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Champaign-Urbana Public Health District Pandemic Influenza Annex February 2010 Champaign-Urbana Pandemic Annex i Champaign-Urbana Public Health District PANDEMIC INFLUENZA ANNEX Table of Contents Table of Contents List of Tables List of Figures Section 1 INTRODUCTION 1.1 Background .............................................................................................. 1-1 1.2 Seasonal Influenza ................................................................................... 1-1 1.3 Pandemic Influenza .................................................................................. 1-2 1.4 Seasonal Influenza vs. Pandemic Influenza ............................................. 1-3 1.5 Avian Influenza ........................................................................................ 1-4 1.6 Swine Influenza ....................................................................................... 1-4 1.7 Phases of Pandemic Influenza ................................................................. 1-4 1.8 Pandemic Severity Index ......................................................................... 1-6 1.9 Potential Impacts of a Pandemic .............................................................. 1-7 Section 2 PURPOSE AND OBJECTIVES 2.1 Purpose..................................................................................................... 2-1 2.2 Objectives ................................................................................................ 2-1 Section 3 PLANNING AND ASSUMPTIONS Section 4 DIRECTION AND CONTROL Section 5 RESPONSIBILITIES 5.1 Champaign-Urbana Public Health District .............................................. 5-1 5.2 Specific Responsibilities of Champaign-Urbana Public Health District Divisions and Sections ................................................................ 5-2 5.2.1 Public Health Administrator ........................................................ 5-2 5.2.2 Emergency Response Planner ...................................................... 5-2 5.2.3 Public Information Officer ........................................................... 5-3 5.2.4 Communicable Disease Control, Epidemiology and Immunization Section .................................................................. 5-3 5.2.5 Wellness and Health Promotion Division .................................... 5-4 5.2.6 Infectious Disease Prevention and Management Division .......... 5-4 5.2.7 Environmental Health Division ................................................... 5-4 5.2.8 All Divisions and Sections ........................................................... 5-4 5.3 Champaign County Coroner .................................................................... 5-5 5.4 Local Hospitals, Clinics, Providers and Other Health System Partners .................................................................................................... 5-5 Champaign-Urbana Pandemic Annex i Table of Contents 5.5 5.6 5.7 5.8 Illinois Department of Public Health ....................................................... 5-6 United States Department of Health and Human Services ...................... 5-6 Centers for Disease Control and Prevention ............................................ 5-6 World Health Organization...................................................................... 5-7 Section 6 CONCEPT OF OPERATIONS 6.1 Interpandemic/Pandemic Alert Period Actions ....................................... 6-1 6.2 Pandemic Response Period Actions ........................................................ 6-3 6.3 Post-Pandemic (Recovery) Period Actions ............................................. 6-7 Section 7 PRIORITIZATION OF VACCINES AND ANTIVIRAL MEDICATIONS Section 8 MITIGATION STRATEGIES 8.1 Infection Prevention and Control Guidelines for Non-Healthcare and Healthcare Settings ........................................................................... 8-1 8.1.1 Overview...................................................................................... 8-1 8.1.2 General Guidelines for Non-Healthcare Settings ........................ 8-3 8.1.3 General Guidelines for Healthcare Settings (Hospitals, Health Centers, Etc.) .................................................................... 8-8 8.2 Personal Protective Equipment .............................................................. 8-10 8.2.1 Overview.................................................................................... 8-10 8.2.2 Assorted Personal Protective Equipment................................... 8-11 8.2.3 Pandemic Response Period ........................................................ 8-15 8.2.4 Post-Pandemic (Recovery) Period ............................................. 8-17 8.3 Non-Pharmaceutical Intervention .......................................................... 8-17 8.3.1 Overview.................................................................................... 8-17 8.3.2 Non-Pharmaceutical Intervention Community Control Measures .................................................................................... 8-18 8.3.3 Criteria for Determining Community Control Measures........... 8-20 Section 9 RISK COMMUNICATION 9.1 Overview.................................................................................................. 9-1 9.1.1 Coordination ................................................................................ 9-1 9.1.2 Risk Communication Principles .................................................. 9-1 9.1.3 Risk Communication Planning Assumptions and Considerations ............................................................................. 9-2 9.1.4 Vulnerable Population Considerations ........................................ 9-2 9.1.5 Desired Outcomes ........................................................................ 9-3 9.2 Communications Infrastructure ............................................................... 9-3 9.2.1 Interpandemic/Pandemic Alert Period ......................................... 9-3 9.2.2 Pandemic Response Period .......................................................... 9-3 9.2.3 Post-Pandemic (Recovery) Period ............................................... 9-4 9.3 Communicating with the General Public ................................................. 9-4 9.3.1 Message Development ................................................................. 9-4 9.3.2 Public Education and Awareness Campaign ............................... 9-5 9.3.3 Message Dissemination ............................................................... 9-5 ii Champaign-Urbana Pandemic Annex Table of Contents 9.4 9.5 9.6 9.7 9.8 Working with the Media .......................................................................... 9-6 9.4.1 Communicating with the Media................................................... 9-6 9.4.2 Spokesperson Training................................................................. 9-7 Coordinating with Healthcare Public Information Officers..................... 9-7 Communicating with Key Partners .......................................................... 9-8 Risk Communication/Public Education Strategies and Key Messages .................................................................................................. 9-9 9.7.1 Interpandemic/Pandemic Alert Period ......................................... 9-9 9.7.2 Pandemic Response Period ........................................................ 9-10 9.7.3 Post-Pandemic (Recovery) Period ............................................. 9-12 Risk Communication Guidance for Hospitals ....................................... 9-12 9.8.1 Risk Communication Strategies ................................................. 9-12 9.8.2 Education and Training .............................................................. 9-14 Section 10 MAINTENANCE OF ESSENTIAL SERVICES Section 11 PLAN DEVELOPMENT AND MAINTENANCE 11.1 Plan Development .................................................................................. 11-1 11.2 Distribution ............................................................................................ 11-1 11.3 Review and Update ................................................................................ 11-1 Section 12 ACRONYMS AND ABBREVIATIONS Champaign-Urbana Pandemic Annex iii Table of Contents List of Tables Table 1-1 Seasonal Influenza vs. Pandemic Influenza ................................................ 1-3 Table 1-2 CDC Pandemic Severity Index Chart .......................................................... 1-7 Table 1-3 Potential Impacts - Estimated Number of Episodes of Illness, Healthcare Utilization and Deaths Associated with Moderate and Severe Pandemic Influenza Scenarios for the U.S. Population and Champaign County .......................................................................................... 1-8 Table 6-1 Pandemic Flu Plan Periods Compared to World Health Organization Phases ......................................................................................... 6-1 Table 6-2 Interpandemic/Pandemic Alert Actions ...................................................... 6-1 Table 6-3 Level 1 Pandemic Response Actions .......................................................... 6-3 Table 6-4 Level 2 Pandemic Response Actions .......................................................... 6-3 Table 6-5 Level 3 Pandemic Response Actions .......................................................... 6-4 Table 6-6 Level 4 Pandemic Response Actions .......................................................... 6-5 Table 6-7 Level 5 Pandemic Response Actions .......................................................... 6-5 Table 6-8 Level 6 Pandemic Response Actions .......................................................... 6-7 Table 6-9 Post-Pandemic (Recovery) Actions ............................................................. 6-7 Table 7-1 Prioritization of Vaccine and Antiviral Distribution ...................................7-1 Table 8-1 Non-Pharmaceutical Intervention Recommendations Based on Pandemic Severity Index ............................................................................... 8-20 List of Figures Figure 1-1 Pandemic Influenza Phases ........................................................................ 