Pandemic Influenza Standard Operating Guidelines

10 Johnston County Public Health Department Pandemic Influenza Standard Operating Guidelines SOGs Created August 2006 – January 29 , 2007 Updated June 16 , 2009PageTable of Contents Pandemic Influenza Definition and Planning Assumptions 3 Purpose and Goals 5 Scope 5 Legal Issues 5 Ethical Issues 6 Threat Assessment 6 Organization , Direction and Control 8 Phases of Influenza Pandemic 10 Surveillance 10 Pharmacologic Issues 12 Federal Role 12 State Role 13 Local Response 14 Phases 1 & 2 15 Phases 3 & 4 16 Phase 5 18 Phase 6 21 Second Wave 22 Individual Preparedness 23 Appendices A Sample Media & Medical Provider Statements 24 B Mass Fatality Planning for Pandemic Influenza 31 C Pandemic Influenza General Information for Public Education 35 D Social Distancing Strategy 41 E Priority Groups for Antiviral Medicine & Pandemic Influenza Vaccine 43 F Risk Communication 59 G Antiviral Medications Estimations Worksheet 65PagePandemic Flu Definition A pandemic is a global disease outbreak A flu pandemic occurs when a new influenza virus emerges for which people have little or no immunity and for which there is no vaccine The disease spreads easily person - to - person , cause’s serious illness , and can sweep across the country and around the world in a very short time It is difficult to predict when the next influenza pandemic will occur or how severe it will be Recent pandemics have occurred in 1918 - 1919 , 1957 - 1958 and 1968 - 1969 Planning Assumptions Pandemic preparedness planning is based on assumptions regarding the evolution and impacts of a pandemic Defining the potential magnitude of a pandemic is difficult because of the large differences in severity for the past pandemics Pandemic planning is based on the following assumptions about pandemic disease • Susceptibility to the pandemic influenza subtype will be universal • The clinical disease attack rate could be up to 30 in the overall population Illness rates could be highest among school - aged children about 40 and decline with age Among working adults , an average of 20 could become ill during a community outbreak • Of those who become ill with influenza , 50 will seek outpatient medical care • Localities might not be able to rely on timely or effective mutual aid resources , State or Federal assistance to support local response efforts • Residents could be required to stay in their homes for a significant period during an influenza pandemic ; thus , residents will need public information , education and tools so they are prepared to take responsibility for basic needs food , water , prescription meds , OTC medications , etc • The number of ill people requiring outpatient medical care and hospitalization could overwhelm the local health care system a Hospitals and clinics might have to modify their operational structure to respond to high patient volumes and maintain functionality of critical systems b The health care system might have to respond to increased demands for service while the medical workforce experiences increased absenteeism due to illness or caring for ill family members Pagec Demand for inpatient beds and assisted ventilators could increase by large margins and patients will need to be prioritized for services d There could be tremendous demand for urgent care services e Infection control measures specific to management of influenza patients will need to be developed and implemented at health care facilities , out - patient care settings and long - term care facilities f The health system could benefit by developing alternative care sites to relieve demand on hospital emergency departments and care for persons not ill enough to merit hospitalization but who cannot be cared for at home g Emergency Medical Service EMS responders could face extremely high call volumes , and may face reductions in available staff h The number of fatalities might overwhelm the resources of the Medical Examiner’s Office , morgues and funeral homes i The demand for home care and social services could increase dramatically • There could likely be significant disruption of public and privately owned critical infrastructure including transportation , commerce , utilities , public safety and communications • Social distancing strategies aimed at reducing the spread of infection such as closing schools , community centers , and other public gathering points and canceling public events will likely be implemented during a pandemic See appendix D for schedule • Some persons might be unable or unwilling to comply with isolation directives For others , social distancing strategies may be less feasible for example , homeless populations who live in congregate settings It will be important to develop and disseminate strategies for infection control appropriate for these environments and populations • Risk Communication will be critically important during all phases of planning and implementation of a pandemic influenza response The general public , health care system , response agencies , and elected leaders will need continuous updates on the status of the pandemic outbreak , impacts on critical services , the steps being taken to address the incident , and steps the public can take to protect themselves • There will not likely be a vaccine for a novel virus for six to nine months after the virus emerges PagePage pageNumber5Purpose and Goals This Pandemic Influenza Plan has three main purposes The Plan will 1 Serve as a planning guide for the Johnston County Public Health Department therein known as JCPHD ; 2 Provide guidance and tools to the many partners in the community who will be involved in the response ; and , 3 Guide activities to educate and prepare the general public regarding this public health threat When implemented , this Plan intends to achieve the following goals 1 Limit morbidity and mortality 2 Preserve continuity of essential government functions 3 Minimize social disruption 4 Minimize economic loss Scope This Plan is an SOG to the Johnston County Emergency Operations Plan The Johnston County Emergency Operations Plan therein known as the JCEOP and its annexes are referenced in this plan as they provide a description of the responsibilities , authorities and actions associated with public health emergencies Pandemic flu response efforts will likely trigger the activation of plans external to the JCPHD , such as the JCEOP , medical provider response plans , and continuity of operations plans However it should be noted that the lead authority by statute for pandemic influenza response rests with local public health departments at the local level and the Division of Public Health at the state level This Plan attempts to provide measures that will lessen the effects of a pandemic influenza outbreak while giving some forethought to how we can utilize the resources available in Johnston County in the most effective and efficient manner possible Variables that are unknown at this time will certainly affect some of the responses provided in this plan thus producing different courses of action to be taken during such an event Even though this is a Pandemic Influenza Plan , this Plan was written in a context whereas it could be used and adapted to fit any infectious respiratory disease such as Severe Acute Respiratory Syndrome SARS Legal IssuesPagePage pageNumber6There are many laws that set forth the response by the State and Local Health Departments in North Carolina Two essential laws concern isolation and quarantine They are set forth as noted below NC GS general statute 130A - 145 which establishes the authority of State Health Director and of a local Health Director to issue isolation or quarantine orders The isolation or quarantine order initially lasts up to 30 days but can be extended by court order 130A - 2 3a Isolation authority means the authority to