Ethical Preparedness for Pandemic Influenza on Campus

Introduction

Pandemic influenza is a very different animal from the seasonal flu that communities are accustomed to slogging through every winter. The form of an influenza virus which creates a flu pandemic is one that is highly contagious and poses a much greater threat to all populations. In a pandemic, many more people are getting sick, when they do get sick they are getting sicker, and more people are dying. Beyond this, a pandemic is extremely widespread, meaning that every community surrounding one’s own is also severely impacted. This is especially significant because of its implications in how communities adapt and respond to the pandemic. When everyone is experiencing the burden of illness, individuals and communities must be much more self-reliant, as they will not be able to draw on external resources the way they could if the outbreak were isolated. In the most severe cases of pandemic influenza, “the cavalry isn’t coming,” and individuals as well as entire communities will need to adjust to the implications associated with shortages of medicine and hospital beds, being turned away from hospitals and clinics, and having movement restricted (which may be enforced by police).

Because a university functions not only as its own community, but also has many ties to the larger community in which it exists, it is important that universities consider how they should adapt to pandemic influenza and the different phases through which it may cycle. Not only should there be response plans, but also there are components of ethical planning and consideration that should inform the logistics of these plans. Particularly at a Jesuit institution, where we strive to become men and women for others, all members of the university community must consider the ethical obligations they have to themselves and to their peers and coworkers should they find themselves in this situation. It is imperative that our actions and intentions move us forward in pursuit of becoming conscientious, competent, compassionate individuals and community members.     

In considering what these ethical obligations might be, it is important to reflect on the principles of both medical ethics and public health ethics, as pandemic influenza bridges these realms by requiring population level health measures while still seeing care delivered at an individual level. From medical ethics, the pillars of autonomy, justice, and beneficence answer to the need for ethics at an interpersonal level, while public health ethics emphasizes the importance of community-based interventions, truthfulness and timeliness of information dissemination, as well as its own form of justice—one which focuses on a broader outlook.

From these ethical commitments and the particular circumstances that arise during a pandemic, we have developed six guiding principles which aim to prepare and inform the university community in particular. These are Obligation to Plan, Community Engagement, Transparency, Reciprocal Responsibility, Mitigation of Panic, and Justice. Obligation to Plan refers to the responsibility to acknowledge the risks posed by a pandemic and prepare for the logistical components as well as the ethical questions that may come into play during a pandemic. Community Engagement refers to the responsibility of communities to participate in the pandemic planning and action process. Transparency and Accessibility demands information dissemination in a clear and timely manner to all stakeholders through the planning process as well as during a pandemic. Mitigation of Panic employs individuals to take responsibility for their own response to the situation and minimize the threat that widespread panic poses. Reciprocal Responsibility invites compliance with restrictive measures and appropriate use of available resources. Justice refers to fairness and deliberate prevention of biases that might influence pandemic responses in undue ways. It is our hope that by making these materials available to the community, we may better inform and prepare the university community for the time when a pandemic is at our doorstep.

Let us now review the six principles and see how they apply to the university in preparing for and responding to a pandemic.

Obligation to Plan

This principle refers to the ethical obligation to develop a strategy for addressing the challenges presented by pandemic influenza. This strategy must be one which is rooted in the realistic response potential of a university, is inclusive of the diverse members of the campus community, and is developed well in advance of a pandemic so as to have time to be impactful. The complex situations brought on by pandemic influenza underline the importance of not only having taken the time to prepare logistically, but also having informed these logistical considerations by ethical guidelines and principles that pertain to the specific pandemic flu circumstances. By the time a pandemic is in progress, it is already too late to plan. During a pandemic, a very high number of people will become sick, and health systems may become overwhelmed and may not be able to care for everyone. Additionally, because pandemics are widespread, many places will be affected, and it will not be possible to go to another county or hospital for care. Individuals and communities must take time to consider how the different stages of a pandemic will impact their members and operations, as well as to better understand the role they will play in the larger community response during such a time.

Because personal preparedness is a critical component of ethical management of pandemic influenza, all persons should do their best to maintain a home care kit with the following components that can be used year to year for seasonal flu care, and continually restocked so as to be prepared for needs during a pandemic: oral thermometer, pain and fever reducing medication, cough medicine, drink with electrolytes (such as Gatorade), pen and paper (for symptom and medication tracking), tissues, face masks, N95 respirators, gloves, antibacterial wipes or gel, and also laundry detergent (it is important to be able to wash bedding or clothes used by the infected person to limit spread).

