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Winter 2021 - Critical Care

Pandemic Preparedness: Ensuring the U.S. Is Ready for the Next One?

After several federal agencies spent two decades and tens of billions of dollars preparing for the next pandemic, critics were not shy about pointing out how unprepared the United States was for the current SARS-Cov-2 pandemic.

Pandemics have been on record as far back as the 1600s. In the last 100 years, there have been four pandemics. In the United States, each pandemic has resulted in hundreds of thousands of illnesses and tens of thousands of deaths, including devastating effects on the nation’s economy. And, after each pandemic, the nation’s many agencies developed new pandemic preparedness plans or, at the least, incorporated lessons learned into existing plans.

If there is one lesson learned from the current pandemic, it is the illumination of shortcomings and gaps in pandemic preparedness plans. What started as a misrepresented pneumonia outbreak in 44 patients in Wuhan, China — reported to the World Health Organization (WHO) China Country Office on Dec. 31, 20191 — quickly morphed into one of the world’s worst pandemics on record. On March 11, 2020, WHO finally judged the SARS-CoV-2 virus, which causes the novel corona influenza virus (COVID-19), could be characterized as a pandemic.2

This two-and-a-half-month delay in announcing the pandemic resulted in the world’s countries delaying their own responses that would have involved calling states of emergencies while the pandemic rapidly unfolded. The adverse effects of this delay were especially profound in the United States where, even after invoking its many agencies’ multifaceted pandemic preparedness plans, there have been more than eight million cases and more than 220,000 deaths as a result of COVID-19 as of this writing.3

However, critics say, notwithstanding WHO’s delay in declaring a pandemic, it was the bureaucracy surrounding the United States’ pandemic preparedness plans that resulted in millions of cases of COVID-19 and hundreds of thousands of deaths, rather than the government’s unpreparedness.

Historically, only one global-based health agency and a few main health agencies in the United States existed in the last two decades to develop pandemic preparedness plans intended as guidance documents for government, healthcare systems and hospitals. And, since many of these agencies work in conjunction with each other, additional information or material has been created that overlaps these plans.

World Health Organization (WHO)

WHO, in working to promote worldwide health, keep the world safe and serve the vulnerable, has developed several guidance documents on pandemic preparedness to help countries plan and prepare for a pandemic. According to WHO, “The objective of pandemic planning is to enable countries to be prepared to recognize and manage an influenza pandemic. Planning may help to reduce transmission of the pandemic virus strain, to decrease cases, hospitalizations and deaths, to maintain essential services and to reduce the economic and social impact of a pandemic.”4

WHO’s Pandemic Influenza Phases comprise an alert system developed to help inform the world about the seriousness of a pandemic. It has six phases, with Phase 1 having the lowest risk of human cases and Phase 6 posing the greatest risk. The system also includes a post-peak period, possible new wave period and post-pandemic period. The phases are applicable globally and provide a framework to aid countries in pandemic preparedness and response planning.5

Since 1952, global influenza surveillance has been conducted through WHO’s Global Influenza Surveillance and Response System (GISRS), which has fostered global confidence and trust for more than half a century through effective collaboration and sharing of viruses, data and benefits based on member states’ commitment to a global public health model. The mission of GISRS is to protect people from the threat of influenza by continuously functioning as a global mechanism of surveillance, preparedness and response for seasonal, pandemic and zoonotic influenza; global platform for monitoring influenza epidemiology and disease; and global alert for novel influenza viruses and other respiratory pathogens.6

In 2005, WHO published its Checklist for Influenza Pandemic Preparedness Planning. In 2009, the agency published its Pandemic Influenza Preparedness and Response Guidance. In 2011, it published its Pandemic Influenza Preparedness (PIP) framework whose purpose is to share information about influenza viruses with member states and stakeholders to increase access to vaccines during pandemics, particularly for developing countries.7 And in 2017, WHO published its Pandemic Influenza Risk Management: A WHO Guide to Inform and Harmonize National and International Pandemic Preparedness and Response guidance document.

