Disease Outbreak

Overview 

An emerging disease with epidemic potential is a disease with new or emerging features that challenge control. This does not include highly-transmissible respiratory viruses, which are addressed under “Respiratory virus with pandemic potential”. Emerging diseases are difficult to contain or treat, and present significant challenges to risk communication since mechanics of transmission, laboratory identification, and effective treatment protocols may be unknown. Previous events that fit this hazard include Ebola, Zika, the emergence of HIV, and the current opioid epidemic. 

A respiratory virus with pandemic potential is a highly contagious respiratory virus that spreads easily from person to person and for which there is little human immunity. This hazard includes pandemic influenza. This hazard strains the healthcare system, requires school closures, causes high rates of illness and absenteeism that undermine critical infrastructure across the city, and decreases community trust due to social distancing measures interfering with personal movement and being perceived as being ineffectual. Previous events that exemplify this hazard include the 1918 (“Spanish flu”) and 2009 (“Swine flu”) influenza pandemics and the 2003 SARS outbreak, which had pandemic potential. 

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What is the Hazard? 

Emerging Disease with Epidemic Potential 

Disease X 

Unknown emerging diseases with epidemic potential are often referred to as “Disease X.” Disease X refers to a pathogen that hasn’t been discovered yet, but which is almost certain to cause a future global epidemic. Because so much is unknown about the next Disease X, countermeasures are insufficient – or don’t exist at all. 

In 2018, the World Health Organization (WHO) included Disease X on its list of priority diseases for vaccine development. According to the WHO, “Disease X represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease, and so the [Research & Development (R&D)] Blueprint explicitly seeks to enable cross-cutting R&D preparedness that is also relevant for an unknown “Disease X”.” Similarly, the City’s efforts to prepare for and respond to disease outbreaks are designed to be as flexible and adaptable as possible for an unknown “Disease X.” 

Large-scale release of biological threat without readily available medical countermeasures. 

This hazard includes the large scale release of a biological threat without readily available medical countermeasures. This includes biological weapons and the release of a novel or altered pathogen from a laboratory. Regardless of whether the release is accidental or intentional, the impact on the public’s health and corresponding response operations in the face of an unknown agent are the same. Both scenarios may result in mental health stress caused by an unknown agent, and reliance on strategies like quarantine and social distancing in the absence of countermeasures. Quarantine requirements in a large scale incident can overwhelm the healthcare system and the societal disruption caused by social distancing can impede a community’s ability to cope. 

Respiratory Virus with Pandemic Potential 

A pandemic is a global infectious disease outbreak. For biological threats, an influenza pandemic presents the highest public health disaster risk to New York City, with the potential for high morbidity and mortality, massive strain on the healthcare system, profound economic impacts, and significant disruptions to daily life for all New Yorkers. 

Influenza viruses, as well as certain other respiratory viruses, are readily transmitted in a population, can mutate frequently so that most of the population has little if any immunity to new strains, and cause severe illness and death. Recently, a novel strain of H7N9 influenza and a novel coronavirus, the Middle Eastern Respiratory Syndrome coronavirus, have emerged; both viruses have been associated with high fatality rates.  Pandemic influenzas typically have two or three waves, or “peaks,” of infection lasting 8 to 12 weeks in duration while other respiratory pandemics have less defined characteristics. 

+ Severity 

Emerging Disease with Epidemic Potential

In 2018, the New York City Department of Health and Mental Hygiene (DOHMH) conducted a citywide Public Health Jurisdictional Risk Assessment to identify and rank the top public health hazards facing the city. Part of this assessment included expanding the traditional definition of public health severity beyond morbidity and mortality to include additional contributors to the overall severity of a hazard with respect to its effect on the public’s health. The final contributors to severity are listed below by weight, according to their importance in calculating the overall severity of a hazard. 

When ranked against other hazards of public health concern, an emerging disease with epidemic potential is estimated to have moderate severity. 

