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BY: PAUL REGA, M.D.; CHRISTOPHER E. BORK, Ph.D.; MICHAEL BISESI, PH.D.; KELLY BURKHOLDER-ALLEN, R.N., M.S.Ed.; and FRANCIS L. AGNOLI, M.D., D.Min.

With Teamwork, Health Care and Preparation, Parish Leaders Can Reduce a Pandemic's Effects

Dr. Rega is assistant professor, Dr. Bork is professor and director, and Ms. Burkholder-Allen is adjunct assistant professor, all in the department of public health and disease prevention, College of Medicine, University of Toledo, Ohio; Dr. Bisesi is associate dean, academic affairs, director of the Center for Public Health Practice, and associate professor, environmental health sciences, College of Public Health, Ohio State University, Columbus, Ohio; and Dr. Agnoli is director of liturgy and director of deacon formation, Diocese of Davenport, Iowa.

Editor's Note: This article is accompanied by a checklist for suggested steps at various stages of pandemic readiness.

The Pandemic Readiness Plan, or model, which we have developed for use by Catholic parishes, represents a systematic, scalable methodology that empowers communities to respond effectively, expeditiously and proactively whenever there is an imminent infectious disease threat. This threat may be a pandemic, an epidemic, or merely an outbreak. In dealing with these "opaque" disasters where the onset may not be easily apparent, it is vital to initiate a response even before all the facts are in. The key to the model, then, is not to develop a response to an actual emergency, but to initiate a careful, considered, incremental response whenever a threat is suspected or imminent. Another key factor in implementing the model is that it does not depend upon any initiatives produced by state public health agencies, the World Health Organization or the Centers for Disease Control and Prevention. It may be activated well before any external agencies have even arrived on scene to investigate. While this may sound reactionary, it is well within the critical components espoused by the National Strategy for Public Health and Medical Preparedness's Homeland Security Presidential Directive-21. One of these components is community resilience where, once an educated community feels threatened, it is empowered to mitigate its own risk. It should be noted that, in spite of the recognized importance of faith-based organizations in all aspects of disaster management, clergy and chaplains have yet to be included in government priority lists for receiving prophylaxis, antivirals, or vaccines in the event of a pandemic.¹

Although faith-based organizations and their places of worship are integral parts of the corporal, spiritual, moral, and psychological fabric of a community, most disaster plans do not concretely recognize their potential role. As part of their mission, faith-based organizations provide tangible (physical) and intangible (spiritual) sustenance to their congregations and communities. The role of these organizations increases exponentially during disasters, as does the risk to clergy and associates who minister to their flocks and to the community at large.

For example, in Philadelphia during the 1918 pandemic, the local archdiocese allowed its priests to work with the city in locating, transporting and burying influenza victims. In addition, the archbishop released nuns for service in hospitals to care for the sick even to the point of dispensing them from their vows of silence.² In the chronicles of modern disasters, a pastor by the name of Vien Nguyen provided shelter and financial support for his congregation in the aftermath of Hurricane Katrina.³

As the various missions of faith-based organizations are interwoven into the vital fabric of the community, the risk during an infectious disease event is great. There is the risk to clergy, associates and lay volunteers who must expose themselves to disease especially in their mission of providing pastoral care for the ill, the infirm and the dead. There is also the risk to all in the congregation as they gather to worship and celebrate the liturgy, thereby increasing the potential for transmission of an infectious disease.

Although this increased risk of transmission may be an accepted risk during normal daily activities (e.g. a cold), it becomes an ominous threat during an epidemic or a pandemic. This risk would be of great concern if the United States were to experience a pandemic on the scale of the 1918 Spanish Influenza. Scientists predict that if a pandemic similar to the Spanish Influenza were to take place, the morbidity could approach 90 million and the number of deaths in the United States could climb to 2 million.⁴ Therefore, it will become crucial for communities to undertake various interventions to minimize the risk of transmission of disease. The interventions would include social distancing and closing down venues of public gathering such as sporting events, conventions, and places of worship.