However, even with these guidance documents, WHO admits the world is not prepared for any pandemic. According to a report of the Review Committee on the Functioning of the International Health Regulations (2005) concerning the H1N1 pandemic H1N1 in 2009, “The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public health emergency.”8

United States Department of Health and Human Services (HHS)/Office of the Assistant Secretary for Preparedness and Response (ASPR)

In 2005, HHS developed a PIP plan to prevent, control and mitigate the effects of influenza viruses that have the potential to become pandemics. HHS has since published four updates to it, the latest of which was published in 2017 that consists of seven domains. According to HHS, “These domains reflect an end-to-end systems approach to improving the way preparedness and response are integrated across sectors and disciplines, while remaining flexible for the conditions surrounding a specific pandemic. This will allow HHS to respond more quickly to a future influenza pandemic and, at the same time, strengthen our response to seasonal influenza to mitigate the next influenza pandemic.”9

HHS has also developed three tools to help guide different aspects of planning and response: the Pandemic Intervals Framework (PIF), the Influenza Risk Assessment Tool and the Pandemic Severity Assessment Framework.

Developed under HHS, the Hospital Preparedness Program (HPP) is a cooperative agreement administered by the ASPR that establishes a foundation for national healthcare preparedness. According to HHS, the HPP prepares the healthcare system to save lives through the development of regional healthcare coalitions (HCCs), which are groups of healthcare and response organizations that collaborate to prepare for and respond to medical surge events. HCCs, it says, incentivize diverse and often competitive healthcare organizations to work together. Since 2002, the HPP has invested $5.9 billion in healthcare preparedness with 96 percent of HCCs reporting they feel HPP support has improved their ability to decrease morbidity and mortality during disasters.10

In fall 2013, HHS, the ASPR and the National Healthcare Preparedness Programs (NHPP) developed the Healthcare Coalition Checklist for Pandemic Planning, which assists HCCs in assessing, developing and improving their preparedness and response plans for a pandemic. The checklist follows the preparedness capabilities outlined in the Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness. It also recommends actions to develop and/or improve coalition-based emergency response plans for pandemic influenza.11

NHPP also developed performance measures, outlined in the 2017-2022 Hospital Preparedness Program: Performance Measures Implementation Guidance, to evaluate program performance and track progress. The guidance is framed for the primary users — awardees and HCCs — to ease comprehension, improve information aggregation and enable faster data collection.12 In addition, the 2017-2022 Health Care Preparedness and Response Capabilities guidance describes what the healthcare delivery system (HCCs, hospitals and emergency medical services) needs to do to effectively prepare for and respond to emergencies that impact the public’s health.13

More recently, the ASPR developed the COVID-19 Healthcare Planning Checklist, which identifies specific activities jurisdictions can implement to prepare for, respond to and be resilient in the face of COVID-19. The checklist is adapted from a variety of HHS influenza pandemic planning resources.14

In 2018, the ASPR began supporting the Regional Disaster Health Response System (RDHRS) pilot projects, which provide funding directly to hospitals and health systems to establish multistate regional partnerships that increase preparedness and response capability and capacity for hospitals and healthcare facilities in advance of, during or immediately following incidents, including emerging infectious diseases.15

Currently, the ASPR is developing a new RDHRS by leveraging and enhancing existing programs such as the HPP and the National Disaster Medical System to create a more coherent, comprehensive and capable healthcare disaster response system integrated into daily care delivery. The proposed RDHRS will be built on a tiered regional framework that emphasizes collaboration among local healthcare coalitions, trauma centers, public and private healthcare facilities, and emergency medical services to expand access to specialty clinical care expertise and increase medical surge capacity.16

In June 2019, the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 was passed to strengthen public health and healthcare readiness, bolster response and recovery programs, and increase transparency. There is now a formal authorization for annual funding for programs to develop medical countermeasures for pandemic influenza and other emerging infectious diseases.16

