Pandemic Influenza Incident Specific Appendix. to the Lake County Emergency Operations Plan

Transcription

1 Pandemic Influenza Incident Specific Appendix to the Lake County Emergency Operations Plan Revised September 2009

2 Table of Contents A. Preface Page B. Basic Plan 1. Purpose 3 2. Objectives 3 3. Scope 3 4. Limitations 4 C. Concept of Operations 1. Decision Making Structure 4 2. Planning Assumptions 4 3. Legal Authority 7 4. Pandemic Severity and Timelines & 7 Triggers 5. Ethical Framework Vulnerable Populations Continuity of Operations 11 D. Technical Chapters A. Communications 12 B. Epidemiological Surveillance 13 C. Community Mitigation Interventions (CMIs) 13 D. Infection Control 14 E. Clinical Issues 14 F. Healthcare Planning 14 G. Asset Distribution (Antivirals & PPE) 15 H. Vaccine Distribution 18 I. Laboratory 23 J. Poultry Worker Health 23 K. Care of the Deceased 23 L. Flu Centers 24 M. Regional Coordination 25 E. Appendices Supporting Materials & Local Resources 1: Background on Intervals, Triggers, Actions 26 2: Risk Communication Guidelines 31 3: CMI Background Information 31 4: Asset Distribution Background Information 32 5: Vaccination Background Information 32 6: Flu Center Plan Template 36 F. Record of Plan Changes 42 2

3 A. Preface An influenza pandemic will place extraordinary and sustained demands on the public health and medical care systems as well as providers of essential services in Lake County. To prepare for the next pandemic, an event considered by many experts to be inevitable, Lake County in cooperation with various state and local organizations has developed the Lake County Pandemic Influenza Incident Specific Appendix to the Lake County All-Hazard Response Plan. This plan was developed in cooperation with local hospitals, clinics, emergency medical services (EMS), emergency management (EM), the Minnesota Department of Health (MDH), and other community agencies/partners. This cooperation is to enhance the plan as well as develop robust and comprehensive plans for other kinds of emergencies that may impact Lake County. Emergency preparation is a continuum and planning efforts will always be evolving. As new information arises and lessons are learned the Lake County Pandemic Influenza Incident Specific Appendix will be updated as necessary. B. Basic Plan 1. Purpose The purpose of the Lake County Pandemic Influenza Incident Specific Annex is to provide a coordinated and comprehensive local response to an influenza pandemic in order to reduce morbidity, mortality, and social disruption and to help ensure a continuation of governmental functions. 2. Objectives The Lake County Pandemic Influenza Incident Specific Appendix has five primary objectives: 1. Maximize the protection of life and property in Lake County. 2. Insure that the response effort be organized under National Incident Management System (NIMS). 3. Delineate roles and responsibilities for other local governmental and non-governmental agencies participating in the response. 4. Assure that the Lake County Pandemic Influenza Incident Specific Appendix is coordinated and consistent with MDH Pandemic Influenza Plan and the plan of other counties in the state. 5. Assure that the Lake County Pandemic Influenza Incident Specific Annex is coordinated with the pandemic influenza response activities identified in the Lake County Emergency Operations Plan. 3. Scope The Pandemic Influenza Plan focuses on emergency response that is unique to pandemic influenza and therefore serves as an Incident Specific Appendix to the all-hazard Lake County Emergency Operations Plan. In Minnesota, Pandemic Influenza Plans consist of three parts: 1. The Basic Plan: an overview of the assumptions, concept of operations, legal authority, ethical framework, and key pandemic influenza functions. The Basic Plan is divided into the Preface and Concept of Operations. It also includes sections on Pandemic Phases and Stages. 3

4 2. Technical Chapters: information that is unique to health departments response to an influenza pandemic, provide response information organized by subject or task, address response actions that are specific to pandemic influenza and are a supplement to the All Hazards Functional Annexes 3. Appendices: supplements including pandemic influenza specific resources and background information. 4. Limitations Emergency preparedness is a continuum, since planning efforts evolve as new information becomes available. The Regional Pandemic Influenza Plan will be updated when necessary. (A record of plan changes is located at the end of this document.) C. Concept of Operations 1. Decision Making Structure The Lake County Emergency Operations Plan and the Lake County Pandemic Influenza incident specific appendix are both organized under the National Incident Management System (NIMS). Details of command structure are provided in the basic plan section of the Lake County Emergency Operations Plan. At the trigger point when Lake County outpatient clinics are overwhelmed (due to patient load or lack of adequate staff), the Lake County Emergency Operations Center (EOC) will be activated to coordinate and support the implementation of this plan. 2. Planning Assumptions Pandemic influenza is a unique public health emergency, in that a pandemic will likely have devastating effects on the health and wellbeing of the American public. Influenza is caused by viruses that infect the respiratory tract. Influenza symptoms include rapid onset of fever, chills, sore throat, runny nose, headache, non-productive cough, and body aches. Influenza is a highly contagious illness and can be spread easily from one person to another. It is spread through contact with small droplets and aerosols from the nose and throat of an infected person during coughing and sneezing. Influenza viruses are unique in their ability to cause sudden infection in all age groups on a global scale. The importance of influenza viruses as biological threats is due to a number of factors, including a high degree of transmissibility, the presence of a vast reservoir of novel (new) variants, and the unusual properties of the viral genome. Two types of influenza viruses cause disease in humans: type A and type B. Influenza A viruses are composed of two major antigenic structures essential to vaccines and immunity: hemagglutinin (H) and neuraminidase (N). The structure of these two components defines the virus subtype. A minor change in the structure caused by a mutation (antigenic drift) results in the emergence of a new strain within a subtype. Mutations (antigenic drifts) can occur in both type A and B influenza viruses. A major change in the structure caused by genetic recombination (antigenic shift) results in the emergence of a novel subtype (i.e., one that has never before occurred in humans or adaptive mutation of an avian virus) most commonly associated with influenza pandemics. This shift only occurs with influenza type A viruses. Influenza A viruses are unique because they can infect both humans and animals thereby 4

5 causing more severe illness. Antigenic shifts in influenza A viruses have been the cause of the last three pandemics: 1918, 1957, and The well-known Spanish flu of 1918 was responsible for more than 20 million deaths worldwide, primarily among young adults. Mortality rates associated with the more recent pandemics of 1957 (A/Asia [H2N2]) and 1968 (A/Hong Kong [H3N2]) were reduced, in part, by antibiotic therapy for secondary bacterial infections and more aggressive supportive care. However, both the 1957 and 1968 pandemics were associated with high rates of morbidity and social disruption. The Centers for Disease Control and Prevention (CDC) uses data from previous pandemics to provide estimates of the impact of pandemic flu. The estimates range from a moderate pandemic (based upon 1958 and 1968) to a severe pandemic (based upon 1918) outbreak. CDC models provide the following estimates. In the United States: 90 million people will be infected (30% of population) 45 million people will require outpatient care (50% of ill) 1-10 million people will be hospitalized (1-11% of ill) Between 200,000 and 2 million people will die (.25-2% of ill) In Minnesota: 1.5 million people will be infected 700,000 people will require outpatient care 15,000 to 150,000 people will be hospitalized Between 3,600 and 33,000 people will die In Lake County (population 11,080) 3300 people will be infected 1600 people will require outpatient care 30 to 350 people will be hospitalized Between 8 and 70 people will die Effective preventive and therapeutic measures including vaccines and antiviral agents will likely be in short supply, as may some antibiotics to treat secondary infections. Healthcare workers and other first responders will likely be at even higher risk of exposure and illness than the general population, further impeding the care of ill persons. Widespread illness in the community will also increase the likelihood of sudden and potentially significant shortages of various personnel who provide other essential community services. Pandemic influenza is considered to be a relatively high probability event - even inevitable - by many experts. Yet no one knows when the next pandemic will occur and there may be very little warning. Most experts believe that we will have one to six months between the identification of a novel influenza virus that results in human-to-human transmission and the time that widespread outbreaks begin to occur in the United States. Outbreaks are expected to occur simultaneously throughout much of the nation and the world thus preventing relocation of human and material resources. The effect of influenza on individual communities will be relatively prolonged six to eight weeks when compared to the minutes-to-days observed in most other natural disasters. 5