Additionally, there is an ethical obligation to practice good health habits. These are described by the CDC as:

• Avoid close contact
• Stay home when ill
• Practice good hand washing behavior
• Refrain from touching face, eyes, nose, and mouth
• Clean and disinfect surroundings that may be contaminated

University and Affiliated Groups:

The university and affiliated groups (such as ASG, SCCAP, MCC, ITW, etc.) have a different kind of preparedness that is ethically mandated compared to that which applies to students and faculty. At the institutional level, the university has an obligation to be in contact with the County Health Department to ensure understanding of the university’s roles and responsibilities to its students and also to the greater community in the event of a pandemic. They also have an ethical obligation to identify the types of supplies that might be needed and how to sustainably maintain their availability (stockpiling items such as cots, gloves, masks, hand sanitizer, tissues). The university is also responsible for developing an information infrastructure that can be used to communicate with necessary community members during a pandemic. It is not enough to just ensure things like campus safety alerts exist; sufficient personnel must be trained on their operation so that should several staff members fall ill, there are still those trained and available to operate the system. The university must also consider what kind of guidelines or restrictions will need to be put in place (e.g. at what point does the university mandate flu shots for those who have ELSJ placements working with children or the elderly, and at what point are ELSJ programs suspended?). Student groups have an obligation to identify what elements of their programming may need to be altered in different pandemic phases. For example, during early phases, groups that interact with young children may require students to receive flu shots to continue their involvement. In later stages, programs that interface with children may need to be suspended indefinitely until the pandemic subsides. Finally, there is an ethical obligation to provide some “safety net” framework for those who fail to meet the preparatory recommendations on an individual level. The university must continue to answer to the needs of its students, which in some cases will be the need to compensate for a lack of planning on the part of the students.

Faculty/Staff:

In the event of a pandemic, many of the county’s (and all surrounding area’s) health facilities will be at maximum capacity, so ethical preparedness necessitates some degree of self-sufficiency achieved through planning and supply gathering. Faculty and staff serve as important role models on campus and their preparedness serves not only their own benefit, but also conveys to students the importance of planning. Faculty and staff should have all of the same supplies that are listed for students available in their own homes (as these things apply to themselves and their families), and if possible, they should keep some key items (thermometer and pain/fever reducing medication, hand sanitizer, soup) at their campus offices as well. Additionally, faculty have an obligation to plan for how their classes may be impacted by a pandemic. Familiarity with online class resources (such as Camino, SCU Gmail, etc.) is imperative. In the event that a pandemic hits Santa Clara County, there may be a large number of absences from class, and, the faculty members themselves may fall ill. They should know how to publish class materials online, to make material accessible for students who cannot come in to class, while still maintaining the course standards for those who remain healthy. Finally, faculty should ensure that:

1) their faculty email accounts are accessible (passwords are known by account user)

2) they are signed up for campus safety alerts

3) they know the channel of the campus radio station

4) they know the phone number of the health center

5) they know the name and number of their primary health care provider

 6) they can access the County Health Department web address for updated guidelines and information.

Students:

Planning is one of the most crucial duties prior to an influenza pandemic. Because pandemics are widespread, some degree of self-sufficiency is an ethical obligation of every person, including students. This self-sufficiency must be developed before a pandemic to be effective. Students should maintain sufficient supplies for home care and symptom management, and should familiarize themselves with different information dissemination pathways, so that in the event of a pandemic, they can care for themselves, know how to seek help and how to find accurate, up-to-date information about the pandemic. With regard to home care supplies, all students should maintain a kit that includes the supplies listed above. This is especially important as students may be acting as care takers for themselves and their friends, and some of the protective measures, such as using face masks and N95 respirators, can help reduce the risks that come with living in close quarters as many students do. Finally, students should ensure that:

1) their student email accounts are accessible (passwords are known by account user)

2) they are signed up for campus safety alerts

3) they know the channel of the campus radio station

4) they know the phone number of the health center

5) they know the name and number of their primary healthcare provider

6) they can access the County Health Department web address for updated guidelines and information.

