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Emergency Preparedness and Response for Infectious Disease Outbreaks

An infectious disease is caused by germs, such as viruses and bacteria, that enter the human body and cause infection and illness. They can spread from person to person or through water, food, air, insects, and animals. There are varying types and severity of infectious diseases that can spread rapidly, resulting in a disease outbreak that may trigger an emergency response in rural communities. An emergency response infrastructure is critical to effectively responding to infectious disease outbreaks in rural areas.

Definitions

The Centers for Disease Control and Prevention (CDC) defines an epidemic, outbreak, and pandemic as follows:

“Epidemic: Occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.”

“Outbreak: Localized occurrence of more cases of disease as opposed to generalized epidemic.”

“Pandemic: Occurs over a very wide area such as several countries or continents, and usually affects a large proportion of the population.”

Planning for Infectious Disease Outbreaks

When planning for infectious disease outbreaks, including epidemics and pandemics, rural communities should consider the following:

The Hospital Personal Protective Equipment Planning Tool, from the Administration for Strategic Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE), is an example of a pre-planning tool for use in determining minimum PPE needs.

Many rural communities are integrating the One Health approach into their preparedness planning efforts for infectious disease prevention. The One Health approach acknowledges that many health threats are shared by people, animals, and the environment. This approach is particularly important in rural areas, where people and animals often share environments due to their occupations, including farming, ranching, and manufacturing. Rural communities can apply this approach by collaborating across disciplines and sectors. This means including partners representing human, animal, and environmental health, such as doctors and nurses, veterinarians, and wildlife experts. For more information on One Health, see the October 2020 Rural Monitor article One Health: Bringing Health to Humans, Animals, and the Environment.

For additional planning considerations, see Rural Community Planning for Emergency Preparedness and Response.

Responding to and Recovering from Infectious Disease Outbreaks

Key considerations for rural communities in infectious disease emergency response and recovery include:

  • Coordinating across local, regional, state, and federal agencies and organizations
  • Consulting with subject matter experts, such as those with epidemiology, laboratory, and surveillance expertise
  • Conducting epidemiological investigation and surveillance, collection and analysis of data, and lab testing
  • Communicating and information sharing with medical providers, first responders, and members of the public
  • Working with medical care systems and alternative care sites and shelters
  • Implementing public health measures to contain the disease, such as quarantine or mass prophylaxis

For additional guidance on emergency response and recovery, see Rural Community Emergency Response and Rural Community Recovery after an Emergency or Disaster.

Considerations for Infectious Disease Outbreaks in Rural Communities

While infectious disease outbreaks can impact both urban and rural areas, rural communities often face unique challenges with infectious disease emergencies. Many rural communities have existing healthcare infrastructure limitations, including personnel and equipment shortages, in addition to other challenges and barriers. Infectious disease outbreaks put added strain on health system resources, resulting in increased risk for adverse health outcomes among rural populations.

Unique considerations for rural healthcare systems during an infectious disease outbreak include:

  • Financial limitations of rural healthcare systems may require financial assistance from federal and state agencies during an emergency.
  • Limited healthcare workforce can cause staffing shortages if there is a patient surge or staff need to quarantine. Partnerships with other healthcare facilities can help mitigate staffing limitations.
  • Existing space, equipment, and supply shortages in rural healthcare systems can be exacerbated during infectious disease outbreaks. Healthcare coalitions can help supplement medical supply and equipment inventories.

Rural populations also commonly experience barriers related to social determinants of health, such as access to housing, food, and digital infrastructure. Infectious disease outbreaks can further limit accessibility to social services and supports, making it harder to ensure that basic needs are met for rural community members. Rural areas may also have transient workers and unique working conditions that require tailored guidance and response during an infectious disease outbreak.

For information, resources, and models to support rural organizations addressing the social determinants of health, see the Social Determinants of Health in Rural Communities Toolkit.

Lessons Learned from Historical Infectious Disease Outbreaks

Historical public health emergencies and infectious disease outbreaks provide lessons learned for rural community emergency preparedness and response to infectious disease outbreaks.