issue an order to limit the freedom of movement or action of a person or animal with a communicable disease or communicable condition for the period of communicability to prevent the direct or indirect conveyance of the infectious agent from the person or animal to other persons or animals who are susceptible or who may spread the agent to others 130a - 2 7a Quarantine authority means the authority to issue an order to limit the freedom of movement or action of persons or animals which have been exposed to or are reasonably suspected of having been exposed to a communicable disease or communicable condition for a period of time as may be necessary to prevent the spread of that disease Quarantine authority also means the authority to issue an order to limit access by any person or animal to an area or facility that may be contaminated with an infectious agent The term also means the authority to issue an order to limit the freedom of movement or action of persons who have not received immunizations against a communicable disease when the State Health Director or a local health director determines that the immunizations are required to control an outbreak of that disease Ethical Issues Pandemics can cause many medicolegal issues to arise Such occurs due to limited supplies with potential greater need as well as due to difficult decisions that have to be made The Institute of Medicine created an Ethics Task Force which produced a Guidance Document on such issues This Document should be consulted during a Pandemic Threat Assessment To analyze this issue at a local level , the following table illustrates the impact pandemic flu will have on Johnston County , North Carolina This estimate was obtained using Flu Aid 20 software available at the Centers for Disease Control and Prevention’s CDC Website The estimates shown in the table below are based on a county population of 151,330 people PagePage pageNumber7POPULATION NUMBERS AND DISTRIBUTION 0 - 18 yrs 19 - 64 yrs 65 + yrs Total Total Non - high risk 41,6 23 79,452 8,427 129,502 86 High risk 2,845 13,365 5,618 21,828 14 Totals 44,468 92,817 14,045 151,330 100 DEATHS NUMBER OF CASES Gross attack rates Distribution by age group of total Most likely 15 25 35 High Risk Total 0 - 18 yrs most likely 1 1 2 0 - 18 yrs 1 2 minimum 0 1 1 maximum 10 16 22 19 - 64 years most likely 2 9 4 8 68 19 - 64 yrs 48 55 minimum 4 7 10 maximum 55 91 127 65 + yrs most likely 2 3 3 8 5 4 65 + yrs 35 43 minimum 22 37 52 maximum 2 9 4 8 6 7 TOTAL Most likely 5 3 8 7 127 Totals 84 100 HOSPITALIZATION NUMBER OF CASES Gross attack rates Distribution by age group of total Most likely 15 25 35 High Risk Total 0 - 18 yrs most likely 12 2 1 2 9 0 - 18 yrs 1 5 minimum 6 10 14 maximum 52 87 122 19 - 64 yrs most likely 1 72 2 86 400 19 - 64 yrs 11 70 minimum 32 5 3 7 4 maximum 18 7 3 12 4 37 65 + yrs most likely 61 102 143 65 + yrs 15 25 minimum 4 4 7 3 102 maximum 7 8 12 9 1 81 TOTAL Most likely 245 409 572 Totals 27 100 The above table was calculated using Johnston County total population of 151,330 Source The North Carolina State Data Center http demogstatencus FluAid 20 2009 Influenza T able for Johnston County , NCPagePage pageNumber8Pandemic Flu Plan Community Planning Benefits Given the above projection , Johnston County’s Pandemic Influenza Standard Operating Guidelines and North Carolina’s Pandemic Influenza Plan are vitally important to protecting our citizen’s health ; therefore the JCPHD cannot plan alone for pandemic influenza These guidelines are designed so that members of the public health community , medical providers and others can be ready to respond if an influenza pandemic strikes While the nature of the challenge places the JCPHD at the center of responsibility for identifying the key actions of the plan , coordinated efforts with partners at all levels is required to best protect the public’s health during a pandemic A multidisciplinary planning committee is a key element in addressing the unique issues of a pandemic ; therefore Johnston County formed a local pandemic influenza planning committee and within this committee this Plan was created These agencies and more are consulted when revising this Plan The member agencies of the local pandemic influenza planning committee are as follows American Red Cross Benson Area Medical Center Brian Center Eastern Carolina Medical Center Johnston Community College Johnston Correctional Facility Johnston County Department of Social Services Johnston County Emergency Services Johnston County Health Department Johnston County Industries Johnston County Mental Health Department Johnston County Public Schools Johnston Memorial Hospital North Carolina Emergency Management Parrish Funeral Home Pine Level Police Department RS Medical Associates Smithfield Selma Chamber of Commerce Smithfield Emergency Services Smithfield Manor Sprint Nextel Talecris Biotherapeutics Thyssen Krupp Precision Forge Walgreen’s Pharmacy Organization , Direction and ControlPagePage pageNumber9The purpose of this section is to delineate the organization , direction and control ; and responsibilities of the federal , state and local agencies that may be involved in the response to a pandemic event Johnston County is unique in that it has created a Community Disaster Preparedness Team which consists of members from the Johnston County Public Health Department , Emergency Management , Law Enforcement and Johnston Memorial Hospital This team is in the process of developing and implementing an Incident Management Team and has worked together to form an Incident Command Structure and organizational chart Please see the organizational chart below ICS for Pandemic Influenza The Johnston County Health Department Incident Commander Health Director Backup - Asst Health Director Backup – Environ Health Director Public Information Officer Health Department PIO - Health Educator Johnston County PIO Liaison Officer Preparedness Coordinator Backup – County ICS Team Member Safety Officer Epidemiology Nurse Manager County Risk Management Officer Backup – County ICS Team Member Operations Section Health Dept Program Manager EMS Backup – County ICS Team Member Planning Section Health Dept Program Manager GIS Backup – County ICS Team Member Logistics Section Emergency Medical Services Johnston Memorial Rep Health Dept Rep Backup – County ICS Team Member Finance Admin Section Preparedness Coordinator Backup – County ICS Team Member Strike teams Interviewers Resources Demobilization Service , Support , Communications Time Unit , Cost Unit , Compensation Unit Concept of Operations Stages of Alert The following table describes the alert phases of an influenza pandemic Differing levels of preparation and response will be associated with the phases of a pandemic event and will be the basis of our concept of operations Page0For purposes of consistency , comparability and coordination of the national , state and local response , identification and declaration of the following “ stages ” will be done at the international level Phases of an Influenza Pandemic , World Health Organization , Second or subsequent pandemic waves may follow the initial wave , usually within three to nine months As the pandemic develops , the World Health Organization WHO will notify the Centers for Disease Control and Prevention CDC and other national health agencies of progress of the pandemic from one stage to the next CDC will communicate with NC Division of Public Health NCDPH and other state agencies about pandemic stages , vaccine availability , virus laboratory findings and other national response coordination The State will communicate with local health agencies through the North Carolina Health Alert Network NCHAN The Johnston County Health Department is the leading authority and legally responsible entity for information and direction in the event of a public health