Case Study: Influenza Preparedness in Marin County

In mid-April 2009, the federal Centers for Disease Control and Prevention (CDC) reported confirmed cases of H1N1 in several states. As the virus continued to spread throughout the country, Marin County, California, just north of San Francisco, was one of the communities quick to respond. On April 25, the county’s Department of Health and Human Services activated its Department Operations Center in coordination with the Sheriff’s Office of Emergency Services (OES). Three days later (April 28), the county announced its first confirmed H1N1 cases.

In the midst of response operations, Marin County recognized that the H1N1 outbreak would continue through the summer into the 2009-10 influenza season. The combination of a severe H1N1 resurgence and the traditional influenza season could potentially exceed the county’s response capabilities and resources. With that in mind, OES searched for specific ways it could prepare for an H1N1 resurgence.

In the absence of federal or state guidance, OES turned to scenario-based planning, a technique the county was familiar with because of its previous experience in planning for earthquakes. OES personnel concluded that an H1N1 resurgence would have to be dealt with in more or less the same way, because, much like an earthquake, it would be impossible to predict exactly where an earthquake would occur and/or the extent of damage it would cause. However, reasonable assumptions could and should lead to effective preparedness efforts.

Designing the Assessment; Checking the Probabilities

In June 2009, OES created a plausible threat assessment with three purposes in mind: (a) to define the specific H1N1 threat facing Marin County; (b) to communicate the nature of that threat to county officials; and (c) to identify Marin County’s own response-capability shortfalls. Such an assessment not only would allow OES to quantify the impact of H1N1 on Marin County but also would help shape the planning efforts being developed in the months leading up to the 2009-10 influenza season. OES also decided to present the assessment in an abbreviated format that would allow for quick and easy briefings to county leaders. The assessment targeted the entire emergency-management community, rather than being made available only to public-health officials.

County officials built the threat assessment around three H1N1 “resurgence” scenarios of varying severity: mild, moderate, and severe. Each scenario included varying attack, hospitalization, and case fatality rates, complete with descriptive narratives. OES based its calculations on the CDC’s FluSurge model, but with slight modifications to account for: (a) the transmission characteristics of the H1N1 virus; and (b) the county’s own demographic data. OES then translated those numbers into absenteeism rates, medical costs, and the probable economic impact on the county. To double-check its own work, OES consulted epidemiologists at the county’s Department of Health and Human Services to ensure the accuracy and plausibility of OES calculations.

OES analyzed the final figures to determine the response measures necessary for each of the scenarios postulated. The response measures included, but were not limited to: the activation of an emergency operations center (EOC); quarantine and social “distancing” practices; several types of public-information campaigns; and the issuance of emergency proclamations. OES determined, for example, that a “moderate” H1N1 resurgence would call for full activation of the county’s Department of Health and Human Services Department of Operations Center and possible restrictions on public gatherings for selected events. After the response requirements were clearly defined, OES was able to highlight specific areas for improvement along with recommended preparedness actions for each scenario.

The threat assessment revealed several gaps in the county’s current response capabilities. For example, OES learned that its virtual EOC capability could not sustain operations for long periods of time and would therefore have to be strengthened. In addition, the assessment helped to guide the county decision-making process by educating local leaders on Marin County’s capabilities gaps and presenting several options for improvements. One example: county leaders decided to relieve emergency-management personnel from responsibilities and engagements – not related to H1N1 preparedness planning – after October 1, 2009.

Not incidentally: (1) Marin County officials said they plan to use the same threat-assessment tool to help cope with future pandemics; and (2) By adjusting the demographics data, the Marin County assessment could easily be made adaptable to other jurisdictions – and for that reason, in fact, has already been passed along to other jurisdictions throughout California.


For additional information on the Marin County Threat Assessment, and for resources on pandemic influenza and the H1N1 outbreak, visit Lessons Learned Information Sharing at

Mary Lilley

Mary Lilley, a contractor with SAIC, is a researcher for Lessons Learned Information Sharing (, the U.S. Department of Homeland Security/Federal Emergency Management Agency’s national online network of lessons learned, best practices, and innovative ideas for the nation’s homeland security and emergency management communities. She received a bachelor’s degree in Political Science from Duke University.



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