Pandemic Influenza (2009)

Pandemic influenza (flu) is a rare outbreak of the influenza A virus. Pandemic flu differs from seasonal flu and spreads quickly due to lack of immunity. Flu causes symptoms such as fever, cough, headaches, and other body aches and sometimes complications, such as pneumonia, that can result in death. Protective measures that help prevent and slow the spread of flu include vaccination, medication, and non-pharmaceutical interventions.

Rural communities may be somewhat protected from the flu because of their remote location and lower population density, compared to urban areas. Yet, rural populations may be more vulnerable to pandemic flu due to demographic and socioeconomic factors such as underlying health conditions and limited access to prevention or treatment services. Rural farmworkers, for example, are at increased risk for flu from livestock, including swine and poultry, that can carry the disease and pose a pandemic threat.

In 2009, the H1N1 (swine flu) pandemic stressed rural resources and highlighted the need to address barriers to access to and cost of vaccines, including equitable distribution to rural areas. By understanding points of service in rural areas — for example, rural populations were more likely to receive vaccines at the health department than a pharmacy or their workplace — rural emergency planners can better prepare for targeted prevention efforts for future pandemics.

Zika Virus (2015-2016)

The Zika virus is primarily spread by mosquito bites. Zika symptoms are often mild, but infection during pregnancy can cause birth defects. Community members can prevent infection by wearing protective clothing, using insect repellent, using physical barriers such as screens in windows and doors, and avoiding travel to areas with high transmission rates.

Prevention and response also include mosquito control programs and interventions. However, comprehensive mosquito control programs may be cost-prohibitive in small, rural communities. Instead, rural communities can implement activities to reduce mosquito populations in their towns, properties, and farms. These include eliminating standing water, which is where mosquitoes breed and lay eggs; keeping grass and weeds trimmed short; and applying barrier treatments to shaded areas, where mosquitoes keep cool during the day.

In 2015 and 2016, large outbreaks of the Zika virus occurred primarily in U.S. territories and freely associated states. There is a strong link between these outbreaks and socioeconomic conditions, as is also the case for other diseases spread by vectors like mosquitoes. For example, poverty is associated with lower use of air conditioning, leading to more open windows and doors. It is also associated with decreased access to water management and sanitation, and poor sanitation systems may lead to standing and stagnant water. Improved water access and sanitation facilities could have reduced the spread of Zika in rural areas.

Additionally, the Zika outbreak highlighted the importance of local community involvement in emergency response, particularly emergency risk communication. Local leaders and community groups can improve the reach of emergency communications and are more likely to influence behavior change.

Ebola Virus Disease (2014-2016)

Ebola virus disease (Ebola) is rare but often fatal. It causes symptoms including fever, body aches, vomiting, and internal and external bleeding. For the Ebola epidemic in West Africa between 2014 and 2016, the U.S. Centers for Disease Control and Prevention (CDC) activated its Emergency Operations Center (EOC) to support affected countries and strengthen public health preparedness and readiness in the U.S. Lessons learned from the CDC response in other countries included a need for surge capacity during an outbreak and improved infection prevention and control within healthcare settings. The response also demonstrated the importance of involving experts from a range of sectors and disciplines, such as epidemiology, laboratory, and health communication, among others.

2019 Novel Coronavirus (COVID-19)

In January 2020, CDC activated its EOC to support the public health response to the outbreak of the 2019 Novel Coronavirus (COVID-19). COVID-19 is caused by the SARS-CoV-2 virus and causes a range of symptoms, from mild to severe.

Rural healthcare facilities have faced many unique challenges responding to the COVID-19 pandemic. Rural areas are home to a higher proportion of older adults, who are at increased risk for negative COVID-19 outcomes. This puts additional strain on the limited service infrastructure of healthcare and public health delivery systems in rural areas. Further, rural populations have been disproportionately impacted by COVID-19, including negative effects on overall health, mental health, employment, and economic outlook. Many of these challenges, such as limited hospital capacity and unemployment, were existing barriers and challenges in rural communities. The COVID-19 pandemic brought to light existing gaps in rural health infrastructure, including limited availability and access to health services.