1-5 iv Champaign-Urbana Pandemic Annex Section 1 INTRODUCTION 1.1 Background Influenza pandemics (or flu) pose a substantial threat to public health as they have the potential to inflict significant illness and death across a broad range of the community, including the young and healthy. A pandemic constitutes a global health emergency. Because the population has little or no immunity to the circulating strain of influenza, pandemics have the capacity to cause serious morbidity. The 20th century saw three influenza pandemics: the 1918 Spanish Flu that resulted in approximately 675,000 deaths in the U.S., with an estimated 40 to 50 million deaths worldwide; the 1957 Asian Flu; and the 1968 Hong Kong Flu. Although there is no way to predict when the next influenza pandemic will occur, health experts at the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) believe that education and outreach are critical to preparing for a pandemic. The emergence and spread of the highly pathogenic avian H5N1 influenza strain in other parts of the world, as well as the more recent emergence and spread of the H1N1 influenza virus (commonly called swine flu), has led many scientists and public health experts to conclude that another influenza pandemic is imminent. 1.2 Seasonal Influenza Influenza is a contagious respiratory illness caused by common influenza viruses that are present in our community—primarily on a seasonal basis. Common symptoms include fever, extreme tiredness, muscle aches, headache, runny or stuffy nose, dry cough and sore throat. Nausea, vomiting and diarrhea can also occur, though these symptoms are more common in children than adults. Influenza can exacerbate underlying medical conditions—particularly pulmonary or cardiac disease—and can even lead to secondary bacterial or viral pneumonia. The risk for complications, hospitalization and deaths from influenza is higher among older adults (65 and over), young children and those persons with certain underlying medical conditions. Approximately 36,000 people die in the U.S. each year due to seasonal flu. The best way to prevent the flu is by getting a flu vaccination each fall. Champaign County residents can schedule appointments for a flu vaccination with the Champaign-Urbana Public Health District (CUPHD) (www.c-uphd.org) by calling (217) 531-2922. Flu vaccinations typically occur from October through March. The location for the flu vaccination is 201 West Kenyon Road, Champaign, Illinois. Flu is primarily transmitted from person to person by droplet spread or direct contact. Droplet spread refers to spray with relatively large, short-range droplets produced by sneezing, coughing, talking or singing. These droplets may spray up to three feet and can land directly in the eyes or be inhaled through the nose or mouth. Transmission can also occur through contact with respiratory secretions, such as when touching Champaign-Urbana Pandemic Annex 1-1 Section 1 surfaces contaminated with the virus and then touching the eyes, nose or mouth. For most adults, the period of communicability ranges from 24 hours before symptoms appear to up to three to five days after symptoms develop. Children and some adults may be infectious for seven or more days after the onset of symptoms. The incubation period is usually two days, but can vary from one to four days. While a fever can typically last three to seven days, coughing and muscle aches can last up to two weeks. Influenza viruses are primarily divided into two types: A and B viruses. The remarkable variation of influenza strains—particularly type A—and their ability to cause annual epidemics of respiratory illness of varying intensity and severity, continue to be the focus of intense investigation. Only type A viruses are known to cause pandemics. Type A viruses are further divided into subtypes based on the specific hemagglutinin (H) and neuraminidase (N) proteins on the virus surface. Hemagglutinin binds to the cell surface to initiate infection. Neuraminidase is involved in the release of virus from infected cells. The emergence of new H or N proteins in the 20th century led to three separate pandemics. For example, the 1918 pandemic resulted from the emergence and spread of the H1N1 virus, while the 1968 pandemic was associated with the H3N2 virus. The 1957 pandemic was associated with the emergence and spread of the H2N2 virus; however, this virus subtype stopped circulating in 1968. Pandemics are believed to have occurred for at least 300 years at unpredictable intervals. 1.3 Pandemic Influenza A pandemic flu occurs when there is an abrupt and major change in the protein structure of the Influenza A virus, resulting in a new subtype. This is known as antigenic shift. This change may occur in two ways. When two viruses infect the same cell, they may share genetic material—a process known as reassortment—and result in a new human virus. A virus may also undergo random mutation resulting in an adaptive form more likely to survive in the host. This second type of change may occur during sequential infection of humans and other mammals, and lead to a virus more efficiently transmitted amongst humans. Three conditions must be met for a pandemic to start: A new flu virus subtype must emerge for which there is little or no human immunity It must infect humans and cause illness It must spread easily and sustainably (i.e., continue without interruption) among humans In the event of a pandemic, any vaccine or therapeutic drug is likely to be delayed and/or in short supply. Because of these characteristics, pandemic flu is likely to last several months and affect a large percentage of the population—both at the national and global level—thereby overloading healthcare systems and causing major social and economic disruption. 1-2 Champaign-Urbana Pandemic Annex INTRODUCTION Recent outbreaks of avian flu, which began in Asia in 1996, and the H1N1 virus (or swine flu), currently pose the greatest threat of triggering a flu pandemic. The H1N1 virus, which began in Mexico in 2009, is easily transmitted from person-to-person. If the avian flu strains mutate into a virus that is just as easily transmitted from personto-person, a pandemic can occur. Scientists and public health experts are concerned that this virus could be particularly lethal to humans. If such a pandemic were to develop, it would likely originate in Asia and quickly spread across the globe to North America, including Champaign County. This scenario is typical of the patterns exhibited by past pandemics. 1.4 Seasonal Influenza vs. Pandemic Influenza Table 1-1 Seasonal Influenza vs. Pandemic Influenza SEASONAL Outbreaks follow predictable seasonal patterns; occur annually, usually in winter, in temperate climates Usually some immunity built up from previous exposure Healthy adults are usually not at risk for serious complications; the very young, the elderly and those with certain underlying health conditions are at increased risk for serious complications Health systems can usually meet public and patient needs Vaccine developed based on known flu strains and available before annual flu season Adequate supplies of antivirals are usually available Average U.S. deaths approximately 36,000 per year Symptoms include fever, cough, runny nose, muscle pain; deaths are often caused by complications such as pneumonia Generally causes modest impact on society (e.g., some school closings, people who are sick are encouraged to stay home) Manageable impact on domestic and world economies Champaign-Urbana Pandemic Annex PANDEMIC Occurs rarely (three times in 20th century – last time in 1968) No previous exposure; little or no pre-existing immunity Healthy people may be at increased risk for serious complications Health systems may be overwhelmed Vaccine probably would not be available in the early stages of a pandemic Effective antivirals may be in limited supply because the demand during a pandemic could possibly overwhelm current national stockpiles Number of deaths could be quite high (e.g., U.S. 1918 death toll was approximately 675,000) Symptoms may be more severe and complications more frequent May cause major impact on society (e.g., widespread restriction on travel, closings of schools and businesses, cancellation of large public gatherings) Potential for severe impact on domestic and world economies 1-3 Section 1 1.5 Avian Influenza Avian influenza (or bird flu) is an infection caused by avian influenza viruses, which occur naturally among birds. Wild birds worldwide carry the viruses in their intestines, but usually do not get sick from them. However, avian influenza is very contagious among birds and can make some domesticated birds—including chickens, ducks and turkeys—very sick and even kill them. Infection from avian influenza viruses in domestic poultry causes two main forms of disease, high pathogenic and low pathogenic. The low pathogenic form may go undetected and usually causes only mild symptoms. Avian influenza virus refers to influenza A viruses found chiefly in birds, although infections with these viruses can occur in humans and other mammals. The risk of human infection from avian influenza is generally low; however, confirmed cases of human infection from several subtypes of avian influenza viruses have been reported since 1997. Influenza A (H5N1) virus is an influenza A virus subtype that occurs mainly in birds; it is highly contagious among birds and can be deadly to them. While the H5N1 virus does not usually infect humans, some cases have occurred. Most of the individuals who have contracted the virus in recent years have had direct or close contact with H5N1-infected poultry or H5N1-contaminated surfaces. As of May 6, 2009, there have been 423 confirmed human Influenza A (H5N1) cases in 25 countries. Of these, 268 humans died as a result of contracting the H5N1 virus. 1.6 Swine Influenza Swine flu is a respiratory disease caused by type A influenza viruses that lead to regular outbreaks in pigs. People do not normally get swine flu, although human infections can and do happen. A novel influenza A (H1N1) virus thought to be of swine origin was first detected in Mexico in April 2009. The virus continues to infect people, spreading from person-toperson and sparking a growing outbreak of illness in the U.S. and worldwide. It is thought that the H1N1 flu spreads in the same way regular seasonal influenza viruses spread (i.e., mainly through the coughs and sneezes of people who are sick with the virus). It is uncertain at this time how severe this novel H1N1 outbreak will be in terms of illness and death as compared to other influenza viruses. As of June 9, 2009, there have been 25,288 reported human cases of influenza A (H1N1) in 73 countries. Of these, 139 humans have died as a result of contracting the H1N1 virus. 