UNITED STATES SOUTHERN COMMAND

1. UNITED STATES SOUTHERN COMMAND U.S. Southern Command Pandemic Influenza Lima Conference Pandemic Influenza Preparation and Response 3 May 2006 CLASSIFICATION:UNCLASSIFIED

2. OUTLINE • Mission • Commander’s Intent • Purpose / Method / End State • Key Assumptions • Operational Constraints / Restraints • Legal Considerations • Force Requirements • Personnel Appraisal • Indications and Warnings • Phases • Specified Tasks • Force Health Protection

3. Mission • On order, USSOUTHCOM and its components and supporting commands respond to minimize and/or delay the regional spread of Pandemic Influenza to ensure that potentially vulnerable U.S. military forces remain operational throughout the pandemic period

4. Commander’s Intent (Purpose) • To preserve and maintain USSOUTHCOM operational capability while simultaneously supporting international and interagency Pandemic Influenza response efforts, as mission permits

5. Commander’s Intent (Method) • When directed by SECDEF, CDRUSSOUTHCOM will coordinate with the U.S. Chief of Mission for deployment of required personnel, equipment and support in combating the spread of Pandemic Influenza • USSOUTHCOM Force Health Protection is the immediate priority • CDRUSSOUTHCOM will normally deploy an assessment team or the Standing Joint Force Headquarters (SJFHQ) to the affected area for initial response • Then designate a Commander Joint Task Force (CJTF) and deploy a Joint Task Force (JTF) to replace the deployed assessment team or SJFHQ

6. Commander’s Intent (End State) • Operational capability is maintained to protect U.S. national interests in the AOR • Outbreak is contained • USSOUTHCOM combat readiness preserved through the timely implementation of appropriate Force Health protection measures • Host nation governments are capable of administering to their affected populations and limiting the further spread of the disease to unaffected areas

7. Key Assumptions • Subsequent waves of Pandemic Influenza may occur weeks to months after the initial outbreak •  No effective vaccine will be available until approximately three to six months or even longer after the development of confirmed, sustained human-to-human Pandemic Influenza transmission occurs •  A Pandemic Influenza outbreak in the USSOUTHCOM AOR will result in 20-35% of the population becoming ill, 3% being hospitalized, and 1% dying

8. Key Assumptions • Due to the highly infectious nature of influenza, efforts at quarantine and isolation will be only partially effective at preventing infection by Pandemic Influenza, but may reduce the speed of disease spread •  Infected individuals may be contagious one or two days prior to manifesting signs and symptoms of disease •  A significant percentage of those infected will not develop signs or symptoms, yet still be infectious for a period of time. This may seriously threaten the efficacy of quarantine and isolation efforts

9. Key Assumptions • Those who recover from Pandemic Influenza will be immune to repeat infection and will be able to safely work with those who are infected with or ill from Pandemic Influenza •  The incubation period (time from exposure to signs and symptoms of disease) will be 1 to 3 days •  Adjacent nations not yet affected by Pandemic Influenza will be willing to allow transit of relief supplies, subject to tight controls

10. Key Assumptions • Successful containment of a Pandemic Influenza outbreak will require effective surveillance and identification of the first cluster of human-to-human cases and rapid delivery of treatment and prophylaxis to targeted groups •  DoS is the lead federal agency for coordinating Pandemic Influenza support to the international community, with USAID, DHHS, USDA and DoD in support if the Pandemic Influenza is contained outside of the U.S. homeland and U.S. territories •  USSOUTHCOM’s first priority in the initial stages of any outbreak is Force Health Protection

11. Operational Constraints • Continue to conduct military operations and Theater Security Cooperation events in the region prior to identification of human-to-human transmission incident • Maintain operational readiness of U.S. forces to conduct assigned operations • During certain operational phases of this plan, require U.S. forces to comply with guidance by DoD and non-DoD agencies • USSOUTHCOM will require additional forces to respond to a Pandemic Influenza

12. Operational Constraints • While airfields are adequate, multiple basing (host nation, strategic airlift, and tactical air/airlift) will reduce throughput capacities • Movement of malpositioned stocks will require theater air, surface line-haul and sealift assets • Proximity of air and sea ports to threatened areas may restrict use of throughput capacity • Due to limited infrastructure and host nation support, including medical facilities available in the USSOUTHCOM AOR, additional forces will be required to support operations in this region

13. Operational Constraints • Limited fuel distribution infrastructure in many of the AOR countries limits ability of some airfields to support military or civilian contracted aircraft operations