Respiratory Virus with Pandemic Potential 

In 2018, DOHMH conducted a citywide Public Health Jurisdictional Risk Assessment to identify and rank the top public health hazards to New York City. Part of this assessment included expanding the traditional definition of public health severity beyond morbidity and mortality to include additional contributors to the overall severity of a hazard with respect to its effect on public health. The final contributors to severity are listed below by weight, according to their importance in calculating the overall severity of a hazard. 

A respiratory virus with pandemic potential can be very severe, driven by high mortality rates and substantial impact on the healthcare system. 

Pandemic Influenza Morbidity and Mortality 

To understand the potential impact on New Yorkers and the healthcare system, DOHMH uses two pandemic influenza scenarios to estimate the burden of disease, a more likely mild/moderate scenario and a severe scenario based on the 1918 influenza pandemic.

Mild/Moderate Pandemic Scenario 

A mild/moderate pandemic wave of a novel influenza hits New York City over a 10-week period. An estimated 1.5 million New Yorkers may become ill and approximately 500 die from the illness citywide. There is above average strain on the healthcare system. Hospital emergency department visits and outpatient services are higher than normal. This pandemic scenario resembles the 1957 influenza season and 2009 H1N1 pandemic. For a mild/moderate pandemic, our general assumptions include: 

• An attack rate of 18% and a case fatality rate of .03%. 
• Susceptibility to the pandemic influenza subtype will be nearly 
• City agencies, healthcare facilities and businesses will experience increased worker absenteeism and increased demand for medical and social services. 
• Surge of healthcare staff will be needed to provide both outpatient and inpatient care staff in emergency departments. Primary care physicians, emergency medicine physicians, and pediatricians especially could become 
• Increased infection control measures may be recommended beyond those normally recommended for seasonal 
• Spot shortages of medications and supplies associated with infection control (e.g., PPE). 
• The anticipated time from identification of a pandemic strain to vaccine manufacture ranges from 4 to 6 months, with early doses most likely to be limited to federally identified priority groups (e.g.: active military, pregnant women, children). 

Severe Pandemic Scenario 

A severe pandemic wave of novel influenza hits New York City over a 10-week period. The attack rate is 33% with a case fatality rate of 2.5% (similar to the pandemic of 1918). An estimated 2.8 million New Yorkers may become ill and approximately 71,000 die from the illness citywide. Morbidity and mortality will be high during this event. There will be great demand on the New York City 911 system to respond to medical calls and high rates of staff absence across the healthcare system will further exacerbate this issue. Hospital capacity within the city is heavily impacted, especially during peak demand. Table 2. Potential NYC Pandemic Influenza Impact Severe Scenario Assumes an attack rate of 33% (similar to 1918) and case fatality rate of 2.5% (same as 1918). These estimates are based on scenarios that are unmitigated, meaning that they do not account for public health interventions that would likely be implemented during a pandemic. 

For a severe pandemic, our general assumptions include those for a mild pandemic scenario as well as: 

• Community mitigation measures (e.g. school closures, cancellation of public events, public to stay home) may be recommended by CDC. 
• Extreme strain on City and other critical (e.g. Con Ed, etc.) agencies to maintain critical functions due to excessive and prolonged staff absenteeism. 
• Increased demand on health and human services by both the ill and the “worried well” seeking information. 
• Increased news coverage and spread of false information may lead to increased stress among the population. 
• Increased demand for information by the public and healthcare providers. 
• Shortages of beds (especially in Intensive Care Units and ventilators), staffing, and supplies within the healthcare system. 
• Potential for antiviral and other medical supply shortages. 
• Public more unwilling or unable to leave home due to illness, self-imposed home isolation, and/or public health requests to avoid going into public places. 

+ Probability 

Emerging Disease with Epidemic Potential 

To estimate the probability of an emerging disease with epidemic potential striking New York City in the next 10 years (relative to other hazards), the 2018 Public Health Jurisdictional Risk Assessment evaluated four contributors that affect the probability of public health hazards. 

