From Binder to Action: Making Infectious Disease Outbreak Plans Operational

An infectious disease response does not begin when the first symptomatic patient walks to the counter. By then, the pharmacy should already know who will separate that patient from the waiting area, where personal protective equipment (PPE) is stored, which clinician will accept a referral, how a staffing shortage will be covered, and who at the health department can answer an urgent question.

The difference between having a plan and being prepared lies in whether the pharmacy team can execute it under pressure.

"A preparedness plan is not merely a binder stored on a shelf," Ayesha Bryant, MD, MSPH, associate professor and associate director of clinical research in the University of Alabama at Birmingham Department of Anesthesiology and Perioperative Medicine and a clinical adviser at Alpas Wellness, said in an interview. "It is a functional system that employees can effectively implement during periods of high stress."

That system has to connect the pharmacy with clinicians, public health agencies, emergency managers, and suppliers. Pharmacies are most useful in a surge when they are built into the response before it begins.

READ MORE: Conflicting Measles Reports Perpetuate as Cases Continue to Rise

Build the Network Before the Alert

Community pharmacies are often treated as downstream recipients of emergency guidance. New York City (NYC) has worked to place them closer to the center of planning. Pharmacists are incorporated into the health and medical component of its incident command system and the NYC Health Care Coalition. The health department also maps pharmacy locations so it can contact stores throughout an emergency.

"Pharmacies are an integral part of the health care system, and in some cases, they become a primary point to access health services during an emergency," Mary Foote, MD, MPH, FIDSA, medical director of the Office of Emergency Preparedness and Response at the NYC Department of Health and Mental Hygiene, said in an interview. "This makes community pharmacies integral to local infectious disease preparedness plans."

That integration matters in a market dominated by independent operators. Vibhuti Arya, PharmD, MPH, FAPhA, clinical professor at St. John's University College of Pharmacy and Health Sciences and clinical adviser to the NYC Department of Health and Mental Hygiene, estimated that independent pharmacies account for approximately 75% of stores citywide and an even greater share in underserved neighborhoods. A message routed only through national chains would therefore miss much of the city's frontline capacity.

The city created an external pharmacy advisory group and strengthened ties with pharmacy networks to make communication move in both directions. The lesson grew out of Hurricane Sandy, when officials discovered they had no reliable way to reach many community pharmacies. Arya and her students later visited more than 2800 stores to help build a usable network.

"Previously, it was a lot of coming at them, but not really collecting information," Arya said. "We would send them things, but we didn't really say, 'Are you experiencing these shortages? How long has it been going on?' Now we have mechanisms for that."

Know When to Escalate

A plan needs triggers, not just procedures. Bryant pointed to health department notifications, emergency department trends, test positivity, case clusters, and school or workplace outbreaks as external signals. Inside the store, changes in requests for fever, respiratory, or gastrointestinal products, longer supplier lead times, and rising numbers of symptomatic visitors can indicate that routine workflow is nearing its limit.

"Public health surveillance exists to recognize and manage changing disease patterns while they exist," Bryant said. "It is not simply there to document them after the fact."

Once a threshold is crossed, teams should be able to screen and separate symptomatic patients, deploy PPE, update scripts, adjust staffing, reconcile inventory, and activate referrals. Those steps should align with current local guidance.

Preparedness also includes the infrastructure that keeps care moving. Current call lists, backup access to records and communications, plans for power loss and cold-chain protection, and procedures for emergency refills or delivery can help keep the pharmacy running with minimal disruptions. Staff should know whether the store is in an evacuation zone and how to request help.

"Align with the local health department protocols, make sure you have communication networks set up, and engage with the health department," Arya said. "The health department can facilitate conversations, broker relationships, and use its leverage to help with supply requests and stockpile activities."

Rehearse the Weakest Links

Annual review should serve as a baseline, not the finish line. Foote recommends that pharmacies update and test emergency plans at least once a year and whenever a specific hazard is approaching. A jurisdictional risk assessment or hazard vulnerability analysis can help owners plan around the events most likely to disrupt their operations, including respiratory disease surges, power failures, floods, and severe storms.

