigation interventions.

Planning and preparedness for implementing

pandemic mitigation strategies is complex and

requires participation by all levels of government

and all segments of society. Pandemic

mitigation strategies call for specific actions by

individuals, families, businesses and employers,

and organizations. Building a foundation

of community and individual and family

preparedness and developing and delivering

effective risk communication for the public in

advance of a pandemic is critical. If embraced

earnestly, these efforts will result in enhanced

ability to respond not only to pandemic influenza

but also to multiple hazards and threats. While

the challenge is formidable, the consequences

of facing a severe pandemic unprepared will be

intolerable. This interim pre-pandemic planning

guidance is put forth as a step in our commitment

to address the challenge of mitigating a pandemic

by building and enhancing community resiliency.
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Crovari P. Socioeconomic impact of influenza on

healthy children and their families. Pediatr Infect Dis J.

2003 Oct;22(10 Suppl):S207-10.

71.	Viboud C, Boelle PY, Cauchemez S, Lavenu A,

Valleron AJ, Flahault A, et al. Risk factors of influenza

transmission in households. Br J Gen Pract. 2004

Sep;54(506):684-9.

72.	Brownstein JS, Kleinman KP, Mandl KD. Identifying

pediatric age groups for influenza vaccination using a

real-time regional surveillance system. Am J Epidemiol.

2005 Oct 1;162(7):686-93.

73.	Becker NG, Dietz K. The effect of household

distribution on transmission and control of highly

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19.

74.	Becker NG, Hall R. Immunization levels for preventing

epidemics in a community of households made

up of individuals of various types. . Math Biosci.

1996;132(2):205-16.

75.	Davis LE, Caldwell GG, Lynch RE, Bailey RE, Chin

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76.	Longini IM, Jr., Koopman JS, Monto AS, Fox JP.

Estimating household and community transmission

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77.	King JC, Jr., Stoddard JJ, Gaglani MJ, Moore KA,

Magder L, McClure E, et al. Effectiveness of schoolbased influenza vaccination. N Engl J Med. 2006 Dec

14;355(24):2523-32.

78.	Paladini M. Do school holidays influence influenza

related visits to the emergency department? (personal

communication). 2007.

79.	Kahn LH. Pandemic influenza school closure policies

[letter]. Emerg Infect Dis. 2007;13(2):344.

80.	Institute of Medicine; Committee on Modeling

Community Containment for Pandemic Influenza.

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Influenza. A Letter Report. Washington D.C.: The

NationalAcademies Press; 2006. p.16.

81.	Markel H, Lippman H. (personal communication).

2007.

82.	Thompson WW, Comanor L, Shay DK. Epidemiology

of seasonal influenza: use of surveillance data and

statistical models to estimate the burden of disease. J

Infect Dis. 2006 Nov 1;194 Suppl 2:S82-91.

83.	Markel H. QUARANTINE! East European Jewish

Immigrants and the New York City Epidemic of 1892.

Baltimore: Johns Hopkins University Press; 1997.

84.	Cetron M, Landwirth J. Public health and ethical

considerations in planning for quarantine. Yale J Biol

Med. 2005 Oct;78(5):329-34.

85.	Bradley RH. Child care and common communicable

illnesses in children aged 37 to 54 months. Arch Pediatr

Adolesc Med. 2003 Feb;157(2):196-200.

86.	U.S. Department of Commerce; U.S. Census

Bureau. School Enrollment – Social and Economic

Characteristics of Students: October 2003.[cited 2007

January 23] Available from: www.census.gov/prod/

2005pubs/p20-554.pdf

87.	U.S. Department of Education; National Center

for Education Statistics. Student Financing of

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pubs2006/2006186.pdf

88.	Centers for Disease Control and Prevention. 121 Cities

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23]; Available from: www.cdc.gov/EPO/DPHSI/

121hist.htm

89.	Harvard School of Public Health. Pandemic Influenza

and the Public; Survey Findings (press release). 2006 

[cited 2007 January 23]; Available from: www.hsph.

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Influenza and the Public; Survey Findings. 2006 [cited

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91.	The Public Engagement Project on Community Control

Measures for Pandemic Influenza. 2006 [cited 2007

January 23]; Available from: www.keystone.org/Public_

Policy/pandemic_control.html

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Secretary for Policy. Calculations from Current

Population Survey (microdata). Washington, D.C.: U.S.

Department of Labor; 2006.

93.	U.S. Department of Commerce; U.S.Census Bureau.

Who’s Minding the Kids? Child Care Arrangements:

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Available from: www.census.gov/prod/2005pubs/p70-

101.pdf

94.	Helpguide. Aging Issues. 2004 [cited 2007 January

23]; Available from: www.helpguide.org/elder_care.htm

95.	U.S. Department of Health and Human Services;

Administraion on Aging. Elderly Nutrition Program. 

2003 [cited 2007 January 23]; Available from: www.

aoa.gov/press/fact/pdf/fs_nutrition.pdf

96.	Johnson A. 2007 (personal communication).

97.	U.S. Department of Labor; Bureau of Labor Statistics.

National Compensation Survey: Employee Benefits

in the United States, March 2006. 2006 [cited 2007

January 23]; Available from: www.bls.gov/ncs/ebs/sp/

ebsmodo4.pdf

98.	U.S. Department of Agriculture; Food and Nutrition

Service. National School Lunch Program. 2006 [cited

2007 January 23]; Available from: www.fns.usda.gov/

cnd/lunch/aboutlunch/NSLPFactSheet.pdf

99.	U.S. Department of Agriculture; Food and Nutrition

Service. The School Breakfast Program. 2006 [cited

2007 January 23]; Available from: www.fns.usda.gov/

cnd/breakfast/aboutbreakfast/sbpfactsheet.pdf

100. U.S. Department of Agriculture; Food and Nutrition

Service. Child Nutrition Tables. National Summer

Food Service Program. 2006 [cited 2007 January 23];

Available from: www.fns.usda.gov/pd/sfsummar.htm

101.	Bernier-Toth M. U.S. Department of State (personal

communication) 2007.

102.	LTC Hachey W. U.S. Department of Defense (personal

communication). 2007.

103.	Triplett J. U.S. Department of State (personal

communication). 2007.

104.	Stohr K. Avian influenza and pandemics--research

needs and opportunities. N Engl J Med. 2005 Jan

27;352(4):405-7.

105.	Glezen WP. Emerging infections: pandemic influenza.

Epidemiol Rev. 1996;18(1):64-76.

106.	Hufnagel L, Brockmann D, Geisel T. Forecast and

control of epidemics in a globalized world. Proc Natl

Acad Sci U S A. 2004 Oct 19;101(42):15124-9.

107.	Kilbourne ED. Influenza pandemics: can we prepare

for the unpredictable? Viral Immunol. 2004;17(3):

350-7.

108.	Petric M, Comanor L, Petti CA. Role of the

Laboratory in Diagnosis of Influenza during Seasonal

Epidemics and Potential Pandemics. J Infect Dis. 2006

Nov 1;194 Suppl 2:S98-S110.
Appendices

XV

Absenteeism rate: Proportion of employed

persons absent from work at a given point in time

or over a defined period of time.

Antiviral medications: Medications presumed to

be effective against potential pandemic influenza

virus strains and which may prove useful for

treatment of influenza-infected persons or for

prophylactic treatment of persons exposed

to influenza to prevent them from becoming

ill. These antiviral medications include the

neuraminidase inhibitors oseltamivir (Tamiflu®)

and zanamivir (Relenza®).

Case fatality ratio: Proportion of deaths among

clinically ill persons.

Childcare: Childcare programs discussed in

this guidance include 1) centers or facilities

that provide care to any number of children in a

nonresidential setting, 2) large family childcare

homes that provide care for seven or more

children in the home of the provider, and 3) small

family childcare homes that provide care to six

or fewer children in the home of the provider.

Children: In this document children are defined

as 17 years of age or younger unless an age

is specified or 12 years of age or younger if

teenagers are specified.

Clinically ill: Those persons who are infected

with pandemic influenza and show signs and

symptoms of illness.

Colleges: Post-high school educational

institutions (i.e., beyond 12th grade).

Community mitigation strategy: A strategy

for the implementation at the community level

of interventions designed to slow or limit the

transmission of a pandemic virus.

Cough etiquette: Covering the mouth and nose

while coughing or sneezing; using tissues and

disposing in no-touch receptacles; and washing

of hands often to avoid spreading an infection to

others.

Countermeasures: Refers to pre-pandemic

and pandemic influenza vaccine and antiviral

medications.

Critical infrastructure: Systems and assets,

whether physical or virtual, so vital to the

United States that the incapacitation or

destruction of such systems and assets would

have a debilitating impact on national security,

economy, or public health and/or safety, either

alone or in any combination. Specifically, it refers

to the critical infrastructure sectors identified

in Homeland Security Presidential Directive 7

(HSPD-7).

Early, targeted, and layered nonpharmaceutical 

interventions (NPIs) strategy: A strategy for

using combinations of selected community-level

NPIs implemented early and consistently to slow

or limit community transmission of a pandemic

virus.

Appendix 1 – Glossary of Terms

71
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Community Mitigation Guidance

Excess rate: Rate of an outcome (e.g., deaths,

hospitalizations) during a pandemic above the

rate that occurs normally in the absence of a

pandemic. It may be calculated as a ratio over

baseline or by subtracting the baseline rate from

the total rate.

Face mask: Disposable surgical or procedure

mask covering the nose and mouth of the wearer

and designed to prevent the transmission of large

respiratory droplets that may contain infectious

material.

Faith-based organization: Any organization that

has a faith-inspired interest.

Generation time: Average number of days taken

for an ill person to transmit the infection to

another person.

Hand hygiene: Hand washing with either plain

soap or antimicrobial soap and water or use

of alcohol-based products (gels, rinses, foams

containing an emollient) that do not require the

use of water.

Illness rate or clinical attack rate: Proportion

of people in a community who develop illness

(symptomatic cases ÷ population size).

Incident of National Significance: Designation

is based on criteria established in Homeland

Security Presidential Directive 5 and include

events with actual or potential high-impact that

requires a coordinated and effective response by

Federal, State, local, tribal, nongovernmental,

and/or private sector entities in order to save

lives, minimize damage, and provide the basis for

long-term community recovery and mitigation

activities.

Incubation period: The interval (in hours, days,

or weeks) between the initial, effective exposure

to an infectious organism and the first appearance

of symptoms of the infection.

Infection control: Hygiene and protective

measures to reduce the risk of transmission of

an infectious agent from an infected person to

uninfected persons (e.g., hand hygiene, cough

etiquette, use of personal protective equipment,

such as face masks and respirators, and

disinfection).

Influenza pandemic: A worldwide epidemic

caused by the emergence of a new or novel

influenza strain to which humans have little or

no immunity and which develops the ability

to infect and be transmitted efficiently for a

sustained period of time in the community

between humans.

Isolation of ill people: Separation or restriction

of movement of persons ill with an infectious

disease in order to prevent transmission to others.

Mortality rate: Number of deaths in a

community divided by population size of

community over a specific period of time (e.g.,

20 deaths per 100,000 persons per week).

Nonpharmaceutical intervention (NPI): 

Mitigation measure implemented to reduce the

spread of an infectious disease (e.g., pandemic

influenza) but one that does not include

pharmaceutical products, such as vaccines and

medicines. Examples include social distancing

and infection control measures.