Compared to other hazards that represent public health concerns, an emerging disease with epidemic potential was estimated to have a moderate likelihood of occurrence. Results from the 2018 Public Health Jurisdictional Risk Assessment will be available in late 2019. 

Respiratory Virus with Pandemic Potential 

Influenza pandemics occur when there is a significant genetic change in a circulating strain of influenza, when most of a population is susceptible, and the strain has the ability to rapidly spread from person to person. Because of a genetic shift and lack of prior exposure and immunity, a large portion of the human population may be entirely vulnerable to infection from the new strain. Influenza pandemics have occurred every 10 to 60 years, with three occurring in the twentieth century (1918, 1957-1958, and 1967-1968) and one in the twenty-first century (2009-2010). To estimate the probability of a respiratory virus with pandemic potential striking New York City in the next 10 years (relative to other hazards), the 2018 Public Health Jurisdictional Risk Assessment evaluated four contributors that affect the probability of public health hazards. 

+ Location 

Emerging Disease with Epidemic Potential 

It is impossible to predict where an emerging disease will first arise. 

Respiratory Virus with Pandemic Potential 

A respiratory virus with pandemic potential will likely impact all New York City neighborhoods, but not all locations will experience the same effects at the same time. 

+ Historic Occurrences 

Emerging Disease with Epidemic Potential 

As no comprehensive database exists, the below events are anecdotal and should not be considered comprehensive. 

Respiratory Virus with Pandemic Potential 

1918 H1N1 “Spanish Flu” Pandemic 

The 1918 influenza pandemic was the most severe pandemic in recent history. It was caused by an H1N1 virus with genes of avian origin. Although there is no universal consensus regarding where the virus originated, it spread worldwide during 1918-1919. In the United States, it was first identified in military personnel in the spring of 1918. It is estimated that about 500 million people or one-third of the world’s population became infected with this virus. The number of deaths was estimated to be at least 50 million worldwide with about 675,000 occurring in the United States. Mortality was high in people younger than 5 years old, 20-40 years old, and 65 years and older. The high mortality in healthy people, including those in the 20-40 year age group, was a unique feature of this pandemic. While the 1918 H1N1 virus has been synthesized and evaluated, the properties that made it so devastating are not well understood. Antibiotics to treat secondary bacterial infections had yet to be discovered and vaccine development was unsuccessful as scientists at the time had not correctly identified the causative virus. With these limitations, control efforts worldwide were limited to non-pharmaceutical interventions such as isolation, quarantine, good personal hygiene, use of disinfectants, and limitations of public gatherings, which were applied unevenly. 

1957 H2N2 “Asian Flu” Pandemic 

In February 1957, a new influenza A (H2N2) virus emerged in East Asia, triggering a pandemic (“Asian Flu”). This H2N2 virus was comprised of three different genes from an H2N2 virus that originated from an avian influenza A virus, including the H2 hemagglutinin and the N2 neuraminidase genes. It was first reported in Singapore in February 1957, Hong Kong in April 1957, and in coastal cities in the United States in the summer of 1957. The estimated number of deaths was 1.1 million worldwide and 116,000 in the United States. 

1968 H3N2 Pandemic 

The 1968 pandemic was caused by an influenza A (H3N2) virus comprised of two genes from an avian influenza A virus, including a new H3 hemagglutinin, but also contained the N2 neuraminidase from the 1957 H2N2 virus. It was first noted in the United States in September 1968. The estimated number of deaths was 1 million worldwide and about 100,000 in the United States. Most deaths in the US were in people 65 years and older. The H3N2 virus continues to circulate worldwide as a seasonal influenza A virus. Seasonal H3N2 viruses, which are associated with severe illness in older people, undergo regular antigenic drift. 

