WHO guidance for contingency planning

WHO guidance for contingency planning 1This document was developed by the WHO Health Emergency Programme (WHE) Country Health Emergency Preparedness and the International Health Regulations department in partnership with all WHO regional offices, other headquarters departments and many country offices from all regions. Many staff from the WHO Health Emer- gencies Programme and beyond provided invaluable inputs based on their experience and expertise. We particularly acknowledge all the WHO Representatives who were invited by our regional colleagues to review and test the guid- ance and who took the time to provide precious feedback in order to make this guidance as user-friendly as possible. We are deeply grateful to, and would like to thank, all those who contributed to the development of this document. 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WHO/WHE/CPI/2018.13 32 The goal of the WHO Health Emergencies Programme is to help countries and to coordinate international ac- tion to prevent, prepare for, detect, rapidly respond to, and recover from outbreaks and emergencies in order to reduce the mortality and morbidity of affected pop- ulations. This includes WHO’s own capacity to manage risks and respond to emergencies in a timely, predictable and effective manner. Headquarters, regional and country offices all need to plan, well ahead of a crisis, for the ap- propriate resources, systems, policies, procedures and capacities to undertake effective risk mitigation and re- sponse operations in support of, and in collaboration with, ministries of health and other partners. Understanding the risk that threatens people’s health, planning to mitigate the impact, and preparing to re- spond can significantly save lives and preserve health and well-being. Thus all WHO offices need to under- take, along with governments, other UN agencies and partners, or alone if needed, regular strategic risk anal- ysis and monitoring, and related contingency planning. In this contingency planning guidance, a set of actions to prepare for emergencies from all hazards and to help minimize their impact, is proposed. These actions in- clude the development, implementation, simulation, monitoring and regular update of risks-based contin- gency plans. This guidance is based on a common organizational approach and procedures for risks management and emergency response across all hazards and at every lev- el of the Organization. It encompasses WHO’s respon- sibilities under the International Health Regulations1 (2005) and other international treaties, as the United Nations’ lead agency for health and the health cluster, and as a member of the United Nations or humanitarian country teams. The guidance has therefore been devel- oped in line with the WHO corporate risk management framework and the WHO readiness checklist, as well as the Inter-Agency Emergency Response Preparedness Framework and its Contingency Plan Guidance2. 1 http://apps.who.int/iris/bitstream/10665/43883/1/9789241580410_eng.pdf 2 https://www.humanitarianresponse.info/en/programme-cycle/space/emergency-response-preparedness-guidance-and-templates FOREWORD TABLE OF CONTENTS 1. Introduction 3 Purpose 4 Scope 4 Accountability 4 2. Guidance 5 Key principles of contingency planning 5 Developing scenarios and assumptions: what could happen? 6 Mitigation strategy: how can health risks linked to the hazard be reduced? 8 Preparing to respond: how can all health needs of affected populations be addressed? 9 Health sector preparedness 9 Developing a response plan 10 WHO specific responsibilities 11 Action plan: how will WHO fulfill its responsibilities? 13 Monitoring: how have the risks evolved? 13 Testing: how can readiness be improved? 14 Hazard based contingency planning flow chart 13 3. WHO office contingency plan template 15 Introduction 15 Scenarios and assumptions 15 Mitigation strategy 15 WHO preparedness strategy 15 Preliminary response plan 16 WHO action plan 16 Testing and maintaining the contingency plan 16 4. Annexes 17 Preparedness timelines 17 5. References 19 54 Contingency planning is part of a cycle in which the identification and regular monitoring of risks, vul- nerabilities and capacities informs the planning and implementation of measures to mitigate the risks and prepare to respond. • Risk mitigation includes all actions to reduce the severity, probability of occurrence of, or exposure to, a given hazard and therefore lessen its impact. • Preparedness refers to all actions to increase knowledge and capacity to anticipate, respond to and recover from the impact of one or more events. • Readiness is the outcome of preparedness actions – it refers to the outcome of planning, allocation of resources, training, exercising and organizing to build, sustain and improve operational capabilities based on risk assessments. All WHO offices need to have available a strategic analysis of the hazards which threaten the health of the populations they serve. This analysis is used to identify the major health threats for which contingen- cy plans (CPs) need to be developed and implement- ed. The aim of contingency planning is to mitigate the potential health consequences of these threats and to be ready to respond should the threats cause an emergency. In countries, the analysis of risks and subsequent contingency planning is usually initiated by the government or the UN