Pandemic vaccine: Vaccine for a specific

influenza virus strain that has evolved the

capacity for sustained and efficient human-tohuman transmission. This vaccine can only be

developed once the pandemic strain emerges.

Personal protective equipment (PPE): PPE is

any type of clothing, equipment, or respiratory

protection device (respirators) used to protect

workers against hazards they encounter while

doing their jobs. PPE can include protection for

eyes, face, head, torso, and extremities. Gowns,

face shields, gloves, face masks, and respirators
73

Community Mitigation Guidance

are examples of PPE commonly used within

healthcare facilities. When PPE is used in a

workplace setting to protect workers against

workplace hazards, its use must be consistent

with regulations issued by the Occupational

Safety and Health Administration (www.osha.

gov/index.html).

Post-exposure prophylaxis: The use of antiviral

medications in individuals exposed to others with

influenza to prevent disease transmission.

Pre-pandemic vaccine: Vaccine against strains

of influenza virus in animals that have caused

isolated infections in humans and which may

have pandemic potential. This vaccine is

prepared prior to the emergence of a pandemic

strain and may be a good or poor match (and

hence of greater or lesser protection) for the

pandemic strain that ultimately emerges.

Prophylaxis: Prevention of disease or of a

process that can lead to disease. With respect to

pandemic influenza, this specifically refers to the

administration of antiviral medications to healthy

individuals for the prevention of influenza.

Quarantine: A restraint upon the activities or

communication (e.g., physical separation or

restriction of movement within the community/

work setting) of an individual(s) who has been

exposed to an infection but is not yet ill to

prevent the spread of disease; quarantine may be

applied voluntarily (preferred) or on compulsory

basis dependent on legal authority.

Rapid diagnostic test: Medical test for rapidly

confirming the presence of infection with a

specific influenza strain.

Recrudescence: Reappearance of a disease after

it has diminished or disappeared.

R0 (“reproductive number”): Average number of

infections resulting from a single case in a fully

susceptible population without interventions. Rt:

the reproductive number at a given time, t.

Schools: Refers to public and private elementary,

middle, secondary, and post-secondary schools

(colleges and universities).

Schools (K-12): Refers to schools, both public

and private, spanning the grades kindergarten

through 12th grade (elementary through high

school).

Seasonal influenza: Influenza virus infections in

familiar annual patterns.

Second- and third-order consequences: Chains

of effects that may arise as a consequence of

intervention and which may require additional

planning and intervention to mitigate. These

terms generally refer to foreseeable unintended

consequences of intervention. For example,

dismissal of students from schools may lead

to workplace absenteeism for child minding. 

Subsequent workplace closings due to high

absenteeism may lead to loss of income for

employees, a third-order effect that could

be detrimental to families living at or near

subsistence levels.

Sector: A subdivision (sociological, economic,

or political) of society.

Social distancing: Measures to increase the

space between people and decrease the frequency

of contact among people.

Surge capacity: Refers to the ability to expand

provision of services beyond normal capacity

to meet transient increases in demand. Surge

capacity within a medical context includes the

ability of healthcare or laboratory facilities

to provide care or services above their usual

capacity and to expand manufacturing capacity

of essential medical materiel (e.g., vaccine) to

meet increased demand.
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Community Mitigation Guidance

Surgical mask: Disposable face mask that covers

the mouth and nose and comes in two basic

types. The first type is affixed to the head with

two ties and typically has a flexible adjustment

for the nose bridge. This type of surgical mask

may be flat/pleated or duck-billed in shape. The

second type of surgical mask is pre-molded, or

cup shaped, and adheres to the head with a single

elastic strap and usually has a flexible adjustment

for the nose bridge. Surgical masks are used to

prevent the transmission of large particles.

Telework: Refers to activity of working away

from the usual workplace (often at home)

through telecommunication or other remote

access means (e.g., computer, telephone, cellular

phone, fax machine).

Universities: Educational institutions beyond

12th grade (post high school).

Viral shedding: Discharge of virus from an

infected person.

Virulence: The ability of the pathogen to

produce disease; or the factors associated with

the pathogen to affect the severity of diseases in

the host.

Voluntary: Acting or done of one’s own free

will without legal compulsion (e.g., voluntary

household quarantine).
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Community Mitigation Guidance

This guidance document was developed

through a collaborative process that gathered

input from a variety of sources, including

subject-matter experts, peer-reviewed scientific

literature, current research, and stakeholders

(i.e., Federal agencies, public health officials,

and the public). A working group composed of

Federal, State, and local public health officials

and representatives from the Association of State

and Territorial Health Officials (ASTHO), the

Council of State and Territorial Epidemiologists

(CSTE), the National Association of County and

City Health Officials (NACCHO), the Infectious

Disease Society of America (IDSA), and the

National Association of Local Boards of Health

(NALBOH) met periodically to review and

evaluate evidence derived from the following

sources:

•	 Preliminary statistical analyses of historical

data on the implementation of selected NPIs

in U.S. cities during the 1918 pandemic.

•	 Stakeholder input from interagency outreach

meetings with public health, private sector,

labor unions, faith-based and community

partners.

•	 Proceedings of community public

engagement meetings conducted in five U.S.

cities (Atlanta, GA; Lincoln, NE; Seattle,

WA; Syracuse, NY; Washington, DC) in

October-November 2006.

•	 Public opinion poll results conducted by

the Harvard School of Public Health in

September-October 2006 surveying 1,697

adults in the United States regarding their

willingness to follow public health officials’

recommendations for selected pandemic

mitigation interventions.

•	 Peer-reviewed mathematical modeling

to assess potential pandemic mitigation

interventions during an influenza pandemic.

•	 Expert opinion of public health officials,

including published findings and

recommendations of the Committee on

Modeling Community Containment for

Pandemic Influenza (Institute of Medicine,

2006).

•	 Preliminary results from a November 2006

Epi-Aid investigation of a seasonal influenza

outbreak with associated school closure.

•	 Preliminary results from review of legal

authorities/policies of school closure in each

state conducted by the Center for Law and

the Public’s Health.

In addition, stakeholders from government,

academia, private industry, educational

organizations, and faith-based and community

organizations reviewed and evaluated these data

during public stakeholder meetings in June and

December 2006. The opinions from individuals

in the working group and stakeholders were

considered during the writing of this guidance.

Pandemic planning with respect to the

implementation of these pandemic mitigation

interventions must be citizen-centric and support

the needs of people across society in as equitable

a manner as possible. Accordingly, the process

for developing this interim pre-pandemic

guidance sought input from key stakeholders,

including the public. While all views and

perspectives were respected, a hierarchy of

values did in fact emerge over the course of

the deliberations. In all cases, the question

Appendix 2 – Interim Guidance Development Process
76

Community Mitigation Guidance

was whether the cost of the interventions was

commensurate with the benefits they could

potentially provide. Thus, there was more

agreement on what should be done when facing

a severe pandemic with a high case fatality ratio

(e.g., a 1918-like pandemic) than on what should

be done when facing a pandemic with a lower

case fatality ratio (e.g., a 1968-like pandemic);

even with the inherent uncertainties involved,

the cost-benefit ratio of the interventions clearly

becomes more favorable as the severity increases

and the number of lives potentially saved

increases. Many stakeholders, for example,

expressed concern about the effectiveness of

the proposed interventions, which cannot be

demonstrated a priori and for which the evidence

base is limited and of variable quality. However,

where high rates of mortality could be anticipated

in the absence of intervention, a significant

majority of stakeholders expressed their

willingness to “risk” undertaking interventions

of uncertain effectiveness in mitigating disease

and death. Where scenarios that would result in

1918-like mortality rates were concerned, most

stakeholders reported that aggressive measures

would be warranted and that the value of the

lives potentially saved assumed precedence over

other considerations. However, the feasibility

of these approaches has not been assessed at the

community level. Local, State, regional, and

Federal exercises will need to be conducted to

obtain more information about the feasibility

and acceptance of these measures. In addition,

ongoing engagement with the public, especially

vulnerable populations, is essential.

CDC Community Mitigation Strategy Team acknowledges the following

for their contributions to the development of this document

Department of Health and Human Services

Department of Commerce

Department of Defense

Department of Education

Department of Homeland Security

Department of the Interior

Department of Justice

Department of Labor

Department of State

Department of Transportation

Department of the Treasury

United States Department of Agriculture

United States Environmental Protection Agency

United States Office of Personnel Management

Department of Veterans Affairs

White House Homeland Security Council

Association of State and Territorial

Health Officials

Council of State and Territorial

Epidemiologists

Harvard School of Public Health

Infectious Diseases Society of America

Institute of Medicine

National Association of County and City Health

Officials

National Association of Local Health Boards

MIDAS Modelers

University of Michigan
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Community Mitigation Guidance

Appendix 3. – WHO Phases of a Pandemic/U.S. Government Stages of a Pandemic
79

Community Mitigation Guidance

Purpose

This Interim Planning Guide for Businesses

and Other Employers is provided as a

supplement to the Interim Pre-Pandemic 

Planning Guidance: Community Strategy for 

Pandemic Influenza Mitigation in the United 

States—Early, Targeted, Layered Use of 

Nonpharmaceutical Interventions. This guide

is intended to assist in pre-pandemic planning. 

Individuals and families, employers, schools,

and other organizations will be asked to take

certain steps (described below) to help limit

the spread of a pandemic, mitigate disease and

death, lessen the impact on the economy, and

maintain societal functioning. This guidance is

based upon the best available current data and

will be updated as new information becomes

available. During the planning process, Federal,

State, local, tribal, and territorial officials should

review the laws, regulations, and policies that

relate to these recommendations, and they should

include stakeholders in the planning process and

resolution of issues. 

Businesses and other employers (including

local, State, and Federal agencies and other

organizations) will be essential partners in

protecting the public’s health and safety when

a pandemic occurs. This Pandemic Influenza 

Community Mitigation Interim Planning Guide 

for Businesses and Other Employers provides

guidance to these groups by describing how

they might prepare for, respond to, and recover

from an influenza pandemic. When an influenza

pandemic starts, public health officials will

determine the severity of the pandemic and

recommend actions to protect the community’s

health. People who become severely ill may

need to be cared for in a hospital. However,

most people with influenza will be safely cared

for at home.

Community mitigation recommendations will be

based on the severity of the pandemic and may

include the following:

1. Asking ill people to voluntarily remain

at home and not go to work or out in the

community for about 7-10 days or until they

are well and can no longer spread the infection

to others (ill individuals may be treated with

influenza antiviral medications, as appropriate, if

these medications are effective and available). 

2. Asking members of households with a person

who is ill to voluntarily remain at home for about

7 days (household members may be provided

with antiviral medications, if these medications

are effective and sufficient in quantity and

feasible mechanisms for their distribution have

been developed).

3. Dismissing students from schools (including

public and private schools as well as colleges

and universities) and school-based activities and

closure of childcare programs for up to 12 weeks,

coupled with protecting children and teenagers

through social distancing in the community,

to include reductions of out-of-school social

contacts and community mixing. Childcare

programs discussed in this guidance include

centers or facilities that provide care to any

number of children in a nonresidential setting,

large family childcare homes that provide care

for seven or more children in the home of the

Appendix 4 - Pandemic Influenza Community Mitigation Interim 

Planning Guide for Businesses and Other Employers
80

Community Mitigation Guidance

provider, and small family childcare homes that

provide care to six or fewer children in the home

of the provider.1

4. Recommending social distancing of adults in

the community, which may include cancellation

of large public gatherings; changing workplace

environments and schedules to decrease social

density and preserve a healthy workplace to

the greatest extent possible without disrupting

essential services; ensuring work-leave policies

to align incentives and facilitate adherence with

the measures outlined above.