2003 SARS Outbreak 

Severe Acute Respiratory Syndrome (SARS) is a respiratory illness that affected many people worldwide in 2003. It was caused by a coronavirus, called SARS-associated coronavirus (SARS-CoV) that had never been found in people. SARS was first reported in Asia in February 2003. The illness spread to 29 countries, where 8,096 people contracted SARS and 774 of them died. Health professionals around the world worked together to successfully contain the outbreak in 2003. In six months, the global SARS outbreak cost the world an estimated $40 billion. The SARS global outbreak was contained in July 2003. Since 2004, there have not been any known cases of SARS reported anywhere in the world. 

2009 H1N1 “Swine Flu” Pandemic 

In the spring of 2009, a novel influenza A (H1N1) virus emerged. It was first detected in the United States and spread quickly across the United States and the world. This new H1N1 virus contained a unique combination of influenza genes not previously identified in animals or people. This virus was designated as influenza A (H1N1)pdm09 virus. The virus genes were a combination of genes most closely related to North American swine-lineage H1N1 and Eurasian swine-lineage H1N1 influenza viruses. Because of this, initial reports referred to the virus as a swine origin influenza virus. However, investigations of initial human cases did not identify exposures to pigs and it quickly became apparent that this new virus was circulating among humans and not among U.S. pig herds. Few young people had any existing immunity (as detected by antibody response) to the (H1N1)pdm09 virus, but nearly one-third of people over the age of 60 years had antibodies against this virus, likely from an exposure to an older H1N1 virus earlier in their lives. The (H1N1)pdm09 virus was very different from H1N1 viruses that were circulating at that time; vaccination with seasonal flu vaccines thus offered little cross-protection against (H1N1)pdm09 virus infection. While a monovalent (H1N1)pdm09 vaccine was produced, it was not available in large quantities until late November, which was after the peak of illness during the second wave had come and gone in the United States. From April 12, 2009 to April 10, 2010, the CDC estimated that there were 60.8 million cases (range: 43.3 – 89.3 million), 274,304 hospitalizations (195,086 – 402,719), and 12,469 deaths (8868 – 18,306) in the United States due to the (H1N1)pdm09 virus. The CDC estimated that between 151,700 and 575,400 people worldwide died from 2009 H1N1 virus infection during the first year the virus circulated. Globally, the CDC estimated that 80 percent of (H1N1)pdm09 virus-associated deaths were in people younger than 65 years of age, which differs from typical seasonal influenza epidemics during which about 70 percent to 90 percent of deaths are estimated to occur in people 65 years of age and older. Though this most recent influenza pandemic primarily affected children and young and middle-aged adults, the impact of (H1N1)pdm09 virus on the global population overall during the first year was less severe than that of previous pandemics. Estimates of pandemic influenza mortality ranged from 0.03 percent of the world’s population during the 1968 H3N2 pandemic to 1 percent to 3 percent of the world’s population during the 1918 H1N1 pandemic. It is estimated that 0.001 percent to 0.007 percent of the world’s population died of respiratory complications associated with the (H1N1)pdm09 virus infection during the first 12 months the virus circulated. The United States mounted a complex, multi-faceted, and long-term response to the pandemic, summarized in “The2009 H1N1 Pandemic: Summary Highlights, April 2009-April 2010.” On August 10, 2010, the World Health Organization (WHO) declared an end to the global 2009 H1N1 influenza pandemic. However, (H1N1)pdm09 virus continues to circulate as a seasonal influenza virus and cause illness and deaths worldwide every year. 

2012 MERS-CoV Identified 

Middle East Respiratory Syndrome (MERS) is an illness caused by a virus (more specifically, a coronavirus) called Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Most MERS patients develop severe acute respiratory illness with symptoms of fever, cough, and shortness of breath. About 3 to 4 out of every 10 patients reported with MERS have died. Health officials first reported the disease in Saudi Arabia in September 2012. Through retrospective (backward-looking) investigations, health officials later concluded that the first known cases of MERS occurred in Jordan in April 2012. So far, all cases of MERS have been linked to travel to, or residence in, countries in and near the Arabian Peninsula. The largest known outbreak of MERS outside the Arabian Peninsula occurred in the Republic of Korea in 2015. The outbreak was associated with a traveler returning from the Arabian Peninsula. MERS-CoV has spread from ill people to others through close contact, such as caring for or living with an infected person. MERS can affect anyone. MERS patients have ranged in age from younger than 1 up to 99 years old. The Centers for Disease Control and Prevention (CDC) continues to closely monitor the MERS situation globally and work with partners to better understand the risks of this virus, including its source, how it spreads, and how infections might be prevented. MERS-CoV has the potential to spread further and cause more cases globally and in the U.S. The CDC works with DOHMH, hospitals, and other partners to work on preparation and prevention. 

