Public Health H1N1 Response Research Protocol

Transcription

1 University of Kentucky From the SelectedWorks of Glen Mays Summer July 15, 2009 Public Health H1N1 Response Research Protocol Glen Mays, University of Kentucky Available at:

2 R ESEARCH P ROTOCOL FOR L OCAL P UBLIC H EALTH R ESPONSE TO H1N1 STUDY Version: North Carolina Draft July 2009 OVERVIEW OF RESEARCH DESIGN Overview and Objectives: The objectives of this study are to: (1) describe the nature and timing of the public health response to the novel H1N1 influenza outbreak in North Carolina at state, local, and regional levels; (2) determine the extent and nature of variation in investigation and response activities across local communities; and (3) identify factors that facilitated and inhibited H1N1 response activities during acceleration interval of outbreak that suggest opportunities for improving preparedness outbreaks. Data obtained from this study will be shared with state and local health officials in order to assist in developing quality improvement plans for future response activities. It is hoped that this project will enable health departments to obtain a more comprehensive review of activities than would otherwise be possible given the demands of ongoing response activities. Study Population and Sample Selection. This research project consists of two phases. During Phase I survey-based and independently conducted After Action Reports (AARs) from each of the 85 local health departments will be reviewed for nature, timing, and variation of H1N1 response and to identify response facilitators and barriers.. For Phase II, 6 to 10 local health jurisdictions with confirmed cases will be selected for more detailed on-site, facilitated data collection that will amplify existing survey and AAR information. A mix of accredited and non-accredited health department jurisdictions will be chosen for on-site visits and data missing from AAR review will be collected using instruments in sections II and III below. Phase I: Review of H1N1 After Action Reports from survey data and written AARs Data Source 1: DPH AAR Survey of Local Health Departments. Research staff will review results of the DPH AAR survey of Local Health Departments to describe the nature, timing and variation of response and identification of response facilitators and barriers. Data Source 2: After-Action Reports. Research staff will review AARs submitted to the State Health Department using data extraction tools. After Action reports will be reviewed for inclusion of time-specific response indicators and capability-based measures related to (1) Surveillance and Investigation; (2) Isolation and Quarantine; (3) Strategic National Stockpile; (4) Communication Interoperability; (5) Specimen collection and handling; (6) Community Preparedness Leadership and Networking; (7) Healthcare and Public Health Partnerships; and (8) Public Information. Results of reviewing these data sources will be used to identify candidate LHDs to include in more in-depth data collection through Phases II and III. 1

3 Phase II: Site Visits Data Source 1: Facilitated Document Review and Recall. On day one researchers will use tools in section I and relevant portions of section II to conduct a guided facilitation with the local health department Preparedness Coordinator or other designee. Facilitated discussion will involve a review of plans and discussion of overall response. Data Source 2: Focus Group Discussion. On day two researchers will conduct a focus group to discuss lessons learned. Response partners including medical care, school administrators, and emergency management officials will be asked to identify positive outcomes and areas for improvement. In order to focus discussion, facilitator will identify items from ARR review (Phase I) and day one site visit that need further clarification. Data Source 3: Key Informant Interviews. On day three, semi-structured interviews will be conducted with local public health officials and other response partners within each of the sampled counties, as well as with state officials and PHRST team members, to obtain more detailed information about the content, timing, and perceived effectiveness of H1N1 response activities. Interviews will be transcribed and coded to collect the data elements described in section III below. Analysis Plan: Information from all three data sources will be compiled and compared across the sampled health department jurisdictions to characterize the extent and nature of variation in H1N1 response activities. Stratified comparisons will be used to test for differences in outbreak responses and timeliness that may be associated with selected public health system resources and capacities, including workforce characteristics, accreditation status, and information resources. Preliminary results will be shared with participating local and state agencies at the conclusion of the outbreak response period to gain additional insight about causes and consequences of variation in outbreak response and to assist in quality improvement efforts. 2