Planning now for a severe pandemic (and

adjusting your continuity plan accordingly) will

help assure that your business is prepared to

implement these community recommendations. 

Businesses and other employers should be

prepared to continue the provision of essential

services during a pandemic even in the face of

significant and sustained absenteeism. Pandemic

preparation should include coordinated planning

with employees and employee representatives

and critical suppliers. Businesses should also

integrate their planning into their communities’

planning. These preparedness efforts will be

beneficial to your organization, staff, and the

community, regardless of the severity of the

pandemic. The following provide information to

guide business planning for a pandemic: Business 

Pandemic Influenza Planning Checklist (www.

pandemicflu.gov/plan/business/businesschecklist.

html), the Pandemic Preparedness Planning 

for U.S. Businesses with Overseas Operations 

Checklist, (www.pandemicflu.gov/plan/

business/businessesoverseaspdf.pdf), and the

Pandemic Influenza Preparedness, Response 

and Recovery Guide for Critical Infrastructure 

and Key Resources (www.pandemicflu.gov/

plan/pdf/cikrpandemicinfluenzaguide.pdf). In

addition, recommendations for implementation

of pandemic mitigation strategies are available

at www.pandemicflu.gov. Reliable, accurate,

and timely information on the status and severity

of the pandemic also will be posted on www.

pandemicflu.gov. Additional information is

available from the Centers for Disease Control

and Prevention (CDC) Hotline: 1-800-CDCINFO (1-800-232-4636). This line is available

in English and Spanish, 24 hours a day, 7 days a

week. TTY: 1-888-232-6348. Questions can be

e-mailed to cdcinfo@cdc.gov.

Recommendations for Planning

1. Plan for ill individuals to remain at home

•	 Plan for staff absences during a pandemic

due to personal illness. 

o	 Encourage ill persons to stay home during

a pandemic and establish return-to-work

policies after illness.

o	 Identify critical job functions and plan for

their continuity and how to temporarily

suspend non-critical activities, cross-train

employees to cover critical functions,

and cover the most critical functions with

fewer staff.

o	 Identify employees who might need extra

assistance to stay home when they are ill

because, for example, they live alone or

have a disability.

o	 Review Federal and State employment

laws that identify your employer

obligations and options for employees.

•	 Establish and clearly communicate policies

on sick (and other) leave and employee

compensation. 

•	 Develop a workplace culture that recognizes

and encourages behaviors such as voluntarily

staying home when ill in order to get well

and to avoid spreading infection to others.

•	 Develop policies on what to do when a

person becomes ill at the workplace.

•	 Provide employees with information on

taking care of ill people at home. Such

information will be posted on www.

pandemicflu.gov.
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Community Mitigation Guidance

2. Plan for all household members of a person 

who is ill to voluntarily remain at home

•	 Plan for staff absences related to family

member illness. 

o	 Identify critical job functions and plan for

their continuity and how to temporarily

suspend non-critical activities, cross-train

employees to cover critical functions,

and cover the most critical functions with

fewer staff.

o	 Establish policies for an alternate or

flexible worksite (e.g., work via the

Internet, e-mailed or mailed work

assignments) and flexible work hours,

where feasible.

o	 Develop guidelines to address business

continuity requirements created by jobs

that will not allow teleworking (e.g.,

production or assembly line workers).

•	 Establish and clearly communicate policies

on family leave and employee compensation,

especially Federal laws and laws in your

State regarding leave of workers who need to

care for an ill family member or voluntarily

remain home.

•	 Provide employees with information on

taking care of ill people at home. Such

information will be posted on www.

pandemicflu.gov.

3. Plan for dismissal of students and

childcare closure 

•	 Identify employees who may need to stay

home if schools dismiss students and

childcare programs close during a severe

pandemic. 

•	 Advise employees not to bring their children

to the workplace if childcare cannot be

arranged.

•	 Plan for alternative staffing or staffing

schedules on the basis of your identification

of employees who may need to stay home.

o	 Identify critical job functions and plan

now for cross-training employees to cover

those functions in case of prolonged

absenteeism during a pandemic.

o	 Establish policies for employees with

children to work from home, if possible,

and consider flexible work hours and

schedules (e.g., staggered shifts).

•	 Encourage employees who have children

in their household to make plans to care

for their children if officials recommend

dismissal of students from schools, colleges,

universities, and childcare programs. Advise

employees to plan for an extended period (up

to 12 weeks) in case the pandemic is severe.

•	 In a severe pandemic, parents would be

advised to protect their children by reducing

out-of-school social contacts and mixing

with other children. Although limiting all

outside contact may not be feasible, parents

may be able to develop support systems with

co-workers, friends, families, or neighbors

if they continue to need childcare. For

example, they could prepare a plan in

which two to three families work together

to supervise and provide care for a small

group of infants and young children while

their parents are at work (studies suggest that

childcare group size of less than six children

may be associated with fewer respiratory

infections).2

•	 Talk with your employees about any benefits,

programs, or other assistance they may be

eligible for if they have to stay home to mind

children for a prolonged period during a

pandemic.

•	 Coordinate with State and local government

and faith-based and community-based

organizations to assist workers who cannot

report to work for a prolonged period.

4. Plan for workplace and community

social distancing measures

•	 Become familiar with social distancing

methods that may be used during a pandemic

to modify the frequency and type of personto-person contact (e.g., reducing handshaking, limiting face-to-face meetings and

shared workstations, promoting teleworking,
82

Community Mitigation Guidance

offering liberal/unscheduled leave policies,

staggered shifts).

•	 Plan to operate businesses and other

workplaces using social distancing and other

measures to minimize close contact between

and among employees and customers. 

Determine how the work environment may

be reconfigured to allow for more distance

between employees and between employees

and customers during a pandemic. If social

distancing is not feasible in some work

settings, employ other protective measures

(guidance available at www.pandemicflu.

gov).

•	 Review and implement guidance from

the Occupational Safety and Health

Administration (OSHA) to adopt appropriate

work practices and precautions to protect

employees from occupational exposure to

influenza virus during a pandemic. Risk

of occupational exposure to influenza virus

depends in part on whether or not jobs

require close proximity to people potentially

infected with the pandemic influenza virus

or whether employees are required to have

either repeated or extended contact with the

public. OSHA will post and periodically

update such guidance on www.pandemicflu.

gov.

•	 Encourage good hygiene at the workplace. 

Provide employees and staff with information

about the importance of hand hygiene

(information can be found at www.cdc.gov/

cleanhands/) as well as convenient access to

soap and water and/or alcohol-based hand gel

in your facility. Educate employees about

covering their cough to prevent the spread of

germs (www.cdc.gov/flu/protect/covercough.

htm).

5. Communicate with your employees

and staff

•	 Disseminate your company’s pandemic plan

to all employees and stakeholders in advance

of a pandemic; include roles/actions expected

of employees and other stakeholders during

implementation of the plan.

•	 Provide information to encourage employees

(and their families) to prepare for a pandemic

by providing preparedness information. 

Resources are available at www.pandemicflu.

gov/plan/individual/checklist.html.

6. Help your community 

•	 Coordinate your business’ pandemic plans

and actions with local health and community

planning.

•	 Find volunteers in your business who want

to help people in need, such as elderly

neighbors, single parents of small children,

or people without the resources to get the

medical or other help they will need.

•	 Think of ways your business can reach

out to other businesses and others in your

community to help them plan for a pandemic.

•	 Participate in community-wide exercises to

enhance pandemic preparedness.

7. Recovery

•	 Assess criteria that need to be met to resume

normal operations and provide notification

to employees of activation of the business

resumption plan.

•	 Assess the availability of medical, mental

health, and social services for employees

after the pandemic.

References:

1 American Academy of Pediatrics. Children in

Out-of-Home Child Care: Classification of Care

Service. In: Pickering LK, ed. Red Book: 2003

Report of the Committee on Infectious Diseases. 

26th ed. Elk Grove Village, IL: American

Academy of Pediatrics; 2003:124.

2 Bradley RH. Child care and common

communicable illnesses in children aged 37 to

54 months. Arch Pediatr Adolesc Med. 2003

Feb;157(2):196-200
83

Community Mitigation Guidance

Purpose

This Interim Planning Guide for Childcare

Programs is provided as a supplement to the

Interim Pre-Pandemic Planning Guidance: 

Community Strategy for Pandemic Influenza 

Mitigation in the United States—Early, 

Targeted, Layered Use of Nonpharmaceutical 

Interventions. The guide is intended to

assist in pre-pandemic planning. Individuals

and families, employers, schools, and other

organizations will be asked to take certain steps

(described below) to help limit the spread of a

pandemic, mitigate disease and death, lessen the

impact on the economy, and maintain societal

functioning. This guidance is based upon the

best available current data and will be updated

as new information becomes available. During

the planning process, Federal, State, local,

tribal, and territorial officials should review

the laws, regulations, and policies that relate

to these recommendations, and they should

include stakeholders in the planning process and

resolution of issues.

Childcare programs will be essential partners in

protecting the public’s health and safety when an

influenza pandemic occurs. Childcare programs

discussed in this guidance include centers or

facilities that provide care to any number of

children in a nonresidential setting, large family

childcare homes that provide care for seven

or more children in the home of the provider

and small family childcare homes that provide

care to six or fewer children in the home of the

provider.1This Pandemic Influenza Community 

Mitigation Interim Planning Guide for Childcare 

Programs provides guidance describing how

such programs might prepare for and respond

to an influenza pandemic. When an influenza

pandemic starts, public health officials will

determine the severity of the pandemic and

recommend actions to protect the community’s

health. People who become severely ill may

need to be cared for in a hospital. However,

most people with influenza will be safely cared

for at home. 

Community mitigation recommendations will be

based on the severity of the pandemic and may

include the following:

1. Asking ill people to voluntarily remain

at home and not go to work or out in the

community for about 7-10 days or until they

are well and can no longer spread the infection

to others (ill individuals will be treated with

influenza antiviral medications, as appropriate, if

these medications are effective and available). 

2. Asking members of households with a person

who is ill to voluntarily remain at home for about

7 days (household members may be provided

with antiviral medications, if these medications

are effective and sufficient in quantity and

feasible mechanisms for their distribution have

been developed).

3. Dismissing students from schools (including

public and private schools as well as colleges

and universities) and school-based activities and

closure of childcare programs for up to 12 weeks,

coupled with protecting children and teenagers

through social distancing in the community

to include reductions of out-of-school social

contacts and community mixing.

Appendix 5 - Pandemic Influenza Community Mitigation

Interim Planning Guide for Childcare Programs
84

Community Mitigation Guidance

4. Recommending social distancing of adults in

the community, which may include cancellation

of large public gatherings; changing workplace

environments and schedules to decrease social

density and preserve a healthy workplace to

the greatest extent possible without disrupting

essential services; ensuring work-leave policies

to align incentives and facilitate adherence with

the measures outlined above. 

Recommendations for closing childcare

facilities will depend upon the severity of the

pandemic. The current three-tiered planning

approach includes 1) no closure in a Category

1 pandemic, 2) short-term (up to 4 weeks)

closure of childcare facilities in a Category 2 or

Category 3 pandemic, and 3) prolonged (up to 12

weeks) closure of childcare facilities in a severe

influenza pandemic (Category 4 or Category

5). These actions may only apply to traditional

forms of center-based care and large family

childcare programs (more than six children). 