outbreak pandemic event Surveillance Since the health department is the local entity for information , it is important that data is monitored and provided to the public and State Health Department on the spread of communicable diseases such as pandemic flu virus Johnston County Public HealthPage1has been involved with the sentinel surveillance program within the state for several years , When the spread of a pandemic flu virus increases , JCPHD will have systems in place to allow health care providers throughout the county to communicate their findings and receive information direction from the public health department Currently this consists of our ability to fax blast , email and call all physicians health care providers While it’s important for JCPHD to communicate with community partners in providing the necessary information data it is just as important for those same partners to communicate with us of their findings Lab diagnostics will include H - 2 Laboratory Submission Form NC DHHS 3431 as required by the Division of Public Health During the latter phases of the pandemic , Pandemic Alert phases 3 - 6 , health care providers , laboratories and health care organizations will be required to notify local public health within 12 hours of identifying cases of “ novel influenza viruses ” This must be done initially through a phone call to the health director or their designee Follow up with an email or fax to our department with individual staff assigned the task of receiving the pertinent information would be helpful Public health would then have the responsibility of forwarding this information to Communicable Disease Branch with the State Division of Public Health within 8 hours of the business day by phone call or other method as directed by the State After such , related reports will be completed and submitted During a pandemic data can provide health officials with the necessary information to take measures that reduce morbidity and mortality Identifying , counting and locating cases or deaths from pandemic influenza should be emphasized as a measure necessary to stop the spread of the virus Constant education for all health care providers , laboratories and health organizations Johnston Memorial Hospital throughout the county on the importance of reporting such information to our department will assist in this purpose While cases will be reported through the normal routine as other diseases unless changes are recommended by the State Division of Public Health , deaths will be verified with medical examiners and laboratory test if possible during latter phases of the pandemic alert Any death verified will be reported by phone call to the health department and called in to CD Branch with the State Division of Public Health within 8 business hours of receiving such information Johnston Memorial Hospital will provide a daily count of death certificates and cause of death during this time All cases and deaths will be identified by our county GIS department through mapping with investigative data fields attached GIS mapping will be used as a tool to further assist us in establishing measures to reduce the spread of the virus Furthermore an epidemiology team of health professionals will be assigned to cases during pandemic alert phases 3 - 5 as we are notified in accordance with staff availability and the number of cases reported This team will consist of public health staff in accordance to manpower availability This team will go through the customary investigative procedures questions as they normally do with other communicable diseases to identify how the disease was contracted and examine what measures were taken to prevent mortality as well as the spread of the disease Conclusions will be compared to other cases for further analysis and reported to the State Division of Public Health Page2Pharmacologic Issues In the early stages of a pandemic , there may be no vaccine at all The federal Pandemic Flu Plan indicates that a minimum of four to six months would elapse before the tens of millions of doses needed could be produced for distribution When vaccine first becomes available the demand will likely exceed the supply Pharmaceutical delivery will become an important issue during a pandemic While antiviral agents will play a role in both prophylaxis and treatment of influenza , the existing supplies would certainly fall short of the need As the pandemic progresses , there may not be sufficient supplies of antibiotics for treating persons with complications of influenza In addition to supply problems , other difficulties are associated with use of antiviral agents Priorities for target groups and the use of limited supplies for prophylaxis versus therapy have been established at the State level Widespread use of antivirals and antibiotics could lead to emergence of drug - resistant viral strains Adverse antiviral reactions and liability issues will also be of concern In a pandemic , JCPHD would provide consultation on the handling and administration of pharmaceuticals in cooperation with NCDPH and will follow State priority group recommendations The Federal Role The Federal government has assumed primary responsibility for a number of key elements of the national plan , including • Vaccine research and development • Coordinating national and international surveillance • Assessing and potentially enhancing the coordination of vaccine and antiviral capacity , and coordinating public - sector procurement • Assessing the need for and scope of a suitable liability program for vaccine manufacturers and persons administering the vaccine • Developing a national clearinghouse for vaccine availability information , vaccine distribution , and redistribution • Developing an adverse events surveillance system at the national level • Developing a central national information database exchange clearinghouse on the Internet The State Role by Pandemic PhasePage3Interpandemic Phases 1 and 2 • During this stage , the North Carolina Department of Public Health NCDPH activities will be limited to CD Branch monitoring reports of progress of the disease and surveillance to detect a case of a new subtype of virus in North Carolina International and national surveillance for a new subtype virus will be coordinated by the World Health Organization WHO and the Centers for Disease Control CDC • The CD Branch will monitor reports of disease spread and meet with surveillance partners to activate and augment surveillance systems • The NC Immunization Branch NCIB will maintain close contact with the CDC and the Food and Drug Administration to obtain information on plans for vaccine delivery NCIB will work with local health departments LHDs and representatives of the private medical sector to plan delivery and administration of vaccines when they are available • NC DPH will consult the NC Hospital Association NCHA , the NC Medical Society , and the NC Pharmacist Association to plan for vaccine administration and for antiviral and antimicrobial supplies The NC Immunization Branch will prepare training materials for vaccine administrators • Technical information , public information and press releases will be disseminated Public information will include travel alerts , guidelines on limiting the spread of the disease and information about when and where to obtain medical care The CDC’s Epidemiology Program Office EPO and the Office of Public Health Preparedness & Response PHP & R will ensure communication among epidemiology staff , laboratory surveillance staff and local emergency management agencies LEMAs Pandemic Alert Phase 3 , 4 and 5 • The pandemic alert activities will continue at an intensified level Surveillance efforts will be increased for both influenza illness and the circulation of the influenza virus • If pre - pandemic vaccine is available , the distribution system will be