APPENDIX 16 PANDEMIC FLU

Transcription

1 APPENDIX 16 PANDEMIC FLU PUBLIC HEALTH, DELTA & MENOMINEE COUNTIES Revised: July 2012

2 Date Reviewer Reviewer Plan Review 1/2008 Mark Weber 12/8/2008 Mark Weber 07/18/2012 Dayna Porter, Emergency Preparedness Coordinator RECORD OF CHANGES DATE DOCUMENT/PAGE NUMBER INFORMATION CHANGED INITIALS ii Records of reviews and changes added SLE All Entire document updated for annual review 1/15/2009 Major portion of Document 4/26/11 Surveillance sections 07/18/2012 All Entire document updated to address OPHP review on 2/28/08 updated procedures and forms based on H1N1 flu experience Updated font and reviewed contents for required OPHP submission RLB/ & MW MW SLE DMP Appendix 16 Pandemic Flu Page ii

3 Table of Contents I. Introduction... 6 II. Planning Assumptions... 6 III. Purpose of the Plan... 7 IV. Phases of a Pandemic... 8 V. Agency Responsibilities... 9 A. Federal B. State (MDCH) C. Local (PHDM) VI. Pre Pandemic Phase A. Command and Management B. Risk Communications C. Surveillance D. Laboratory Guidelines E. Community Containment & Infection Control Isolation and Quarantine Social Distancing F. Medical Management G. Data Management H. Border Health and Travel Issues I. Recovery/Consequence Management VII. Pandemic Phase A. Command and Management B. Activation of PHDM Pandemic Response Plan C. Risk Communications D. Surveillance E. Laboratory Guidelines F. Community Containment & Infection Control G. Medical Management H. Data Management I. Border Health and Travel Issues J. Recovery/Consequence Management Appendix 16 Pandemic Flu Page iii

4 VIII. Post Pandemic Phase A. Command and Management B. Risk Communications C. Surveillance D. Laboratory Guidelines E. Community Containment & Infection Control F. Medical Management G. Data Management H. Border Health and Travel Issues I. Recovery/Consequence Management IX. References RESOURCES A. SUPPORTING DOCUMENTS A.1: Pandemic Influenza Manager A.2: Clinical Management Flow Chart A.3: Case Detection (Flow Chart) A.4: HHS Vaccine Tiered Priority Groups A.5: Graded Community Containment Measures A.6: Antiviral Drug Priority Groups A.7: Influenza Case Definition A.8: Fact Sheet on Avian Influenza for Providers A.9: MCIR All Hazards Module Activation A.10: Laboratory Guidelines A.11: Antiviral Therapy A.12: Guidelines for Collection/Sending Lab Specimens A.13 Standing Orders For Antivirals A.14 Medical History Form A.15 Influenza Vaccine Storage Guidelines B. RISK COMMUNICATION INFORMATION B.1: Hand Hygiene B.2: How to Care for Someone with Influenza B.3: Sample Key Massages for Public Health Officials a) What are Pandemic Flu and Avian Flu? b) What Individual Families Can Do c) How to Protect Yourself during a Pandemic d) Do you have Influenza? e) The Best Line of Defense---Personal Hygiene Appendix 16 Pandemic Flu Page iv

5 f) Will There Be Vaccine During a Pandemic? g) The Benefits of Getting a Yearly Flu Shot h) How to Care For Someone at Home i) Sample PSA s for Public Health Officials j) School Closure Press Release B.4: PHDM Instructions During a Pandemic Flu B.5: Pandemic Influenza Public Information Material B.6: Community Mitigation Measures in Michigan C. TRACKING INFORMATION C.1: Influenza like Illness Assessment Form C.2: Contact Tracing Form C.3: Daily Workplace Roster C.4: School Weekly Report of CD to LHD C.5: Overview of Influenza Surveillance D. CONTAINMENT INFORMATION D.1: Policy Example of Exposed or Ill Employees D.2: Telephone Triage for Flu-Like Illness D.3: Infection Control Measures - Providers D.4: Infection Control Measures - Public D.5: Pandemic Severity Indexes Appendix 16 Pandemic Flu Page v

6 I. Introduction This document has been developed to lay out the policies and requirements that need to be addressed when responding to a Pandemic Influenza Incident. An Influenza Pandemic is an epidemic occurring worldwide and usually affecting a large proportion of the population. Pandemics occur when a new subtype of influenza A virus emerges. All influenza A viruses originate in birds (avian); and a pandemic influenza can arise when an avian influenza virus acquires the ability to infect and cause disease in humans and then spread rapidly from person to person. Unlike the flu we see yearly, no one would be immune to this new flu virus, which would spread quickly, resulting in widespread epidemic disease a pandemic. There are several features of influenza pandemic that differentiate it from other public health emergencies. First, it has the potential to cause illness for a very large number of people who could overwhelm the health care system throughout the nation. A pandemic outbreak could also jeopardize essential community services by affecting large numbers of people in critical positions in the workforce. Because a novel virus will cause the pandemic, there may be insufficient or no vaccine against the pandemic virus available for six to eight months or longer. Basic services, such as health care, law enforcement, fire, emergency response, communications, transportation, and utilities, could be disrupted by a virulent flu epidemic. Finally, the pandemic, unlike many other emergency events, could last for many weeks, if not months. Pandemic influenza will affect many regions simultaneously; therefore, outside resources may be unavailable. The threat of a human influenza pandemic has greatly increased over the past several years with the emergence of highly virulent avian influenza viruses, notably H5N1 viruses. The current widespread circulation of H5N1 viruses among avian populations and their potential for increased transmission to humans necessitates preparedness planning for pandemic influenza response. II. Planning Assumptions When preparing for a Pandemic, planning needs to address the following assumptions: Influenza pandemics are expected but unpredictable and arrive with very little warning. Outbreaks will occur simultaneously throughout the country. Delta and Menominee counties will need to rely on their own resources to respond. The effect of influenza on individual communities will be relatively prolonged (weeks to months) in comparison with other types of disasters. The number of ill people requiring outpatient medical care and hospitalization will overwhelm the local healthcare systems. Health care workers and other first responders will be at higher risk of exposure and illness than the general population, further straining the health care system. Effective therapeutic measures, such as vaccines and antiviral medications, will be delayed and in short supply. Appendix 16 Pandemic Flu Page 6

7 Widespread illness in the community will result in significant shortages of personnel in sectors that provide critical public safety services. There will be significant disruption of critical business and public infrastructure including transportation, commerce, utilities, public safety, and communications. Due to the high degree of infectiousness of pandemic influenza, the number of persons affected will be high. The WHO has estimated a contraction rate of 25% of the population for the flu strain that may develop from the current avian flu threat. This means that approximately 25% of the U.S. population is expected to become ill from the pandemic virus. Due to the severity of the avian flu strain, experts also believe that it would result in a very high hospitalization rate. The chart below estimates the potential impact a pandemic will have on the state of Michigan and the populations of Delta & Menominee counties. State of Michigan (9,773,892) Delta & Menominee Counties Clinically Ill 3.4 million 22,750 Require Outpatient Care 2 million 13,350 Hospitalizations 51, Deaths 15, III. Purpose of the Plan The purpose of this plan is to provide requirements and policies to Public Health and local partners regarding detection of, response to, and recovery from an influenza pandemic. The plan is an appendix to PHDM s All Hazard Emergency Response Plan. The plan will define preparedness and response activities that will enhance the effectiveness of response measures during a pandemic in order to: Limit death and illness Preserve continuity of essential government and other core infrastructure functions Minimize social disruption Minimize economic losses Coordinate response activities with the local medical community to reduce stress on the medical system IV. Phases of Pandemic Influenza The World Health Organization (WHO) along with the United State Government has established a system defining influenza pandemic phases. These pandemic phases are detailed below: Appendix 16 Pandemic Flu Page 7

8 PHDM Pandemic Influenza Plan provides response guidelines to an influenza pandemic. The plan cannot eliminate the disease but can reduce the impact by anticipating, preparing, and responding efficiently to the disease. The plan details necessary activities at the local level. The plan includes information regarding: Command and management Risk communications Surveillance Laboratory guidelines Community containment/infection control Appendix 16 Pandemic Flu Page 8

9 Medical management Data management Border/travel issues Recovery/Consequence Management Descriptions of Pandemic Influenza Phases For purposes of consistency, comparability and coordination with the national, state and local responses, the identified phases are combined into Pre-Pandemic, Pandemic, and Post Pandemic phases and are explained as follows: Pre-Pandemic Phase A novel virus, somewhere in the world, has been detected in humans and the human population is not immune. The novel strain has been found in a small number of people or demonstrates sustained person-to-person transmission causing multiple cases in the same geographic area. This phase may last from days to years. Pandemic Phase The novel virus causes unusually high rates of morbidity or mortality, multiple continents are affected, and the WHO and CDC declare an influenza pandemic is underway. This phase may last from several months to over a year. Post-Pandemic Phase The number of deaths from and cases of influenza returns to normal. The WHO and CDC declare the pandemic to be over V. Agency Responsibilities A. Federal Responsibilities The federal government has primary responsibility for many key elements of the national pandemic flu plan ( including nationwide coordination of the pandemic influenza response. Specific areas of coordination include the following: Surveillance in the U.S. and globally Epidemiological investigation in the U.S. and globally Development and use of diagnostic laboratory tests and reagents Development of reference strains and reagents for vaccines Vaccine evaluation and licensure Determination of populations at highest risk and strategies for vaccination and antiviral use Assessment of measures to decrease transmission (such as travel restrictions, isolation, and quarantine) Deployment of federally purchased vaccine Deployment of antiviral agents in the Strategic National Stockpile (SNS) Evaluation of vaccine safety Appendix 16 Pandemic Flu Page 9

10 Deployment of the Commissioned Corps Readiness Force and Epidemic Intelligence Service officers Medical and public health communications B. State Responsibilities State public health (MDCH) responsibilities and local health department considerations are delineated as needed in each section of this plan. The current version of the state plan applies to any activities or responses identified for novel strain or pandemic response, and are subject to change. MDCH guidelines for a novel strain or avian influenza and pandemic influenza response are described in Attachment 8 of the MDCH Pandemic Plan located at MDCH - MDCH Pandemic Plan (v4.0) Redacted. C. PHDM Responsibilities Enhancing disease surveillance to ensure early detection of the first cases of pandemic influenza within the jurisdictions Distributing public stocks of antiviral drugs and/or vaccine and providing local physicians and hospital administrators with updated guidance on clinical management and infection control as the situation unfolds VI. Pre-Pandemic Phase (WHO Phases 1-5, Federal Stages 0-2) A. Command and Management (Pre-Pandemic Phase) All planning, response and consequence management functions will follow the National Incident Management System (NIMS). Reference the PHDM All Hazard Response Plan, (Command and Control, Section II) for the department s NIMS structure. Local government response will follow NIMS and all planning and response will be a function of the county EOC under the direction of the emergency management division of Delta or Menominee County. Throughout this plan, it is understood that detailed direction and coordination of all efforts will be accomplished through the interventions of PHDM s Emergency Response Team which consists of: Michael Snyder, Health Officer/Environmental Health Director Teresa Frankovich, M.D., Medical Director Debbie Poquette, Nursing Director Jennie Miller, Communicable Disease and Immunizations Coordinator Dayna Porter, Emergency Preparedness Coordinator (EPC) Federal Level Responsibilities Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (DHHS) is the lead public health agency in the US. DHHS is the lead agency for Emergency Support Function Eight (ESF-8) Appendix 16 Pandemic Flu Page 10

11 public health and medical services DHHS/CDC support includes the following: Provide technical information to states and the public Conduct research to support the scientific foundations of public health actions Mobilize and deploy personnel when necessary to assist state and local officials with epidemiological investigations Advise on specimen collection and transport Monitor adverse events Stockpile and distribute medications (e.g., chemical antidotes, Strategic National Stockpile) Coordinate public and media communications with state/local authorities The Department of Homeland Security (DHS) is the lead agency in the event of a terrorist attack, natural disaster or other large-scale emergency, and will provide a coordinated comprehensive federal response and recovery effort. The department assumes primary responsibility for ensuring that emergency response professionals are prepared for any situation. State Level Responsibilities See State Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities During the pre-pandemic phase, activities to strengthen PHDM response to a pandemic influenza will include the following: It will be the responsibility of PHDM to provide administrative and organizational leadership during a Public Health emergency based on the Incident Command Structure. PHDM will continue to finalize MOAs/MOUs necessary to implement sharing of staff or resources within and across borders. PHDM will conduct exercises and update pandemic plans accordingly. PHDM will develop jurisdictional Pandemic Influenza Coordinating Committees that have representation from schools, businesses, faith-based organizations, hospitals, and other sectors of society. Upon receiving a novel virus alert, the Health Officer may: Assemble key staff to review current information and PHDM s Pandemic Influenza Plan. Identify key personnel and establish roles and responsibilities. Prepare to carry out activities such as communicating with health care providers and health care institutions. Consider activation of an informational hot-line for public information. Ensure that necessary resources are in place to ensure that operational protocols can be executed in a timely manner when necessary. B. Risk Communications (Pre-Pandemic Phase) Dissemination and sharing of timely and accurate information with the health care community, the media, and the general public will be one of the most important facets of the pandemic response. Advising the public of actions they can take to minimize their risk of exposure, or Appendix 16 Pandemic Flu Page 11

12 actions to take if they have been exposed, will reduce the spread of the pandemic and may also serve to reduce panic and unnecessary demands on vital services. Refer to Annex B (Crisis and Emergency Risk Communication Plan) found in PHDM s All Hazard Plan for guidance in effectively communicating with the public in a pandemic. Other reference materials are located at: B.3 (Sample Press releases, for Public Health Officials, a through j), B.4 (PHDM Instructions During a Pandemic), and B.5 (Pandemic Influenza Public Information Material). State Responsibilities (Lead: Communications Office and OPHP) Note: Tactical and All Hazard Risk Communications planning for MDCH are located in Attachment 5 of the State s MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities PHDM in cooperation with the MDCH crisis communication protocols (refer to the MDCH pandemic influenza plan) will: Develop procedures for addressing demands for media information. Sample press releases and public information is included in section B.3 (Sample Press Information for Public Health Officials). Messages will include the expected influenza activity due to the new strain of virus The existence of state and local plans for dealing with increased influenza activity Actions the public can take to better protect themselves Disseminate educational curricula and materials for local hospitals and other health care providers. Identify population subgroups which are likely to be disproportionately affected by pandemics and design materials appropriate for these subgroups. Disseminate information to special populations and prepare messages for those groups. As necessary, contact interpreters to help communicate to non-english speaking groups. Prepare and disseminate translated materials. MDCH will assist in providing templates. Any PHDM public announcement, statement or press release must be released according to the PHDM Risk Communications Policy. Develop, maintain and update fact sheets as well as prepared risk communication material for the public regarding prevention strategies, antiviral medications, etc. C. Surveillance (Pre-Pandemic Phase) The priority areas for planning and preparedness for an influenza pandemic include surveillance. Passive surveillance will be in effect during the pre-pandemic phase through established procedures employed by local public health to assess the health of the community, such as school and private provider reports. Through the Syndromic Surveillance System, PHDM Immunizations/Communicable Disease Coordinator and PHDM Medical Director monitor local Emergency Room activity. Also, through the Sentinel Physician Surveillance Network, local physicians can provide information about influenza activity and the strains circulating in the area. One sentinel physician is located within PHDM s jurisdiction: Dr. Ronald Bissett of OSF St. Francis Hospital. Appendix 16 Pandemic Flu Page 12

13 State Responsibilities (Lead: MDCH Epidemiology) The state responsibilities for influenza surveillance in the pre-pandemic phase include: The Bureau of Laboratories (BOL) The Bureau of Epidemiology (BOE) The state ensures these bureaus operate a 24/7 coverage at for issues regarding the notification of communicable disease, public health disasters, or the shipping, testing or handling of clinical specimens. All testing requests for novel influenza must be approved by BOE for BOL to process. See Attachment 4 of the MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities PHDM communicable disease team will review any circumstance surrounding an unusual event and consult with the Medical Director, or his/her designee, regarding initiation of active surveillance. If active surveillance is deemed warranted, PHDM will contact the Michigan Department of Community Health, Bureau of Epidemiology at during work hours and after hours. The regional epidemiologist for Region 8 will also be contacted by and/or phone: Scott Schreiber, schreibers@michigan.gov; Office ext. 108; Cell To prepare for a pandemic influenza, PHDM will develop a means to count or estimate the number of influenza cases and deaths within the health jurisdiction. The approach used to determine these numbers will be dependant upon formulas and data systems available at the state level. (CDC has release software Flu-Surge and Flu Aid to assist with determining morbidity and mortality within PHDM s jurisdiction.) As part of the pre-pandemic process of surveillance, PHDM will: Receive reports of influenza-like illness (ILI) from schools (via the Michigan School Building Weekly Report of Communicable Disease Reference C.4) and from private providers and submit the information electronically each week to MDCH through the Michigan Disease Surveillance System (MDSS). Work with MDCH to recruit clinicians for the Sentinel Physician Surveillance Network (SPSN). Reference C.5 Maintain demographic statistics on jurisdiction s groups at high risk for influenza. Identify disease reporting agencies within the jurisdiction and maintain their addresses, fax numbers, and names of contact persons. Strengthen systems for monitoring local hospital census data. Strengthen systems for timely monitoring of local death rates. Review the level of influenza-like illness (ILI) reporting from schools and assure that these facilities are reporting on a regular basis as required by law. Michigan School Building Weekly Report of Communicable Disease (Reference C.4) will be used by the schools in collecting this data. Review and refine systems for monitoring ILI in other congregate facilities that accommodate children such as daycare centers. Educate these facilities regarding their reporting duties under the Michigan Communicable Disease Rules. Appendix 16 Pandemic Flu Page 13

14 Provide notification and updates to disease reporters (physicians, hospitals, emergency rooms, clinical laboratories and long-term care facilities), local emergency management, EMS, local law enforcement agencies, and other local, private and public partners within the PHDM jurisdiction. Advise them of protocols for increased surveillance of influenza. (Reference A.8 Fact Sheet on Avian Flu for Providers) Have available and distribute MDCH-provided specimen collection and submission kits to appropriate providers. Coordinate collection of additional clinical specimens for influenza surveillance according to protocols disseminated by MDCH. (Reference Supporting Document A.10 Laboratory Guidelines) Investigate suspect cases of novel influenza virus in coordination with MDCH using the Case Detection Algorithms, Supporting Document A.3. PHDM will enhance surveillance capabilities by maintaining routine contact with hospital infection control practitioners (ICP). Surveillance contact activity with ICPs will increase in coordination with the rise in the Pandemic Phase levels. The names and numbers of the hospital ICPs in the two-county health jurisdiction are as follows: Delta County Hospital ICP Other OSF St. Francis Hospital 3401 Ludington St. Escanaba Michigan Laurie Montgomery Office: Ext Fax: Menominee County Hospital ICP Other Bay Area Medical Center 3100 Shore Drive Marinette, WI Tracy Cisneros Phone: ext Fax: Information regarding influenza surveillance, prevention, detection, and control is available at D. Laboratory Guidelines (Pre-Pandemic Phase) The MDCH can provide laboratory testing support at no charge and will provide respiratory specimen collection kits to PHDM upon request. To obtain such kits, contact MDCH by fax at (517) Laboratory testing and transport procedures and algorithms are located in Attachment 4 of the MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. State Level Responsibilities (Lead: BOL) Annually, the Virology Section Manager will confirm and document the location of all clinical laboratories in the state which have the capability to isolate and sub-type influenza viruses and arrange for submission of influenza virus isolates. Appendix 16 Pandemic Flu Page 14

15 The Bureau of Laboratory (BOL) maintains routine seasonal influenza testing (November through April) of specimens submitted by sentinel influenza sites enrolled under the SPSN. The Virology Section at BOL isolates, types, and subtypes Influenza A & B viruses. The Virology Section performs polymerase chain reaction (PCR) from clinical specimens and subtype influenza viruses by PCR at capacity levels sufficient to meet the demand during a normal influenza season. BOL will provide respiratory virus testing for outbreak and cluster investigations. BOL has developed guidance for notification, clinical specimen selection and submission during seasonal, novel virus alerts, or pandemic flu. See Attachment 4 of the MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. Protocols for sending laboratory specimens are located in reference A.12. BOL has defined appropriate specimen collection and transport guidelines as described in reference A.12. BOL periodically sends representative virus isolates to CDC for further antigenic characterization. It will also immediately send any unusual virus isolates to CDC for further studies including antiviral resistance. BOL will increase testing capacity for influenza viruses, including pandemic strains, in specimens obtained from travelers from affected areas and other targeted surveillance populations as need arises. PHDM Responsibilities Encourage clinical laboratories within PHDM jurisdiction to submit influenza virus isolates and specimens as requested by MDCH. Assist as necessary with specimen collection, storage, and transit to the MDCH laboratories. E. Community Containment & Infection Control (Pre-Pandemic Phase) The goal of containment strategies is to limit transmission of a novel influenza virus as much as possible. The ability of containment strategies, including isolation and quarantine and social distancing strategies, to substantially slow the spread of pandemic influenza may be limited by the short incubation period for influenza, the transmission mode (contact, airborne, droplet), the large proportion of asymptomatic infections, and the non-specific nature of clinical illness from influenza infection. The following challenges exist: Difficulty in identifying infected persons Difficulty in quarantining contacts of an infected person prior to onset of illness Difficulty in marshalling the substantial resources that would be needed to initiate and monitor the use of containment measures Lack of data demonstrating the effectiveness of containment measures in preventing transmission, particularly in the community setting However, during the early stages of a pandemic, particularly if the novel influenza virus is not efficiently transmitted, use of containment measures may help to slow transmission of a pandemic influenza virus and allow time for the development and use of vaccine and antiviral medications. Appendix 16 Pandemic Flu Page 15