Small family childcare programs (less than seven

children) may be able to continue operations. 

In the most severe pandemic, the duration of

these public health measures would likely be

for 12 weeks and will undoubtedly have serious

financial implications for childcare workers

and their employers as well as for families who

depend on their services. In a severe pandemic,

parents will be advised to protect their children

by reducing out-of-school social contacts and

mixing with other children. Although limiting

all outside contact may not be feasible, families

may be able to develop support systems with

co-workers, friends, families, or neighbors if

they continue to need childcare. For example,

they could prepare a plan in which two or

three families work together to supervise and

provide care for a small group of infants and

young children while their parents are at work

(studies suggest that childcare group size of less

than six children may be associated with fewer

respiratory infections).2

Planning now for a severe pandemic will help

assure that your childcare program is prepared to

implement these community recommendations. 

These preparedness efforts will be beneficial

to your programs, staff, families, and the

community, regardless of the severity of the

pandemic. The Pandemic Flu Planning Checklist 

for Childcare Facilities (www.pandemicflu.gov/

plan/school/index.html) provides an approach to

planning for a pandemic. Recommendations for

implementation of pandemic mitigation strategies

are available at www.pandemicflu.gov. Reliable,

accurate, and timely information on the status

and severity of the pandemic will be posted on

www.pandemicflu.gov. Additional information

is available from the Centers for Disease Control

and Prevention (CDC) Hotline: 1-800-CDCINFO (1-800-232-4636). This line is available

in English and Spanish, 24 hours a day, 7 days a

week. TTY: 1-888-232-6348. Questions can be

e-mailed to cdcinfo@cdc.gov.

Recommendations for Planning

1. Plan for ill individuals to remain at home 

•	 Develop a plan of childcare operations for

implementation during pandemics of all

levels of severity. 

•	 Develop a plan for employee absences due to

personal illness. Plan for alternative staffing:

o	 Identify critical job functions and plan

for alternate coverage of those functions

during a pandemic. Family childcare

programs may consider prearranging

childcare coverage with other providers

in their areas.

o	 Review and analyze Federal and State

employment laws that identify employer

obligations and options for personnel.

•	 Establish and clearly communicate policies

on sick leave and employee compensation. 

•	 Encourage ill persons to stay home during

a pandemic and establish return-to-work

policies after illness.

•	 Establish policies for sick-leave absences

unique to a pandemic (e.g., liberal/

unscheduled leave). 

•	 Develop policies on observation for illness
85

Community Mitigation Guidance

and what to do when a child or employee

becomes ill at the workplace.

•	 Advise employees to look for information

on taking care of ill people at home. Such

information will be posted on www.

pandemicflu.gov.

2. Plan for all household members of a person 

who is ill to voluntarily remain at home

•	 Develop a plan for employee absences related

to family member illness. Plan for alternate

staffing:

o	 Identify critical job functions and plan

now for coverage of those functions.

o	 Review Federal and State employment

laws that identify your employer

obligations and options for employees.

•	 Establish and clearly communicate policies

on family leave and employee compensation.

•	 Establish policies for sick-leave absences

unique to a pandemic (e.g., liberal/

unscheduled leave). 

•	 Establish policies for employees who have

to stay home because someone in their

household is ill with pandemic influenza.

•	 Be familiar with Federal and State laws

regarding leave of workers who need to

care for an ill family member or voluntarily

remain at home.

•	 Advise employees to look for information

on taking care of ill people at home. Such

information will be posted on www.

pandemicflu.gov.

3. Plan for dismissal of students from school 

and childcare closure, considering the 

impact on employees and parents

•	 Develop a plan for program operations during

all levels of pandemic severity. 

•	 Plan for alternate staffing based on your

assessment.

o	 Identify critical job functions and plan

now for coverage of those functions in

case of prolonged absenteeism during a

pandemic.

•	 Work with State and local government

and faith-based and community-based

organizations to provide any needed

assistance to staff who are not able to work

for a prolonged period of time.

4. Plan for workplace and community social 

distancing measures

•	 Become familiar with social distancing

actions that may be used during a pandemic

to modify frequency and type of person-toperson contact (e.g., reducing hand-shaking,

limiting face-to-face meetings, promoting

teleworking, and offering liberal/unscheduled

leave policies and staggered shifts).

•	 Plan to operate the workplace using social

distancing and other measures to minimize

close contact between employees.

•	 Review and implement guidance from

the Occupational Safety and Health

Administration (OSHA) on appropriate

work practices and precautions to protect

employees from occupational exposure to

influenza virus during a pandemic. Risks

of occupational exposure to influenza virus

depends in part on whether jobs require close

proximity to people who may be infectious

with the pandemic influenza virus or whether

employees are required to have either

repeated or extended contact with the general

public. OSHA will post and periodically

update such guidance on www.pandemicflu.

gov.

•	 If the childcare program is to remain in

operation during a Category 1-3 pandemic,

provide staff with information about the

measures that the program will institute in

order to reduce virus transmission among

staff and children. These may include

o	 Restructuring and keeping groups of staff

and children from mixing together to

minimize social contacts.

o	 Asking ill staff to stay home while they

are ill.

o	 Modifying exclusion policies to include

ill children and possibly, based on public
86

Community Mitigation Guidance

health recommendations made at the time of

the pandemic, those with ill family members.

o	 Implementing staggered shifts.

o	 Implementing social distancing practices,

including

• Eliminating gatherings of staff and

• Minimizing contact between staff and

parents.

•	 Encourage good hygiene at the workplace. 

Provide children and staff with information about

the importance of hand hygiene (information

can be found at www.cdc.gov/cleanhands/) as

well as convenient access to soap and water and

alcohol-based hand gel in your facility. Educate

employees and children about covering their

cough to prevent the spread of germs (see www.

cdc.gov/flu/protect/covercough.htm).

•	 Promote social distancing of children outside the

childcare setting by advising parents that children

reduce their social interaction and contacts to the

greatest extent possible. 

5. Communicate with staff and parents/families

•	 Be prepared to provide parents/families with

information about

o	 Why programs will be cancelled and the

importance of keeping infants and children

from congregating with other children in the

community.

o	 How alternative childcare options may be

accessed.

o	 How students who need free meals may

qualify for other types of nutrition assistance

in the community.

•	 Provide information to staff and parents/families

on what they can do to prepare their families for

a pandemic. Resources are available at www.

pandemicflu.gov/plan/individual/checklist.html

and www.ready.gov/america/index.html.

•	 Provide systematic emergency communications to

childcare staff and families during the pandemic. 

Use a telephone calling tree, an e-mail alert, or

call-in voice recording to communicate pandemic

status in the community and status of childcare

program activities. Messages for staff and

families should be targeted and provided in the

different languages that reflect the languages

within the community.

•	 Recommend that parents/families seek further

information about pandemic through other sources

including key Federal, State, local, tribal, and

territorial public health resources and regularly

provided pandemic updates at www.pandemicflu.

gov.

6. Help your community 

•	 Coordinate your pandemic plans and actions with

local health and community planning.

•	 Think of ways your childcare program can reach

out to other childcare programs and others in your

community to help them plan for a pandemic.

•	 Participate in community-wide exercises to

enhance pandemic preparedness.

7. Recovery

•	 Establish the criteria and procedures for resuming

childcare operations and activities.

•	 Develop communication plans for advising

employees, staff, and families of the resumption

of programs and activities.

•	 Develop the procedures, activities, and services

needed to restore the childcare environment.

References:

1 American Academy of Pediatrics. Children in Outof-Home Child Care: Classification of Care Service. 

In: Pickering LK, ed. Red Book: 2003 Report of

the Committee on Infectious Diseases. 26th ed. Elk

Grove Village, IL: American Academy of Pediatrics;

2003:124.

2 Bradley RH. Child care and common communicable

illnesses in children aged 37 to 54 months. Arch

Pediatr Adolesc Med. 2003 Feb;157(2):196-200
87

Community Mitigation Guidance

Purpose

This Interim Planning Guide for Elementary

and Secondary Schools is provided as a

supplement to the Interim Pre-Pandemic 

Planning Guidance: Community Strategy for 

Pandemic Influenza Mitigation in the United 

States—Early, Targeted, Layered Use of 

Nonpharmaceutical Interventions. The guide

is intended to assist in pre-pandemic planning. 

Individuals and families, employers, schools,

and other organizations will be asked to take

certain steps (described below) to help limit

the spread of a pandemic, mitigate disease and

death, lessen the impact on the economy, and

maintain societal functioning. This guidance is

based upon the best available current data and

will be updated as new information becomes

available. During the planning process, Federal,

State, local, tribal, and territorial officials should

review the laws, regulations, and policies that

relate to these recommendations, and they should

include stakeholders in the planning process and

resolution of issues.

Schools will be essential partners in protecting

the public’s health and safety when an influenza

pandemic occurs. This Pandemic Influenza 

Community Mitigation Interim Planning Guide 

for Elementary and Secondary Schools provides

guidance to educational institutions, describing

how they might prepare for and respond to

an influenza pandemic. When an influenza

pandemic starts, public health officials will

determine the severity of the pandemic and

recommend actions to protect the community’s

health. People who become severely ill may

need to be cared for in a hospital. However,

most people with influenza will be safely

cared for at home.

Community mitigation recommendations will be

based on the severity of the pandemic and may

include the following:

1. Asking ill people to voluntarily remain

at home and not go to work or out in the

community for about 7-10 days or until they

are well and can no longer spread the infection

to others (ill individuals will be treated with

influenza antiviral medications, as appropriate, if

these medications are effective and available). 

2. Asking members of households with a person

who is ill to voluntarily remain at home for about

7 days (household members may be provided

with antiviral medications, if these medications

are effective and sufficient in quantity and

feasible mechanisms for their distribution have

been developed).

3. Dismissing students from schools (including

public and private schools as well as colleges

and universities) and school-based activities and

closure of childcare programs for up to 12 weeks,

coupled with protecting children and teenagers

through social distancing in the community

to include reductions of out-of-school social

contacts and community mixing. Childcare

programs discussed in this guidance include

centers or facilities that provide care to any

number of children in a nonresidential setting,

large family childcare homes that provide care

for seven or more children in the home of the

provider and small family childcare homes that

provide care to six or fewer children in the home

of the provider.1

Appendix 6 - Pandemic Influenza Community Mitigation Interim 

Planning Guide for Elementary and Secondary Schools
88

Community Mitigation Guidance

4. Recommending social distancing of adults in

the community, which may include cancellation

of large public gatherings; changing workplace

environments and schedules to decrease social

density and preserve a healthy workplace to

the greatest extent possible without disrupting

essential services; ensuring work-leave policies

to align incentives and facilitate adherence with

the measures outlined above. 

Recommendations for dismissing students from

schools will depend upon the severity of the

pandemic. The current three-tiered planning

approach includes 1) no dissmissals in a

Category 1 pandemic, 2) short-term (up to four

weeks) dismissal of students from schools during

a Category 2 or Category 3 pandemic, and 3)

prolonged (up to 12 weeks) dismissal of students

from schools during a severe influenza pandemic

(Category 4 or Category 5 pandemic). 