implemented and security measures will be put in place to ensure that vaccine will be given first to groups with the highest priority • Information flow to LHDs , medical providers and all other stakeholders will be increased • The NC Office of Emergency Medical Services NCOEMS , local emergency management , LHDs and hospitals will activate their emergency response systems Page4Pandemic Period Phase 6 • During the pandemic phase and subsequent waves , routine surveillance systems could be overwhelmed Emphasis will shift from detecting cases by the influenza virus to monitoring demographic characteristics that may indicate a need to revise priority groups for receiving vaccine and antiviral medications if available supplies are limited If vaccine is available , vaccine delivery and administration will be at the highest level and the system to detect possible adverse reactions to the vaccine will be closely monitored LHDs , in conjunction with LEMAs will establish alternate care facilities since hospitals will be overwhelmed • Prior to the Second Wave , all agencies and health care providers must make use of the interim period to prepare for a resurgence of disease This includes addressing shortfalls in supplies and personnel Planning must include the ongoing need to continue vaccination after the first wave has ended The vaccination campaign should include giving the second booster dose of vaccine to individuals who only received one dose of vaccine , and offering vaccine to the entire population if there is an adequate supply • The LHD should have contingency plans in place to manage the local response at the time of the pandemic These plans should include temporary redirection of personnel and financial resources from other programs to assist with the pandemic influenza response It is unlikely that medical resources and other assistance will be available from state and federal agencies Local Response by Pandemic Phase In addition to its longstanding all hazards planning , Johnston County has conducted extensive bioterrorism response planning that addresses the expanded role of the JCPHD in a public health emergency This Plan will likely be implemented in tandem or reference sections of the following plans • Federal Pandemic Flu Plan • North Carolina Pandemic Influenza Plan • Johnston County Emergency Operations Plan • Johnston County Public Health Department’s All Hazards Plan • Johnston County Health Department Strategic National Stockpile Plan • Johnston County Public Health Department’s Smallpox Response Plan • Johnston Memorial Hospital Infection Control Policy Pandemic Influenza Plan Public Health Response ProceduresPage51 Interpandemic Phases 1 and 2 Phase 1 – No new influenza virus subtypes have been detected in humans An influenza virus subtype that has caused human infection may be present in animals If present in animals , the risk of human infection or disease is considered to be low Phase 2 - No new influenza virus subtypes have been detected in humans However , a circulating animal influenza virus subtype poses a substantial risk of human disease a Surveillance • Johnston County Public Health Department is currently a sentinel surveillance site that collects lab specimens to verify influenza strains via the state lab and CDC Our participation in and familiarity with the program will assist in collecting data to determine where the virus is and how it is spreading among the population of the county in the pandemic alert and pandemic phases • Monitor bulletins from CDC and NCDPH concerning regular virologic , epidemiologic and clinical findings associated with new variants isolated within or outside the US • Meet with appropriate partners and stakeholders and review major elements of enhanced surveillance activities ; modify and update Plan as needed • Continue participation in the Influenza Sentinel Surveillance Program with the CDC , the NCSLPH and the CD Branch b Vaccine and Pharmaceutical Delivery • Modify plans as needed to account for updates , if any , on recommended target groups and projected vaccine supply c Emergency Response and Communications • Test local communications systems , eg pack radios , 800 system radios , the NCHAN , NCPHP & R Web EOC and the Johnston County Web EOC to ensure that local and statewide communications are functional • Modify Communications Plan and written materials as needed in collaboration with state officials to account for updates , if any , on projected effects of the novel virus • Implement contingency plans , if any , for obtaining critical hardware , software or personnel to expand communication systems if needed for a pandemic eg install wireless technology into health department laptops • Ensure ongoing coordination among surveillance , epidemiology , laboratory , EMS and other local response efforts • Include a local Pandemic Flu Information page on the County Website wwwjohnstonnccom that is easily accessible to the public This can also be found in appendix E , entitled “ Pandemic Influenza and You ” in both English and Spanish Page62 Pandemic Alert Phases 3 and 4 Phase 3 – Human infections s with a new subtype but no human - to - human spread or at most rare instances of spread to a close contact Phase 4 – Small clusters s with limited human - to - human transmission but spread is highly localized , suggesting that the virus is not well adapted to humans a Surveillance • Activate enhanced surveillance activities as warranted Assess functionality , timeliness and completeness of data entry and dissemination , data links and feedback mechanisms throughout the local system • Monitor daily CDC and weekly State reports which will include information from the following sources o JMH facilities inpatient diagnosis and pharmacy surveillance systems o State and regional laboratories and LHDs o Local physicians who report directly to CDC and or NCDPH • Meet with surveillance partners such as local physicians and hospital to increase the amount of patient demographic information collected , in order to identify groups with increased risk • Inform surveillance partners of the need to increase specimen collection for detection of novel virus and alert laboratories to prepare for increased numbers of specimens • Recruit pharmacists to participate in reporting antiviral prescriptions filled • Assess inventory of laboratory equipment and supplies , noting what is needed • Assess or suggest medical providers inventory medical equipment and supplies including ventilators , ICU equipment , PPE and oxygen saturation monitors , noting what is needed • Develop contingency plans for procurement of laboratory equipment and supplies , and also for possible redirection and hiring of additional laboratory employees , including clerical data entry personnel • Explore re - certification of non - traditional labor pool and redirection of staff with appropriate skills to alleviate need for additional laboratory personnel b Vaccine and Pharmaceutical Delivery • Monitor reports from the CDC , FDA and NCDPH to obtain information on plans for vaccine manufacture • Prepare to implement Plan for storing and delivering vaccine when it becomes available to JCPHD • Review elements of Plan for vaccine delivery with partners and stakeholders • Ensure that human resources , equipment and plans for mass immunization clinics are in place Page7• Obtain latest NCDPH recommendations for priority groups for vaccine allocation and modify as necessary based on current surveillance data • Meet as needed with local pharmacists and medical association to discuss potential need to • Increase antiviral and antimicrobial supplies • Increase role of pharmacists in vaccine delivery c Emergency Response and Communications • Ensure communication among JCPHD epidemiology , health surveillance programs and emergency management • Identify ICS positions as needed