Download Guidance on Pandemic Influenza Planning for MN Local Public

Pandemic Influenza
Incident Specific Appendix
to the Lake County
Emergency Operations Plan
Revised
September 2009
Table of Contents
A. Preface
Page
B. Basic Plan
1.
2.
3.
4.
C. Concept of
Operations
1. Decision Making Structure
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2. Planning Assumptions
3. Legal Authority
4. Pandemic Severity and Timelines &
Triggers
5. Ethical Framework
6. Vulnerable Populations
7. Continuity of Operations
4
7
7
10
11
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A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
12
13
13
14
14
14
15
18
23
23
23
24
25
D. Technical Chapters
E. Appendices
F. Record of Plan
Changes
Purpose
Objectives
Scope
Limitations
Communications
Epidemiological Surveillance
Community Mitigation Interventions (CMIs)
Infection Control
Clinical Issues
Healthcare Planning
Asset Distribution (Antivirals & PPE)
Vaccine Distribution
Laboratory
Poultry Worker Health
Care of the Deceased
Flu Centers
Regional Coordination
Supporting Materials & Local Resources
1: Background on Intervals, Triggers, Actions
2: Risk Communication Guidelines
3: CMI Background Information
4: Asset Distribution Background Information
5: Vaccination Background Information
6: Flu Center Plan Template
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3
3
4
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31
31
32
32
36
42
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A. Preface
An influenza pandemic will place extraordinary and sustained demands on the public health and
medical care systems as well as providers of essential services in Lake County.
To prepare for the next pandemic, an event considered by many experts to be inevitable, Lake County
in cooperation with various state and local organizations has developed the Lake County Pandemic
Influenza Incident Specific Appendix to the Lake County All-Hazard Response Plan. This plan was
developed in cooperation with local hospitals, clinics, emergency medical services (EMS), emergency
management (EM), the Minnesota Department of Health (MDH), and other community
agencies/partners. This cooperation is to enhance the plan as well as develop robust and
comprehensive plans for other kinds of emergencies that may impact Lake County.
Emergency preparation is a continuum and planning efforts will always be evolving. As new information
arises and lessons are learned the Lake County Pandemic Influenza Incident Specific Appendix will be
updated as necessary.
B. Basic Plan
1. Purpose
The purpose of the Lake County Pandemic Influenza Incident Specific Annex is to provide a
coordinated and comprehensive local response to an influenza pandemic in order to reduce
morbidity, mortality, and social disruption and to help ensure a continuation of governmental
functions.
2. Objectives
The Lake County Pandemic Influenza Incident Specific Appendix has five primary objectives:
1. Maximize the protection of life and property in Lake County.
2. Insure that the response effort be organized under National Incident Management
System (NIMS).
3. Delineate roles and responsibilities for other local governmental and non-governmental
agencies participating in the response.
4. Assure that the Lake County Pandemic Influenza Incident Specific Appendix is
coordinated and consistent with MDH Pandemic Influenza Plan and the plan of other
counties in the state.
5. Assure that the Lake County Pandemic Influenza Incident Specific Annex is coordinated
with the pandemic influenza response activities identified in the Lake County Emergency
Operations Plan.
3. Scope
The Pandemic Influenza Plan focuses on emergency response that is unique to pandemic
influenza and therefore serves as an Incident Specific Appendix to the all-hazard Lake County
Emergency Operations Plan.
In Minnesota, Pandemic Influenza Plans consist of three parts:
1. The Basic Plan: an overview of the assumptions, concept of operations, legal authority,
ethical framework, and key pandemic influenza functions. The Basic Plan is divided into the
Preface and Concept of Operations. It also includes sections on Pandemic Phases and
Stages.
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2. Technical Chapters: information that is unique to health departments’ response to an
influenza pandemic, provide response information organized by subject or task, address
response actions that are specific to pandemic influenza and are a supplement to the All
Hazards Functional Annexes
3. Appendices: supplements including pandemic influenza specific resources and background
information.
4. Limitations
Emergency preparedness is a continuum, since planning efforts evolve as new information
becomes available. The Regional Pandemic Influenza Plan will be updated when necessary. (A
record of plan changes is located at the end of this document.)
C. Concept of Operations
1. Decision Making Structure
The Lake County Emergency Operations Plan and the Lake County Pandemic Influenza
incident specific appendix are both organized under the National Incident Management System
(NIMS). Details of command structure are provided in the basic plan section of the Lake County
Emergency Operations Plan. At the trigger point when Lake County outpatient clinics are
overwhelmed (due to patient load or lack of adequate staff), the Lake County Emergency
Operations Center (EOC) will be activated to coordinate and support the implementation of this
plan.
2. Planning Assumptions
Pandemic influenza is a unique public health emergency, in that a pandemic will likely have
devastating effects on the health and wellbeing of the American public.
Influenza is caused by viruses that infect the respiratory tract. Influenza symptoms include rapid
onset of fever, chills, sore throat, runny nose, headache, non-productive cough, and body
aches. Influenza is a highly contagious illness and can be spread easily from one person to
another. It is spread through contact with small droplets and aerosols from the nose and throat
of an infected person during coughing and sneezing.
Influenza viruses are unique in their ability to cause sudden infection in all age groups on a
global scale. The importance of influenza viruses as biological threats is due to a number of
factors, including a high degree of transmissibility, the presence of a vast reservoir of novel
(new) variants, and the unusual properties of the viral genome.
Two types of influenza viruses cause disease in humans: type A and type B. Influenza A viruses
are composed of two major antigenic structures essential to vaccines and immunity:
hemagglutinin (H) and neuraminidase (N). The structure of these two components defines the
virus subtype.
A minor change in the structure caused by a mutation (antigenic drift) results in the emergence
of a new strain within a subtype. Mutations (antigenic drifts) can occur in both type A and B
influenza viruses. A major change in the structure caused by genetic recombination (antigenic
shift) results in the emergence of a novel subtype (i.e., one that has never before occurred in
humans or adaptive mutation of an avian virus) most commonly associated with influenza
pandemics. This shift only occurs with influenza type A viruses.
Influenza A viruses are unique because they can infect both humans and animals thereby
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causing more severe illness. Antigenic shifts in influenza A viruses have been the cause of the
last three pandemics: 1918, 1957, and 1968.
The well-known “Spanish flu” of 1918 was responsible for more than 20 million deaths
worldwide, primarily among young adults. Mortality rates associated with the more recent
pandemics of 1957 (A/Asia [H2N2]) and 1968 (A/Hong Kong [H3N2]) were reduced, in part, by
antibiotic therapy for secondary bacterial infections and more aggressive supportive care.
However, both the 1957 and 1968 pandemics were associated with high rates of morbidity and
social disruption.
The Centers for Disease Control and Prevention (CDC) uses data from previous pandemics to
provide estimates of the impact of pandemic flu. The estimates range from a moderate
pandemic (based upon 1958 and 1968) to a severe pandemic (based upon 1918) outbreak.
CDC models provide the following estimates.
In the United States:
 90 million people will be infected
 45 million people will require outpatient care
 1-10 million people will be hospitalized
 Between 200,000 and 2 million people will die
(30% of population)
(50% of ill)
(1-11% of ill)
(.25-2% of ill)
In Minnesota:
 1.5 million people will be infected
 700,000 people will require outpatient care
 15,000 to 150,000 people will be hospitalized
 Between 3,600 and 33,000 people will die
In Lake County (population 11,080)
 3300 people will be infected
 1600 people will require outpatient care
 30 to 350 people will be hospitalized
 Between 8 and 70 people will die
Effective preventive and therapeutic measures – including vaccines and antiviral agents – will
likely be in short supply, as may some antibiotics to treat secondary infections. Healthcare
workers and other first responders will likely be at even higher risk of exposure and illness than
the general population, further impeding the care of ill persons. Widespread illness in the
community will also increase the likelihood of sudden and potentially significant shortages of
various personnel who provide other essential community services.
Pandemic influenza is considered to be a relatively high probability event - even inevitable - by
many experts. Yet no one knows when the next pandemic will occur and there may be very
little warning. Most experts believe that we will have one to six months between the
identification of a novel influenza virus that results in human-to-human transmission and the
time that widespread outbreaks begin to occur in the United States. Outbreaks are expected to
occur simultaneously throughout much of the nation and the world thus preventing relocation of
human and material resources.
The effect of influenza on individual communities will be relatively prolonged – six to eight
weeks – when compared to the minutes-to-days observed in most other natural disasters.
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Should a pandemic occur, every community would have to rely primarily on its own resources
as it combats the pandemic.
The following planning assumptions are generalized for pandemics. Because the Novel H1N1
Virus is currently circulating around the globe in 2009, more specific planning assumptions may
be added to this plan as time passes.
 Susceptibility to the pandemic influenza virus will be universal.
 Efficient and sustained person-to-person transmission of a novel influenza virus signals an
imminent pandemic.
 The clinical disease attack rate will likely be 30% or higher in the overall population. Illness
rates will be highest among school-aged children (about 40%) and decline with age. Among
working adults, an average of 20% will become ill during a community outbreak.
 Some persons will become infected but not develop clinically significant symptoms.
Minimally symptomatic individuals can transmit infection and develop immunity to
subsequent infection.
 Of those who become ill with influenza, 50% will seek outpatient medical care; however, if
antiviral drugs are effective, this proportion may be higher in the next pandemic.
 The number of hospitalizations and deaths will depend on the virulence of the pandemic
virus. Estimates differ about 10-fold between more and less severe scenarios. Planning
should include the more severe scenario.
 Risk groups for severe and fatal infection cannot be predicted with certainty but are likely to
include infants, the elderly, pregnant women, and persons with chronic medical conditions.
 Rates of absenteeism will depend on the severity of the pandemic.
 In a severe pandemic, absenteeism attributable to illness, the need to care for ill family
members, and fear of infection may reach 40% during the peak weeks of a community
outbreak, with lower rates of absenteeism during the weeks before and after the peak.
 Certain public health measures (closing schools, quarantining household contacts of
infected individuals, “snow days”) are likely to increase rates of absenteeism.