Inter-Agency Standing Committee country team, and is jointly performed with all sectors and partners3. It should cover all haz- ards; WHO and the ministry of health need to ensure that all health related issues are effectively included and all health partners are involved. WHO and the ministry of health also need to ensure that specific health sector CPs are available for all ma- jor health threats. Each CP should clearly define the roles, responsibilities, planned actions and support that each partner committed to prepare for and pro- vide in case of an emergency. As part of this process, WHO needs to perform an in- dependent analysis of the plan‘s comprehensiveness and quality. Any gaps identified need to be addressed by government/partners. Finally, WHO must develop its own set of time-bound actions to be accomplished in order to address the threats. The implementation of these actions can be organized and monitored through an action plan. 1 INTRODUCTION 3 see: Emergency response and preparedness (ERP). Risk analysis and monitoring, minimum preparedness, advanced preparedness and contingency planning. Inter-Agency Standing Commit- tee; July 2015 (available at https://www.humanitarianresponse.info/en/programme-cycle/space/emergency-response-preparedness-guidance-and-templates) WHO offices at country, regional and headquarters lev- els must take all possible measures to mitigate risks and have in place the appropriate resources, systems, pol- icies, procedures and capacities in order to prepare for and respond to emergencies whenever and wherever they occur. Contingency planning is the framework that enables each WHO office to: • prepare for threats and reduce their potential public health consequences • identify needs and outline related actions • plan the implementation of these actions • identify resources and the time needed for implementation • monitor progress in implementation. This guidance note is to be used to direct the planning of mitigation and preparedness actions to address specific health threats; the note can be adapted to the context and needs of each WHO office. As a member of the UN system, and lead in the health sector, WHO needs to be involved in contingency planning exercises and ensure the inclusion of all necessary health issues and partners. Quality, comprehensiveness, efficiency, timeliness and effective implementation and monitoring of plans are also essential. Contingency plans need to be developed for each major threat identified in the risks analysis. All plans must be regularly updated based on the evolving risks and environment. The head of each WHO office is responsible for ensuring that: • health is appropriately integrated in all multisectoral contingency planning; • high quality, health sector specific CPs are developed and implemented; • the WHO action plans developed and implemented: » set out the roles and responsibilities to which WHO is committed as part of the UN, and as lead in the health sector; » prepare WHO to respond to emergencies as per the Emergency Response Framework; • plans are regularly tested, updated, monitored, and maintained; • the resources necessary to implement the action plans are identified and mobilized; • the office contingency plans are formally handed over to his/her successor. Purpose Scope Accountability4 4 Accountability is defined in WHO’s Accountability Framework as the obligation of every member of the Organization to be answerable for his/her actions and decisions, and to accept responsi- bility for them. http://intranet-pdrive.who.int/public-drives/PubDept/DGO-CRE%20-%20Compliance%2C%20Risk%20Management%20and%20Ethics%20Office/CMP/reference/accountability_framework.pdf 1 76 While each emergency is different in nature and con- text, there are many similarities, such that common emergency management practices and policies can be built into the health system to create resilience. Thus, although a separate CP should be developed for each type of threat, much of WHO contingency planning is generic and applicable to all types of emergencies. The key principles to bear in mind are that contingency planning should be: • practical • simple and easy to do • realistic and feasible • needs based and efficient, ensuring fair use of resources • process driven for effective operationalization • regularly tested through exercises • monitored and updated. 2 GUIDANCE Key principles of contingency planning 5 An approach for the integrated and strategic risks assessment of public health threats. Draft version. Geneva: World Health Organization; October 2016 Hazard based contingency planning flow chart Developing scenarios and assumptions: what could happen? • Identify and monitor priority hazards threatening health • Make assumptions and potential scenarios • Identify risk mitigation measures to reduce health consequences • Ensure direct implementation • Identify preparedness measures to ensure readiness to respond • Plan implementation according to level of needs and / or imminence of risks • Introduce a contingency or preliminary response plan based on scenarios • Set preliminary response specific objectives, activities, targets and indicators • Develop action plan • Test plan to ensure validity and functionality and address identified weaknesses • Monitor progress of achievements and adequacy with evolution of risks Risk analysis Risk mitigation Preparedness actions Contingency plan Action