4 DATA SOURCES AND DATA ELEMENTS I. Data Extraction, After Action Report Review and Site Visits: Time-line 1. Did you use your Pandemic Influenza Plan or Annex? Yes (Date activated:) No Unknown 2. Does the local health department have a formal in-house EOC? Yes No Unknown If yes, was the EOC activated during H1N1 response? Yes: (Date activated: / / 2009, Date deactivated: / / 2009) No Unknown If yes, was the local WebEOC activated? Yes: (Date activated: / / 2009, Date deactivated: / / 2009) No Unknown 3. Was the local Emergency Management EOC activated? Yes: (Date activated: / / 2009, Date deactivated: / / 2009) No Unknown 4. Was the local public health incident command activated? Yes: (Date activated: / / 2009, Date deactivated: / / 2009) No Unknown 5. Were confirmed cases identified within the local health department jurisdiction? Yes: No Unknown If yes, Date of first confirmed case: / / 2009 Number of confirmed cases: as of date: 6. Does your jurisdiction have a local epi response team? Yes No Unknown If yes, was the local epi response team activated? Yes: (Date activated: / / 2009, Date deactivated: / / 2009) No Unknown 7. Was a case definition for H1N1 acquired by the local health department and disseminated to the epi response team and other members of the investigative team? 3

5 Yes: (Date acquired: / / 2009, Date disseminated: / / 2009) No Unknown 8. What types of response guidelines/protocols were disseminated by the local health department? Responder type Physicians Initial release date: Release of revised versions: Hospitals Initial release date: Revised release dates: Schools/day care Initial release date: Revised release dates: Content of Guidelines/Protocols Identification of suspected cases Case reporting protocol Specimen collection and testing protocol Treatment protocol Containment guidelines Risk communication guidelines Acquisition or distribution of supplies Other: Identification of suspected cases Case reporting protocol Specimen collection and testing protocol Treatment protocol Containment guidelines Risk communication guidelines Acquisition or distribution of supplies Other: Identification of suspected cases Case reporting protocol Specimen collection and testing protocol Treatment protocol Containment guidelines Risk communication guidelines Acquisition or distribution of supplies Other: Methods Fax Phone Web Other: Fax Phone Web Other: Fax Phone Web Other: Dissemination volume Number of physicians reached in initial dissemination: Number of physicians reached in revised dissemination: Number facilities reached in initial dissemination: Number facilities reached in revised dissemination: Number of facilities reached in initial dissemination: Day care elementary secondary post-secondary Number of facilities reached in revised dissemination: Developer of guidance your agency other local agency state agency CDC other: your agency other local agency state agency CDC other: your agency other local agency state agency CDC other: Pharmacies Initial release date: Revised release Identification of suspected cases Case reporting protocol Specimen collection and Fax Phone Web Number of facilities reached in initial dissemination: Day care elementary your agency other local agency state agency CDC 4

6 dates: testing protocol Treatment protocol Containment guidelines Risk communication guidelines Acquisition or distribution of supplies Other: Other: secondary post-secondary Number of facilities reached in revised dissemination: other: 9. Was there any evidence of loss of specimens or other loss of evidence during the process of case investigation, laboratory testing, case confirmation, contact tracing, or other aspects of the outbreak investigation? Yes: if so indicate number, types, and dates of occurrence: No Unknown 10. Did your local agency and/or other agencies undertake active case ascertainment activities in your jurisdiction during the H1N1 response? Yes: No Unknown If so, indicate which of the following population groups were targeted for case ascertainment in your jurisdiction: Population Group Date initiated Initiating Agency Hospitalized patients Unknown LHD State DPH Other Travelers Unknown LHD State DPH Other Schools Unknown LHD State DPH Other Day care facilities Unknown LHD State DPH Other Long-term care facilities Unknown LHD State DPH Other Correctional facilities Unknown LHD State DPH Other Military service personnel Unknown LHD State DPH Other Other: Unknown LHD State DPH Other Other: Unknown LHD State DPH Other Other: Unknown LHD State DPH Other 11. Which of the following risk mitigation strategies were initiated in the local health department jurisdiction? Additional lines may be added for multiple strategy responses Strategy Date initiated Initiating Agency Case investigation Unknown LHD State DPH Other Contact tracing of cases Unknown LHD State DPH Other Household contact notification Unknown LHD State DPH Other Social contact notification Unknown LHD State DPH Other School notification Unknown LHD State DPH Other School closure Unknown LHD State DPH Other Employer/worksite notification Unknown LHD State DPH Other Health care professional notification Unknown LHD State DPH Other Health care facility notification Unknown LHD State DPH Other Voluntary isolation/quarantine order Unknown LHD State DPH Other Mandatory isolation/quarantine order Unknown LHD State DPH Other 5

