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

tlc

February 2007

Early, Targeted, Layered Use of Nonpharmaceutical Interventions

Interim Pre-Pandemic Planning Guidance:

Community Strategy for Pandemic Influenza Mitigation in the United States—

	 	 I Executive	Summary ........................................................................	07

	 	 II Introduction ..................................................................................	17

	 	 III Rationale	for	Proposed	Nonpharmaceutical	Interventions ..........................	23

	 	 IV Pre-pandemic	Planning:		the	Pandemic	Severity	Index	 .............................	29

	 	 V Use	of	Nonpharmaceutical	Interventions	by	Severity	Category	 ...................	33

	 	 VI Triggers	for	Initiating	Use	of	Nonpharmaceutical	Interventions ...................	39

	 	VII Duration	of	Implementation	of	Nonpharmaceutical	Interventions ..........................	43

VIII 	 Critical	Issues	for	the	Use	of	Nonpharmaceutical	Interventions ...................	45

	 	 IX Assessment	of	the	Public	on	Feasibility	of	Implementation	and	Adherence .....	47

	 	 X Planning	to	Minimize	Consequences	of	Community	Mitigation	Strategy	 .......	49

									XI Testing	and	Exercising	Community	Mitigation	Interventions .....................	55

	 	XII Research	Needs .............................................................................	57

XIII Conclusions	 .................................................................................	61

XIV 	 References ...................................................................................	63

	 	XV Appendices ..................................................................................	69

Appendix	1.			 Glossary	of	Terms ...........................................................	69

	 Appendix	2.			 Interim	Guidance	Development	Process .....................................	73

	 Appendix	3.		 WHO	Phases	of	a	Pandemic/U.S.	Government	Stages	of	a	Pandemic .......	75

	 Appendix	4.		 Pandemic	Influenza	Community	Mitigation	Interim

	 	 	 Planning	Guide	for	Businesses	and	Other	Employers ........................	77

	 Appendix	5.			 Pandemic	Influenza	Community	Mitigation	Interim

	 	 	 Planning	Guide	for	Childcare	Programs .....................................	81

	 Appendix	6.			 Pandemic	Influenza	Community	Mitigation	Interim

	 	 	 Planning	Guide	for	Elementary	and	Secondary	Schools .....................	85

	 Appendix	7.			 Pandemic	Influenza	Community	Mitigation	Interim

	 	 	 Planning	Guide	for	Colleges	and	Universities ...............................	91

	 Appendix	8.			 Pandemic	Influenza	Community	Mitigation	Interim

	 	 	 Planning	Guide for	Faith-based	and	Community	Organizations .............	97

	 Appendix	9.			 Pandemic	Influenza	Community	Mitigation	Interim	Planning	Guide .......	103

	 	 	 for	Individuals	and	Families

Contents

7

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 decisionmakers with recommendations that are matched to the

severity of future influenza pandemics.

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
8

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 the 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-ofschool 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 gathering 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. 

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.

Community Mitigation Guidance
9

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 1, 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. 

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

Community Mitigation Guidance
10

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	second-order	

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	1,	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.

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.		Prepandemic	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	

Figure 1. Pandemic Severity Index

Projected

Number of Deaths*

US Population, 2006

Assumes 30% Illness Rate and Unmitigated Pandemic Without Interventions

Community Mitigation Guidance
11

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	laboratory-confirmed	cluster	

of	infection	with	a	novel	influenza	

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	age-specific	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

Pandemic Severity Index

Interventions* by Setting 1 2 and 3 4 and 5

Home

Voluntary isolation of ill at home (adults 

and children); combine with use of antiviral 

treatment as available and indicated

Recommend†§ Recommend†§ Recommend†§

Voluntary quarantine of household 

members in homes with ill persons¶ (adults 

and children); consider combining with 

antiviral prophylaxis if effective, feasible, 

and quantities sufficient

Generally not 

recommended Consider** Recommend**

School

Child social distancing

-dismissal of students from schools and 

school based activities, and closure of child 

care programs

-reduce out-of-school social contacts and 

community mixing

Generally not 

recommended

Consider:

≤4 weeks††

Consider:

≤4 weeks††

Recommend:

≤12 weeks§§

Recommend:

 ≤12 weeks§§

Generally not 

recommended

Workplace / Community

Adult social distancing

-decrease number of social contacts (e.g., 

encourage teleconferences, alternatives to 

face-to-face meetings)

Generally not 

recommended Consider Recommend

-increase distance between persons (e.g., 

reduce density in public transit, workplace)