to respond eg Incident Commander , PIO • Prepare and disseminate public information as needed to inform the public of situation • Prepare fact sheets detailing responses to questions coming from the media and the public • Include documents intended for electronic distribution on wwwjohnstonnccom • Include telecommuting advice to employers , government agencies and others • Include travel alert information received from the State and or the CDC • Respond to media inquiries regarding outbreak , also found in this plan under Appendix H • Notify hospital , health care providers , emergency responders , coroner and mortuary organizations via the NCHAN , the JCPHD Blast Fax , or other means as needed • Increase monitoring of State laboratory surveillance and disease surveillance • Alert emergency responders to work with JCOES to inventory critical supplies eg masks , etc and solve problems arising from high response volumes • Conduct inventory of critical equipment , supplies and personnel , including availability of hospital beds , antiviral pharmaceuticals , and refrigerated depots for vaccines and transport for delivery of vaccines • Identify methods to address personnel and supply shortfalls • Plan for implementation of Alternate Care Facilities , in coordination with local private providers , Emergency Management and the Red Cross • Send bulletins to private providers via local medical association and or lists acquired from state licensing boards • Issue guidelines on influenza control measures for workplaces , emergency departments , EMS , jails , prison , public safety agencies and individuals • Review county continuity plan for essential infrastructure eg water , electricity , transport etc These plans have been established , they are under final review by an outside consultant Once completed , we will attach to this plan as an appendix • Implement health education campaign with emphasis on the following • Hand washingPage8• Stay home rather than be exposed to spread the influenza virus • Check on family , friends living alone • Vaccination clinic locations • Signs and symptoms • Vaccine safety and storage 3 Pandemic Alert Phase 5 Phase 5 - Large cluster s but human - to - human spread is still localized , suggesting that the virus is becoming increasingly better adapted to humans but may not be fully transmissible substantial pandemic risk a Surveillance • Outside of normal surveillance season , verify that hospital and health care surveillance have been activated and JCPHD is receiving ongoing reports of cases within the county • Surveillance Partners Johnston Health Systems , Johnston County Schools , private industry , correctional facility , nursing rest homes , county government , and others as identified • Inform surveillance partners of the need to increase specimen collection for detection of novel virus and alert laboratories to prepare for increased numbers of specimens • At Phase 5 , we will be faxing and emailing all partners as needed to receive surveillance data For instance we would want reports from any medical provider on confirmed cases of pandemic flu From the school system we would request for contact to be made when absenteeism rises above a normal level as indicated by the school system • Recruit pharmacists to participate in reporting antiviral prescriptions filled • Report the data collected by JCPHD to all participating facilities • Analyze the inpatient data to determine which population groups are at greatest risk and provide the information to NCDPH and to those determining priority groups for vaccine allocation when the supply is limited • Prepare to participate in special studies , if as requested by the NCDPH • To describe unusual clinical syndromes • To describe unusual pathologic features associated with fatal cases • To conduct efficacy studies of vaccination or chemoprophylaxis • To assess the effectiveness of control measures such as school and business closings • Maintain increased monitoring of state laboratory surveillance and other activities outlined in the previous alert phase • Report send suspect viral specimens to the NCSLPH using Laboratory Submission Form NC DHHS 343 ; 1 for a copy of the form please go to http slphstatencus Forms DHHS - 3431 pdf Page9b Vaccine and Pharmaceutical Delivery • Continue activities as listed in the pandemic alert phases 3 & 4 • If no vaccine is available , coordinate with NCDPH to • Estimate and order number of antiviral doses needed utilizing the NC Pandemic Influenza Plan’s Antiviral Medication Estimations Worksheet see worksheet in Appendix J • Establish local delivery date • Review distribution plan use existing standard operating procedures for influenza vaccine administration • Establish storage area for antivirals Currently working with Johnston Memorial Hospital to establish a location that has 24 hour security and well suited access • If vaccine delivery date is predicted by the CDC , work with NCDPH to • Estimate and order number of vaccine doses needed utilizing the NC Pandemic Influenza Plan’s Influenza Vaccine Estimations Worksheet see worksheet in Appendix B • Establish local delivery date • Review distribution plan • Establish storage area for vaccine Currently working with Johnston Memorial Hospital to establish a location that has 24 hour security and well suited access • Obtain signed agreements MOU’s with hospitals and private providers on priority of groups to receive vaccine when supply is limited • Alert law enforcement of the need for security at immunization storage and distribution sites • Alert Division of Public Health of the need for reporting adverse effects to VAERS Vaccine Adverse Events Reporting system c Emergency Response and Communications • Notify hospital , health care providers and first response agencies of pandemic imminent stage Set up information flow to all partners and stakeholders , including posting information on wwwjohnstonnccom and the NCHAN • Update documents and fact sheets based on current surveillance information • Activate JCPHD continuity of operations plan • Provide translations of all public information messages into Spanish and the other major languages spoken in Johnston County • Monitor the ability of hospital and outpatient clinics to cope with increased patient loads • Work with employers and other organizations to implement a telecommuting system so more people can stay home Page0• Activate emergency response system , including Emergency Operations Center with Johnston County Public Health Department • Implement mutual aid or other procedures to address supply and personnel shortfalls • Continue to inventory of critical supplies personnel and solve problems shortage of supplies gloves , masks , safety needles , and ventilators , personnel shortage how to get nontraditional labor pool re - certified or alternative staff redirected • Develop plan for counseling psychiatric services • Develop plan for children orphaned by death of parents or caregivers • Alert law enforcement as to the existing situation and need to prepare for a response to meet the needs of security of medical facilities sites , to assist in isolation and quarantine support , and assist with temporary mortuary services as needed Appendix I addresses the roles of law enforcement and how they can protect themselves with disease outbreaks as well as continue to provide the necessary public safety to assure services and business can function • Refer to mass fatality appendix See Appendix B • Activate county continuity plan for essential infrastructure water , electricity , transport etc • Develop specific social distancing plan measures such as cancellation of mass gatherings , school closures and or building closures See Appendix D for schedule of social distancing plan • Follow recommendations as provided by CDC Based on the projected severity of the pandemic , government and health officials may recommend different actions communities can take in order to try to limit the spread of disease These actions , which are designed primarily to reduce contact between people , may include • Asking ill persons to remain at home or not go to work until they are no longer contagious seven to 10 days Ill persons will be treated with antiviral medication if drugs are available and effective against the pandemic strain • Asking household members of ill persons to stay at home for seven days • Dismissing students from schools and closing child care programs for up to three months for the most severe pandemics , and reducing contact among kids and teens in the community • Recommending social distancing of adults in the community and at work , which may include closing large public gatherings , changing workplace environments and shifting work schedules without disrupting essential services These measures will be most effective if they are implemented early and uniformly across communities during a pandemic The guidance illustrates the interventions that are likely to be recommended at each category of severity Page14 Pandemic Phase 6 • Phase 6 – Pandemic phase increased and sustained transmission in the general population NOTE These are steps and activities that could be taken based on many factors of the pandemic including the virulence of the virus a Surveillance • Continue to monitor selected vital statistics for mortality and morbidity data received from the inpatient diagnosis surveillance system to establish age - and geographic area - specific rates • Provide above data to NCDPH to assist in establishing priority groups for immunization as vaccine availability changes • Continue to monitor reports from WHO , CDC and NCDPH on national and worldwide morbidity and mortality data • Laboratory surveillance will focus on detection of antigenic drift variants and resultant viruses that could limit the efficacy of vaccines produced against the original pandemic strain b Vaccine and Pharmaceutical Delivery • Monitor VAERS data for evidence of adverse reaction to the influenza vaccine Report findings routinely to NCDPH • Review surveillance data for changes in risk factors that could require modification of recommendations for priority groups for receiving vaccine • Monitor availability of antivirals and , when appropriate , recommend changes in priority groups for receiving vaccine or antivirals c Emergency Response and Communications All of the activities of the pandemic alert phases and the following • Notify hospital , health care providers and first responder agencies of Pandemic Phase • Implement emergency medical treatment sites and Alternate Care Facilities as needed in coordination with local mass - care organizations , such as Red Cross , Salvation Army , County Government and county school system to respond to the overwhelming caseload • Implement social distancing measures such as cancellation of mass gatherings , closing of schools and or building closures A schedule of social distancing measures can be found in Appendix F • Continue to suggest or require social distancing measures or other actions to prevent the spread of the virus Page2• Increase public information effort designed to keep ill persons at home , providing translations into Spanish and other major languages in Johnston County • Request law enforcement mutual aid , if needed If law enforcement mutual aid system is overwhelmed , the Governor may issue a waiver to allow National Guard and military to act as law enforcement 5 Second Wave Typically in a pandemic , the number of new cases of influenza peaks , then declines , giving the impression that the pandemic is over Then within a few months , influenza incidence once again increases State and local officials and health care providers need to remain vigilant for a return of the epidemic activity This is especially difficult given that all personnel and supplies involved in responding to the epidemic will be exhausted by effort to respond to the pandemic The perceived “ end of the pandemic ” may be viewed as an opportunity to relax and recover However , all essential functions should be restored to pandemic alert status Public health personnel who provide the data to NCDPH will probably still be backlogged with reports , but should be encouraged to maintain extra staffing levels All sources of surveillance data will need to be convinced that their contributions are still essential because of the likelihood of a second wave If the decline in the number of cases occurs outside the normal influenza season , it will be necessary to explain the importance of maintaining vigilance because the second wave could occur at any time , usually within 3 to 9 months after the first wave Immunization efforts in lower risk groups should continue as vaccine becomes available to increase “ herd immunity ” in the population in the event of a second wave Laboratory surveillance should also return to pandemic imminent status while maintaining surveillance for possible antigenic drift 6 Post pandemic Period Return to Interpandemic Period Phase 1 Individual Preparedness To better prepare individuals families or an organization business , planning guides have been established to assist you and can be found at wwwpandemicflugov plan tab3 html for an individual family planning checklist and wwwpandemicflugov plan tab4 html for business organization checklists Page3Appendix A Sample Media or Medical Provider Information StatementsPage4Template I - A - 1 Sample Provider Information Statement – Novel Virus Alert Novel Virus Alert As you are aware , one or more human cases of a new subtype influenza virus , for which there is no immunity in the general population , has been detected in ______________ This could potentially , but not inevitably , be a precursor to an influenza pandemic Johnston County Public Health is working closely with the State to monitor reports of disease progression and surveillance to detect the arrival of disease caused by the novel virus in North Carolina Currently there have been no reported cases in Guilford County The CDC has issued recommendations for enhanced influenza surveillance for state health departments The purpose of these recommendations is to enhance the capacity to rapidly identify an importation of this virus Current recommendations are at wwwcdcgov We will continue to provide you with updates on influenza activity and will distribute recommendations on any additional surveillance activities that may become necessary If you have any questions please call JCPHD at 919 - 989 - 5200 Page5Template I A - 2 Sample Provider Information Statement – Pandemic Alert Period Pandemic Alert The new subtype influenza virus is causing unusually high rates of morbidity and mortality in widespread geographic areas Travel advisories remain in effect for the following areas If your patient is ill with influenza - like illness and has recently traveled to these areas , or is a close contact to someone who has traveled to these areas the following recommendations should be considered 1 home isolation 2 antivirals for household contacts 3 self - monitoring of symptoms 4 report to Public Health 919 989 - 5200 Johnston County continues to work closely with the State and CDC regarding influenza vaccine We do not have a manufacturer’s release date at this time but continue to review plans for distribution Providers are encouraged to use antivirals for household contacts of confirmed or strongly suspected cases of influenza Enforcement of respiratory hygiene is essential Continue to implement respiratory programs in your area of practice • At entry , triage , or registration , ask all patients with symptoms of respiratory illness to wear a surgical mask , and provide instructions on their proper use and disposal • Offer