6 Should a pandemic occur, every community would have to rely primarily on its own resources as it combats the pandemic. The following planning assumptions are generalized for pandemics. Because the Novel H1N1 Virus is currently circulating around the globe in 2009, more specific planning assumptions may be added to this plan as time passes. Susceptibility to the pandemic influenza virus will be universal. Efficient and sustained person-to-person transmission of a novel influenza virus signals an imminent pandemic. The clinical disease attack rate will likely be 30% or higher in the overall population. Illness rates will be highest among school-aged children (about 40%) and decline with age. Among working adults, an average of 20% will become ill during a community outbreak. Some persons will become infected but not develop clinically significant symptoms. Minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection. Of those who become ill with influenza, 50% will seek outpatient medical care; however, if antiviral drugs are effective, this proportion may be higher in the next pandemic. The number of hospitalizations and deaths will depend on the virulence of the pandemic virus. Estimates differ about 10-fold between more and less severe scenarios. Planning should include the more severe scenario. Risk groups for severe and fatal infection cannot be predicted with certainty but are likely to include infants, the elderly, pregnant women, and persons with chronic medical conditions. Rates of absenteeism will depend on the severity of the pandemic. In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members, and fear of infection may reach 40% during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak. Certain public health measures (closing schools, quarantining household contacts of infected individuals, snow days ) are likely to increase rates of absenteeism. The typical incubation period (interval between infection and onset of symptoms) for influenza is approximately 2 days. Persons who become ill may shed virus and can transmit infection for up to 1 day before the onset of illness. Viral shedding and the risk of transmission will be greatest during the first 2 days of illness. Children usually shed the greatest amount of virus and therefore are likely to post the greatest risk for transmission. On average, infected persons will transmit infection to approximately two other people. In an affected community, a pandemic outbreak will last about 6 to 8 weeks. Multiple waves (periods during which community outbreaks occur across the country) of illness could occur with each wave lasting 2-3 months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty. When the influenza pandemic first reaches the state of increased and sustained transmission in the general population, there will be no vaccine against the specific strain of influenza for 4-6 months. An influenza pandemic can: Occur at any time. Require significant communications and information sharing across jurisdictions and between the public and private sectors. Involve multiple geographic areas. Impact critical infrastructures. Overwhelm the capabilities of local and tribal governments. 6

7 Require short-notice asset coordination and response timelines. Require prolonged, sustained incident management operations and support activities There are a few additional planning assumptions that are specific to Minnesota regional response planning. Minnesota s regions plan and prepare for health emergencies regionally under the guidance and direction of the MDH. During any health emergency, the MDH district office response teams will work as liaisons with local public health departments to communicate local needs and state direction. 3. Legal Authority As the lead public health agency in the state, the MDH is responsible for protecting, maintaining, and improving the health of all Minnesotans. There is a strong state-local partnership where the MDH provides leadership and direction to front-line public health and private healthcare entities. Lake County Public Health will take the lead technical role, under the guidance of MDH, in Lake County. Lake County Emergency Management will be the lead coordinating agency in a pandemic influenza outbreak, and will work closely with Public Health in preparation and response to the flu. Chapter 12 of Minnesota Statutes grants the Governor and Homeland Security and Emergency Management (HSEM) overall responsibility of preparing for and responding to emergencies and disasters. Chapter 12 directs the Governor and HSEM to develop and maintain a comprehensive state emergency operations plan, known as the Minnesota Emergency Operations Plan (MOEP). Furthermore, Minnesota Statutes, including Minnesota Chapter 12 (Minnesota Emergency Management Act) Minnesota Chapter 144 (General Duties of the Commissioner of Health), Minnesota Chapter 145A (Powers and Duties of a Community Health Board) and Chapter 157 outline the authorities of local public health agencies and grant the Commissioner of Health broad authority to protect, maintain, and improve the health of the public. In a pandemic, the Commissioner of Health may delegate responsibility to Lake County Public Health to protect the health of the jurisdiction s residents and visitors. 4. Pandemic Severity and Pandemic Timelines and Triggers Since 2007, the HHS and Centers for Disease Control and Prevention (CDC) have been using the pandemic Severity Index (PSI) to categorize the response needed to a pandemic flu outbreak. The CDC (Director) will designate the PSI with five categories of increasing severity based on the estimated case fatality ratio (this ratio reflects the percent of people with disease who have died from the disease). A category five pandemic would be a severe pandemic. This category will be determined early and revised as needed throughout the pandemic. Additionally, other epidemiologic features that may be used to determine pandemic severity (when available) are: total illness rate, age-specific illness and mortality rates, the reproductive number, intergeneration time, and incubation period. 7

8 Figure 1: Pandemic Severity Index Case Fatality Ratio Projected Number of Deaths* U.S. Population, 2006 >2.0% Category 5 >1,800, <2.0% Category 4 900,000 - <1,800, <1.0% <0.5% <0.1% Category 3 Category 2 Category 1 450,000 - <900,000 90,000 - <450,000 < *Assumes 30% Illness Rate Table 3: Pandemic Severity Index Characteristics Case Fatality Ratio (percentage) Excess Death Rate (per 100,000) Illness Rate (percentage of population) Potential Number of Deaths (based on 2006 U.S. population) 20 th Century U.S. Experience Pandemic Severity Index (PSI) Category 1 Category 2 Category 3 Category 4 Category 5 < < < <2.0 >2.0 < < < <600 > <90,000 Seasonal Influenza (illness rate 5 20%) 90,000 - <450, ,000 - <900,000 90,000 - <1.8 million 1957, 1968 None None >1.8 million 1918 Pandemic Intervals, Triggers, and Actions (ITA) In 2008, the CDC released an interim guidance document on the use of Intervals, Triggers, and Actions in CDC Pandemic Influenza Planning. The ITA guidance introduces a conceptual framework to guide pandemic influenza preparedness and response activities at the national, state and local level. This framework will facilitate better coordinated and timelier strategies at all levels, while acknowledging the heterogeneity of conditions affecting different U.S. 8

9 communities during the progression of a pandemic. (For more background on Pandemic planning phases, see Appendix A.) Minnesota Intervals, Triggers, and Actions MDH intends to use the interval triggers in Table 4 for pandemic influenza response actions, though available epidemiologic data, (e.g. illness rates, age-specific morbidity and mortality rates, reproductive number, intergeneration time, and incubation period) will inform timing of response actions in an influenza pandemic. MDH is modifying the CDC interval onset definitions in order to (1) take a slightly more aggressive approach to the timing of community mitigation response actions, and (2) move away from laboratory specimen definitions (proportion of specimens from patients with influenza-like illness who are positive for the pandemic strain) since the volume of laboratory testing in a pandemic will be insufficient to assess pandemic progression and deceleration in the state. Table 4: Minnesota Trigger Definitions Interval Investigation Recognition Initiation Acceleration Peak Minnesota Trigger Identification of human case of potential novel influenza A infection in the state OR Identification of animal case of influenza A subtypes with potential implications for human health within the state Confirmation of human cases of novel influenza A and demonstration of efficient and sustained human to human transmission anywhere in the world (Minnesota is using CDC s national trigger definition instead of the state trigger definition where recognition occurs in the state only if the first recognition that a pandemic has emerged occurs in that state). A laboratory confirmed case of pandemic influenza detected in Minnesota or its contiguous states (North Dakota, South Dakota, Iowa, and Wisconsin) (CDC does not include contiguous states in its trigger definition). One or two laboratory-confirmed cases in Minnesota that are not epidemiologically linked to any previous case OR Number of cases exceed the resources necessary for case/contact-based control measures OR A significant exposure has occurred in a setting where a large number of individuals cannot be identified for case/contact-based control measures OR There are indications that case/contact-based control measures are not effective (CDC uses the first two criteria as triggers). Widespread transmission with a level, but high number of new cases and resources exceeded in most areas of Minnesota (CDC trigger focuses on proportion of laboratory confirmed cases for specimens from patients with ILI, or regional activity per current CDC surveillance criteria or health care surge capacity exceeded). 9