16 Severity Index - The Pandemic Severity Index provides communities a tool for scenario-based contingency planning to guide local pre-pandemic preparedness efforts. Accordingly, communities facing the imminent arrival of pandemic disease will be able to use the pandemic severity assessment to define which pandemic mitigation interventions are indicated for implementation. See Resource Document D5 for interpretation of Pandemic Severity Indexes 1-5. Summary of the Community Mitigation Strategy by Pandemic Severity Appendix 16 Pandemic Flu Page 16

17 1. Isolation and Quarantine (Pre-Pandemic Phase) In the State of Michigan, the authority to impose Quarantine and Isolation measures is given to the local Health Officer. The Public Health Code Act 368, Section 5201 delineates the specific process for taking isolation and quarantine measures. Reference PHDM s Emergency Operations Plan, Annex D, Community Containment/Infection Control Section for more information on the quarantine and isolation plan. State Level Responsibilities (Lead: BOE) MDCH, as a state agency, may provide infection control recommendations to health practitioners, hospitals and medical facilities within the state of Michigan. Preparedness activities that health care facilities can address, implement and exercise prior to a pandemic occurrence will strengthen their ability to be prepared and respond effectively and efficiently. PHDM Responsibilities Educate key stakeholders, including health care professionals and the public, about influenza pandemics and the use of isolation and quarantine measures to prevent transmission of influenza. Education will include respiratory etiquette and staying home when sick. Review the Health Threats to Others Policy located in the All Hazard Plan, Isolation and Quarantine Plan, Community Containment Section. Coordinate planning for isolation and quarantine procedures with response partners, including law enforcement. Promote the use of standard infection control practices to prevent influenza transmission in healthcare facilities. Reference the CDC guidelines for standard precautions for healthcare settings: Other resource information is included in attachment B.1 (Hand Hygiene). Develop protocols for quarantine of close contacts of persons infected with a potential pandemic strain. Reference the All Hazard Plan, (Section VIII, Community Containment/Infection Control). Advise health care professionals to immediately report influenza-like illness (ILI) in travelers with onset within seven days of travel from affected regions. Recommend and facilitate testing for influenza A for persons with ILI who have recent travel history (within 7 days) to an affected region or who have had contact with poultry. Initiate contact tracing. Ensure persons who have suspected or confirmed infection are in isolation until laboratory sub-typing results are available. Containment measures will be initiated if novel virus transmission is detected in the U.S. Persons with suspected or confirmed infection should be isolated at home or in a hospital, if necessary, until at least 7 days after onset of illness or until viral strain is determined not to be a novel influenza A virus. Contacts of cases should be quarantined for at least 7 days. Recommend reverse quarantine of long-term care facilities e.g., prohibit people entering from outside of facility, except for essential staff, in order to protect residents. Activate protocols for quarantine of close contacts of persons infected with a potential pandemic strain. Appendix 16 Pandemic Flu Page 17

18 Provide technical assistance to health care providers and hospitals regarding options for management of health care workers who come in contact with influenza patients or who develop influenza. 2. Social Distancing Strategies (Pre-Pandemic Phase) In the event of a pandemic influenza outbreak, County officials may need to implement a number of actions to reduce the potential for transmission of the virus. The Health Officer will assess the risk to the public health based on current knowledge of the epidemiology and the impact of the influenza pandemic on the population and the anticipated benefits of available containment measures. The Health Officer will make recommendations to key elected officials and superintendents of public school districts about actions that should be taken to control the spread of the disease. The situation will be reviewed daily and recommendations to public officials about containment measures will be made. Social distancing strategies are non-medical measures intended to reduce the spread of disease from person-to-person by discouraging or preventing people from coming in close contact with each other. These strategies could include closing public and private schools, colleges and universities; closing non-essential government functions; implementing emergency staffing plans for the public and private sector, including increasing telecommuting, flex scheduling and other options; and closing public gathering places such as stadiums, theaters, churches, community centers, and other facilities. Implementation of social distancing may create social disruption and significant, long-term economic impacts. It is unknown how the public will respond to these measures. PHDM Responsibilities PHDM will consider the following social distancing strategies during the Pre-Pandemic Phase: Educate key stakeholders, including public officials, school officials, leaders of the business community, and the public about influenza pandemics and community containment measures and social distancing strategies. Educate the media and the public about community containment measures and social distancing strategies to control the spread of novel influenza virus. Refer to Annex B (Crisis and Emergency Risk Communication Plan) in PHDM s Emergency Operations Plan. Other resource information is included in attachment A.5 (Graded Community Containment Measures). Utilize the messages from Peter Sandman located at Direct government agencies and the private sector to implement emergency staffing plans to maintain critical business functions while maximizing the use of telecommuting, flex schedules and alternate work options. Reference documents D.1 (Policy Example of Exposed or Ill Employees), D.2 (Telephone Triage for Flu-Like Illness), D.3 (Infection Control Measures for Health Care) and D.4 (Infection Control Measures for the Public). Suspend public events where large numbers of people congregate, including sporting events, concerts, and parades. Close churches, theaters, community centers, and other places where large groups gather. Appendix 16 Pandemic Flu Page 18

19 Dismiss students from public and private schools, colleges and universities. Reference the following website for the School Pan Flu Preparedness tool kit - Encourage the public to curtail the use of public transportation. Use public transportation for essential travel only. Activate the department s emergency response plan. Activate and implement protocols for conducting active surveillance at hospitals or other health care facilities for illness due to infection with a novel influenza virus. Request that hospitals inform the health department of the number of deaths due to pneumonia and influenza. Request influenza physicians obtain specimens from persons with influenza-like illness (ILI) who are at increased risk for infection with the novel virus as defined by CDC or who received influenza vaccination at least two weeks before illness onset. Investigate outbreaks of influenza-like illness in schools, Long Term Care Facilities (LTCFS), and providers and clinics. Enhance surveillance of severe respiratory illnesses, unexplained deaths and clinics catering to international travelers. Inform all health care providers and LTCFS of first local human case and instruct them to contact the health department immediately of any suspect cases. Utilize the Public Health Notification Procedure located in the All Hazard Plan, Command and Control section. Investigate epidemiology of all early local cases and monitor contacts. In consultation with CDC and MDCH, assess the need to screen and/or quarantine travelers arriving from affected countries. Evaluate the need to activate the Mass Fatality Guidelines, refer to Appendix 38 in the Emergency Operations Plan. Contact the funeral home directors and hospitals for the number of deaths. F. Medical Management of Vaccine/Antivirals (Pre-Pandemic Phase) In the United States, the primary option for reducing the effect of seasonal influenza is immunoprophylaxis with vaccine. Inactivated (i.e., killed virus) influenza vaccine and live, attenuated influenza vaccine are available for use in the United States. Vaccinating persons at high risk for complications and their contacts each year before seasonal increases in influenza virus circulation is the most effective means of reducing the effect of influenza. In the event of a pandemic, the SNS contains a small stockpile of antivirals, which contains 2.16 million treatment courses of oseltamivir and about 5 million treatment courses of rimantadine as of March, This means that Michigan could expect about 73,000 courses of oseltamivir and 170,000 courses of rimantadine if distributed on the basis of population size. Since Michigan has about 10 million residents, less than 3% of the population would be treated under this scenario. Therefore, it is important to obtain and maintain priority listings of groups who should receive antiviral agents or vaccines when the SNS is made available. (See supporting documents A.4 and A.6.) Supporting Document A.11 is a reference in the event of a pandemic, as it will be critical to follow recommended guidelines by the CDC for the optimum antiviral medication, dose and duration of treatment. Standing orders for administering antiviral medication can be found in supporting document A.13. Appendix 16 Pandemic Flu Page 19

20 During the first wave of pandemic influenza, it is unlikely that vaccine for the particular influenza strain will be available. If available, the vaccine will be severely limited. Recommendations for prioritizing who will receive the initial doses of vaccine have been determined at the state or federal level, and PHDM will follow those guidelines. Vaccine information statements (VISs) for the new virus vaccine will be ordered either through the state health department or CDC s Immunization Hotline at (800) These will be provided to all vaccine recipients prior to immunization. VISs are also available in a variety of languages from the Immunization Action Coalition s website at If needed, PHDM will have translators available during clinic hours for those clients who do not speak English. Adverse effects following vaccination will be reported in a manner recommended by national and state officials. If no other system is advanced for adverse event reporting, PHDM will use the Vaccine Adverse Event Reporting System (VAERS). VAERS is a national system for reporting health problems that occur around the same time that a vaccination is given. While vaccine for a novel flu strain may not be available, prophylaxis and treatment with antivirals would be an option. Chemoprophylactic drugs are not a substitute for vaccination, although they are critical adjuncts in preventing and controlling influenza. When considering the antivirals, it is important to remember that most healthy people recover from influenza without complications. However, in the event of a pandemic, the antiviral medications are a valuable resource for some people who may be at high risk from complications of the flu. Whether clients receive antiviral medication or immunization, a medical history form must be completed and reviewed by a medical professional (medical director, nurse, etc.). (Supporting Document A.14) Regardless of the presence or absence of vaccine and antivirals, in the event of pandemic influenza there are measures that will be implemented at the order of PHDM s Emergency Response Team or state/national decision makers to slow the spread of disease. On a state or national level these measures might include assessing the need to screen all travelers arriving in the United States from affected countries, instituting travel restrictions, and/or implementing quarantine laws. On a local level, school and business closings, and suspension of public gatherings might be considered by PHDM s Emergency Response Team. State Level Responsibilities (Lead: BOE and OPHP) See MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities Promote yearly vaccination with influenza vaccine for high-risk populations and the general population, as well as pneumococcal polysaccharide vaccine (PV) in high-risk groups as recommended by the Advisory Committee on Immunization Practices (ACIP). Appendix 16 Pandemic Flu Page 20

21 Maintain the priority listing of groups needing influenza vaccine or prophylaxis antiviral medication, e.g., health care workers, emergency responders, public health personnel, and high risk individuals. Consider the distribution and administration of vaccine and antivirals within and between jurisdictions. PHDM will collaborate to assure that those within the targeted groups receive the influenza vaccine before others who are not in the targeted groups. Such collaborations may include: Sharing of standing orders Communication between LHDs, providers, community partners, MDCH, and others to share information about who has vaccine or antivirals and who needs them Use of the Influenza Vaccine Exchange Network (IVEN) on MCIR Implement strategies, if needed, to utilize additional personnel if a pandemic is imminent. Consideration should include: Process of identification Training guidance Authorization for usage Supervision of activities Identify transportation resources within the community for transportation of: Vaccine and antivirals Individuals within the high recipient tiers Supplies and equipment Health care workers Identify persons who can be reassigned to provide surge capacity for necessary pandemic prophylaxis-related activities. PHDM and partners will plan for rapid distribution of a tool to screen persons attending community vaccination clinics along with a guidance document for implementation by all community partners for targeting priority groups. PHDM will individualize the document and will be responsible for assuring communication with their community partners regarding the implementation and compliance. PHDM and partners will customize their biologics distribution plan to address: Designation of priority groups to receive vaccines and antivirals Amount of influenza vaccine/antiviral agents that are needed to treat various groups in their jurisdiction Role of community partners (home health care agencies, hospitals, long term care facilities, pharmacies, university health centers, correctional facilities, Red Cross, National Guard, etc.) Surge capacity Staffing needs and identification of necessary staff Storage location and capacity Signed agreements/contracts (e.g., home health care agencies, hospitals, long term care facilities, pharmacies, university health centers, etc.) Communication/educational capabilities Ensure designation of at least one appropriate Dispensing Site Appendix 16 Pandemic Flu Page 21

22 G. Data Management (Pre-Pandemic Phase) For Disease-Based Surveillance, the State will maintain data received from providers and LHDs regarding ILI. The MiFluFocus surveillance report is posted at Where possible, all identifiable data will be maintained in a HIPAA-compliant manner. For specific information regarding Data Management, please refer to Section X of PHDM s All Hazard Plan. H. Border Health and Travel Issues (Pre-Pandemic Phase) The potential for a rapid global spread of pandemic influenza is facilitated by international travel. Because of the significant impact of travel across each county and Michigan s many international and intrastate entry points (airports, bridges, tunnels), these must be monitored to prevent the import/export of serious communicable diseases. There is legal authority at the local, state, and federal level to control the movement of persons within local jurisdictions, the state, and across U.S. borders. State Level Responsibilities The MDCH will assist both federal and local health authorities in the identification and surveillance of travelers who may be at risk for contracting a pandemic influenza strain. See pages in the State plan for more information regarding federal and state responsibility. The MDCH may also provide an advisory role in the event of early influenza control activities involving border travel. PHDM Responsibilities PHDM will have jurisdiction over quarantine and isolation within Delta & Menominee counties. PHDM will request the support for public health activities as available from MDCH. PHDM will work collaboratively with State and Federal officials in all travel-related actions for pandemic influenza. PHDM will issue appropriate protective measures and orders as necessary to control the spread of pandemic influenza within our borders. Refer to PHDM s Emergency Operations Plan (Section XI, Border/Travel Health) for more information. I. Recovery/Consequence Management (Pre-Pandemic Phase) Please refer to the Post Pandemic Phase of Recovery/Consequence Management section of this plan for detailed information regarding resumption of normal operations. VII. Pandemic Phase (WHO Phase 6, Federal Stages 3-6) A. Command and Management (Pandemic Phase) A pandemic is acknowledged when there is increased and sustained transmission of Influenza A within the worldwide population. The Department of Health and Human Services has identified Appendix 16 Pandemic Flu Page 22

23 several issues for state and local partners to consider that will require real-time guidance during a pandemic. They are: What are the case definitions for suspected and confirmed cases of pandemic influenza? What types of epidemiologic data should be collected? (The answers may change over time depending on the characteristics of the pandemic virus and the geographical spread of the pandemic.) What are the drug susceptibilities of the pandemic virus? What amounts of antiviral drugs are available to PHDM from public and private stocks? What amounts of pandemic influenza vaccine are available from public stock? Which groups of people are at greatest occupational and medical risk? What modifications should be made to the national recommendations for distribution and use of antiviral drugs and vaccines to reflect this information? Which laboratory tests may be used locally for laboratory confirmation of pandemic influenza cases? How fast is the pandemic spreading within PHDM s jurisdiction? What does local surveillance data on number of hospitalizations and deaths suggest in regard to: Distribution of hospital supplies and hospital beds on a regional or statewide basis How fast local and regional hospital resources are being depleted Implementation of school closings and other community containment measures Situating and opening alternative care sites and quarantine facilities Absentee rates at hospitals and at businesses that provide essential services Impact of the outbreak on the public health and medical workforce Is anything unusual or unexpected? If so, should any modifications be made in infection control practices or in the detection or management? Is there evidence from statistical modeling that predicts where and how fast the pandemic will spread? State CHECC Activation Modes by Phase/Stage/Category - Pandemic The Director of MDCH and/or OPHP will implement the CHECC modes in the pandemic phase/stages for Pandemic Severity Indexes (PSI) 1-5 as follows: WHO Phase 6/USG Stage 3: Alert or Standby WHO Phase 6/USG Stage 4: Standby or Activate WHO Phase 6/USG Stage 5: Response (Activate a confirmed human cluster identified and epi-linked in or surrounding Michigan) Table 1: CHECC Activation Modes by WHO Phase and USG Stage PSI Phase 3/ USG 0-1 Phase 4 USG 2 Phase 5 USG 2 Phase 6 USG 3 Phase 6 USG 4 Phase 6 USG 5 1 W W W PAR PAR FAR 2-3 W W W PAR PAR FAR 4-5 W W PAR PAR FAR FAR W = watch PAR = Partial response activation FAR = Full response activation PSI = Pandemic Severity Index see Resource Document D5 for interpretation of PSI 1-5 Appendix 16 Pandemic Flu Page 23

24 In compliance with the National Incident Management System (NIMS), activation can be done partially or completely as indicated by the level of response required or requested. See the State s MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. B. Activation of the PHDM Pandemic Influenza Response Plan The decision to activate the Pandemic Influenza Response Plan rests exclusively with the Health Officer or designated members of the PHDM Emergency Response Team. It is generally anticipated that the plan would be activated early on in the Pandemic Period, WHO Phase 6. Activating the plan would involve contacting the Epidemiology Section of the MDCH, local physicians, and regional epidemiologists. In addition, neighboring health departments will be contacted. The following local officials will also be contacted: PHDM Medical Director Teresa Frankovich, M.D. (906) (Office) (906) (Cell) (906) (Home) Delta County Emergency Manager Bob Berbohm (906) (Office) (906) (Cell) Menominee County Emergency Manager Trina Rabida (906) (Office) (906) (Cell) Delta County Chairperson, Board of Commissioners Tom Elegeert (906) (Home) Menominee County Chairperson, Board of Commissioners James Furlong (Home) When activating the pandemic plan, the PHDM Emergency Response Team may choose to request the simultaneous activation of its Emergency Coordination Center (ECC). The PHDM ECC is a resource to the Emergency Response Team and to other public health emergency responders that may be called upon in response to an incident. The PHDM ECC is the command post from which decisions will be made and implemented. Fast access to material support, assistance amongst groups that are part of the response effort, and enhanced ability for interagency communication are facilitated by operating within the PHDM ECC. Appendix 16 Pandemic Flu Page 24

25 PHDM Responsibility PHDM will operate according to the Pandemic Influenza Response Plan, the Crisis & Emergency Risk Communication Plan and, if appropriate, the Strategic National Stockpile Plan. Refer to the PHDM All Hazard Public Health Emergency Response Plan regarding emergency response activation. Other responsibilities will include: Identifying roles and responsibilities within the incident or unified command system Verifying employee contact information Verifying that 24/7 contact information is up-to-date and distributing it to key local partners as necessary Responding at the level necessary with local and/or county Emergency Operation Centers Ensuring all members of the PHDM Emergency Response Team are NIMS/ICS compliant Responding at the level required or requested with the Regional Bio-Defense Network C. Risk Communication (Pandemic Phase) Should MDCH determine that an influenza pandemic emergency is imminent a state-wide communications response will be initiated. State Level Responsibilities Lead: Communication Office and OPHP See the MDCH Pandemic Plan, Attachment 5: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities During a pandemic response, health communications will be a prominent tool used to assist in containing the outbreak. Sharing of coordinated, timely and accurate information can guide the public, media, and health care providers in responding appropriately and complying with exposure-control measures. PHDM will: Initiate regular communication briefings with hospital emergency rooms, infection control practitioners, infectious disease specialists, and community providers, and will regularly communicate with experts at the CDC and MDCH. Reference documents A.2 (Clinical Management Flow Chart), A.3 (Case Detection Flowchart), and A.4 (HHS Vaccine Tiered Priority Groups). In coordination with MDCH, notify and update local health care facilities, emergency medical services agencies, emergency management agencies, and other responders that an influenza pandemic has been declared. Notify local media and share press releases, fact sheets, media packets, health recommendations, travel advisories, and other guidance. Notify and provide guidance to physicians, health care facilities, long-term care facilities, schools, and day care centers using the Crisis & Emergency Risk Communication Plan. Notify the public of targeting recipient tiers for vaccination and stress the importance of compliance with these recommendations. Be open and honest about shortages of vaccines and antivirals Include statements about what is being done to protect the public Inform the public about actions to slow or stop the spread of the virus Include information on legal authorities invoked for pandemic control as needed Appendix 16 Pandemic Flu Page 25

26 Communicate with vulnerable populations. Reference Annex B, Appendix I (Special Populations Contacts) located in the Crisis and Risk Communications Plan. D. Surveillance (Pandemic Phase) During an influenza pandemic, PHDM will enhance local surveillance activities. Local surveillance information will be shared with local partners and MDCH. This information will be used by PHDM and MDCH to track and document outbreak locations. MDCH will identify regions and collect data within the state that is experiencing high levels of influenza. These data will be used to immediately address questions related to the initial cases and to provide guidance to the public regarding disease susceptibility, diagnosis, and management. State Level Responsibilities Lead: BOE Refer to the MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities Monitor local emergency room activity via the Syndromic Surveillance System. Utilize MDSS to track communicable disease, especially certain types of pneumonia and influenza-related deaths. Closely monitor sites with increased potential for disease morbidity including: Schools and day care providers Colleges and universities Long-term care facilities Provide guidance to clinicians, health care facilities, long-term care facilities, schools and day care centers regarding changes or enhancements to influenza reporting requirements. Implement system for receiving reports on ILI from health care, long-term care facilities, and schools on a more frequent basis, possibly daily. Monitor workforce absenteeism within the community through reporting from major employers. Reference materials include: C.1 (Influenza-Like Illness Form), C.2 (Contact Tracking Form) and C.3 (Daily Workplace Roster). Request and monitor local hospital census data on an ongoing basis. This can be facilitated with Regional Medical Coordination Center. In coordination with MDCH, provide timely notification and updates to hospitals, EMS, local law enforcement agencies, and local private and public partners on an on-going basis. Request and monitor local death rates on an ongoing basis. Enlist additional clinicians in the Sentinel Physician Surveillance program in Michigan as recommended by MDCH. Assist in coordination of the collecting and shipping of clinical specimens to MDCH laboratory, according to protocols established by MDCH. Be able to switch from individual to aggregate reporting as indicated. Work with MDCH to conduct special studies, according to protocols supplied by MDCH. Remain in close communication with Region 8 Regional Medical Coordination Center for evaluating the status of pre-hospital and hospital capacities within the jurisdiction. Appendix 16 Pandemic Flu Page 26