 The typical incubation period (interval between infection and onset of symptoms) for
influenza is approximately 2 days.
 Persons who become ill may shed virus and can transmit infection for up to 1 day before the
onset of illness. Viral shedding and the risk of transmission will be greatest during the first 2
days of illness. Children usually shed the greatest amount of virus and therefore are likely to
post the greatest risk for transmission.
 On average, infected persons will transmit infection to approximately two other people.
 In an affected community, a pandemic outbreak will last about 6 to 8 weeks.
 Multiple waves (periods during which community outbreaks occur across the country) of
illness could occur with each wave lasting 2-3 months. Historically, the largest waves have
occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with
certainty.
 When the influenza pandemic first reaches the state of increased and sustained
transmission in the general population, there will be no vaccine against the specific strain of
influenza for 4-6 months.
An influenza pandemic can:
 Occur at any time.
 Require significant communications and information sharing across jurisdictions and
between the public and private sectors.
 Involve multiple geographic areas.
 Impact critical infrastructures.
 Overwhelm the capabilities of local and tribal governments.
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Require short-notice asset coordination and response timelines.
Require prolonged, sustained incident management operations and support activities
There are a few additional planning assumptions that are specific to Minnesota regional response
planning. Minnesota’s regions plan and prepare for health emergencies regionally under the
guidance and direction of the MDH. During any health emergency, the MDH district office response
teams will work as liaisons with local public health departments to communicate local needs and
state direction.
3. Legal Authority
As the lead public health agency in the state, the MDH is responsible for protecting, maintaining,
and improving the health of all Minnesotans. There is a strong state-local partnership where the
MDH provides leadership and direction to front-line public health and private healthcare entities.
Lake County Public Health will take the lead technical role, under the guidance of MDH, in Lake
County. Lake County Emergency Management will be the lead coordinating agency in a
pandemic influenza outbreak, and will work closely with Public Health in preparation and
response to the flu.
Chapter 12 of Minnesota Statutes grants the Governor and Homeland Security and Emergency
Management (HSEM) overall responsibility of preparing for and responding to emergencies and
disasters. Chapter 12 directs the Governor and HSEM to develop and maintain a
comprehensive state emergency operations plan, known as the Minnesota Emergency
Operations Plan (MOEP).
Furthermore, Minnesota Statutes, including Minnesota Chapter 12 (Minnesota Emergency
Management Act) Minnesota Chapter 144 (General Duties of the Commissioner of Health),
Minnesota Chapter 145A (Powers and Duties of a Community Health Board) and Chapter 157
outline the authorities of local public health agencies and grant the Commissioner of Health
broad authority to protect, maintain, and improve the health of the public. In a pandemic, the
Commissioner of Health may delegate responsibility to Lake County Public Health to protect the
health of the jurisdiction’s residents and visitors.
4. Pandemic Severity and Pandemic Timelines and Triggers
Since 2007, the HHS and Centers for Disease Control and Prevention (CDC) have been using
the pandemic Severity Index (PSI) to categorize the response needed to a pandemic flu
outbreak.
The CDC (Director) will designate the PSI with five categories of increasing severity based on
the estimated case fatality ratio (this ratio reflects the percent of people with disease who have
died from the disease). A category five pandemic would be a severe pandemic. This category
will be determined early and revised as needed throughout the pandemic. Additionally, other
epidemiologic features that may be used to determine pandemic severity (when available) are:
total illness rate, age-specific illness and mortality rates, the reproductive number,
intergeneration time, and incubation period.
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Figure 1: Pandemic Severity Index
Case Fatality
Ratio
Projected Number of Deaths*
U.S. Population, 2006
>2.0%
>1,800,000
Category 5
1.0 - <2.0%
Category 4
900,000 - <1,800,000
0.5 - <1.0%
Category 3
450,000 - <900,000
0.1 - <0.5%
Category 2
90,000 - <450,000
<0.1%
Category 1
<90.000
*Assumes 30% Illness Rate
Table 3: Pandemic Severity Index
Characteristics
Pandemic Severity Index (PSI)
Category 1 Category 2 Category 3 Category 4 Category 5
Case Fatality Ratio
(percentage)
<0.1
0.1 - <0.5
0.5 - <1.0
1.0 - <2.0
>2.0
Excess Death Rate
(per 100,000)
<30
30 - <150
150 - <300 300 - <600
>600
Illness Rate
(percentage of
population)
20 - 40
20 - 40
20 - 40
Potential Number of
Deaths
(based on 2006 U.S.
population)
<90,000
90,000 <450,000
450,000 <900,000
20th Century U.S.
Experience
Seasonal
Influenza
1957, 1968
(illness rate
5 – 20%)
None
20 - 40
20 - 40
90,000 >1.8 million
<1.8 million
None
1918
Pandemic
Intervals, Triggers, and Actions (ITA)
In 2008, the CDC released an interim guidance document on the use of Intervals, Triggers, and
Actions in CDC Pandemic Influenza Planning”. The ITA guidance introduces a conceptual
framework to guide pandemic influenza preparedness and response activities at the national,
state and local level. This framework will facilitate better coordinated and timelier strategies at
all levels, while acknowledging the heterogeneity of conditions affecting different U.S.
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communities during the progression of a pandemic. (For more background on Pandemic
planning phases, see Appendix A.)
Minnesota Intervals, Triggers, and Actions
MDH intends to use the interval triggers in Table 4 for pandemic influenza response actions,
though available epidemiologic data, (e.g. illness rates, age-specific morbidity and mortality
rates, reproductive number, intergeneration time, and incubation period) will inform timing of
response actions in an influenza pandemic.
MDH is modifying the CDC interval onset definitions in order to (1) take a slightly more
aggressive approach to the timing of community mitigation response actions, and (2) move
away from laboratory specimen definitions (proportion of specimens from patients with
influenza-like illness who are positive for the pandemic strain) since the volume of laboratory
testing in a pandemic will be insufficient to assess pandemic progression and deceleration in the
state.
Table 4: Minnesota Trigger Definitions
Interval
Minnesota Trigger
Investigation
Identification of human case of potential novel influenza A infection in the state
OR… Identification of animal case of influenza A subtypes with potential
implications for human health within the state
Recognition
Confirmation of human cases of novel influenza A and demonstration of efficient
and sustained human to human transmission anywhere in the world (Minnesota is
using CDC’s national trigger definition instead of the state trigger definition where
“recognition” occurs in the state only if the first recognition that a pandemic has
emerged occurs in that state).
Initiation
A laboratory confirmed case of pandemic influenza detected in Minnesota or its
contiguous states (North Dakota, South Dakota, Iowa, and Wisconsin) (CDC does
not include contiguous states in its trigger definition).
Acceleration
One or two laboratory-confirmed cases in Minnesota that are not epidemiologically
linked to any previous case
OR… Number of cases exceed the resources necessary for case/contact-based
control measures
OR… A significant exposure has occurred in a setting where a large number of
individuals cannot be identified for case/contact-based control measures
OR… There are indications that case/contact-based control measures are not
effective (CDC uses the first two criteria as triggers).
Peak
Widespread transmission with a level, but high number of new cases and resources
exceeded in most areas of Minnesota (CDC trigger focuses on proportion of
laboratory confirmed cases for specimens from patients with ILI, or “regional”
activity per current CDC surveillance criteria or health care surge capacity
exceeded).
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Deceleration
Number of new cases drops from peak level for at least two consecutive weeks
(CDC trigger focuses on proportion of laboratory confirmed cases for specimens
from patients with ILI and health care system is below surge capacity).
Resolution
Cases without an identified household exposure are “sporadic” per CDC influenza
surveillance criteria. MDH will determine that the state has met the trigger (cases
without an identified household exposure are “sporadic”) through case-based
reporting which will be re-instituted once the number of new hospitalized cases
drops to 10% of cases occurring at the pandemic peak.
(CDC trigger is laboratory confirmed cases are occurring sporadically or the health
care system is approaching pre-pandemic levels).
5. Ethical Framework
Lake County and MDH accept the ethical framework developed by the Minnesota Pandemic
Ethics Project of the Minnesota Center for Health Care Ethics and the University of Minnesota
Center for Bioethics. This project’s purpose is to propose ethical frameworks and procedures for
ethically rationing scarce health resources, including antiviral medications, N95 respirators,
surgical masks, vaccines, and mechanical ventilators, in a severe pandemic. These ethical
frameworks are based upon four elements: ethical commitments, principles, goals, and
strategies, and may be summarized as follows.
Commitments: The common good for all Minnesotans will be pursued in ways that:
 Are accountable, transparent and worthy of trust
 Promote solidarity and mutual responsibility
 Respond to needs fairly, effectively and efficiently
Principles: Resources will be stewarded to promote Minnesotans’ common good by balancing
three equally important ethical principles:
 Protect the population’s health
 Protect public safety and civil order
Treat people fairly, recognizing the moral equality of all
Goals:
Protect the population’s health
 Reduce mortality and serious morbidity
Protect public safety and civil order
 Reduce disruption to the basic health care, public health, public safety and other critical
infrastructures
 Promote public understanding about and confidence in the distribution of health care
resources
Fairness
 Reduce significant group differences in mortality and serious morbidity
 Make reasonable efforts to remove barriers to fair access
 Reciprocate to groups accepting high risk in the service of others
 Reduce significant differences in opportunities to live a normal lifespan
Promote equitable access through fair random processes for individuals equally prioritized
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6. Vulnerable Populations
The Lake County Pandemic Influenza plan will include consideration of minority and vulnerable
populations within the county. These populations include but are not limited to children, the
elderly, non-English speakers, those with physical, mental, developmental or emotional
disabilities, those who are isolated by remote locations or insufficient transportation,
economically disadvantaged, pet owners, or religions or ethnic restrictions. Special
consideration will be given to providing adequate communications, supervision, transportation
and other resources as needed to serve all populations and residential or care facilities.
7. Continuity of Operations
Continuity of local government operations and services during a pandemic will follow the
guidelines set forth in the Lake County Continuity of Operations Plan.