14. Operational Restraints • We are unable to develop an effective vaccine and provide it to our forces in advance of a Pandemic Influenza outbreak • We are unable to routinely identify specific influenza strains at most laboratories within the AOR • We cannot proactively vaccinate to prevent Pandemic Influenza among U.S. forces operating in the AOR

15. Operational Restraints • We cannot ensure personnel will be allowed to travel into or out of affected areas once a Pandemic Influenza outbreak occurs • We are unable to provide antiviral prophylaxis to all service members and beneficiaries

16. Legal Considerations • Military commander’s actions regarding force protection • Authority to restrict movement on a military installation • Treatment of infected or possibly infected DoD and non-DoD personnel • Actions by U.S. forces to enforce isolation, quarantine and containment operations

17. Force Requirements • U.S. Chief of Mission, at the request of the stricken country, may issue a pandemic declaration initiating U.S. Government (USG) Pandemic Influenza response operations • The U.S. Embassy notifies DoS. DoS will coordinate and orchestrate the total USG response. • When directed by SECDEF to participate, USSOUTHCOM deploys forces as required • Emergency relief support could range from coordinating the movement of medical supplies to the deployment of forces to conduct hands-on Pandemic Influenza response operations

18. Personnel Appraisal • CDRUSSOUTHCOM will request the appropriate type units and personnel from the Joint Staff and advise the supporting force providers (USJFCOM) of the forecasted requirements • For planning purposes it is assumed that CDRUSSOUTHCOM will receive the forces requested to accomplish the mission

19. Indications and Warnings • Geographic spread of contagious high priority pathogens in birds • Cases of high priority pathogens in mammals (non-human) • Evidence of genetic shift or reassortment of contagious high priority pathogen strains in humans, birds or other animals • Evidence/indications of increased influenza like illness (ILI) in humans (e.g. increased drug store/pharmacy sales of medications; increased work absenteeism due to illness)

20. Indications and Warnings • Confirmed increase of highly pathogenic infection in humans • Cases of ILI that result in death, or that exhibit unusually strong symptoms • Cases of H5N1 in humans in the absence of known poultry outbreaks • Indications of human-to-human transmission of contagious high priority pathogens • Confirmed human-to-human transmission of contagious high priority pathogens

21. Phases • Phase 0 – Shape: No sustained human-to-human transmission • Phase 1 – Prevent: Sustained human-to-human transmission is identified in areas without major U.S. Force presence • Phase 2 – Contain: Sustained human-to-human transmission is identified in areas where U.S. Forces are located • Phase 3 – Respond: This phase occurs when broad sustained human-to-human transmission is identified • Phase 4 – Stabilize: This phase is required when a host nation is not capable of handling the pandemic • Phase 5 – Recover: Characterized by joint force support to legitimate civil governance in order to enable the host nation to respond effectively to a pandemic and the redeployment of forces

22. Present and Planned Activities • Continue close collaboration with State Dept and USAID • Coordinate project proposals with all those supporting the region and try to build capacity in lab testing and host nation capacity building • Building response teams and train other Host Nations • All based on funding

23. Questions? • Back up slides follow

24. Phase 0 (Shape) • This phase occurs when no sustained human-to-human transmission is identified • Ongoing influenza activity is dealt with by existing organized systems of medical and laboratory surveillance, vaccine production, and vaccine administration • USSOUTHCOM conducts medical surveillance of influenza-like illness (ILI) • Main focus includes Theater Security Cooperation (TSC) and other efforts to build relationships, trust and capacity with countries and organizations within the AOR to respond to pandemics

25. Phase 0 (Shape) • This phase represents normal, steady-state operations to enhance Partner Nation (PN) Pandemic Influenza preparedness in the USSOUTHCOM AOR • TSC activities in the USSOUTHCOM AOR include the Medical Readiness Training Exercise (MEDRETE) program • Phase 0 operations include detailed planning and revision to existing plans to ensure forces are ready to respond to a pandemic in the AOR • Beginning and ending phase of any Pandemic Influenza response operation

26. Phase 0 (Shape) Actions • Develop and periodically update USSOUTHCOM plan in close collaboration with relevant partners, including those outside the health sector, and with reference to current WHO guidance • Implement plans and preparedness activities at all levels of command • Exercise pandemic plans and use the results to improve and refine plans and preparedness

27. Phase 0 (Shape) Actions • Designate a Public Health Emergency Officer (PHEO). The PHEO is the Medical Treatment Facility Commander, or senior clinician with experience and training in functions essential to effective public health emergency management