Community Engagement

All members of the community have an ethical obligation to be engaged in the pandemic response planning process as is appropriate given their role in the community. Community members enjoy the right to protection and support in the event of a pandemic, but with this right comes the responsibility to contribute and be engaged to ensure the diverse needs of the community are anticipated as best as possible, so there is no forgotten population. A strong, coordinated community effort is pertinent to the successful management of the pandemic; therefore individuals must contemplate how they will be integrated into this system as there will be no “opt out.” For universities and affiliated organizations, the primary obligations include operating within parameters set by pandemic oversight groups (such as the County Health Department), coordinating and organizing events that facilitate, first, community engagement and feedback regarding pandemic planning, then, second, events that facilitate learning about the community-developed plan. For students, faculty and staff, the primary obligation is primarily to show up; attend the events put on by institutions at both the planning and then educational phases. It is not helpful to only attend the educational events and at that point highlight flaws in the plan. Planning and feedback opportunities must be utilized for these purposes.

Universities and Affiliated Organizations:

The university and its affiliated organizations should be in communication with supervising bodies (for the university, this is the public health department, for campus organizations, this is the university administration) to know what elements of planning fall under their purview. The should be ready to host community events and comment periods for any proposed plans and be receptive to community feedback, making a deliberate effort to have any plan deliberately address the particular needs, within reason, for all community populations. Any group which will formulate drafts of a plan should include diverse individuals who can speak for the experiences of many persons on campus (including but not limited to staff from different departments; students of different degree levels and types; dorm residents; commuters; non-dorm campus residents; different ages; and people of different sociocultural, gender, sexual identity, religious, immigration, and economic backgrounds). After engagement and consideration of community commentary in planning processes, there must also be facilitated community education efforts to widely disseminate information, particularly that which is relevant to planning (which will be most effective if done before a pandemic hits).

Students:

Be aware of opportunities which invite your engagement. Know what modes of communication will be used to convey these opportunities (primarily email, perhaps also a critical website or posting board on campus) and be attuned to when these opportunities arise. The primary ethical obligation of students is not only to show up, but also to bring peers that represent different parts of the campus community (dorm residents, commuters, non-dorm campus residents, different age, sociocultural, religious, and economic background representations). In addition to being present and bringing a convicted, respectful representation of one’s own needs to community forums, students should attend with the intent of listening to the needs of others.

Faculty and Staff:

As leaders and mentors on campus, faculty and staff have the obligation not to attend information sessions but also to aid in information dissemination. Announcing community forums that are available, particularly that faculty and staff themselves will be attending, can set an example to students about how to be an informed and engaged community member.

Information Accessibility and Transparency

This principle involves the willing sharing of accurate, truthful, and complete information in a timely manner among groups and between agencies and persons so as to enable efficiency and measured decision making. Transparency within a community and between functional bodies during a pandemic as well as during the planning process is critical to establishing trust and developing plans that are maximally informed by abilities and limitations of all persons and institutions. In addition to transparency with information, it is critical that this information be provided through many platforms in ways that make it accessible to a wide range of stakeholders. When implemented, this principle is ethically significant because of its ability to help mitigate panic, enhancing a sense of community ownership, and respect for the agency and autonomy of stakeholders within a community setting.

Universities and Affiliated Organizations:

Transparency and accessibility are particularly pertinent to institutions and organizations, as they are generally the informational point of contact between sources and members of the broader community. There are four realms described below in which this principle is most likely to reveal itself in a university context.

• Situational severity: It is important that updated information about situational severity, and how this severity will impact different persons, be readily available. Though the county will be responsible for providing this on their website and through other means, the university is also responsible for communicating and providing situational updates as they pertain to its community. There should be a centralized information source that can be referred to for information regarding if classes are canceled, where to go for care on campus, what kinds of events and programs have been modified or canceled, who to call for questions, etc.
• Resource availability: There should be an understanding that in the event of a pandemic, resources (e.g. medications, water, food, etc.) will be limited. Information should be made available to the campus community regarding resource efficiency. This must be very thoughtfully managed, so as to not to incite panic. The purpose of this transparency is to help the public be informed, understand the situation more completely, and adapt their expectations accordingly.
• Triage: In the event of a pandemic there will be a standard set of protocols that will determine who receives what type of care at hospitals and clinics. Not everyone will have access to the same type of care because of resource limitations, and a community-based triage protocol ought to inform triage guidelines. The guidelines that will be used for triage should be made public, and also made accessible so that individuals are able to evaluate their own symptoms and determine if they might qualify for hospital-level care. Clearly and transparently providing these guidelines is a key component of ethically mediating community expectations in the event of a pandemic.
• Development of Decision Making Process: Part of such a planning process is determining how decisions will be made in the midst of a pandemic, particularly for situations that arise which are not clearly discussed in the existing plan. For the county, the County Health Supervisor has a great deal of power and is entrusted with this authority. At the university level, it should be made very clear to the university community who is in charge and what the process is for deciding adjustments to university life, including restricting movement through quarantines of those exposed to the virus and isolation of those who are sick. Just as health care facilities are expected to be transparent in their triage protocol, universities must be transparent in their decision making protocol.