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Technical Chapter A – Public Health Communication Plan
Lake County Public Health will insure that its communications systems—from the local Health Alert
Network to redundant daily communication modes—are up to date. Triggers for pubic health care
communication may include vaccination planning, surge situations, flu center activation, mass dispensing
activities, etc. Communications plans for health care providers and the public will follow protocols and
public information/notification guidelines in the all-hazard Lake County Emergency Operations Plan.
Tactical Communications Options include:
 HAN – statewide and local
 Phone, email, satellite phone
 GETS (Government Emergency Telecommunications Service) priority phones are available in
the Lake County Emergency Operations Center (EOC) if necessary
 Public safety radios
 RACES (Radio Amateur Civil Emergency Services) can be activated through Lake County
Emergency Management
The Emergency Contact List Supplement to the Lake County EOP will include:
 Hospitals
 Practitioners & Clinics
 Long-term care and Home Care
 Group homes and Treatment Centers
 Regional Networks (NE Regional MAC)
 Adjacent jurisdictions (Cook and St. Louis County and MDH contacts)
Public Information and notification:
Lake County Public Health, in cooperation with the Emergency Manager and Public Information
Officer, will identify the messages that need to be developed and disseminated based upon the
extent of the flu outbreak. More information on public information and media contacts, protocols
and plans is available in the all-hazard Lake County Emergency Operations Plan (EOP) Basic
Plan under public information/notification.
Emergency contact lists (including media contacts) are included as a supplement to the EOP.
While talking points and fact sheets will be provided by MDH using CDC and state guidelines,
Lake County will prepare formats, contacts, and local information in advance, and will review
public information guidelines in the Lake County Emergency Operations Plan (EOP). Together,
they will determine:
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Who needs to be notified
What communication medium(s) should be used
How quickly does the message need to be delivered to those target populations
What is the message
Who will deliver the message
Are the messages effective and reaching the desired populations
Following is a list of potential public information and notification options.
 Nixle public notification system
 ISD 381 Instant Alert messaging system
 NOAA weather radio emergency alert system.
 Media releases including radio, television and newspaper
 Press Conferences
 State (MDH) or local phone Hotlines
 Displays and Fact Sheets
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Technical Chapter B: Epidemiological Surveillance
This chapter is currently optional (in 2009) and will be added when guidance becomes available from the
Minnesota Department of Health.
Technical Chapter C: Community Mitigation Intervention Plan
Community Mitigation Intervention (CMI) measures, also known as non-pharmaceutical interventions, are
aimed at slowing or limiting the transmission of the pandemic virus by limiting social interaction rather
than on medication or vaccination. It is assumed that these measures will be voluntary, but highly
recommended. In the event that legal order becomes necessary, Ramsey County District Court, by
Minnesota statute, has statewide jurisdiction for isolation and quarantine actions in Minnesota.
Should Lake County determine to initiate CMI measures ahead of state recommendations, Lake County
Public Health or Emergency Manager will notify the NE regional in order to assure clear communication
and consistency across jurisdictions.
Mitigation Measures by Pandemic Severity
CDC has issued interim recommendations for use of community mitigation measures matched to
pandemic severity. In a severe pandemic, community mitigation measures would be more intense than if
the pandemic were mild. These recommendations are depicted in the following table. Further, more
information on CMIs, including definitions and explanations, can be found in Appendix 3.
Interventions by Pandemic Severity
Pandemic Severity Index
Interventions by Setting
1
2 and 3
4 and 5
Home
Voluntary isolation of ill at home (adults and children);
combine with use of antiviral treatment as available and
indicated
Recommend
Recommend
Recommend
Voluntary quarantine of household members in homes
with ill persons (adults and children); consider combining
with antiviral prophylaxis if effective, feasible, and
quantities sufficient
Generally not
recommended
Consider
Recommend
School: Child social distancing
Dismissal of students from schools and school based
activities, and closure of child care programs
Generally not
recommended
Consider <4
weeks*
Recommend
<12 weeks*
Reduce out-of school social contacts and community
mixing
Generally not
recommended
Consider <4
weeks*
Recommend
<12 weeks*
Workplace/Community: Adult social distancing
Decrease number of social contacts (e.g., encourage
Generally not
Consider
Recommend
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Pandemic Severity Index
Interventions by Setting
1
2 and 3
4 and 5
teleconferences, alternatives to face-to-face meetings)
recommended
Increase distance between persons (e.g., reduce density
in public transit, workplace)
Generally not
recommended
Consider
Recommend
Modify, postpone, or cancel selected public gatherings to
promote social distance (e.g., postpone indoor stadium
events, theatre performances)
Generally not
recommended
Consider
Recommend
Modify work place schedules and practices (e.g.,
telework, staggered shifts)
Generally not
recommended
Consider
Recommend
*These are estimates and based on assumptions about the length of a pandemic wave.
Technical Chapter D: Infection Control
This chapter is currently optional (in 2009) and will be added when guidance becomes available from the
Minnesota Department of Health.
Technical Chapter E: Clinical Issues
This chapter is currently optional (in 2009) and will be added when guidance becomes available from the
Minnesota Department of Health.
Technical Chapter F: Healthcare Planning
This chapter is currently optional (in 2009) and will be added when guidance becomes available from the
Minnesota Department of Health.
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Technical Chapter G: Asset Distribution Plan of antiviral medications and
personal protective equipment (PPE)
MDH guidance on distribution of Minnesota Asset Caches to assist with H1N1 Response
(Draft 1: July, 2009 This document will be continually updated as situation evolves)
Introduction
This guidance is to assist planning partners with the request, distribution and use of Minnesota Asset
Caches (MACache). The caches consist of pharmaceuticals and personal protective equipment. While
these assets can be used for various incidents, this guidance will address the current H1N1 Flu outbreak.
Antivirals
The Minnesota Department of Health (MDH) considers the use of antiviral drugs as one component of a
comprehensive containment and treatment plan to assist in the control of an outbreak of a novel
influenza virus with pandemic potential. The use of antiviral drugs serves to complement Community
Mitigation Interventions (Chapter C) and other non-pharmaceutical interventions.
Limited supplies of antiviral drugs (Oseltamivir and Zanamivir) were purchased by the MDH and the
federal government (Strategic National Stockpile (SNS) cache. For planning purposes, these assets
have been combined to make up the MACache. These antivirals are earmarked for specific use during
an outbreak of novel influenza, specifically to be used as a backup supply for antivirals when they are no
longer available through normal supply chains (e.g., community pharmacies for prescriptions, distributors
for hospitals). Normal supply chains will continue as sources of antivirals for citizens and health care
facilities through normal processes.
Since the cache for Minnesota is small compared to the Minnesota population, the MDH developed these
guidance and recommendations.
Currently, the MDH has distributed 10% of its 25% allotted SNS antivirals to all 8 of the public health
regions at Regional Placement Sites (RPS). This was an interim decision to speed up the delivery
process during the Spring 2009 response of H1N1. These assets are still located in these RPS but MDH
is open to further consideration of regional redistribution on a case by case basis.
Primary Goals of the Distribution System:
 To strategically place federal and state caches of antiviral drugs in areas that do not have, have
exhausted, or will soon exhaust normal supply chains;
 To ensure a mechanism to identify persons in priority target groups for antiviral distribution using
MDH Clinical Guidelines and;
 To distribute in a timely manner utilizing current systems Minnesota has planned for as much as
possible.
Clinical Guidelines:
These clinical guidelines for use are consistently aligned with the guidelines established by the Centers
for Disease Control and Prevention and are constantly under review at MDH by infectious disease
Personnel. Because this is subject to change according to the disease severity, they will not be listed in
this guidance. Updated information regarding this can be found at:
http://www.health.state.mn.us/divs/idepc/diseases/flu/h1n1/hcp/antiviral.html
Assumptions for Asset Distribution Planning:
 Correct use of non-pharmaceutical intervention strategies will decrease the need for prophylaxis
 The number of antiviral courses is limited and must last throughout the current outbreak and
possibly subsequent waves
 There may be potential for a change in influenza virulence and transmissibility over time
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

Individuals who are ill and prescribed antivirals by physicians will obtain them through their
regular channels or through flu centers when activated by Lake County
There are priorities for the antiviral distribution based on CDC priorities
Request for antiviral supplies will follow the established process for requesting resources
Opportunity to access resources should be assured to local health departments consistent with
population and level of influenza activity (supplying of heath care providers within communities
when normal supply sources are no longer available is the responsibility of local health
departments)
Commitment to fair distribution of resources by making sure assets will be available to someone
in need within a reasonable driving and/or walking perimeter of dispensing sites
Current Policies for Antivirals
 Assets are only available after all other resources have been exhausted. This includes use of
vendors that a facility is not under normal contract with.
 Assets may not be assessed any value or cost. *An administrative fee is permitted*.
 Assets will be prescribed and dispensed to patient through normal physician/pharmacy channels.
This could include hospitals, clinics, pharmacies and flu centers when activated.
 Local health departments will not currently prescribe or dispense to individual patients.
 Local health departments will lead partnership planning for their jurisdictions and/or as a public
health region in asset distribution.
 Further discussion is taking place with CDC at this time on this issue. More information is
expected in the future.
Distribution of Antiviral Caches:
It is the role of Lake County Public Health to distribute medical supplies during a public health
emergency. The MDH will follow current planning strategies associated with medical material distribution
as closely as possible. While the intent is to honor this system, other scenarios may evolve during an
event and the distribution plan will need to be adjusted to accommodate the needs to of the
region/community.
Lake County Public Health will coordinate with the NE MN regions regarding the “ship to” site for
antivirals. Once delivery sites are identified, service agreements* will be signed between the local health
department and the site. Sites may be pharmacies, clinics, and/or hospitals. (*A service agreement
template is currently under legal review and will be released soon.) The following items will be
considered regarding distribution:
 Where are the regional storage facilities?
 Who are our prescribing and dispensing partners?
 What are the burdens/access barriers in our current plans?