Public health laws enacted to shut down church activities in the United States were commonplace in 1918. The closing of churches occurred in Philadelphia, Los Angeles and Cumberland, Md., to name but a few.⁵ Similarly, the closing of churches was one of the social distancing measures used in Mexico during the initial stages of the recent outbreak of H1N1; commonly known as "swine flu."⁶

A number of questions concerning the role of faith-based organizations need to be addressed before the onset of an epidemic or a pandemic. What role do faith-based organizations and places of worship play with regard to pandemic preparedness and response? Do they remain venues of physical and spiritual sustenance that should be nurtured and protected when a pandemic crisis assaults a community? If the answer to this question is in the affirmative, then steps need to be undertaken expeditiously to fulfill the various missions while protecting members of the clergy, personnel and the congregation. But are these places of worship potential sites of secondary transmission? If the answer to that is in the affirmative, then they should be shuttered quickly until the crisis passes. And what if they are both? How does a faith-based organization balance meeting the spiritual needs of its congregation with protecting them from disease transmission?

The Pandemic Readiness Plan for Parishes has been created to provide a framework for a community under an infectious disease threat to initiate a measured response to that threat even before the event has been acknowledged by external agencies. The troublesome event may be as seemingly insignificant as an outbreak two counties away or similar outbreaks in adjoining states or a progressive one extending across continents. Implementation of this incremental approach, in order to be effective, demands an efficacious response to even seemingly innocuous events that may portend an actual threat to one's community.

The plan proposes a gradual ramping up from the Traditional Phase (business as usual) to a transitional system that informs without alarming the community it serves and simultaneously protects it. The plan outlined below includes a Transitional Phase, which is divided into four levels, followed by a Catastrophic Phase and a Recovery Phase.

The purpose of the Transitional Phase is:

1. To augment, enhance and empower the parish to take action at the first suggestion that a pandemic may be starting someplace in the world;
2. To mitigate the worst medical, psychological, ethical, societal and legal consequences of a pandemic, thereby minimizing the proportion of ill and dead;
3. To preserve the parish's religious, paternal, and communal functions to the greatest extent possible.

The Transitional Phase is an actionable intermediary phase situated on a continuum between the Traditional Phase, when no disaster is imminent, and the Catastrophic Phase, when the disaster has taken control of the community. This intermediary affords faith-based organizations time to transition from day-to-day activities to activities that are designed to protect both the mission of the organization and its followers.

The following outline exemplifies the essential actions that faith-based organizations should consider with regard to a pandemic. Although the example that follows is limited to a Roman Catholic parish, the basic tenets can be employed by any religious community, its places of worship, its schools and its congregation. It should be noted that, according to Roman Catholic ecclesiology, the term "local church" refers to the diocese and not to an individual parish. It is not the intention of the authors to subvert any Roman Catholic diocese, but to empower individual parishes in building their disaster management capacities. The foundation of any parish-level plan should be the diocesan plan. For the purpose of this article, we have elected to build upon that planning at the level of the individual parish, so that each parish can take steps to improve upon its current plan to meet the needs of its parishioners.

This model may be modified as needed to adapt to the unique features of an event or the specific needs of the community. In essence the Pandemic Readiness Plan for Parishes provides a road map for parishes to follow as the threat of any infectious disease outbreak progresses. It outlines actions that should be considered from the Traditional Phase through the various levels of the Transitional Phase and into the Catastrophic Phase.

Implementation of these concepts and practices by a parish will enhance the safety and well-being of the congregation, clergy and staff and may forestall its closure by public health authorities, thereby allowing the staff and congregation to continue serving the community during increasingly arduous times.

The Traditional Phase:
Trigger: Ongoing (e.g., World Health Organization Phases 1-3).

Description:
There is no evidence of an outbreak threat locally or globally. The parish, its congregation or the community in which they reside are not threatened by any perceived disaster.

Primary Goals:
Education and Preparedness

Actions:
Although the Traditional Phase assumes "business as usual" in the community, it is a time when a parish should be considering a series of activities that will prepare it, its congregation, and its staff for a response to a pandemic. These activities can be grouped into the following general categories: identification of resources; acquisition of resources; education of staff and congregation; and development, testing and refinement of response strategies. The principal activities therefore, are to plan, to educate, to drill and to revise.

Table 1 (posted online) summarizes the principal activities that the parish may consider during the Traditional Phase.

Transitional Phase
The evolution from the Traditional Phase to the Transitional Phase does not depend upon external agencies, but upon community leaders, among whom diocesan representatives should play an active role. An outbreak has been identified that may, in time, incorporate the community.

Transitional Phase, Level 1:
Possible Triggers:

1. Type 1: Clusters of influenza-like illnesses in multiple locations on one continent other than North America (e.g., as part of a declared pandemic [World Health Organization Phase 4]) suggestive of human-to-human transmission, or
2. Type 2: Clusters of an outbreak in multiple locations in North America (other than the diocese) suggestive of human-to-human transmission, or
3. Type 3: A particularly serious outbreak (significant morbidity or mortality) in contiguous states in which human-to-human transmission is possible and morbidity or mortality is considerable.