Faculty/Staff:

Faculty and staff have a twofold role of making necessary information (that they are in a position to distribute) accessible to students, while also advocating for transparency among colleagues and throughout the university. Faculty and staff play a critical role in helping to develop a culture of forthright communication through the way they interact with colleagues and communicate with students. Their participation and advocacy for transparency set an important precedent. Additionally, faculty and staff have a responsibility to make use of the information that is given to them by administration and the County Public Health Department. This may be as simple as being sure to read the emails that are sent containing updated pandemic information. These small efforts help to create an informed campus community.

Students:

Students in particular have a responsibility to take advantage of the different ways that information is made accessible in order to stay up to date on what is going on, how situations are changing, and how their day-to-day life is being impacted. The information being made available is only valuable to those who access it. The other role of students is to “check” the university and affiliated groups which they are a part of, ensuring that whatever roles they hold throughout organizations are acting in accordance with this principle. Students should speak up about their information needs and expectations so that institutional administration knows there is a receiving audience that motivates their compliance with this principle.

Mitigation of Panic

Mitigation of Panic refers to the ethical obligation to create and foster strategies for minimization and management of an emotionally charged sense of panic that individuals may experience throughout the pandemic. It involves minimizing causes for panic as well as promoting strategies to address panic should it arise. Because of rapidly changing conditions, supply shortages, uncertainty, and a bombardment of complex circumstances, it is not unreasonable for the initial response in a pandemic to be panic. However, panic is a great detriment to the wellbeing of individuals, communities, and society as a whole, as it causes us to skew facts, distort situations, and impede thoughtful decision-making capacity. Because of the likelihood of tangible harm, there is an ethical obligation to address and mitigate panic. By participation in advance planning and education, a panic-resistant community ethic may be developed, and therefore improve resiliency in the event of pandemic influenza. A community that is better able to manage panic will be better able to respond to the challenges of pandemic flu and more effectively respond to the outbreak.

University and Affiliated Groups:

Facilitating trainings and dissemination of information are the primary responsibilities held by institutions and organizations. In advance of an epidemic, holding trainings that educate the community about response plans, where to go for reliable information, and basic principles of home care can be the types of events that help a community to “gear up” for a pandemic, so they are prepared and not taken by surprise. An organization must consider what roles its members play in the community, help them to consider what obstacles they may face in the event of a pandemic, and help them to anticipate effective problem-solving methods for these situations. Advance thought given to these ideas will not only help to minimize panic in the moment of a pandemic but will also promote a swifter and more effective response.

Faculty/Staff:

Faculty and staff, as leaders and role models in the campus community, have an obligation to prepare themselves to a degree where they will be able to resist the temptation to panic and in this way, may serve as examples for students. Additionally, faculty and staff must mitigate panic by being knowledgeable about what resources are available for students who express concerns about what is going on. Faculty and staff must be able to instruct students about where they can go to find information that can help them feel informed, and should also be able to offer reassurance and recommend strategies for pandemic related anxiety reduction. Panic is a normal, human response, and it is okay for faculty to acknowledge this with students, but faculty must be active agents in controlling their own panic and in helping students move past their panic so it does not consume them.

Students:

Students may be especially inclined to panic because of feeling unable to control the situation and feeling that they are dependent on other powers (university administration, public health department, etc.) for information. It is important for students to remember that they do in fact have agency and must make use of this. Students need to participate in advance trainings that help to prepare them for a pandemic influenza outbreak, as this will help minimize surprise and panic. Additionally, students have an ethical responsibility to reach out to faculty, staff, and peers when they find themselves unable to manage their own panic so that they find the support that will allow them to do so. The natural response of panic is not a wrong way to feel, but students must take responsibility for those feelings and address them with the support of the community to prevent the creation of a culture of panic and resulting disarray. Furthermore, students who have successfully developed coping mechanisms have an ethical obligation to offer peer-to-peer support for those who are not coping as successfully.