Obtaining MACache Assets:
The process for obtaining the MACache assets will follow normal communication and request systems
during a public health event
Antiviral Asset Requests
1. Local prescriber/dispenser goes to fill a prescription request.
2. There is no asset available in their facility.
3. They contact their facilities contracted and non-contracted vendors to fill supply.
4. There is still no supply available. They contact their local public health department or regional
contact (depending on what is planned for their jurisdiction)
5. Region is contacted; supply is still not available.
6. Region contacts MDH DOC if they are open or the emergency on call number at 651-2015735 to report shortage and need.
7. MDH releases asset verbally if located in region or begins a shipment process from MDH.
16
PPE Asset Requests:
The process for PPE will be similar to antivirals.
1. Local healthcare facilities run low on PPE..
2. They contact their facilities’ contracted and non-contracted vendors to fill supply. There is still no
supply available
3. They contact their local public health department or regional contact (depending on what is
planned for their region).
4. Region is contacted; supply is still not available.
5. Region contacts MDH DOC if they are open or the emergency on call number at 651-201-5735 to
report shortage and need.
6. MDH releases asset verbally if located in region or begins a shipment process from MDH.
17
Technical Chapter H: Vaccination Distribution Plan
Introduction
This guidance is provided to assist MDH partners with planning activities to distribute vaccine and
provide immunizations for the current H1N1 novel influenza situation. While these guidelines utilize
current knowledge of H1N1 influenza virus as well as vaccine manufacturing capabilities, the roles and
responsibilities will apply to a future novel influenza virus outbreak.
MDH considers vaccination delivery one component of the overall plan to minimize morbidity and
mortality, and to protect critical infrastructure and key resources when the pandemic influenza threatens
social disruption. Vaccination delivery consists of two major activities: 1) vaccination and follow-up of
appropriate targeted individuals according to the MDH and CDC guidelines and 2) distribution of vaccine
and ancillary supplies and resources within the time parameters established by the incident objectives
that maximize the impact of #1.
Multiple factors influence the implementation and outcomes of vaccination delivery. Characteristics of
the targeted population(s), vaccine manufacturing capacity, vaccine distribution capacity, requirements
for multiple doses, the risk of adverse events and other factors require ongoing modification of response
actions.
The availability and readiness of resources that can effectively implement the required activities also
impact the outcome. The efficiency, capacities and accessibility of vaccinating organizations in addition
to the appropriate vaccine administration, documentation, patient education, vaccine handling and other
activities help assure that resources are used effectively.
The ability of public health to monitor and control the progress and measures of vaccination delivery is
critical to the effectiveness of an H1N1 vaccination response. While disease surveillance and
immunologic response will be utilized to gauge population and individual effectiveness, intermediate
situational assessment and control of the implementation methods will enable public health to apply
resources to meet needs and to quickly respond to changing targeting and temporal criteria. Both MDH
and local and tribal health departments have responsibilities in situational assessment and adapting the
use of resources to accomplish goals.
Primary goals of vaccination delivery
Safe and effective administration of vaccinations to the targeted populations within the established time
frames.
Distribution of vaccine and supplies and management of vaccinating organizations, volunteers and other
resources to meet jurisdictional needs.
Maintenance of systems that facilitate vital situational awareness for state and local public health and
supplemental activities, e.g. reporting and tracking of adverse events, immunization documentation for
2nd dose follow-up and immunization coverage reports and inventory tracking.
MDH Working Assumptions



to Minnesota. The vaccine
will remain a state asset until administered to individuals.
Planning and response activities will utilize the framework of emergency preparedness and its
systems, e.g. ICS, NIMs, emergency planning, training and exercising.
l health departments will be responsible for assuring vaccination coverage of the
population, which includes occupational and general population and high risk groups, in their
jurisdiction.
18







The current vaccine distribution system consists of one ship-to site designated by each local
health department and tribal health department with further redistribution managed by the
individual sites. However, CDC is anticipating a change that will allow multiple distribution sites
per jurisdiction.
While the private sector can contribute to vaccination efforts, it is unclear at this time how much of
the vaccination effort the private sector will be able to take on. It is anticipated that vaccine will be
administered through a combination of public and private sites.
The process for identifying, engaging, controlling and utilizing traditional and non-traditional
immunization providers under a new distribution system is pending.
Local health departments are responsible for maintaining awareness of provider activities in their
jurisdictions to avoid duplication of efforts and to address gaps.
accomplish vaccination delivery.
Local health departments will play a specific key role in coordinating the vaccination of
occupational target groups. Employers of workers in targeted groups will be responsible for
identifying workers that fit the target criteria and providing the information to the local health
department or the designated vaccinating organization.
administering vaccinations and/or managing vaccine. Guidelines and information for vaccinating
organizations will be posted at: http://www.health.state.mn.us/divs/idepc/diseases/flu/h1n1/
vaccine/index.html

the MDH Workspace >> SNS >> Mass Dispensing >> Pandemic Influenza.
CDC Planning Assumptions & Scenarios, July 8, 2009
MDH is planning for vaccine distribution under the umbrella of CDC planning assumptions and planning
scenarios.
These planning scenarios are not official ACIP recommendations but provide direction for state and
local planning based on current assumptions. The scenarios are based on the following assumptions
at the time vaccine becomes available and distribution begins:
1.
2.
3.
4.
5.
severity of illness is unchanged from what has already been observed
risk groups affected by this virus do not change significantly
vaccine testing suggests safe and efficacious product
adequate supplies of vaccine can be produced
no major antigenic changes are evident that would signal the lack of likely efficacy of the vaccines
being produced
Target Populations
Primary Venues
LPH Considerations/Issues
Students and staff (all ages)
associated with schools (K-12th
grade)
Children (age ≥6 months) and staff
(all ages) in child care centers
schools
On-site vaccine clinic is planned.
child care centers
Pregnant women, children 6 months –
4 years of age, new parents and
household contacts of children <6
months of age.
Non-elderly adults (age <65 years)
Provider offices,
community clinics.
Public vaccine clinic target to this
group is planned during the same
week as the school clinic.
Vaccine will be provided on WIC
clinic days near the same clinic.
Occupational
Primary clinics in Two Harbors and
19
Target Populations
Primary Venues
LPH Considerations/Issues
with medical conditions that increase
the risk of complications of influenza.
settings, community
clinics, pharmacies,
providers’ offices.
Occupational settings,
providers’ offices.
Silver Bay will service this group.
Health care workers and emergency
services sector personnel (regardless
of age).
Primary clinics in Two Harbors and
Silver Bay will service this group.
Vaccine Availability Considerations
If vaccine becomes widely available, CDC would recommend offering vaccine at multiple venues to
anyone who wants to be vaccinated. Although the benefits of vaccine may be greatest in the persons in
groups at increased risk, and interest in being vaccinated may be lower among the general population,
offering vaccine to everyone can reduce the risk of influenza for general population may reduce
transmission to unvaccinated persons. At the same time, if vaccine supply is limited, it will be important
to consider a balance between international needs for vaccine in relation to the vaccination of low risk
individuals in the United States.
Pandemic Vaccine Program Planning Elements for LPH
Vaccination
Planning/Preparedness
Activity
1. Develop core planning
team
2. Plan for projected amount
of vaccine allocated for
jurisdiction
3. Identify & organize target
groups and the measures
utilized for their vaccination
4. Coordinate writing of the
medical protocol (standing
order) by the local medical
director for H1N1 vaccination
for health dept. immunizations
5. Determine models for
administration of vaccine: a)
Agency administration or b)
delegation to another agency
6. Organize Mass Dispensing
Clinics (for general population)
7. Organize vaccination teams
(for designated non-medical
groups such as law
enforcement or schools)
8. Delegate vaccination to
organizations that have
employees in a target group
that can vaccinate themselves
and also to clinics or
Resources
Respon
si-bility
of:
LPH
Local
Considerations &
Issues
Include Emergency
Mgmt Coordinator
Follow MDH
guidelines
“Projected Minnesota Shipment
Allocations”(Workspace &
Appendix 3)
Pandemic Target Group Worksheet
(Workspace)
LPH
LPH
Follow MDH
guidelines
MDH will provide the clinical
guidelines for prescribing vaccine.
MDH may also providing a sample
medical protocol and a screening
form that would include the
required data fields
LPH
LPH will follow MDH
protocol
LPH
LPH and
SuperiorHealth will
administer
Mass Dispensing Plans; Planning
documents on workspace
Mass Dispensing Plans; Planning
documents on workspace
LPH
See Mass Dispensing
Plan
See Mass Dispensing
Plan
Encourage potential vaccination
providers to pre-register on an
MDH web site. The list of potential
clinics will be shared with local
health departments. Model MOAs
LPH
LPH
MOA in process
20
Vaccination
Planning/Preparedness
Activity
organizations that could
vaccinate a target group such
as pregnant women.
9. Contact school
administrators and school
nurses to begin planning for
school based clinics
10. Coordinate vaccination
plans with flu center planning.
11. Determine supply and
equipment needs.
12. Organize and train
volunteers
Resources
will be posted or the MOA will be
implemented between the clinic
and MDH
School associated clinics can
included a variety of models
including local public health, health
systems, and/or community
vaccinating teams (or a
combination of these) providing
coordination,
staff and volunteers.
MDH Flu Center and Mass
Dispensing staff
SNS will provide syringes, alcohol
swabs, and sharps containers
Provide pre-training on mass
dispensing sites, blood borne
pathogens, vaccine administration
and entering data into MIIC.
Respon
si-bility
of:
Local
Considerations &
Issues
LPH
Planning in process
LPH
Planning in process
LPH
Planning in process
LPH
Planning in process
This table details the roles and responsibilities of local public health and MDH during the pandemic
vaccination program.
Pandemic Flu Immunization and Vaccine Management Public Health Roles
and Responsibilities
Activity
State
Local
Community/
Population
Assessment
Preparedness: Provide baseline
population data. Provide framework
including definitions and models of
special needs populations.
Response: Provide guidance on target
populations for receipt of
countermeasures.
Prophylaxis
strategies
and methods
Campaign
planning
Preparedness: Provide guidance and
framework for specific strategies based
on federal guidance and state needs.
Provide the framework and materials
for delegating the immunization function
to other institutions.