10 Deceleration Resolution Number of new cases drops from peak level for at least two consecutive weeks (CDC trigger focuses on proportion of laboratory confirmed cases for specimens from patients with ILI and health care system is below surge capacity). Cases without an identified household exposure are sporadic per CDC influenza surveillance criteria. MDH will determine that the state has met the trigger (cases without an identified household exposure are sporadic ) through case-based reporting which will be re-instituted once the number of new hospitalized cases drops to 10% of cases occurring at the pandemic peak. (CDC trigger is laboratory confirmed cases are occurring sporadically or the health care system is approaching pre-pandemic levels). 5. Ethical Framework Lake County and MDH accept the ethical framework developed by the Minnesota Pandemic Ethics Project of the Minnesota Center for Health Care Ethics and the University of Minnesota Center for Bioethics. This project s purpose is to propose ethical frameworks and procedures for ethically rationing scarce health resources, including antiviral medications, N95 respirators, surgical masks, vaccines, and mechanical ventilators, in a severe pandemic. These ethical frameworks are based upon four elements: ethical commitments, principles, goals, and strategies, and may be summarized as follows. Commitments: The common good for all Minnesotans will be pursued in ways that: Are accountable, transparent and worthy of trust Promote solidarity and mutual responsibility Respond to needs fairly, effectively and efficiently Principles: Resources will be stewarded to promote Minnesotans common good by balancing three equally important ethical principles: Protect the population s health Protect public safety and civil order Treat people fairly, recognizing the moral equality of all Goals: Protect the population s health Reduce mortality and serious morbidity Protect public safety and civil order Reduce disruption to the basic health care, public health, public safety and other critical infrastructures Promote public understanding about and confidence in the distribution of health care resources Fairness Reduce significant group differences in mortality and serious morbidity Make reasonable efforts to remove barriers to fair access Reciprocate to groups accepting high risk in the service of others Reduce significant differences in opportunities to live a normal lifespan Promote equitable access through fair random processes for individuals equally prioritized 10

11 6. Vulnerable Populations The Lake County Pandemic Influenza plan will include consideration of minority and vulnerable populations within the county. These populations include but are not limited to children, the elderly, non-english speakers, those with physical, mental, developmental or emotional disabilities, those who are isolated by remote locations or insufficient transportation, economically disadvantaged, pet owners, or religions or ethnic restrictions. Special consideration will be given to providing adequate communications, supervision, transportation and other resources as needed to serve all populations and residential or care facilities. 7. Continuity of Operations Continuity of local government operations and services during a pandemic will follow the guidelines set forth in the Lake County Continuity of Operations Plan. 11

12 Technical Chapter A Public Health Communication Plan Lake County Public Health will insure that its communications systems from the local Health Alert Network to redundant daily communication modes are up to date. Triggers for pubic health care communication may include vaccination planning, surge situations, flu center activation, mass dispensing activities, etc. Communications plans for health care providers and the public will follow protocols and public information/notification guidelines in the all-hazard Lake County Emergency Operations Plan. Tactical Communications Options include: HAN statewide and local Phone, , satellite phone GETS (Government Emergency Telecommunications Service) priority phones are available in the Lake County Emergency Operations Center (EOC) if necessary Public safety radios RACES (Radio Amateur Civil Emergency Services) can be activated through Lake County Emergency Management The Emergency Contact List Supplement to the Lake County EOP will include: Hospitals Practitioners & Clinics Long-term care and Home Care Group homes and Treatment Centers Regional Networks (NE Regional MAC) Adjacent jurisdictions (Cook and St. Louis County and MDH contacts) Public Information and notification: Lake County Public Health, in cooperation with the Emergency Manager and Public Information Officer, will identify the messages that need to be developed and disseminated based upon the extent of the flu outbreak. More information on public information and media contacts, protocols and plans is available in the all-hazard Lake County Emergency Operations Plan (EOP) Basic Plan under public information/notification. Emergency contact lists (including media contacts) are included as a supplement to the EOP. While talking points and fact sheets will be provided by MDH using CDC and state guidelines, Lake County will prepare formats, contacts, and local information in advance, and will review public information guidelines in the Lake County Emergency Operations Plan (EOP). Together, they will determine: Who needs to be notified What communication medium(s) should be used How quickly does the message need to be delivered to those target populations What is the message Who will deliver the message Are the messages effective and reaching the desired populations Following is a list of potential public information and notification options. Nixle public notification system ISD 381 Instant Alert messaging system NOAA weather radio emergency alert system. Media releases including radio, television and newspaper Press Conferences State (MDH) or local phone Hotlines Displays and Fact Sheets 12

13 Technical Chapter B: Epidemiological Surveillance This chapter is currently optional (in 2009) and will be added when guidance becomes available from the Minnesota Department of Health. Technical Chapter C: Community Mitigation Intervention Plan Community Mitigation Intervention (CMI) measures, also known as non-pharmaceutical interventions, are aimed at slowing or limiting the transmission of the pandemic virus by limiting social interaction rather than on medication or vaccination. It is assumed that these measures will be voluntary, but highly recommended. In the event that legal order becomes necessary, Ramsey County District Court, by Minnesota statute, has statewide jurisdiction for isolation and quarantine actions in Minnesota. Should Lake County determine to initiate CMI measures ahead of state recommendations, Lake County Public Health or Emergency Manager will notify the NE regional in order to assure clear communication and consistency across jurisdictions. Mitigation Measures by Pandemic Severity CDC has issued interim recommendations for use of community mitigation measures matched to pandemic severity. In a severe pandemic, community mitigation measures would be more intense than if the pandemic were mild. These recommendations are depicted in the following table. Further, more information on CMIs, including definitions and explanations, can be found in Appendix 3. Interventions by Pandemic Severity Pandemic Severity Index Interventions by Setting 1 2 and 3 4 and 5 Home Voluntary isolation of ill at home (adults and children); combine with use of antiviral treatment as available and indicated Recommend Recommend Recommend Voluntary quarantine of household members in homes with ill persons (adults and children); consider combining with antiviral prophylaxis if effective, feasible, and quantities sufficient Generally not recommended Consider Recommend School: Child social distancing Dismissal of students from schools and school based activities, and closure of child care programs Generally not recommended Consider <4 weeks* Recommend <12 weeks* Reduce out-of school social contacts and community mixing Generally not recommended Consider <4 weeks* Recommend <12 weeks* Workplace/Community: Adult social distancing Decrease number of social contacts (e.g., encourage Generally not Consider Recommend 13