27 E. Laboratory Guidelines (Pandemic Phase) The goals of diagnostic testing during a pandemic are to: Identify the earliest cases of pandemic influenza (whether the pandemic begins in the United States or elsewhere). Support disease surveillance to monitor the pandemic s geographic spread and impact of interventions. Facilitate clinical treatment by distinguishing patients with influenza from those with other respiratory illnesses. Monitor circulating viruses for antiviral resistance. During the earliest stages of a pandemic, public health, hospital, and clinical laboratories might receive a large and potentially overwhelming volume of clinical specimens. Pre-pandemic planning is therefore essential to ensure the timeliness of diagnostic testing and the availability of diagnostic supplies and reagents, to address staffing issues, and to disseminate protocols for safe handling and shipping of specimens. Once a pandemic is underway, the need for laboratory confirmation of clinical diagnoses may decrease as the virus becomes widespread. State Level Responsibility Lead: BOL Receive guidance from CDC on the criteria for specimen submission as well as the appropriate influenza diagnostic testing to be performed on surveillance specimens. Determine current surge capacity and testing priorities in consultation with the BOE. Consider how many specimens can be processed daily, which tests will be performed, and which specimen submitters have priority. Develop staffing schedules to accommodate extra testing shifts using personnel from other sections, other state laboratories, and regional labs. Work with MDCH purchasing to maintain sufficient supply of reagents and materials. Virology Section will report only confirmed positive results to the submitter and LHDs simultaneously via the EPIC reporting system and MDSS. The Virology Section manager will define appropriate specimens for submission and communicate this information to the medical community, including LHDs, clinical lab directors, epidemiology staff, and physicians. Updates will be available at: Communicate the updated information on pandemic influenza to Michigan laboratories via broadcast fax or MIHAN. Send selected influenza isolates to CDC for strain characterization and antiviral resistance testing. Collaborate with clinicians and clinical laboratories for information on secondary bacterial infection isolates associated with influenza and request submission of these bacterial isolates to MDCH. Collaborate with pathologists and medical examiners to facilitate transport of special or post-mortem specimens to BOL for testing or forwarding to CDC. Additional information can be found in the MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. Appendix 16 Pandemic Flu Page 27

28 PHDM Responsibilities Distribute MDCH-provided specimen collection and submission kits to appropriate providers, according to protocols established by MDCH. Coordinate collection and shipping of clinical specimens to MDCH laboratory, according to protocols established by MDCH. Refine specimen collection and transport procedures based upon guidance from MDCH. See Resource Document A12 F. Community Containment and Isolation (Pandemic Phase) During a pandemic influenza event, containment measures applied to individuals (e.g. isolation and quarantine) may have limited impact in preventing the transmission of pandemic influenza due to: The short incubation period of the illness The ability of persons with asymptomatic infection to transmit the virus The possibility that early symptoms among persons infected with a novel influenza strain may be non-specific, delaying recognition and implementation of containment However, the implementation of Non-Pharmaceutical Interventions (NPI) may work as well or better to slow the spread of disease. The following table illustrates when the Director of MDCH and/or OPHP will implement NPI. See Table 2 below and Attachment 7 of the State s MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. Implementation of Non-Pharmaceutical Interventions (NPI) in a Pandemic Table 2: Community Mitigation Measures in Michigan PSI Phase 3/ USG 0-1 Phase 4 USG 2 Phase 5 USG 2 Phase 6 USG 3 Phase 6 USG 4 Phase 6 USG 5 1 Watch Alert Alert Alert Standby Activate 2-3 Watch Alert Alert Alert Standby Activate 4-5 Watch Alert Alert Standby Standby/Activate Activate PHDM Responsibilities The PHDM Health Officer, as the local Public Health Authority, will consider implementing non-pharmaceutical measures as well as quarantine and isolation orders for residents of Delta & Menominee counties as a means to contain the spread of pandemic influenza. The following are local considerations that may be necessary to contain disease: Implement emergency orders as indicated for social distancing or other community containment measures. Upon notification by Bureau of Epidemiology, utilize aggregate reporting form within the MDSS for reporting aggregate counts of cases, deaths, new and total hospitalized, new and total isolated or quarantined patients. Activate and implement portions of PHDM All Hazard Public Health Emergency Response Plan, Annex D, Isolation and Quarantine Plan. Communicate regularly with the community on mitigation measures. Communicate results of mitigation measures to MDCH. Provide updated guidance to healthcare facilities, businesses, other agencies and stakeholders as requested. Appendix 16 Pandemic Flu Page 28

29 Coordinate with law enforcement or National Guard if widespread community quarantine is required. Considerations for community containment: Contact investigation Home isolation Community facility isolation Quarantine (home, work, facility) Monitoring and support of quarantined persons Management of household members in contact with quarantined persons Social distancing Actively or passively monitor contacts with or without any restriction of movement unless symptoms develop. Consideration should be given to confining and/or restricting the movement of contacts with high-risk exposures (e.g., healthcare workers) even in the absence of symptoms. Quarantine contacts to reduce disease transmission. Monitor contacts regularly for symptom development. Advise contacts to seek healthcare evaluation immediately if symptoms develop. An attempt should be made to relocate household members (especially those with risk of developing serious complications) so only the primary caregiver and patient resides in the residence. If this is not possible, only the primary caregiver can have contact with the patient. Perform home inspection Home Isolation/Quarantine Assessment form (see below) for the following: Ability to maintain isolation/quarantine of patient Availability of primary caregiver to assist patient with basic needs Functioning utilities (e.g., telephone and electricity) Separate bathroom and bedroom facilities for the patient only Provide caregivers with adequate Personal Protection Equipment if possible and instructions for use Availability of resources such as masks, tissues, hand hygiene products and information on infection control procedures Provide instructions on discarding contaminated waste materials. Provide follow-up instructions for caregivers who develop symptoms. Assemble a team to activate community isolation facilities. Coordinate facility activation activities with the county emergency manager and other medical management personnel. Identify, monitor, and evaluate contacts of cases to ensure early symptom identification and rapid institution of infection control precautions to prevent further spread of disease. Types of Quarantines for Health Department Consideration: Quarantine at home is most suitable for contacts that have a home environment in which their basic needs will be met. The minimum criteria that must be met to enable optimal implementation of home quarantine are: Ability to determine compliance on a regular basis Ability for contact to monitor own symptoms Appendix 16 Pandemic Flu Page 29

30 Availability of mechanisms for addressing special needs (e.g., filling prescriptions) Access to healthcare workers, ambulance personnel, mental health and other psychological support services Work Quarantine applies to heath care workers or other essential personnel who have been exposed to cases and who may need to continue working (with appropriate infection control precautions) but who are quarantined either at home or in a designated facility during off-duty hours. Quarantine in Designated Facilities is used for contacts that do not have an appropriate home environment for quarantine or contacts that do not wish to be quarantined at home. They may be quarantined in specific facilities designated for this purpose. Monitoring and Support of Quarantined Persons Local public health is responsible for assuring the provision of essential goods and services for residents who are isolated/quarantined. These essential goods and services may include food, medications, medical care, mental health care, and safe shelter (e.g. heat, air conditioning, water, sanitation). In addition, medical monitoring processes must be implemented in order to fully support the quarantined person or persons. Action would include: Determine how and when symptom monitoring should occur. Provide medical evaluation plans for those contacts that develop symptoms. Implement plans for support services such as financial support, psychological support, and essential services (e.g., food, prescription refills, and care supplies). Provide a hotline number for quarantined persons to call if they develop symptoms or have other immediate needs. Management of Household Members in Contact with Quarantined Persons No precautions are indicated for household members if contact remains asymptomatic. Supply instructions to household members if contact develops symptoms. Community-Wide Containment Measure Implementation Social Distancing If necessary, issue emergency order to suspend public gatherings, close public buildings, cancel events, close non-essential government functions, and close or limit mass transit. MDCH, with the Michigan Department of Education and representatives from Local Public Health, has created a School Closure Working Group to determine the impact of implementing public health measures such as school closures and to identify appropriate triggers for implementation of approved measures. See Resource Document B.6 for guidelines and activities that should occur in an Alert, Standby or Activate mode of response. Implement curfews and travel restriction procedures depending on current situation. Collaborate with emergency management to provide essential services to the mass populace. Infection Control/Personal Protection Any disaster has the potential to introduce microorganisms that threaten health, disrupt patient care activities and disrupt the healthcare environment. Infection prevention and control measures are essential to ensure the safety of patients, healthcare workers and emergency responders. Appendix 16 Pandemic Flu Page 30

31 Specific infection control measures will be based upon the situation/event. However, basic and consistent infection control measures exist that, when used consistently and positively, impact the prevention and control of infection. PHDM employees are required to undergo training each year that outlines guidelines for infection control and includes: The PHDM respiratory control program Fit testing of approved respirators The use of protective equipment including respirators (N95), gloves, gowns, face shields, etc. Additional infection control measures based on identified need Bloodborne pathogen and Right-To-Know training. State level and healthcare facility considerations for infection control are located in Attachment 7 of the MDCH Pandemic Plan. MDCH - MDCH Pandemic Plan (v4.0) Redacted. Local public health considerations for infection control include: Provide guidance to healthcare facilities and stakeholders as indicated Maintain updated guidelines upon collaboration with MDCH and CDC/DHHS G. Medical Management: Vaccines and Antivirals (Pandemic Phase) State Responsibilities Leads: BOE and OPHP State level responsibilities are based upon the identified Federal Stage of the pandemic influenza. See MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities: Vaccines and Antivirals Obtain updated information on local influenza vaccine supplies, antiviral supplies and other clinic supplies. Maintain close communication with local health care facilities and clinicians on their vaccine and antiviral status. Activate the PHDM Strategic National Stockpile (SNS) Plan and identify dispensing sites for activation. Implement the PHDM SNS Plan Determine if there are sufficient supplies of vaccine syringes, needles, information sheets, staff, clinic space, laptops with data collection. software, signs, waiting areas, greeters, cots, phones, volunteers, etc. Monitor availability and coordinate distribution and delivery of influenza vaccines and antivirals. Ensure runners available for redistribution/transportation of vaccine and/or antivirals between clinic sites, if needed. Administer influenza vaccine and/or antivirals to targeted groups of people identified by the CDC Advisory Committee on Immunization Practices (ACIP). Use MCIR to record vaccine/antivirals between clinic sites. If unlicensed pharmaceuticals will be used, obtain signatures of consent from all persons receiving them. Appendix 16 Pandemic Flu Page 31

32 Store influenza vaccine according to MDCH guidelines. (See A.15) Request security from local agencies (i.e. law enforcement) for vaccine/antiviral supplies and clinics. Notify MDCH (OPHP) and local law enforcement agencies about any newly identified security concerns. Ensure that pre-identified dispensing sites are notified and on alert. Report adverse events to MDCH and to Vaccine Adverse Events Reporting System (VAERS): Continually assess local supplies of influenza vaccine and antiviral agents and notify MDCH regarding availability. If vaccines/antivirals are obtained from the SNS, standing orders for their administration will be executed. These orders will need to be developed in accordance with CDC guidelines, as some avian influenza strains are noted to be resistant to particular antivirals and resistance patterns change over time. Current non-pandemic influenza treatment guidelines (February 2005) are available via the CDC at the following website: H. Data Management (Pandemic Phase) State Responsibilities Data management plans will remain consistent with that outlined in the pre-pandemic phase. Disease-based Surveillance: Individual case-based reporting: Healthcare providers and/or the Local Health Department will enter individual cases (influenza-like disease diagnosis) into the Michigan Disease Surveillance System (MDSS). These cases are generally lab- confirmed cases. Aggregate case reporting: Local Health Departments enter aggregate counts of influenza-like illness into the MDSS. This data is collected from schools by the Local Health Department using the IP-10 forms. Schools also report whether or not the school closed due to excessive absences that week. The MDSS records this information from Sunday to Saturday and derives a total number for the week. The number entered into the MDSS is a running total and must be updated with each additional entry. Laboratory-based reporting: The Bureau of Labs maintains laboratory influenza data. All results of testing performed at MDCH are tracked and reported via EPIC Cohort, the laboratory electronic reporting system. This information is uploaded into the MDSS. Specimens sent to CDC must be tracked through EPIC Cohort. All out-going specimens must receive an EPIC tracking number prior to shipping to CDC. All results from CDC must be submitted to the Data Acquisition and Specimen Handling (DASH) Unit. Appendix 16 Pandemic Flu Page 32

33 The Virology Section manager maintains an Excel spreadsheet that contains the results of all specimens from sentinel influenza sites and all positive respiratory cultures from non-sentinel sites. The MDCH Communicable Disease Division maintains reports and data regarding suspect or confirmed influenza outbreaks on a case-by-case basis. Paper/hard copy records are maintained for three years in locked files in the MDCH Communicable Disease Division. US Influenza Sentinel Provider Surveillance Network (SPSN) data: The MDCH Division of Immunization section maintains Michigan s sentinel reporting data in a spreadsheet, which is also maintained nationally by the CDC using an online database. The data is maintained at MDCH on a secure network drive in various Excel workbooks and is updated weekly so that epidemiologists can analyze and examine it. PHDM Responsibilities PHDM will use the Michigan Disease Surveillance System (MDSS) for the reporting of pandemic flu cases until directed otherwise by MDCH. Refer to the section above for descriptions of the data that will be transmitted. The PHDM Communicable Disease staff will be responsible for other data collection and management issues, i.e., hospital census data, local mortality data, etc. Data will be maintained in a HIPAA-compliant manner. I. Border Health & Travel Issues (Pandemic Phase) Federal Level Responsibilities (in consultation with State and Local Health Departments) Minimizing or prohibiting non-essential travel Medical screening of passengers and quarantine of contacts as necessary Antiviral prophylaxis for exposed passengers or treatment of ill Prohibition of travel for all persons meeting the case definition for possible, suspected or pandemic influenza Requirement of health certificates for travel Distribution of health alert notices to passengers traveling to or from affected areas Mandatory quarantine the length of time determined by the incubation period of the novel virus for all asymptomatic arrivals from pandemic areas Collection of contact information on all arriving passengers State Level Responsibilities Support to the Federal Government in the above listed actions Support to Local Health Departments as requested Restricting use of mass transit systems Finalize any MOAs/MOUs necessary to implement sharing of staff or resources across borders PHDM Responsibilities Refer to the PHDM All Hazard Public Health Response Plan regarding Border/Travel Health Issues Collaboration with the Federal Government in the above listed actions Collaboration with MDCH officials as needed Appendix 16 Pandemic Flu Page 33

34 Finalize any MOAs/MOUs necessary to implement sharing of staff or resources across borders J. Recovery/Consequence Management (Pandemic Phase) State Level Responsibilities Lead: MDCH Admin/OPHP See the MDCH Pandemic Influenza Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibility During the active phase of Pandemic Influenza, PHDM along with county Emergency Operation Centers will establish the need for humanitarian relief. This may include: Emergency medical care Emergency communications Temporary morgue establishments Enactment of special ordinances Mental health support for first responders, medical staff and survivors In the short term, other consequence/recovery actions may be implemented: Methodology for post-decontamination of vehicles Restoration or re-supply of equipment Federal and State assistance requests (individual and public) Evaluation of long-term mental health support Restoration of comprehensive public health services and health care facilities Ongoing activity will include: Continue emergency communication risk messages. Provide mental health support for PHDM staff. Conduct risk assessment and review. Assist with economic redevelopment. Establish community recovery programs. VIII. Post Pandemic Phase The post pandemic phase begins when the number of cases of influenza returns to normal or prepandemic levels. This phase focuses on returning health, municipal, schools and other services to business as usual, dealing with any service backlogs, assessing the impact of the pandemic, and evaluating the pandemic response. A. Command and Management (Post Pandemic Phase) State Level Responsibilities Lead: OPHP Command and management of the post pandemic phase is located in the MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. PHDM Responsibilities Convene relevant parties to debrief from response activities. Appendix 16 Pandemic Flu Page 34

35 Submit an AAR to the MDCH Emergency Preparedness Coordinator at OPHP within 30 days of the conclusion of the incident. Develop a Corrective Action Plan. Review and update PHDM Public Health Emergency Response plan and the PHDM Pandemic Influenza plan based on Corrective Action Plan. B. Risk Communication (Post Pandemic Phase) State Level Responsibilities Lead: MDCH Communications Office/OPHP The MDCH Executive Committee will determine that an end to the first wave or to the pandemic should be declared. This will follow an international (WHO) declaration and/or national (CDC) declaration. State level responsibilities for influenza communications during the post-pandemic stage include: The MDCH will notify LHD partners and the public of the end of the first wave, but advise of the need to remain alert and continue surveillance for another wave. This will be communicated using press releases, the MIHAN, professional organizations, etc. When appropriate, MDCH shall notify all partners and the public of the end of the pandemic. The MDCH PIO shall prepare final news releases and advise media representatives of points-of-contact for follow-up stories. MDCH shall evaluate the response to the pandemic and produce an after action report (AAR) which will review emergency communication activities, including media relations, health recommendations to the public, and rumor control. Useful evaluation documents include press releases, press clips, a summary of public reactions and concerns based on communication with other public health agencies, and a final chronology of the event. Continue reporting adverse events associated with vaccine or antivirals via VAERS or AERS, respectively. PHDM Responsibilities Follow directive from the MDCH and notify local partners of the end of the first wave, but advise of the need to remain alert and continue surveillance to detect and respond to a possible second wave of illness, or notify partners of the pandemic end. Participate in evaluation of the pandemic communications response and identify areas that worked well and those that will require Risk Communication Plan adjustment. Produce an AAR summarizing lessons learned from the pandemic. The AAR must be submitted to the MDCH EPC in OPHP within 30 days from the declaration of the end of the incident. C. Surveillance (Post Pandemic Phase) The MDCH executive committee will determine that an end to the first wave or to the pandemic should be declared using information from the CDC. See the MDCH Pandemic Plan: MDCH - MDCH Pandemic Plan (v4.0) Redacted. Appendix 16 Pandemic Flu Page 35

36 State Level Responsibilities Lead: BOE Assist in notifying Local Health Departments and other partners of the end of the first wave and/or that an end to the pandemic is declared. Continue surveillance for influenza according to CDC recommendations. Maintain high level of sentinel provider surveillance to aid detection of successive waves of influenza outbreaks, pandemic or otherwise. Review participation status of enrolled sites and recruit new sites as needed to maintain high participation rates. Compile and distribute an AAR on surveillance activities including a review of surveillance structure, identification of system weaknesses and recommendations for improvement. This will also be sent to OPHP to be included in the MDCH agency AAR. Compile, analyze and distribute data pertaining to vaccine efficacy in collaboration with the Immunization Division. Summarize findings from the epidemiological characteristics of the pandemic in Michigan and submit to the Director of MDCH and to CDC. Review, evaluate and update surveillance component of the pandemic response plan. Assess vaccine coverage and determine the number of people who remain unprotected. PHDM Responsibilities Continue increased influenza surveillance with local partners according to MDCH recommendations. Communicate to health care facilities the need to remain vigilant in facility-specific surveillance activities to avoid an unrecognized second wave within the facility. Maintain high level of sentinel provider surveillance to aid detection of successive waves of influenza outbreaks, pandemic or otherwise. Review participation status of enrolled sites and continue recruitment of new sites in order to maintain high participation rates within the jurisdiction. Compile an AAR on surveillance activities including a review of surveillance structures, identification of system weaknesses and recommendations for improvement. Submit to OPHP for inclusion into the State AAR. Implement updated surveillance protocols as identified in the AAR. In coordination with MDCH, provide surveillance summaries to health care facilities, Emergency Medical Services, local law enforcement agencies, and local private and public partners. Report pandemic-related summaries and other relevant information to MDCH. Review and address gaps in surveillance reporting systems for influenza-associated morbidity and mortality. Review, evaluate, and modify, as needed, the surveillance component of the local pandemic response. D. Laboratory Guidelines (Post Pandemic Phase) State Level Responsibilities Lead: BOL The Virology Section at the Bureau of Labs will maintain routine testing of specimens submitted by sentinel influenza sites. This system will be augmented with other activities according to CDC recommendations. Appendix 16 Pandemic Flu Page 36