plan Testing and monitoring The planning process is initiated by a strategic risk assess- ment5. The purpose of this assessment is to identify and rank the risks and their geographical locations, and de- fine those hazards and scenarios for which contingency planning is required. Each priority hazard needs its own contingency plan based on flexible and realistic scenari- os. Scenario development provides a basis for planning and generates consensus on the nature of the potential crisis and the response to be provided. Most contingency planning takes place at multisectoral or interagency level to ensure coordination and maximize synergy of the pre- paredness and response actions and the use of resources. WHO and the health sector need to be part of these efforts to ensure that health issues are included in the plans. 2 98 The specific health risks posed by each hazard should be considered. In this document, floods are used as an example hazard. This hazard: • carries specific health risks, such as trauma or water-borne diseases, that need to be addressed by the health sector; and • requires different approaches in urban settings and remote villages. An example of a flood scenario is: Hazard Floods Early warning mechanisms Rainfall forecast, high risks areas mapping Scenario • Number of people affected • Number of people drowned/killed • Number of people injured (50–100) • Number of inaccessible or damaged hospitals and health facilities (2 of the 3 hospitals not accessible by road) • Number of houses destroyed or damaged (10 000–20 000) • Electricity cuts: highly likely • Lack of or limited access likely • Contaminated fresh water sources (5 out of 10) • Crops destroyed Health needs and risks • Trauma care (short term) • Lack of access to essential services • Watery diarrhoea including cholera • Malnutrition (longer term unless already present, and depending on the harvest calendar) Assumptions • Security problems do not hamper access • Boats are available for transport • Pre-positioned stocks are not affected by flooding 2 2 Once the risks to health have been identified, the next step is to ascertain which measures are already in place, and which can be taken, to prevent or miti- gate the impact of the risks. These measures should be put in place or strengthened as soon as the risks have been identified. Relevant actions to be taken in all areas and countries need to be identified in order to prevent and/or control public health risks. Such actions include: vaccination; enhanced surveillance and early warning, alert and response systems; vector control; infection control (in- cluding personal protection); enhanced sanitation and hygiene; increased provision of water and/or nutrients; prepositioning of drugs and medical supplies, etc. Mitigation strategy: how can health risks linked to the hazard be reduced? Identified health risks Floods Trauma • Public risk communication to promote personal safe behaviours • Training in mass casualty management Lack of access to essential services • Identify flood prone areas and evaluate the health infrastructures • Strengthen community based first aid • Identify back-up for referral systems Risk for watery diarrhoea including cholera • Improve water and sanitation in high risk areas • Assess opportunities for cholera vaccination campaign in high risk areas • Develop and implement risk communication campaign Malnutrition • Map vulnerabilities and determine follow-up actions accordingly • Develop community based preventive interventions Continuing with the example of floods, mitigation measures for this hazard include: 1110 Once mitigation strategies are in place, potential response needs have to be determined; this will allow WHO to identify and plan for related preparedness actions and for the response itself. Health sector preparedness Preparing to respond: how can health needs of affected populations be addressed? 2 Actions need to be developed, coordinated and planned with the ministry of health and all health sector partners. If a national contingency plan already exists for the hazard or scenario in question, it should provide a summary in which the respective roles and responsibilities of each stakeholder are outlined. Specific timelines for preparedness actions are im- portant to ensure that most of the response elements are in place at the time of the event/emergency. An example of a preparedness timeline for a seasonal epidemic disease such as meningococcal meningitis is provided in annex 1, which lists the main risk mon- itoring and preparedness actions advisable ahead of the outbreak season and their suggested sequence. As well as for seasonal outbreaks, it is important to for- mulate preparedness timelines for other foreseeable or seasonal events such as mass gatherings, droughts and floods. 