Reciprocal Responsibility

The principle of reciprocal responsibility means that all persons have some burden of responsibility in a pandemic, but all are entitled to certain things as well. The responsibility and entitlement are dependent on one another, and one does not exist without the other. This concept is particularly important in the context of pandemic influenza. Widespread resource shortages and the reality that “the cavalry isn’t coming” dramatically alter the decision-making processes of individuals and institutions, and the community standards for medical care.  As a consequence, there is an ethical obligation for members of a community to “pitch in,” to be compliant and adaptive to the measures that are implemented to help the community as they work through the challenges of pandemic influenza. The principle of reciprocal responsibility requires adaptation of individuals in their daily lives and also institutions in their policies to effectively protect the community from risks of disease spread. This includes cooperation during the implementation of isolations, quarantines, travel restrictions, and denial of access to medical care.

University and Affiliated Groups:

Institutions and organizations have a responsibility to comply with the recommendations of the public health department and adjust their standards and policies to promote and encourage compliance with these policies. This means major adjustments, such as complying with event cancellations as implemented by the health officer, but also includes smaller adjustments. Not only should adaptations be made to encourage persons who are sick to stay home from work, school, and other public gatherings, but also efforts should be made to encourage a community culture that is supportive of this model. It is important that individuals feel empowered to stay home when they pose a risk to others, as opposed to the present model where people are often expected to push through the illness so as to not fall behind on other work.

Faculty/Staff:

Faculty in particular must balance the responsibilities of being employees who monitor their own health and determine when they are healthy enough to attend class, but also influence the way that students understand when it is appropriate to stay home. Faculty may have to adjust attendance policies to be flexible with students who, in compliance with County Public Health recommendations, ought not to venture into public spaces. This does not mean the student is not responsible for the material but instead highlights an overlap with the principle of Obligation to Plan and the importance of making course material accessible online, enabling students to continue course work without violating their responsibility to self-isolate while contagious.

Students:

Students should expect certain event cancelations and/or restrictions, and ought to be cooperative with such restrictions in recognition of the severity of the situation and of the goals of the governing bodies to help minimize harm and promote health. Students have an ethical obligation to comply with event closures and other restrictive measures, such as quarantine and isolation, imposed on those who have been exposed to the flu or who are believed to be contagious. This is especially important for those who are living in close quarters, such as dorm rooms. Additionally, one of the primary ethical obligations of students is to be honest and compliant with attendance policies. The more lenient attendance policies that may arise during a pandemic invite more personal responsibility from students. It is imperative that students hold each other accountable to keep sick persons home, the healthy ones in class, and minimize people either going to class or staying home from class unnecessarily, as both can be detrimental when not implemented appropriately.

Justice

Justice is understood to be a key pillar of medical ethics and is just as important in pandemics as in other medical scenarios of any scale. The principle of justice in its own right is based in the idea that there should be some system of fairness and that no population ought to bear a disproportionate burden of the system. Traditional definitions of justice state that all people should be treated equally unless there is sufficient reason to treat them differently. Because a pandemic presents situations that offer this sufficient reason for difference (e.g. wildly varying need between different people and subcommunities), it can be especially complicated to maintain justice in a sea of immense need for protections and treatment. What is important to consider is what differences in circumstance amount to differences in resource access. One example is the idea that all caretakers are issued masks to protect themselves—not only the caretakers who can afford to purchase a mask—and masks are withheld from those who are not caretakers so as to conserve limited resources. Another example would be prioritizing Tamiflu access to first responders and medical providers, and those whose wellbeing must be prioritized to offer the best chance of community scale recovery. This illustrates how justice can be particularly complicated in a pandemic because of the low resource availability. Justice becomes a key principle for consideration with regard to triage, because common service methods, such as first-come-first-serve, may have inherent biases in them that need to be mitigated. There must be deliberate effort to ensure treatment and prevention measures are being implemented on a sliding scale that is proportional to the relative need of any particular individual, potential efficacy of this measure for this individual, and availability of the resource. It is important for all members of a community to understand and participate in the justice principle, so that patient values and universal protocol determine care standards, and not any other underlying systemic biases.