1.7 Phases of Pandemic Influenza In a 2009 revision of its phase descriptions, the WHO retained the use of a six-phased approach for easy incorporation of new recommendations and approaches into existing national preparedness and response plans. The grouping and description of pandemic phases have been revised to make them easier to understand, more precise and based upon observable phenomena. Phases 1 through 3 correlate with preparedness, 1-4 Champaign-Urbana Pandemic Annex INTRODUCTION including capacity development and response planning activities, while Phases 4 through 6 signal the need for response and mitigation efforts. Furthermore, periods after the first pandemic wave are elaborated to facilitate post-pandemic recovery activities. Figure 1-1 Pandemic Influenza Phases In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1, no viruses circulating among animals have been reported to cause infections in humans. In Phase 2, an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat. In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-tohuman transmission sufficient to sustain community-level outbreaks. Limited humanto-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained the level of transmissibility among humans necessary to cause a pandemic. Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause community-level outbreaks. The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with the WHO so that the situation can be Champaign-Urbana Pandemic Annex 1-5 Section 1 jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion. Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication and implementation of the planned mitigation measures is short. Phase 6, the pandemic phase, is characterized by community-level outbreaks in at least one other country in a different WHO region, in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way. During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave. Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature. In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required. 1.8 Pandemic Severity Index The Pandemic Severity Index (PSI) is a proposed classification scale for reporting the severity of influenza pandemics in the U.S. The PSI was accompanied by a set of guidelines intended to help communicate appropriate actions for communities to follow in potential pandemic situations. Released by the U.S. Department of Health and Human Services (HHS) on February 1, 2007, the PSI was designed to resemble the Saffir-Simpson Hurricane Scale classification scheme. The PSI was developed by the CDC as a new pandemic influenza planning tool for use by states, communities, businesses and schools, as part of a drive to provide more specific community-level prevention measures. The index and guidelines were developed by applying principles of epidemiology to data from the history of the last three major flu pandemics and seasonal flu transmission, mathematical models, and input from experts and citizen focus groups. During the onset of a growing pandemic, local communities cannot rely upon widespread availability of antiviral drugs and vaccines. The goal of the index is to 1-6 Champaign-Urbana Pandemic Annex INTRODUCTION provide guidance as to what measures various organizations can enact that will slow down the progression of a pandemic, easing the burden of stress upon community resources, while definite solutions, like drugs and vaccines, can be brought to bear on the situation. The CDC expects adoption of the PSI will allow early coordinated use of community mitigation measures to affect pandemic progression. The index focuses less on how likely a disease will spread worldwide (i.e., become a pandemic) and more upon how severe the epidemic actually is. The main criterion used to measure pandemic severity will be the Case Fatality Ratio (CFR), the percentage of deaths out of the total reported cases of the disease. The actual implementation of PSI alerts is expected to occur after the WHO announces Phase 6 pandemic phase (human-to-human) in the United States. This would likely result in the immediate announcement of a PSI level 3-4 situation. The analogy of category levels was introduced to provide an understandable connection to hurricane classification schemes, with specific reference to the recent aftermath of Hurricane Katrina. Like the Saffir-Simpson Hurricane Scale, the PSI ranges from 1 to 5, with Category 1 pandemics being the most mild (equivalent to seasonal flu) and level 5 being reserved for the most severe, worst-case scenario pandemics (such as the 1918 Spanish flu). Table 1-2 CDC Pandemic Severity Index Chart CATEGORY 1 2 CFR Less than 0.1% 0.1% to 0.5% 3 0.5% to 1% 4 1% to 2% 5 2% or higher EXAMPLE(S) Seasonal Flu Asian Flu and Hong Kong Flu Spanish Flu 1.9 Potential Impacts of a Pandemic The CDC estimates that in the U.S. alone, an influenza pandemic could affect up to 200 million people, causing between 200,000 and 1,900,000 deaths. Champaign-Urbana Pandemic Annex 1-7 Section 1 Table 1-3 Potential Impacts - Estimated Number of Episodes of Illness, Healthcare Utilization and Deaths Associated with Moderate and Severe Pandemic Influenza Scenarios for the U.S. Population and Champaign County Moderate (1958/68 – like) Characteristics Severe (1918 – like) U.S. Champaign County U.S. Champaign County Illness 90 Million 57,315 90 Million 57,315 Outpatient Care 45 Million 28,658 45 Million 28,658 Hospitalization 865,000 551 9,900,000 6,305 ICU Care 128,750 82 1,485,000 946 Mechanical Ventilation 64,875 41 742,500 473 Deaths 209,000 133 1,903,000 1,212 1 Estimates are based on extrapolation from past pandemics in the U.S. and do not include the potential impacts of interventions not available during the 20th century pandemics. 2 The calculations used to determine the figures in the table are based on the following assumptions: Champaign County accounts for 0.063684 percent of the total U.S. population. Susceptibility to the pandemic influenza subtype will be universal. The clinical disease attack rate will be 30 percent in the overall population. Illness rates will be highest among school-aged children (about 40 percent) and decline with age. Among working adults, an average of 20 percent will become ill during a community outbreak. Of those who become ill with influenza, 50 percent will seek outpatient medical care. 1-8 Champaign-Urbana Pandemic Annex Section 2 PURPOSE AND OBJECTIVES 2.1 Purpose The CUPHD Pandemic Influenza Plan (Plan) provides guidance to public health and regional partners regarding detection, response and recovery from an influenza pandemic. The Plan describes the unique challenges posed by a pandemic that may necessitate specific leadership decisions, response actions and communication mechanisms. Specifically, the purpose of the Plan is to: Define preparedness activities that should be undertaken before a pandemic occurs to enhance the effectiveness of response measures. Describe the response, coordination and decision-making structure that will incorporate the healthcare system in Champaign County, other local response agencies, and state and federal agencies during a pandemic. Define roles and responsibilities for CUPHD, local healthcare partners and local response agencies during all phases of a pandemic. Describe public health interventions in a pandemic response and the timing of such interventions. Serve as a guide for local healthcare system partners, response agencies and businesses in the development of pandemic influenza response plans. Provide technical support and information on which preparedness and response actions are based. 2.2 Objectives The primary objectives of the Plan are to: Limit the number of illnesses and deaths Preserve continuity of essential functions (government and business) Minimize social disruption Minimize economic losses The Plan will be coordinated with other CUPHD preparedness plans and activities and will be coordinated with the plans of community, state and federal partners. Champaign-Urbana Pandemic Annex 2-1 Section 3 PLANNING AND ASSUMPTIONS The CDC developed a list of assumptions to guide pandemic influenza planning for federal, state and local governments, businesses, individuals and families. These assumptions are based on a careful analysis of previous pandemic influenza events and currently available information regarding seasonal influenza viruses. The following represent key assumptions critical to the development of the Plan. Susceptibility to the pandemic influenza virus will be universal. Efficient and sustained person-to-person transmission signals an imminent pandemic. The clinical disease attack rate will likely be 30 percent or higher in the overall population during the pandemic. Illness rates will be highest among school-aged children (about 40 percent) and decline with age. Among working adults, an average of 20 percent will become ill during a community outbreak. Some persons will become infected but not develop clinically significant symptoms. Asymptomatic or minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection. Of those who become ill with influenza, 50 percent will seek outpatient medical care. With the availability of effective antiviral drugs for treatment, 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 tenfold between more and less severe scenarios. Two scenarios are presented based on extrapolation of past pandemic experience (Table 1-3). 