14 Pandemic Severity Index Interventions by Setting 1 2 and 3 4 and 5 teleconferences, alternatives to face-to-face meetings) recommended Increase distance between persons (e.g., reduce density in public transit, workplace) Generally not recommended Consider Recommend Modify, postpone, or cancel selected public gatherings to promote social distance (e.g., postpone indoor stadium events, theatre performances) Generally not recommended Consider Recommend Modify work place schedules and practices (e.g., telework, staggered shifts) Generally not recommended Consider *These are estimates and based on assumptions about the length of a pandemic wave. Recommend Technical Chapter D: Infection Control This chapter is currently optional (in 2009) and will be added when guidance becomes available from the Minnesota Department of Health. Technical Chapter E: Clinical Issues This chapter is currently optional (in 2009) and will be added when guidance becomes available from the Minnesota Department of Health. Technical Chapter F: Healthcare Planning This chapter is currently optional (in 2009) and will be added when guidance becomes available from the Minnesota Department of Health. 14

15 Technical Chapter G: Asset Distribution Plan of antiviral medications and personal protective equipment (PPE) MDH guidance on distribution of Minnesota Asset Caches to assist with H1N1 Response (Draft 1: July, 2009 This document will be continually updated as situation evolves) Introduction This guidance is to assist planning partners with the request, distribution and use of Minnesota Asset Caches (MACache). The caches consist of pharmaceuticals and personal protective equipment. While these assets can be used for various incidents, this guidance will address the current H1N1 Flu outbreak. Antivirals The Minnesota Department of Health (MDH) considers the use of antiviral drugs as one component of a comprehensive containment and treatment plan to assist in the control of an outbreak of a novel influenza virus with pandemic potential. The use of antiviral drugs serves to complement Community Mitigation Interventions (Chapter C) and other non-pharmaceutical interventions. Limited supplies of antiviral drugs (Oseltamivir and Zanamivir) were purchased by the MDH and the federal government (Strategic National Stockpile (SNS) cache. For planning purposes, these assets have been combined to make up the MACache. These antivirals are earmarked for specific use during an outbreak of novel influenza, specifically to be used as a backup supply for antivirals when they are no longer available through normal supply chains (e.g., community pharmacies for prescriptions, distributors for hospitals). Normal supply chains will continue as sources of antivirals for citizens and health care facilities through normal processes. Since the cache for Minnesota is small compared to the Minnesota population, the MDH developed these guidance and recommendations. Currently, the MDH has distributed 10% of its 25% allotted SNS antivirals to all 8 of the public health regions at Regional Placement Sites (RPS). This was an interim decision to speed up the delivery process during the Spring 2009 response of H1N1. These assets are still located in these RPS but MDH is open to further consideration of regional redistribution on a case by case basis. Primary Goals of the Distribution System: To strategically place federal and state caches of antiviral drugs in areas that do not have, have exhausted, or will soon exhaust normal supply chains; To ensure a mechanism to identify persons in priority target groups for antiviral distribution using MDH Clinical Guidelines and; To distribute in a timely manner utilizing current systems Minnesota has planned for as much as possible. Clinical Guidelines: These clinical guidelines for use are consistently aligned with the guidelines established by the Centers for Disease Control and Prevention and are constantly under review at MDH by infectious disease Personnel. Because this is subject to change according to the disease severity, they will not be listed in this guidance. Updated information regarding this can be found at: Assumptions for Asset Distribution Planning: Correct use of non-pharmaceutical intervention strategies will decrease the need for prophylaxis The number of antiviral courses is limited and must last throughout the current outbreak and possibly subsequent waves There may be potential for a change in influenza virulence and transmissibility over time 15

16 Individuals who are ill and prescribed antivirals by physicians will obtain them through their regular channels or through flu centers when activated by Lake County There are priorities for the antiviral distribution based on CDC priorities Request for antiviral supplies will follow the established process for requesting resources Opportunity to access resources should be assured to local health departments consistent with population and level of influenza activity (supplying of heath care providers within communities when normal supply sources are no longer available is the responsibility of local health departments) Commitment to fair distribution of resources by making sure assets will be available to someone in need within a reasonable driving and/or walking perimeter of dispensing sites Current Policies for Antivirals Assets are only available after all other resources have been exhausted. This includes use of vendors that a facility is not under normal contract with. Assets may not be assessed any value or cost. *An administrative fee is permitted*. Assets will be prescribed and dispensed to patient through normal physician/pharmacy channels. This could include hospitals, clinics, pharmacies and flu centers when activated. Local health departments will not currently prescribe or dispense to individual patients. Local health departments will lead partnership planning for their jurisdictions and/or as a public health region in asset distribution. Further discussion is taking place with CDC at this time on this issue. More information is expected in the future. Distribution of Antiviral Caches: It is the role of Lake County Public Health to distribute medical supplies during a public health emergency. The MDH will follow current planning strategies associated with medical material distribution as closely as possible. While the intent is to honor this system, other scenarios may evolve during an event and the distribution plan will need to be adjusted to accommodate the needs to of the region/community. Lake County Public Health will coordinate with the NE MN regions regarding the ship to site for antivirals. Once delivery sites are identified, service agreements* will be signed between the local health department and the site. Sites may be pharmacies, clinics, and/or hospitals. (*A service agreement template is currently under legal review and will be released soon.) The following items will be considered regarding distribution: Where are the regional storage facilities? Who are our prescribing and dispensing partners? What are the burdens/access barriers in our current plans? Obtaining MACache Assets: The process for obtaining the MACache assets will follow normal communication and request systems during a public health event Antiviral Asset Requests 1. Local prescriber/dispenser goes to fill a prescription request. 2. There is no asset available in their facility. 3. They contact their facilities contracted and non-contracted vendors to fill supply. 4. There is still no supply available. They contact their local public health department or regional contact (depending on what is planned for their jurisdiction) 5. Region is contacted; supply is still not available. 6. Region contacts MDH DOC if they are open or the emergency on call number at to report shortage and need. 7. MDH releases asset verbally if located in region or begins a shipment process from MDH. 16

17 PPE Asset Requests: The process for PPE will be similar to antivirals. 1. Local healthcare facilities run low on PPE.. 2. They contact their facilities contracted and non-contracted vendors to fill supply. There is still no supply available 3. They contact their local public health department or regional contact (depending on what is planned for their region). 4. Region is contacted; supply is still not available. 5. Region contacts MDH DOC if they are open or the emergency on call number at to report shortage and need. 6. MDH releases asset verbally if located in region or begins a shipment process from MDH. 17

18 Technical Chapter H: Vaccination Distribution Plan Introduction This guidance is provided to assist MDH partners with planning activities to distribute vaccine and provide immunizations for the current H1N1 novel influenza situation. While these guidelines utilize current knowledge of H1N1 influenza virus as well as vaccine manufacturing capabilities, the roles and responsibilities will apply to a future novel influenza virus outbreak. MDH considers vaccination delivery one component of the overall plan to minimize morbidity and mortality, and to protect critical infrastructure and key resources when the pandemic influenza threatens social disruption. Vaccination delivery consists of two major activities: 1) vaccination and follow-up of appropriate targeted individuals according to the MDH and CDC guidelines and 2) distribution of vaccine and ancillary supplies and resources within the time parameters established by the incident objectives that maximize the impact of #1. Multiple factors influence the implementation and outcomes of vaccination delivery. Characteristics of the targeted population(s), vaccine manufacturing capacity, vaccine distribution capacity, requirements for multiple doses, the risk of adverse events and other factors require ongoing modification of response actions. The availability and readiness of resources that can effectively implement the required activities also impact the outcome. The efficiency, capacities and accessibility of vaccinating organizations in addition to the appropriate vaccine administration, documentation, patient education, vaccine handling and other activities help assure that resources are used effectively. The ability of public health to monitor and control the progress and measures of vaccination delivery is critical to the effectiveness of an H1N1 vaccination response. While disease surveillance and immunologic response will be utilized to gauge population and individual effectiveness, intermediate situational assessment and control of the implementation methods will enable public health to apply resources to meet needs and to quickly respond to changing targeting and temporal criteria. Both MDH and local and tribal health departments have responsibilities in situational assessment and adapting the use of resources to accomplish goals. Primary goals of vaccination delivery Safe and effective administration of vaccinations to the targeted populations within the established time frames. Distribution of vaccine and supplies and management of vaccinating organizations, volunteers and other resources to meet jurisdictional needs. Maintenance of systems that facilitate vital situational awareness for state and local public health and supplemental activities, e.g. reporting and tracking of adverse events, immunization documentation for 2 nd dose follow-up and immunization coverage reports and inventory tracking. MDH Working Assumptions apple Vaccine will be purchased by the federal government and provided to Minnesota. The vaccine will remain a state asset until administered to individuals. apple Planning and response activities will utilize the framework of emergency preparedness and its apple systems, e.g. ICS, NIMs, emergency planning, training and exercising. Local health departments will be responsible for assuring vaccination coverage of the population, which includes occupational and general population and high risk groups, in their jurisdiction. apple The current vaccine distribution system consists of one ship-to site designated by each local health department and tribal health department with further redistribution managed by the 18