masks to all other persons who enter the emergency room to use voluntarily for their own protection • For patients who cannot wear a surgical mask , provide tissues to cover the nose and mouth when coughing or sneezing and a small bag for mask and tissue disposal • Encourage and provide access to hand washing or a waterless hand hygiene product and instruct patients to decontaminate their hands after handling respiratory secretions and before their contact with a healthcare worker • Separate patients with respiratory illness from other patients by either placing them into a cubicle , examination room , or some physical separation by at least 3 feet Johnston County has reported ________deaths related to complications of influenza Page6Template I - A - 3 Sample Provider Information Statement – Pandemic Influenza Declaration Pandemic Influenza Declaration A formal declaration was made today by the WHO regarding the influenza pandemic Further spread with involvement of multiple continents has been reported The United States reported ___________________hospitalizations or deaths to the CDC with ____________being from North Carolina Johnston County has had _______________deaths Hospitalizations related to complications from influenza Manufacturers of flu vaccine report a release date of _______________ Johnston County continues to make plans for mass vaccination prophylaxis public education Current supply of antivirals remains low Page7Template I - A - 4 Sample Provider Information Statement – Pandemic Influenza Case Information Pandemic Influenza Case Information The new subtype virus_____________ has demonstrated sustained person - to - person transmission and multiple cases in the same geographic area Confirmed case definition Probable case definition Possible case definition The number of confirmed cases is __________ Number of deaths is ___________ The CDC and NC DPH has released a travel advisory for____________________ Johnston County has reported ___________number of confirmed probable case s of influenza A ___________ No deaths have been reported Antivirals are recommended for household contacts of confirmed cases and strongly suspected cases of influenza Page8Template I - A - 5 Sample Provider Information Statement – Pandemic Second Wave Pandemic Second Wave Typically in a pandemic , the number of new cases of influenza peaks and then declines , giving the impression that the pandemic is over Health care providers need to remain vigilant for the return of pandemic activity Health care providers must make use of the interim period to prepare for a resurgence of disease Johnston County continues to urge providers to keep a respiratory hygiene program in place Inventory and order supplies that may be necessary for disease resurgence Continue to vaccinate if applicable Log onto the Johnston County web site at wwwjohnstonnccom for information about self protection Page9Figure IV - D - 6 Influenza Alert for Public Release FOR PUBLIC RELEASE Influenza Alert For Immediate Release Contact _____________________ Date _____________ Title _______________________ Smithfield – Dr Marilyn Pearson , MD , Johnston County Health Director , declared a public health emergency this morning evening , alerting Johnston County residents to take precautions to minimize the spread of the influenza virus There is new strain of influenza virus that is unusually virulent , which means that most people have little or no natural immunity to protect them from illness This means that , not only have more people come down with the “ flu , ” the illness is likely to be more severe Add data about current number of local hospitalizations , etc At this time , there is no vaccine available to prevent this new strain of the flu Vaccine development may be delayed and vaccine may initially be in short supply This makes prevention measures even more important Symptoms of the flu include abrupt onset of chills and fever , muscle aches , sore throat , and cough Those who develop flu symptoms should notify their health care provider Consider if we want everyone to do this , or just recommend that the elderly and those with medical conditions that increase their risk contact their provider o Influenza virus is contagious from person - to - person Infection spreads when droplets from a cough or sneeze of an infected person reach another person’s mouth , nose , or eyes The virus can also be transmitted if a person touches a surface or object such as a doorknob or stair railing contaminated with infectious droplets and then touch their own mouth , nose , or eyes o The risk of becoming ill can be reduced by frequent hand washing and keeping your hands away from your eyes , nose , and mouth Also , try to avoid contact with people who have respiratory illnesses Those who become ill should stay home This is crucial to preventing the spread of this disease to others , including co - workers and other people who would be encountered in public places o If someone in the household has the flu , other family members can decrease their risk of becoming ill by wearing a mask over their nose and mouth whenever they come within three feet of the sick person They should wear gloves whenever they come in contact with him or her or items they have handled and wash their hands after removing the gloves Page0For more information , visit the Johnston County website at wwwjohnstonnccom Consider more extreme measures , such as canceling public gatherings , encouraging telecommuting , etc Page1Appendix B Mass Fatality Planning for Pandemic InfluenzaPage2Planning Assumptions • The vast majority of resources devoted to pandemic management will , and should be , devoted to care for the living Nonetheless , appropriate and respectful treatment of pandemic flu fatalities is a moral necessity , and can be of significant psychological assurance and comfort to both the intimates of the deceased and the larger community • Risk groups for severe and fatal infections from pandemic flu cannot be predicted with certainty During annual fall and winter influenza season , infants and the elderly , persons with chronic illnesses , and pregnant women are usually at higher risk of complications from influenza infections In contrast , in the 1918 pandemic , most deaths occurred among young , previously healthy adults The fatality rate for pregnant women during the 1918 pandemic was over 50 • Deaths due to pandemic influenza will exceed deaths due to seasonal influenza • The majority of the deceased will not be owners of cemetery property , and available grave property , including church cemeteries , could be in limited supply New cemetery property or areas for temporary internment may need to be identified Typically , these properties become memorial spaces after the incident has passed , so this property would likely not be used for commercial purposes again • Supplies for caring for the remains of the deceased such as embalming fluid , coffins , body bags and areas for storage will be in very short supply during the pandemic period as multiple waves hit the country simultaneously Most should try to increase their on - hand supplies in anticipation of a pandemic • Funeral directors will likely need guidance on risks of handling bodies of pandemic flu fatalities , but typically have a level of comfort in handling bodies of people with infectious diseases They practice universal precautions with all bodies • One to two trained funeral directors are required to perform the preparation process recovery , storage , preparation , and casketing and this process takes about five hours There are 2 crematories in Johnston County , McLaurin and Parrish’s Funeral Homes and 3 certified technicians for cremations Other fueral directors without that certification could be rapidly trained in performing cremations An average cremation from start to finish last