Overview:
At this stage, there is no change in activities because, despite evidence that the outbreak may involve human-to-human transmission, there is no immediate threat to the community and the parish. Nevertheless, it must be remembered that, should an outbreak begin in a distant locale, it may only take a matter of days for it to reach the community and the parish.

Primary Goals:
Notification and Review

Actions:
This level can be thought of as similar to a tropical storm watch: the conditions appear to be appropriate for a potential problem. The principal action is to place the congregation and staff on alert. It is the time to urge staff and the congregational members to review their plans and commence their personal preparations and for the parish leaders to review their plans and diocesan plans. The goals are to maintain and augment parish operations and its missions safely. The potential for the outbreak to involve the community becomes a possibility. Events must be monitored and evaluated. Table 2 (posted online) summarizes a checklist of activities to be considered for implementation during Transitional Phase, Level 1.

Transitional Phase, Level 2:
Possible Triggers:

1. Type 1: Clusters of influenza-like illnesses on more than one continent other than North America (e.g., as part of a declared pandemic [World Health Organization Phase 5]), or
2. Type 2: Increased numbers of suspect cases located in multiple locations within the United States, highly suggestive of human-to-human transmission, or
3. Type 3: Scattered numbers of suspected cases around the United States and the contiguous states, but with an unusually high mortality rate or significant morbidity. Human-to-human transmission is likely. or
4. Type 4: Report of suspected cases in the state in which the parish resides as well as elsewhere.

Overview:
In-depth analysis of media reports, such as those found at ProMEDmail.org, Center for Infectious Disease Research and Policy, Centers for Disease Control and Prevention, and World Health Organization, indicate that the possibility of an outbreak involving the community and the parish is more real than theoretical. Therefore, at this level, the parish and diocese, other stakeholders and the public should begin activating their plans.

Primary Goal:
Initial activation of plans

Actions:
This level can be thought of as similar to a tropical storm warning: The conditions have resulted in a tropical storm and appropriate preparations must be executed. At this level the epidemic/pandemic is becoming a reality that is threatening the welfare of the parish and the community at large. For the parish, Level 2 focuses upon non-pharmaceutical interventions such as hand washing and distancing. Table 3 (posted online) summarizes a checklist of activities to be considered for implementation during Transitional Phase, Level 2.

Transitional Phase, Level 3:
Potential Triggers:

1. Type 1: Clusters of influenza-like illnesses in North America and elsewhere (e.g., as part of a declared pandemic [World Health Organization Phase 6]), or
2. Type 2: Increased numbers of suspect cases in multiple locations within the United States that are highly suggestive of human-to-human transmission and beginning to increase in numbers throughout the diocese's state, but not necessarily within the diocese's region, or
3. Type 3: Multiple scattered suspected or definitive cases around the United States, but with an unusually high mortality rate or significant morbidity and probable human-to-human transmission, or
4. Type 4: Reports of suspected cases in diocese's region as well as elsewhere and possible human-to-human transmission.

Overview:
It is now obvious that an epidemic or pandemic is occurring and has encroached or is about to encroach on the diocese. While it may not have reached the parish's community, the potential looms greater than ever.

Primary Goals:
Emphasis on social distancing and personal hygienic practices.

Actions:
This level can be thought of as similar to a hurricane watch: The conditions have resulted in a strengthening of the tropical storm into a hurricane. In this level the pandemic becomes a reality and further distancing is enacted to reduce or prevent infection within the congregation. Greater emphasis must also be placed on parishioners who may be more severely impacted by this threat than others. Table 4 (posted online) summarizes a checklist of activities to be considered for implementation during Transitional Phase, Level 3.

Transitional Phase, Level 4:
Potential Triggers:

1. Major increase of influenza-like cases in and around the community (e.g., as part of a declared pandemic [World Health Organization Phase 6]). or
2. Infectious disease outbreak or epidemic within the diocese. Confirmed cases are few, but there is a surge of medical visits to hospitals, clinics and medical offices.

Overview:
The epidemic/pandemic is becoming embedded in the community. This is based upon a number of indicators, such as absenteeism, calls to emergency services, emergency room visits or hospitalizations. These triggers may also be applied to a particularly virulent seasonal flu or infectious disease outbreak that has taken a stronghold on an individual community. The corporal and spiritual roles of the parish and diocese may be impaired due to illness and fear.