Response: Develop and maintain
incident objectives for a consistent state
response based on the national
strategy and current situation; convey
to local health departments.
Preparedness: Provide guidance for
elements specific to pandemic flu –
vaccine security, vaccine volume
Preparedness: Describe the jurisdiction’s
population including size and vulnerabilities.
Enumerate priority groups. Identify
populations reachable through methods
external to mass dispensing sites.
Response: Consider the specific needs of
the community with the implementation of the
incident strategies and tactics.
Preparedness: Identify, plan, and exercise
methods and strategies appropriate to the
community for administering vaccinations.
Develop agreements and operational plans
for delegation of vaccination to local
institutions employing priority group
members.
Response: Choose strategies based on the
target population, the incident objectives, and
the resources available.
Preparedness: Procure sites, develop site
specific plans including security; client, staff,
and supply flow. Identify, enumerate, and
21
Activity
Resources
Policy,
protocols,
and legal
issues
Tracking and
monitoring
Critical
infrastructur
e or mission
critical
personnel
State
Local
planning scenarios, vaccine storage
and distribution, infection control,
patient triage, etc.
train staff and volunteers. Pre-roster key
positions. Develop workforce deployment,
monitoring, and demobilization plan.
Response: Provide incident
parameters and objectives (timelines,
target groups, etc.). Monitor event and
CDC recommendations and revise
guidance as appropriate.
Preparedness: Maintain distribution
plans for resources accessed by the
state including vaccine and syringes.
Develop and maintain systems to track
resources.
Response: Activate plan and provide
immunizations according to the incident
objectives.
Response: Coordinate the distribution
and tracking of state and federal
assets.
Preparedness: Develop policies and
procedures, including immunization
protocols, for statewide consistency.
Response: Facilitate resolution of
policy or legal obstacles to the
response as they arise.
Response: Coordinate resource distribution
with the state and with supply recipients.
Track resources using state systems.
Preparedness: Identify state protocols and
policy and integrate into plans. Identify local
gaps and issues.
Preparedness: Develop and maintain
tracking systems and protocols for
medical countermeasure inventory,
vaccine administration, and adverse
event monitoring. Provide education
and materials to users.
Preparedness: Identify state method of
tracking and monitoring countermeasures,
throughput and adverse events and integrate
into planning. Train staff.
Response: Implement tracking
systems and provide instructions and
parameters to users. Compile reports.
Preparedness: Formulate guidance
for prioritization and allocation of
vaccine for local use. Provide
definitions of priority groups.
Response: Monitor appropriate
utilization of guidance. Revise
guidelines when appropriate for incident
objectives.
Preparedness: Identify supplies, equipment
computer and communications, and
medications and/or vaccine (and syringes)
needed. Plan for procuring, storing, and
managing and tracking resources.
Response: Identify policy gaps or issues and
facilitate coordination of resolution.
Response: Assure systems, hardware, staff
and protocols are available. Implement
tracking functions and provide data and
reports to the state as requested.
Preparedness: Identify and enumerate
according to MDH definitions. Coordinate with
local institutions for further stratification or
prioritization of groups. Develop a plan for
prophylaxis of identified critical infrastructure
including methods of notification and
identification at site. Utilize “delegation of
immunization” as described under
“Prophylaxis Strategies and Methods.”
Response: Assure appropriate utilization of
prioritization and critical infrastructure
guidance.
From MDH Pandemic Influenza Immunization and Vaccine Management Annex, March 2008
See Appendix 5 for more resources on pandemic vaccination programming.
22
Technical Chapter I: Laboratory
This chapter is currently optional (in 2009) and may be added when guidance becomes available from
the Minnesota Department of Health.
Technical Chapter J: Poultry/Swine Worker Health
This chapter is currently optional (in 2009) and may be added when guidance becomes available from
the Minnesota Department of Health.
Technical Chapter K: Care of the Deceased
This chapter is currently optional (in 2009) and may be added when guidance becomes available from
the Minnesota Department of Health. For most cases, procedures for care of the deceased are outlined
in the all-hazards Lake County Emergency Operations Plan (EOP) under Emergency Support Annex 8:
Health and Medical Functions.
23
Technical Chapter L: Flu Centers
The development and implementation of Flu Centers is a statewide strategy for Minnesota. Flu Centers
are designed to integrate community wide interventions such as anti-viral distribution with a surge of
moderately ill citizens to a stressed health care system. The Flu Center strategy has been designed as a
collaboration between health care, public health, and other partners on a community basis.
Flu Center Planning Element
Community Names:
Advisory Committee Formed?
Lead Agencies
1. Lake County Public Health
2. Lake County Emergency
Management
3. Lake View Hospital
1. 4. Lake View Clinic
Contact Information Available
Flu Center Services Delineated
1. Triage
2. Vital Sign Monitoring
3. IV Fluids
4. Anti-virals
5. Flu Symptom Kits
Triggers for Opening Flu Center
1. Adequate hospital/clinic staff
2. Number of requests for help
from community
3. Schools closing
Sites determined (insert Address)
and signed MOUs available (Y/N)
Command Structure determined
(Y/N)
Flu Center Layout and Flow
Delineated (Y/N)
Staffing Plan Complete (Y/N)
Infection Control Plan Complete
(Y/N)
Transportation Plan Complete
(Y/N)
Security / Traffic Control Plans
Complete (Y/N)
Explanation
Local health departments should
reproduce the summary chart if
their jurisdiction contains more
than four flu centers.
Was an Advisory Committee
formed?
List the cooperating local health
departments and health care
facilities (and others if applicable)
Has contact information been
compiled?
What services (for example
triage, antiviral distribution,
education and referral) will the
local flu center provide?
What will be the criteria for
opening the local flu center (for
example, surge in emergency
department visits, phone lines
jammed)?
List the flu center site name and
address and state if the MOU for
its use is in place
Has the Incident Command
structure been finalized?
Has the flu center layout and flow
been diagrammed?
Has staffing been determined
(components of MRCs, Health
Care, Public Health, other)?
Has an Infection Control
(including PPE resourcing) been
developed?
Is there a plan for transporting ill
patients, populations with mobility
problems, etc?
Has law enforcement
collaborated on the planning?
Will there be adequate parking?
Enter data for each Flu Center
in jurisdiction)

Two
Silver
Isabella
Harbors
Bay
Comm
Comm
Reunion
Center
Center
Hall
Y
Y
y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
24
Technical Chapter M: Regional Coordination
Many of the Minnesota Pandemic Influenza strategies are designed to use regional coordination through
Multi-Agency Coordination (MAC) systems/groups. Lake County Public Health and MACs will be in close
collaboration throughout the planning and response periods. Strategies for rapid communication and
decision-making (such as the use of MN Trac Coordination Centers) will be tested in advance of the
pandemic acceleration.
During an incident or emergency when Lake County Public Health is in need of further resources or
assistance, the Lake County Emergency Manager will be contacted as well as the Northeast Public
Health Preparedness Consultant, Marilyn Cluka (noted below) and/or NE-MAC (218-625-5515) who, in
turn, will notify the Minnesota Department of Health.
For a list of Pandemic Influenza contacts, please see the Pan Flu Contact List under the Emergency
Contacts Supplement to the Lake County Emergency Operations Plan.
25
Appendices
Appendix 1. Background Information on Intervals, Triggers, and Actions
ITA Background
Global Preparedness Planning – WHO Phases
The WHO has defined six phases, occurring before and during a pandemic, that are linked to the
characteristics of a new influenza virus and its spread through the population. These phases are
described below:
Inter-Pandemic Period
 Phase 1: No new influenza virus subtypes have been detected in humans. An influenza virus
subtype that has caused human infection may be present in animals. If present in animals, the
risk of human disease is considered to be low.
 Phase 2: No new influenza virus subtypes have been detected in humans. However, a
circulating animal influenza virus subtype poses a substantial risk of human disease.
Pandemic Alert Period
 Phase 3: Human infection(s) with a new subtype, but no human-to-human spread, or at most
rare instances of spread to a close contact.
 Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly
localized, suggesting that the virus is not well adapted to humans.
 Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is
becoming increasingly better adapted to humans, but may not yet be fully transmissible
(substantial pandemic risk).
Pandemic Period
 Phase 6: Pandemic phase: increased and sustained transmission in general population.
U.S. Preparedness Planning – U.S. Stages
In the U.S. government’s approach to the pandemic response, it is more useful to characterize the
stages of an outbreak in terms of the immediate and specific threat a pandemic virus poses to the U.S.
population. The following stages provide a framework for federal government actions:
 Stage 0: New Domestic Animal Outbreak in At-Risk Country
 Stage 1: Suspected Human Outbreak Overseas
 Stage 2: Confirmed Human Outbreak Overseas
 Stage 3: Widespread Human Outbreaks in Multiple Locations Overseas
 Stage 4: First Human Case in North America
 Stage 5: Spread throughout United States
 Stage 6: Recovery and Preparation for Subsequent Waves
Minnesota Preparedness Planning – Minnesota Phases
The Minnesota HSEM developed the Minnesota Response Phases to provide a standard framework for
the State of Minnesota’s response to an influenza pandemic. The Minnesota phases are as follows:
MN Phase PO: Suspected Human Outbreak Overseas
MN Phase P1: Confirmed, Sustained, Human-to-Human Transmission Overseas
MN Phase P2: Suspected or Confirmed Human Case in North America
MN Phase P3: Outbreak in United States
MN Phase P4: Suspected or Confirmed Human Case in MN
MN Phase P5: Limited Outbreak in MN
MN Phase P6: Widespread Throughout MN
MN Phase P7: Recovery and Preparation for Subsequent Waves
26
U.S., and State Preparedness Planning – Intervals, Triggers and Actions
The Intervals, Triggers and Actions conceptual framework is based on a model epidemic curve.
For the purposes of pandemic preparedness, CDC is using seven intervals to represent the sequential
units of time that occur along a hypothetical pandemic curve. For state planning, use of the intervals to
describe the progression of the pandemic provides a framework for defining when to respond with
various actions and interventions during U.S. Government stages 4, 5 and 6.