What is the Risk? 

Emerging Disease with Epidemic Potential 

+ Social Environment 

At Risk Populations 

Until an emerging disease is detected and characterized, health officials will not know the segment of the population that will be most at risk. Early detection and robust epidemiological investigations are needed to determine who will be most impacted by the particular disease or biological agent. 

The Potential for Communities to be Targeted 

Regardless of the origin, new disease outbreaks often lead to communities being unjustly singled out by others as “responsible” for the disease. These assumptions are based on perceived associations like a virus’ country of origin or the community in which it was first identified. Clear and consistent risk communication is essential to dispel myths before they take hold. 

+ Built Environment 

Biological hazards are an inherent danger to living organisms but generally do not pose a significant threat to the built environment. 

+ Natural Environment 

Biological releases in New York City could be devastating to plants and animals. Microorganisms and pathogens affect their hosts in different ways and severity of the threat depends upon the type of biological material released. 

A significant biological release has the potential to cause the same type of wide-ranging impacts that would result from a significant chemical release. 

+ Future Environment 

A New Threat from Synthetic Biology 

This hazard includes the growing threat theorized from recent advances in synthetic biology. The creation and manipulation of pathogens is facilitated by increasingly accessible technologies and starting materials, including DNA sequences in public databases. A wide range of pathogen characteristics could be explored as part of such efforts. With regard to pathogens, synthetic biology is expected to: 

• Expand the range of what could be produced, including making bacteria and viruses more harmful; 
• Decrease the amount of time required to engineer such organisms; and 
• Expand the range of actors who could undertake such efforts. 

In 2017, the National Academy of Sciences assessed emerging threats due to advances in synthetic biology. The highest-level concerns were: 

• Re-creating known pathogenic viruses. Constructing a known, naturally occurring pathogenic virus from the starting point of information about its genetic sequence. 
• Making existing bacteria more dangerous. Creating a modified version of a known bacterium in which one or more traits have been altered to make the bacterium more dangerous. 
• Making biochemicals via in situ synthesis. Engineering an organism, such as a microorganism that can survive in the human gut, to produce a desired biochemical and delivering this microorganism in such a way that it can produce and release this product in situ. 

A Decrease in Global Surveillance Efforts 

An emerging disease can arise anywhere in the world. Emerging diseases are monitored globally by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and other national and international public health organizations for their potential to develop into a pandemic. Global disease surveillance and robust field investigations are needed for early detection of a global disease outbreak before it reaches our shores. 

Respiratory Virus with Pandemic Potential

 + Social Environment 

At Risk Populations 

Pandemics will impact some people more than others for a number of reasons. First, some people can be immune because of some similarity between the pandemic virus and older viruses people may have been exposed to. Second, there will always be people who are more likely to be severely impacted by the disease if they are infected – usually people with underlying medical conditions, pregnant women and older people – people in “traditional” risk groups. However, precise risk groups vary from one pandemic to another. Until a respiratory pandemic strikes, we will not know for certain who the most at risk will be. Unlike seasonal influenza, which typically impacts the very young and very old, pandemics can affect school-aged children and working adults. Early detection and robust epidemiological investigations are needed to determine who will be the most impacted by the particular strain. 