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 percent 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 (e.g., 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 two days. Champaign-Urbana Pandemic Annex 3-1 Section 3 Persons who become ill may shed virus and can transmit infection for up to one day before the onset of illness. Viral shedding and the risk of transmission will be greatest during the first two days of illness. Children usually shed the greatest amount of virus and therefore are likely to pose 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 six to eight weeks. Multiple waves of illness (periods during which community outbreaks occur across the country) could occur, with each wave lasting two to three months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty. 3-2 Champaign-Urbana Pandemic Annex Section 4 DIRECTION AND CONTROL The CUPHD Public Health Administrator is responsible for the direction and control of all public health activities in coordination with the Champaign County Emergency Operations Center (EOC). CUPHD will be the lead agency in the pandemic influenza response per the guidance, protocols and authorities listed in this Plan. The response will be initiated based on discussion between the CUPHD Public Health Administrator, the Infectious Disease and Management Division staff, the Illinois Department of Public Health (IDPH), the CDC (as appropriate), the Champaign County Emergency Management Agency (EMA) and the Champaign County Board. Once Champaign County activates the EOC, CUPHD will coordinate its activities through the EOC by providing a qualified staff member to serve as the EOC’s Health Officer. Champaign-Urbana Pandemic Annex 4-1 Section 5 RESPONSIBILITIES 5.1 Champaign-Urbana Public Health District Facilitate countywide pandemic planning and preparedness efforts. Coordinate the community’s emergency public health response through the EOC and the Champaign County Emergency Operations Plan (EOP). Educate the public, healthcare system partners, response partners, business, community-based and organization elected leaders about influenza pandemics, expected impacts and consequences, and preventive measures. Provide training and technical support to assist the preparedness planning efforts of local agencies, community-based organizations (CBOs) and government entities serving vulnerable populations. Conduct countywide surveillance to track the spread of the human disease and its impact on the community. Through liaison with agriculture and wildlife agencies, facilitate surveillance in animals within Champaign County and monitor surveillance data. Identify and declare disease of public health significance and communicate such declarations to health system partners. Coordinate planning for and implementation of disease containment strategies and authorities. Provide ongoing technical support to the healthcare system, including current surveillance guidelines, recommendations for clinical case management, infection control measures and laboratory testing. Support the healthcare system’s planning and response efforts for medical surge capacity, including mass casualty and mass fatality incidents. Support the development and management of local antiviral medication stockpiles. Implement protocols for the use of limited supplies of influenza vaccine and antiviral medications consistent with national guidelines. Direct distribution and administration of vaccine, including mass vaccination efforts. Provide effective communications to the public, the media, elected officials, healthcare providers, business and community leaders throughout public health emergencies. Champaign-Urbana Pandemic Annex 5-1 Section 5 5.2 Specific Responsibilities of Champaign-Urbana Public Health District Divisions and Sections 5.2.1 Public Health Administrator Communicate and coordinate directly with the Champaign County Board Chairperson, Champaign County EMA, executive heads of cities and towns, Champaign Board of Health and healthcare partners regarding pandemic preparedness and response activities. Coordinate directly with healthcare partners and make decisions regarding strategies, thresholds and methods for reallocating resources, and temporary restructuring of health system operations in response to a pandemic. Authorize and communicate public health directives regarding social distancing strategies and other protective actions to elected leaders, the business community, schools, healthcare partners and other partners. Assign responsibilities to CUPHD staff for planning and responding to the pandemic. Ensure business continuity of critical CUPHD functions during all phases of the pandemic. Direct isolation and quarantine of individuals and groups, as needed, based on recommendations from the Chief Communicable Disease Investigator. 5.2.2 Emergency Response Planner Coordinates bioterrorism/public health emergency response planning for CUPHD. Participates in the development of plans and systems that include all the partners in the local public health jurisdiction. Develops public health emergency response plans for CUPHD that are fully integrated with other local government plans within CUPHD jurisdiction. Develops and implements simulation exercises to ensure the effectiveness of the emergency plans and systems for CUPHD. Collaborates with IDPH, regional staff, CUPHD administrative personnel and other health departments to develop plans and policies to be able to respond in the event of a public health emergency. Prepares, updates and maintains mutual aid agreements with other health-related agencies and offices within the CUPHD jurisdiction. Prepares necessary reports describing the activities, accomplishments and status of emergency response preparedness and planning functions. Coordinates and facilitates meetings of CUPHD personnel and terrorism task force partners. 5-2 Champaign-Urbana Pandemic Annex RESPONSIBILITIES Writes grant applications and monitors contracts. Establishes and maintains a cooperative and effective working relationship with hospitals, EMS agencies, emergency services, government officials, employees and other health-related partners. Performs other duties as required. 5.2.3 Public Information Officer Provide accurate, timely information to the public regarding preparations for a pandemic, the impacts of the outbreak, local response actions and disease control recommendations. Educate the public on how they can protect themselves from becoming infected and infecting others. Activate and direct the management of public information call centers focused on providing health information to the public. 5.2.4 Communicable Disease Control, Epidemiology and Immunization Section Carry out countywide surveillance, epidemiological investigation and disease control activities. Provide information and technical support on surveillance, epidemiology and clinical issues—including case identification, laboratory testing, management and infection control—to healthcare providers and facilities. Make decisions regarding the need for individual and group isolation and quarantine. Work with the CUPHD PIO to develop and disseminate risk communications messages to the public. Provide recommendations to the CUPHD Public Health Administrator regarding measures to sustain the functionality of the local healthcare system. Advise the CUPHD Public Health Administrator regarding the need for and potential consequences of social distancing measures. Coordinate receipt of vaccines in and develop strategies for storage, distribution and allocation of vaccines among healthcare system partners. Follow established or recommended modifications to established protocols for prioritizing limited supplies of antiviral medicines and vaccines in Champaign County. Champaign-Urbana Pandemic Annex 5-3 Section 5 5.2.5 Wellness and Health Promotion Division Lead pandemic planning and preparedness efforts for CUPHD in conjunction with local, state and federal response partners. Conduct training, drills and evaluated exercises to enhance CUPHD’s readiness to respond to a pandemic. Coordinate planning and response activities with hospitals and community health clinics in collaboration with the Communicable Disease Investigator and Infectious Disease Prevention and Management Division. Advise the CUPHD Public Health Administrator regarding the potential social and economic impacts of social distancing measures, and the extent to which implementation of such measures is feasible. Coordinate department-wide business continuity efforts specific to the potential impacts of a pandemic. Coordinate countywide pandemic planning, education and outreach efforts with school systems, the business community and CBOs. Coordinate with economic development agencies and chambers of commerce regarding the economic consequences of a pandemic. 5.2.6 Infectious Disease Prevention and Management Division Participate in planning activities focused on developing capacity for communitybased influenza evaluation and treatment clinics. Lead and coordinate all mass vaccination response activities. Lead efforts with community partners to manage a client care call center. Develop infection control plans for CUPHD sites, with technical assistance from the Communicable Disease Investigator, to protect staff and clients. 5.2.7 Environmental Health Division Assist in surveillance for animal influenza viruses through liaison with the Illinois State Departments of Agriculture and Natural Resources. Work with the CUPHD PIO to develop and disseminate risk communications messages to the public concerning zoonotic influenza virus transmission, food safety and animal waste disposal issues. 5.2.8 All Divisions and Sections Identify mission critical functions that must be maintained during all hazards, including a pandemic. Identify staff that can be cross-trained to perform emergency response functions. 5-4 Champaign-Urbana Pandemic Annex RESPONSIBILITIES Identify functions that can be temporarily discontinued or performed via telecommuting for several weeks. Be prepared to mobilize all necessary staff to support the CUPHD pandemic influenza response, as directed by the CUPHD Public Health Administrator. 5.3 Champaign County Coroner Lead mass fatality planning and response efforts. Coordinate with and support hospitals regarding mass fatalities planning and response. Incorporate funeral home directors into planning efforts for pandemic response. In conjunction with community partners, coordinate planning and development of victim assistance centers. 5.4 Local Hospitals, Clinics, Providers and Other Health System Partners Healthcare system partners will participate in a CUPHD Pandemic Flu Committee facilitated by the CUPHD to maximize the healthcare system’s ability to provide medical care during a pandemic. Specific steps include: Identify and prioritize response issues affecting the countywide healthcare system during a pandemic. Develop mechanisms to efficiently share information and resources between health system partners, and communicate with CUPHD and relevant emergency operations centers, as appropriate. Coordinate with the CUPHD Public Health Administrator regarding policy level decisions regarding the operations of the local healthcare system. Assure that healthcare professionals receive relevant communications from CUPHD in a timely manner. Hospitals and other healthcare facilities will develop pandemic response plans consistent with the healthcare planning guidance contained in this Plan. Healthcare facility pandemic response plans will address medical surge capacity to sustain healthcare delivery capabilities when routine systems are overwhelmed. Healthcare facilities and healthcare providers will participate in local influenza surveillance activities. Hospitals will develop infection control plans to triage and isolate infectious patients and protect staff from disease transmission. Champaign-Urbana Pandemic Annex 5-5 Section 5 5.5 Illinois Department of Public Health Coordinate statewide pandemic planning and preparedness efforts. Coordinate statewide surveillance activities. Operate a CDC Laboratory Response Network public health reference laboratory for novel influenza virus testing. Coordinate submission of pandemic epidemiological data to the CDC and dissemination of statewide data situation updates to local health jurisdictions. Coordinate development and implementation of disease containment strategies across multiple counties and regions within the state. Provide state assistance, when available, and request federal assistance to support the local health and medical response. Receive antiviral medications and other medical supplies form the Strategic National Stockpile (SNS) and immediately deploy these supplies to local health departments and health districts based on population. Educate and inform the public on the course of the pandemic and preventive measures. 