7 Unknown LHD State DPH Other Unknown LHD State DPH Other Media briefing/press release Unknown LHD State DPH Other Unknown LHD State DPH Other Unknown LHD State DPH Other Health alert network notification Unknown LHD State DPH Other Other: Unknown LHD State DPH Other 12. Was a local plan for receipt, staging, and storage of supplies from the Strategic National Stockpile activated? Yes: (Date activated: / / 2009) No Unknown 13. Was a local antiviral distribution plan activated? Yes: (Date activated: / / 2009) No Unknown 14. Was a local distribution plan activated for other supplies or equipment? Yes: (Date activated: / / 2009) No Unknown If so, for which supplies or equipment: 15. Was there any indication of shortages of needed supplies or equipment needed for H1N1 response in the local health department jurisdiction? Yes No Unknown If yes, indicate type of supply and key dates Date shortage was first detected Supply item Antivirals Specimen kits Surgical face masks Other: Other: Date shortage was resolved Description of resolution 16. Did the local agency initiate conference calls or briefings with local health care professionals, health care facilities, and other organizations regarding H1N1 response? Yes: (Date of initial communication: / / 2009) No Unknown If yes, how frequently were these communications held during the first 14 days of the response? Number of times: < Frequency per: Day Week If yes, what types of organizations participated in these briefings or calls Type of organization Hospitals Physician practices Urgent care clinics Pharmacies Number of organizations of this type participating in a typical briefing/call 6

8 Nursing homes EMS Other health providers & facilities Primary/secondary schools Universities/colleges Day care facilities Religious organizations Community organizations Media organizations State health dept/health agencies Other local health departments Other (specify): 17. Did the local agency invite health care professionals, health care facilities, and other organizations to join statewide Public Health calls regarding H1N1 response? Yes: (Date of initial communication: / / 2009) No Unknown 18. Did the local agency hold separate briefings or press conferences with media organizations regarding H1N1 response? Yes: (Date of initial communication: / / 2009) No Unknown If yes, how frequently were these communications held during the first 14 days of the response? Number of times: < Frequency per: Day Week If yes, how frequently were Spanish language media outlets included in these communications during the first 15 days of the response? Number of times: < Frequency per: Day Week 19. Did the local health department designate a public information officer to process inquiries regarding H1N1? Yes: (Date of designation: / / ) No Unknown 20. Did the local health department use media protocols for processing media inquiries regarding H1N1? Yes No Unknown If yes, when were these protocols first disseminated to agency personnel: / / 21. What other communication materials and channels were used for dissemination to the public? Phone hotline: Date initiated: / /09 Total call volume: as of date: / /09 Unk Consumer web page: Date initiated: / / Total hits: as of date: / /09 Unk Brochures: Date initiated: / / Number distributed: as of date: / /09 Unk Other: Date initiated: / / Other: Date initiated: / / 7

9 Other: Date initiated: / / 22. Was there a plan in place for activating and enforcing quarantine and isolation orders that included appropriate provisions for H1N1 cases in the local health department jurisdiction? Yes No Unknown If yes, when was plan developed: / / If yes, was the plan reviewed with public safety and law enforcement officials and legal council during the course of the H1N1 outbreak: Yes (date reviewed ) No Unknown If yes, was the plan activated during the course of the H1N1 outbreak: Yes (date activated ) No Unknown 23. Did the local agency activate any mutual aide agreements or similar agreements with other local or state public health agencies for the purposes of H1N1 response activities? Yes No Unknown If so, indicate the type(s) of activities covered in the agreements that were activated: Type of activity Date Activated List Other Agencies Involved Case investigation/ascertainment Unknown Laboratory testing Unknown Case surveillance and reporting Unknown Acquisition/distribution of supplies Unknown Communications activities Unknown Mitigation activities Unknown Other: Unknown Other: Unknown Other: Unknown 8

10 II. Data Extraction, After Action Report Review and Site Visits: General Capacity I. Epidemiological Surveillance and Investigation Activity 1: Develop and Maintain Plans, Procedures, Programs and Systems 1.A Epidemiological emergency response plans in place 1.B. Epidemiological emergency response plans delineate the epidemiological investigation steps and include: 1B.1 Surveillance ongoing and event- specific collection of health data 1.B.2 Procedures for enhanced surveillance once a pandemic is detected to ensure recognition of the first cases of pandemic virus infection in time to initiate appropriate containment protocols, and exercise regularly. 1.B.3 Compare cases to the baseline and confirm diagnosis 1.B.4 Case finding actively search for cases 1.B.5 Conduct contact tracing 1.B.6 Develop /NA description of cases through interviews, medical record review and other mechanisms (person, place and time) 1.B.7 Generate possible associations of transmission, exposure and source 1.B.8 Identify population at risk 1.B.9 Coordinate with environmental investigation 1.B.10 Report appropriate 9