Primary Goals:
Added emphasis to outreach activities while maintaining social distancing and personal hygienic practices

Actions:
This level of the Transitional Phase is analogous to a hurricane warning: The epidemic or pandemic is real, and is now affecting both the community and the parish. The imminent landfall and storm surge may be catastrophic. As more people become ill, it may become necessary to consider canceling all public gatherings in the community and closing down the parish. Table 5 summarizes actions to be considered when the church remains open, and Table 6 (both posted online) summarizes actions when the church closes and is taking steps to gradually re-open.

The Catastrophic Phase
Potential Triggers:
Type 1: The infrastructure of the community has been severely compromised in the wake of an epidemic or pandemic; caused by a novel virus, virulent seasonal influenza or infectious disease outbreak with high morbidity and mortality.

Overview:
There is landfall. The infectious disease "storm surge" has reached such a level that the community in which the parish resides is witnessing a general deterioration of all its functions. As for the community's health, numbers of fatalities are increasing, hospitals are inundated with critical care patients and there is a disruption of infrastructural services at all levels due to lack of personnel and re-supply. With regard to the parish and diocese, the effects of the disease may have claimed the lives of clergy members and associates, or incapacitated them. At this point, liturgical adaptations are made in accord with the Code of Canon Law and the directives of the diocesan bishop.

Actions:
The parish is closed (even if it was open in Transitional Level 4) either as a result of insufficient staff or as the result of public health policy. The ecclesiastical laws that address extraordinary circumstances are brought to bear in order to continue the provision of pastoral care and the sacraments.

Goals:
Provide the greatest good for the greatest number. Offer spiritual and corporal works in innovative formats while minimizing individual risk.

The Recovery Phase
Trigger:
The community, the state and the nation are witnessing a drop in influenza-like illnesses among citizens. The Centers for Disease Control and Prevention has declared that the pandemic is on the wane.

Overview:
At this stage, the ravages of the pandemic are subsiding. The community is witnessing a decrease in hospital visits, number of cases of illness and number of deaths. There is a resurgence of communal activities, commercial and noncommercial. The previously compromised functions of governmental services, (e.g., electrical power, garbage service, the courts, libraries) are returning to normal. In light of this, a procedure must be in place to allow for the orderly reopening of the school system.

Goals:
Return to normalcy, review prior actions of the parish, diocese and community, revise plans, enhance resilience capacity and prepare for the next wave.

Actions:
The principal actions during this phase focus upon initiating steps in an orderly sequence that will gradually enable the parish and parishioners to resume their lives. This recovery phase for both parish and diocese may be prolonged because of death or incapacitation of members of the clergy during the outbreak. Nevertheless, the parish must become a focus for re-establishing the congregation's sense of community, assist parishioners with their bereavement and continue with the mission of the church. Table 7 (posted online) summarizes the actions for the parish during the Recovery Phase.

Discussion
When a community is in peril of falling victim to a disaster, faith-based organizations must provide workable solutions to the problem, not impediments to planning and response. These organizations through their parishes and congregations are obligated to fulfill their spiritual and corporal missions despite the onus of an infectious disease epidemic or pandemic. In addition, they have a responsibility to foster the common good by their actions — even if that means adjusting their practices temporarily.

These activities can be accomplished safely only if careful thought and consideration are given to protecting the participants once the threat is recognized and if innovative means are employed to accomplish these missions. To provide these measures, arduous though they may be, may minimize the risk of closing down places of worship and continue providing assistance to the community as long as possible.⁷

Employing the Pandemic Readiness Plan for Parishes may obviate or at least delay the necessity of parish closures. Although it is not inappropriate to expect guidance from certain state and federal agencies, past and recent events, such as Hurricane Katrina, indicate that the major response to an emergency is more likely to be initiated locally. Although a community may wish to rely on state and federal agencies for guidance and resources, it cannot remain constrained or justify inaction by this expectation. Rather, the community, including faith-based organizations and their places of worship, must evaluate events around the world, assess its own strengths and weaknesses, make a decision to act and begin to protect and defend its congregation even before external agencies implement their plans.

Although it would be more effective for local public health officials to institute a pandemic readiness plan for the entire community, the parish, with the support of its diocese, should perform its own surveillance of the global situation in order to activate its own plans as early as possible. Implementing these strategies and tactics will protect the congregation, continue the mission and minimize the likelihood that the local public health department will close down parish activities prematurely, if at all.