5.6 United States Department of Health and Human Services Provide overall guidance on pandemic influenza planning within the U.S. Coordinate the national response to an influenza pandemic. Provide guidance and tools to promote pandemic preparedness planning and coordination for states and local jurisdictions. Provide guidance to state and local health departments regarding prioritization of limited supplies of antiviral medications and vaccines. Determine and communicate the pandemic phase for the U.S. based on the global pandemic phase (established by the WHO) and the extent of disease spread throughout the country. 5.7 Centers for Disease Control and Prevention Conduct national and international disease surveillance. Serve as a liaison to the WHO. Develop reference strains for vaccines and conduct research to understand transmission and pathogenicity of viruses with pandemic potential. Develop, evaluate and modify disease control and preventions strategies. 5-6 Champaign-Urbana Pandemic Annex RESPONSIBILITIES Support vaccination programs; monitor vaccine safety. Investigate pandemic outbreaks; define the epidemiology of the disease. Monitor the nationwide impact of a pandemic. Coordinate the stockpiling of antiviral drugs and other essential materials within the SNS. Activate the SNS when the WHO raises the global pandemic alert level to Phase 4 and deploy antiviral supplies to each state. Coordinate the implementation of international–U.S. travel restrictions. Under federal authority, implement isolation, quarantine and social distancing measures on tribal lands, as needed. 5.8 World Health Organization Monitor global pandemic conditions and provide information updates. Facilitate enhanced global pandemic preparedness, surveillance, vaccine development and health response. Declare global pandemic phase and adjust phases based on current outbreak conditions. Champaign-Urbana Pandemic Annex 5-7 Section 6 CONCEPT OF OPERATIONS The WHO uses a series of six phases of pandemic alert as a system for informing the world of the seriousness of the threat and the need to launch progressively more intense preparedness activities. The organization recently added a post-pandemic period to the end of their six phases. This Plan divides the six threat phases and the post-pandemic period into three broader periods. The chart below shows the comparison of the three broader periods to the phases used by the WHO. Table 6-1 Pandemic Flu Plan Periods Compared to World Health Organization Phases Period WHO Pandemic Phases Interpandemic/Pandemic Alert 1-5 Pandemic Response 6 Post-Pandemic (Recovery) Post-Pandemic Period During the Interpandemic/Pandemic Alert Period, CUPHD will conduct surveillance and preparedness activities to track any emerging novel viruses and prepare Champaign County for the health impact of a potential pandemic flu. During the Pandemic Response Period, CUPHD will undertake response activities to limit the number of illnesses and deaths, preserve continuity of essential functions for both government and business, and minimize social disruption and economic losses. The Post-Pandemic (Recovery) Period will include an assessment of the situation, bring an end to many response activities, and restore normal services and routines within Champaign County. A post-pandemic recovery will also require the treatment of the many physical and psychosocial effects that will have taken a toll on the greater population. Recovery from a pandemic will begin when it is determined by the CUPHD Health Administrator that adequate supplies, resources and response system capacity exist to manage a return to normal activities. In consultation with IDPH, CUPHD will recommend specific actions to restore the healthcare system to normal status. 6.1 Interpandemic/Pandemic Alert Period Actions Table 6-2 Interpandemic/Pandemic Alert Actions WHO Phase Actions Periodically review existing plans (e.g., pandemic flu plan, mass vaccination/antiviral plan, alternate medical care plans, medical surge plan, Champaign-Urbana Pandemic Annex 6-1 1 Section 6 WHO Phase 2 Actions mass casualty plan, etc.) Continue vaccination efforts for seasonal influenza and pneumonia, if advisable Same activities as Phase 1 Same activities as Phase 1 and Phase 2, in addition to the following: Activate the CUPHD Pandemic Flu Committee composed of key community response leaders; hospitals; college, university and school systems. The committee meets quarterly to track the pandemic threat and develop impact estimates Prepare and conduct public education/preparedness campaign following guidance found in the Risk Communication section of the Plan Plan and conduct pandemic tabletop and functional exercises Begin stockpiling critical resources (e.g., antivirals, N95 masks, syringes) based on impact estimates and financial resources available Review and/or implement pre-disaster contracts for anticipated resource needs Select and train CUPHD personnel that will work in the County EOC should it be activated Update Medical Reserve Corps contact information. Begin recruiting new members The CUPHD Pandemic Flu Committee continues to meet quarterly, or more frequently as needed, to track the pandemic threat and refine impact estimates Increase the emphasis on the public education/preparedness campaign following guidance found in the Risk Communication section of the plan Increase emphasis on stockpiling critical resources (e.g., antivirals, N95 masks, syringes) based on impact estimates and financial resources available Encourage school systems, colleges and universities to develop distance learning curriculum should school closures occur in the Pandemic Response Period Begin training agencies to conduct fit testing for N95 masks Continue to review and/or implement pre-disaster contracts for anticipated resource needs Update contact information of CUPHD staff and points of contact for key partners Cross-train staff to perform multiple critical duties in the event of significant absenteeism Update Medical Reserve Corps contact information. Increase emphasis on recruiting new members Increase emphasis on community vaccination efforts for seasonal influenza and pneumonia, if advisable 3 4 5 6-2 Same activities as Phase 4, but with increased emphasis/urgency Champaign-Urbana Pandemic Annex CONCEPT OF OPERATIONS 6.2 Pandemic Response Period Actions The Pandemic Response Period is broken down into six levels describing the local spread and progression of pandemic flu activity. The primary public health and emergency measures for each level are summarized in the following tables. The activities listed in the tables are purposefully general so that response actions can be modified and updated based on the latest state and federal guidance and epidemiological information. The response actions in each level build upon activities of previous levels. These tables do not include risk communication as a response component. Risk communication is critical enough to warrant a section of its own. Level 1: Increased and sustained transmission, but outbreaks and the spread of novel influenza is still outside North America Table 6-3 Level 1 Pandemic Response Actions Response Component Actions Pandemic Influenza and Management Vaccine/Antivirals Community Infection Control and Healthcare Planning CUPHD Pandemic Flu Committee meets weekly, or more frequently as needed, and distributes situation reports to CUPHD staff and the Champaign County Board Coordinate with IDPH and neighboring counties Implement county employee health monitoring Monitor status/guidelines for vaccine from CDC and IDPH If sufficient antivirals are available, activate plan to provide antivirals to priority groups If vaccine is available, activate plan to provide vaccination first to priority groups, and then to the general public Ensure that law enforcement is capable of providing security for public health workers and citizens waiting to be vaccinated Continue vaccination efforts for seasonal influenza and pneumonia, if advisable Review federal/state guidance on traveler screening and coordinate with county stakeholders (e.g., bus, train and air) Review CDC and state travel alerts and advisories and issue as appropriate Recommend home or hospital isolation of recent travelers to affected countries that have influenza-like illness. Monitor CDC/IDPH websites for latest guidelines. Recommend home quarantine for contacts of influenzalike cases Level 2: Outbreaks of novel influenza detected in North America Table 6-4 Level 2 Pandemic Response Actions Response Component Pandemic Influenza and Management Actions Champaign-Urbana Pandemic Annex CUPHD Pandemic Flu Committee to meet daily, or as needed, and distribute situation reports internally to CUPHD staff and the Champaign 6-3 Section 6 Response Component Actions County Board Review CDC and IDPH guidelines Continue to coordinate with IDPH and neighboring counties Coordinate with Champaign County Mental Health Board to activate mental health response and initiate community support services Meet with hospitals, Emergency Medical Services (EMS) and EMA to review plans for alternate medical care and transport Continue county employee health monitoring Implement workforce support activities Assess local resource needs for hospitals and long term care facilities, and assist in helping them meet those needs Monitor and disseminate information to healthcare provider groups and partners Monitor WHO/CDC/IDPH bulletins and modify surveillance activities, as needed Surveillance and Laboratories Vaccine/Antivirals Same activities as Level 1 Same activities as Level 1, in addition to the following: Review CDC/IDPH guidance on social distancing; limit or suspend public gatherings, if indicated. Consider closure of schools. Monitor hospital/urgent care center activity; activate alternate healthcare delivery plan, if necessary Community Infection Control and Healthcare Planning Level 3: First case of novel influenza detected in Champaign County Table 6-5 Level 3 Pandemic Response Actions