11 information to partners 1.B.11 Evaluate therapeutic outcome 1.B.12 Monitor adverse reactions to public health interventions 1.C State notifiable conditions list distinguishes between select conditions that require immediate reporting to the public health agency (at a minimum, Cat A agents), and conditions for which a delay in reporting is acceptable Activity 2: Direct Epidemiological Surveillance and Investigation Operations 2.A Time to issue information to the public that acknowledges the event, provides status, and commits to continued communication once a response plan is activated 2.B Time from case definition to dissemination of case finding and public health instruction to all hospitals in jurisdiction through the Health Alert Network (HAN) whose supporting information systems comply with the PHIN functional requirements for Partner Communications and Alerting. 2.C Percent of public health epidemiological staff with sufficient equipment (e.g., PPE, IT, communication, clinical sampling equipment, specimen collection material) to conduct investigation 2.D Time to have a knowledgeable local public health professional answer a call of urgent public health consequence 24/7/365 2.E Time to obtain message approval and authorization for distribution of public health and medical information to clinicians and other responders once message has been finalized Within 60 minutes of implementing response plan Within 12 hours of case Definition 100% 15 minutes or less Or N/A Within 60 minutes 10

12 Activity 3: Surveillance and Detection 3.A Year-round traditional surveillance for seasonal influenza (e.g., virologic, outpatient visits, hospitalization, and mortality data), including electronic reporting is conducted within the jurisdiction. 3.B Ability exists to receive, review, and analyze data warranting public health attention 3.C Time to implement enhanced Within 24 hours surveillance once a pandemic is detected to ensure recognition of the first cases of pandemic virus infection in time to initiate appropriate containment protocols, and exercise regularly. 3.D Influenza data from animal and human health surveillance systems is linked 3.D.1 Data is routinely shared. 3.E Information is tracked daily during a pandemic (coordinating with epidemiologic and medical personnel) on the numbers and location of newly hospitalized cases, newly quarantined persons, and hospitals with pandemic influenza cases. At least once/month 3.E.1 Reports are used to determine priorities among community outreach and education efforts. Activity 4: Conduct Epidemiological Investigation 4.A Time from initial notification Within 3 hours of initial to public health Notification epidemiologist to initiate Or N/A initial investigation 4.B Time from first identification of agent to first recommendation for public health intervention Within 6 hours of identification of agent Or N/A 11

13 4.C Time to identify suspect case and send to key Federal, State, and local public health partners (e.g., CDC, FBI, law enforcement, State, and local) 4.D Time for a health alert that describes the initial report of first case in your jurisdiction along with known cases, possible risk factors, and initial public health interventions to be distributed via Epi-X, Health Alert Network (HAN), fax, and e- mail 4.E Time from initial laboratory confirmation of high priority diseases or events with suspicion of terrorism to notification of law enforcement 4.F Time from epidemiologist acquisition of clinical diagnostic specimens/samples to receipt at the State laboratory 4.G Time for 75 percent of known suspected cases (or proxies) to be contacted/interviewed for more detailed epidemiologic follow-up 4.H Time for an initial report to be produced describing all suspected cases by person, place, and time Within 3 hours Or N/A Within 12 hours of initiation of case investigation Within one hour of confirmation. Or N/A Within 6 hours of acquisition Or N/A Within 48 hours of identification of the index case Or N/A Within 60 hours of identification of the index case Or N/A II. Isolation and Quarantine Activity 1: Develop and Maintain Plans, Procedures, Programs and Systems 1.A Legislation has been enacted authorizing appropriate isolation and quarantine measures (including quarantine of groups) 1.B Plan is in place that addresses coordinating quarantine activation and enforcement with public safety and law enforcement 1.C Plan is in place that addresses implementation of infection control precautions 1.D Plans are scalable, to the magnitude and severity of the 12