28. Phase 1 (Prevent) • This phase occurs when sustained human-to-human transmission is identified in areas without major U.S. Force presence • Focus includes annual immunization campaigns, year-round immunization of USSOUTHCOM deployed forces, and bolstering capabilities within the AOR, especially education

29. Phase 1 (Prevent) Activities • Verify stockpiles of personal protective equipment (PPE) to ensure adequate on-hand quantities, and timely controlled accessibility • Gowns, gloves, protective eyewear, alcohol-based hand cleansers and N95 respirators should be pre-positioned at MILGROUP and component locations • Use of PPE will be reserved for medical providers and others with required exposure to those who are actively infected • Strengthen the general knowledge on personal respiratory hygiene in the community

30. Phase 1 (Prevent) Activities • Ensure that personal advice about reducing the risk of transmission is easily available to the public • Develop or enhance guidelines for the prevention of influenza in humans who have contact with animals or birds infected with influenza • Assess the need for additional infection control guidelines for non-medical settings, for instance for specific places where people gather or where there is a high risk of spread of infection

31. Phase 1 (Prevent) Activities • Determine potential alternative sites for medical care. Possible sites could include schools, gymnasiums, nursing homes, day care centers or tents in hospital grounds or at other sites • Identify facilities other than normal hospital or clinic locations at which mass influenza vaccinations can be effectively delivered outside of the usual influenza immunization period • Determine the priority of personnel to receive anti-influenza drugs in the event of vaccine shortages • Continue and refine surveillance for influenza-like illnesses during non-pandemic seasons

32. Phase 1 (Prevent) Activities • Identify facilities that could serve as expanded military treatment facilities in the event of overwhelming numbers of patients with severe influenza pneumonia • Determine food and water stockpiling and re-supply measures • Define how the prohibition of mass gatherings can be carried out and when this should be implemented • Train healthcare providers in influenza recognition and response

33. Phase 1 (Prevent) Activities • Establish clinical guidelines for treatment, including immunization, timing and use of antivirals and other medications, timing of hospitalization and prevention of transmission • Train and exercise epidemic and medical treatment response teams • Maintain a supply of shipping materials for influenza-infected specimens • Develop and publish public affairs guidance

34. Phase 1 (Prevent) Activities • Review, update and implement force health protection guidance including Force Health Protection (FHP) messages, travel advisories and/or restrictions to target countries and health education for USSOUTHCOM staff, components, sub-unified commands and CJTFs as appropriate • Ensure ability to mobilize and rapidly deploy a response team • Ensure ability to conduct mass immunization programs • Ensure ability to rapidly deploy stockpile resources to deployed locations

35. Phase 1 (Prevent) Activities • Update recommendations for prophylaxis and treatment with antivirals • Direct the establishment of a Single Integrated Medical Logistics Manager (SIMLM)/Lead agent as needed • Consider providing resources and technical assistance during pandemic alert periods to resource-poor countries in the USSOUTHCOM AOR with foci of influenza activity • Decide whether to further deploy part of the stockpile components according to risk assessment and release by ASD(HA)

36. Phase 1 (Prevent) Activities • Solicit our allies and Partner Nations via established channels to ascertain the extent and status of their specific PI response plans • Implement an education plan that will raise the level of awareness for medical staff and the installation personnel throughout the AOR, and advise all military units within the AOR to be alert for evidence of influenza-like illness in their unit • USSOUTHCOM Surgeon staff coordinate with influenza pandemic response staff at Host Nation ministries of health to synchronize information exchange

37. Phase 2 (Contain) • This phase occurs when sustained human-to-human transmission is identified in areas where U.S. Forces are located in the AOR • In this phase, the focus includes rapid preventative medical intervention, including isolation and quarantine • Phase II ends when the pandemic has been contained or when additional assistance is required to prevent further spread of the disease

38. Phase 2 (Contain) Activities • Evaluating installations as “no impact” (less than 5% not able to work), “minimal impact” (At least 5% and less than 15% not able to work), “moderate impact” (At least 15% and less than 30% not able to work), or “severe impact” (30% or more not able to work) by the pandemic influenza based on the proportion of individuals unable to perform their military duties • Limiting or canceling public and community gatherings • Closing educational institutions and day-care facilities

39. Phase 2 (Contain) Activities • Home quarantine • Setting up triage clinics and influenza hotlines to distinguish those who may need hospitalization from those who can be cared for at home • Staffing MTFs to treat influenza patients • Designating an Influenza Coordination Cell to coordinate the DoD response and provide a focal liaison with federal and local influenza response coordinators