In the most severe pandemic, the duration of

these public health measures would likely be

for 12 weeks, which would have educational

implications for students. Planning now for a

prolonged period of student dismissal may assist

schools to be prepared as much as possible to

provide opportunities for continued instruction

and other assistance to students and staff. 

Federal, State, local, tribal, and territorial laws,

regulations, and policies regarding student

dismissal from schools school closures, funding

mechanisms, and educational requirements

should be taken into account in pandemic

planning. If students are dismissed from school

but schools remain open, school- and educationrelated assets, including school buildings, school

kitchens, school buses, and staff, may continue to

remain operational and potentially be of value to

the community in many other ways. In addition,

faculty and staff may be able to continue to

provide lessons and other services to students

by television, radio, mail, Internet, telephone,

or other media. Continued instruction is not

only important for maintaining learning but

also serves as a strategy to engage students in a

constructive activity during the time that they are

being asked to remain at home. 

Planning now for a severe pandemic will

ensure that schools are prepared to implement

the community interventions that may be

recommended. Be prepared to activate the

school district’s crisis management plan for

pandemic influenza that links the district’s

incident command system with the local and/or

State health department/emergency management

system’s incident command system(s).

The Pandemic Flu Planning Checklist for K-12 

School Districts describes approaches to school

planning for a pandemic and can be found

at www.pandemicflu.gov/plan/school/index.

html and www.ed.gov/admins/lead/safety/

emergencyplan/pandemic/planning-guide/index.

html. Recommendations for implementation of

pandemic mitigation strategies are available at

www.pandemicflu.gov, and reliable, accurate,

and timely information on the status and severity

of a pandemic will also be posted on the Web

site. Additional information is available from

the Centers for Disease Control and Prevention

(CDC) Hotline: 1-800-CDC-INFO (1-800-232-

4636). This line is available in English and

Spanish, 24 hours a day, 7 days a week. TTY: 

1-888-232-6348. Questions can be e-mailed to

cdcinfo@cdc.gov.

Recommendations for Planning

1. Plan for ill individuals to remain at home 

•	 Develop a plan for faculty and staff absences

due to personal illness. Plan for alternative

staffing:

o	Identify critical job functions and plan

for alternate coverage of those functions

during a pandemic.

o	Review and analyze Federal and State

employment laws that identify employer

obligations and options for personnel.

•	 Establish and clearly communicate policies

on sick leave and employee compensation. 

•	 Encourage ill persons to stay home during
89

Community Mitigation Guidance

a pandemic and establish return-to-work

policies after illness.

•	 Establish policies for sick-leave absences

unique to a pandemic (e.g., liberal/

unscheduled leave). 

•	 Develop policies on observation for illness

and what to do when a student or staff

member becomes ill at the workplace.

•	 Advise employees to look for information

on taking care of ill people at home. Such

information will be posted on www.

pandemicflu.gov.

2. Plan for all household members of a person 

who is ill to voluntarily remain at home

•	 Develop a plan for faculty and staff absences

related to family member illness. Plan for

alternate staffing:

o	 Identify critical job functions and plan

now for coverage of those functions.

o	 Establish policies for alternate or flexible

worksite (e.g., videoconferencing and

teleworking) and flexible work hours.

o	 Review Federal and State employment

laws that identify your employer

obligations and options for employees.

•	 Establish and clearly communicate policies

on family leave and employee compensation.

•	 Establish policies for sick-leave absences

unique to a pandemic (e.g., liberal/

unscheduled leave). 

•	 Establish policies for employees who have

to stay home because someone in their

household is ill with pandemic influenza.

•	 Be familiar with Federal and State laws

regarding leave of workers who need to

care for an ill family member or voluntarily

remain at home.

•	 Advise employees to look for information

on taking care of ill people at home. Such

information will be posted on www.

pandemicflu.gov.

3. Plan for dismissal of students and childcare 

closure for employees

•	 Develop a plan for school operations during

all levels of pandemic severity. Even if

students are dismissed, schools may remain

operational. 

•	 Identify and plan for employees and staff

who may have to stay home if schools and

childcare programs dismiss students/children

during a pandemic. 

•	 Plan for alternate staffing based on your

assessment.

o	 Identify critical job functions and plan

now for coverage of those functions in

case of prolonged absenteeism during a

pandemic.

o	 Establish policies for employees to

possibly work flexible work hours and

schedules (e.g., staggered shifts) to

accommodate their childcare needs.

•	 Encourage your employees who have

children to make their own plans to care for

children if officials recommend dismissal

of students from schools and closure of

childcare programs. Advise that employees

plan for an extended period (up to 12 weeks)

in case the pandemic is severe. Instruct

employees not to bring their children to the

workplace if childcare cannot be arranged.

•	 In a severe pandemic, parents would be

advised to protect their children by reducing

out-of-school social contacts and mixing

with other children. Although limiting all

outside contact may not be feasible, families

may be able to develop support systems with

co-workers, friends, families, or neighbors

if they continue to need childcare. For

example, they could prepare a plan in

which two to three families work together

to supervise and provide care for a small

group of infants and young children while

their parents are at work (studies suggest that

childcare group size of less than six children

may be associated with fewer respiratory

infections).2
90

Community Mitigation Guidance

•	 Determine if schools must, may, or cannot

compensate, continue benefits, and extend

leave to employees who are not working

during the pandemic.Inform employees of

the decision.

•	 Work with your State legislatures if

modifications to State laws are needed

for flexibilities regarding, for example,

requirements for the number of instruction

days, amount of instruction time, and length

of the school day.

•	 Work with State and local governments

and faith-based and community-based

organizations to provide any needed

assistance to staff who cannot report to work

for a prolonged period.

4. Plan for dismissal of students

•	 Develop a plan for continuity of instruction

•	 Inform teachers, students and parents how

alternate learning opportunities will be

provided. 

o	This may include assignments by radio,

television, regular mail, e-mail, telephone,

and teleconferencing or through the media

o	Consider potential restructuring of the

school calendar

•	 Provide school nurses, counselors, school

psychologists, special-needs teachers, and

social workers guidance on maintaining

needed health, counseling, and social services

for students with physical and mental/

emotional healthcare needs.

•	 Identify and inform parents on how students

who need free meals may qualify for

other types of nutrition assistance in the

community.

•	 Provide systematic emergency

communications to school staff and families

during the pandemic, using a telephone

calling tree, an e-mail alert, call-in voice

recording, or regular mail to communicate.

5. Plan for workplace and community

social distancing measures

•	 Become familiar with social distancing

actions that may be used during a pandemic

to modify frequency and type of person-toperson contact (e.g., reducing hand-shaking,

limiting face-to-face meetings, promoting

teleworking, liberal/unscheduled leave

policies, and staggered shifts).

•	 Plan to operate the workplace using social

distancing and other measures to minimize

close contact between employees.

•	 Review and implement guidance from

the Occupational Safety and Health

Administration (OSHA) on appropriate

work practices and precautions to protect

employees from occupational exposure to

influenza virus during a pandemic. Risks

of occupational exposure to influenza virus

depends in part on whether jobs require close

proximity to people who may be infectious

with the pandemic influenza virus or whether

employees are required to have either

repeated or extended contact with the general

public. OSHA will post and periodically

update such guidance on www.pandemicflu.

gov.

•	 Encourage good hygiene at the workplace. 

Provide students, faculty, and staff with

information about the importance of hand

hygiene (information can be found at www.

cdc.gov/cleanhands/) as well as convenient

access to soap and water and alcohol-based

hand gel in your facility. Educate employees

and students about covering their cough to

prevent the spread of germs (see www.cdc.

gov/flu/protect/covercough.htm).

•	 Promote social distancing of children and

teens outside the school setting by advising

they reduce their social interaction and

contacts to the greatest extent possible. This

may include cancelling after-school and

extracurricular group activities.
91

Community Mitigation Guidance

6. Communicate with faculty, staff, students, 

and parents/families

•	 Make sure your school’s pandemic plan is

explained and understood by faculty, staff,

and parents in advance of a pandemic,

including expected roles/actions for

employees and others during implementation.

•	 Provide information to school staff and

parents/families on what they can do to

prepare themselves and their families for the

pandemic. Resources are available at www.

pandemicflu.gov/plan/individual/checklist.

html and www.ready.gov/america/index.html. 

o	Be prepared to provide parents/families

with information discussing student

dismissal from school and the importance

of keeping students from congregating

with other students in out-of-school

settings.

•	 Provide staff with information on the school

district’s plan for

o	Assuring that essential central office

functions, including payroll, and

communications with staff, students, and

families will continue.

o	Adapting school facilities to supplement

healthcare delivery if needed by local

public health officials.

o	Encouraging school nurses, counselors,

school psychologists, and social workers

to establish supportive long-distance

relationships with particularly vulnerable

students via the phone, e-mail, or regular

mail.

•	 Coordinate strategies with other districts in

your region.

7. Help your community 

•	 Coordinate your pandemic plans and actions

with local health and community planning.

•	 Find volunteers in your school who want

to help people in need, such as elderly

neighbors, single parents of small children,

or people without the resources to get the

medical or other help they will need.

•	 Think of ways your school can help others in

your community to plan for a pandemic.

•	 Participate in community-wide exercises to

enhance pandemic preparedness.

8. Recovery

•	 Establish the criteria and procedure with

State and local planning teams for resuming

school activities.

•	 Develop communication for advising

employees, students, and families of the

resumption of school programs and activities.

•	 Develop the procedures, activities, and

services needed to restore the learning

environment.

References:

1 American Academy of Pediatrics. Children in

Out-of-Home Child Care: Classification of Care

Service. In: Pickering LK, ed. Red Book: 2003

Report of the Committee on Infectious Diseases. 

26th ed. Elk Grove Village, IL: American

Academy of Pediatrics; 2003:124.

2 Bradley RH. Child care and common

communicable illnesses in children aged 37 to

54 months. Arch Pediatr Adolesc Med. 2003

Feb;157(2):196-200.
93

Community Mitigation Guidance

Purpose

This Interim Planning Guide for Colleges and

Universities is provided as a supplement to the

Interim Pre-Pandemic Planning Guidance: 

Community Strategy for Pandemic Influenza 

Mitigation in the United States—Early, 

Targeted, Layered Use of Nonpharmaceutical 

Interventions. The guide is intended to

assist in pre-pandemic planning. Individuals

and families, employers, schools, and other

organizations will be asked to take certain steps

(described below) to help limit the spread of a

pandemic, mitigate disease and death, lessen the

impact on the economy, and maintain societal

functioning. This guidance is based upon the

best available current data and will be updated

as new information becomes available. During

the planning process, Federal, State, local,

tribal, and territorial officials should review

the laws, regulations, and policies that relate

to these recommendations, and they should

include stakeholders in the planning process and

resolution of issues.

Colleges and universities will be essential

partners in protecting the public’s health and

safety when an influenza pandemic occurs. This

Pandemic Influenza Community Mitigation 

Interim Planning Guide for Colleges and 

Universities provides guidance to post-secondary

institutions, describing how they should prepare

for an influenza pandemic. At the onset of an

influenza pandemic, public health officials will

determine the severity of the pandemic and

recommend actions to protect the community’s

health. People who become severely ill may

need to be cared for in a hospital. However,

most people with influenza will be safely cared

for at home. 

Community mitigation recommendations will be

based on the severity of the pandemic and may

include the following:

1. Asking ill people to voluntarily remain

at home and not go to work or out in the

community for about 7-10 days or until they

are well and can no longer spread the infection

to others (ill individuals will be treated with

influenza antiviral medications, as appropriate, if

these medications are effective and available). 