37 The Bureau of Labs will evaluate its pandemic response and document lessons learned with an AAR in order to improve response to future pandemics or public health emergencies and forward it to the OPHP Emergency Management Coordinator. PHDM Responsibilities Continue to communicate laboratory-specific information received from MDCH Bureau of Labs to health care facilities and providers. Monitor disease reporting and assist with ongoing surveillance and specimen submissions. Develop AAR as necessary and forward to Emergency Preparedness Coordinator. Assess status of resources and supplies. Assist CDC and MDCH with specimen requests and post-event assessments. E. Community Containment & Infection Control (Post Pandemic) State Level Responsibilities Lead: BOE Assess impact of community containment measures with local public health partners, including secondary, tertiary and unintended consequences. The MDCH Executive Committee will make recommendations for transition from response to recovery phase. Terminate emergency orders or community containment measures as indicated. Compile an AAR and CAP, review and submit to the MDCH Exercise Coordinator. Implement Corrective Action Plan components as indicated. PHDM Responsibilities The Health Officer or designee, in consultation with the Medical Director, will make the determination to release an individual or individuals from isolation or quarantine based on criteria set forth in the PHDM Public Health All Hazard Plan, Annex D, Isolation & Quarantine Plan. Infection control activities for the post pandemic phase include: Assess impact of community containment measures, including secondary, tertiary and unintended consequences. Facilitate recovery phase of response. Assess the effectiveness of community containment measures with MDCH. Terminate emergency orders or community containment measures as indicated. Compile an AAR and CAP. Implement CAP. Continue to participate in surveillance and monitoring activities and remain vigilant to a potential second wave of pandemic influenza. Consider continuing telephone triage system for a period of time once the end of the pandemic phase has been declared. Appendix 16 Pandemic Flu Page 37

38 F. Medical Management, Vaccines and Antivirals (Post Pandemic) State Level Responsibilities Leads: BOL and OPHP Continue sharing information with CDC about adverse events associated with vaccine or antiviral medication via VAERS or AERS, respectively. MDCH and CDC will determine when to discontinue the adverse events reporting system. MDCH, in conjunction with CDC recommendations, will determine need to discontinue distribution of antivirals and make recommendations to local public health. MDCH will compile and distribute lessons learned regarding the treatment and prophylaxis process to aid in planning for future pandemics or other public health emergencies. MDCH will give directions to LHDs on the return of unused vaccines, drugs, and other equipment. MDCH will continue to provide public health recommendations to health care providers as requested and appropriate. PHDM Responsibilities Contribute after action items and review to the MDCH AAR and CAP. These serve to aid in planning for future public health emergencies. Return all unused and unopened vaccines and antivirals according to directives from MDCH. G. Data Management (Post Pandemic Phase) State Level Responsibilities Assess performance of various data systems and take steps to upgrade as necessary. Make data available for research and review to develop clearer understandings of pandemic characteristics or state response. PHDM Responsibilities Assess local performance of various data systems utilized during pre and pandemic phases and take steps to upgrade as necessary. Make data available for research and review to develop clearer understandings of pandemic characteristics or state response. H. Border Health and Travel Issues (Post Pandemic Phase) State Level Responsibilities Upon de-activation of any federal travel measures or emergency orders, notify stakeholders of changes in travel advisories. Assess impact of border measures upon resources or citizens. Appendix 16 Pandemic Flu Page 38

39 PHDM Responsibility Upon de-activation of any federal travel measures or emergency orders, notify stakeholders of changes in travel advisories. Assess impact of border measures upon resources or citizens. I. Recovery/Consequence Management (Post Pandemic Phase) State Level Responsibilities Lead: MDCH Administration/OPHP Provide Traumatic Incident Stress Management (TISM) Serves affected state employees. Provides comprehensive statewide support, assessment and intervention services to state employees who are impacted by a traumatic situation related to the workplace. Provides services, which include consultation, on-site support, individual crisis intervention, group services such as defusing or debriefing sessions, and referral and follow-up. Functions under the leadership of the Employee Services Program with MDCH leadership provided by the MDCH Department Coordinator. Take lessons learned and modify existing plans as needed. Develop and review event summary utilizing the MDCH AAR and CAP. Provide guidance to LHDs and other state and local agencies for the recovery and maintenance of the public health infrastructure, as pandemic influenza constitutes a significant public health emergency. Other activities may be added as conditions dictate. Most of the activities listed below will be initiated locally with assistance and guidance from multiple state agencies including MDCH. The Michigan Emergency Management Plan contains information regarding roles and responsibilities of state and local agencies in these efforts. (OPHP has this on file.) Identify effective surveillance, community containment and infection control procedures in preparation for a possible second pandemic wave. PHDM Responsibilities People involved in a disaster can experience depression, anxiety and post-traumatic stress disorder. Planning for and responding to these mental health issues can help alleviate the pain and suffering that may accompany large-scale tragedies of every type. See the PHDM All Hazard Public Health Emergency Response Plan, Section XII for Mental Health Information. Other responsibilities Short Term Recovery Responsibilities: In cooperation with county Emergency Management, implement methodology for postdecontamination vehicle and equipment restoration and re-supply Federal assistance programs (individual and public) Evaluate the need for long-term mental health support Restoration of comprehensive public health services and health care facilities Appendix 16 Pandemic Flu Page 39

40 Long Tem Recover Period Responsibilities Risk assessment and review Economic redevelopment Establish community recovery programs Consider pulling together local health care and emergency first responders for an overall AAR Take lessons learned and modify existing plans as needed Identify effective surveillance, community containment and infection control procedures in preparation for a possible second pandemic wave Implement measures to assist community and public health to return to baseline status IX. References U.S. Department of Health and Human Services Pandemic Flu Plan and Information: Centers for Disease Control and Prevention: Influenza References and Resources: CDC National Immunization Program: World Health Organization: Planning Guidance for State and Local Health Departments: Pandemic Flu Website Center for Infectious Disease Research and Policy - PHDM web site Pandemic Influenza Plan Appendix 16 Pandemic Flu Page 40

41 A.1: Pandemic Influenza Manager Position Assigned to: Pandemic Influenza Manager You Report To: Mission: The Pandemic Influenza Manager is responsible for workplace health and safety and to carry out the Pandemic Influenza Response Plan. Job Duties: Duties the Pandemic Influenza Manager will perform included: Immediate Duties Seek out and obtain knowledge in Pandemic Influenza Procure credible sources of information for use in the Education Plan Develop and institute an Employee Education Plan Develop employee monitoring plan for Influenza Like Illness (ILI) Contact potential individuals who may be utilized as a Medical Advisor, discuss position duties and enlist their assistance Develop a process for employee return to work Assure the workplace has sufficient personal hygiene and environmental cleaning supplies, monitor inventory and re-order when needed Identify workplace practices or engineering controls that can be instituted Erect barriers, increase social distancing, reduce or eliminate group meetings, remove commonly shared items Increase cleaning frequency throughout the day Duties when Pandemic is declared Monitor the progression of the disease while being alert to health authority advisories, institute advancing measures as warranted Implement the Education Plan, conduct employee training Monitor all employees, assess those who are ill, or suspected to be ill, determining if employee meets the Influenza Like Illness criteria (see ILI Assessment Form) Investigate contacts and conduct contact tracing to limit disease spread Notify the employee s direct supervisor of ILI assessment results As employees are excused from work, ensure those employees are cared for in their homes or health care facility; notify the employee s primary physician Report illness cases to local public health on a daily basis Appendix 16 Pandemic Flu Page 41

42 A.2: Clinical Management Flow Chart Appendix 16 Pandemic Flu Page 42

43 A.3: Case Detection (Flow Chart) Appendix 16 Pandemic Flu Page 43

44 A.4: HHS Vaccine Tiered Priority Groups Appendix 16 Pandemic Flu Page 44

45 A.5: Graded Community Containment Measures Level of Influenza Activity No Novel influenza strains of public health concern in global circulation. Phase 0 Limited novel influenza virus transmission abroad; all local cases are either imported or have clear epidemiological links to other cases. Phase I & II Limited novel influenza virus transmission in the area, with either a small number of cases without clear epidemiological links to other cases or with increased occurrence of influenza among their close contacts. Phase III & IV Sustained novel influenza virus transmission in the area, with a large number of cases without clear epidemiological links to other cases; control measures aimed at individuals and groups appear to be effective. Phase V Sustained novel influenza activity in the area, with a large number of cases in persons without an identifiable epidemiological link at the time of initial evaluation; control measures are believed to be effective. Phase VI Decrease in the number of new cases, unlinked (or unexpected) cases, and generations of transmission. Phase VI Transmission has been controlled or eliminated; no new cases reported. Phase VI Response Preparedness planning Quarantine close contacts Quarantine close contacts Focused measures to increase social distance; consider community-based measures Community-level measures to increase social distance; consider snow days and community-wide quarantine Quarantine of contacts Active monitoring in high-risk populations; continue for 2-3 incubation periods after control or elimination of transmission Appendix 16 Pandemic Flu Page 45

46 A.6: Antiviral Drug Priority Groups Group Strategy Rationale 1 Patients admitted to hospital T Consist with medical practice and ethics to treat those serious illness and most likely to die 2 Health care workers with direct patient contact and Emergency medical service (EMS) 3 Highest risk outpatient immunocompromised persons and pregnant women 4 Pandemic health responders: public health vaccinators, public safety: police, fire, corrections, government decision makers 5 Increased risk outpatients: young children months, >65 years old, persons with underlying chronic health conditions 6 Outbreak response in nursing homes, long term care facilities, other residential facilities 7 Health care workers in emergency departments, intensive care units, dialysis centers, EMS providers 8 Pandemic societal responders: critical infrastructure groups and health care workers without direct patient contact T T T T PEP P T Health care workers are required for quality care. There is little surge capacity among health care sector personnel to meet increased demand Groups at greatest risk of hospitalization & death: immunocompromized cannot be protected by vaccination Groups are critical for an effective public health response to a pandemic Groups at high risk for hospitalization & death Treatment of patients and prophylaxis of contacts is effective in stopping outbreaks; vaccination priorities do not include nursing home residents These groups are most critical to an effective health care response and have limited surge capacity. Prophylaxis will best prevent absenteeism Infrastructure groups that have impact on maintaining health, implementing a pandemic response, and maintaining societal functions 9 Other outpatients T Includes other who develop influenza and do not fall within above groups 10 Highest risk outpatients P Prevents illness in the highest risk groups for hospitalization & death 11 Other Health care workers with direct patient contact P Prevention would best reduce absenteeism and preserve optimal function Strategy: T- Treatment: requires 10 capsules and is defined as a single course. PEP- Post Exposure Prophylaxis: Also requires a single course. Appendix 16 Pandemic Flu Page 46

47 P- Prophylaxis: Is assumed to require 40 capsules (4 courses) although more may be needed if outbreak continues for a longer period. * Treatment initiated within 48 hours of onset of symptoms The CDC Advisory Committee on Immunization Practices defines groups at high risk (or increased risk) of complications from influenza infection during annual outbreaks based on age (6-23 months and > 65 years) and underlying illness. These include persons with hematopoetic stem cell transports and solid organ transplants; those with severe immunosuppression due to chemotherapy or disease conditions; persons receiving immunosuppression therapy for other illness; persons with HIV+ and CD4 counts of < 200; persons on dialysis treatment; and women in their second or third trimester of pregnancy. Appendix 16 Pandemic Flu Page 47

48 A.7: Influenza Case Definition The Centers for Disease Control and Prevention defines an influenza-like illness as having the following symptoms: Fever greater than 101.4º degrees Fahrenheit AND ONE OR MORE OF THE FOLLOWING Cough Sore throat Headache Muscle ache A student with flu-like symptoms must be sent to the office for screening (symptom check and/or taking temperature). If student meets the case definition as described above, he/she must be excluded from school until symptom free. Appendix 16 Pandemic Flu Page 48

49 A.8: Fact Sheet on Avian Influenza for Providers Avian influenza ("bird flu") - Fact sheet February 2006 The disease in birds The role of migratory birds Countries affected by outbreaks in birds The disease in humans History and epidemiology Assessment of possible cases Clinical features Countries with human cases in the current outbreak THE DISEASE IN BIRDS Avian influenza is an infectious disease of birds caused by type A strains of the influenza virus. The disease occurs worldwide. While all birds are thought to be susceptible to infection with avian influenza viruses, many wild bird species carry these viruses with no apparent signs of harm. Other bird species, including domestic poultry, develop disease when infected with avian influenza viruses. In poultry, the viruses cause two distinctly different forms of disease one common and mild, the other rare and highly lethal. In the mild form, signs of illness may be expressed only as ruffled feathers, reduced egg production, or mild effects on the respiratory system. Outbreaks can be so mild they escape detection unless regular testing for viruses is in place. In contrast, the second and far less common highly pathogenic form is difficult to miss. First identified in Italy in 1878, highly pathogenic avian influenza is characterized by sudden onset of severe disease, rapid contagion, and a mortality rate that can approach 100% within 48 hours. In this form of the disease, the virus not only affects the respiratory tract, as in the mild form, but also invades multiple organs and tissues. The resulting massive internal haemorrhaging has earned it the lay name of chicken Ebola. All 16 HA (haemagluttinin) and 9 NA (neuraminidase) subtypes of influenza viruses are known to infect wild waterfowl, thus providing an extensive reservoir of influenza viruses perpetually Appendix 16 Pandemic Flu Page 49

50 circulating in bird populations. In wild birds, routine testing will nearly always find some influenza viruses. The vast majority of these viruses cause no harm. To date, all outbreaks of the highly pathogenic form of avian influenza have been caused by viruses of the H5 and H7 subtypes. Highly pathogenic viruses possess a tell-tale genetic trade mark or signature a distinctive set of basic amino acids in the cleavage site of the HA that distinguishes them from all other avian influenza viruses and is associated with their exceptional virulence. Not all virus strains of the H5 and H7 subtypes are highly pathogenic, but most are thought to have the potential to become so. Recent research has shown that H5 and H7 viruses of low pathogenicity can, after circulation for sometimes short periods in a poultry population, mutate into highly pathogenic viruses. Considerable circumstantial evidence has long suggested that wild waterfowl introduce avian influenza viruses, in their low pathogenic form, to poultry flocks, but do not carry or directly spread highly pathogenic viruses. This role may, however, have changed very recently: at least some species of migratory waterfowl are now thought to be carrying the H5N1 virus in its highly pathogenic form and introducing it to new geographical areas located along their flight routes. Apart from being highly contagious among poultry, avian influenza viruses are readily transmitted from farm to farm by the movement of live birds, people (especially when shoes and other clothing are contaminated), and contaminated vehicles, equipment, feed, and cages. Highly pathogenic viruses can survive for long periods in the environment, especially when temperatures are low. For example, the highly pathogenic H5N1 virus can survive in bird faeces for at least 35 days at low temperature (4oC). At a much higher temperature (37oC), H5N1 viruses have been shown to survive, in faecal samples, for six days. For highly pathogenic disease, the most important control measures are rapid culling of all infected or exposed birds, proper disposal of carcasses, the quarantining and rigorous disinfection of farms, and the implementation of strict sanitary, or biosecurity, measures. Restrictions on the movement of live poultry, both within and between countries, are another important control measure. The logistics of recommended control measures are most straightforward when applied to large commercial farms, where birds are housed indoors, usually under strictly controlled sanitary conditions, in large numbers. Control is far more difficult under poultry production systems in which most birds are raised in small backyard flocks scattered throughout rural or periurban areas. When culling the first line of defence for containing outbreaks fails or proves impracticable, vaccination of poultry in a high-risk area can be used as a supplementary emergency measure, provided quality-assured vaccines are used and recommendations from the World Organisation for Animal Health (OIE) are strictly followed. The use of poor quality vaccines or vaccines that poorly match the circulating virus strain may accelerate mutation of the virus. Poor quality animal vaccines may also pose a risk for human health, as they may allow infected birds to shed virus while still appearing to be disease-free. Apart from being difficult to control, outbreaks in backyard flocks are associated with a heightened risk of human exposure and infection. These birds usually roam freely as they scavenge for food and often mingle with wild birds or share water sources with them. Such Appendix 16 Pandemic Flu Page 50

51 situations create abundant opportunities for human exposure to the virus, especially when birds enter households or are brought into households during adverse weather, or when they share areas where children play or sleep. Poverty exacerbates the problem: in situations where a prime source of food and income cannot be wasted, households frequently consume poultry when deaths or signs of illness appear in flocks. This practice carries a high risk of exposure to the virus during slaughtering, defeathering, butchering, and preparation of poultry meat for cooking, but has proved difficult to change. Moreover, as deaths of birds in backyard flocks are common, especially under adverse weather conditions, owners may not interpret deaths or signs of illness in a flock as a signal of avian influenza and a reason to alert the authorities. This tendency may help explain why outbreaks in some rural areas have smouldered undetected for months. The frequent absence of compensation to farmers for destroyed birds further works against the spontaneous reporting of outbreaks and may encourage owners to hide their birds during culling operations. THE ROLE OF MIGRATORY BIRDS During 2005, an additional and significant source of international spread of the virus in birds became apparent for the first time, but remains poorly understood. Scientists are increasingly convinced that at least some migratory waterfowl are now carrying the H5N1 virus in its highly pathogenic form, sometimes over long distances, and introducing the virus to poultry flocks in areas that lie along their migratory routes. Should this new role of migratory birds be scientifically confirmed, it will mark a change in a long-standing stable relationship between the H5N1 virus and its natural wild-bird reservoir. Evidence supporting this altered role began to emerge in mid-2005 and has since been strengthened. The die-off of more than 6000 migratory birds, infected with the highly pathogenic H5N1 virus, that began at the Qinghai Lake nature reserve in central China in late April 2005, was highly unusual and probably unprecedented. Prior to that event, wild bird deaths from highly pathogenic avian influenza viruses were rare, usually occurring as isolated cases found within the flight distance of a poultry outbreak. Scientific studies comparing viruses from different outbreaks in birds have found that viruses from the most recently affected countries, all of which lie along migratory routes, are almost identical to viruses recovered from dead migratory birds at Qinghai Lake. Viruses from Turkey s first two human cases, which were fatal, were also virtually identical to viruses from Qinghai Lake. COUNTRIES AFFECTED BY OUTBREAKS IN BIRDS The outbreaks of highly pathogenic H5N1 avian influenza that began in south-east Asia in mid and have now spread to a few parts of Europe, are the largest and most severe on record. To date, nine Asian countries have reported outbreaks (listed in order of reporting): the Republic of Korea, Viet Nam, Japan, Thailand, Cambodia, the Lao People s Democratic Republic, Indonesia, China, and Malaysia. Of these, Japan, the Republic of Korea, and Malaysia have controlled their outbreaks and are now considered free of the disease. Elsewhere in Asia, the virus has become endemic in several of the initially affected countries. In late July 2005, the virus spread geographically beyond its original focus in Asia to affect poultry and wild birds in the Russian Federation and adjacent parts of Kazakhstan. Almost simultaneously, Mongolia reported detection of the highly pathogenic virus in wild birds. In Appendix 16 Pandemic Flu Page 51

52 October 2005, the virus was reported in Turkey, Romania, and Croatia. In early December 2005, Ukraine reported its first outbreak in domestic birds. Most of these newer outbreaks were detected and reported quickly. Further spread of the virus along the migratory routes of wild waterfowl is, however, anticipated. Moreover, bird migration is a recurring event. Countries that lie along the flight pathways of birds migrating from central Asia may face a persistent risk of introduction or re-introduction of the virus to domestic poultry flocks. Prior to the present situation, outbreaks of highly pathogenic avian influenza in poultry were considered rare. Excluding the current outbreaks caused by the H5N1 virus, only 24 outbreaks of highly pathogenic avian influenza have been recorded worldwide since Of these, 14 occurred in the past decade. The majority have shown limited geographical spread, a few remained confined to a single farm or flock, and only one spread internationally. All of the larger outbreaks were costly for the agricultural sector and difficult to control. THE DISEASE IN HUMANS History and epidemiology. Influenza viruses are normally highly species-specific, meaning that viruses that infect an individual species (humans, certain species of birds, pigs, horses, and seals) stay true to that species, and only rarely spill over to cause infection in other species. Since 1959, instances of human infection with an avian influenza virus have been documented on only 10 occasions. Of the hundreds of strains of avian influenza A viruses, only four are known to have caused human infections: H5N1, H7N3, H7N7, and H9N2. In general, human infection with these viruses has resulted in mild symptoms and very little severe illness, with one notable exception: the highly pathogenic H5N1 virus. Of all influenza viruses that circulate in birds, the H5N1 virus is of greatest present concern for human health for two main reasons. First, the H5N1 virus has caused by far the greatest number of human cases of very severe disease and the greatest number of deaths. It has crossed the species barrier to infect humans on at least three occasions in recent years: in Hong Kong in 1997 (18 cases with six deaths), in Hong Kong in 2003 (two cases with one death) and in the current outbreaks that began in December 2003 and were first recognized in January A second implication for human health, of far greater concern, is the risk that the H5N1 virus if given enough opportunities will develop the characteristics it needs to start another influenza pandemic. The virus has met all prerequisites for the start of a pandemic save one: an ability to spread efficiently and sustainably among humans. While H5N1 is presently the virus of greatest concern, the possibility that other avian influenza viruses, known to infect humans, might cause a pandemic cannot be ruled out. The virus can improve its transmissibility among humans via two principal mechanisms. The first is a reassortment event, in which genetic material is exchanged between human and avian viruses during co-infection of a human or pig. Reassortment could result in a fully transmissible pandemic virus, announced by a sudden surge of cases with explosive spread. The second mechanism is a more gradual process of adaptive mutation, whereby the capability of the virus to bind to human cells increases during subsequent infections of humans. Adaptive mutation, expressed initially as small clusters of human cases with some evidence of human-to- Appendix 16 Pandemic Flu Page 52