The Centers for Disease Control and Prevention (CDC)

CDC works to improve global control and prevention of seasonal and novel influenza, as well as improve influenza pandemic preparedness and response. CDC’s response to the COVID-19 pandemic includes preparing first responders, healthcare providers and health systems; providing advice to businesses, communities and schools about how they can manage the pandemic; sharing what it has learned about COVID-19; maintaining safety at the nation’s borders by issuing extensive travel guidance; and publishing a variety of communication resources that state and local governments and community organizations can use to support their own pandemic response.17 According to CDC, “Since launching an agency-wide response to this pandemic on Jan. 21, 2020, CDC has been preparing healthcare workers, learning more about how the disease spreads, and supporting state, local, tribal and territorial governments on the front lines of this outbreak.”18

Although CDC has not developed a pandemic preparedness framework specifically for COVID-19, it has developed influenza preparedness frameworks. And, since COVID-19 is an influenza virus, the majority of the agency’s PIF can be applied to this pandemic. CDC’s PIF describes the progression of an influenza pandemic using six intervals to guide influenza pandemic planning and provides recommendations for risk assessment, decision-making and action in the United States.19

The Federal Emergency Management Agency (FEMA)

As an agency of the United States Department of Homeland Security, FEMA’s mission is to help people before, during and after disasters. 

In 2008, FEMA published a template guidance document titled Pandemic Influenza Continuity of Operations Annex Template (PICOAT), which was last updated in 2009, to address a pandemic influenza that focuses on a whole community response.20

In 2015, FEMA produced the second edition of its National Preparedness Goal that describes five mission areas (prevention, protection, mitigation, response and recovery) and 32 activities grouped under three core capabilities (planning, public information and warning, and operational coordination) that address the greatest risks to the nation.21

In 2017, FEMA published the Biological Incident Annex (BIA) to the Response and Recovery Federal Interagency Operations Plan. While BIA is not scenario-specific, there is significant discussion about federal coordination, response and recovery activities to a pandemic influenza event that capitalizes on its existing plans for the H1N1 (2009) influenza virus, the emergence of MERS-CoV and H7N9 influenza, and the Pandemic Crisis Action Plan.22

In August 2019, FEMA participated in the HHS-led Crimson Contagion national level exercise that involved multiple federal and state agencies and major hospitals, which exercised a nationwide pandemic influenza response, testing current plans, policies and procedures, as well as the nation’s core capability to respond. The exercise found that, in the event of a pandemic, the United States lacks sufficient domestic manufacturing capacity and/or raw materials for almost all pandemic influenza medical countermeasures, including vaccines and therapeutics, the needles and syringes needed to administer them, and personal protective equipment, including masks, needles and syringes.22

In October 2019, FEMA published the fourth edition of its National Response Framework (NRF), a guide to how the United States responds to all types of disasters and emergencies. The NRF is built on scalable, flexible and adaptable concepts identified in the National Incident Management System to align key roles and responsibilities. It is structured to help jurisdictions, citizens, nongovernmental organizations and businesses develop whole community plans; integrate continuity plans; build capabilities to respond to cascading failures among businesses, supply chains and infrastructure sectors; and collaborate to stabilize community lifelines and restore services. This edition includes lessons learned from previous disasters, new initiatives and enhances the unified effort between the government and the private sector through better coordination and collaboration.23

In May 2020, FEMA published its COVID-19 Pandemic Operational Guidance for the 2020 Hurricane Season to help states, tribes and territories address additional planning and safety considerations in the face of COVID-19.24

According to a FEMA spokesperson, “FEMA is continuously learning from past disasters and using those lessons learned to inform planning and response decisions. Disaster response cannot be conducted by FEMA alone, it is a whole-of-America effort involving coordination with and expertise from local, state and federal governments, as well as private sector and voluntary organizations.”