2. Asking members of households with a person

who is ill to voluntarily remain at home for about

7 days (household members may be provided

with antiviral medications, if these medications

are effective and sufficient in quantity and

feasible mechanisms for their distribution have

been developed).

3. Dismissing students from schools (including

public and private schools as well as colleges

and universities) and school-based activities and

closure of childcare programs for up to 12 weeks,

coupled with protecting children and teenagers

through social distancing in the community

to include reductions of out-of-school social

contacts and community mixing. Childcare

programs discussed in this guidance include

centers or facilities that provide care to any

number of children in a nonresidential setting,

large family childcare homes that provide care

for seven or more children in the home of the

provider and small family childcare homes that

provide care to six or fewer children in the home

of the provider.1

Appendix 7 - Pandemic Influenza Community Mitigation

Interim Planning Guide for Colleges and Universities
94

Community Mitigation Guidance

4. Recommending social distancing of adults in

the community, which may include cancellation

of large public gatherings; changing workplace

environments and schedules to decrease social

density and preserve a healthy workplace to

the greatest extent possible without disrupting

essential services; and ensuring work-leave

policies to align incentives and facilitate

adherence with the measures outlined above. 

Recommendations for dismissing students

from college and university classes will depend

upon the severity of the pandemic. The current

three-tiered planning approach includes 1) no

dismissals in a Category 1 pandemic, 2) shortterm (up to 4 weeks) dismissal from classes

in a Category 2 or Category 3 pandemic, and

3) prolonged (up to 12 weeks) dismissal from

classes in a severe influenza pandemic (Category

4 or Category 5). 

Dismissing students for up to 12 weeks will have

educational implications. Planning now for a

prolonged period of student dismissal will help

colleges and universities to plan for alternate

ways to provide continued instruction and

services for students and staff. Even if students

are dismissed from classes, the college/university

facility may remain open during a pandemic and

may continue to provide services to students

who must remain on campus and provide lessons

and other services to off-campus students via

Internet or other technologies. Some students,

particularly international students, may not be

able to rapidly relocate during a pandemic and

may need to remain on campus for some period. 

They would continue to need essential services

from the college/university during that time. 

Continued instruction is not only important for

maintaining learning but also serves as a strategy

to reduce boredom and engage students in a

constructive activity while group classes are

cancelled. Planning now for a severe pandemic

will help assure that your college or university

is prepared to implement these community

recommendations. These preparedness efforts

will be beneficial to your school, staff, students,

and the community, regardless of the severity

of the pandemic. Be prepared to activate

the university’s crisis management plan for

pandemic influenza, which links the university’s

incident command system with the local and/or 

State health department/emergency management

system’s incident command system(s).

The Pandemic Flu Planning Checklist for 

Colleges and Universities describes approaches

to school planning for a pandemic and can be

found at www.pandemicflu.gov/plan/school/

index.html and www.ed.gov/admins/lead/safety/

emergencyplan/pandemic/planning-guide/index.

html. Recommendations for implementation of

pandemic mitigation strategies are available at

www.pandemicflu.gov, and reliable, accurate,

and timely information on the status and severity

of a pandemic will also be posted on this site. 

Additional information is available from the

Centers for Disease Control and Prevention

(CDC) Hotline: 1-800-CDC-INFO (1-800-232-

4636). This line is available in English and

Spanish, 24 hours a day, 7 days a week. TTY: 

1-888-232-6348. Questions can be e-mailed to

cdcinfo@cdc.gov.

Recommendations for Planning

1. Plan for ill individuals to remain at home 

•	 Develop a plan for faculty and staff absences

due to personal illness. Plan for alternative

staffing.

o	Identify critical job functions and plan

for alternate coverage of those functions

during a pandemic.

o	Review and analyze Federal and State

employment laws that identify employer

obligations and options for personnel.

•	 Establish and clearly communicate policies

on sick leave and employee compensation. 

• Encourage ill persons to stay home during

a pandemic and establish return-to-work

policies after illness.

•	 Establish policies for sick-leave absences
95

Community Mitigation Guidance

unique to a pandemic (e.g., liberal/

unscheduled leave). 

•	 Develop policies on observation for illness

and what to do when a student or staff

member becomes ill at the college/university.

•	 Advise employees to look for information

on taking care of ill people at home. Such

information will be posted on www.

pandemicflu.gov.

2. Plan for all household members of a person 

who is ill to voluntarily remain at home

•	 Develop a plan for faculty and staff absences

related to family member illness. Plan for

alternate staffing.

o	Identify critical job functions and plan

now for coverage of those functions.

o	Establish policies for alternate or flexible

worksite (e.g., videoconferencing and

teleworking) and flexible work hours.

o	Review Federal and State employment

laws that identify your employer

obligations and options for employees.

•	 Establish and clearly communicate policies

on family leave and employee compensation.

•	 Establish policies for sick-leave absences

unique to a pandemic (e.g., liberal/

unscheduled leave). 

•	 Establish policies for employees who have

to stay home because someone in their

household is ill with pandemic influenza.

•	 Be familiar with Federal and State laws

regarding leave of workers who need to

care for an ill family member or voluntarily

remain at home.

•	 Advise employees to look for information

on taking care of ill people at home.

Such information will be posted on www.

pandemicflu.gov.

3. Plan for dismissal of students and childcare 

closure for employees

•	 Identify and plan for employees and staff

who may have to stay home if schools and

childcare programs dismiss students/children

during a severe pandemic. 

•	 Plan for alternate staffing based on your

assessment.

o	 Identify critical job functions and plan

for coverage of those functions in case

of prolonged absenteeism during a

pandemic.

o	 Establish flexible work policies for

employees, such as flexible work hours

and schedules (e.g., staggered shifts) to

accommodate childcare needs.

•	 Encourage your employees who have

children to make their own plans to care for

children if officials recommend dismissal

of students from schools and closure of

childcare programs. Advise that employees

plan for an extended period (up to 12 weeks)

in case the pandemic is severe. Instruct

employees not to bring their children to the

workplace if childcare cannot be arranged.

•	 In a severe pandemic, parents will be advised

to protect their children by reducing outof-school social contacts and mixing with

other children. Although limiting all outside

contact may not be feasible, families may

be able to develop support systems with

co-workers, friends, families, or neighbors,

if they continue to need childcare. For

example, they could prepare a plan in

which two to three families work together

to supervise and provide care for a small

group of infants and young children while

their parents are at work (studies suggest that

childcare group size of less than six children

may be associated with fewer respiratory

infections).2

•	 Determine if schools must, may, or cannot

compensate, continue benefits to and extend

leave to employees who are not working

during the pandemic. Inform employees of

the decision.

•	 Coordinate with State and local government

and faith-based and community-based

organizations to assist staff that are not able

to work for a prolonged period.
96

Community Mitigation Guidance

4. Plan for dismissal of students

•	 Inform students about plans and procedures

for providing and completing course work.

•	 Provide guidance to students and faculty

on continuing student instruction. Such

guidance may include

o Assessing the possibility of altering

course-work requirements.

o Providing ongoing assignments by

regular mail, e-mail, Internet links,

telephone, teleconferencing, or calling

into a recorded message at the university

o Gathering information in advance

that would identify students’ mailing

addresses, telephone/cell numbers, and

e-mail addresses

•	 Encouraging faculty who teach the same

subject to share in the development of

distance-learning instructional materials for

their students.

•	 Providing information on accessing

university healthcare staff (e.g., nurses, nurse

practitioners, physicians, physician assistants,

counselors, and psychologists) who could be

recommended as consultation resources for

students with physical and mental/emotional

healthcare needs.

•	 Develop a plan for accommodating students,

especially international students, who remain

on campus during an influenza pandemic.

•	 Review and implement guidance from

the Occupational Safety and Health

Administration (OSHA) on appropriate

work practices and precautions to protect

employees from occupational exposure to

influenza virus during a pandemic. Risks

of occupational exposure to influenza virus

depends in part on whether or not jobs

require close proximity to people who may

be infectious with the pandemic influenza

virus or whether employees are required to

have either repeated or extended contact with

the public. OSHA will post and periodically

update such guidance on www.pandemicflu.

gov.

5. Plan for workplace and community social 

distancing measures

•	 Learn about social distancing methods that

may be used during a pandemic to limit

person-to-person contact during a pandemic

and reduce the spread of disease (e.g.,

reducing hand-shaking, limiting face-to-face

meetings and shared workstations, work from

home policies, staggered shifts).

•	 Use social distancing measures to minimize

close contact at your college/university. 

Determine how your facility could be

rearranged to allow more distance between

people during a pandemic. 

•	 Develop plans for alternatives to mass

gatherings. Examples could range, for

example, from video messages on the Internet

to e-mailed messages, mailed newsletters,

pre-recorded messages on a designated callin phone number. 

•	 Encourage good hygiene at the workplace. 

Provide faculty, staff, and students with

information about the importance of hand

hygiene (information can be found at www.

cdc.gov/cleanhands/) as well as convenient

access to soap and water and alcohol-based

hand gel in your facility. Educate faculty,

staff, and students about covering their cough

to prevent the spread of germs (see www.

cdc.gov/flu/protect/covercough.htm).

6. Communicate with faculty, staff, students, 

and parents/families

•	 Provide faculty, staff, and parents with

information on the college/university’s

pandemic preparedness plan in advance of

a pandemic. This communication should

include

o	 Identifying expected roles/actions

for faculty, staff, students, and other

stakeholders during implementation

o	 Assuring that essential central office

functions, including payroll, and

communications with staff, students and

families will continue
97

Community Mitigation Guidance

o	 Identifying how the college/university’s

physical facilities may be used for other

purposes during a pandemic

•	 Develop a plan to inform parents/families

that students may be dismissed during a

Category 4-5 pandemic.

o	 Encourage them to plan for that

contingency, including plans for

relocating students to home or elsewhere

o	 Inform them of school procedures and

policies regarding tuition, fees, and

contractual obligations

•	 Provide systematic emergency

communications to faculty, staff, and

students (both on and off campus) during the

pandemic by using multiple methods (e.g.,

a telephone calling tree, an e-mail alert, or

call-in voice recording) to communicate

pandemic status in the community and status

of classes and other university activities.

•	 Be prepared to provide parents/families with

information discussing

o	 How dismissal of students will be

announced

o	 Why students will be dismissed from

classes and the importance of keeping

students from congregating with others in

the community 

o	 How alternate instruction will be

provided

•	 Be prepared to provide students who soon

will be leaving for home with information

discussing

o	 Why students are being dismissed from

classes and the importance of keeping

students from congregating with other

students in the community. Students

should understand 

•	 Differences between seasonal and

pandemic influenza

•	 How influenza is spread

•	 What individuals can do help prevent

the spread of influenza

•	 Remind students who live in residence

halls to take their books and other personal

items with them on the last day of classes, if

indicated.

•	 Provide information to university faculty,

staff, and parents/families on what they can

do to prepare their families for the pandemic. 

Resources are available at www.pandemicflu.

gov/plan/individual/checklist.html and www.

ready.gov/america/index.html.

•	 Recommend that faculty, staff, students and

their families seek further information about

the pandemic through resources, including

key Federal, State, and local public health

that provide regular updates on the status of

the pandemic. For reliable, accurate, and

timely information about pandemic flu, see

www.pandemicflu.gov.