40. Phase 2 (Contain) Activities • Encouraging people to voluntarily limit their movements from the time they are ill until about 6 days after the onset of symptoms • Imposing travel or movement restrictions • Identifying ability to respond to requests for international assistance • Use of antivirals for early treatment of cases, and consider antiviral prophylaxis for close contacts of cases based on risk assessment and severity of illness in humans

41. Phase 2 (Contain) Activities • Re-emphasizing infection-control measures and issue stockpiles of personal protective equipment and medications to health care providers • Reinforcing and intensifying key messages on prevention of human-to-human spread • Authorizing the administration of antiviral prophylaxis for personnel traveling to affected areas • Implementing a routine vaccination program to prevent morbidity and mortality in the target risk groups

42. Phase 2 (Contain) Activities • Identifying priority geographical areas and risk groups for targeting with preventive measures • Assessing effectiveness of treatment protocols and infection control measures and revise if necessary • Implementing real-time monitoring of essential resources (medical supplies, pharmaceuticals, infrastructure, vaccines, hospital capacity, human resources, etc) • Planning for vaccine distribution and accelerate preparations for mass vaccination campaigns (e.g. education, legal/liability issues) for when pandemic vaccine becomes available

43. Phase 2 (Contain) Activities • Monitoring the development of antiviral resistance • Canceling exercises as required in the AOR • Increasing state of awareness for medical staff and general public by advising all military units to be alert for evidence of illness in their units • Increasing coordination with public health and government authorities regarding port and airport quarantine and general travel restrictions as well as local public health measures

44. Phase 2 (Contain) Activities • Increasing coordination with the U.S. Public Health Service, U.S. NORTHCOM, U.S JFCOM and U.S. TRANSCOM regarding movement of personnel into and from CONUS • Coordinating with OSD, JS and U.S. JFCOM and/or other agencies for possible augment of HSS or other personnel from CONUS in order to ensure operational readiness and ability to conduct assigned PI response efforts

45. Phase 3 (Respond) • This phase occurs when broad sustained human-to-human transmission is identified in the AOR • The focus during this phase is to minimize the effects of the pandemic and prevent further spread of the disease • This phase normally begins when directed by CDRUSSOUTHCOM to implement this plan in response to a U.S. Chief of Mission (CoM) request for assistance and SECDEF direction • CoM will normally request DoD support when the pandemic exceeds USAID capabilities

46. Phase 3 (Respond) • A USSOUTHCOM Humanitarian Assistance Survey Team (HAST) may be deployed during this phase • Follow-on forces may be deployed and employed as a JTF in support of USAID as the lead federal agency in order to provide immediate assistance to relieve conditions that precipitated the pandemic • When a host nation is not capable of handling the pandemic, Phase IV is required

47. Phase 3 (Respond) Activities • USSOUTHCOM, at the direction of the Department of State (DOS), may conduct non-combatant evacuation operations (NEO) to move evacuees to a safe haven • Implement real-time monitoring of essential resources (medical supplies, pharmaceuticals, infrastructure, vaccines, hospital capacity, etc) • Appoint Vaccination Site Coordinators and plan for vaccine distribution. Accelerate preparations for mass vaccination campaigns when pandemic vaccine becomes available • Adjust priority lists of persons to be vaccinated

48. Phase 3 (Respond) Activities • Monitor the development of antiviral resistance • Eliminate non-essential social gatherings • Position forces and resources to conduct extended operations • Implement travel restrictions and quarantine as required to prevent or delay spread of the disease • Limit/bar travel to CONUS • Stop all movement to/from affected area

49. Phase 3 (Respond) Activities • In response to spreading Pandemic Influenza, consider suspending non-critical military operations in order to preserve personnel availability for critical response for Pandemic Influenza operations • Identify the most effective surveillance and control measures for subsequent pandemic waves • Inform service members about interventions that may be modified or implemented during a pandemic, e.g. prioritization of health-care services and supplies, travel restrictions, shortages of basic commodities, etc

50. Phase 3 (Respond) Activities • Implement corpse-management procedures • Redefine key messages; set reasonable public expectations; emphasize need to comply with public health measures despite their possible limitations • Be prepared to augment and support local, state, federal, and host nation governments with medical advice and resources, to include quarantine operations, when requested by the applicable lead federal agency and directed by SECDEF • On order, be prepared to move non-infectious U.S. military and other authorized personnel out of the area at risk in advance of the pandemic’s spread