Generally not 

recommended Consider Recommend

-modify postpone, or cancel selected public 

gatherings to promote social distance (e.g., 

postpone indoor stadium events, theatre 

performances)

Generally not 

recommended Consider Recommend

-modify work place schedules and practices 

(e.g., telework, staggered shifts)

Generally not 

recommended Consider Recommend

Table 1. Summary of the Community

Mitigation Strategy by Pandemic Severity

Community Mitigation Guidance
12

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 scenario-specific 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, 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/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

Community Mitigation Guidance
13

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 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 the poll is available at the “Pandemic

Influenza and the Public: Survey Findings” available

at http://www.keystone.org/Public_Policy/Pandemic_

control.html.

The Public Engagement Project on Community

Control Measures for Pandemic Influenza (see

link at http://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

Community Mitigation Guidance
14

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, faithbased and community organizations, and individuals

and families. It is also critical 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. Communitylevel 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.

Community Mitigation Guidance
15

Community Mitigation Guidance
16
17

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 for healthcare

services, including intensive care unit (ICU)

admissions and the number of individuals requiring

mechanical ventilation, would vastly exceed current

Introduction

II

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 crossprotection 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 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 pre-pandemic vaccine did

prove to be effective, projected stockpiles of such a

vaccine would be sufficient for only a fraction of the

U.S. population.
18

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

the 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

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

Figure 1. 

Community Mitigation Guidance
19

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 1, 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-ofschool 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 is 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

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

Community Mitigation Guidance
20

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 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 terms generally refer to foreseeable unintended

consequences of intervention. For example, dismissal

of students from school classrooms may lead to the

second-order 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 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). 

Community Mitigation Guidance
21

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 human-tohuman 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 At-Risk

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

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.

Community Mitigation Guidance
22
23

Rationale for Proposed

Nonpharmaceutical Interventions

III

The three major goals of mitigating a communitywide 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 community-wide 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.

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
24

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 onehalf 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. 

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

Figure 2. 

Community Mitigation Guidance
25

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 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.

Community Mitigation Guidance
26

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 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

Community Mitigation Guidance
27

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 influenza-related 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 schoolage 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 school 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 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

Community Mitigation Guidance
28

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 community-based interventions (case isolation,

household quarantine, child and adult social

distancing through school or workplace closure or

restrictions, and restrictions on travel).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 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.
29

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 pre-pandemic 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

consideration of other available information. Pending

this announcement, communities facing the imminent

arrival of pandemic disease will be able to define

Pre-pandemic Planning:

The Pandemic Severity Index

IV

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, age-specific 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

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
30

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.

Characteristics

Pandemic Severity Index (PSI)

Category 1 Category 2 Category 3 Category 4 Category 5

Case Fatality Ratio 

(percentage)

Excess Death Rate 

(per 100,000)

Illness Rate 

(percentage of the 

population)

Potential Number of 

Deaths (based on 2006 

U.S. population)

20th Century 

U.S.Experience

<0.1

<30

20-40

<90,000

Seasonal

Influenza

(illness rate

5-20%)

0.1-<0.5

30-<150

20-40

90,000-

<450,000

1957,1968

0.5-<1.0

150-<300

20-40

450,000-

<900,000

None

1.0-<2.0

300-<600

20-40

900,000-

<1.8 million

None

≥2.0

≥600

20-40

≥1.8 million

1918

Pandemic

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 

Community Mitigation Guidance
31

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 

Community Mitigation Guidance
32

Projected

Number of Deaths*

US Population, 2006

Assumes 30% Illness Rate and Unmitigated Pandemic Without Interventions

Figure 4. Pandemic Severity Index
33

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. 

3.	 Dismissal of students from school (including

public and private schools as well as colleges and

Use of Nonpharmaceutical Interventions

by Pandemic Severity Category

V

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-ofschool 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. 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
34

Pandemic Severity Index

Interventions* by Setting 1 2 and 3 4 and 5

Home

Voluntary isolation of ill at home (adults 

and children); combine with use of antiviral 

treatment as available and indicated

Recommend†§ Recommend†§ Recommend†§

Voluntary quarantine of household 

members in homes with ill persons¶ (adults 

and children); consider combining with 

antiviral prophylaxis if effective, feasible, 

and quantities sufficient

Generally not 

recommended Consider** Recommend**

School

Child social distancing

-dismissal of students from schools and 

school based activities, and closure of child 

care programs

Generally not 

recommended

Consider:

≤4 weeks††

Recommend:

≤12 weeks§§

-reduce out-of-school social contacts and 

community mixing

Generally not 

recommended

Consider:

≤4 weeks††

Recommend:

 ≤12 weeks§§

Workplace / Community

Adult social distancing

-decrease number of social contacts (e.g., 

encourage teleconferences, alternatives to 

face-to-face meetings)

Generally not 

recommended Consider Recommend

-increase distance between persons (e.g., 

reduce density in public transit, workplace)

Generally not 

recommended Consider Recommend

-modify postpone, or cancel selected public 

gatherings to promote social distance (e.g., 

postpone indoor stadium events, theatre 

performances)

Generally not 

recommended Consider Recommend

-modify work place schedules and practices 

(e.g., telework, staggered shifts)

Generally not 

recommended Consider Recommend

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 age-specific 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.

Community Mitigation Guidance
35

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 prepandemic 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.

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

Community Mitigation Guidance
36

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.

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 pre-pandemic

planning for this intervention include a three-tiered

Community Mitigation Guidance
37

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) cancellation

of classes 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 NPIs.

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 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.

Community Mitigation Guidance
38
39

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 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

Triggers for Initiating Use of

Nonpharmaceutical Interventions

VI

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 key component

is the development of scenario-specific 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
40

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.

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/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

Pandemic

Severity Index

WHO Phase 6, U.S. 

Government stage 3*

WHO Phase 6, U.S. 

Government Stage 4† 

and

First human case in the 

United States 

WHO Phase 6, U.S. 

Government Stage 5§

and

First laboratory 

confirmed cluster in 

state or region¶

1 Alert Standby Activate

2 and 3 Alert Standby Activate

4 and 5 Standby** Standby/Activate†† 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.

Community Mitigation Guidance
41

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 (Stage 5). 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 pre-pandemic 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

influenza-like 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.

Community Mitigation Guidance
42
43

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 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 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

Duration of Implementation of

Nonpharmaceutical Interventions

VII

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)

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.
44
45

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 to State and local decisionmakers 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 influenzalike illness due to seasonal influenza strains and

other respiratory pathogens from illnesses due to

pandemic influenza strains. Accurate ascertainment

of pandemic influenza 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.

Critical Issues for the Use of

Nonpharmaceutical Interventions

VIII
46

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.
47

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 September-October 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 threefourths (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, about one in four (24

percent) said they would not have someone to take

care of them.

Assessment of the Public on Feasibility

of Implementation and Adherence

IX

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 or disabled person, 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, 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 three-fourths

of respondents (76 percent) thought they would have

such problems if they were away from work for 3

months.
48

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 onethird 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.
49

Pandemic mitigation interventions will pose

challenges for individuals and families, employers

(both public and private), and local communities. 

Some cascading second- and third-order 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 schoolrelated 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 and employees. 

These consequences associated with the pandemic

mitigation interventions must be weighed against

Planning to Minimize Consequences

of Community Mitigation Strategy

X

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

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. 
50

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 (singleperson 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 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

Community Mitigation Guidance
51

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 oneadult 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 childminding 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

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-of-school

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

Community Mitigation Guidance
52

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 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 lowincome 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.

Community Mitigation Guidance
53

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 education-related 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. 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 single-parent

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

Community Mitigation Guidance
54

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

country-specific announcements online 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-inplace” 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 http://

travel.State.gov/travel/tips/health/health_3096.html.
55

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 an after-action-report to describe

corrective actions to fix response problems, including

who is responsible for fixing what by when (a

Testing and Exercising Community

Mitigation Interventions

XI

“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 http://www.bt.cdc.gov/planning/

coopagreement/pdf/phase2-panflu-guidance.pdf.
56
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 laboratoryconfirmed 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

interventions, including vaccines, antiviral

medications, and NPIs.

Research Needs

XII

•	 Development of rapid diagnostics: The

development of sensitive and specific point-ofcare 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 community-based 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.

•	 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
58

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 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

Community Mitigation Guidance
59

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.

Community Mitigation Guidance
60
61

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, scenario-based

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 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

Conclusions

XIII

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 homecare 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 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
62

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.
63

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69

Appendices

XVII

Appendix 1 - Glossary of Terms 

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.

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.
70

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 alcoholbased 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 and sustainably 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-to-human 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 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 (http://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

Community Mitigation Guidance
71

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.

Surgical mask: Disposable face masks 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).

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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).