approximately 4 hours Neither cremation nor mass cremation has ever been mandated in the United States in any past event Should mass cremations become necessary , alternative cremation sites and technologies , such as large kilns in brickyards , may be considered There is a 24 - hour waiting period for performing cremations in North Carolina , a rule that is likely to be temporarily lifted during a pandemic • Johnston County has approximately 38 licensed funeral directors , including part - time employees and retirees • Many families may not be able to have traditional burials and funeral services within several days of the death of the deceased , as it may become necessary to store bodies for longer periods , and personnel to assist with preparation and burial are also affected by thePage3pandemic If a public gatherings ban is in effect , funerals would need to be postponed until the ban is lifted • “ Direct burials ” , involving uncasketed burial without embalming can be performed with minimal assistance from funeral professionals This may be a more attractive option to families , particularly rural residents with land , than body storage or funeral postponement There is also opportunity for fraud or abuse and the public would need to be educated on necessary procedures for direct burial , and site selection of graves in family cemeteries Pandemic Phase 3 • Educate our local PIO on communications during a mass fatality situation and the importance of explaining all steps involved in preparing the deceased and the reasons for these steps • Identify individuals responsible for the tracking recordkeeping process of mass fatality management and train them in tracking system which will include record or recovery of remains , record of any personal effects , a death certificate , record of burial preparation , record of internment and custody chain • Recruit local funeral directors for training and response • Create a resource list of suppliers of necessary supplies and begin to stockpile disaster pouches body bags • Create a list of available storage morgue capacity in Johnston County and a roster of funeral directors , embalmers , medical examiners current and former and resident trainees Pandemic Phase 4 • Begin in earnest to stockpile disaster pouches and other necessary supplies such as fluids • Emergency Management will prepare lists of suppliers for these items as well as refrigerated trucks , refrigerated warehouses , and portable storage units or tents which could be refrigerated bodies must be stored at 37o – 42o to retard decomposition , and can be stored as long as 6 months at these temperatures before they begin to decay Approximately 40 bodies can be stored in a regular tractor trailer Emergency Management will identify areas to serve as temporary or permanent internment sites 1 • Identify vehicles and personnel that could be trained in the recovery of remains • Determine the NC Medical Examiner plan for investigating unattended deaths during this pandemic phase and phases 5 and 6 • PIOs will undertake efforts to educate the public , through the media , about the steps involved in traditional burials and what deviations would be expected during a pandemic • Authorities will review state laws for burial requirements in order to inform the public of legal burial solutions 1 Land may be donated or designated for such use In Johnston County , graves in city cemeteries are opened dug by city personnel There are only a few 2 - 3 private companies that open graves , and these are small , 1 - 2 person operations However , anyone with backhoe experience can open a grave , which is typically a 4 ’ x 8 ’ hole State law requires a minimum of 18 ” of dirt covering all graves Page4Pandemic Phase 5 and 6 • Create a “ Mass Fatalities Unit ” in the Incident Command Structure • Designate a PIO or spokesperson for the funeral director community to speak to the media about the processes involved in preparing bodies for burial and any deviations from normal procedures necessary because of mass fatalities • Designate a collection point or points to which EMS , funeral directors and the public can bring the deceased Page5Appendix C Johnston County Public Health PANDEMIC INFLUENZA AND YOUPage6Johnston County Public Health wants you to know about the possibility of a serious influenza virus that could affect us all The threat of an influenza virus that spreads easily from human to human and for which there is no known immunity is labeled Pandemic Influenza We must plan for such an event to lessen the effects we may have to deal with Currently there is no pandemic flu in the world today and no one knows when or where a pandemic may begin or how severe it will be However county , state , federal and international governments along with the world health organization , WHO , are preparing for such an event to reduce our risks First let’s discuss seasonal influenza or “ the flu ” for which an annual vaccination is recommended Seasonal influenza is a highly contagious respiratory illness that occurs annually Each year , on average , 200,000 Americans are hospitalized and 36,000 die from influenza or a flu complication like pneumonia Most of the people seriously affected by seasonal influenza are the elderly and the very young Pandemic influenza is different than seasonal influenza It occurs when a new influenza virus surfaces – one that people have no immunity against Because people have no immunity – and there is no vaccine against this new strain – more people across the world can get sick or die from the new strain There were three influenza pandemics during the 20th century The “ Spanish ” flu pandemic of 1918 - 19 was the most notorious ; more than 20 to 40 million people died worldwide In the United States , more than 500,000 people died Most of these deaths occurred in healthy young adults Influenza viruses constantly change ; they have the ability to change in two different ways Small mutations , changes occur almost every year ; that’s why there is a new flu vaccine every year Large mutations occur less often Large mutations result in a new influenza virus to which the human population has no protection These large mutations are almost always followed by an influenza pandemic Avian influenza bird flu viruses can be a source of new influenza viruses Humans cannot catch bird flu easily ; however , the recent bird flu outbreak which started in Asia has shown that this does happen Most of the known cases occurred from very close exposure to sick birds In many cases , the infected people were literally living with chickens The greatest fear is that a person infected with the seasonal flu could become infected with the avian flu , and the two viruses could combine into a new virus that can easily spread person - to - person So far , that hasn’t happened But the possibility of that happening is why the entire world health community is focused on the avian or bird flu Based on observations from previous pandemics , it has been estimated that the economic losses in the United States associated with the next pandemic could be in the billions of dollars The impact of an influenza pandemic on the health care system could be devastating In the United States , approximately 90 million people could become ill , and 45 million could seek outpatient care The number of hospitalizations and deaths will vary depending on how deadly the pandemic flu strain is a moderate pandemic could result in more than 800,000 hospitalizations and 200,000 deaths A severe pandemic could result in 10 times as many hospitalizations and deaths The potential for high levels of sickness and death , as well as the significant disruption to society , make planning for the next influenza pandemic imperative to reduce sickness , death and social disruption Johnston County Public Health has formed a committee of public pr