14 pandemic and available resources and can be revised as necessary. 1.E Identify for all stakeholders the legal authorities responsible for executing the operational plan, especially those authorities responsible for case identification, isolation, quarantine, movement restriction, healthcare services, emergency care, and mutual aid. 1.F Legal authority to isolate and/or quarantine individuals, groups, facilities, animals and food products is defined 1.G State and local law enforcement personnel who will maintain public order and help implement control measures have been defined. 1.H Plans define in advance what will constitute a law enforcement emergency and educate law enforcement officials so that they can preplan for their families and sustain themselves during the emergency. 1.I The jurisdiction's containment operational plan delineates procedures for implementing and enforcing containment measures (such as school closures, canceling public transportation, and other movement restrictions within, o, and from the jurisdiction) 1.J The jurisdiction's containment operational plan delineates the methods that will be used to support, service, and monitor those affected by these containment measures in healthcare facilities, other residential facilities, homes, community facilities, and other settings. 1.K Plan addresses having or having access to information systems to support tracking adherence to isolation and quarantine measures that 13

15 comply with the PHIN functional requirements for Countermeasure and Response Administration. 1.L Plan addresses how to ensure adequate stockpiles of appropriate personal protective equipment Activity 2: Direct Isolation and Quarantine Tactical Operations Was Isolation and Quarantine IF NO, SKIP THIS necessary given the scenario/event SECTION 2.A Public health official with legal authority to issue isolation and quarantine orders is identified 2.B Time to issue isolation and quarantine order 2.C Time to provide educational information for release 2.D Time to establish communications with state public health officials Within 4 hours of notification of need to implement isolation and quarantine Within 1 hour of order being issued Within 30 minutes of need to implement isolation and quarantine Activity 3 : Activate Isolation and Quarantine Was Isolation and Quarantine necessary given the scenario/event 3.A Time to stand up isolation and Within 12 to 24 hours of notification quarantine staff for enhanced of need to implement isolation and contact follow-up quarantine Or N/A IF NO, SKIP THIS SECTION 3.B Time to deploy personnel to traveler screening locations 3.C Time to disseminate restriction guidelines and treatment protocols to medical care providers 3.D Percent of caregivers for isolated patients who become infected while patient was under voluntary isolation and quarantine While caring for patient under mandatory isolation and quarantine 3.E Frequency of updates to tracking system from Within 2 hours of identifying screening locations Within 2 hours of order being issued Or N/A 0% 0% or N/A Daily 14

16 voluntarily isolated or quarantined individuals while under voluntary isolation and quarantine Frequency of updates once mandatory isolation and quarantine was in effect 3.F Percent of persons receiving care and prevention instruction while under voluntary isolation and quarantine Percent while under mandatory isolation and quarantine 3.G Percent of caregivers using infection control precautions while caring for patient under voluntary isolation and quarantine 3.H Percent of persons under mandatory isolation or quarantine receiving daily monitoring and compliance contact 3.I Percentage of known cases and exposed successfully tracked from identification through disposition to enable follow-up 3.J Percentage of persons exposed to known case successfully tracked from identification through disposition to enable followup Daily or N/A 100% 100% or N/A 100% 100% Or N/A 100% 100% III. Medical Supplies Management and Distribution ( Strategic National Stockpile) Activity 1: Develop and Maintain Plans, Procedures, Programs and Systems 1.A Emergency public health and medical material distribution plans are in place 1.B The jurisdiction has a contingency plan if unlicensed antiviral drugs administered under Investigational New Drug or Emergency Use Authorization provisions are needed. 1.C Plans for the procurement, rotation and maintenance of 15

17 Federal, State, local stockpiled assets or private/commercial inventories were implemented 1.D Medical treatment facilities and State, county and local governments have coordinated with medical distributors to develop preplanned worst-case scenario orders that reflect differing needs for various possible scenarios (chemical, biological attacks, natural disaster) 1.E Frequency with which preplan worst-case scenario orders are reviewed and updated 1.F Medical treatment facilities and State, county and local government plans reflect input from local and regional sources of potential medical supplies and pharmaceuticals to power dependency on federal assets 1.G Plans are in place for assuring physical security of medical materiel in transport and distribution 1.H Distributors plans and logistical systems are in place to identify potential sources of excess in their supply chains that might be diverted to higher need locations 1.I Jurisdiction has identified locally available sources of critical medical supplies to use prior to arrival of external (State/Federal) resources 1.J Jurisdiction has acquired and established access, through MOUs, contracts or established supply depots, to effective pharmaceuticals (including medical gases) and medical material in accordance with forecasted needs Semiannually 16