53 human transmission, would probably give the world some time to take defensive action, if detected sufficiently early. During the first documented outbreak of human infections with H5N1, which occurred in Hong Kong in 1997, the 18 human cases coincided with an outbreak of highly pathogenic avian influenza, caused by a virtually identical virus, in poultry farms and live markets. Extensive studies of the human cases determined that direct contact with diseased poultry was the source of infection. Studies carried out in family members and social contacts of patients, health workers engaged in their care, and poultry cullers found very limited, if any, evidence of spread of the virus from one person to another. Human infections ceased following the rapid destruction within three days of Hong Kong s entire poultry population, estimated at around 1.5 million birds. Some experts believe that that drastic action may have averted an influenza pandemic. All evidence to date indicates that close contact with dead or sick birds is the principal source of human infection with the H5N1 virus. Especially risky behaviours identified include the slaughtering, defeathering, butchering and preparation for consumption of infected birds. In a few cases, exposure to chicken faeces when children played in an area frequented by freeranging poultry is thought to have been the source of infection. Swimming in water bodies where the carcasses of dead infected birds have been discarded or which may have been contaminated by faeces from infected ducks or other birds might be another source of exposure. In some cases, investigations have been unable to identify a plausible exposure source, suggesting that some as yet unknown environmental factor, involving contamination with the virus, may be implicated in a small number of cases. Some explanations that have been put forward include a possible role of peri-domestic birds, such as pigeons, or the use of untreated bird faeces as fertilizer. At present, H5N1 avian influenza remains largely a disease of birds. The species barrier is significant: the virus does not easily cross from birds to infect humans. Despite the infection of tens of millions of poultry over large geographical areas since mid-2003, fewer than 200 human cases have been laboratory confirmed. For unknown reasons, most cases have occurred in rural and periurban households where small flocks of poultry are kept. Again for unknown reasons, very few cases have been detected in presumed high-risk groups, such as commercial poultry workers, workers at live poultry markets, cullers, veterinarians, and health staff caring for patients without adequate protective equipment. Also lacking is an explanation for the puzzling concentration of cases in previously healthy children and young adults. Research is urgently needed to better define the exposure circumstances, behaviours, and possible genetic or immunological factors that might enhance the likelihood of human infection. Assessment of possible cases. Investigations of all the most recently confirmed human cases, in China, Indonesia, and Turkey, have identified direct contact with infected birds as the most likely source of exposure. When assessing possible cases, the level of clinical suspicion should be heightened for persons showing influenza-like illness, especially with fever and symptoms in the lower respiratory tract, who have a history of close contact with birds in an area where confirmed outbreaks of highly pathogenic H5N1 avian influenza are occurring. Exposure to an environment that may have been contaminated by faeces from infected birds is a second, though less common, source of human infection. To date, not all human cases have arisen from exposure to dead or visibly ill domestic birds. Research published in 2005 has shown that domestic ducks can excrete large quantities of highly pathogenic virus without showing signs of illness. A history of poultry consumption in an affected country is not a risk factor, provided the food was Appendix 16 Pandemic Flu Page 53

54 thoroughly cooked and the person was not involved in food preparation. As no efficient humanto-human transmission of the virus is known to be occurring anywhere, simply travelling to a country with ongoing outbreaks in poultry or sporadic human cases does not place a traveller at enhanced risk of infection, provided the person did not visit live or wet poultry markets, farms, or other environments where exposure to diseased birds may have occurred. Clinical features 1. In many patients, the disease caused by the H5N1 virus follows an unusually aggressive clinical course, with rapid deterioration and high fatality. Like most emerging disease, H5N1 influenza in humans is poorly understood. Clinical data from cases in 1997 and the current outbreak are beginning to provide a picture of the clinical features of disease, but much remains to be learned. Moreover, the current picture could change given the propensity of this virus to mutate rapidly and unpredictably. The incubation period for H5N1 avian influenza may be longer than that for normal seasonal influenza, which is around two to three days. Current data for H5N1 infection indicate an incubation period ranging from two to eight days and possibly as long as 17 days. However, the possibility of multiple exposure to the virus makes it difficult to define the incubation period precisely. WHO currently recommends that an incubation period of seven days be used for field investigations and the monitoring of patient contacts. Initial symptoms include a high fever, usually with a temperature higher than 38oC, and influenza-like symptoms. Diarrhoea, vomiting, abdominal pain, chest pain, and bleeding from the nose and gums have also been reported as early symptoms in some patients. Watery diarrhoea without blood appears to be more common in H5N1 avian influenza than in normal seasonal influenza. The spectrum of clinical symptoms may, however, be broader, and not all confirmed patients have presented with respiratory symptoms. In two patients from southern Viet Nam, the clinical diagnosis was acute encephalitis; neither patient had respiratory symptoms at presentation. In another case, from Thailand, the patient presented with fever and diarrhoea, but no respiratory symptoms. All three patients had a recent history of direct exposure to infected poultry. One feature seen in many patients is the development of manifestations in the lower respiratory tract early in the illness. Many patients have symptoms in the lower respiratory tract when they first seek treatment. On present evidence, difficulty in breathing develops around five days following the first symptoms. Respiratory distress, a hoarse voice, and a crackling sound when inhaling are commonly seen. Sputum production is variable and sometimes bloody. Most recently, blood-tinted respiratory secretions have been observed in Turkey. Almost all patients develop pneumonia. During the Hong Kong outbreak, all severely ill patients had primary viral pneumonia, which did not respond to antibiotics. Limited data on patients in the current outbreak indicate the presence of a primary viral pneumonia in H5N1, usually without microbiological evidence of bacterial supra-infection at presentation. Turkish clinicians have also reported pneumonia as a consistent feature in severe cases; as elsewhere, these patients did not respond to treatment with antibiotics. In patients infected with the H5N1 virus, clinical deterioration is rapid. In Thailand, the time between onset of illness to the development of acute respiratory distress was around six days, with a range of four to 13 days. In severe cases in Turkey, clinicians have observed respiratory failure three to five days after symptom onset. Another common feature is multiorgan Appendix 16 Pandemic Flu Page 54

55 dysfunction. Common laboratory abnormalities, include leukopenia (mainly lymphopenia), mildto-moderate thrombocytopenia, elevated aminotransferases, and with some instances of disseminated intravascular coagulation. Limited evidence suggests that some antiviral drugs, notably oseltamivir (commercially known as Tamiflu), can reduce the duration of viral replication and improve prospects of survival, provided they are administered within 48 hours following symptom onset. However, prior to the outbreak in Turkey, most patients have been detected and treated late in the course of illness. For this reason, clinical data on the effectiveness of oseltamivir are limited. Moreover, oseltamivir and other antiviral drugs were developed for the treatment and prophylaxis of seasonal influenza, which is a less severe disease associated with less prolonged viral replication. Recommendations on the optimum dose and duration of treatment for H5N1 avian influenza, also in children, need to undergo urgent review, and this is being undertaken by WHO. In suspected cases, oseltamivir should be prescribed as soon as possible (ideally, within 48 hours following symptom onset) to maximize its therapeutic benefits. However, given the significant mortality currently associated with H5N1 infection and evidence of prolonged viral replication in this disease, administration of the drug should also be considered in patients presenting later in the course of illness. Currently recommended doses of oseltamivir for the treatment of influenza are contained in the product information at the manufacturer s web site. The recommended dose of oseltamivir for the treatment of influenza, in adults and adolescents 13 years of age and older, is 150 mg per day, given as 75 mg twice a day for five days. Oseltamivir is not indicated for the treatment of children younger than one year of age. As the duration of viral replication may be prolonged in cases of H5N1 infection, clinicians should consider increasing the duration of treatment to seven to ten days in patients who are not showing a clinical response. In cases of severe infection with the H5N1 virus, clinicians may need to consider increasing the recommended daily dose or the duration of treatment, keeping in mind that doses above 300 mg per day are associated with increased side effects. For all treated patients, consideration should be given to taking serial clinical samples for later assay to monitor changes in viral load, to assess drug susceptibility, and to assess drug levels. These samples should be taken only in the presence of appropriate measures for infection control. In severely ill H5N1 patients or in H5N1 patients with severe gastrointestinal symptoms, drug absorption may be impaired. This possibility should be considered when managing these patients. COUNTRIES WITH HUMAN CASES IN THE CURRENT OUTBREAK To date, human cases have been reported in six countries, most of which are in Asia: Cambodia, China, Indonesia, Thailand, Turkey, and Viet Nam. The first patients in the current outbreak, which were reported from Viet Nam, developed symptoms in December 2003 but were not confirmed as H5N1 infection until 11 January Thailand reported its first cases on 23 January The first case in Cambodia was reported on 2 February The next country to report cases was Indonesia, which confirmed its first infection on 21 July. China s first two cases were reported on 16 November Confirmation of the first cases in Turkey came on 5 Appendix 16 Pandemic Flu Page 55

56 January 2006, followed by the first reported case in Iraq on 30 January All human cases have coincided with outbreaks of highly pathogenic H5N1 avian influenza in poultry. To date, Viet Nam has been the most severely affected country, with more than 90 cases. Altogether, more than half of the laboratory-confirmed cases have been fatal. H5N1 avian influenza in humans is still a rare disease, but a severe one that must be closely watched and studied, particularly because of the potential of this virus to evolve in ways that could start a pandemic. 1 This section has been reviewed by a virtual network of clinicians experienced in the treatment of H5N1 infections and other severe respiratory diseases. The network was convened for the first time on 16 January Physicians from Yüzüncü Yil University, Faculty of Medicine, Van, Turkey participated in the exchange of information and experiences. Other institutions represented include the University of Hong Kong (China); the Hospital for Tropical Diseases, Ho Chi Minh City (Viet Nam); and the University of Virginia, Charlottesville, Virginia (USA). Appendix 16 Pandemic Flu Page 56

57 A.9: MCIR All Hazards Module Activation In any public health emergency affecting the community, the MCIR All Hazards module serves a useful role in tracking persons affected, treated, and/or provided prophylaxis as a result of the emergency. This tracking function allows local health departments to maintain accurate, realtime patient data, and also serves as a record keeping mechanism for short and long-term event recovery. For Pandemic Flu Preparedness, The MDCH Division of Immunization will activate the All Hazards module in MCIR at WHO Phase 4 and Federal Stage 2, and it will be operational immediately. During this phase All Hazard Scan forms will be distributed via , MCIR.ORG and/or HAN. Regional MCIR staff will begin training Local Public Health and Hospital employees on how to use the All Hazards module in MCIR. On line training will be available by 2/15/2007. For Anthrax, Botulism, Plague, Smallpox and Tularemia, the LHD Health Officer, Emergency Planning Coordinator or designee will notify OPHP of the event. OPHP will notify the Division of Immunizations at MDCH to activate the All Hazards module in MCIR specific to the event. All Hazards module will become operational immediately and enhancements to the MCIR application will occur during some events. Biological Event Happening in Local Health Jurisdiction LHD contacts OPHP at or after hour s number at to notify need for MCIR start-up. OPHP Director or Designee contacts Bureau of Immunizations or Division Director System Activated LHD can now access All Hazards module. Regional MCIR Coordinators will do Just In time training as needed. Module will be turned off at the end of the event with notification from the Community Health Emergency Coordination Center. At the conclusion of the event, the local health department will notify OPHP that the event has ended. OPHP will notify the Division of Immunizations at MDCH to turn off the All Hazards Module in MCIR. Appendix 16 Pandemic Flu Page 57

58 Depending on the size of the event, the LHD will determine data entry methods into MCIR. Current options are scan form or direct data entry into the application. If the scan forms option is selected, scan forms will be completed and faxed or mailed to the scan center or mailed to: The Michigan Department of Community Health Division of Immunization Attn: Scan Center Operations 201 Townsend Street PO Box Lansing MI Appendix 16 Pandemic Flu Page 58

59 A.10: Laboratory Guidelines Appendix 16 Pandemic Flu Page 59

60 Appendix 16 Pandemic Flu Page 60

61 Appendix 16 Pandemic Flu Page 61

62 A.11: Antiviral Therapy Virus sensitivity Administration route Prophylaxis licensure Treatment licensure Selected adverse events (see package insert) Adult treatment dose (see package insert) Adamanatane Derivitives Neuraminidase Inhibitors Amantadine Rimantadine* Oseltamivir Zanamivir Influenza A Influenza A Influenza A & Influenza A & B B Oral Oral Oral Inhalation 1 year of age > 1 year of age 13 years of Not approved age 1 year of age Adults 1 year of age 7 years of age CNS (dizziness, insomnia) may include severe as in suicidal and seizures. GI (nausea) Possible cardiac toxicity especially in overdose 200 milligrams, once daily, or, 100 milligrams twice daily, reduce for elderly and renal impaired CNS (insomnia, dizziness) GI (nausea, vomiting) 200 milligrams, once daily, or, 100 milligrams twice daily, reduce for elderly and renal impaired GI (mainly nausea, vomiting) 75 milligrams twice daily, reduce for renal impaired Generic Yes Yes No No Rimantadine is the only antiviral within the SNS Reports of bronchospasm, decreased lung function, especially with underlying lung disease 10 milligrams twice daily Appendix 16 Pandemic Flu Page 62

63 Dosage Dosage recommendations vary by age group and medical conditions. The text provided here is taken directly from Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP) (MMWR 28 May 2004; 53[RR06]:1-40). Appendix 16 Pandemic Flu Page 63

64 A.12: Guidelines for Collection & Sending Laboratory Specimens Specimen Collection Procedures for Michigan Before collecting specimens, review infection control precautions at: A. Respiratory Tract Specimens Respiratory specimens should be collected as soon as possible in the course of illness for most respiratory pathogens. The likelihood of recovering most viruses diminishes markedly >72 hours after symptom onset. Types of respiratory specimens that may be collected for viral and/or bacterial diagnostics include: 1) Nasopharyngeal wash/aspirates 2) Nasopharyngeal (N/P) swabs 3) Oropharyngeal swabs 4) Broncheoalveolar lavage 5) Tracheal aspirate 6) Pleural tap, or 7) Sputum (Note: Nasopharyngeal wash/aspirates are the specimen of choice for detection of most respiratory viruses and are the preferred collection method among children aged <2 years. 1. Upper respiratory tract: Collection of nasopharyngeal wash/aspirate Have the patient sit with the head tilted slightly backward. Using a sterile rubber bulb syringe, or 14 French catheter or similar tubing connected to a disposable, Luer-tip syringe, instill 4-5 ml of non bacteriostatic saline (ph 7.0) into one nostril. Aspirate nasopharyngeal secretions with bulb syringe or tubing connected to Luer-tip syringe or tilt the head forward and allow fluid to drain out of the nares into a sterile container. Repeat this procedure for the other nostril. Collect specimens in sterile vials. Each specimen container must be labeled with patient identifier and the date collected. Ship with cold packs to keep the sample at 4ºC. Collection of nasopharyngeal or oropharyngeal swabs Use only sterile Dacron or rayon swabs with plastic shafts. Do NOT use calcium alginate swabs or swabs with wooden sticks, as they may contain substances that inactivate some viruses and inhibit PCR testing. 1) Nasopharyngeal swabs Evaluate nasal septum; do not proceed if septum deviated. Insert swab into nostril parallel to the palate and leave in place for a few seconds to absorb secretions. If swab both nostrils, use one swab. 2) Oropharyngeal swabs- Swab both posterior pharynx and tonsillar areas, avoiding the tongue. Place swabs (whether NP or OP) immediately inot sterile vials containing viral media. Rotate swabs in fluid. Express excess fluid by turning against sides of tube and discard swabs prior to tightening the cap. Each specimen container must be labeled with patient identifier and the date collected. Ship with cold packs to keep the sample at 4ºC. Appendix 16 Pandemic Flu Page 64

65 2. Lower Respiratory tract Collection of bronchalveolar lavage, tracheal aspirate, pleural tap If these specimens have been obtained, half should be centrifuged and the cellpellet fixed in formalin. Remaining unspun fluid should be placed in sterile vials with caps which cover the threads of the tube and internal O-ring seals. If there are no internal O-rings, then seal tightly with the available cap and secure with Parafilm Each specimen container must be labeled with patient identifier and date sample was collected. Ship with cold pack to keep the sample at 4ºC. Collection of sputum Educate the patient about the difference between sputum and spit. Have the patient rinse the mouth with water then expectorate deep cough sputum directly into a sterile screwcap sputum collection cup or sterile dry container. Label with patient identifier. Ship with cold packs to keep the sample at 4ºC. Holding and Shipping Specimens Specimens should be collected as early in the course of disease as possible (as soon as influenza is considered in the differential diagnosis, or rapid influenza tests are positive) and transported to the lab. Complete a test requisition, adding the approval number supplied by EOE (call or after hours) in the Submitter s Patient Number space. Samples will not be tested without this number. If approval from BOE for testing is not available please freeze specimens taken during 72-hour observation period of the patient at -70ºC. Once MDCH BOE approves testing, samples should be expeditiously transported to MDCH BOL on dry ice. Contact the MDCH BOL ( or after hours) if assistance is needed to expedite shipment. Packages containing clinical specimens and/or diagnostic agents must conform to federal regulations. Note: Specimens shipped by commercial couriers, which may utilize air transport even when delivering within the state of Michigan, must be packed in 6.2 packaging as diagnostic specimens. Turn around time for Influenza Tests Specimens approved for testing by BOE tested positive for influenza by rapid tests need to be transported to BOL at MDCH immediately for testing. Specimens submitted in the pre-pandemic phase will be tested by Influenza A, H5 PCR. Results can be expected within 24 hours from the time the specimen arrives at the MDCH BOL, depending upon the volume of tests received. Positive results suggesting a pandemic or novel strain will require confirmation by repeat testing, and possibly retesting at CDC. Once a pandemic strain circulates widely, testing pre-approval will be discontinued at the direction of BOE staff in coordination with the BOL. Turn-around time may be extended to 2-3 days, depending upon workload. Once a pandemic strain becomes widespread, diagnostic testing may be discontinued at the direction of BOE staff in coordination with the BOL. Surveillance testing will continue for areas that have not yet had documented cases. Turn-around time will likely decrease as the volume of testing decrease Appendix 16 Pandemic Flu Page 65

66 Laboratory Biosafety Guidelines for Michigan Laboratories Handling and Processing Specimens Associated with Influenza Key Messages Information is subject to modification. Check for most recent guidelines. Laboratories performing routine hematology and clinical chemistry studies should handle specimens from potential pandemic/novel flu cases similarly to specimens containing other blood borne pathogens (e.g., hepatitis or HIV, see specific biosafety guidelines at Use Standard Precautions/Universal precautions, wear Personal Protective Equipment (lab coat & cloves) PLUS goggles and a face shield or mask and avoid creating or contain aerosols. Any procedures with potential to generate aerosols should be performed in biological safety cabinets (BSCs). When centrifuging samples, use sealed centrifuge rotors or sample cups. Rotors and cups need to be loaded and unloaded in BSC. Laboratories performing serology or RT-PCR testing should handle potential flu specimens using Standard Precautions (Previously Universal Precautions, wear PPE [lab coat & glove], avoid creating or contain aerosols). A detailed description of recommended facilities, practices, and protective equipment for the various laboratory biosafety levels (BSLs), can be found in the CDC/NIH Biosafety in Mirobiological and Biomedical Laboratories (BMBL0 Manual at Use BSL-2 with standard with standard BSL-2 work practices* for: 1) Routine examinations of bacterial and mycotic cultures; 2) Routine staining and microscopic analysis of fixed smears; 3) Final packaging of specimens to transport to diagnostic laboratories for additional testing; (Specimens should already be in a sealed, decontaminated primary container.) 4) Molecular analysis of extracted nucleic acid preparations; 5) Electron microscopic studies with glutaraldehyde-fixed grids; 6) Rapid (membrane-bound EIA) influenza tests; 7) Pathologic examination and processing formalin-fixed or otherwise inactivated tissues. Use BSL-2 Practices with Class II BSC for: 1) Aliquoting and/or diluting specimens other than blood and urine; 2) Inoculation of bacterial or mycological culture media: performing diagnostic tests that don t involve propagation of viral agents in-vitro or in-vivo; 3) Nucleic acid extraction procedures involving untreated specimens; 4) Preparation and chemical or heat fixing of smears for microscopic analysis. Use BSL 3 facility with BSL-3 work practices with shower out facilities (BSL3+) for: 1) Highly pathogenic avian influenza (HPAI) A culture, (e.g., H5N1 with specific BSL3+ conditions) which include controlled access double door entry with changing room and shower-out facilities Appendix 16 Pandemic Flu Page 66

67 2) Laboratories working with live H5N1 influenza virus or other HPAI cultures must also be certified by the USFA Restricted Animal Pathogen Program. Therefore, respiratory virus cultures of patients suspected of having H5N1 infection must NOT be offered or performed in laboratories without BLS3+ facilities. *See BMBL for explanation of BSL practices/facilties It is recommended that testing be performed by PCR assays only. For more information, visit or call the CDC public response hotline in English: (800) Español: (800) ; TTY: (800) Clinician Hotline English: * For information specific to Michigan Response, call MDCH BOE at or Virology Section Manager at Resources: Contacts: 1. Anthony Muyombwe. PhD Manager, Virology/Immunology Section Bureau of Laboratories Phone: Patricia A. Clark, MPH, Unit Manager Viral Isolation and Serology Bureau of laboratories Phone: Dr. Patricia A. Somsel, DrP.H., Director Division of Infectious Diseases Bureau of Laboratories Phone: Appendix 16 Pandemic Flu Page 67