The strategies are aligned with the:
 World Health Organization (WHO) phases of a pandemic.
 United States stages of a pandemic.
 United States pandemic intervals as modified for use in Minnesota.
In actual practice, the distinction between the various phases, stages, or intervals of an influenza
pandemic may be blurred or shift in a matter of hours, which underscores the need for flexibility. The
timing and scope of actions ultimately must be based on available scientific and epidemiological data at
the time a pandemic occurs.
The U.S. stages provide a high-level view of pandemic activity in the nation. The CDC intervals
recognize that the progression of a pandemic likely will occur asynchronistically across the United States,
affecting states at different times. Consequently, the intervals are geared to states determining the
imminence of a pandemic threat in their jurisdiction in order to trigger response actions. CDC has
defined both national and state triggers for recognizing that a new interval is occurring.
In general, and from a state “triggers” perspective, the intervals as defined by CDC are as follows
Investigation (pre-pandemic interval):
Sporadic cases of a novel influenza virus occurring overseas or in the United States. A state is “affected” if it
identifies a human case of potential novel influenza A infection or an animal case of influenza A subtype with
potential implications for human health within its jurisdiction (though because this is a pre-pandemic interval,
the virus is not yet efficiently transmitted human to human).
 Recognition:
Clusters of novel influenza cases in humans and confirmation that a pandemic strain with efficient
and sustained human to human transmission has emerged overseas or in the U.S.
 Initiation:
Identification of the first human case of pandemic influenza in the U.S. A state becomes an “affected
state” when it has its first laboratory-confirmed case.
 Acceleration:
 A state is “affected” when increasing numbers of cases exceed resources to provide case-based
control measures or the state identifies two or more laboratory-confirmed cases in the state that are
not epidemiologically linked to any previous case.
 Peak:
Extensive transmission in the community and a state reaches its greatest number of newly identified
cases. (Specific criteria are > 10% of specimens from patients with influenza-like illness submitted to
the state public health laboratory are positive for the pandemic strain during a 7-day period; or
“regional” activity is occurring in the state using CDC surveillance criteria; or the health care system
surge capacity has been exceeded.)
 Deceleration:
Rates of pandemic infection in the state are declining. (Specific criteria are <10% of specimens from
patients with influenza-like illness submitted to the state public health laboratory are positive for the
pandemic strain for at least two consecutive weeks or, the health care system is below surge
capacity.)
 Resolution:
Pandemic cases in the state are occurring sporadically. (Specific criteria are laboratory-confirmed
cases are occurring sporadically, or the health care system is approaching pre-pandemic levels).
27
Phases, Stages, Intervals, and Triggers for Pandemic Influenza Response
WHO
Phase
1:
Low risk of
human cases
USG
Stage
0:
P0:
New Domestic
Suspected Human
Animal Outbreak
Outbreak Overseas.
in At-Risk
Country
2:
Higher risk of
human cases
3:
No or very
limited humanhuman
transmission
4:
Evidence of
increased
human-human
transmission
Minnesota
Phases
Influenza
Interval
Investigation
of Novel Influenza
A Infection in
Animals and
Humans
Minnesota
Trigger
National
Trigger
Identification of human case of Identification of
potential novel influenza A
animal case of
infection in the state
influenza A
OR
subtypes with
Identification of animal case of potential
influenza A subtypes with
implications for
human health
potential implications for
human health within the state anywhere in the
world
Identification of
human case of
potential novel
influenza A
infection anywhere
in the world
1:
Suspected
Human Outbreak
Overseas
2:
P1/P2/P3:
Recognition
Confirmation of human cases
Confirmed Human Confirmed,
of Pandemic Virus of novel influenza A and
Outbreak
Sustained Human-todemonstration of efficient and
Overseas
Human Transmission
sustained human-to-human
Overseas;
transmission anywhere in the
Suspected or
world
Confirmed Human
Case in North
America; Outbreak in
United States.
Confirmation of
human cases of
novel influenza A
and demonstration
of efficient and
sustained humanto-human
transmission
anywhere in the
world
28
WHO
Phase
5:
Evidence of
significant
human-human
transmission
USG
Stage
Minnesota
Phases
Influenza
Interval
Minnesota
Trigger
National
Trigger
3:
Widespread
Human Outbreaks
in Multiple
Locations
Overseas
6:
Efficient
and
4:
P4:
sustained
First Human Case Suspected or
human-human
in North America
transmission
Confirmed Human
Case in MN.
5:
Spread
Throughout
United States
Initiation
of Pandemic
Wave
Laboratory-confirmed case of
defined pandemic influenza
P5/P6:
Limited Outbreak in
MN; Widespread
Throughout MN.
Acceleration
of Pandemic
Wave
One or two laboratoryconfirmed cases in Minnesota
that are not epidemiologically
linked to any previous case
Or
Number of cases exceed the
resources necessary for
case/contact-based control
measures
Or
A significant exposure has
occurred in a setting where a
large number of individuals
cannot be identified for
case/contact-based control
measures
Or
There are indications that
case/contact-based control
measures are not effective
At least one state in
five of the ten
FEMA/HHS regions
have met the
Acceleration criteria
P5/P6:
Limited Outbreak in
MN; Widespread
Throughout MN.
Peak
Widespread transmission with
a level, but high number of
new cases and resources
exceeded in most areas of
Minnesota
The majority of
states have met the
Peak/Established
Transmission
criteria (includes
states that have
transitioned into the
Deceleration
Interval)
Deceleration
Number of new cases drops
The majority of
from peak level for at least two
states have met the
consecutive weeks
detected in Minnesota or its
contiguous states
Laboratoryconfirmed case of
defined pandemic
influenza detected
within the US
Deceleration
criteria (includes
states that have
transitioned into the
Resolution Interval)
6:
Recovery
P7:
Recovery and
Preparation for
Subsequent Waves.
Resolution
Cases without an identified
The majority of
household exposure are
“sporadic” per CDC influenza states have met the
surveillance criteria. MDH will Resolution criteria
determine that the state has
met the trigger (cases without
an identified household
exposure are “sporadic”)
through case-based reporting
which will be re-instituted once
the number of new
hospitalized cases drops to
10% of cases occurring at the
pandemic peak.
29
MDH Flu Plan
Appendix 2—Communication Guidelines
These guidelines are incorporated in the all-hazard Lake County Emergency Operations Plan (EOP)
under Emergency Support Function 15: External Affairs.
Appendix 3--Community Mitigation Intervention Background Information
Community Mitigation Interventions Planning Considerations
Social Distancing – Adult
The goal of adult social distancing is to reduce transmission in the workplace and the community at
large. In general, workplace social distancing is altering workplace environments and schedules to
decrease social density while preserving a healthy and functioning workplace. The goals of
workplace measures are to reduce transmission in the workplace (and thus into the community at
large); to ensure a safe working environment thereby promoting confidence in the workplace; and to
maintain business continuity especially for critical infrastructure.
HSEM is the lead state agency for assisting businesses in planning for continuity of operations and
workplace social distancing in a pandemic. HSEM issued a Continuation Planning Guide for
Businesses and for Local Jurisdictions. MDH developed the health and safety sections of this
guidance document including recommendations on workplace social distancing. These documents
are located on the HSEM website: http://www.hsem.state.mn.us HSEM has conducted workshops
with businesses and other groups throughout the state to assist them with pandemic planning.
Social distancing in office settings may include establishing telecommuting policies, staggered shifts,
remote meetings, and prompt exclusion of workers with influenza symptoms. Other actions include
promoting hand hygiene and respiratory etiquette, cleaning of workplace surfaces, use of stairs
instead of crowded elevators, avoidance of group situations (e.g. meetings and cafeterias), and
curtailing face-to-face customer service unless the service is essential to the health of others.
Businesses and government entities in which employees typically interact with customers should plan
for business methods that modify or eliminated such actions (e.g. limit method for obtaining retail
items to phone, fax, or internet, and delivery or pick-up).
Social distancing also may include measures such as cancellation or postponement of large public
gatherings (e.g. concerts, theater showings, sporting events, stadium events) and modifications to
mass transit to decrease passenger density. Individuals also may take measures to decrease their
risk of infection by minimizing non-essential social contacts and exposure to socially dense
environments. If emergency conditions warrant it, social distancing in a pandemic may also include
“snow days” (including closure of businesses) in which it is recommended or ordered that only critical
activities (e.g. essential to health and safety) continue.
Requirements for the success of adult social distancing measures include:
o Commitment of employers to provide options and make changes in work environments to reduce
contacts while maintaining daily operations.
o
Support from political and business leaders, and the public.
Social Distancing - Child
Child social distancing consists of dismissal of students from schools and school-based activities,
and closure of childcare programs. It also encompasses reduction of out-of-school contacts and
30
community mixing. The latter is a critical component of child social distancing since congregating at
places other than school could defeat the benefits of school closure in protecting children.
Schools and childcare programs represent socially dense environments. Further, children are
particularly important in the transmission of influenza viruses. Compared to adults, children usually
shed more influenza virus and shed virus for a longer period of time. Schools serve as amplification
points of seasonal influenza and children are thought to play a significant role in introducing and
transmitting influenza virus in their households. Given the disproportionate contribution of children to
influenza transmission, targeting their social networks within and outside of schools would be
expected to disproportionately disrupt influenza spread.
“Schools” refers to public and private elementary, middle, secondary, and post-secondary schools
(e.g. colleges and universities). The same dismissal recommendations apply to colleges and
universities. Colleges and universities present unique challenges because many aspects of student
life and activity encompass factors that are common to both the child school environment (e.g.
classroom and dormitory density) and the adult sphere (e.g. commuting for class attendance and
participating in behaviors associated with an older student population).
Requirements for the success of child social distancing measures include:
o Consistent implementation among all schools in a region.
o
Commitment of the community and parents to keep children from congregating out of school.
o
Alternative options for the education and social interaction of children.
o
Support for parents and adolescents who need to stay home from work.