Shorter exercises can turn written roles into practiced behavior. Bryant recommended quarterly tabletops and an annual functional drill, with additional testing after a material change. Scenarios should include a symptomatic patient, a medication or vaccine shortage, staff absences, a failed communication channel, and an urgent referral.

The debrief should measure performance through response time, correct PPE use, referral accuracy, inventory reconciliation, and completed corrective actions. Mystery-patient exercises can expose problems a scheduled drill will not.

"Preparedness plans are most effective when staff practice using them prior to a disaster rather than writing them while the crisis occurs," Bryant said.

Make Speed Part of the Clinical Protocol

New interventions can change the clock that a pharmacy is working against. For instance, the FDA approved Xocova (ensitrelvir) for postexposure prophylaxis of COVID-19 in adults and adolescents 12 years and older following contact with someone with COVID-19. The regimen must begin as soon as possible and within 72 hours of exposure.¹

That narrow window turns a dispensing decision into a preparedness test. A pharmacy needs a pathway to identify an exposure, coordinate a prescription, and complete the required medication and reproductive safety reviews. Staff also need to know whether the product is stocked and where to refer a patient if the pharmacy cannot complete the process.

"Upon learning of an exposure to COVID-19, the priority is a timely clinical assessment by a health care professional to determine if Xocova is appropriate for the individual," said Jerry Abraham, MD, MPH, CMQ, director of integrated services and public health at Kedren Community Health Center in Los Angeles, California. "If so, enabling rapid prescription and dispensing supports initiation of therapy as early as possible within the 72-hour window."

Postexposure prophylaxis does not displace vaccination, testing, treatment, or infection control. It adds another step that must be incorporated into screening, referral, and counseling. The same implementation principle applies whenever a new vaccine, diagnostic, or therapy arrives during a response. Clinical availability matters only if the local system can move an eligible patient to it in time.

That urgency is especially pronounced in multigenerational homes, long-term care facilities, shelters, and other settings where exposure can quickly reach medically vulnerable people.

"Public health strategies need to reflect the realities of people coming in and out of households for work, school, and day care, while others may be homebound or medically vulnerable," Abraham said. "The focus has to be on protecting everyone in the household, especially the most vulnerable."

Use Data to Protect Access

An emergency can amplify access gaps if officials do not know which pharmacies remain open or where demand is rising. Pharmacies can report shortages, closures, and patient questions while public health agencies share case trends, guidance, and allocation decisions.

In New York City, registry connections, syndromic surveillance, and geographic information system data help identify high-need areas below the zip code level. A standing-order program involving more than 300 independent and small-chain pharmacies creates a workforce that has agreed to vaccinate during an emergency. During the COVID-19 pandemic, CPESN helped independent pharmacies obtain vaccines and therapeutics through the federal retail pharmacy partnership.

Data should guide not only where products go, but also how they reach patients. Home delivery, telehealth-linked services, pop-up vaccination sites, and home visits can extend the response, but those capabilities require agreements and training before demand spikes.

Pharmacists also provide a form of surveillance that is easy to overlook. After all, they hear confusion. Questions and rumors at the counter can be reported to public health partners as community intelligence, allowing agencies to update messages. At the same time, pharmacists translate evolving recommendations into concrete steps patients trust.

Sustaining that role will require stronger infrastructure. Foote identified provider status and reimbursement, consistent emergency-preparedness education, and clearer workplace-safety expectations as unresolved barriers. Pharmacies cannot be expected to maintain clinical surge capacity indefinitely when the services that make it possible are uncompensated.

The goal is a practiced operating system that can absorb new information, move supplies, protect staff, and connect patients with care as conditions change. It begins with relationships sturdy enough to work throughout the emergency.

"When community pharmacies have a seat at the table, they can better educate partners on the roles they can play to support the health care response and the communities they serve," Foote said.

READ MORE: Infectious Disease Resource Center

REFERENCES

1. Shionogi Announces FDA Approval of XOCOVA (ensitrelvir), the First and Only Oral Option to Help Prevent COVID-19 Following Exposure. News release. Shionogi. June 1, 2026. Accessed September 14, 2026. https://www.shionogi.com/us/en/news/2026/06/shionogi-announces-fda-approval-of-xocova-ensitrelvir-the-first-and-only-oral-option-to-help-prevent-covid-19-following-exposure.html