2 To continue with the floods example, preparedness actions are outlined here: Health risk Needs Planned response Preparedness action Trauma • Trauma care and mass casualty management systems (MCM) • Referral of injured to hospitals • Availability of drugs, medical supplies and equipment • Rapid activation of reliable, predictable and quality MCM systems, including referral to secondary and tertiary health care as per agreed protocols • Continuous drugs and supplies chain management based on regular needs assessments • Develop a rapid alert system with key actors of MCM, from community- based first-aid actors to referral hospitals to emergency medical teams • Train and exercise MCM actors, procedures and systems • Prepare memorandum of understanding with transport com- panies; predict boat requirements • Preposition trauma kits • Evaluate warehouse and supply chain capacity Lack of access to essential health care • Mobile or temporary clinics to provide alternative access to essential health care and services • Rapidly reestablish access to essential health care • Mapping of areas and/or affected populations without access to health care • Information sharing with partners, coordination for increased/priority coverage of health operations • Targeted mobilization of mobile clinics, field hospitals etc., as per needs • Prepare inventory of current capacities of field hospitals and/ or mobile clinics, including staff, activities, drugs and supplies • Identify response gaps as per scenarios, and potential partners to fill gaps (e.g. emergency medical teams, Red Cross) • Identify potential obstacles to access (geographic, political, socio-cultural) and needed actions to address these obstacles (negotiations and advocacy, special transport such as helicopters, etc.) Outbreaks of diarrhoeal diseases • Ensure rapid detection, confirmation and alert • Provide materials to test for and treat cholera • Ensure treatment • Activate early warning alert and response systems (EWARS) in hot spots • Deploy rapid response teams for rapid investigation and early response • Provide case management at rehydration and treatment centres adapted to required infection control standards • Ensure availability and adapted coverage of EWARS, provide refresher training • Order rapid tests and cholera kits • Identify possible placement of future rehydration or cholera treatment centres • Prepare for water testing and treating Malnutrition • Prevention of risks by food/cash distribution • Screening and referral • Case management at community and health facility levels • Coordination with livelihood and nutrition cluster • Regular screening in hot spots and EWAR • Initiate community based management of malnutrition and referral to appropriate health facilities for severe cases and/or medical complications • Select sentinel sites for malnutrition screening • Identify potential health facilities to establish therapeutic feeding centres • Preposition kits for the management of severe acute malnourished children with medical complications 1312 Developing a response plan The response can be activated as soon as the event/emergency has been graded7. To continue with the example of floods: 2 2 Activity Target population Indicator Responsible actors Estimated cost First strategic objective: The immediate wounds and trauma of the people affected by the flood are addressed Second strategic objective: All affected people have access to an essential package of health services 7 As per: Emergency Response Framework. Second edition. Geneva: World Health Organization; 2017 (http://www.who.int/hac/about/erf/en/) 8 Emergency Response Framework. Second edition. Geneva: World Health Organization; 2017 (http://www.who.int/hac/about/erf/en/) With the response needs identified above, a preliminary response plan is developed with the objectives6 of: • fostering common understanding among all partners of the anticipated scope of the emergency, the possible health and health related needs, and the nature and scope of the planned operational response; • clearly explaining WHO and the health sector/cluster response strategy to address the needs of the affected population in the first weeks of an emergency; • reflecting specific challenges/gaps in the potential response in order to communicate anticipated funding requirements; • supporting the timely drafting of a resource mobilization document, e.g. a flash appeal, in the event of an emergency. This preliminary response plan sets out the initial response strategy and operational plan for meeting critical humani- tarian needs during the first three to four weeks of an emer- gency. The plan should therefore use the same format as a response plan and state the preliminary response objec- tives, activities, targets and indicators. WHO specific responsibilities In addition to the overall health sector contingency plan, WHO has additional responsibilities to ensure it is prepared to respond and deliver on the specific functions it has com- mitted to perform during an emergency, as per the Emer- gency Response Framework8. The WHO contingency plan therefore needs to include the preparedness and response actions to be implemented in order to achieve these goals. Continuing with the example of floods: Responsibility Response needs Preparedness action Coordination • A collective and synergic health sector response which covers all needs and all affected people • Synergy and complementarity with other sectors e.g. water sanitation and hygiene, nutrition, logistics • Harmonious decision-making with ministry of health and other decision-makers • Define coordination mechanisms and architecture with host government, ministry of health, UN agencies, other sectors and health partners • Ensure procedures are in place for requesting and coordinating international assistance (emergency medical teams(EMT), Global Outbreak Alert and Response Network (GOARN), standby partners) Information and planning • Updated epidemiological profile of the affected or exposed population • Understanding of