19 individual sites. However, CDC is anticipating a change that will allow multiple distribution sites per jurisdiction. apple While the private sector can contribute to vaccination efforts, it is unclear at this time how much of the vaccination effort the private sector will be able to take on. It is anticipated that vaccine will be administered through a combination of public and private sites. apple The process for identifying, engaging, controlling and utilizing traditional and non-traditional immunization providers under a new distribution system is pending. apple Local health departments are responsible for maintaining awareness of provider activities in their jurisdictions to avoid duplication of efforts and to address gaps. apple Local health departments will be responsible for developing and managing resources to accomplish vaccination delivery. apple Local health departments will play a specific key role in coordinating the vaccination of occupational target groups. Employers of workers in targeted groups will be responsible for identifying workers that fit the target criteria and providing the information to the local health department or the designated vaccinating organization. apple apple MDH will provide the criteria and standards that will be utilized by all organizations administering vaccinations and/or managing vaccine. Guidelines and information for vaccinating organizations will be posted at: vaccine/index.html Planning guidance and tools for the use of local and tribal health departments will be posted on the MDH Workspace >> SNS >> Mass Dispensing >> Pandemic Influenza. CDC Planning Assumptions & Scenarios, July 8, 2009 MDH is planning for vaccine distribution under the umbrella of CDC planning assumptions and planning scenarios. These planning scenarios are not official ACIP recommendations but provide direction for state and local planning based on current assumptions. The scenarios are based on the following assumptions at the time vaccine becomes available and distribution begins: 1. severity of illness is unchanged from what has already been observed 2. risk groups affected by this virus do not change significantly 3. vaccine testing suggests safe and efficacious product 4. adequate supplies of vaccine can be produced 5. no major antigenic changes are evident that would signal the lack of likely efficacy of the vaccines being produced Target Populations Primary Venues LPH Considerations/Issues Students and staff (all ages) associated with schools (K-12th grade) Children (age 6 months) and staff (all ages) in child care centers Pregnant women, children 6 months 4 years of age, new parents and household contacts of children <6 months of age. Non-elderly adults (age <65 years) with medical conditions that increase the risk of complications of influenza. schools child care centers Provider offices, community clinics. Occupational settings, community clinics, pharmacies, providers offices. On-site vaccine clinic is planned. Public vaccine clinic target to this group is planned during the same week as the school clinic. Vaccine will be provided on WIC clinic days near the same clinic. Primary clinics in Two Harbors and Silver Bay will service this group. 19

20 Target Populations Primary Venues LPH Considerations/Issues Health care workers and emergency services sector personnel (regardless of age). Vaccine Availability Considerations Occupational settings, providers offices. Primary clinics in Two Harbors and Silver Bay will service this group. If vaccine becomes widely available, CDC would recommend offering vaccine at multiple venues to anyone who wants to be vaccinated. Although the benefits of vaccine may be greatest in the persons in groups at increased risk, and interest in being vaccinated may be lower among the general population, offering vaccine to everyone can reduce the risk of influenza for general population may reduce transmission to unvaccinated persons. At the same time, if vaccine supply is limited, it will be important to consider a balance between international needs for vaccine in relation to the vaccination of low risk individuals in the United States. Pandemic Vaccine Program Planning Elements for LPH Vaccination Planning/Preparedness Activity 1. Develop core planning team 2. Plan for projected amount of vaccine allocated for jurisdiction 3. Identify & organize target groups and the measures utilized for their vaccination 4. Coordinate writing of the medical protocol (standing order) by the local medical director for H1N1 vaccination for health dept. immunizations 5. Determine models for administration of vaccine: a) Agency administration or b) delegation to another agency 6. Organize Mass Dispensing Clinics (for general population) 7. Organize vaccination teams (for designated non-medical groups such as law enforcement or schools) 8. Delegate vaccination to organizations that have employees in a target group that can vaccinate themselves and also to clinics or organizations that could vaccinate a target group such as pregnant women. Resources Projected Minnesota Shipment Allocations (Workspace & Appendix 3) Pandemic Target Group Worksheet (Workspace) MDH will provide the clinical guidelines for prescribing vaccine. MDH may also providing a sample medical protocol and a screening form that would include the required data fields Mass Dispensing Plans; Planning documents on workspace Mass Dispensing Plans; Planning documents on workspace Encourage potential vaccination providers to pre-register on an MDH web site. The list of potential clinics will be shared with local health departments. Model MOAs will be posted or the MOA will be implemented between the clinic and MDH Respon si-bility of: LPH LPH LPH LPH LPH LPH LPH LPH Local Considerations & Issues Include Emergency Mgmt Coordinator Follow MDH guidelines Follow MDH guidelines LPH will follow MDH protocol LPH and SuperiorHealth will administer See Mass Dispensing Plan See Mass Dispensing Plan MOA in process 20

21 Vaccination Planning/Preparedness Activity 9. Contact school administrators and school nurses to begin planning for school based clinics 10. Coordinate vaccination plans with flu center planning. 11. Determine supply and equipment needs. 12. Organize and train volunteers Resources School associated clinics can included a variety of models including local public health, health systems, and/or community vaccinating teams (or a combination of these) providing coordination, staff and volunteers. MDH Flu Center and Mass Dispensing staff SNS will provide syringes, alcohol swabs, and sharps containers Provide pre-training on mass dispensing sites, blood borne pathogens, vaccine administration and entering data into MIIC. Respon si-bility of: LPH LPH LPH LPH Local Considerations & Issues Planning in process Planning in process Planning in process Planning in process This table details the roles and responsibilities of local public health and MDH during the pandemic vaccination program. Pandemic Flu Immunization and Vaccine Management Public Health Roles and Responsibilities Activity State Local Community/ Population Assessment Prophylaxis strategies and methods Campaign planning Preparedness: Provide baseline population data. Provide framework including definitions and models of special needs populations. Response: Provide guidance on target populations for receipt of countermeasures. Preparedness: Provide guidance and framework for specific strategies based on federal guidance and state needs. Provide the framework and materials for delegating the immunization function to other institutions. Response: Develop and maintain incident objectives for a consistent state response based on the national strategy and current situation; convey to local health departments. Preparedness: Provide guidance for elements specific to pandemic flu vaccine security, vaccine volume planning scenarios, vaccine storage and distribution, infection control, patient triage, etc. Preparedness: Describe the jurisdiction s population including size and vulnerabilities. Enumerate priority groups. Identify populations reachable through methods external to mass dispensing sites. Response: Consider the specific needs of the community with the implementation of the incident strategies and tactics. Preparedness: Identify, plan, and exercise methods and strategies appropriate to the community for administering vaccinations. Develop agreements and operational plans for delegation of vaccination to local institutions employing priority group members. Response: Choose strategies based on the target population, the incident objectives, and the resources available. Preparedness: Procure sites, develop site specific plans including security; client, staff, and supply flow. Identify, enumerate, and train staff and volunteers. Pre-roster key positions. Develop workforce deployment, monitoring, and demobilization plan. 21