United States’ Nurses Unprepared for the COVID-19 Pandemic

Despite the HPP and a multitude of other pandemic preparedness plans, nurses in U.S. hospitals were woefully unprepared to meet COVID-19 patients’ needs. They were acutely aware there was not enough medical PPE (masks, face shields, gloves and gowns), emergency beds or staff, ventilators or specific pandemic information.

Nurses cite a current lack of emergency preparedness education, the public health system’s lack of drilling nurses on emergency situations, staffing shortages, a lack of cross-training and a lack of adequate mental healthcare as reasons they were so unprepared for the pandemic. A recent survey of 32,000 nurses revealed 87 percent of nurses are afraid to go to work, and 36 percent reported having to care for an infectious patient despite inadequate PPE. They also reported an urgent need for education on caring for COVID-19 patients, PPE usage, personal safety and COVID-19 testing.25

The Failure of United States’ Pandemic Preparedness Plans

Even before WHO officially announced the COVID-19 pandemic, many government officials, academics and media organizations criticized the federal government’s handling of it. An article titled “Why Two Decades of Pandemic Planning Failed” outlines how many federal agencies during the past two decades prepared a multitude of pandemic preparedness plans, but when the COVID-19 pandemic occurred, it was not a lack of a pandemic preparedness plan, but rather the bureaucracy of the agencies and the plans that prevented the nation from responding to the pandemic effectively. “The failure of the United States government to respond to the coronavirus was not a failure of foresight,” says the article’s author. “It was a failure to create a coherent strategy and to provide clear lines of authority to implement it.”26

In a remarkable case of foreshadowing, the author of a Politico magazine article titled “Inside America’s 2-Decade Failure to Prepare for Coronavirus,” says the HHS’ Pandemic Influenza Plan, which was announced in November 2005, “includes tactics, models and other details that eerily resemble today’s coronavirus crisis. One scenario, cut from the final report, even described how a respiratory disease would swiftly move from sickening dozens in an Asian village to killing as many as 1.9 million Americans — a ‘grimly compelling’ vision, the New York Times reported at the time, and a framework that would have foreshadowed future discussions about the COVID-19 outbreak. Staff who worked on the plan say they can’t remember why the Asian flu scenario was removed from the final plan.”27

The headline in an article in The Washington Post that retraces the failures over the first 70 days of the coronavirus crisis and is based on 47 interviews with administration officials, public health experts, intelligence officers and others involved in fighting the pandemic, reads, “The U.S. Was Beset by Denial and Dysfunction as the Coronavirus Raged. From the Oval Office to the CDC, Political and Institutional Failures Cascaded Through the System, and Opportunities to Mitigate the Pandemic Were Lost.”28

Another article, in which a disaster response expert was interviewed, says, “While the United States is well-prepared to respond to some diseases, COVID-19 just isn’t one of them.” And “some clear missteps have hindered our ability to lessen the spread and severity of COVID-19 in the U.S.”29

Yet another article that reviews a breakdown of federal government spending to prepare for health crises, says, “Over the past decade, the U.S. government spent nearly $100 billion on preparation for major health crises, including pandemics … though the coronavirus outbreak still had Washington and states across the country scrambling to muster supplies and respond when it hit. The sad truth is that the U.S. government did plan for just such a crisis as the one we now face. But we cannot count on planning to solve a future crisis. We need to simplify and clarify our federal bureaucracy so it can respond more nimbly to such a crisis in the future, even while we continue to rely on the wisdom of many thousands of Americans in state and local governments to lead.”30


1. World Health Organization. Pneumonia of Unknown Cause — China, January 9, 2020. Accessed at,the%20national%20authorities%20in%20China.

2. World Health Organization. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19, March 11, 2020. Accessed at—11-march-2020.