health system modus operandi • Updated data on partners’ activities and coverage (4Ws – who, what, where and when) • Joint risks and needs assessments • Identification of triggers for activation of the response • Response plan • Ensure availability and good understanding of: − baseline data − triggers of activation of response, including EOC.. − needs assesment methodologies and tools − data collection tools for 4Ws, Health Resources Availability Mapping System (HeRAMS), EWARS − response plan templates and procedures Health operations and expertise • Technical guidances on mass casualty management (MCM), case management of waterborne diseases, and malnutrition. • Early warning, alert and response systems (EWARS) and rapid response teams (RRTs) • Risk communication campaign • Delivery of basic package of health services in areas with issues of access • Procure all needed guidelines • Training on EWARS, case management, MCM, infection prevention and control (IPC), etc. • Identify/clarify essential package of health services to deliver in areas with no or limited access • Prepare risk communication messages • Pre-identify possible communications channels Operations support and logistic • Uninterrupted supply chain • Communications facilities, transport, housing and accomodation for sub-offices and surge team • List warehouse capacity and transportation modalities • Ensure catalogues and lists of prepositioned supplies available • Obtain waivers for customs or visas • Pre-identify accommodation for surge teams Finance and administration • Availability or rapid access to contingency funds • Availability of budget lines that can be repurposed • Development of donor appeals • Development of proposals and grants management • Human resources management • Ensure emergency standard operating procedures (E SOPs) are known and understood • Make proposal and reporting templates available • Ensure grant management procedures are known • Identify and contact potential donors • Ensure visa and work permit procedures are in place 1514 The ultimate but most important planning step is to de- termine the means and resources by which WHO will implement its mitigation and preparedness actions ac- cording to the agreed schedule. A standard logical framework format can be used to de- velop the details, timing and budget requirements of the different elements of each plan. As risks are dynamic and evolve continuously, there is a need to keep monitoring them, and adjust plans and actions accordingly. WHO staff should: • re-evaluate the risks and priorities, and revise the assumptions, adequacy of mitigation and preparedness activities, and the implementation schedule, as necessary; • regularly compare the actual and planned implementation; • diagnose delays and identify remedial actions. Action plan: how will WHO fulfill its responsibilities? Monitoring: how have the risks evolved? 2 2 Continuing with the floods example: Objectives WHO activity Priority Start date End date Resources needed Responsible WHO staff Estimated cost in USD Risk mitigation Map flood-prone areas 2 Jan 2017 • Geographical information system • Consultant • Public health officer 5,000 Evaluate safe hospitals 3 Mar 2017 • Consultant • Public health officer 5,000 etc. Preparedness actions Preposition trauma kits 1 Oct 2016 Dec 2016 • Funding • Warehouse • Logistics supply system • Emergency coordinator • Logistics officer 12,000 Train health care workers on cholera diagnostics 1 Nov 2016 Dec 2016 • Trainer • Funding • Training room • Training material • Public health officer 6,000 etc. Regular review is a crucial element in assessing an of- fice`s readiness to respond. In order to be effective and reliable, the contingency plan needs to be constantly improved through testing to ensure that emergency management capabilities are consistent with the plans, procedures and policy. Exercises are therefore an integral part of contingency planning. Selection, planning and costing of exercises are well explained in section 3 of the WHO exercise manual and the related exercise planning tool9. The head of office ensures the contingency plan is tested before approval; he/she also ensures the contingency plan is well maintained and enhanced through yearly updates, reviews and exercises. Exercises enable: • validation of the adequacy of emergency plans, sys- tems and procedures; • familiarization of all stakeholders with the plan, pro- cedures and systems; • assessment and enhancement of functionality; • identification of gaps or weaknesses, and subse- quently of remedies for these deficiencies; • maintainance and updating of the continuity plan. The head of office ensures the continuity plan is tested before approval. 9 The WHO exercise manual, July 2016, and the exercise planning tool, November 2016, http://www.who.int/ihr/publications/WHO-WHE-CPI-2017.10/en/ Testing: how can readiness be improved? 