68 A.13 Standing Orders for Antivirals STANDING ORDERS FOR RIMANTADINE HYDROCHLORIDE OVERVIEW Influenza is a contagious respiratory illness caused by Influenza type A virus (which is divided into subtypes based on two surface proteins labeled hemagglutinin (H) and neuraminidase (N)) and Influenza B virus. Influenza can cause mild to severe illness, and at times, can lead to death. The risks for complications, hospitalizations, and deaths from influenza are higher among persons aged among persons aged >65 years, young children, and persons of any age with certain underlying health conditions than among healthy older children and younger adults. Antiviral drugs for influenza are an adjunct to influenza vaccine for controlling and preventing influenza. Rimantadine was approved in 1993 for treatment and chemoprophylaxis of influenza A infection among adults and prophylaxis among children. Rimantadine treatment should be considered for adults who develop an influenza-like illness during known or suspected influenza A infection in the community. When administered within 48 hours after onset of signs and symptoms of infection caused by influenza A virus strains, rimantadine has been shown to reduce the duration of fever and systemic symptoms. In controlled studies of children over the age of 1 year, healthy adults and elderly patients, rimantadine has been shown to be safe and effective in preventing signs and symptoms of infection caused by various strains of influenza A virus. Although rimantadine is approved only for chemoprophylaxis of influenza A infection among children, rimantadine treatment for influenza A among children can be beneficial. CLINICAL FEATURES Influenza viruses are spread from person-to-person primarily through the coughing and sneezing of infected persons. The typical incubation period for influenza is 1 4 days, with an average of 2 days. Adults can be infectious from the day before symptoms begin through approximately 5 days after illness onset. Children can be infectious for > 10 days, and young children can shed virus for several days before their illness onset. Severely immunocompromised persons can shed virus for weeks or months. Symptoms of influenza include: o fever (usually high) o headache o extreme tiredness o dry cough o sore throat o runny or stuffy nose o o muscle aches nausea, vomiting, and diarrhea can also occur but are more common in children than adults. TREATMENT AND PROPHYLAXIS Any person experiencing a potentially life-threatening influenza-related illness should be treated with antiviral medications. Appendix 16 Pandemic Flu Page 68

69 Any person at high risk for serious complications of influenza and who is within the first 2 days of illness onset should be treated with antiviral medications. Pregnant women should consult their primary provider regarding use of influenza antiviral medications. Rimantadine is indicated for the treatment of uncomplicated acute illness caused by various strains of influenza A virus in adults who have been symptomatic for no more than 2 days. It is also indicated for the prophylaxis against influenza A in adults and children over 1 year of age. The medication is supplied as a tablet and as a syrup for oral administration. Each tablet contains 100 mg of rimantadine hydrochloride and each teaspoonful (5 ml) of the syrup contains 50 mg of rimantadine hydrochloride. TABLE 1: Recommended treatment of influenza with rimantadine a Dosage Duration Age Adults age b 100 mg twice daily c and d 7 days from initial onset of symptoms Adults 65 b 100 mg daily f 7 days from initial onset of symptoms a Only approved by FDA for treatment among adults. b A reduction in dosage to 100 mg/day of rimantadine is recommended for persons who have severe hepatic dysfunction or those with creatinine clearance of 10 ml/min. Other persons with less severe hepatic or renal dysfunction taking 100mg/day of rimantadine should be observed closely, and the dosage should be reduced or the drug discontinued, if necessary. c Children aged 10 years who weigh<40 kg should be administered rimantadine at a dosage of 5 mg/kg body weight/day d Rimantadine is approved by FDA for treatment among adults. However, certain specialists in the management of influenza consider rimantadine appropriate for treatment among children. Studies evaluating the efficacy of rimantadine in children are limited, but they indicate that treatment with rimantadine diminishes the severity of influenza A infection when administered within 48 hours of illness onset. e To reduce the emergence of antiviral drug-resistant viruses rimantadine therapy for persons with influenza A illness should be discontinued as soon as clinically warranted, typically after 3--5 days of treatment or within hours after the disappearance of signs and symptoms f Older nursing home residents should be administered only 100 mg/day of rimantadine. A reduction in dosage to 100 mg/day should be considered for all persons aged 65 years, if they experience possible side effects when taking 200 mg/day. TABLE 2: Recommended prophylaxis of influenza with rimantadine Age Dosage Duration 1-9 a 5mg/kg/day (up to 150 mg) in 2 divided doses b Following vaccination, 2 to 4 week period to develop an antibody response. To be maximally effective as prophylaxis, the drug must be taken each day for the duration of influenza activity in the community d a 100 mg twice daily b and c Following vaccination, 2 to 4 week period to develop an antibody Appendix 16 Pandemic Flu Page 69

70 response. To be maximally effective as prophylaxis, the drug must be taken each day for the duration of influenza activity in the community d 65 a 100 mg daily e Following vaccination, 2 to 4 week period to develop an antibody response. To be maximally effective as prophylaxis, the drug must be taken each day for the duration of influenza activity in the community d a A reduction in dosage to 100 mg/day of rimantadine is recommended for persons who have severe hepatic dysfunction or those with creatinine clearance of 10 ml/min. Other persons with less severe hepatic or renal dysfunction taking 100mg/day of rimantadine should be observed closely, and the dosage should be reduced or the drug discontinued, if necessary. b 5 mg/kg body weight of rimantadine syrup = 1 teaspoon/2.2 lbs. c Children aged 10 years who weigh<40 kg should be administered rimantadine at a dosage of 5 mg/kg body weight/day d The safety and effectiveness of rimantadine prophylaxis have not been demonstrated for longer than 6 weeks. e Older nursing home residents should be administered only 100 mg/day of rimantadine. A reduction in dosage to 100 mg/day should be considered for all persons aged 65 years, if they experience possible side effects when taking 200 mg/day. CONTRAINDICATIONS, DRUG INTERACTIONS, AND ADVERSE EVENTS The dose and safety precautions for rimantadine can change over time. Clinicians should seek the most current and comprehensive product information before using this drug as treatment or prophylaxis for influenza. Rimantadine Contraindications Rimantadine is contraindicated in patients with known hypersensitivity to any of the components of the product. Precautions: In clinical trials of rimantadine, the occurrence of seizure-like activity was observed in a small number of patients with a history of seizures who were not receiving anticonvulsant medication while taking rimantadine. If seizures develop, rimantadine should be discontinued. The safety and pharmacokinetics of rimantadine in renal and hepatic insufficiency have only been evaluated after single-dose administration. Because of the potential for accumulation of rimantadine and its metabolites in plasma, caution should be exercised when patients with renal or hepatic insufficiency are treated with rimantadine. (Fix spacing below) No clinical studies have been conducted regarding the safety or efficacy or rimantadine during pregnancy. Rimantadine should only be used during pregnancy if the potential benefit justifies the potential risk to the embryo or fetus. Rimantadine should not be administered to nursing mothers. Consideration for use must weigh the potential benefit for the mother versus the potential risk to the nursing infant/child. Rimantadine Drug Interactions: Live-attenuated influenza vaccine The use of cimetidine, acetaminophen and aspirin have shown to reduce the plasma concentration of rimantadine when coadministered. Rimantadine Adverse Events: Appendix 16 Pandemic Flu Page 70

71 Gastrointestinal side effects (nausea, vomiting, anorexia, dry mouth, and abdominal pain) were reported in controlled clinical trials using the recommended dose. CNS side effects reported were insomnia, dizziness, headache, nervousness and fatigue using the recommended dose. INFECTION CONTROL AND ENVIRONMENTAL DECONTAMINATION Infection control in healthcare facilities Use Standard and Droplet Precautions for infected individuals; only use Airborne Precautions if clinically indicated Standard precautions are recommended for environmental cleanup. Use an Environmental Protection Agency (EPA)-registered household disinfectant labeled for activity against bacteria and viruses, an EPA-registered hospital disinfectant, or EPA-registered chlorine bleach/hypochlorite solution. When generic (i.e., store brand) chlorine bleach is used, mix 2.5 tablespoons chlorine bleach with 1 gallon of cool water (1:100 dilution). Infection control in the community: Avoid close contact with persons who are ill Stay home from work and school when ill Attempt containment of the virus by covering your mouth and nose when coughing and sneezing Avoid touching your eyes, nose and mouth to prevent possible contamination. Practice frequent hand washing Get your annual flu shot every year REFERENCES CDC. Antiviral agents for influenza: background information for clinicians. Fact Sheet March 31, CDC. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunizations Practices (ACIP). MMWR July 13, 2005;54 (Early Release):1-40. Rimantadine Product Information Sheet STANDING ORDERS FOR ZANAMIVIR (RELENZA) OVERVIEW Influenza is a contagious respiratory illness caused by Influenza type A virus, divided into subtypes based on two surface proteins labeled hemagglutinin (H) and neuraminidase (N), and Influenza B virus. Influenza can cause mild to severe illness, and at times, can lead to death. The risks for complications, hospitalizations, and deaths from influenza are higher among persons aged >65 years, young children, and persons of any age with certain underlying health conditions than among healthy older children and younger adults. Antiviral drugs for influenza are an adjunct to influenza vaccine for controlling and preventing influenza. Controlled clinical trials have demonstrated the efficacy of zanamivir, a neuraminidase inhibitor, in reducing symptom duration when used for treatment of influenza infections in both influenza type A and B viruses in patients 7 years and older who have been symptomatic for no more than 2 days. Appendix 16 Pandemic Flu Page 71

72 CLINICAL FEATURES Influenza viruses are spread from person-to-person primarily through the coughing and sneezing of infected persons. The typical incubation period for influenza is 1 4 days, with an average of 2 days. Adults can be infectious from the day before symptoms begin through approximately 5 days after illness onset. Children can be infectious for > 10 days, and young children can shed virus for several days before their illness onset. Severely immunocompromised persons can shed virus for weeks or months. Symptoms of influenza include: fever (usually high) headache extreme tiredness dry cough sore throat runny or stuffy nose muscle aches nausea, vomiting, and diarrhea, also can occur but are more common in children than adults. TREATMENT AND PROPHYLAXIS Any person experiencing a potentially life-threatening influenza-related illness should be treated with antiviral medications. Any person at high risk for serious complications of influenza and who is within the first 2 days of illness onset should be treated with antiviral medications. Pregnant women should consult their primary provider regarding use of influenza antiviral medications. Zanamivir is indicated for the treatment of uncomplicated acute illness due to influenza A and B virus in adults and pediatric patients 7 years and older who have been symptomatic for no more than 2 days. Zanamivir is indicated for the prophylaxis of influenza in adults and pediatric patients 5 years of age and older in a household setting. Zanamivir is indicated for the prophylaxis for adults and adolescents in community outbreaks. The medication is supplied in a circular double-foil pack (ROTADISK) containing 4 blisters of the drug. Five ROTADISKS are packaged in a white polypropylene tube. The tube is packaged in a carton with a DISKHALER inhalation device. TABLE 1: Recommended treatment of influenza with zanamivir Age Dosage Duration Adults and children 7 years and older 10 mg twice daily 5 Days (2 oral inhalations twice daily) a TABLE 2: Recommended prophylaxis for influenza in a household setting Age Dosage Duration Adults and children 5 years and older 10 mg once daily (2 oral inhalations) a 10 days b Appendix 16 Pandemic Flu Page 72

73 TABLE 3: Recommended prophylaxis for influenza in a community outbreak Age Dosage Duration Adults and adolescents 10 mg once daily 28 days c (2 oral inhalations) a a Zanamivir administered through inhalation by using a plastic device included in the medication package. Patients will benefit from instruction and demonstration of the correct use of the device (See below for instructions). b The dose should be administered at approximately the same time each day. There are no data on the effectiveness of prophylaxis with zanamivir in a household setting when initiated more than 1.5 days after the onset of signs or symptoms in the index case. c The dose should be administered at approximately the same time each day. There are no data on the effectiveness of prophylaxis with zanamivir in a community outbreak when initiated more than 5 days after the outbreak was identified in the community. The safety and effectiveness of prophylaxis with zanamivir have not been evaluated for longer than 28 days duration. CONTRAINDICATIONS, DRUG INTERACTIONS, AND ADVERSE EVENTS The dose and safety precautions for zanamivir can change over time. Clinicians should seek the most current and comprehensive product information before using this drug as treatment or prophylaxis for influenza. Zanamivir Contraindications: Zanamivir is contraindicated in patients with known hypersensitivity to any of the components of the product. Warnings: Zanamivir is not recommended for treatment or prophylaxis of influenza in individuals with underlying airways disease (such as asthma or chronic obstructive pulmonary disease). Zanamivir has not been shown to shorten the duration of influenza in people with these diseases, and some people have had serious side effects of bronchospasm (wheezing) and worsening lung function. Serious cases of bronchospasm, including fatalities, have been reported during treatment with zanamivir in patients with and without underlying airways disease. Zanamivir should be discontinued in any patient who develops bronchospasm or decline in respiratory function; immediate treatment should be sought. If treatment with zanamivir is considered for a patient with underlying airway disease, the potential risks and benefits should be carefully weighed. If a decision is made to prescribe zanamivir for such a patient, this should be done only under conditions of careful monitoring of respiratory function, close observation, and appropriate supportive care including availability of fast-acting bronchodilators. Zanamivir Precautions: Patients should be instructed in the use of the delivery system. Instructions should include a demonstration whenever possible. Allergic-like reactions, including oropharyngeal edema, serious skin rashes, and anaphylaxis have been reported in post-marketing experience with zanamivir. The medication should be stopped and appropriate treatment instituted if an allergic reaction occurs or is suspected. Safety and efficacy have not been demonstrated in patients with high-risk underlying medical conditions. The use of zanamivir for treatment of influenza has not been show to reduce the risk of transmission of influenza to others. There are no adequate and well-controlled studies of zanamivir in pregnant women. Zanamivir should be used during pregnancy only if the potential benefit justifies the risk to the embryo or fetus. Appendix 16 Pandemic Flu Page 73

74 It is not known if whether zanamivir is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when zanamivir is administered to a nursing mother. Zanamivir Drug Interactions: Live attenuated influenza vaccine Zanamivir Adverse Events: The most common side effects during treatment with zanamivir in adults and adolescents are headache; diarrhea; nausea; vomiting; nasal irritation; bronchitis; cough; sinusitis; ear, nose and throat infections; and dizziness. In children, the most common side effects are ear, nose and throat infections; vomiting; and diarrhea. Rashes have been reported. INFECTION CONTROL AND ENVIRONMENTAL DECONTAMINATION Infection control in healthcare facilities Use Standard and Droplet Precautions for infected individuals; only use Airborne Precautions if clinically indicated Standard precautions are recommended for environmental cleanup. Use an Environmental Protection Agency (EPA)-registered household disinfectant labeled for activity against bacteria and viruses, an EPA-registered hospital disinfectant, or EPA-registered chlorine bleach/hypochlorite solution. When generic (i.e., store brand) chlorine bleach is used, mix 2.5 tablespoons chlorine bleach with 1 gallon of cool water (1:100 dilution). Infection control in the community: o Avoid close contact with persons who are ill o Stay home from work and school when ill o Attempt containment of the virus by covering your mouth and nose when coughing and sneezing o Avoid touching your eyes, nose and mouth to prevent possible contamination. o Practice frequent hand washing o Get your annual flu shot every year REFERENCES CDC. Antiviral agents for influenza: background information for clinicians. Fact Sheet March 31, CDC. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunizations Practices (ACIP). MMWR July 13, 2005;54 (Early Release):1-40. Zanamivir product information sheet Appendix 16 Pandemic Flu Page 74

75 A.14 Patient History Forms Public Health, Delta & Menominee Counties / Health History and Consent Form (Tamiflu) Please print clearly and press firmly. Dispensing site: /Date / / Last Name: First Name: Middle Initi Date of Birth: / / Age: For office use only: Weight, if under age 13 yrs.: Street Address: City: State: Zip: County: Home Phone: ( ) Alternate Phone: ( Medical Information Do you have kidney disease? Yes No Are you pregnant? Yes No Are you breastfeeding? Yes No Do you have allergies? Yes No Please List: If any of the above responses are yes, refer to a medical screener PARTICIPANT CONSENT OR REFUSAL TO RECEIVE VACCINATION OR MEDICATION I HAVE: 1) been informed of reasons why I am being vaccinated/receiving medication; 2) received the vaccine/medication information sheet indicating the risks and benefits of the vaccine/medication, its side effects, and where I will be able to receive additional information if side effects were to develop; 3) received information about the infectious agent; 4) had an opportunity to have my questions answered. I am seeking medication in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and the state and county health department. I agree to take medications as prescribed or to provide medications and instructions to the above named individual for whom I am authorized to sign. CONSENT: Participant/Parent or Guardian Signature: Date: REFUSAL: Participant/Parent or Guardian Signature: Date: STOP! (For staff use only) Adults and Adolescents Age Dosage Duration Adults and Adolescents (13 years and older) 75 mg once daily 10 days Tamiflu 75 mg capsule, orally, Renal dosage: Tamiflu 75 mg Renal Dosage: Tamiflu 30 mg oral once a day for 10 days capsule, orally, every other day suspension once a day for 10 days for 10 days Pediatric Patients The recommended dose of Tamiflu oral suspension for children greater than 1 year of age is adjusted by weight Body weight in kg Body Weight (lbs) Recommended dose # of bottles of Tamiflu for Oral Suspension Needed to Obtain the Recommended dose for a 10 day regimen Number of Tamiflu capsules Needed to obtain the recommended does for a 10 day regimen 15 kg 33 lbs 30 mg. once daily 1 10 capsules (30mg) >15 to 23 kg 33-51lbs 45mg once daily 2 10 capsules (45mg) >23 to 40 kg lbs 60 mg once daily 2 20 capsules (30 mg) >40 kg > 88lbs 75 mg once daily 3 10 capsules (75mg) Tamiflu 30mg., ½ teaspoon orally, once a day for 10 days Tamiflu 45mg., 3/4 teaspoon, orally, once a day for 10 days Tamiflu 60mg., 1teaspoon, orally, once a day for 10 days Tamiflu 75mg., 1¼ teaspoon, orally, once a day for 10 days Quantity dispensed: 10 day supply Other: AFFIX Barcode Lable Manufacturer: Lot Number: Exp Date: Staff Initials: Prescribing Physician: Date: Appendix 16 Pandemic Flu Page 75

76 Public Health, Delta & Menominee Counties / Health History and Consent Form Please print clearly and press firmly. Dispensing site: /Date / / Last Name: First Name: Middle Initial Date of Birth: / / Age: For office use only: Weight, if under age 13 yrs.: Street Address: City: State: Zip: County: Home Phone: ( ) Alternate Phone: ( ) Medical Information Do you have kidney disease? Yes No Are you pregnant? Yes No Are you breastfeeding? Yes No Do you have asthma or Chronic Obstructive Pulmonary Disease? Yes No Do you have allergies? Yes No Please List: If any of the above responses are yes, refer to a medical screener PARTICIPANT CONSENT OR REFUSAL TO RECEIVE VACCINATION OR MEDICATION I HAVE: 1) been informed of reasons why I am being vaccinated/receiving medication; 2) received the vaccine/medication information sheet indicating the risks and benefits of the vaccine/medication, its side effects, and where I will be able to receive additional information if side effects were to develop; 3) received information about the infectious agent; 4) had an opportunity to have my questions answered. I am seeking medication in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and the state and county health department. I agree to take medications as prescribed or to provide medications and instructions to the above named individual for whom I am authorized to sign. CONSENT: Participant/Parent or Guardian Signature: Date: REFUSAL: Participant/Parent or Guardian Signature: Date: STOP! (For staff use only) Adults and Adolescents Age Dosage Duration Adults and Adolescents (7 and older) 10 mg. once daily ( the 10mg dose is provided by 2 mg inhalations. Should be administered approximately the same time each day 10 days The safety and effectiveness of Relenza have not been assessed in pediatric patients less than 7 years of age. Quantity dispensed: 10 day supply Other: AFFIX Barcode Label Manufacturer: Lot Number: Exp Date: Staff Initials: Prescribing Physician: Date: Appendix 16 Pandemic Flu Page 76

77 A.15 Packing, Transport, and Storage of Inactivated Influenza Vaccine Influenza vaccine should always be transported in an insulated cooler with ice/cold packs (large quantities will require a refrigerated truck/trailer) Use crumpled newspaper, bubble wrap, or corrugated cardboard between vaccine and cold packs as a barrier to prevent vaccine from contacting the cold pack and freezing. Place thermometer in the cooler to monitor temperature (35-45 F or 2-8 C) Storage & Handling of Influenza Vaccine Shipping Requirements: Should be delivered in the shortest possible time. Should not be exposed to excessive temperatures. Condition on Arrival*: Should not have been frozen. Refrigerate on arrival. Storage Requirements: Refrigerate immediately on arrival. Store at F. (2-8 C). Do not freeze. Shelf Life: Formulated for use within current influenza season. Instructions for Reconstitution or Use: Shake vial vigorously before withdrawing each dose. Shelf Life after Reconstitution, or Opening: Until, outdated, if not contaminated. Special Instruction: Rotate stock so that the shortest dated vaccine is used first. * If you have questions about the condition of the material at the time of delivery, you should: 1) Immediately place material in recommended storage; and 2) Notify the Quality Control office of the vaccine manufacturer; or 3) Notify the MDCH Regional Immunization Field Representative. Appendix 16 Pandemic Flu Page 77