3. Worldometer. United States Coronavirus. Accessed at

4. World Health Organization. WHO Checklist for Influenza Pandemic Preparedness Planning, 2005. Accessed at

5. World Health Organization. Current WHO Phase of Pandemic Alert for Pandemic (H1N1) 2009. Accessed at

6. World Health Organization. Global Influenza Surveillance and Response System. Accessed at

7. World Health Organization. Addressing Our Health Responsibilities for Pandemic Influenza Preparedness. Accessed at

8. World Health Organization. Pandemic Influenza Risk Management: A WHO Guide to Inform & Harmonize National & International Pandemic Preparedness and Response, May 2017. Accessed at

9. United States Department of Health and Human Services. Pandemic Influenza Plan: 2017 Update. Accessed at

10. United States Department of Health and Human Services/Office of the Assistant Secretary for Preparedness and Response. Hospital Preparedness Program. Accessed at

11. United States Department of Health and Human Services/Office of the Assistant Secretary for Preparedness and Response. Interim Healthcare Coalition Checklist for Pandemic Planning/National Healthcare Preparedness Programs, Fall 2013. Accessed at

12. Office of the Assistant Secretary for Preparedness and Response. 2017-2022 Hospital Preparedness Program: Performance Measures Implementation Guidance. Accessed at

13. Office of the Assistant Secretary for Preparedness and Response. 2017-2022 Health Care Preparedness and Response Capabilities, November 2016. Accessed at

14. Office of the Assistant Secretary for Preparedness and Response. COVID-19 Healthcare Planning Checklist. Accessed at

15. United States Department of Health and Human Services. Flu Season: U.S. Public Health Preparedness and Response, Statement of Robert Kadlec, MD, MTM&H, MS, Assistant Secretary for Preparedness and Response, Dec. 4, 2019. Accessed at

16. United States Department of Health and Human Services/Office of the Assistant Secretary for Preparedness and Response. Regional Disaster Health Response System. Accessed at

17. Centers for Disease Control and Prevention. Coronavirus Disease 2019: CDC’s Response, Aug, 31, 2020. Accessed at

18. Centers for Disease Control and Prevention. Coronavirus Disease 2019: CDC in Action, July 8, 2020. Accessed at

19. Centers for Disease Control and Prevention. Updated Preparedness and Response Framework for Influenza Pandemics, Recommendations and Reports, Sept. 26, 2014. Accessed at

20. Federal Emergency Management Agency. Pandemic Influenza Continuity of Operations Annex Template, 2009. Accessed at

21. Federal Emergency Management Agency. National Preparedness Goal, Second Edition, September 2015. Accessed at

22. Federal Emergency Management Agency. Biological Incident Annex to the Response and Recovery Federal Interagency Operational Plans: Final — January 2017. Accessed at

23. Federal Emergency Management Agency. National Response Framework, Fourth Edition, Oct. 28, 2019. Accessed at

24. Federal Emergency Management Agency. COVID-19 Pandemic Operational Guidance for the 2020 Hurricane Season, May 2020. Accessed at

25. Veenema TG and Meyer D. Why America’s Nurses Were Not Prepared for the Coronavirus Pandemic. Forbes, June 4, 2020. Accessed at

26. Glock J, Why Two Decades of Pandemic Planning Failed. Medium, April 9, 2020. Accessed at

27. Diamond D. Inside America’s 2-Decade Failure to Prepare for Coronavirus. Politico, April 11, 2020. Accessed at

28. Abutaleb Y, Dawsey J, Nakashima E, and Miller G. The U.S. Was Beset by Denial and Dysfunction as the Coronavirus Raged: From the Oval Office to the CDC, Political and Institutional Failures Cascaded Through the System and Opportunities to Mitigate the Pandemic Were Lost. The Washington Post, April 4, 2020. Accessed at

29. Lewis W. Disaster Response Expert Explains Why the U.S. Wasn’t More Prepared for the Pandemic. USC Dornsife, March 24, 2020. Accessed at

30. Olson T. Feds Spent Nearly $100B on Pandemic Readiness, Health Security in Decade Leading Up to Coronavirus Crisis. Fox News, May 11, 2020. Accessed at

Diane L.M. Cook
Diane L.M. Cook, BComm, is a freelance trade magazine writer based in Canada.