22 Activity State Local Resources Policy, protocols, and legal issues Tracking and monitoring Critical infrastructur e or mission critical personnel Response: Provide incident parameters and objectives (timelines, target groups, etc.). Monitor event and CDC recommendations and revise guidance as appropriate. Preparedness: Maintain distribution plans for resources accessed by the state including vaccine and syringes. Develop and maintain systems to track resources. Response: Coordinate the distribution and tracking of state and federal assets. Preparedness: Develop policies and procedures, including immunization protocols, for statewide consistency. Response: Facilitate resolution of policy or legal obstacles to the response as they arise. Preparedness: Develop and maintain tracking systems and protocols for medical countermeasure inventory, vaccine administration, and adverse event monitoring. Provide education and materials to users. Response: Implement tracking systems and provide instructions and parameters to users. Compile reports. Preparedness: Formulate guidance for prioritization and allocation of vaccine for local use. Provide definitions of priority groups. Response: Monitor appropriate utilization of guidance. Revise guidelines when appropriate for incident objectives. Response: Activate plan and provide immunizations according to the incident objectives. Preparedness: Identify supplies, equipment computer and communications, and medications and/or vaccine (and syringes) needed. Plan for procuring, storing, and managing and tracking resources. Response: Coordinate resource distribution with the state and with supply recipients. Track resources using state systems. Preparedness: Identify state protocols and policy and integrate into plans. Identify local gaps and issues. Response: Identify policy gaps or issues and facilitate coordination of resolution. Preparedness: Identify state method of tracking and monitoring countermeasures, throughput and adverse events and integrate into planning. Train staff. Response: Assure systems, hardware, staff and protocols are available. Implement tracking functions and provide data and reports to the state as requested. Preparedness: Identify and enumerate according to MDH definitions. Coordinate with local institutions for further stratification or prioritization of groups. Develop a plan for prophylaxis of identified critical infrastructure including methods of notification and identification at site. Utilize delegation of immunization as described under Prophylaxis Strategies and Methods. Response: Assure appropriate utilization of prioritization and critical infrastructure guidance. From MDH Pandemic Influenza Immunization and Vaccine Management Annex, March 2008 See Appendix 5 for more resources on pandemic vaccination programming. 22

23 Technical Chapter I: Laboratory This chapter is currently optional (in 2009) and may be added when guidance becomes available from the Minnesota Department of Health. Technical Chapter J: Poultry/Swine Worker Health This chapter is currently optional (in 2009) and may be added when guidance becomes available from the Minnesota Department of Health. Technical Chapter K: Care of the Deceased This chapter is currently optional (in 2009) and may be added when guidance becomes available from the Minnesota Department of Health. For most cases, procedures for care of the deceased are outlined in the all-hazards Lake County Emergency Operations Plan (EOP) under Emergency Support Annex 8: Health and Medical Functions. 23

24 Technical Chapter L: Flu Centers The development and implementation of Flu Centers is a statewide strategy for Minnesota. Flu Centers are designed to integrate community wide interventions such as anti-viral distribution with a surge of moderately ill citizens to a stressed health care system. The Flu Center strategy has been designed as a collaboration between health care, public health, and other partners on a community basis. Flu Center Planning Element Explanation Enter data for each Flu Center in jurisdiction) Community Names: Local health departments should reproduce the summary chart if their jurisdiction contains more Two Harbors Comm Silver Bay Reunion Isabella Comm Center than four flu centers. Center Hall Advisory Committee Formed? Was an Advisory Committee Lead Agencies 1. Lake County Public Health 2. Lake County Emergency Management 3. Lake View Hospital 4. Lake View Clinic Contact Information Available Flu Center Services Delineated 1. Triage 2. Vital Sign Monitoring 3. IV Fluids 4. Anti-virals 5. Flu Symptom Kits Triggers for Opening Flu Center 1. Adequate hospital/clinic staff 2. Number of requests for help from community 3. Schools closing Sites determined (insert Address) and signed MOUs available (Y/N) Command Structure determined (Y/N) Flu Center Layout and Flow Delineated (Y/N) Staffing Plan Complete (Y/N) Infection Control Plan Complete (Y/N) Transportation Plan Complete (Y/N) Security / Traffic Control Plans Complete (Y/N) formed? Y Y y List the cooperating local health departments and health care facilities (and others if applicable) Has contact information been compiled? Y Y Y What services (for example triage, antiviral distribution, education and referral) will the local flu center provide? Y Y Y What will be the criteria for opening the local flu center (for example, surge in emergency department visits, phone lines jammed)? Y Y Y List the flu center site name and address and state if the MOU for its use is in place N N N Has the Incident Command structure been finalized? N N N Has the flu center layout and flow been diagrammed? N N N Has staffing been determined (components of MRCs, Health Care, Public Health, other)? N N N Has an Infection Control (including PPE resourcing) been developed? N N N Is there a plan for transporting ill patients, populations with mobility problems, etc? N N N Has law enforcement collaborated on the planning? Will there be adequate parking? N N N 24

25 Technical Chapter M: Regional Coordination Many of the Minnesota Pandemic Influenza strategies are designed to use regional coordination through Multi-Agency Coordination (MAC) systems/groups. Lake County Public Health and MACs will be in close collaboration throughout the planning and response periods. Strategies for rapid communication and decision-making (such as the use of MN Trac Coordination Centers) will be tested in advance of the pandemic acceleration. During an incident or emergency when Lake County Public Health is in need of further resources or assistance, the Lake County Emergency Manager will be contacted as well as the Northeast Public Health Preparedness Consultant, Marilyn Cluka (noted below) and/or NE-MAC ( ) who, in turn, will notify the Minnesota Department of Health. For a list of Pandemic Influenza contacts, please see the Pan Flu Contact List under the Emergency Contacts Supplement to the Lake County Emergency Operations Plan. 25

26 Appendices Appendix 1. Background Information on Intervals, Triggers, and Actions ITA Background Global Preparedness Planning WHO Phases The WHO has defined six phases, occurring before and during a pandemic, that are linked to the characteristics of a new influenza virus and its spread through the population. These phases are described below: Inter-Pandemic Period Phase 1: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human disease is considered to be low. Phase 2: No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease. Pandemic Alert Period Phase 3: Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact. Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk). Pandemic Period Phase 6: Pandemic phase: increased and sustained transmission in general population. U.S. Preparedness Planning U.S. Stages In the U.S. government s approach to the pandemic response, it is more useful to characterize the stages of an outbreak in terms of the immediate and specific threat a pandemic virus poses to the U.S. population. The following stages provide a framework for federal government actions: Stage 0: New Domestic Animal Outbreak in At-Risk Country Stage 1: Suspected Human Outbreak Overseas Stage 2: Confirmed Human Outbreak Overseas Stage 3: Widespread Human Outbreaks in Multiple Locations Overseas Stage 4: First Human Case in North America Stage 5: Spread throughout United States Stage 6: Recovery and Preparation for Subsequent Waves Minnesota Preparedness Planning Minnesota Phases The Minnesota HSEM developed the Minnesota Response Phases to provide a standard framework for the State of Minnesota s response to an influenza pandemic. The Minnesota phases are as follows: MN Phase PO: Suspected Human Outbreak Overseas MN Phase P1: Confirmed, Sustained, Human-to-Human Transmission Overseas MN Phase P2: Suspected or Confirmed Human Case in North America MN Phase P3: Outbreak in United States MN Phase P4: Suspected or Confirmed Human Case in MN MN Phase P5: Limited Outbreak in MN MN Phase P6: Widespread Throughout MN MN Phase P7: Recovery and Preparation for Subsequent Waves 26