Strict confinement of children during a pandemic will raise significant problems for many families and
may cause psychosocial stress to children and adolescents. These considerations must be weighed
against the risk of a pandemic virus to the community at large and to children in particular. In
response to the weighing of factors, the risk of introduction of an infection into a group and
subsequent transmission among group members is directly related to the number of individuals in the
group. Although available evidence does not permit specification of a “safe” group size, gatherings of
children that are comparable to family size units may be acceptable and could be important in
promoting emotional and psychosocial stability. If a recommendation for child social distancing is
made during a pandemic and families must nevertheless group their children for pragmatic reasons,
group sizes should be held to a minimum and mixing between groups should be minimized (e.g.
children should not move from group to group or have extended social contacts outside the
designated group).
Mitigation Measures in Minnesota
Key decisions on the scope of community mitigation measures in a pandemic ultimately will be made by
the Governor. MDH will use the CDC framework of interventions by pandemic severity index (PSI) as
primary guidance for community mitigation recommendations and has, in accordance with this
framework, developed potential recommendations for a mild, moderate, and severe pandemic. (see
attachments)
Cessation of Mitigation Measures in Minnesota
When cases without an identified household exposure are “sporadic” per CDC influenza surveillance
criteria, MDH anticipates recommending cessation of community mitigation measures. Cessation of
community mitigation measures also will be influenced by the epidemiology of the pandemic virus and
availability of vaccine. Each category of measure will be separately considered for mitigation; for
example, recommendations for isolation of individuals who meet case criteria are likely to continue even
when other recommendations are lifted. MDH may re-institute case-based isolation and quarantine
informed in part by the proportion of susceptible individuals in the population and the experience with
these case-based measures prior to the acceleration interval.
31
Appendix 4-- Asset Distribution (Antivirals and PPE)
Additional resources for additional planning resources for Asset Distribution will be available in future on
the MDH Workspace.
Appendix 5– Vaccination Background Information
Planning Scenarios The following are best-case planning scenarios that would be recommended
in a setting of limited initial vaccine availability.
Target population: Students and staff (all ages) associated with schools (K-12th grade) and
children (age ≥6 months) and staff (all ages) in child care centers.
Primary venues: schools and child care centers.
Goals: Provide direct protection against illness among persons who have high attack rates of illness,
reduce likelihood of outbreaks that may lead to disruptive school dismissals, reduce transmission
from schools into homes and the community.
Adherence to these guidelines will require state and local authorities to carry out extensive planning
to reach school-aged populations either through venues such as school-associated mass vaccination
efforts, or, where private capacity is sufficient, through local pediatric providers. Local pediatric care
providers may play a particularly prominent role in vaccinating preschool-aged children who have a
medical home. These planning efforts will reinforce longer-term immunization targets of
strengthening vaccination efforts in these populations, and building links between health and
education. The disruptive outbreaks prevalent in schools and some universities in the spring of 2009
may provide impetus for these planning steps to move forward actively. They will also permit
strengthening capacity for seasonal influenza vaccination of school-aged children in future seasons.
Target population: Pregnant women, children 6 months – 4 years of age, new parents and
household contacts of children <6 months of age.
Primary venues: Provider offices, community clinics.
Goal: Reduce complications of novel H1N1 influenza, such as excess hospitalizations and deaths
among those vulnerable for serious complications of influenza, as evidenced by higher rates of
hospitalization; protect the youngest (<6 months) who are not themselves able to be vaccinated
through immunization of their household contacts.
Sustaining a focus on pregnant women and young children is appropriate given their high rates of
complications and hospitalizations to date, and is consistent with tier 1 prioritization for these groups
in pre-pandemic planning.
Target population: Non-elderly adults (age <65 years) with medical conditions that increase the
risk of complications of influenza.
Primary venues: Occupational settings, community clinics, pharmacies, providers’ offices.
(Experience with seasonal influenza vaccine suggests that persons with underlying illness age 50 to
64 years may be more likely to receive vaccine from their provider, while younger persons may be
more likely to be vaccinated elsewhere).
Goal: Reduce risk of hospitalizations and deaths among persons with higher rates of these
complications than the general population, and focus vaccine where its impact can be most beneficial
for direct protection.
32
The planning requirement to offer vaccine to young adults with risk factors will permit state and local
authorities to address a group that does not frequently seek health care and has relatively low rates
of vaccination against seasonal influenza. Links with occupational clinics, adult providers, or
contingency plans for community venues or pharmacies are all options that might address this
important at-risk group.
Target population: Health care workers and emergency services sector personnel (regardless of
age).
Primary venue: Occupational settings, providers’ offices.
Goal: Reduce risk of illness, sustain health system functioning, and reduce absenteeism among
front-line providers; reduce transmission from emergency services personnel and health care
workers to patients; provide additional worker protection in settings of increased exposure; reinforce
importance of influenza vaccination among all health care workers.
Vaccine Availability Considerations
If vaccine is widely available, CDC would recommend offering vaccine at multiple venues to anyone who
wants to be vaccinated. Although the benefits of vaccine may be greatest in the persons in groups at
increased risk, and interest in being vaccinated may be lower among the general population, offering
vaccine to everyone can reduce the risk of influenza for general population may reduce transmission to
unvaccinated persons. At the same time, if vaccine supply is limited, it will be important to consider a
balance between international needs for vaccine in relation to the vaccination of low risk individuals in the
United States.
33
Vaccine Planning Algorithm
34
Appendix 6-- Flu Center Plan Template
Flu Center Plan Template
(Community Assessment, Treatment & Referral Center)
Lead Coordinating Agency:
Primary Agency:
Secondary Agency:
Support Agencies:
I.
Introduction and Background
During influenza pandemics, it is predicted that 30% of the United States population will
become moderately to severely ill. Even a low frequency of complications related to
influenza could result in marked increase in rates of hospitalizations. A vaccine may not be
available until four to five months after the pandemic strain is identified and prophylaxis
medication will be in short supply. An estimate of the health impact of a pandemic in
Minnesota is summarized below:
2007 MN
Population
(2% OF US
POPULATION)
5,263,493
(ESTIMATE)
ILLNESS
OUTPATIENT
MEDICAL CARE
HOSPITALIZATIONS
12,000/16,000
MODERATE
PANDEMIC
SEVERE
PANDEMIC
MODERATE
PANDEMIC
SEVERE
PANDEMIC
MODERATE
PANDEMIC
SEVERE
PANDEMIC
30% OF
POPULATION
30% OF
POPULATION
50% OF ILL
50% OF ILL
1% OF ILL
11% OF ILL
1,580,000
1,580,000
790,000
790,000
16,000
174,000
[Insert Regional and/or Local Statistics or include in appendices.]
Note: Minnesota statistics by Region is available on the MDH website under Flu Center
II.
Purpose
During a severe pandemic, the healthcare system will be overwhelmed with a surge of patients. Flu
centers are established to make the most effective use of healthcare capacity during a pandemic.
These flu centers can be established to provide a safety valve for our communities by:
1) Providing a community resource for the assessment, referral and treatment of people with
influenza-like illness, and
2) Managing the surge in an overwhelmed healthcare system to allow the acute care
facilities to care for the more critically ill people with influenza-like illness and people with
life-threatening illnesses or injuries.
Flu center planning and implementation requires a bridge between local public health and
healthcare systems to meet the needs of the community. This is a shared responsibility with
shared benefits for both types of agencies. Establishing non-traditional sites such as flu centers is
a method for augmenting the provision of medical care during a pandemic.
III.
Planning Assumptions
 Flu Center Advisory Committees, composed of public health, healthcare and other community
partners, will be responsible for planning and implementing flu centers on a regional and/or
local basis.
 Plans will be flexible and able to adapt to changing community needs.
 Plans will ensure that all people in the community will receive equitable services.
35








Presenting family members will be allowed to remain together.
People presenting themselves at flu centers will be provided with the appropriate level of
support.
Levels of support include relevant information, appropriate medication and/or healthcare or
community referrals.
Infection control is a priority in planning, facility layout and procedures.
Assessment and pharmaceuticals will be provided according to protocols outlined by the
Minnesota Department of Health.
Planning for flu centers will be part of a continuum of care that includes mass dispensing sites
and/or alternative care sites as appropriate.
Flu centers will operate within the Incident Command (ICS)/National Incident Management
System (NIMS) and plans will include the use of appropriate documentation and job action
sheets.
[Insert local assumptions]
IV. Authority
Chapter 12 of the Minnesota Statutes grants the Governor and HSEM overall responsibility of
preparing for and responding to emergencies and disasters. Chapter 12 directs the Governor and
HSEM to develop and maintain a comprehensive state emergency operations plan. Furthermore,
the Minnesota Statutes grant the Commissioner of Health broad authority to protect, maintain,
and improve the health of the public. In a pandemic, the Commissioner of Health may delegate
responsibility to local public health agencies and/or regional coalitions to protect the health of
residents and visitors. See Appendix E for list of applicable statutes for a pandemic influenza
response.
V.
Scope
This plan is a scalable response to a declared influenza pandemic and is limited to the protection
of citizens and visitors within [insert jurisdiction]. Government entities, public and private
institutions, businesses and citizens will be impacted by this situation.
The plan is intended to assure coordination and consistency with the Pandemic Influenza
components of the [insert jurisdictional name] Emergency Response Plans and Continuity of
Operations Plans (COOP). This plan defines the roles and responsibilities in the planning,
opening and operating of a community flu center.
VI. Concept of Operations
This document is a planning tool for developing an integrative approach to patient care
coordination during a pandemic influenza incident within the State of Minnesota. Since the size,
scope and nature of the influenza incident will determine the response, some roles and
responsibilities may not be included here. The goal of this plan is to describe a framework for an
integrative system that provides the most appropriate care, in the most appropriate location, by the
most appropriate staff. Care may be provided at an existing clinic or hospital, a designated
alternative care site or mass dispensing site, or at another location within the community. Flu
Centers will:
1. Use a consistent approach for the assessment and triage of people with symptoms of
influenza-like illness.
2. Refer individuals to the appropriate community-based agency or healthcare facility for
additional care, if required.
3. Provide access to self-care information for all people in a form appropriate for their needs.
4. Provide treatments, including the administration of antiviral drugs, as available, within the
clinical guidelines provided at the time of the pandemic.