7. Help your community 

•	 Coordinate your pandemic plans and actions

with local health planning.

•	 Find volunteers in your college/university

who want to help people in need, such as

elderly neighbors, single parents of small

children, or people without the resources to

get the medical or other help they will need.

•	 Think of ways your institution can reach out

to others in your community to help them

plan for a pandemic.

•	 Participate in community-wide exercises to

enhance pandemic preparedness.

8. Recovery

•	 Establish with State and local planning teams

the criteria and procedures for resuming

college/university activities.

•	 Develop communication for advising

employees and students and families of the

resumption of school programs and activities.

•	 Develop the procedures, activities, and

services needed to restore the learning

environment.

References:

1 American Academy of Pediatrics. Children in

Out-of-Home Child Care: Classification of Care

Service. In: Pickering LK, ed. Red Book: 2003
98

Community Mitigation Guidance

Report of the Committee on Infectious Diseases. 26th

ed. Elk Grove Village, IL: American Academy of

Pediatrics; 2003:124.

2 Bradley RH. Child care and common communicable

illnesses in children aged 37 to 54 months. Arch

Pediatr Adolesc Med. 2003 Feb;157(2):196-200.
99

Community Mitigation Guidance

Purpose

This Interim Planning Guide for Faith-based

and Community Organizations is provided

as a supplement to the Interim Pre-Pandemic 

Planning Guidance: Community Strategy for 

Pandemic Influenza Mitigation in the United 

States—Early, Targeted, Layered Use of 

Nonpharmaceutical Interventions. The guide

is intended to assist in pre-pandemic planning. 

Individuals and families, employers, schools,

and faith-based and community organizations

will be asked to take certain steps (described

below) to help limit the spread of a pandemic,

mitigate disease and death, lessen the impact

on the economy, and maintain societal

functioning. This guidance is based upon the

best available current data and will be updated

as new information becomes available. During

the planning process, Federal, State, local,

tribal, and territorial officials should review

the laws, regulations, and policies that relate

to these recommendations, and they should

include stakeholders in the planning process and

resolution of issues.

Faith-based and community organizations

(FBCOs) will be essential partners in protecting

the public’s health and safety when an influenza

pandemic occurs. This Pandemic Influenza 

Community Mitigation Interim Planning Guide 

for Faith-Based and Community Organizations

provides guidance for religious organizations

(including, for example, places of worship—

churches, synagogues, mosques, and temples—

and faith-based social service providers), social

service agencies, and community organizations

in preparing for and responding to an influenza

pandemic. When an influenza pandemic starts,

public health officials will determine the severity

of the pandemic and recommend actions to

protect the community’s health. People who

become severely ill may need to be cared for in

a hospital. However, most people with influenza

will be safely cared for at home.

Community mitigation recommendations will be

based on the severity of the pandemic and may

include the following:

1. Asking ill people to voluntarily remain

at home and not go to work or out in the

community for about 7-10 days or until they

are well and can no longer spread the infection

to others (ill individuals will be treated with

influenza antiviral medications, as appropriate, if

these medications are effective and available). 

2. Asking members of households with a person

who is ill to voluntarily remain at home for about

7 days (household members may be provided

with antiviral medications, if these medications

are effective and sufficient in quantity and

feasible mechanisms for their distribution have

been developed).

3. Dismissing students from schools (including

public and private schools as well as colleges

and universities) and school-based activities and

closure of childcare programs for up to 12 weeks,

coupled with protecting children and teenagers

through social distancing in the community

to include reductions of out-of-school social

contacts and community mixing. Childcare

programs discussed in this guidance include

Appendix 8 - Pandemic Influenza Community Mitigation Interim 

Planning Guide for Faith-Based and Community Organizations
100

Community Mitigation Guidance

centers or facilities that provide care to any

number of children in a nonresidential setting,

large family childcare homes that provide care

for seven or more children in the home of the

provider and small family childcare homes that

provide care to six or fewer children in the home

of the provider.1

4. Recommending social distancing of adults in

the community, which may include cancellation

of large public gatherings; changing workplace

environments and schedules to decrease social

density and preserve a healthy workplace to

the greatest extent possible without disrupting

essential services; and ensuring work-leave

policies to align incentives and facilitate

adherence with the measures outlined above. 

Planning now for a severe pandemic will help

assure that your organization is prepared to

implement these community recommendations. 

These preparedness efforts will be beneficial

to your organization, volunteer and paid staff,

and community, regardless of the severity of

the pandemic. The Faith-Based & Community 

Organizations Pandemic Influenza Preparedness 

Checklist (available at

www.pandemicflu.gov/plan/community/

faithcomchecklist.html) provides an approach

to pandemic planning by FBCOs. In addition,

recommendations for implementation of

pandemic mitigation strategies are available at

www.pandemicflu.gov. Reliable, accurate, and

timely information on the status and severity

of the pandemic also will be posted on www.

pandemicflu.gov. Additional information is

available from the Centers for Disease Control

and Prevention (CDC) Hotline: 1-800-CDCINFO (1-800-232-4636). This line is available

in English and Spanish, 24 hours a day, 7 days a

week. TTY: 1-888-232-6348. Questions can be

e-mailed to cdcinfo@cdc.gov.

Recommendations for Planning

1. Plan for ill individuals to remain at home 

•	 Plan for employee and volunteer staff

absences during a pandemic due to personal

illness. 

o	 Identify critical job functions and plan

how to temporarily suspend non-critical

activities, cross-train staff to cover critical

functions, and cover the most critical

functions with fewer staff.

o	 Identify employees, volunteers, and

members or clients that live alone or

might need extra assistance if they need

to stay home because they are ill.

o	 Review Federal and State employment

laws that identify your employer

obligations and options for employees.

•	 Establish and clearly communicate policies

on sick leave and employee compensation.

• Encourage ill persons to stay home during

a pandemic and establish return to work

policies after illness.

•	 Encourage leadership to model staying at

home when ill as well as the use of proper

cough and sneeze etiquette and hand hygiene.

•	 Where appropriate, align public health

messages and recommendations with your

organization’s values and beliefs. For

example, develop a culture that recognizes

the positive behaviors of voluntarily

staying home when ill to get well and avoid

spreading infection to others.

•	 Develop policies on what to do when a

person becomes ill at the workplace.

•	 Advise employees, volunteers, and members

or clients to look for information on taking

care of ill people at home. Such information

will be posted on www.pandemicflu.gov.

2. Plan for all household members of a person 

who is ill to voluntarily remain at home

•	 Plan for employee and volunteer staff

absences during a pandemic related to family

member illness. 
101

Community Mitigation Guidance

o	 Identify critical job functions and plan

how to temporarily suspend non-critical

activities, cross-train staff to cover critical

functions, and cover the most critical

functions with fewer staff.

o	 Establish policies for alternate or flexible

worksite (e.g., work via the Internet, email, mailed or phone work assignments)

and flexible work hours.

•	 Establish and clearly communicate policies

on family leave and employee compensation,

especially Federal laws and laws in your

State regarding leave of workers who need to

care for an ill family member or voluntarily

remain at home.

•	 Establish and clearly communicate policies

for volunteers to ensure that critical functions

are covered.

•	 Advise staff and members to look for

information on taking care of ill people at

home. Such information will be posted on

www.pandemicflu.gov.

3. Plan for dismissal of students and childcare 

closure 

•	 Find out how many employee and volunteer

staff may have to stay at home to care for

children if schools and childcare programs

dismiss students. 

o	Identify critical job functions and plan

for temporarily suspending non-critical

activities and cross-training staff to cover

critical functions with fewer staff.

o	Establish policies for staff with children to

work from home, if possible, and consider

flexible work hours and schedules (e.g.,

staggered shifts).

•	 Encourage staff with children to make plans

for what they will do if officials recommend

dismissal of students from schools and

closure of childcare programs. Instruct staff

and volunteers not to bring their children

to the workplace if childcare cannot be

arranged.

•	 In a severe pandemic, parents will be advised

to protect their children by reducing outof-school social contacts and mixing with

other children. Although limiting all outside

contact may not be feasible, parents may

be able to develop support systems with

co-workers, friends, families, or neighbors,

if they continue to need childcare. For

example, they could prepare a plan in

which two to three families work together

to supervise and provide care for a small

group of infants and young children while

their parents are at work (studies suggest that

childcare group size of less than six children

may be associated with fewer respiratory

infections).2

•	 Help your staff explore about benefits they

may be eligible for if they have to stay home

to mind children for a prolonged period

during a pandemic.

4. Prepare your organization

•	 Consider potential financial deficits due to

emergencies when planning budgets. This is

useful for pandemic planning and many other

unforeseen emergencies, such as fires and

natural disasters.

•	 Many FBCOs rely on community-giving to

support their activities. Develop strategies

that will allow people to continue to make

donations and contributions via the postal

service, the Internet, or other means if they

are at home for an extended period.

•	 Develop a way to communicate with your

employee and volunteer staff during an

emergency to provide information and

updates.

•	 Meet with other FBCOs to develop

collaborative efforts to keep your

organizations running, such as large

organizations collaborating with small ones

or several small organizations working

together.
102

Community Mitigation Guidance

5. Plan for workplace and community social 

distancing measures

•	 Learn about social distancing methods that

may be used during a pandemic to limit

person-to-person contact during a pandemic

and reduce the spread of disease (e.g.,

reducing hand-shaking, limiting face-to-face

meetings and shared workstations, work from

home policies,

staggered shifts).

•	 Use social distancing measures to minimize

close contact at your facility. Determine

how your facility could be rearranged to

allow more distance between people during a

pandemic. 

•	 Develop plans for alternatives to mass

gatherings. Examples could range from

video messages on the Internet to emailed messages, mailed newsletters, prerecorded messages from trusted leaders on a

designated call-in phone number, and daily

teaching guides from trusted leaders.

•	 Encourage good hygiene at the workplace. 

Provide staff, volunteers, and members with

information about the importance of hand

hygiene (information can be found at www.

cdc.gov/cleanhands/) as well as convenient

access to soap and water and alcohol-based

hand gel in your facility. Educate employees

about covering their cough to prevent the

spread of germs (see www.cdc.gov/flu/

protect/covercough.htm).

•	 Identify activities, rituals, and traditions, such

as hand shaking, hugging, and other closeproximity forms of greeting that may need to

be temporarily suspended or modified during

a pandemic.

•	 Review and implement guidance from

the Occupational Safety and Health

Administration (OSHA) to adopt appropriate

work practices and precautions to protect

employees from occupational exposure to

influenza virus during a pandemic. Risks

of occupational exposure to influenza virus

depends in part on whether or not jobs

require close proximity to people potentially

infected with the pandemic influenza virus

or whether they are required to have either

repeated or extended contact with the general

public. OSHA will post and periodically

update such guidance on www.pandemicflu.

gov. 

6. Communicate with your employee and

volunteer staff and members

•	 Share your organization’s pandemic

plan, including expected roles/actions for

employee and volunteer staff and members

during implementation.

•	 Suggest that all employee, volunteers, and

members or clients prepare for a pandemic. 

Resources are available at www.pandemicflu.

gov/plan/individual/checklist.html and www.

ready.gov/america/index.html. For example,

individuals and families should have a

reserve supply of food and water. People

with more resources might consider obtaining

enough supplies to support 1-2 other families

in an emergency. 

•	 Ensure that your organization has up-todate contact information for employees,

volunteers, and members or clients, including

names of family members, addresses, home,

work, and cell phone numbers, e-mail

addresses, and emergency contacts. 