Response Component Actions Pandemic Influenza and Management Surveillance and Laboratories Vaccine/Antivirals Community Infection Control and Healthcare Planning 6-4 Same activities as Level 1 and 2, in addition to the following: Notify IDPH, CDC and neighboring counties of cases identified in Champaign County, and consult regarding contact tracing. If advisable, conduct contact tracing and implement appropriate isolation/quarantine and disease prevention measures Coordinate with EMA to activate the Champaign County EOC Same activities as Level 2, in addition the following: Monitor number of cases and geographic/demographic distribution of cases Continue to monitor absenteeism and influenza-like illness Same activities as Level 1 and 2, in addition to the following: Administer antivirals, if available, to case(s) and contacts. Consult CDC/IDPH guidance on appropriate antiviral treatment Conduct contact tracing of influenza case(s) in coordination with hospitals. Implement isolation of case(s) and quarantine of contacts; treat with antivirals as per latest CDC/IDPH guidelines Implement isolation of all individuals presenting with influenza-like illness and quarantine of contacts. Monitor CDC/IDPH websites for latest guidance on isolation/quarantine protocols for influenza-like illness Champaign-Urbana Pandemic Annex CONCEPT OF OPERATIONS Response Component Actions Consider suspension of all public events and closure of schools Issue travel advisories to limit travel within and outside of county Monitor healthcare system volume and capacity. Review alternate care plans and activate, if necessary Review mass fatalities plan and modify as necessary Level 4: Epidemic level of novel influenza in Champaign County Table 6-6 Level 4 Pandemic Response Actions Response Component Pandemic Influenza and Management Surveillance and Laboratories Actions Same activities as previous levels Monitor number of cases, hospitalizations and deaths in the county Monitor geographic and demographic distribution of cases; if advisable, continue monitoring absenteeism and influenza-like illness Monitor and disseminate data reports to providers, surveillance partners and media Continue to monitor WHO/CDC/IDPH bulletins and modify surveillance activities as needed Vaccine/Antivirals Community Infection Control and Healthcare Planning Same activities as previous levels Same activities as Level 3, in addition to the following: Monitor CDC/IDPH guidelines for community control measures and modify pandemic plan as necessary Review state/federal guidance on traveler screening and suspend screening, if advisable Activate or continue operation of alternate care sites Activate medical surge plan Level 5: End of first pandemic wave in Champaign County Table 6-7 Level 5 Pandemic Response Actions Response Component Actions Pandemic Influenza and Management Champaign-Urbana Pandemic Annex CUPHD Pandemic Flu Committee to meet daily, or as necessary, and distribute situation reports internally to CUPHD staff and Champaign County Board Coordinate with CDC and IDPH to modify pandemic plan in preparation for second wave Obtain status reports and feedback from partner agencies on first pandemic wave Scale back or suspend activities of alternate care, mass fatalities, isolation/quarantine and volunteer plans Review alternate triage, mass fatalities, isolation/quarantine, volunteer, hotline and mass clinic plans, and modify as needed, in preparation for 6-5 Section 6 Response Component Actions Surveillance and Laboratories Vaccine/Antivirals Community Infection Control and Healthcare Planning 6-6 second wave Continue monitoring county employee health Implement workforce support activities for period between pandemic waves Assess local resource needs for hospitals and long-term care facilities and assist in helping them to meet these needs Same activities as Level 4, in addition to the following: Evaluate surveillance activities per CDC guidelines Assess health impact (e.g., number of cases, hospitalizations, deaths, hardest hit demographics, geographic distribution of cases, etc.) Assess economic impact (e.g., absenteeism, business and school closures, etc.) Assess vaccine/antiviral distribution, coverage and adverse events Resume sentinel data collection for early detection of second wave Monitor and disseminate data reports to providers, sentinel partners and media If vaccine is available, continue or start mass vaccination efforts. Monitor status/guidelines for antivirals and vaccine from CDC and IDPH and modify priority groups and vaccination plan as necessary Update mass clinic partners and providers on vaccine/antiviral guidelines and the need to continue mass vaccination in advance of second wave Access mass clinic supplies and restock as needed If vaccine is available for the novel virus, activate or continue operating a plan for mass vaccination to provide vaccination to priority groups and then the general public. Track doses and monitor inventories, demand, distribution, costs and adverse events. Otherwise, continue procurement efforts for vaccine, review the mass vaccination plan and conduct mass clinic trainings as needed If sufficient antivirals are available, activate or continue operating a plan for providing antivirals to priority groups. Monitor inventories, demand, distribution, costs and adverse events. Otherwise, continue procurement efforts for antivirals and conduct mass clinic trainings as needed Continue vaccination for seasonal influenza and pneumonia, if advisable Review CDC and IDPH guidelines on social distancing measures and modify pandemic plan as necessary Lift suspensions on public events, end closures of school and businesses, if advisable Consider maintaining suspension or limitations on public gatherings Consider maintaining travel advisories Implement isolation of individuals presenting with influenza-like illness and quarantine of contacts Monitor CDC/IDPH website for latest guidelines on isolation/quarantine protocols Suspend or scale back activities of alternate care and mass fatalities plans Level 6: Second/Subsequent waves of pandemic flu activity Champaign-Urbana Pandemic Annex CONCEPT OF OPERATIONS Table 6-8 Level 6 Pandemic Response Actions Actions Refer to tables for Levels 3 through 5 6.3 Post-Pandemic (Recovery) Period Actions Table 6-9 Post-Pandemic (Recovery) Actions Response Component Actions Convene CUPHD Pandemic Flu Committee and review CDC and IDPH guidelines regarding end of pandemic Terminate all contingency plans Conduct debriefings to obtain feedback from CUPHD staff and partner agencies and organizations (e.g., hospitals, other healthcare providers, EMA, transportation officials) Implement support activities for county employees Participate in EOC debriefing activities Document lessons learned and disseminate findings to partner agencies; modify pandemic plan and other contingency plans as needed Review expenses of response activities and prepare expense report Terminate surveillance activities Prepare summaries on morbidity and mortality by demographic subgroups Evaluate vaccine/antiviral distribution and coverage processes Assess social and economic impact (e.g., absenteeism, closures, gaps in essential services and cost estimates) Obtain feedback from surveillance partners and evaluate surveillance activities. Incorporate improvements into surveillance plan Terminate mass vaccination and antiviral plans Inventory supplies and manage any remaining vaccine/antivirals as directed by CDC and IDPH Coordinate with federal, state and county surveillance efforts to assess vaccine and antiviral coverage, efficacy and safety Conduct debriefings of mass clinic staff and partners to evaluate clinic operation. Modify mass vaccination plans as needed Remove restriction on travel Lift social distancing measures (e.g., quarantine, closures, suspensions) Evaluate compliance with, and efficacy of, social distancing measures Evaluate alternate care/triage operations and mass fatality operations Champaign-Urbana Pandemic Annex 6-7 Command and Control Surveillance and Laboratories Vaccine/Antivirals Community Infection Control and Healthcare Planning Section 7 PRIORITIZATION OF VACCINES AND ANTIVIRAL MEDICATIONS Two federal advisory committees, the National Vaccine Advisory Committee (NVAC) and the Advisory Committee on Immunization Practices (ACIP), offer guidance for the distribution and prioritization of vaccines during a pandemic event. While under normal conditions the distribution of vaccines would be given to those most at risk of experiencing grave health consequences, a severe pandemic will require the consideration of additional principles. A pandemic event will have a large effect on the entire community; therefore, it is essential that public health officials prioritize the “preservation of a functioning society.” CUPHD has used NVAC and ACIP’s recommendations as the foundation for local vaccine and antiviral prioritization planning. In Champaign County, decisions regarding vaccine and antiviral distribution will be made in close coordination between CUPHD, IDPH and Champaign County EMA, with additional consultation from the Champaign County Board of Health and a certified bioethicist. Through a process that takes careful account of developing local infection rates, those individuals who are essential to the provision of healthcare, public safety and the maintenance of critical infrastructure will receive priority in the distribution of vaccines and antivirals. The following table is the prioritization of vaccine and antiviral distribution during a pandemic event. Table 7-1 Prioritization of Vaccine and Antiviral Distribution Tier 1A 1B 1C 1D 2A Group Description Healthcare Workers Healthcare workers with direct patient contact and critical healthcare support staff Vaccine and antiviral manufacturing personnel Highest Risk Groups Patients 65 and older with at least one high-risk condition Patients 6 months to 64 years with at least two high-risk conditions Patients hospitalized in the past year because of pneumonia, influenza or another highrisk condition Household Contacts and Pregnancy Household contacts of children under 6 months Household contacts of severely immunocompromised individuals Pregnant women Pandemic Responders Key government leaders and critical pandemic public health responders Other High-Risk Groups Patients 65 and older with no high-risk conditions Patients 6 months to 64 years with one high-risk condition Children 6 months to 23 months Champaign-Urbana Pandemic Annex 7-1 Section 7 Tier 2B 3 4 7-2 Group Description Critical Infrastructure Groups Other public health emergency responders, public safety workers, utility workers, critical transportation workers and telecommunications workers Other Key Government Healthcare Decision-Makers; Individuals Providing Mortuary Services Healthy Patients 2 to 64 Years without any High-Risk Condition Champaign-Urbana Pandemic Annex Section 8 MITIGATION STRATEGIES It is highly unlikely that a vaccine will be available when a pandemic begins. This means that we must be prepared to face the first wave of a pandemic without a vaccine. Evidence to determine the best strategies for protecting people during a pandemic is very limited. The CDC has proposed a pandemic mitigation framework that is based upon the use of infection prevention control and the application of nonpharmaceutical interventions (NPIs). It is recommended that the non-vaccine mitigation measures be initiated early, before explosive growth of the disease, and in the case of severe pandemics, that they be maintained consistently during a pandemic wave within the community. 