Modeling Community Vulnerability to Pandemic Influenza 

Studies of pandemic influenza have shown that some populations are more susceptible to infection or significant illness than others. Infection rates may be highest in school-aged children (as much as 40 percent) who are often the biggest transmitters of influenza viruses in the community. The World Health Organization (WHO) considers the following populations to be at higher risk for negative medical outcomes (such as significant illness, hospitalizations, or death) from pandemic influenza: pregnant women, children, and seniors (aged 65 years or older), individuals with chronic health conditions, and healthcare workers. Certain physical and health conditions make some populations more vulnerable to pandemic influenza, and societal factors can also amplify the risk of disease spread. DOHMH conducted a study to identify areas of clustered population groups most vulnerable to a pandemic in New York City. The study was based on a model of vulnerability that examined how income, race, and other social attributes influence exposure, susceptibility, and access to treatment during an outbreak. 

Vulnerability to pandemic influenza is based on: 

Exposure. Transmission of pandemic influenza is typically airborne, but the flu can also spread through direct and indirect contact. Low-income populations may be more vulnerable to exposure to the virus than other groups because they are more likely to experience crowded living conditions and workplaces and tend to depend on public transportation. Because frequent contact with infected populations increases the risk of exposure, healthcare providers, caregivers, and first responders are especially vulnerable. Susceptibility. The elderly, very young, and people with pre-existing conditions such as diabetes, cardiovascular disease, or HIV are more susceptible to negative outcomes from an influenza infection. Environmental stressors and social behaviors including high-stress work environments, poor or unsafe housing, drug addiction, or alcoholism can increase the likelihood and severity of infection. Access to treatment. Lack of access to treatment may also increase vulnerability. In general, uninsured, low-income populations, immigrants, and people with disabilities have less access to care and treatment. People unwilling or unable to get vaccinations or to obtain care if needed may be more vulnerable to severe medical complications. 

DOHMH identified population clusters vulnerable to pandemic influenza outbreaks in New York City based on its analysis of exposure, susceptibility, and access to treatment. Clusters of those most vulnerable to a pandemic are found in Southwest Bronx, Morningside Heights, Chinatown and the Lower East Side, Bedford-Stuyvesant, East New York, Crown Heights, and Coney Island. 

The Potential for Communities to be Targeted 

Regardless of the origin of the disease, pandemics often lead to communities being unjustly singled out by others as “responsible” for the disease based on perceived associations like a virus’ country of origin or community where it was first identified. Clear and consistent risk communication is essential to dispel myths before they take hold. “In 2003, hundreds of Canadians fell ill with SARS after a Toronto resident returned from Hong Kong infected with the virus. In the panicked hysteria that followed, Asians of all stripes-whether they had traveled abroad or not-found themselves singled out for social exclusion. Chinese Canadians were shunned on the subway. White Canadians pulled their jackets over their faces when passing Asians in hallways and wore masks in their offices if they had Asian coworkers. Families told their children not to play with Asian kids at school, employers withdrew job offers to Asian candidates, and landlords kicked Asian families out of their homes. Losses to Chinese-owned businesses reached up to 80 percent.” – From Pandemic, Sonia Shah. 

Impact on the Healthcare System 

In a severe pandemic, competing demands on resources, long-duration impact, and potential staff illness contribute to very limited options for importing resources or transferring patients. Most models of severe pandemics predict that current and surge capacities for critical care would be exceeded. 

Challenges to Healthcare Delivery 

+ Built Environment 

Biological hazards are an inherent danger to living organisms but generally do not pose a significant threat to the built environment. 

+ Natural Environment 

Little research exists on the impact to the environment from a respiratory virus pandemic. The largest impact will likely be from the increase in antivirals and antibiotics (for any further complications of the virus) prescribed to treat the disease. These drugs are excreted into wastewater in a biologically active form, which presents a new and potentially significant ecotoxicological challenge to microorganisms responsible for wastewater nutrient removal in wastewater treatment plants and receiving rivers. A mild pandemic is likely to have negligible impact on the environment. However, a severe pandemic might result in the discharge of insufficiently treated wastewater into receiving rivers, thereby increasing the risk of contaminated waterways. Widespread drugs in the environment could also hasten the generation of drug resistance. 