27 U.S., and State Preparedness Planning Intervals, Triggers and Actions The Intervals, Triggers and Actions conceptual framework is based on a model epidemic curve. For the purposes of pandemic preparedness, CDC is using seven intervals to represent the sequential units of time that occur along a hypothetical pandemic curve. For state planning, use of the intervals to describe the progression of the pandemic provides a framework for defining when to respond with various actions and interventions during U.S. Government stages 4, 5 and 6. The strategies are aligned with the: World Health Organization (WHO) phases of a pandemic. United States stages of a pandemic. United States pandemic intervals as modified for use in Minnesota. In actual practice, the distinction between the various phases, stages, or intervals of an influenza pandemic may be blurred or shift in a matter of hours, which underscores the need for flexibility. The timing and scope of actions ultimately must be based on available scientific and epidemiological data at the time a pandemic occurs. The U.S. stages provide a high-level view of pandemic activity in the nation. The CDC intervals recognize that the progression of a pandemic likely will occur asynchronistically across the United States, affecting states at different times. Consequently, the intervals are geared to states determining the imminence of a pandemic threat in their jurisdiction in order to trigger response actions. CDC has defined both national and state triggers for recognizing that a new interval is occurring. In general, and from a state triggers perspective, the intervals as defined by CDC are as follows Investigation (pre-pandemic interval): Sporadic cases of a novel influenza virus occurring overseas or in the United States. A state is affected if it identifies a human case of potential novel influenza A infection or an animal case of influenza A subtype with potential implications for human health within its jurisdiction (though because this is a pre-pandemic interval, the virus is not yet efficiently transmitted human to human). Recognition: Clusters of novel influenza cases in humans and confirmation that a pandemic strain with efficient and sustained human to human transmission has emerged overseas or in the U.S. Initiation: Identification of the first human case of pandemic influenza in the U.S. A state becomes an affected state when it has its first laboratory-confirmed case. Acceleration: A state is affected when increasing numbers of cases exceed resources to provide case-based control measures or the state identifies two or more laboratory-confirmed cases in the state that are not epidemiologically linked to any previous case. Peak: Extensive transmission in the community and a state reaches its greatest number of newly identified cases. (Specific criteria are > 10% of specimens from patients with influenza-like illness submitted to the state public health laboratory are positive for the pandemic strain during a 7-day period; or regional activity is occurring in the state using CDC surveillance criteria; or the health care system surge capacity has been exceeded.) Deceleration: Rates of pandemic infection in the state are declining. (Specific criteria are <10% of specimens from patients with influenza-like illness submitted to the state public health laboratory are positive for the pandemic strain for at least two consecutive weeks or, the health care system is below surge capacity.) Resolution: Pandemic cases in the state are occurring sporadically. (Specific criteria are laboratory-confirmed cases are occurring sporadically, or the health care system is approaching pre-pandemic levels). 27

28 Phases, Stages, Intervals, and Triggers for Pandemic Influenza Response WHO Phase 1: Low risk of human cases 2: Higher risk of human cases 3: No or very limited humanhuman transmission 4: Evidence of increased human-human transmission USG Stage 0: New Domestic Animal Outbreak in At-Risk Country 1: Suspected Human Outbreak Overseas 2: Confirmed Human Outbreak Overseas Minnesota Phases P0: Suspected Human Outbreak Overseas. P1/P2/P3: Confirmed, Sustained Human-to- Human Transmission Overseas; Suspected or Confirmed Human Case in North America; Outbreak in United States. Influenza Interval Investigation of Novel Influenza A Infection in Animals and Humans Recognition of Pandemic Virus Minnesota Trigger Identification of human case of potential novel influenza A infection in the state OR Identification of animal case of influenza A subtypes with potential implications for human health within the state Confirmation of human cases of novel influenza A and demonstration of efficient and sustained human-to-human transmission anywhere in the world National Trigger Identification of animal case of influenza A subtypes with potential implications for human health anywhere in the world Identification of human case of potential novel influenza A infection anywhere in the world Confirmation of human cases of novel influenza A and demonstration of efficient and sustained humanto-human transmission anywhere in the world 28

29 WHO Phase 5: Evidence of significant human-human transmission 6: Efficient and sustained human-human transmission USG Stage 3: Widespread Human Outbreaks in Multiple Locations Overseas 4: First Human Case in North America 5: Spread Throughout United States 6: Recovery Minnesota Phases P4: Suspected or Confirmed Human Case in MN. P5/P6: Limited Outbreak in MN; Widespread Throughout MN. P5/P6: Limited Outbreak in MN; Widespread Throughout MN. P7: Recovery and Preparation for Subsequent Waves. Influenza Interval Initiation of Pandemic Wave Acceleration of Pandemic Wave Peak Deceleration Resolution Minnesota Trigger Laboratory-confirmed case of defined pandemic influenza detected in Minnesota or its contiguous states One or two laboratoryconfirmed cases in Minnesota that are not epidemiologically linked to any previous case Or Number of cases exceed the resources necessary for case/contact-based control measures Or A significant exposure has occurred in a setting where a large number of individuals cannot be identified for case/contact-based control measures Or There are indications that case/contact-based control measures are not effective Widespread transmission with a level, but high number of new cases and resources exceeded in most areas of Minnesota Number of new cases drops from peak level for at least two consecutive weeks Cases without an identified household exposure are sporadic per CDC influenza surveillance criteria. MDH will determine that the state has met the trigger (cases without an identified household exposure are sporadic ) through case-based reporting which will be re-instituted once the number of new hospitalized cases drops to 10% of cases occurring at the pandemic peak. National Trigger Laboratoryconfirmed case of defined pandemic influenza detected within the US At least one state in five of the ten FEMA/HHS regions have met the Acceleration criteria The majority of states have met the Peak/Established Transmission criteria (includes states that have transitioned into the Deceleration Interval) The majority of states have met the Deceleration criteria (includes states that have transitioned into the Resolution Interval) The majority of states have met the Resolution criteria 29