18 Activity 2: Direct SNS Management and Distribution Tactical Operations Were warehousing operations IF NO, SKIP THIS activated? SECTION 2.A Time from approved request 6 hours from request for Federal medical assets to activation and full staffing of warehouse 2.B Time for request of local 2 hours from request supplies to arrival at warehouse (to be used until Federal/State assets arrive) 2.C Medical supplies and pharmaceuticals were properly maintained and arrived in undamaged, serviceable condition and within the expiration date indicated on each container (bottle, case, vial, etc.) 2.D Time to begin backfill of medical support packages from Strategic National Stockpile n(sns) Within 36 hours or N/A Activity 3: Establish Security Was warehouse activated? IF NO, SKIP THIS SECTION 3A Security and credentialing (badging) is provided at all steps of transportation of pharmaceuticals and supplies Activity 4: Repackage and Distribute Were SNS assets repackaged and IF NO, SKIP THIS delivered to PODs and/or medical SECTION facilities? 4.A Citizens were informed in /NA advance about where they would be vaccinated or receive prophylaxis. 4.B Time from arrival of medical resources/sns at warehouse to arrival at points of 12 hours from arrival distribution (PODs) 4.C Time from approval of request for re-supply to the delivery of additional medical assets to PODs hours from Approval Or N/A Activity 5: Communication and Coordination 17

19 Were SNS assets distributed? IF NO, SKIP THIS SECTION 5.A Medical Supplies Management capability and the Emergency Operations Center communicated operational and resource needs to one another. 5.B Medical resource shortages and issues were identified and communicated to the appropriate contact for Medical Supplies Management. IV. Communications Interoperability and Coordination Activity: Develop and Maintain Plans, Procedures, Programs and Systems 1.A Local Health Department has Communication Operational Plan that specifies procedures for regularly updating providers as a influenza pandemic unfolds 1.B Communication operational plan addresses the needs of targeted public, private sector, governmental, public health, medical, and emergency response audiences; 1.B.1 Plan identifies priority channels of communication; 1.B.2 Plan Delineates the network of communication personnel, including lead spokespersons and persons trained in emergency risk communication 1.B.3 Plan links to other communication networks 1.C Operable communications systems, supported by redundancy and diversity, 18

20 provide service across jurisdictions, which meets everyday internal agency requirements are in place. 1.C.1 Documentation of system design is available 1.D Communications Continuity of Operations Plan (COOP) that outlines back-up systems is in place and available for use 1.E Set of communications standard operating procedures (SOPs) that conform to NIMS are in place and used in routine multiple jurisdictional responses 1.E.1 Copy is available and in the local Health Department 1.F Redundant and diverse interoperable communication systems are available 1.F.1 Descriptions are available 1.G Formal interoperable communications agreements have been established with local Emergency Management 1.G.1 Documentation is available 1.H Formal interoperable communications agreements have been established with local healthcare providers 1.H.1 Documentation is available 1.I Formal interoperable communications agreements have been established with education partners 1.I.1 Documentation is available 1.J Formal interoperable communications agreements have been established with local industry and local nonprofit partners 19

21 1.J.1 Documentation is available 1.K Plans to acquire and influence sustained interoperability and systems maintenance funding have been developed Activity 2: Provide Health Emergency Operations Center Communications Support Was the jurisdiction s local or IF NO, SKIP THIS regional health EOC activated? SECTION 2.A Communications sent and received between state and If no, please specify local Public Health were understood without ambiguity by the sender or the intended receiver 2.B Frequency with which communications back-up is provided during emergencies when the conventional mode of communications fail or become overloaded Continuous or N/A 2.B.1 COOP and/or Incident Action Plan process in place to assure continued service amidst incident 2.B.2 Documentation is available Activity 3: Communication with Healthcare and Public Health Partners 3.A Percentage of practicing, At least 80% licensed, frontline healthcare personnel the Health Alert Network in the jurisdiction reaches and links to other pandemic responders 3.B Local Healthcare Providers were reminded of existing 24- hour infectious disease reporting mechanisms 3.C Healthcare providers were updated regularly, as specified in the Local Health Department Communication Plan, as the influenza pandemic unfolds 3.D Frontline clinicians and 20

22 laboratory personnel receive information of protocols for safe specimen collection and testing, 3.D.1 How and to whom a potential case of novel influenza should be reported, 3.D.2 The indications and mechanism for submitting specimens to referral laboratories 3.E Local Public Health Authorities are trained and have access to EPI-X 3.F Local Public Health Authorities used Web EOC during event Or NA V. Laboratory Specimen Collection and Handling Pandemic Influenza Activity 1: Develop and Maintain Plans, Procedures, Programs and Systems 1.A Laboratory emergency plans are in place that augment the capacity of public health and clinical laboratories to meet the needs of the jurisdiction during an influenza pandemic. 1.B Plans include: 1.B.1 Protocols for safe specimen collection and testing 1.B.2 Protocols for proper handling and shipment of specimens 1.B.3 Mechanisms for submitting specimens to referral laboratories 1.B.4 Protocols for notifying and reporting any novel specimen findings 1.C Does the plan include staff identified with contact information for information sharing between the animal and human health surveillance systems? 21