7. Help your Community

•	 Identify people who are vulnerable and

may need assistance in your community

(i.e., elderly people who live alone, persons

with disabilities, people with limited skill

in speaking English, low-income families,

children, or teens who may lack supervision). 

Designate people from your organization to

be responsible to check on specific vulnerable

people or families.

•	 Determine ways your facility might be used

during a pandemic, such as a temporary

care facility or a central distribution site for

providing meals, supplies, or medicine to

those who cannot obtain them.
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Community Mitigation Guidance

•	 Identify and meet with local emergency

responders, health departments, and

healthcare organizations to learn about

their planning and educate them about your

organization’s planning.

•	 Suggest that each household maintain a

current list of emergency contacts in your

community.

•	 Meet with other FBCOs to develop

collaborative efforts to care for those in need,

such as large organizations partnering with

small ones or several small organizations

working together.

•	 Identify employee and volunteer staff in

advance who would be willing to help others

in need during a pandemic and help them

to receive training through the local health

department, emergency services, or other

resources.

•	 Designate an experienced person who can

take calls and organize individuals who

call spontaneously to volunteer during an

emergency to facilitate the best use of their

particular skills and experience.

•	 Develop or identify an existing mental health

or counseling hotline that people in the

community can call during a pandemic or

other emergency.

•	 Participate in community-wide exercises to

enhance pandemic preparedness.

8. Recovery

•	 Assess which criteria would need to be met to

resume normal operations.

•	 Plan for the continued need for medical,

mental health, and social services after a

pandemic.

References:

1 American Academy of Pediatrics. Children in

Out-of-Home Child Care: Classification of Care

Service. In: Pickering LK, ed. Red Book: 2003

Report of the Committee on Infectious Diseases. 

26th ed. Elk Grove Village, IL: American

Academy of Pediatrics; 2003:124.

2

Bradley RH. Child care and common

communicable illnesses in children aged 37 to

54 months. Arch Pediatr Adolesc Med. 2003

Feb;157(2):196-200.
105

Community Mitigation Guidance

Purpose

This Interim Planning Guide for Individuals

and Families is provided as a supplement to

the Interim Pre-Pandemic Planning Guidance: 

Community Strategy for Pandemic Influenza 

Mitigation in the United States—Early, 

Targeted, Layered Use of Nonpharmaceutical 

Interventions. The guide is intended to

assist in pre-pandemic planning. Individuals

and families, employers, schools, and other

organizations will be asked to take certain steps

(described below) to help limit the spread of a

pandemic, mitigate disease and death, lessen the

impact on the economy, and maintain societal

functioning. This guidance is based upon the

best available current data and will be updated

as new information becomes available. During

the planning process, Federal, State, local,

tribal, and territorial officials should review

the laws, regulations, and policies that relate

to these recommendations, and they should

include stakeholders in the planning process and

resolution of issues.

Individuals and families will have an essential

role in protecting themselves and the public’s

health and safety when an influenza pandemic

occurs. This Pandemic Influenza Community 

Mitigation Interim Planning Guide for 

Individuals and Families provides guidance

describing how individuals and families

might prepare for and respond to an influenza

pandemic. At the onset of an influenza

pandemic, public health officials will determine

the severity of the pandemic and recommend

actions to protect the community’s health. 

People who become severely ill may need to be

cared for in a hospital. However, most people

with influenza will be safely cared for at home.

Community mitigation recommendations will be

based on the severity of the pandemic and may

include the following:

1. Asking ill people to voluntarily remain

at home and not go to work or out in the

community for about 7-10 days or until they

are well and can no longer spread the infection

to others (ill individuals will be treated with

influenza antiviral medications, as appropriate, if

these medications are effective and available). 

2. Asking members of households with a person

who is ill to voluntarily remain at home for about

7 days (household members may be provided

with antiviral medications, if these medications

are effective and sufficient in quantity and

feasible mechanisms for their distribution have

been developed).

3. Dismissing students from schools (including

public and private schools as well as colleges

and universities) and school-based activities and

closure of childcare programs for up to 12 weeks,

coupled with protecting children and teenagers

through social distancing in the community

to include reductions of out-of-school social

contacts and community mixing. Childcare

programs discussed in this guidance include

centers or facilities that provide care to any

number of children in a nonresidential setting,

large family childcare homes that provide care

for seven or more children in the home of the

provider and small family childcare homes that

provide care to six or fewer children in the home

of the provider.1

Appendix 9 - Pandemic Influenza Community Mitigation

Interim Planning Guide for Individuals and Families
106

Community Mitigation Guidance

4. Recommending social distancing of adults in

the community, which may include cancellation

of large public gatherings; changing workplace

environments and schedules to decrease social

density and preserve a healthy workplace to

the greatest extent possible without disrupting

essential services; and ensuring work-leave

policies to align incentives and facilitate

adherence with the measures outlined above. 

Planning now for a severe pandemic will

assist you and your family as you prepare for

interventions that might be recommended. 

Resources are available at www.pandemicflu.

gov/plan/individual/checklist.html and www.

ready.gov/america/index.html. In addition,

reliable, accurate, and timely information

on the status and severity of a pandemic and

recommendations for implementation of

pandemic mitigation strategies is available at

www.pandemicflu.gov. Additional information

is available from the Centers for Disease Control

and Prevention (CDC) Hotline: 1-800-CDCINFO (1-800-232-4636). This line is available

in English and Spanish, 24 hours a day, 7 days a

week. TTY: 1-888-232-6348. Questions can be

e-mailed to cdcinfo@cdc.gov.

Recommendations for Planning

1. Plan for ill individuals to remain at home 

•	 Be prepared to stay at home if you are ill with

pandemic influenza. Information on taking

care of ill people at home will be posted on

www.pandemicflu.gov.

o	It will be important to have extra supplies

on hand during a pandemic, as you may

not be able to get to a store or stores may

be out of supplies. You should have a

reserve of at least a two-week supply of

water and food; however, if the pandemic

is severe, community disruption may last

for a longer period. If community water

supplies are not suitable for consumption

during a pandemic, your local water utility

or public health authorities will notify the

community.

o	Periodically check your regular

prescription drugs to ensure a continuous

supply in your home.

o	Have any nonprescription drugs and

other health supplies on hand, including

a thermometer, pain relievers, stomach

remedies, cough and cold medicines, and

other over-the-counter medicines that you

and your family use on a regular basis.

o	Designate one person in the household

who could be the caregiver if anyone in

the household becomes ill with pandemic

influenza. Develop an alternate plan for

someone to be the caregiver if that person

becomes sick.

o	Talk with neighbors, friends, and family

about your plans for staying at home if

you or someone in your household is ill. 

Share ideas.

o	Ensure that each household has a current

list of emergency contacts in your

community, including mental health and

counseling resources.

2. Plan for all household members of a person 

who is ill to voluntarily remain at home

•	 Be prepared to stay at home if someone in

your household is ill. Information on taking

care of ill people at home will be posted on

www.pandemicflu.gov.

o	Have any nonprescription drugs and

other health supplies on hand, including

a thermometer, pain relievers, stomach

remedies, cough and cold medicines, and

other over-the-counter medicines that you

and your family use on a regular basis.

o	Talk with family members and members of

your household about how they would be

cared for if they become ill and about what

will be needed to care for them in your or

their home.

o	Designate one person in the household

who could be the caregiver if anyone in

the household becomes ill with pandemic

flu. Make plans for a backup if that person

gets ill.
107

Community Mitigation Guidance

o	Consider how to care for people in your

household with special needs in case the

services they rely on are not available.

o	Talk with neighbors, friends, and family

about your plans for staying at home if

someone in your household is ill. Share

ideas.

o	 Ensure that each household has a current

list of emergency contacts in your

community, including mental health and

counseling resources.

3. Plan for dismissal of students and childcare 

closure 

•	 If you have children in your household, make

plans for their care if officials recommend

dismissal of students from schools and

closure of childcare programs.

o	Plan and arrange now for who will care for

children if schools and childcare programs

dismiss students and children during a

pandemic. Plan for an extended period

(up to 12 weeks) in case the pandemic is

severe.

o	Do not plan to bring children to the

workplace if childcare cannot be arranged.

o	If you have children in a college or

university, have a plan for the student to

relocate or return home, if desired, or if

the college/university dismisses students,

at the onset of a Category 4-5 pandemic.

o	Plan home-learning activities and

exercises. Have materials, such as books,

on hand.

o	Public health officials will likely

recommend that children and teenagers

do not gather in groups in the community

during a pandemic. Plan recreational

activities that your children can do at

home. 

o	Find out now about the plans at your

child’s school or childcare facility during a

pandemic. 

•	 In a severe pandemic, parents will be advised

to protect their children by reducing outof-school social contacts and mixing with

other children. Although limiting all outside

contact may not be feasible, parents may be

able to develop support systems with coworkers, friends, families, or neighbors, if

they continue to need childcare. For example,

they could prepare a plan in which two to

three families work together to supervise and

provide care for a small group of infants and

young children while their parents are at work

(studies suggest that childcare group size of

less than six children may be associated with

fewer respiratory infections).2

 4. Plan for workplace and community social 

distancing measures

•	 Become familiar with social distancing

actions that may be used during a pandemic

to modify frequency and type of person-toperson contact (e.g., reducing hand-shaking,

limiting face-to-face meetings, promoting

teleworking, liberal/unscheduled leave

policies, and staggered shifts).

•	 Talk to your employer

o	 Talk to your employer about the pandemic

influenza plan for your workplace to

include issues about benefits, leave,

telework, and other possible policies to go

into effect during a pandemic. 

o	 Ask your employer about how your

employer will continue during a pandemic

if key staff cannot come to work.

o	 Plan for the possible reduction or loss of

income if you are unable to work or your

place of employment is closed. Consider

maintaining a cash reserve.

o	 Check with your employer or union about

leave policies for workers who are ill,

live in a household with someone ill with

pandemic influenza, or have to take off

work to take care of children.

o	Find out if you can work from home.

o	Discuss alternative ways of holding

meetings at work, including, for example,

teleconferences, during a pandemic.

o	Find out how you will receive information

from your employer during a pandemic.
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Community Mitigation Guidance

•	 Prepare backup plans in case public gatherings,

such as community events and meetings and

worship services, are cancelled.

o	 Talk with others in your community about

other ways of communicating during a

pandemic if public gatherings are cancelled

o	 Plan for recreational activities that you and

your household members can do at home if

community gatherings are cancelled during a

pandemic.

o	 Discuss with your faith-based organization

or place of worship their plans for

communicating with members during a

pandemic. 

5. Help others

•	 Prepare backup plans for taking care of loved ones

who are far away.

•	 Find volunteers who want to help people in need,

such as elderly neighbors, single parents of small

children, or people without the resources to get

the medical help they will need.

•	 Think of ways you can reach out to others in your

neighborhood or community to help them plan for

and respond to a pandemic. 

References:

1

American Academy of Pediatrics. Children in Outof-Home Child Care: Classification of Care Service. 

In: Pickering LK, ed. Red Book: 2003 Report of

the Committee on Infectious Diseases. 26th ed. Elk

Grove Village, IL: American Academy of Pediatrics;

2003:124.

2

Bradley RH. Child care and common communicable

illnesses in children aged 37 to 54 months. Arch

Pediatr Adolesc Med. 2003 Feb;157(2):196-200.
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

February 2007

CS108488