In response to the COVID-19 pandemic, the following emergency response strategies have been implemented in rural areas:

  • Partnerships – Collaboration among public health, hospitals, clinics, pharmacies, and other organizations for COVID-19 testing and vaccination helped ease workforce, space, and equipment limitations in rural areas. Healthcare coalitions were developed to coordinate the COVID-19 emergency response across partners in a region.
  • Community-designed testing – Involving the community to design and implement response activities can help ensure the strategies are aligned with community values and needs. For example, a program in Oklahoma increased access to COVID-19 testing in the state through community-designed testing events in rural and marginalized populations.
  • Vaccination/immunization – To support response to the COVID-19 pandemic, many local communities established infrastructure and venues for vaccination that did not exist previously. For example, in Louisiana, the Bureau of Emergency Medical Services (EMS) partnered with the Office of the State Fire Marshal (OSFM) to set up a travel plan to vaccinate EMS personnel across rural areas of the state.
  • Telehealth – During the COVID-19 pandemic, expanded access and increased use of telehealth services helped rural healthcare providers reach rural and vulnerable populations when social distancing measures were in effect. Telehealth can also be used to screen patients prior to arrival at a healthcare system to limit use of PPE and mitigate overcrowding. However, many rural communities did not have the necessary bandwidth or internet access to utilize telehealth services.

Other Infectious Disease Outbreaks

Other infectious disease outbreaks that may result in emergency responses in rural areas include:

  • Tuberculosis
  • Measles
  • Pertussis
  • Mumps
  • Bacterial meningitis
  • Mononucleosis
  • Monkeypox
  • Polio

Emergency Preparedness and Response Case Studies

Community-Designed Testing Programs Benefit Rural and Underserved Communities in Oklahoma
During the COVID-19 pandemic, Community-Engaged Approaches to Testing in Community and Healthcare Settings for Underserved Populations (CATCH-UP Oklahoma) increased access to COVID-19 testing in Oklahoma through community-designed testing events in rural and underserved communities. The CATCH-UP project provided community partners with supplies, including rapid antigen, PCR, and code serology antibodies testing materials, as well as funding to perform community-designed testing events with community residents. Throughout the course of the project, which started in March 2021 and lasted nine months, the community-designed testing-in-place initiative hosted nearly 400 testing events and administered around 7,500 COVID-19 tests of varying types to communities across Oklahoma.

Pandemic Vaccination Efforts by the Louisiana Bureau of Emergency Medical Services
When the COVID-19 vaccine became available at the end of 2020, the Louisiana Bureau of EMS was placed in charge of rural vaccine distribution and administration to first responders throughout the state. All in all, over 20,000 doses of COVID-19 vaccine were distributed to rural first responders and EMS personnel through either direct delivery and administration or through a partnership with the Louisiana Sheriff's Association.

COVID-19 Symptom Tracking and Exposure Notification Tools Developed by the University of Alabama at Birmingham Extend Awareness and Access to Rural Communities in Alabama
On March 14, 2020, one day after the first COVID-19 case was documented in Alabama, researchers at the University of Alabama at Birmingham (UAB) began developing symptom tracking tools. These tools increased access to COVID-19 awareness and education resources for rural communities across the state of Alabama and centered on behavioral change as a way to slow the spread of infectious disease. These efforts reinforced that rural communities must know where their resources are located, how to access them, and if they will cost money in order to ensure an effective emergency response.

Wayne Memorial Community Health Centers in Pennsylvania Stay Ahead of the Curve, Keep Emergency Response Plans Updated throughout the COVID-19 Pandemic
When the COVID-19 pandemic reached Pennsylvania in March 2020, the Wayne Memorial Community Health Centers in Honesdale, Pennsylvania, tailored their response plan to meet their specific community needs. In doing so, they were able to respond to the pandemic quickly and efficiently. They recognized what worked well in their community response based on experiences from previous near-outbreaks of infectious diseases in their community. Their response plan was updated to incorporate lessons learned from previous emergencies as well as the COVID-19 pandemic.