+ Future Environment 

Pandemics are unpredictable and spread rapidly – due to modern air travel, a new virus could reach New York City within six weeks from anywhere in the world. Possible pandemic diseases are being monitored globally by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC) and other national and international public health organizations for their potential to develop into a pandemic. 

Global disease surveillance and robust field investigations are needed for early detection of a global disease outbreak before it reaches the city. Recent budget cuts to the CDC’s global health security initiatives have significantly decreased the City’s ability to know beforehand about an approaching pandemic and prepare mitigation efforts that could decrease the impact to the city. 

How to Manage the Risk? 

Emerging Disease with Epidemic Potential 

Managing an emerging disease or the release of an unknown biological agent relies on strong public health infrastructure and collective action across government, healthcare, and community stakeholders. 

DOHMH works to prevent, protect against, respond to, and increase the city’s ability to recover from public health emergencies. In a public health emergency, DOHMH works to: 

• Conduct robust surveillance and epidemiological investigations to detect, characterize, and monitor the emerging disease; 
• Provide New Yorkers with up-to-date and actionable public health messages to protect themselves, their loved ones, and their community during the emergency; 
• Support the healthcare system in meeting the needs of all persons in New York City during the emergency (including mental health); and 
• Provide widespread access to antivirals, vaccine, and medical material (as available). 

DOHMH does this through partnerships with various city, state, and federal agencies, health care facilities and community leaders and organizations to better protect and meet the needs of New York City citizens. 

To learn more about public health preparedness in New York City see: 

https://www1.nyc.gov/site/doh/health/emergency-preparedness/what-we-do.page

Respiratory Virus with Pandemic Potential 

Preventing a pandemic respiratory virus from establishing itself within the city is impossible. Actions will prioritize limiting the impact and slowing the spread of disease. The City will work with the healthcare system, state and federal partners, including the CDC, and private and non-profit sectors to manage the response and lessen its impact on New York City. 

While the occurrence of a pandemic may be unpredictable, well-understood strategies can be employed to manage its risks. The City, including DOHMH, relies on protocols, communications tools, public education efforts, and the promotion of community mitigation efforts in order to reduce and lessen the potential impacts from a pandemic. 

Goals of community mitigation for pandemic influenza 

Disease Surveillance and Epidemiology 

DOHMH will assess epidemiological, clinical, and behavioral characteristics of the pandemic strain and recommend containment measures to limit the spread of the disease while minimizing social disruption and cost. 

DOHMH has a state-of-the-art 24/7 system for monitoring disease patterns. The syndromic surveillance system involves routinely monitoring emergency room visits, ambulance calls, and pharmacy sales to detect early warning signs of a possible outbreak. 

In the event of a pandemic, DOHMH will increase surveillance activities and monitor illness within the city to detect further pandemic waves and guide clinical and public health decisions about how to best use limited medical resources. 

Social Distancing as a Selectively Applied Containment Strategy 

In the early stages of an influenza pandemic, before a vaccine is available (usually 4 to 6 months but possibly longer), community measures are essential to limiting the spread of disease. As droplets can reach from 3 to 6 feet after they are expelled into the environment by a cough or sneeze, increasing the spacing between individuals can reduce exposure. 

New York City’s dense concentration of living and working space and its heavy dependence on public transportation make social distancing particularly challenging. Closing schools and canceling public events during a severe pandemic can have far reaching social and economic impacts on New Yorkers. These closures will only be recommended if the benefits are considered greater than the impacts. 

Mobilizing Resources for a Multi-Pronged Response 

During a pandemic, healthcare facilities will face a massive increase in patients seeking care. Planning for this demand focuses on developing surge capacity in acute critical care facilities and on further strengthening communication between DOHMH and healthcare providers. DOHMH will work with the New York State Department of Health (NYS DOH) to monitor and address staffing, supply, and resource needs. 