University and Affiliated Groups:

Organizations have a responsibility to examine the resources available to the university community and to determine what will be the need among different subpopulations in that community. They must  assess what barriers and biases may impact people accessing treatment under the universally applied triage and distribution protocol. This may include considering the ways that they can facilitate distribution of supplies, information, and treatment in a way that is just. This may mean having distribution sites in a variety of locations that are socially accessible to diverse groups (e.g. not everything can be done from the health center because some students may not be comfortable in the clinical setting, for whatever reason, so having an additional site in the library or basketball stadium could be beneficial). Also, in line with the idea of transparency, information about situational severity and triage and distribution procedures should be made accessible to help people better understand any limitations that are placed on treatment and resource access. This may especially come into play with the student health center. It is important that the center embody justice so that center staff and the university community all understand that there are consistent standards for operation which are being applied, and a social connection to a center staff member does not make a person more worthy of care or provide greater access.

Faculty/Staff:

One of the roles of faculty and staff will be to help educate and support students who struggle with the complex implications of the justice principle. There may be many students who do not understand why certain things are done the way they are, or how treatments and supplies are allocated. It will be important for faculty and staff to know how to help students work through what is going on and also know where to direct them (to an official public health department site for appropriate and genuine complaints, to CAPS for psychological and emotional support, etc.). Faculty and staff’s should reassure students that they are one of many, and as the whole community struggles through the pandemic so will the community pull through. This attitude is critical to helping communicate the idea that students are only a small piece of a greater unit, and the systems in place are designed to preserve the unit. Faculty and staff must accept personal responsibility for their own care when able and not manipulate systems in place, especially those designed to help more vulnerable populations, for their own benefit. This could be something as simple as not going to two separate sites for distribution of masks and gloves for home care, recognizing that other people have the same needs and may not have the luxury of traveling between distribution sites.

Students:

Although a pandemic may be a time of confusion and uncertainty, it is important for students to maintain sight of the bigger picture. There will be limited resources available across the board. In light of the scarcity, students may be a tempted to hoard supplies when they are given access. However, the justice principle requires not taking more than is needed. It is important to consider that this may apply beyond medical supplies, but may also include things like food, water, and gas. This will help others also be able to care for themselves and their loved ones, even if they do not have the privilege of access that students will likely encounter. Taking only what is needed does not mean students will never be able to get additional supplies later on, but it helps limit the acute strain for resources. College students’ affinity for free things, particularly stocking up on free things, will likely make this the most important point for them to consider. Panic is one of the greatest threats in a pandemic, and not panicking is one of the greatest challenges. Panic may incline students to take more than they need, but allowing for the fair distribution of resources is an important aspect of the justice principle.

Acknowledgements

Thank you to David DeCosse whose mentorship, guidance, and feedback made this project possible. Thank you to Margaret McLean and Anna Kozas for their consultation and diligent editing. Thank you to the Santa Clara County Public Health Department, particularly Jacquelyn Nash and Salvador Murillo, for their support, sharing of resources, and time spent offering insight pertinent to the direction of this project. Thank you to Peggie Robinson and Don Mattei for their time and expertise. Thank you to Craig Stephens and Laura Chyu for your willingness to participate and connect networks that broadened this project.

Bibliography

Centers for Disease Control and Prevention. “Pandemic Influenza (Flu).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 5 Mar. 2018, www.cdc.gov/flu/pandemic-resources/index.htm.

Pandemic Influenza Working Group. Stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza. 2005.

McLean, Margret. “Ethical Preparedness for Pandemic Influenza: A Toolkit.” Markkula Center for Applied Ethics, 1 Oct. 12AD, www.scu.edu/ethics/focus-areas/bioethics/resources/ethical-preparedness-for-pandemic-influenza/.

Santa Clara County Public Health Department. “Functional Annex 3.3 Pandemic Influenza Preparedness and Response Plan.” 8 Apr. 2015.

World Health Organization. “Global Influenza Programme.” World Health Organization, World Health Organization, 15 May 2018, www.who.int/influenza/en/.

Additional Resources

Centers for Disease Control and Prevention:
https://www.cdc.gov/flu/pandemic-resources/index.htm

https://www.cdc.gov/flu/pandemic-resources/pdf/colleges_universities.pdf

World Health Organization:
http://www.who.int/influenza/preparedness/pandemic/en/ 

Occupational Safety and Health Administration:
https://www.osha.gov/SLTC/pandemicinfluenza/index.html

Santa Clara County Public Health Department:
https://publichealth.sccgov.org/disease-information/influenza-flu

Markkula Center for Applied Ethics - Pandemic Influenza:
https://www.scu.edu/ethics/focus-areas/bioethics/resources/ethical-preparedness-for-pandemic-influenza/