1716 3 WHO OFFICE CONTINGENCY PLAN TEMPLATE Title: WHO Office [name of country/region] Contingency Plan for [name of hazard] Date of approval Signed by [name] Identified health risks Mitigation measures Introduction Results of risk assessment related to hazard Please provide a short description of: • the hazard and its characteristics (seasonality, transmission/amplification, scale, etc.) • impact and likelihood of the hazard. Situation analysis Please provide a short overview of: • the demographic and health profile of the country and the affected population • health system structure and services provision at national and sub-national levels • recent disasters/emergencies with public health impact. Scenarios and assumptions • Description of specific contingency plan scenario(s) • Description of early warning systems • Description of health needs and risks linked to the hazard • Description of planning assumptions. WHO preparedness strategy List all preparedness actions WHO has to deliver and which are linked to the identified response needs: Mitigation strategy List all mitigation measures for the identified health risks linked to the hazard: Health risk Response needs Preparedness action Preliminary response plan WHO action plan Testing and maintaining the contingency plan Exercise calendar Test calendar Activity Target population Indicator Responsible actors Estimated cost First strategic objective First strategic objective Target population Indicator Responsible actors Estimated cost Objectives WHO Activity Priority Start In place Resources needed Responsible WHO staff Estimated cost in USD Risk mitigation Preparedness actions From the identified response needs, define the key strategic objectives of the response and list the related main activities that will need to be implemented in the first weeks of the emergency in order to reach these objectives. Clearly identify the population targetted (based on assumptions) and the indicators, enabling monitoring of progress and/or achievments. If already identified, responsible actors can be listed for each activity. Estimating preliminary funding needs for the response avoids difficult discussions at the time of the response and developing the appeal. List all mitigation and preparedness actions that will be implemented by WHO and define the means and resources (human, logistics, financial) needed to imple- ment these activities according to an agreed schedule. 3 1918 4 ANNEXES Preparedness timelines and matrices can be developed for predictable events such as important mass gatherings or seasonal epidemics of communicable diseases. The example below is a preparedness timeline for menin- gococcal meningitis, in which the main risk monitoring and preparedness actions advisable ahead of the out- break season are listed in a suggested sequence. Preparedness timelines ACTIVITIES Months10 Epidemic season Months10 -4 -3 -2 -1 E1 E2 E3 E4 E5 E6 +1 +2 Collect, analyse and report surveillance data Risk monitoring Identify and monitor the distribution of bacterial meningitis pathogens and meningococcal serogroups Risk monitoring Map and monitor the distribution of germs and drug resistance Risk monitoring Send specimens to WHO collaborating centres to monitor the distribution and emergence of epidemic strains Risk monitoring Establish epidemic contingency funds mechanism Preparedness Develop preparedness and response plans with clear priorities, funding and responsibilities Preparedness Establish an epidemic preparedness and response committee Preparedness Identify high risk epidemic areas Preparedness Constitute a local strategic vaccine stockpile for epidemic response (according to risk identified) Preparedness Ensure up-to-date knowledge on access to the International Coordinating Group on global emergency vaccine stockpile for meningitis, through availability of standard operating procedures (SOPs), training, etc. Preparedness Reinforce laboratory diagnostic confirmation techniques and equipment Preparedness Strengthen lumbar puncture capacity (policy, training, personnel) Preparedness Evaluate laboratory supply needs Preparedness Procure/distribute laboratory diagnostics supplies Preparedness Perform laboratory after actions review and establish/revise testing and feedback algorithms and SOPs across the laboratory network (tests conducted at peripheral level vs intermediate vs central vs WHO collaborating centre level) Preparedness Establish mechanism for transport of laboratory samples Preparedness Evaluate laboratory supplies, reagents and equipment needs Preparedness Procure/distribute laboratory diagnostics supplies, reagents and equipment Test laboratory capacity through proficiency testing Conduct on-site training and supervision visits to check the availability of all necessary reagents and laboratory proficiency Preparedness Carry out additional corrective actions for low performing laboratories Reproduce and disseminate standardized data collection and transmission tools, case definitions, guidelines and SOPs Preparedness Establish standard surveillance data flow circuits and feedback Preparedness Conduct training on epidemiological surveillance – Integrated Disease Surveillance and Response/meningitis enhanced surveillance Preparedness Estimate antibiotics needs according to risk, procure and preposition Preparedness Identify hospital structures to care for increased number of cases Preparedness Establish rapid investigation teams and protocols Preparedness Prepare community awareness and information plan Preparedness Inform population on meningitis during the season: risk of meningitis cases, symptoms, importance of seeking prompt care/treatment, evolution of epidemic, etc. Preparedness Conduct evaluation of meningitis epidemic season and response – identify challenges and lessons learned to integrate in next preparedness plan Preparedness 4 20 • Coularton R. 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