Ensuring Access to Medication 

Before a vaccine is available, antiviral medications can be prescribed by a doctor within 48 hours of the appearance of symptoms to shorten the time a person is ill. When the pharmaceutical supply chain is strained by high national demand, DOHMH will work with  hospitals, clinics, nursing homes, and other healthcare facilities to ensure medication is available across the city. 

Meanwhile, officials at the Centers for Disease Control and Prevention (CDC) will work with research partners as well as state and local health authorities to produce a vaccine for the virus that is causing a pandemic. Once a vaccine becomes available, the City will work to promote vaccination and open temporary vaccination sites if needed. 

Risk Communication 

Communicating clear accurate information to the public throughout an influenza outbreak is critical to limiting exposure. The City prepares for pandemic influenza by testing communication protocols, developing communication tools, training agency staff, and coordinating with agency stakeholders and community groups to build strong partnerships. In the event of an influenza pandemic, the government at the federal, state, and local levels will issue prompt alerts. As the outbreak progresses the City will keep the public informed using television, radio, websites, and social media platforms. 

Promoting Workplace Controls 

Respiratory viruses can easily spread in the workplace. Both employers and employees can exercise environmental controls to limit its spread. Employers can: 

• Maintain standard workplace cleaning routines. 
• Encourage employees to stay home if they are sick and to not return to work until they have been fever-free for 24 hours without the use of fever-reducing medications. 

• Ensure access to hand-washing facilities or to alcohol-based hand sanitizer if soap and water are not available. 
• Promote vaccination. 
• Promote respiratory etiquette, which includes encouraging covering coughs and sneezes, keeping hands clean and away from your face, and discouraging hand shaking. 

The City created an Influenza Citywide Health and Safety Program aimed at reducing the occupational exposure of non-medical City employees. It is designed to help City agencies develop their own agency-specific plans for limiting the spread of viruses. The program includes a Job Risk Assessment that entails careful examination of a workplace and the tasks each worker performs. The objective is to identify workplace hazards and determine whether existing precautions are sufficient, or if further controls should be put in place. 

The approach can be adapted to differing agency conditions and can be used for multiple-scale influenza scenarios. The City’s Awareness Level Training program helps City agencies promote staff awareness through employee training that covers influenza health effects, modes of transmission, preventative measures, and job risk assessments. Control measures include safe work practices, administrative controls, engineering controls, and the use of personal protective equipment. 

To learn more about pandemics see https://www.cdc.gov/flu/pandemic-resources/index.htm 

Link: Emerging Diseases with Epidemic Potential – Bibliography

National Academies of Sciences, Engineering, and Medicine 2018. “Biodefense in the Age of Synthetic Biology.” Washington, DC: The National Academies Press. 2018. https://www.nap.edu/download/24890. 

Sun, Lena H. “CDC to Cut by 80 Percent Efforts to Prevent Global Disease Outbreak.” Washington Post. 1 February 2018. https://www.washingtonpost.com/news/to-your-health/wp/2018/02/01/cdc-to-cut-by-80-percent-efforts-to-prevent-global-disease-outbreak. 

World Health Organization. “R&D Blueprint: List of Blueprint Priority Diseases.” World Health Organization. http://www.who.int/blueprint/priority-diseases/en/. 

Link: Respiratory Virus with Pandemic Potential – Bibliography 

Blumenshine P, Reingold A, Egerter S, Mockenhaupt R, Braveman P, Marks J. “Pandemic Influenza Planning in the United States from a Health Disparities Perspective.” Emerging Infectious Diseases. May 2008. http://www.cdc.gov/EID/content/14/5/709.htm. 

Center for Earth and Environmental Studies. Texas A&M International University. http://cees.tamiu.edu/covertheborder/TOOLS/NationalPlanningSen.pdf. 

Centers for Disease Control and Prevention. “Disease of the Week: SARS (10 Years After).” Centers for Disease Control and Prevention. 3 March 2016. https://www.cdc.gov/dotw/sars/index.html. 

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