5. Provide supportive care strategies, including community referrals, as needed.
6. [Insert local additions]
36
Note: Communities that choose to provide more advanced patient care, such as overnight
treatment/stays or advanced assessment/treatment procedures, will have to consider the more
robust skill sets/supplies that will be required.
VII. Responsibilities
A. Minnesota Department of Health (MDH)
MDH, as the lead public health agency in the state, is responsible for protecting, maintaining,
and improving the health of all Minnesotans. There is a strong state-local partnership wherein
MDH provides leadership and direction to front-line public health and healthcare entities.
B. Regional Multi-Agency Coordination Center (MACC)
The MACC will support regional resource management in coordination with MDH.
C. Local Advisory Committee
Communities are encouraged to establish a local Flu Center Advisory Committee to develop
their flu centers. Membership should include: public health, community-based healthcare
providers, hospitals, clinics, emergency medical services, emergency management, law
enforcement, public works, and representatives of tribal communities, local community
agencies and faith-based groups.
[Insert roster for local Flu Center Advisory Committee.]
D. Lead Agency
The decision to open and operate a flu center will need to be shared by the affected public
health and healthcare systems. The parties designated to open and operate flu centers for
[insert geographic area covered by plan] are:
[Insert name & title of parties designated to open and operate a flu center]
[Insert name & title of parties representing support agencies assisting with the opening
and operating of a flu center]
VIII. Triggers for Opening a Flu Center
The decision to open flu centers will be based on the severity of the pandemic and its impact on
existing health care services.
Criteria may include:
 Federal, state and/or local emergency declaration and emergency executive order for
pandemic influenza.
 Confirmation of a widespread influenza-like illness in a neighboring area.
 Reports from local primary care providers that they can no longer assess and treat people
appropriately in a timely manner (e.g. unable to provide antivirals within 12-24 hours of onset of
symptoms or have cancelled primary care or other non-influenza-like illness appointments).
 Proportion of emergency department visits attributable to influenza-like illness.
 Proportion of influenza-like illness cases requiring hospitalization.
 [Insert local triggers - For your local community, identify what factors would warrant the
opening of a flu center and identify who would be notified.]
IX. Development of Flu Centers
A. Level of Care
The level of care provided at the flu center is based on the anticipated needs of the
community and available resources for staffing and supplying the flu center.
[Insert description of level of care that is planned for the flu center.
For example, will you only provide palliative care for presenting symptoms?
37
Will you provide more specific treatment based on the ability to provide a diagnosis?
Specific treatment may include fever management, IV fluids, extended length of stay.]
B. Site Selection
1. Criteria for location and type of facility:
[List criteria used to determine location(s) of flu center (s).]
Note: Flu center plan should identify the criteria for determining the location of flu centers. For
example, the plan could specify:
 The population base per flu center (e.g. 1 flu center for every X number of persons)
and/or the maximum travel distance that would be served by flu centers (e.g. no one
would have to travel more than 75 miles).
 Facility needs to accommodate desired level of care provided.
Flu center locations selected should promote use of flu centers by people in the affected
jurisdiction by ensuring that they are not too far away, too crowded and/or difficult to access.
These locations can be established healthcare facilities such as a clinic or a non-healthcare
building in the community. The public should be familiar with the flu center location and willing
to go there.
2. Flu Center Site(s):
[Insert for each selected site:
 Facility Manager contact information (24/7)
 Address
 Phone numbers
 Inventory of available office equipment and material handling equipment on
site
 Floor plans & flu center flow charts
 Delivery site schematic
 Security Issues
 Crowd control and traffic management plans
 Parking plans
 Memorandum of Understanding (MOU)]
Note: When considering appropriate facilities for flu centers, remember that space will be
needed for the following functions:
 Initial Screening Area
 Waiting Area
 Worried Well/Symptom Free Education Area
 Registration Area for People with Symptoms
 Detailed Triage Area
 Medical Care Area
 Medication & Education Area
 Sanitation and Disposal Capabilities
In addition, based on the level of care provided, space may also be needed for:
 Pharmacy
 Lab
 Support Areas, e.g. behavioral health, family services, referrals, temporary morgue
 Restrooms
C. Equipment and Supplies
[Insert list of needed equipment & supplies to open and operate the flu center
(reference Alternate Care Sites or Mass Dispensing plans).]
38
X.
Command Structure
The Advisory Committee/lead agency will develop a command and control structure for the flu
center that can be integrated with the existing local emergency management command structure.
A copy of the organizational chart should be given to all staff and posted in the flu center. Note:
Depending on the size of the operation, one person may fulfill the functions of two or more boxes.
Site
Commander
Security/Safety
Section
Communications
Section
Planning
Unit
Community Liaison
Section
Operations
Section
Registration//
Admissions
Unit
Medical
Operations\
Branch
Logistics
Section
Ancillary
Service
\Branch
Finance
Section
Facility
Maintenance
Unit
Cost Accounting
Unit
Labor
Pool
Unit
Initial
Screening
Unit
Education
Unit
Materials
Supply
Unit
Time
Accounting
Unit
Patient
Tracking
Unit
Assessment
Unit
OutProcessing
Unit
Food
Service
Unit
Procurement
Treatment &
Stabilization
Unit
Family
Services
Unit
Resource
Transportation
Unit
Pharmacy
XI. Flu Center Layout
The flu center has been designed to have people move in one direction after entering the building
until the completion of the process. Clear signage as well as greeters will assist in directing people
to the appropriate area. Security may be required to ensure that those lining up at the entrance
are orderly and unruly people are managed.
In planning the layout and flow of people for the flu center, the following key considerations will be
incorporated:
 Security will be planned to assure safety of people and supplies.
 Initial screening provided at the front entrance will include the provision of hand hygiene
and masks.
 Registration and waiting areas will be large enough to accommodate anticipated number of
people.
 An expedited triage process will accommodate those people unable to wait in line.
 Non-symptomatic persons will be provided with self-care education and vaccinations if
available.
 Space allocated for triage, treatment and/or referrals of symptomatic people is adequate for
the planned level of care.
 Space allocated for the administration of antivirals and vaccines as available will
accommodate storage, recordkeeping and administration needs.
Appendix ____ contains a diagram of the Flu Center Layout. [
layouts are available on the MDH website under Flu Center.]
Note: Sample flu center
XII. Staffing
The staff required for the flu center fall into six broad categories:
1. Administrative Services: to include incident management structure, records management,
and communications infrastructure.
2. Medical Care: to include assessment and triage, providing direct care to people with
influenza-like illness, and development of care and/or discharge plans.
39
3. Education: to include education on preventing influenza and providing lay home care/selfcare, and just-in-time training for health care workers and volunteers at the flu center.
4. Support Services: to include behavioral health, interpreters, referrals and family assistance.
5. Transportation Services: to include transportation of people to and/or from the flu center.
6. Infection Control/Occupational Health: to include training in infection control and monitoring
workplace safety.
7. Security: to include protection of people and supplies.
The proposed Flu Center Staffing Chart is in Appendix ____. [Note: Sample staffing chart is
available on the MDH website under Flu Center.]
XIII. Infection Control
Each flu center must establish occupational health and safety, and infection prevention and control
policies and procedures to minimize transmission and protect people. The safety section on the
organizational chart is responsible for infection prevention and control measures at the site. The
Ambulatory Care Clinic Tool Kit available on the MDH website provides information and resources
for general infection control and for ambulatory care pandemic influenza infection control. The web
link is http://www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/amb/index.html.
In general, prevention and control measures at the flu center should include:
 Providing education.
 Ensuring hand hygiene supplies (i.e. alcohol-based hand rubs) are readily available and
used.
 Posting signs about routine infection prevention and control measures (i.e. hand hygiene,
cough etiquette).
 Providing guidance on appropriate use of personal protective equipment (PPE) and
infection control practices.
 Establishing and maintaining cleaning and disposal procedures and a regular cleaning
schedule for workspace and equipment that will support the operation of the flu center.
 Working with other health care workers in the community to implement and reinforce an
awareness campaign about routine infection prevention and control practices that can
prevent the spread of respiratory illness.
XIV. Transportation
[Insert transportation plan – may want to refer to ACS or MDS plans]
Note: Flu center plans must address transportation concerns. The plans should identify:
 Who will be transported?
 Will transportation be provided to and from the flu center?
 To what locations will people be transported?
 How will transportation arrivals and departures to & from flu center be coordinated?
 How will patients be tracked?
XV. Security & Traffic Control
[Insert Security & Traffic control plan]
Note: Flu centers will require security (particularly if distributing antivirals):
 To assist with flow of people
 Controlling the entrance and exits
 Directing traffic around the site
 Maintaining controlled points of entry for people
 Establishing secure sites for parking
 Securing ambulance staging, mortuary pick-up and supply delivery zones.
40
XVI. Demobilization of the Flu Center
Demobilization of the flu center operation will begin when predetermined closing triggers or
progress milestones have been reached and ends when existing healthcare facilities are able to
handle the surge of people with influenza-like illness. Public notice must be published announcing
the closing date of the flu center and providing information for the on-going care of people with
influenza-like illness.
Planning to demobilize usually begins with an assessment of the center operation’s progress and a
determination of approximately when various services will be completed or no longer needed.
From this assessment, center operation management can begin planning for the closing of the flu
center in close cooperation with public health, healthcare and other community partners. A
coordinated and integrated approach must be taken to prevent any disruption in the care of people
with influenza-like illness when the flu center closes.
XVII. Appendices
[Insert desired appendices.]
Note: Examples of Appendices:
A. Assessment Record
B. Flu Center Layout
C. Staffing Plan
D. Forms
E. Legal Summary of Applicable Statutes
F. Regional and/or Local Pandemic Influenza Statistics
G. Contact Information
41
Pandemic Influenza
Incident Specific Appenidix
to the Lake County
Emergency Operations Plan
Signatures
___________________________________
Director, Lake County Public Health
_______________
Date
___________________________________
Coordinator, Lake County Emergency Management
_______________
Date
___________________________________
Chair, Lake County Board of Commissioners
_______________
Date
42