78 B.1: Hand Hygiene Hand Hygiene is the most effective manner to limit the spread of any disease and to break the chain of transmission between individuals. Note: Hand wash with soap and water if hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids. Appendix 16 Pandemic Flu Page 78

79 B.2: How to Care for Someone with Influenza Pandemic Flu How to care for someone with influenza During a severe influenza outbreak or pandemic, the media and healthcare providers will notify residents of PHDM with instructions for obtaining medical advice and receiving medical care. The following information is a general guide and is not intended to take the place of medical advice from a healthcare provider. Monitoring & Comforting Keep a care log. Record the following information about the ill person at least once each day or more often as symptoms change, along with the date and time. Check the patient s temperature Check the patient s skin for color (pink, pale or bluish?) and rash Record the approximate quantity of fluids consumed each day and through that night Record how many times the ill person urinates each day and the color of the urine (clear to light yellow, dark yellow, brown, or red) Record all medications, dosages and times given Keep the ill person as comfortable as possible. Rest is important. Keep tissues and a trash bag for their disposal within reach of the patient. Keep in mind that fever is a sign that the body is fighting the infection. It will go away as the patient is getting better. Sponging with lukewarm (wrist-temperature) water may lower the patient s temperature, but only during the period of sponging. Do not sponge with alcohol. Watch for complications of influenza. Complications are more common in individuals with health conditions such as diabetes, heart and lung problems, but may occur with anyone who has the flu. Call your healthcare provider or the pandemic flu hotline if the ill person: Has difficulty breathing, fast breathing, or bluish color to the skin or lips Begins coughing up blood Shows signs of dehydration and cannot take enough fluids Does not respond or communicate appropriately or appears confused Complains of pain or pressure in the chest Has convulsions (seizures) Is getting worse again after appearing to improve Is an infant younger than 2 months old with fever, poor feeding, urinating less than 3 times per day or other signs of illness Medications Use ibuprofen or acetaminophen or other measures, as recommended by your healthcare provider, for fever, sore throat and general discomfort. Appendix 16 Pandemic Flu Page 79

80 Do not use aspirin in children or teenagers with influenza because it can cause Reye s syndrome, a life-threatening illness. Fluids & Nutrition If the patient is not vomiting, offer small amounts of fluids frequently to prevent dehydration, even if he or she does not feel thirsty. If the ill person is not eating solid foods, include fluids that contain sugars and salts, such as broth or soups, sports drinks, like Gatorade (diluted half and half with water), Pedialyte or Lytren (undiluted), ginger ale and other sodas, but not diet drinks. Regular urination is a sign of good hydration. Recommended minimum daily fluid intake, if not eating solid food: o Young children 1-1/2 oz. per pound of body weight per day o (Example: A 20 lb. child needs approximately 30 oz. fluid per day) o Older children and adults 1-1/2 to 2-1/2 quarts per day If the patient is vomiting, do not give any fluid or food by mouth for at least 1 hour. Let the stomach rest. Next, offer a clear fluid, like water, in very small amounts. Start with 1 teaspoon to 1 tablespoon of clear fluid every 10 minutes. If the patient vomits, let the stomach rest again for an hour. Again, try to give small frequent amounts of clear fluid. When there is no vomiting, gradually increase the amount of fluid offered and use fluids that contain sugars and salts. After 6-8 hours of a liquid diet without vomiting, add solid food that is easy to digest, such as saltine crackers, soup, mashed potatoes or rice. Gradually return to a regular diet. Babies who are breast-fed and vomiting can continue to nurse. Feed smaller amounts more often by breast-feeding on only one breast for 4-5 minutes every minutes or by offering teaspoonfuls of Pedialyte or Lytren every 10 minutes. Make sure the patient avoids drinking alcohol and using tobacco. Smoking should not be allowed in the home. Watch for signs of dehydration: o Weakness or unresponsiveness o Decreased saliva/dry mouth and tongue o Skin tenting: check this by picking up layers of skin between your thumb and forefinger and gently pinching for 1 second. Normally, the skin will flatten out into to its usual shape right away. If patient is dehydrated, the skin will tent or take 2 or more seconds to flatten out. This is best checked on the belly skin of a child and on the upper chest of an adult. o Decreased output of urine, which becomes dark in color from concentration. Ill persons who are getting enough fluids should urinate at least every 8-12 hours. If the ill person is dehydrated, give sips or spoonfuls of fluids frequently over a 4-hour period. Watch for an increase in urination, a lighter color of the urine and improvement in the patient s overall condition. These are signs that the increased fluids are working. o Children under 5 years: Give 1 ounce fluid per pound body weight over 4 hours (Example: A 20 lb. child needs 20 oz. or 2-3 cups over 4 hours) o Older children & adults will need 1-2 quarts of fluids over the first 4 hours Appendix 16 Pandemic Flu Page 80

81 B.3(a): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) WHAT ARE PANDEMIC FLU AND AVIAN FLU? Pandemic Influenza is a global disease outbreak. According to Public Health Officials, an influenza pandemic occurs when a new influenza A virus appears for which there is little or no immunity in the human population, begins to cause serious illness and then spreads easily from person-to-person. There will be little to no natural immunity and no vaccine available at the onset of a pandemic. The main differences from a seasonal (or common) flu and a pandemic are that most people have some immunity to the seasonal flu and a vaccine is available for it. Pandemics are different from seasonal flu outbreaks or epidemics of influenza. Seasonal outbreaks are caused by subtypes of influenza viruses that already circulate among people, whereas pandemic outbreaks are caused by new subtypes or by subtypes that have never circulated among people before. Past influenza pandemics have led to high levels of illness, death, social disruption, and economic loss. Many people have heard that a strain of flu called Avian (or bird) flu could cause a pandemic a very dangerous, worldwide outbreak of illness. According to (Local Health Official) This will only happen if the current Avian virus changes, so that people can get it easily from each othernot just from birds. That hasn t happened yet and it may never happen. Public Health Officials do believe that we will have a flu pandemic sooner or later and it may be caused by the Avian strain or some other strain of the flu virus. Planning and preparation is the key to being prepared for a pandemic, states (Local Health Official). Public Health has been developing a pandemic influenza response plan that details local strategies to combat an influenza outbreak. In addition, exercises have been conducted with local and regional emergency response partners to test our ability to dispense vaccines to residents of Delta and Menominee counties. For additional information on what you can do to prepare for this type of emergency and others, check out our website at Appendix 16 Pandemic Flu Page 81

82 B.3(b): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) What Individual Families Can Do to Prepare for A Pandemic What can I do to prepare myself and my family for a public health emergency like a pandemic? According to (Public Health Official) at Public Health, Delta & Menominee Counties, You can protect yourself against the flu by working to improve your health and getting the annual flu shot. Although a vaccine against the seasonal flu will not protect you against a pandemic flu outbreak, it will help keep you healthy and may help you fight off the pandemic flu. The next best thing you can do is practice good hygeine. Wash your hands often and cover your cough! During a pandemic or other Public Health emergency, residents may be restricted to home for a period of time. People can plan ahead and think about what they need to have in their house in case someone in their household were to become infected with influenza and need to receive care at home. It is a good idea to have the following items stored in your home: A two-week supply of food and water. You may not be able to get to a store, or stores may be out of supplies so it s important to have enough items to feed yourself and your family. (Ready to eat meats, soups, beans, vegetables, dry cereal, canned fruit, crackers, juices, bottled water, & pet food). Ensure that you have enough prescription medications on hand that you or a family member requires. Have nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, fluids with electrolytes, vitamins and a thermometer. (cleansing soaps, flashlight, batteries, radio, can opener, garbage bags, tissues, toilet paper and diapers) To help limit the spread of germs and prevent infection: Teach children to wash hands frequently and always have soap and water available Cover coughs and sneezes with tissue Stay away from people who are sick. These simple yet important measures can help your family through a pandemic. For additional information on what you can do to prepare for this type of emergency and others, check out our website at Appendix 16 Pandemic Flu Page 82

83 B.3(c): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) How to Protect Yourself at Work and Home During a Pandemic Public Health Delta & Menominee Counties officials are releasing infection control measures to help protect the health and well-being of i s residents at work and home. Routine practices of infection prevention both at work and home should be practiced. Children and adults are encouraged to use disposable tissues for wiping noses, covering coughs and sneezes and good hand washing techniches should be practiced. The use of hand antiseptsis should also be used on hands after coughing or sneezing. Normal cleaning of all surfaces at work or home should be followed. In addition to the routine personal hygiene measures above, consider the following ideas for the workplace: Limit or separate staff-to-staff interaction. Increase the distance between work stations to more than 4 feet. Remove shared utensils like pencils, staplers, tape and other office equipment in break- rooms and copy rooms. Consider allowing employees to work from an alternative location to eliminate face-to- face contact. Limit and suspend group meetings, stagger shifts and breaks to avoid staff interaction, encourage use of s, phone and memos. At home the same rules should be applied in addition to the following: Soiled dishes and eating utensils should be washed in a dishwasher or by hand with warm water and soap. Separation of eating utensils for us and someone with influenza is not necessary. Laundry can be washed in a standard washing machine with warm or cold water and detergent. It is not necessary to separate soiled linen from other household laundry. Care should be used when handling soiled laundry (i.e., avoid hugging the laundry). Tissues used by an ill patient should be placed in a bag and disposed of with other household waste. Consider placing a bag for this purpose at a bedside. For additional information on pandemic influenza, check out our website at Appendix 16 Pandemic Flu Page 83

84 B.3(d): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) Do you have Influenza? When Should You Seek Help? Public Health Officials urge its residents to assist in monitoring and identifying residents who meet the influenza-like illness guidelines. The Centers for Disease Control and Prevention defines someone as having influenza-like illness if they have the following symptoms: Fever of greater than degrees Fahrenheit AND ONE OR MORE OF THE FOLLOWING: Cough Sore Throat Headache Muscle Ache If a patient is identified with a fever and and at least one other symptom, they should be considered as a possible influenza case. Patient should call their general practioner by phone and advise them of their condition. Symptoms to seek urgent medical care are: High or prolonged fever for more than 4-5 days Difficulty breathing, fast breathing or shortness of breath Bluish skin color (lips and hands) Cough becomes productive of yellow sputum Not drinking enough fluids Changes in mental status, irritability Confusion or seizures Worsening of underlying chronic medical condition (heart or lung disease or diabetes) Pain or pressure in the chest Symptoms improve but return with fever and cough worsens Severe or persistent vomiting (2-3 times in a day) Certain people are at high risk for development of complications. These people include: o People age 65 and older o People with chronic medical conditions o Very young children o Pregnant women These persons should seek medical attention at their physicians office, urgent care facility or hospital emergency department. For additional information on pandemic influenza, check out our website at Appendix 16 Pandemic Flu Page 84

85 B.3(e): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) The Best Line of Defense Personal Hygiene According to (Local Health Officials) at Public Health, Delta & Menominee Counties, The most effective way to limit the spread of any disease is to break the chain of transmission between individuals. To limit the spread of germs and prevent infection: Teach your children to wash hands frequently with soap and water, and model the current behavior. Teach your children to cover coughs and sneezes with tissues, and be sure to model that behavior. Teach your children to stay away from others as much as possible if they are sick. Stay home from work and school if sick. To wash hands properly, rub all parts of the hands and wrists with soap and water or an alcoholbased hand sanitizer. Wash hands for at least 15 seconds or more. Pay special attention to the areas of the hand most frequently missed. Keep nails short, avoid wearing rings, artificial nails or nail varnish. Remove watches and bracelets. Wash wrists and forearms if they are likely to have been contaminated and make sure that sleeves are rolled up and do not get wet during washing. Respiratory hygiene/cough etiquette has been promoted as a strategy to contain repiratory viruses and to limit their spread. By containing respiratory secretions, we help to prevent the transmission of influenza and other respiratory viruses. Always cover the mouth/nose with a tissue when coughing and dipose of used tissues appropriately. Wash hands after contact with respiratory secretions, and stay three feet or more away from persons in common areas when possible. For additional information on pandemic influenza, check out our website at Appendix 16 Pandemic Flu Page 85

86 B.3(f): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) Will There Be Vaccine During a Pandemic and Who Will Get It? A Pandemic is a worldwide spread of disease. Pandemic Influenza is a unique public health emergency. No one knows when the next influenza pandemic will occur. Experts believe that we will have between one and six months between the identification of a novel influenza virus and the Worldwide spread of the disease. According to (Local Health Officials) at Public Health, Delta & Menominee Counties, Vaccination is one of the most effective ways to minimize suffering and death from influenza. Research efforts from the Centers for Disease Control tell us that in the event of a pandemic, it could take months to develop an effective vaccine. Federal officials have drafted a plan that spells out who gets priority for the first vaccinations. Research continues into effective antivirals, seeking medications that can reduce the severity of an influenza attack. Antivirals are drugs that are used to prevent or cure a disease caused by a virus, by interfering with the ability of the virus to multiply in number or spread from cell to cell. One of the highest priority groups will be health care workers providing direct patient care services. This will help to protect those who will have to provide care and support services to the public. Currently, the best line of defense against any virus, where a vaccine is unavailable, is good personal hygiene, wash your hands frequently and cover your coughs and sneezes. This helps to prevent person-to-person contamination and is a proactive measure to stem transmission of viruses. For additional information on pandemic influenza, check out our website at Appendix 16 Pandemic Flu Page 86

87 B.3(g): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) The Importance of Getting the Flu Shot According to Public Health Officials, the single best way to protect against the flu is to get vaccinated each year. The "flu shot" an inactivated vaccine (containing killed virus) is given with a needle, usually in the arm. The flu shot is approved for use in people older than six months, including healthy people and people with chronic medical conditions. The vaccine contains three influenza viruses-one A (H3N2) virus, one A (H1N1) virus, and one B virus. The viruses in the vaccine change each year based on international surveillance and scientists' estimations about which types and strains of viruses will circulate in a given year. About two weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body. When to Get Vaccinated October or November is the best time to get vaccinated, but you can still get vaccinated in December and later. Flu season can begin as early as October and last as late as May. Who Should Get Vaccinated In general, anyone who wants to reduce their chances of getting the flu can get vaccinated. However, it is recommended by ACIP that certain people should get vaccinated each year. They are either people who are at high risk of having serious flu complications or people who live with or care for those at high risk for serious complications. During flu seasons when vaccine supplies are limited or delayed, ACIP makes recommendations regarding priority groups for vaccination. People who should get vaccinated each year are: People at high risk for complications from the flu, including: Children aged 6 months until their 5th birthday Pregnant women People 50 years of age and older People of any age with certain chronic medical conditions People who live in nursing homes and other long-term care facilities People who live with or care for those at high risk for complications including: from flu, Household contacts of persons at high risk for complications from the flu (see above). Appendix 16 Pandemic Flu Page 87

88 Household contacts and out of home caregivers of children less than six months of age (these children are too young to be vaccinated) Healthcare workers Who Should Not Be Vaccinated There are some people who should not be vaccinated without first consulting a physician. These include: People who have a severe allergy to chicken eggs People who have had a severe reaction to an influenza vaccination in the past People who developed Guillain-Barré syndrome (GBS) within six weeks of getting an influenza vaccine previously Influenza vaccine is not approved for use in children less than six months of age. People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen. Vaccine Effectiveness The ability of flu vaccine to protect a person depends on the age and health status of the person getting the vaccine, and the similarity or "match" between the virus strains in the vaccine and those in circulation. Testing has shown that both the flu shot and the nasal-spray vaccine are effective at preventing the flu. Vaccine Side Effects (What to Expect) Different side effects can be associated with the flu shot and LAIV. The flu shot: The viruses in the flu shot are killed (inactivated), so you cannot get the flu from a flu shot. Some minor side effects that could occur are: Soreness, redness, or swelling where the shot was given Fever (low grade) Aches If these problems occur, they begin soon after the shot and usually last 1 to 2 days. Almost all people who receive influenza vaccine have no serious problems from it. However, on rare occasions, flu vaccination can cause serious problems, such as severe allergic reactions. Appendix 16 Pandemic Flu Page 88

89 B.3(h): Sample Press Releases For Immediate Release (Date) Contact: (PIO name and Number) How to Care for Someone at Home During a Pandemic According to (Local Health Officials) at Public Health, Delta & Menominee Counties, We know this is an anxious time for our community and our hearts go out to those that are ill. Because the pandemic flu continues to spread, we are urging people to help protect themselves and loved ones and prevent further spread of the disease. Because pandemic flu is easily spread from person-to-person, it is unsafe for large groups of people to gather. You should stay home to help decrease the risk of getting sick and limit the spread of infection. Some guidelines for caring for individuals at home are provided below. Caring for Well Persons in the Home: Well persons should avoid close contact with infected persons (consider having one person designated to care for ill patients) Well persons should monitor their own symptoms closely for signs of illness Caring for Ill Persons in the Home: Alternate ibuprofen (Motrin and acetaminophen (Tylenol) for fever reduction Do NOT give aspirin to children or teenagers Get plenty of fluids (non-caffeinated and non-alcohol) Get plenty of rest Do not smoke Cover mouth and nose with tissue when coughing or sneezing Keep at least 3 feet from others Extra measures/precautions to take when caring for the ill at home: Wash hands often for seconds with soap and water, immediately after contact with an ill patient Do not share eating utensils or drinks Avoid touching eyes, nose or mouth Physically separate ill and well person as much as possible Keep a patient care long that documents regular temperature readings, skin color, note any rashes, record the amount of fluids consumed, number of times the ill Appendix 16 Pandemic Flu Page 89

90 person urinates, the color of the urine and note any medications, dosages and times given Keep a trash bag close for contaminated tissues Watch for complications and seek medical attention if complications appear (difficulty breathing, bluish skin or lips, coughing up blood, signs of dehydration, chest pressure or pain, seizures, getting worse after appearing to improve and infants younger than 2 months with fever, poor feeding, urinating or other signs of illness) This information is not intended to take the place of medical advice from a healthcare provider but is to be used as a general guide. If any complications develop individuals should seek medical attention. For questions regarding caring for persons at home, contact the telephone hotline at (hotline number) or check out our website at Appendix 16 Pandemic Flu Page 90

91 B.3(i): Sample Press Releases SAMPLE PUBLIC SERVICE ANNOUNCEMENTS FOR PUBLIC HEALTH OFFICIALS We know this is an anxious time for our community and our hearts go out to those who are ill. We are working closely with local health care and government officials to deal with the situation and will keep citizens updated with any important information. At this time, under the guidance of the county health department, we believe persons can safely attend to normal activities and businesses and schools will remain open. Our thoughts are with all of our families and individuals who are affected. If pandemic flu continues to spread and more persons become ill, health officials may recommend that schools close for an extended period of time (for example, up to 6 weeks). The purpose of closing schools will be to decrease contact among children in order to decrease their risk of getting sick and to limit the spread of infection. If schools are closed, children should stay at home. We urge parents to plan now for the possibility of schools closing. Arrange day care and home schooling. People can help protect themselves and loved ones and prevent the spread of pandemic flu as they would colds and other flu by taking the following precautions: Wash hands frequently with soap and water for 20 seconds. Cover coughs and sneezes with tissues or by coughing into the inside of the elbow. Stay away from people who are sick and stay home from work or school if you are sick. Recommendations may change during the course of a flu pandemic. We will make public announcements through the media and people can call the health department hotline at (INSERT HOTLINE). Officials of Public Health, Delta & Menominee Counties have ordered the closure of schools as a result of the pandemic flu outbreak in our county. Schools may be closed for an extended period of time (for example, up to 6 weeks). During this time, children and adults should stay away from other people and groups as much as possible. Health officials also advise people not to gather in other locations such as homes, shopping malls, movie theaters or community centers. Parents can help protect their children and prevent the spread of pandemic flu as they would colds and other flu by taking the following precautions: Teach your children to wash hands frequently with soap and water for 20 seconds. Be sure to set a good example by doing this yourself. Teach your children to cover coughs and sneezes with tissues or by coughing into the inside of the elbow. Teach your children to stay at least three feet from people who are sick and stay home from work or school if you are sick. Appendix 16 Pandemic Flu Page 91

92 Recommendations may change during the course of a flu pandemic. We will make public announcements through the media and parents can contact the school district s hotline at (INSERT NUMBER) All PSA s should have the following trailer: For more information on pandemic flu and prevention, visit Public Health, Delta & Menominee Counties website at Appendix 16 Pandemic Flu Page 92

93 B.3(j): Sample Press Releases For immediate release (DATE) Contact: (PIO name and number) Health officials order closure of schools in Delta and Menominee Counties Health officials from Public Health, Delta & Menominee Counties have ordered the closure of schools as a result of the pandemic flu outbreak in the district. Schools may be closed for a period of time - days or even weeks. Because the virus is easily spread from person-to-person, Public Health has also ordered colleges, day care centers and preschools to close. Because it is unsafe for large groups of people to gather, health officials warn people to stay away from shopping malls, community centers and other places where germs can be spread. We know this is an anxious time for our community and our hearts go out to those who are ill. We are working closely with the schools to deal with the situation and will keep parents updated with any important information, said (Local Health Official) According to (LOCAL HEALTH OFFICAL), the purpose of closing schools is to limit contact among children and to decrease their risk of getting sick and to limit the spread of infection. Because so many people are sick with the flu, health officials acknowledge that it may be hard to get a doctor s appointment, go to a clinic or even be seen in a hospital emergency room. They provided some tips for residents to care for the sick at home: Have them drink a lot of liquid (juice, water) Keep the sick person as comfortable as possible; rest is important. For adults with fever, sore throat and muscle aches, use ibuprofen (Motrin) or acetaminophen (Tylenol). Do not use aspirin for children or teenagers; it can cause Reye s Syndrome, a life-threatening illness. Keep tissues and a trash bag within reach of the sick person. Be sure everyone in your home washes their hands frequently. Keep the people who are sick with the flu away from the people who are not sick. More information on pandemic flu is available on Public Health, Delta & Menominee Counties website at Appendix 16 Pandemic Flu Page 93