8.1 Infection Prevention and Control Guidelines for Non-Healthcare and Healthcare Settings 8.1.1 Overview This section provides general infection control guidance, including the use of personal protective equipment (PPE) for both non-healthcare settings (e.g., workplaces, jails, schools) and healthcare settings. The CDC, WHO, IDPH and OSHA have all issued guidelines and recommendations that are consistent with current scientific knowledge and accepted infection prevention and control practices. These guidelines will undergo modification as more is learned about the characteristics of the pandemic influenza strain, and as new medications and vaccines become available. Strategies that may be appropriate at the early onset of the pandemic, such as isolation and quarantine of individuals suspected or infected with pandemic flu, may not be sustainable over the course of the pandemic. Supplies may become scarce, human resources may fluctuate and care delivery may require modification. After pandemic flu begins circulating in Champaign County, full community cooperation will be necessary to control the spread of the disease. The essential goal of infection prevention and control is to minimize the transmission of illness from infected individuals to uninfected individuals. This is accomplished through practices designed to prevent the spread of disease throughout all levels of the community. This section is divided into two broad categories: General infection control guidelines for non-healthcare facilities (e.g., businesses, schools, boarding and care facilities, jails) and home care. More detailed infection control guidelines for licensed and acute care facilities. Champaign-Urbana Pandemic Annex 8-1 Section 8 The primary Infection Control objectives during the Interpandemic/Pandemic Alert Period are to: Implement effective control measures to slow the spread of pandemic flu. Ensure common understanding of appropriate infection control measures across all levels of care in Champaign County. Modes of Influenza Transmission The mode of transmission defines how an infectious viral particle is transmitted from an infected person (commonly referred to as a source person) to a well person (commonly referred to as a susceptible person) and causes infection. The major mode of transmission for influenza is not entirely clear; however, the pattern of person-toperson spread is generally consistent with spread through close contact (e.g., exposure to large respiratory droplets, direct contact or near-range exposure to aerosols). Some studies support airborne transmission through small particle aerosols; however, there is little evidence of airborne transmission over long distances or prolonged periods of time. Unfortunately, the relative contributions and clinical importance of the different modes of influenza transmission are currently unknown. Droplet Transmission – Droplet transmission occurs when a person who has symptomatic illness, or who is a carrier of the virus, generates droplets containing virus when they cough, sneeze or talk. These droplets then contact the conjunctivae (the covering of the eyeball) or the mucous membranes of the nose or mouth of a susceptible person, causing infection. Transmission via largeparticle droplets (greater than 10 µm in diameter) requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only short distances (about three feet) through the air. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission. Contact Transmission – Direct contact transmission involves skin-to-skin contact and physical transfer of virus from an infected person to a susceptible person. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object—usually inanimate—in the person’s environment. Transmission via contaminated hands and fomites (inanimate objects) has been suggested as a contributing factor in some studies; however, there is insufficient data to determine the proportion of influenza transmission that is attributable to direct or indirect contact. In an experimental study, influenza viruses could be transferred from hard, non-porous surfaces such as stainless steel and plastic to hands for 24 hours, and from tissues to hands for up to 15 minutes. Virus can survive on hands for up to five minutes after transfer from an environmental surface. Higher humidity shortens virus survival. Airborne Transmission – Airborne transmission occurs by dissemination into the air of either airborne droplet nuclei (less than 5 µm in diameter) or small particles in the respirable size range containing the infectious agent. Microorganisms carried in this manner may be dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face- 8-2 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES to-face interaction with the infectious individual. Organisms transmitted in this manner must be capable of sustaining infectivity, despite desiccation and environmental variation that generally limit survival in the airborne state. Preventing the spread of agents that are transmitted by the airborne route requires the use of special air handling and ventilation systems (e.g., negative pressure rooms). Small Particle Aerosols – There is no evidence that influenza transmission can occur across long distances (e.g., through ventilation systems) or through prolonged residence in air, as seen with airborne diseases such as tuberculosis. However, transmission may occur at shorter distances through inhalation of small particle aerosols (droplet nuclei), particularly in shared spaces with poor air circulation. In summary, the precise mode of transmission and the relative contribution of each mode of transmission are not known; however, several observations suggest that influenza is spread primarily through close contact and does not travel long distances. Our recommendations are thus based on close contact spread. 8.1.2 General Guidelines for Non-Healthcare Settings Schools, Businesses, Jails, Boarding and Care Facilities, Etc. The most important element in limiting the spread of influenza is to prevent introduction of the virus into the respiratory tract. During the alert period and throughout the pandemic, each facility in Champaign County should establish and implement basic infection control practices to limit transmission of and exposure to pandemic influenza. This includes policies, such as those mandating “no work while sick” and the use of appropriate personal hygiene, to decrease the spread of pandemic flu in the workplace. Infection Control Practices to Prevent Spread of Disease The following recommendations are based on what is known about the modes of influenza transmission. The most important concept in preventing the spread of influenza is to prevent the direct and indirect inoculation of the respiratory tract. There are four major ways to accomplish this: Protect the well with hand hygiene and personal protective equipment Hand hygiene: If hands are visibly soiled, wash them with warm water and soap. If hands are not visibly soiled, perform hand hygiene. Perform hand hygiene after contact with a person who may be ill, after removing mask or gloves, or after touching items or surfaces that may be soiled. Persons in contact with individuals suspected to be infected with influenza (e.g., during transport of an ill person; in the home; in the jails; or in a Champaign-Urbana Pandemic Annex 8-3 Section 8 daycare, school or work setting) can protect themselves by doing the following: Wear a surgical or procedure mask when in close contact (less than three feet) with an infectious person. A mask should be changed and discarded when it becomes moist. Perform hand hygiene after touching or discarding a mask. Wear gloves if there is likely to be contact with respiratory secretions. Discard gloves immediately after use and perform hand hygiene. Limit contact between infected and uninfected persons Whenever possible, isolate infected persons. In the workplace or at school, persons with symptoms of influenza (e.g., fever, headache, muscle aches, cough, runny nose or sore throat) should be sent home. If they cannot be sent home immediately, they should be confined to a separate room. If contact between infected and uninfected cannot be avoided (e.g., during transport in a car), place a surgical or procedure mask over the nose and mouth of the ill person, and open the windows to increase air circulation. For workers uncertain of potential exposure (such as in a day care center), wear a surgical or procedure mask when in close contact (less than three feet) with a potentially infectious person. Change the mask when it becomes moist, and perform hand hygiene after discarding the mask. Wear gloves if there is contact with respiratory secretions; discard gloves immediately after use and perform hand hygiene. Contain infectious respiratory secretions of the ill All persons with signs and symptoms of a respiratory infection, regardless of presumed cause, should: Cover their nose and mouth when coughing or sneezing, preferably with a tissue or cloth Use tissues to contain respiratory secretions Dispose of tissues in the nearest waste receptacle after use Perform hand hygiene after contact with respiratory secretions and contaminated objects or materials Schools, workplaces, businesses and other places where people congregate should ensure availability of supplies to facilitate use of tissues, proper disposal and hand hygiene. Wherever possible, such places should: Provide tissues and garbage receptacles Provide facilities for hand hygiene (either sink, water and soap, or alcoholbased hand rub dispensers) Promote air circulation and keep environment clean Good air circulation has been shown to decrease the chance of spreading respiratory viruses. When caring for a patient in the