An example of how to be proactive is seen on the Diocese of Davenport, Iowa, website, where two pages are devoted specifically to the recent H1N1 epidemic/pandemic.⁸ In addition, the website provides a comprehensive multi-lingual document containing concepts, ideas and modifications that may be used by a diocese and its parishes in the event of a pandemic.⁹ This is an outstanding example of a pandemic preparedness and response plans, in contrast to other diocesan websites where the mention of H1N1, let alone planning for and responding to it, is all but ignored.¹⁰ Even a statement from the United States Conference of Catholic Bishops regarding the liturgy in relation to H1N1 evokes more questions than answers.

With regard to the Diocese of Davenport's pandemic document, the tactical measures that the diocese and its parishes would institute are integrally interwoven with World Health Organization and the federal government's pandemic stages. It is but one element of a global preparation for any disaster. Cementing planning and response activities to external dogma may paralyze a community's actions when events occur quickly and are more proximate to that community. The Pandemic Readiness Plan for Parishes empowers the community and its infrastructure, including faith-based organizations, to assume the mantle of community resilience in order to mitigate its own risk. The guidelines found in the accompanying tables are a distillate of the key actions found in the Davenport document and addenda to it that each parish and its leaders should consider when confronted with an impending crisis — infectious or otherwise.

Although much of this article is devoted to ways in which parishes can prepare for and respond to an infectious disease emergency, they are under the jurisdiction of the bishop and must function within the framework of diocesan imperatives. To assist with these imperatives in the face of an acute emergency, a diocesan disaster council convened by the bishop may be of enormous assistance.

It is to be hoped that, should these transitional steps be activated early and remain in place long enough, a Catastrophic Phase may never occur.

NOTES

1. U.S. Department of Homeland Security, Homeland Security Presidential Directive/HSPD-21: Public Health and Medical Preparedness (October 18, 2007), www.dhs.gov/xabout/laws/gc_1219263961449.shtm#1.
2. John M. Barry, The Great Influenza (New York: The Penguin Group, 2004); Patricia Talone, "All God's Sick Children," Health Progress 88, no. 6, (2007):  38-42.
3. Christopher Cooper and Robert Block, Disaster: Hurricane Katrina and the Failure of Homeland Security, (New York: Times Books Publishers, 2006).
4. John G. Barlett and Luciana Borio, "The Current Status of Planning for Pandemic Influenza and Implications for Health Care Planning in the United States," Clinical Infectious Diseases 46 (2008): 919-25.
5. Richard J. Hatchett, Carter E. Mecher, and Marc Lipsitch, "Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic," Proceedings of the National Academy Sciences 104, no. 18 (May 1, 2007): 7582-87; Howard Markel, Nonpharmaceutical Interventions Implemented by U.S. Cities During the 1918-1919 Influenza Pandemic, JAMA 298, no. 6 (2007), 644-54; and Martin C.J. Bootsma and Neil M. Ferguson, "Effect of Public Health Measures on the 1918 Influenza Pandemic in U.S. Cities," Proceedings of the National Academy of Sciences 104, no. 18 (May 1, 2007): 7588-93.
6. Thomas H. Maugh and Ken Ellingwood, "Mexican Officials Lower Flu Alert Level," Los Angeles Times, May 5, 2009, www.latimes.com/news/nationworld/nation/la-sci-swine-flu5-2009may05,0,1635155.story; Gardiner Harris and Elizabeth Milkin, "Health Officials Begin to Ease Public Alerts About Swine Flu," New York Times, May 5, 2009, www.nytimes.com.
7. Hatchett; Markel; Bootsma; Maugh; and Harris.
8. Diocese of Davenport, Swine Flu Information, www.davenportdiocese.org/disaster/index.htm.
9. Diocese of Davenport, Policies Relating to Planning for Pandemic Influenza, updated April 7, 2008, http://www.davenportdiocese.org/disaster/disasterlibrary/
   PlanningforPandemicInfluenzaRevised090809.pdf.
10. Archdiocese of Washington, Guidance for Parishes and Schools in Light of H1N1/Swine Flu Concerns, www.adw.org/news/news.asp?ID=638&Year=2009; Archdiocese of New York, www.archny.org/; Archdiocese of Boston, www.bostoncatholic.org/; Bishop Kevin Farrell, Roman Catholic Diocese of Dallas in Response to Concerns Regarding the "Swine Flu," www.cathdal.org/default.asp?contentid=137&newsid=73.