30 MDH Flu Plan Appendix 2 Communication Guidelines These guidelines are incorporated in the all-hazard Lake County Emergency Operations Plan (EOP) under Emergency Support Function 15: External Affairs. Appendix 3--Community Mitigation Intervention Background Information Community Mitigation Interventions Planning Considerations Social Distancing Adult The goal of adult social distancing is to reduce transmission in the workplace and the community at large. In general, workplace social distancing is altering workplace environments and schedules to decrease social density while preserving a healthy and functioning workplace. The goals of workplace measures are to reduce transmission in the workplace (and thus into the community at large); to ensure a safe working environment thereby promoting confidence in the workplace; and to maintain business continuity especially for critical infrastructure. HSEM is the lead state agency for assisting businesses in planning for continuity of operations and workplace social distancing in a pandemic. HSEM issued a Continuation Planning Guide for Businesses and for Local Jurisdictions. MDH developed the health and safety sections of this guidance document including recommendations on workplace social distancing. These documents are located on the HSEM website: HSEM has conducted workshops with businesses and other groups throughout the state to assist them with pandemic planning. Social distancing in office settings may include establishing telecommuting policies, staggered shifts, remote meetings, and prompt exclusion of workers with influenza symptoms. Other actions include promoting hand hygiene and respiratory etiquette, cleaning of workplace surfaces, use of stairs instead of crowded elevators, avoidance of group situations (e.g. meetings and cafeterias), and curtailing face-to-face customer service unless the service is essential to the health of others. Businesses and government entities in which employees typically interact with customers should plan for business methods that modify or eliminated such actions (e.g. limit method for obtaining retail items to phone, fax, or internet, and delivery or pick-up). Social distancing also may include measures such as cancellation or postponement of large public gatherings (e.g. concerts, theater showings, sporting events, stadium events) and modifications to mass transit to decrease passenger density. Individuals also may take measures to decrease their risk of infection by minimizing non-essential social contacts and exposure to socially dense environments. If emergency conditions warrant it, social distancing in a pandemic may also include snow days (including closure of businesses) in which it is recommended or ordered that only critical activities (e.g. essential to health and safety) continue. Requirements for the success of adult social distancing measures include: o Commitment of employers to provide options and make changes in work environments to reduce contacts while maintaining daily operations. o Support from political and business leaders, and the public. Social Distancing - Child Child social distancing consists of dismissal of students from schools and school-based activities, and closure of childcare programs. It also encompasses reduction of out-of-school contacts and 30

31 community mixing. The latter is a critical component of child social distancing since congregating at places other than school could defeat the benefits of school closure in protecting children. Schools and childcare programs represent socially dense environments. Further, children are particularly important in the transmission of influenza viruses. Compared to adults, children usually shed more influenza virus and shed virus for a longer period of time. Schools serve as amplification points of seasonal influenza and children are thought to play a significant role in introducing and transmitting influenza virus in their households. Given the disproportionate contribution of children to influenza transmission, targeting their social networks within and outside of schools would be expected to disproportionately disrupt influenza spread. Schools refers to public and private elementary, middle, secondary, and post-secondary schools (e.g. colleges and universities). The same dismissal recommendations apply to colleges and universities. Colleges and universities present unique challenges because many aspects of student life and activity encompass factors that are common to both the child school environment (e.g. classroom and dormitory density) and the adult sphere (e.g. commuting for class attendance and participating in behaviors associated with an older student population). Requirements for the success of child social distancing measures include: o Consistent implementation among all schools in a region. o o o Commitment of the community and parents to keep children from congregating out of school. Alternative options for the education and social interaction of children. Support for parents and adolescents who need to stay home from work. Strict confinement of children during a pandemic will raise significant problems for many families and may cause psychosocial stress to children and adolescents. These considerations must be weighed against the risk of a pandemic virus to the community at large and to children in particular. In response to the weighing of factors, the risk of introduction of an infection into a group and subsequent transmission among group members is directly related to the number of individuals in the group. Although available evidence does not permit specification of a safe group size, gatherings of children that are comparable to family size units may be acceptable and could be important in promoting emotional and psychosocial stability. If a recommendation for child social distancing is made during a pandemic and families must nevertheless group their children for pragmatic reasons, group sizes should be held to a minimum and mixing between groups should be minimized (e.g. children should not move from group to group or have extended social contacts outside the designated group). Mitigation Measures in Minnesota Key decisions on the scope of community mitigation measures in a pandemic ultimately will be made by the Governor. MDH will use the CDC framework of interventions by pandemic severity index (PSI) as primary guidance for community mitigation recommendations and has, in accordance with this framework, developed potential recommendations for a mild, moderate, and severe pandemic. (see attachments) Cessation of Mitigation Measures in Minnesota When cases without an identified household exposure are sporadic per CDC influenza surveillance criteria, MDH anticipates recommending cessation of community mitigation measures. Cessation of community mitigation measures also will be influenced by the epidemiology of the pandemic virus and availability of vaccine. Each category of measure will be separately considered for mitigation; for example, recommendations for isolation of individuals who meet case criteria are likely to continue even when other recommendations are lifted. MDH may re-institute case-based isolation and quarantine informed in part by the proportion of susceptible individuals in the population and the experience with these case-based measures prior to the acceleration interval. 31

32 Appendix 4-- Asset Distribution (Antivirals and PPE) Additional resources for additional planning resources for Asset Distribution will be available in future on the MDH Workspace. Appendix 5 Vaccination Background Information Planning Scenarios The following are best-case planning scenarios that would be recommended in a setting of limited initial vaccine availability. Target population: Students and staff (all ages) associated with schools (K-12th grade) and children (age 6 months) and staff (all ages) in child care centers. Primary venues: schools and child care centers. Goals: Provide direct protection against illness among persons who have high attack rates of illness, reduce likelihood of outbreaks that may lead to disruptive school dismissals, reduce transmission from schools into homes and the community. Adherence to these guidelines will require state and local authorities to carry out extensive planning to reach school-aged populations either through venues such as school-associated mass vaccination efforts, or, where private capacity is sufficient, through local pediatric providers. Local pediatric care providers may play a particularly prominent role in vaccinating preschool-aged children who have a medical home. These planning efforts will reinforce longer-term immunization targets of strengthening vaccination efforts in these populations, and building links between health and education. The disruptive outbreaks prevalent in schools and some universities in the spring of 2009 may provide impetus for these planning steps to move forward actively. They will also permit strengthening capacity for seasonal influenza vaccination of school-aged children in future seasons. Target population: Pregnant women, children 6 months 4 years of age, new parents and household contacts of children <6 months of age. Primary venues: Provider offices, community clinics. Goal: Reduce complications of novel H1N1 influenza, such as excess hospitalizations and deaths among those vulnerable for serious complications of influenza, as evidenced by higher rates of hospitalization; protect the youngest (<6 months) who are not themselves able to be vaccinated through immunization of their household contacts. Sustaining a focus on pregnant women and young children is appropriate given their high rates of complications and hospitalizations to date, and is consistent with tier 1 prioritization for these groups in pre-pandemic planning. Target population: Non-elderly adults (age <65 years) with medical conditions that increase the risk of complications of influenza. Primary venues: Occupational settings, community clinics, pharmacies, providers offices. (Experience with seasonal influenza vaccine suggests that persons with underlying illness age 50 to 64 years may be more likely to receive vaccine from their provider, while younger persons may be more likely to be vaccinated elsewhere). Goal: Reduce risk of hospitalizations and deaths among persons with higher rates of these complications than the general population, and focus vaccine where its impact can be most beneficial for direct protection. 32

33 The planning requirement to offer vaccine to young adults with risk factors will permit state and local authorities to address a group that does not frequently seek health care and has relatively low rates of vaccination against seasonal influenza. Links with occupational clinics, adult providers, or contingency plans for community venues or pharmacies are all options that might address this important at-risk group. Target population: Health care workers and emergency services sector personnel (regardless of age). Primary venue: Occupational settings, providers offices. Goal: Reduce risk of illness, sustain health system functioning, and reduce absenteeism among front-line providers; reduce transmission from emergency services personnel and health care workers to patients; provide additional worker protection in settings of increased exposure; reinforce importance of influenza vaccination among all health care workers. Vaccine Availability Considerations If vaccine is widely available, CDC would recommend offering vaccine at multiple venues to anyone who wants to be vaccinated. Although the benefits of vaccine may be greatest in the persons in groups at increased risk, and interest in being vaccinated may be lower among the general population, offering vaccine to everyone can reduce the risk of influenza for general population may reduce transmission to unvaccinated persons. At the same time, if vaccine supply is limited, it will be important to consider a balance between international needs for vaccine in relation to the vaccination of low risk individuals in the United States. 33

34 Vaccine Planning Algorithm 34