COVID-19 Community Task Force Utilizes Cross-Sector Response in Rural Greenbrier County, West Virginia
In March 2020, the Greenbrier County COVID-19 Task Force was formed. Leaders in public health, emergency management, education, business, nonprofit, and government worked across sectors to bring vaccinations to the rural area for emergency pandemic response. Being able to put together a network where people communicate, collaborate, and coordinate in a systematic way allowed the Greenbrier County COVID-19 Task Force to open up its abilities for a successful response that amounted to more than the sum of its parts.

COVID-19 Community Impact Mitigation: COVID Caring Cash Program Provides Economic Relief to Local Businesses in Richland Center, Wisconsin
Southwest Partners, a community development group in Richland County, Wisconsin, developed the COVID Caring Cash program as a form of emergency economic relief in response to the COVID-19 pandemic in April 2020. The program encouraged the residents of Richland Center to shop locally by providing vouchers and sponsor-backed incentives to be used in local stores, restaurants, and venues. COVID Caring Cash was a community-wide success.

Federally Qualified Health Center Provides COVID-19 Care to Rural and Underserved Populations in Pennsylvania and Northeastern Ohio through Mobile Health Unit and Vaccine Hesitancy Work
In 2020, a Federally Qualified Health Center provided a mobile health unit to bring testing and vaccinations to rural and underserved communities. Clinicians and support staff also conducted outreach to dispel vaccine hesitancy, reluctance, and misinformation in addition to providing healthcare services. The mobile unit was an anchor around which essential COVID-19 mitigation efforts took place.

Fall 2021 COVID-19 Surge Hits Remote Island Community in Alaska: Local Critical Access Hospital Responds Under Challenging Circumstances
In response to a sharp increase in COVID-19 infections, driven largely by the appearance of the Delta variant, Alaska activated crisis standards of care (CSC) guidelines for 20 medical facilities in the fall of 2021. One rural community affected by this was the Borough of Petersburg, located on Mitkof Island in southeastern Alaska, which had COVID cases spike from October through November. To address the situation, the island's sole healthcare provider, Petersburg Medical Center, saw the need to go beyond their normal role as a Critical Access Hospital to serve as a focal point for Petersburg's public health response to the pandemic. In this expanded role, the hospital faced significant challenges related to geography, workforce, transportation, and community perceptions and attitudes. Coordinating closely with the borough, public schools, the state health department, and other key partners, the hospital provided a strong response in multiple areas, including testing and vaccination, provision of evidence-based COVID treatments, wraparound services, implementation of state and federal policies, and public communications.

Resources to Learn More

State Strategies to Increase COVID-19 Vaccine Uptake in Rural Communities
Document
Offers best practices, identified by state officials, national experts, and community-based organizations, for building COVID-19 vaccine confidence, increasing access to vaccines, and developing sustainable methods for distribution of vaccines in rural populations.
Author(s): LeBlanc, M., Ruane, K., Fairbanks, M., & Roy, B.
Organization(s): National Governors Association Center for Best Practices (NGA Center)
Date: 8/2021

Strengthening Rural States' Capacity to Prepare for and Respond to Emerging Infectious Diseases, 2013-2015
Document
Provides clinicians information about the efforts of state and local public health agencies, from 14 states with large rural areas, to prepare for and respond to infectious diseases.
Author(s): Santibañez, S., Bellis, K.S., Bay, A., et al.
Citation: Southern Medicine Journal, 112(2), 101-105
Date: 2/2019

Topic Collection: Influenza Epidemic/ Pandemic
Website
Expands upon the influenza epidemic and provides links related to pandemic planning.
Organization(s): Administration for Strategic Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE)
Date: 8/2022