23 Activity 2: Specimen collection and testing 2.A Local healthcare providers and laboratories were notified of enhanced surveillance testing and reporting recommendations 2.B Local laboratories were notified of protocols for testing of suspect cases of pandemic influenza 2.C Local clinicians were notified of methods for acquisition of testing supplies for pandemic influenza 2.D The local public health department notified healthcare providers of testing options for uninsured, suspect cases of pandemic influenza 2.E The local public health jurisdiction coordinated testing of suspect cases of pandemic influenza with local healthcare providers to ensure testing of uninsured individuals 2.F The local health department coordinated with local clinical laboratories to ensure proper handling and shipment of all specimens 2.F.1 Individual from local health department was assigned to coordinate specimen submission and transport 2.F.2 SPHL specimen submission data was reviewed to ensure LHD was aware of all specimens submitted 2.G Chain of evidence and chain of custody protocols were followed according to SOP zero loss of evidence or specimens VI. Community Preparedness Leadership and Networking Activity 1: Develop and Maintain Plans, Procedures, Programs and Systems 1.A. Established Pandemic 22

24 Preparedness Coordinating Committee that represents all relevant stakeholders in the jurisdiction (including governmental, public health, healthcare, emergency response, agriculture, education, business, communication, community based, and faith-based sectors, as well as private citizens) and that is accountable for articulating strategic priorities and overseeing the development and execution of the jurisdiction's operational pandemic plan exists and has met at least once within the last three months. 1.B Written guidance exists that delineates accountability and responsibility, capabilities, and resources for key stakeholders engaged in planning and executing specific components of the operational plan. 1.B.1 Plan includes timelines, deliverables, and performance measures. 1.C Plans and procedures delineate activities that will be performed at the state, local, regional or coordinated level. 1.C.1 Plans establish role regional teams and state will have in providing guidance and assistance. 1.D Operational Plan for Pandemic Influenza is an integral element of the overall local emergency response plan established under Federal Emergency Support Function 8 (ESF8) and is compliant with the National Incident Management System (NIMS) 1.E Local Pandemic Operational Plan is well integrated with 23

25 state, local, tribal, territorial, and regional plans. 1.E.1 Local Operational Plan delineates accountability and responsibility, capabilities, and resources of each. 1.F Formalized agreements with neighboring jurisdictions are in place that address communication, mutual aid, and other cross-jurisdictional needs. 1.G A demographic profile of the community (including special needs populations and language minorities) exists. 1.G.1 The needs of these populations are addressed in the operation plan. 1.H Plan addresses provision of psychosocial support services for the community, including patients and their families, and those affected by community containment procedures. 1.I Local Public Health response partners have received written procedures and are aware of the process for requesting, coordinating, and approving requests for resources to local, state and federal Public Health agencies 1.J An Incident Command System for the pandemic plan is based on the National Incident Management System. 1.J.1 This system has been exercised along with other operational elements of the plan. 1.K Community-based task forces exist that support healthcare institutions on a local or regional basis. 1.L The authority responsible for declaring a public health 24

26 emergency at the state and local levels and for officially activating the pandemic influenza response plan is clearly defined and documented. 1.M Percentage of laboratory specimen forms submitted by the jurisdiction that were fully complete when submitted to state public health laboratory 100% VIII. Healthcare and Public Health Partnerships Pandemic Influenza Activity: Develop and Maintain Plans, Procedures, Programs and Systems 1.A Comprehensive operational plan for the healthcare sector (as part of the overall plan) is in place. Plan addresses: 1.A.1 Healthcare of persons with influenza during a pandemic, 1.A.2 Legal issues that can affect staffing and patient care, 1.A.3 Continuity of services for other patients, 1.A.5 Protection of the healthcare workforce 1.A.6 Medical supply contingency plans. 1.A.7 Plan has been exercised 1.B All components of the healthcare delivery network (e.g., hospitals, long-term care, home care, emergency care) are included in the operational plan. 1.C Operational plan addresses the special needs of vulnerable and hard-to-reach patients. 1.D Operational plan includes provisions for surge capacity of healthcare services, 25