94 B.4: PHDM Instructions During a Pandemic Throughout a pandemic flu, people may be asked or required to do things to help hold back the spread of the disease in our community. Here are some examples of what Public Health Delta Menominee may ask people to do: STAY HOME People who are sick should stay home. Children should not go to school if they are sick. Staying home will be absolutely necessary during a pandemic flu to limit the spread of the disease. AVOID LARGE GROUPS People even those who are well should stay away from gatherings of people such as sporting events, movies and festivals. During a pandemic flu these kinds of events could be cancelled because large gatherings of people help spread the flu virus. Isolation and Quarantine are public health actions used to contain the spread of a contagious disease. If asked, it will be important to follow Isolation and/or Quarantine instructions. ISOLATION is for people who are already ill. When someone is isolated, they are separated from people who are healthy. Having the sick person isolated (separated from others) can help to slow or stop the spread of disease. People who are isolated can be cared for in their homes, in hospitals, or other healthcare facilities. Isolation is usually voluntary, but local, state and federal government have the power to require the isolation of sick people to protect the public. QUARANTINE is for people who have been exposed to the disease but are not sick. When someone is placed in quarantine, they are also separated from others. Even though the person is not sick at the moment, they were exposed to the disease and may still become infectious and then spread the disease to others. Quarantine can help to slow or stop this from happening. States have the power to enforce quarantines within their borders. Appendix 16 Pandemic Flu Page 94

95 B.5: Pandemic Influenza Public Information Material Public Information Material Links International Federal State Local: For Community and Public Settings like Schools and Child Care Facilities Cover your Cough Poster - CDC Influenza Prevention Materials for Specific Groups Schools, Childcare Providers, Parents Health Care Professionals Laboratories Health Care Facilities Provider Education Materials Patient Education Materials Businesses and the Workplace Colleges and Universities People with Chronic Conditions Legal Professionals Children Under 6 months Old Appendix 16 Pandemic Flu Page 95

96 B.6: Community Mitigation Measures in Michigan: Pandemic Influenza Response by WHO Phase, Federal Stage, and Category Category of Severity Category 1 (Least severe) Category 2-3 (Moderately Severe) Widespread human to human spread of pandemic/novel strain influenza overseas (WHO Phase 6 / USG Stage 3 First case of pandemic/novel strain influenza in North America (WHO Phase 6/USG Stage 4) Widespread pandemic/novel strain influenza in US and confirmed cluster in MI or region (WHO Phase 6/USG Stage 5) Alert Standby Activate Recommend Voluntary isolation of sick at home Antiviral treatment (if available) Alert Standby Activate Recommend: Voluntary isolation of sick at home Antiviral treatment (if available) Category 4-5 (Most Severe Standby Standby / Activate Recommend: Voluntary isolation of sick at home Antiviral treatment (if available) Consider / Recommend: Voluntary quarantine Dismiss students / child care programs 12 weeks Cancel activities / gatherings 12 weeks Modify work schedules / practices Consider: Voluntary quarantine Dismiss students/child care programs 4-5 weeks. Cancel activities/gatherings 4-5 weeks Modify work schedules/practices Appendix 16 Pandemic Flu Page 96

97 C.1: Influenza-Like Illness Assessment Form An Influenza-Like Illness (ILI) Assessment may be used to help determine if an employee should be excluded from duties due to illness. Name Date Please check the following boxes for positive responses. ILI is determined by the presence of high temperature (item 1), and one or more of the remaining items: Symptoms Present: 1. Oral temperature of > F + one or more of the following: 2. Sudden onset of respiratory illness 3. Cough 4. Body aches 5. Sore throat 6. Weakness/Fatigue Fit for Work Unfit for Work Fit for Work with Restrictions Recovered from illness Meets disease criteria Symptomatic, but able to perform Vaccinated for > 2 weeks Employee sent home On antiviral medication Recommended to se MD Asymptomatic Employee s Primary Physician Contact # Physician contacted Yes Date Time regarding employee No condition? Completed by Date An ILI assessment tool is to be used for immediate triage of staff. This is not intended to be used as a human resource management tool. Appendix 16 Pandemic Flu Page 97

98 Screening Flowchart for Employer Appendix 16 Pandemic Flu Page 98

99 C.2: Contact Tracking Form Persons Whom the Affected Staff Has Interacted with Since Displaying Symptoms Name Telephone no. Address Appendix 16 Pandemic Flu Page 99

100 C.3: Daily Workplace Roster Place check mark in box for affirmative response Employee No history Ill, but able Name/ID Number of illness/ to work vaccinated Ill, not at work Not at work, caretaking responsibilities, at home DATE: Evaluated Postillness, Deceased for return to work returned to work Appendix 16 Pandemic Flu Page 100

101 C.4: School Weekly Report of Communicable Disease Appendix 16 Pandemic Flu Page 101

102 C. 5: Overview of Influenza Surveillance in the United States January 11, 2006 The Influenza Branch at CDC collects and reports information on influenza activity in the United States each week from October through May. The U.S. influenza surveillance system has 7 different components that allow CDC to: Find out when and where influenza activity is occurring Determine what type of influenza viruses are circulating Detect changes in the influenza viruses Track influenza-related illness Measure the impact influenza is having on deaths in the United States The 7 Components of Influenza Surveillance: 1. World; Health; Organization(WHO) And National Respiratory and Enteric Virus Surveillance System (NREVSS) Collaborating Laboratories About 75 WHO and 50 NREVSS collaborating laboratories located throughout the United States report the total number of respiratory specimens tested and the number positive for influenza types A and B each week. Some laboratories also report the influenza A subtype (H1N1 or H3N2) of the viruses they have isolated and the ages of the persons from whom the specimens were collected. Some of the influenza viruses collected by laboratories are sent to CDC for more testing. 2. U.S. Influenza Sentinel Providers Surveillance Network Each week, approximately 1,000 health-care providers around the country report the total number of patients seen and the number of those patients with influenza-like illness ( ILI ) by age group. For this system, ILI is defined as fever (temperature of 100 F) plus either a cough or a sore throat. The percentage of patient visits to sentinel providers for ILI reported each week is weighted on the basis of state population. This percentage is compared each week with the national baseline of 2.2%. The baseline is the mean percentage of visits for ILI during non-influenza weeks for the to seasons plus 2 standard deviations. Due to wide variability in regional level data, it was not possible to calculate region-specific baselines, and it is not appropriate to apply the national baseline to regional data Cities Mortality Reporting System Each week, the vital statistics offices of 122 cities report the total number of death certificates filed and the number of those for which pneumonia or influenza was listed as the underlying or as a contributing cause of death. The percentage of all deaths due to pneumonia and influenza are compared with a baseline and epidemic threshold value calculated for each week. 4. State and Territorial Epidemiologists Reports State health departments report the estimated level of influenza activity in their states each week. States report influenza activity as no activity, sporadic, local, regional, or widespread. These levels are defined as follows: No Activity: No laboratory-confirmed cases of influenza and no reported increase in the number of cases of ILI. Sporadic: Small numbers of laboratory-confirmed influenza cases or a single influenza outbreak has been reported, but there is no increase in cases of ILI. Appendix 16 Pandemic Flu Page 102

103 Local: Outbreaks of influenza or increases in ILI cases and recent laboratory-confirmed influenza in a single region of the state. Regional: Outbreaks of influenza or increases in ILI and recent laboratory confirmed influenza in at least 2 but less than half the regions of the state. Widespread: Outbreaks of influenza or increases in ILI cases and recent laboratoryconfirmed influenza in at least half the regions of the state. 5. Influenza-associated pediatric mortality Influenza-associated pediatric mortality is a newly added nationally notifiable condition. Laboratory-confirmed influenza-associated deaths in children less than 18 years old are reported through the Nationally Notifiable Disease Surveillance System. 6. Emerging Infections Program (EIP) The EIP Influenza Project conducts surveillance for laboratory-confirmed influenza related hospitalizations in persons less than 18 years of age in 57 counties covering 11 metropolitan areas of 10 states (San Francisco CA, Denver CO, New Haven CT, Atlanta GA, Baltimore MD, Minneapolis/St. Paul MN, Albuquerque NM, Albany NY, Rochester NY, Portland OR, and Nashville TN). Cases are identified by reviewing hospital laboratory and admission databases and infection control logs for children with a documented positive influenza test (culture, DFA/IFA, PCR, or a rapid test) conducted as a part of routine patient care. 7. New Vaccine Surveillance Network (NVSN) The New Vaccine Surveillance Network (NVSN) provides population-based estimates of laboratory-confirmed influenza hospitalization rates for children less than 5 years old residing in 3 counties: Hamilton County OH, Davidson County TN, and Monroe County NY. Children admitted to NVSN hospitals with fever or respiratory symptoms are prospectively enrolled and respiratory samples are collected and tested by viral culture and RT-PCR. NVSN estimated rates are reported every 2 weeks. Together, the 7 influenza surveillance components are designed to provide a national picture of influenza activity. Pneumonia and influenza mortality is reported on a national level only. Sentinel physician and laboratory data are reported on a national level and by influenza surveillance region. ( The state and territorial epidemiologists' reports of influenza activity are the only state-level information reported. Both the EIP and NVSN data provide population-based, laboratory-confirmed estimates of influenza-related pediatric hospitalizations but are reported from limited geographic areas. It is Important to Remember the Following about Influenza Surveillance in the United States: All influenza activity reporting by states and health-care providers is voluntary. The reported information answers the questions of where, when, and what influenza viruses are circulating. It can be used to determine if influenza activity is increasing or decreasing, but cannot be used to ascertain how many people have become ill with influenza during the influenza season. The system consists of 7 complementary surveillance components. These components include reports from more than 120 laboratories, about 1,000 regularly reporting sentinel health care providers, vital statistics offices in 122 cities, research and healthcare personnel at the NVSN and EIP sites, and influenza surveillance coordinators Appendix 16 Pandemic Flu Page 103

104 and state epidemiologists from all 50 state health departments, and the New York City and District of Columbia health departments. Influenza surveillance data collection is based on a reporting week that starts on Sunday and ends on Saturday of each week. Each surveillance participant is requested to summarize weekly data and submit it to CDC by Tuesday afternoon of the following week. Those data are then downloaded, compiled, and analyzed at CDC. The report is distributed and posted on the CDC Web site ( each Friday. For more information, visit or call the CDC Flu Information Line at 800-CDC- INFO (English and Spanish) or (TTY). Appendix 16 Pandemic Flu Page 104

105 D.1: Policy Example of Exposed or Ill Employees Subject: Management of Employees who are ill while at the workplace Purpose: To guide the management of employees who are exhibiting signs of an illness, or who have been exposed and risk illness. To limit the impact of illnesses regarding the ongoing business concerns of the organization. Policy: Any employee that self reports they are ill, or an employee that exhibits signs and symptoms of being ill will be evaluated by their immediate supervisor, or person designated as having these duties. Employees whom meet the criteria of illness while in the performance of their duties will be evaluated to determine if other employees or customers are at risk for contracting the illness from this person. If the conclusion is that the ill employee is a risk to others, managerial decisions will be made as to the course of action regarding the work status of the ill employee. Employees determined to be ill and at risk of infecting others can be directed to leave the work place and go to their home residence, or seek medical evaluation for the diagnosis and treatment of the illness. Illness criteria include: oral temperature equal to or greater than F, and one or more of the following symptoms: coughing, body aches, fatigue, sore throat, or other manifestation of an illness. Employees are able to return to work when symptoms have subsided to the degree that greatly lessens the possibility of infecting others. Usually 3 7 days after the initial onset of symptoms. Employees continuing to exhibit signs of the illness and are potentially a risk to others can be directed to leave the work place. Managerial decisions can be made to permit the employees to remain at work under specified conditions or restrictions. This may include, but not limited to social isolation of the employee from other employees or customers, or other measures to limit the spread of the disease to other persons, such as the use of a mask. The ill employee will be granted sick leave for the duration of their illness. If the employee is not eligible for sick leave, or has not accrued a sufficient number of hours to cover the time of illness, a leave of absence will be granted and the level of monetary compensation will be determined. Appendix 16 Pandemic Flu Page 105

106 D.2: Telephone Triage for Flu-like Illness Name of caller Name of patient, (if different) Date : Time: Questions Assessment Are any of the following present? Age of the patient >65 <65 with co-morbidity child <12 Pregnancy Are you pregnant or breast feeding? Duration When did symptoms start? Previous history / co-morbid conditions Are you normally fit and well? Do you have any existing medical conditions? Prescribed medication What medicines are you taking? Provides an indication of history if not clearly given by patient. If unsure, check list of common drugs prescribed for these conditions. Pregnant or unsure Breast feeding <36 Hours >36 hours but <1 week > 1 week Any of the following conditions? Asthma requiring regular medication COPD Heart disease excluding uncomplicated hypertension Immunosuppressed (treatment, illness such as asplenia or splenic dysfunction) Diabetes mellitus Respiratory drugs Cardiovascular drugs Immunosuppressants (including anticancer drugs), oral corticosteroids Diabetic drugs What are the symptoms? Fever Feeling hot? Sweating, shivering? Cough Have you got a cough? Are you coughing anything up? What color is the sputum? Breathlessness Have you any difficulty breathing Marked fever > 101 F No fever Unproductive cough Productive cough, colored sputum, blood stained Breathing difficulties, chest pain Appendix 16 Pandemic Flu Page 106

107 apart from nasal congestion? Loss of consciousness Have you fainted or lost consciousness Rash Do you have a rash anywhere on your body? Sore throat Have you any difficulty swallowing? General aches and pains Muscle and joint aches? Headache? Lethargy Are you feeling tired and lethargic? Fluid intake Are you eating or drinking anything? Nausea/vomiting Are you feeling sick? Have you been sick? Loss of consciousness, delirium Rash Difficulty swallowing Joint aches and pains Headache Lethargy, tiredness Not drinking fluids Loss of appetite Nausea Vomiting Action BLUE RED BLACK Flu is circulating Do not require transport Suggest stay at home, rest and fluids. Call doctor for advice. Completion of form Patients who fulfill any of the red conditions should be transported Patients in the black category do not require transport Circle or write in patient/caller response Circle action taken Signature DATE: Appendix 16 Pandemic Flu Page 107

108 D.3: Infection Control Measures Health Care Providers Infection Control Precautions in Healthcare Facilities with suspected pandemic influenza cases: Transmission of human influenza is by droplets and fine droplet nuclei (airborne). Transmission by direct and indirect contact is also recognized. However, during the 1997 influenza A (H5N1) outbreak in humans in Hong Kong (China), droplet and contact precautions successfully prevented nosocomial spread of the disease. So far, there is no evidence to suggest airborne transmission of the disease in the current outbreaks in SE Asia. Nevertheless, because of the high mortality of the disease and the possibility of the virus mutating to cause efficient human-to-human transmission, WHO is currently recommending the use of high-efficiency masks in addition to droplet and contact precautions in healthcare facilities. WHO recommends standard precautions, which apply to ALL patients at ALL times, including those who have influenza A (H5N1) infection. Standard Precautions involve work practices that are essential to provide a high level of protection to patients, health care workers and visitors of patients. These include the following: Hand washing and antisepsis (hand hygiene) Use of personal protective equipment (PPE) when handling blood, body substances, excretions and secretions Appropriate handling of patient care equipment and soiled linen Prevention of needlestick/sharp injuries Environmental cleaning and spills-management Appropriate handling of waste Additional (transmission-based) precautions are taken while still ensuring standard precautions are maintained. These include: Droplet precautions Contact precautions Airborne precautions (including high efficiency masks and negative pressure rooms, if available in the health care facility) PPE used for influenza A (H5N1) When health care workers are in a setting with infected patients, the use of PPE can reduce the risk of infection if used correctly. PPE includes: Gloves (nonsterile) High-efficiency fit-tested masks or Positive Air Pressure Respiratory Systems (PAPRS) Protective eyewear Cap (may be used in high risk situations where there may be increased aerosols) Plastic apron if splashing of blood, body fluids, excretions and secretions are anticipated Appendix 16 Pandemic Flu Page 108

109 Who should use personal protective equipment? All health care workers who provide direct patient care All support staff, including medical aides and cleaning staff All laboratory workers handling specimens from a patient being investigated for influenza A (H5N1) All sterilizing service workers handling equipment that requires decontamination and has come from a patient with influenza A (H5N1) Visitors to infected patients Health care workers who are involved in caring for a patient with influenza A (H5N1) should receive training on the mode of transmission, the appropriate infection control precautions and the exposure protocol. Antiviral prophylaxis and influenza vaccination for exposed health care workers: It is recommended by WHO that all health care workers who are expected to have contact with influenza A (H5N1) virus, or an influenza A (H5N1) patient, or an environment that is likely to be contaminated with the virus should take the following steps: Be vaccinated with the current WHO recommended influenza vaccine as soon as possible. This will not protect against influenza A (H5N1), but it will help to avoid simultaneous infection by human influenza and avian influenza. This will minimize the possibility of re-assortment. ) Antiviral prophylaxis: one oseltamivir phosphate 75 mg tablet each day for at least 7 days beginning as soon as possible after exposure. Antiviral prophylaxis should begin immediately, or at least within 2 days of exposure and may continue up to 6 weeks. Self-Management for exposed health care workers: Observe good respiratory and hand hygiene at all times Check temperature twice daily and monitor self for respiratory symptoms, especially cough Keep a personal diary of contacts, when at all possible In the event of a fever, immediately limit interactions and exclude yourself from public areas Notify your supervisor and your health care provider if you think you have been exposed to H5N1 influenza Appendix 16 Pandemic Flu Page 109

110 D.4: Infection Control Measures Public Infection Control Precautions for the General Public As outlined in the Public Information and Risk Communication Section of this Plan, PHDM will educate the public about influenza pandemics and steps that can be taken to reduce exposure and infection during a pandemic outbreak. Educational materials will be developed and distributed that will discuss infection control practices, including respiratory etiquette ( Cover Your Cough ), hand washing, when to stay home, and when to wear a mask and the appropriate use of a mask. Preparation: The most important thing anyone can do in preparation for a pandemic flu is to learn about and practice effective infection control. The main way that flu is spread is from person-to-person through coughs and sneezes. This can happen when droplets from the cough or sneeze of an infected person travel through the air and reach the mouth or nose of people nearby. Flu can also be spread when a person touches droplets, nose drainage or saliva from an infected person, or a solid object, and then touches one s own (or someone else s) nose or mouth before washing their hands. Recognizing Symptoms and When to Stay Home: Symptoms of flu include fever (usually high), headache, extreme tiredness, dry cough, sore throat, runny or stuffy nose, and muscle aches. Nausea, vomiting, and diarrhea also can occur, and are much more common among children than adults. It is important to stay home when experiencing any symptoms of flu. School and childcare personnel should observe closely, all infants and children for symptoms of illness. Notify the parent if a child develops a fever (100F or higher under the arm), chills, cough, sore throat, headache, or muscle aches. Send the child home, if possible, and advise the parent to contact the child s doctor. Wash hands: Use soap and water to wash hands when hands are visibly soiled, or an alcohol-based hand rub when soap and water are not available. Wash hands as soon as possible after sneezing or coughing. Wash hands to the extent possible between contacts with infants and children, such as before meals or feedings, after wiping the child s nose or mouth, after touching objects such as tissues or surfaces soiled with saliva or nose drainage, after diaper changes, and after assisting a child with toileting. Wash the hands of infants and toddlers when the hands become soiled. Teach children to wash hands when their hands have become soiled. Teach children to wash hands for seconds. Practice good respiratory hygiene and cough etiquette: Anyone with signs or symptoms of a respiratory infection should: Cover the nose and mouth when coughing or sneezing. Use tissues to contain respiratory secretions and dispose of them in the nearest receptacle after use. Appendix 16 Pandemic Flu Page 110

111 Always wash hands after having any contact with respiratory secretions and contaminated objects/materials. Be careful with respiratory secretions (i.e. coughing and sneezing) when around other people, especially small children. Avoid contact with individuals at risk (small children or people with illnesses), until respiratory symptoms have resolved. Avoid contact with secretions of people who have respiratory illnesses. Ask people to use a tissue and cover their nose and mouth when coughing or sneezing. As much as possible, avoid contact with people known to have influenza A (H5N1) during the infectious period of their illness: When visiting a patient who is suspected or confirmed as having influenza A (H5N1), follow the infection control precautions set by the hospital, which will include the use of protective equipment. This protective equipment will include a mask, gown, gloves, and goggles. Be sure the mask is properly fitted. When leaving the room, remove these items and wash hands very well. Appendix 16 Pandemic Flu Page 111

112 D5: Pandemic Severity Index Appendix 16 Pandemic Flu Page 112