Community Mitigation Guidance
73

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 SeptemberOctober 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 EpiAid 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 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

Appendix 2 – Interim Guidance Development Process

Community Mitigation Guidance
74

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

Community Mitigation Guidance
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Appendix 3 - WHO Phases of a Pandemic/

U.S. Government Stages of a Pandemic

Community Mitigation Guidance
76

Community Mitigation Guidance
77

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 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

Appendix 4 - Pandemic Influenza Community Mitigation Interim 

Planning Guide for Businesses and Other Employers

Community Mitigation Guidance
78

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, (http://www.pandemicflu.gov/plan/

business/businessesoverseaspdf.pdf), and the

Pandemic Influenza Preparedness, Response 

and Recovery Guide for Critical Infrastructure 

and Key Resources (http://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-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

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 are

disabled.

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.

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

Community Mitigation Guidance
79

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 person-to-person contact

(e.g., reducing hand-shaking, limiting face-to-face

meetings and shared workstations, promoting

teleworking, 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

Community Mitigation Guidance
80

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 http://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 (http://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 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

Community Mitigation Guidance
81

Purpose

This Interim Planning Guide for Childcare Programs

is provided as a supplement to the Interim PrePandemic 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.

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

Appendix 5 - Pandemic Influenza Community Mitigation

Interim Planning Guide for Childcare Programs

Community Mitigation Guidance
82

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 (http://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 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

Community Mitigation Guidance
83

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 faithbased 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-to-person 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 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 http://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 http://

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

•	 Promote social distancing of children outside the

childcare setting by advising parents that children

Community Mitigation Guidance
84

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 http://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.

using 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 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

•	 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

Community Mitigation Guidance
85

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

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

Appendix 6 - Pandemic Influenza Community Mitigation Interim 

Planning Guide for Elementary and Secondary Schools

Community Mitigation Guidance
86

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 education-related 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 

http://www.pandemicflu.gov/plan/school/index.

html and http://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-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.

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 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.

Community Mitigation Guidance
87

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

•	 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 faithbased 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

Community Mitigation Guidance
88

•	 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-to-person contact

(e.g., reducing hand-shaking, limiting face-toface 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 http://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 http://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.

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 http://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 outof-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.

Community Mitigation Guidance
89

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 others in your

community to help them 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 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.

Community Mitigation Guidance
90

Community Mitigation Guidance
91

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 postsecondary 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

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

Appendix 7 - Pandemic Influenza Community Mitigation

Interim Planning Guide for Colleges and Universities

Community Mitigation Guidance
92

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, 2)

short-term (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 offcampus 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 

http://www.pandemicflu.gov/plan/school/index.

html and http://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-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.

Planning Recommendations

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 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 

Community Mitigation Guidance
93

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 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

•	 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.

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 coursework 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

Community Mitigation Guidance
94

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-toperson 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 call-in 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 http://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 http://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

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

Community Mitigation Guidance
95

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 http://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 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.

Community Mitigation Guidance
96

Community Mitigation Guidance
97

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

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 8 - Pandemic Influenza Community Mitigation Interim 

Planning Guide for Faith-Based and Community Organizations

Community Mitigation Guidance
98

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

http://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-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.

Planning Recommendations

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. 

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, e-mail,

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.

Community Mitigation Guidance
99

•	 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 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

•	 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.

5. Plan for workplace and community social 

distancing measures

•	 Learn about social distancing methods that may

be used during a pandemic to limit person-toperson 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 e-mailed messages, mailed

newsletters, pre-recorded 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 http://www.cdc.gov/

cleanhands/) as well as convenient access to soap

and water and alcohol-based hand gel in your

Community Mitigation Guidance
100

facility. Educate employees about covering their

cough to prevent the spread of germs (see http://

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

•	 Identify activities, rituals, and traditions, such as

hand shaking, hugging, and other close-proximity

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 http://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-to-date

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.

•	 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.

Community Mitigation Guidance
101

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 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.

Community Mitigation Guidance
102

Community Mitigation Guidance
103

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

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

Appendix 9 - Pandemic Influenza Community Mitigation

Interim Planning Guide for Individuals and Families

Community Mitigation Guidance
104

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 http://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-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.

Planning Recommendations

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-thecounter 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-thecounter 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.

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.

Community Mitigation Guidance
105

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 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

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-to-person contact

(e.g., reducing hand-shaking, limiting face-toface 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.

•	 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. 

Community Mitigation Guidance
106

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.

Community Mitigation Guidance
107

Community Mitigation Guidance
tlc

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