27 workforce, and supplies to meet the needs of the jurisdiction during a pandemic. 1.D.1 Surge Capacity has been tested 1.E Jurisdiction has a plan for provision of mortuary services during a pandemic 1.E.1 Plan has been tested 1.F Plans define what constitutes a medical staffing emergency 1.G Operational plan contains guidance on how to obtain appropriate credentials of volunteer healthcare personnel (including in-state, out-of-state, international, returning retired, and nonmedical volunteers) to meet staffing needs during a pandemic. 1.H Healthcare facilities in the jurisdiction have tested a plan for isolating and cohorting patients with known or suspected influenza, for training clinicians, and for supporting the needs for personal protective equipment. 1.I Healthcare facilities in the jurisdiction have tested an operational plan to initiate, support, and implement quarantine of potentially exposed healthcare personnel IX. Public Health Communications (Public Information) Pandemic Influenza Activity 1: Develop and Maintain Plans, Procedures, Programs and Systems 1.A Emergency Communication Plan ensures coordination of activities with private industry, education, and nonprofit partners (e.g., local Red Cross chapters). 1.B Emergency Communications identifies lead subject-specific spokespersons. 1.C Public health communications staff has been trained on risk communications for use 26

28 during an influenza pandemic. 1.D Up-to-date communications contacts of key stakeholders have been developed and are maintained 1.D.1 The plan to provide regular updates as the influenza pandemic unfolds has been exercised. 1.E Community resources, such as hotlines and Web site, to respond to local questions from the public and professional groups are implemented and maintained. 1.F Public health messages have been reviewed and approved by behavioral health experts Y X. Workforce Support: Psychosocial Considerations and Information Needs Activity 1: Develop and Maintain Plans, Procedures, Programs and Systems 1.A The Local Public Health Agency has a continuity of operations plan for essential health department services that includes contingency planning for increasing the public health workforce in response to absenteeism among health department staff and stakeholder groups that have key responsibilities under a community's response plan. 1.B Formal agreements exist to ensure availability of psychosocial support services (including educational and training materials) for employees who participate in or provide support for the response to public health emergencies such as influenza pandemics. 27

29 III. Information to be Obtained through Interviews with Local, Regional and State Key Informants 1. Capacities and constraints in local epi teams: How quickly were teams mobilized? How well did teams know their roles? How much training and review did teams require? How well were teams able to balance their roles in producing and disseminating guidance with their roles in conducting epidemiological investigation and response? What could these teams have done differently in terms of planning, organization, investigation, communication, and/or response that would have improved their effectiveness? 2. Laboratory capacities and constraints: To what extent did capacity constraints at local, state, and/or clinical labs affect H1N1 response activities? Were there preventable lag times in laboratory testing and confirmation? What could state or local officials have done differently in terms of planning, organization, staffing and/or response that would have improved laboratory capacities? 3. Capacities and constraints at the state level: How quickly and how well was the state mobilized to provide support to the locals regarding guidance, reporting conduits, call center capacity, and staff deployments? What could the state have done differently in terms of planning, organization, staffing and/or response that would have improved the effectiveness of the H1N1 response? 4. Opportunity costs and economic impact: What activities did local agencies discontinue, delay, or curtail in order to sustain H1N1 response efforts? What activities did PHRST teams discontinue or curtail? What activities did DPH personnel discontinue or curtail? How many staff and what types of staff were diverted from their normal job duties and detailed to the H1N1 response effort (local, regional, and state levels)? How long did these diversions last? What were the response costs incurred at local, regional, and state levels (probe for direct costs of surveillance and investigation, direct costs of communication, direct costs of response, indirect costs due to lost revenue from diversions)? 5. Medical Countermeasures: How well did local and state agencies receive, manage and distribute the SNS: timeliness, logistics choke points, other issues identified? What could agencies have done differently in terms of planning, organization, staffing and/or response that would have improved the effectiveness of the distribution effort? 6. Isolation and Quarantine: Were the mechanisms in place to issue isolation orders? What barriers were faced with implementing and enforcing these orders? What gaps were identified surrounding these orders in terms of the isolated individuals, the general public and law enforcement/judicial systems? What could agencies have done differently in terms of planning, organization, staffing, communication and/or legal preparedness that would have improved the effectiveness of the isolation and quarantine strategies? 7. Coordination of Response: How well did local response organizations/agencies coordinate activities? What did agencies do right? What could agencies have done differently? 28