home or at a residential 8-4 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES facility, place the patient in a separate room with an operable window. Keep the window open as the climate permits, and if necessary use a fan to circulate the fresh air. UV light can kill the influenza virus; open the shades and allow sunlight into the room. Tissues used by the ill person and other waste should be placed in a bag and disposed of with other household waste. Laundry may be washed in a standard washing machine with warm or cold water and detergent. It is not necessary to separate soiled linen and laundry used by a patient with influenza from other household laundry. Care should be used when handling soiled laundry (e.g., avoid “hugging” the laundry) to avoid selfcontamination. Hand hygiene should be performed after handling soiled laundry. Soiled dishes and eating utensils should be washed either in a dishwasher or by hand with warm water and soap. Separation of eating utensils for use by a patient with influenza is not necessary. Environmental surfaces can be cleaned using normal procedures. An EPAregistered hospital disinfectant can be used according to the manufacturer’s instructions, but is not necessary. There is no evidence to support the widespread disinfection of the environment or air. Infection Control Considerations for Specific Settings The infection control guidance in the previous section is also applicable in each of the following settings. Home Care The use of respiratory hygiene, hand hygiene, cough etiquette, and droplet and contact precautions are recommended, as possible. Symptomatic patients who do not require hospitalization should not go to work, school, childcare centers or other public areas until 14 days after the onset of symptoms. During this time, the infection prevention recommendations below should be used to minimize the potential for transmission: Physically separate the patient with influenza from non-ill persons living in the home. If more than one person in the home has influenza, all ill persons can share the same room. Ideally, the patient(s) with influenza should have his or her (or their) own room with windows that open to increase air circulation. The patient should cover his or her mouth and nose with a facial tissue when coughing or sneezing; wear a surgical mask when uninfected persons enter the room; or, if unable, uninfected persons should wear a N95 respirator when entering the room. When travel outside the home is necessary for a patient (e.g., for medical care), the patient should cover his or her mouth and nose when coughing and sneezing, and wear a mask. Champaign-Urbana Pandemic Annex 8-5 Section 8 One person in the home should be the designated caregiver and all others should limit contact to the extent possible. Follow general infection control measures described above. Caregivers should: Wear disposable gloves when in contact with the ill person’s blood or bodily fluids—including respiratory secretions or items such as disposable tissues contaminated with respiratory secretions—and the immediate environment. Gloves should be removed and discarded immediately after activities involving contact with blood or body fluids, and hand hygiene should be performed. Gloves are not intended to replace proper hand hygiene. Wash hands with soap and water after gloved and ungloved contact with the ill person’s blood or body fluids—including respiratory secretions or items such as disposable tissues contaminated with respiratory secretions—and the ill person’s immediate environment. If soap water is not immediately accessible, and hands are not visibly soiled with respiratory secretions, blood or other bodily fluids, then alcohol-based hand hygiene products can be used after removing gloves. Gloves should never be washed or reused. Unwashed dishes and utensils should not be shared. Wash dishes and utensils with warm to hot water and any commercial detergent after each use. Disposable plates or eating utensils are not necessary. Clean and disinfect environmental surfaces in the kitchen, bathroom and bedroom at least daily with a household cleaner diluted and used according to manufacturer’s instructions. Bleach, if used, should be diluted one part bleach to 10 parts water. A fresh solution should be mixed daily. Linens should not be shared between household members until they have been washed. Wash clothes, bed linens and towels in water at any temperature, using any commercial laundry product, and dry at an appropriate fabric temperature. Gloves should be worn when handling soiled linens. Dispose of surgical masks and waste soiled with respiratory secretions, blood or other bodily fluids as normal household waste. Any rented, non-disposable medical or respiratory equipment should be placed in a plastic bag and labeled contaminated prior to their return. Schools and Daycare Providers Keep sick students, teachers and other workers away from school or daycare while ill. If there will be a lag time between when a potentially infectious person is identified and when he or she can leave school, move him or her to a separate and well-ventilated room during the waiting period. Promote respiratory hygiene, cough etiquette and hand hygiene as for any respiratory infection. 8-6 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES Routine environmental cleaning is adequate. Workplace (See also Non-pharmaceutical Interventions) Keep sick workers away from the workplace while ill and potentially infectious— generally up to 14 days from onset of illness. This may be revised to a shorter period once more is known about the virus. If there will be a lag time between when a potentially infectious person is identified and when he or she can leave the workplace, move him or her to a separate and well-ventilated room during the waiting period. Promote respiratory hygiene, cough etiquette and hand hygiene as for any respiratory infection. Routine environmental cleaning is adequate. Jails, Correctional Facilities and Locked Wards Jails, correctional facilities or other locked wards represent unique settings in which crowding, barrack-style living and freedom of mobility may increase transmission of influenza. Special care should be taken to identify infectious inmates as early as possible. To the extent possible, house inmates in three groups: ill, exposed and those who are neither. Keep ill inmates in a well-ventilated room or rooms physically separate from the remainder of the population. Avoid allowing jail staff assigned to the ill inmates to float or have any contact with the second or third groups. Promote respiratory hygiene, cough etiquette and hand hygiene as for any respiratory infection. Once a pandemic is established, considering using masks for all inmates and staff. Routine environmental cleaning is adequate. Law Enforcement Law enforcement personnel—particularly those who may have contact with or transport ill people, or those who have been potentially exposed to pandemic flu— should follow law enforcement’s standard procedures for infection control, implement PPE protocol per departmental policy, and use patrol cars with plastic dividers that separate officers from suspects or passengers. Follow the infection control guidelines above—including those for the workplace—in addition to the following: If contact between infected and uninfected cannot be avoided (e.g., during transport in a car), place a surgical or procedure mask over the nose and mouth of the ill person, and open the windows to increase air circulation. For workers uncertain of potential exposure, wear a surgical or procedure mask when in close contact or in an enclosed area (less than 3 feet) with a potentially Champaign-Urbana Pandemic Annex 8-7 Section 8 infectious person. Change the mask when it becomes moist, washing hands with soap and water or an alcohol-based hand rub after discarding the mask. Wear gloves if there is contact with respiratory secretions and discard gloves immediately after use, washing hands or using an alcohol-based hand rub. Law enforcement vehicles should be equipped with masks and alcohol hand sanitizer. Pre-Hospital Care Situations (Emergency Medical Services/Ambulance Drivers, Etc.) For ambulance drivers or others who may transport ill patients or suspected cases of pandemic flu, implement usual standard protocol, in addition to the following: Screen patients requiring emergency transport for symptoms of influenza. Follow standard and droplet precautions when transporting symptomatic patients. Once pandemic influenza has been identified in the community, use N95 respirators for all patient transport. If possible, place a surgical or procedure mask on the patient to contain droplets expelled during coughing. If this is not possible (e.g., such action would further compromise respiratory status or be difficult for the patient to wear), have the patient cover his or her mouth and nose with tissue when coughing, or use the most practical alternative to contain respiratory secretions. Oxygen delivery with a non-rebreather facemask can be used to provide oxygen support during transport. If needed, positive-pressure ventilation should be performed using resuscitation bag-valve mask. Unless medically necessary to support life, aerosol-generating procedures (e.g., mechanical ventilation) should be avoided during pre-hospital care. Optimize the vehicle’s ventilation to increase the volume of air exchange during transport. When possible, use vehicles that have separate driver and patient compartments that can provide separate ventilation to each area. Notify the receiving facility that a patient with possible pandemic influenza is being transported. Follow standard operating procedures for routine cleaning of emergency vehicles and reusable patient care equipment. 8.1.3 General Guidelines for Healthcare Settings (Hospitals, Health Centers, Etc.) In addition to the above guidelines, healthcare facilities are encouraged to implement additional precautions. Standard Precautions These precautions should be observed in all patient care interactions, and are designed to reduce the risk of transmission of microorganisms from both recognized and 8-8 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES unrecognized sources of infection within healthcare facilities. The precautions apply to blood and all bodily fluids except sweat regardless of whether or not they contain visible blood, non-intact skin and mucous membranes. All healthcare facilities and providers must ensure: Barriers are used to protect the skin and mucous membranes of the healthcare worker from contact with the blood and/or bodily fluids of the patient(s). Availability of PPE, including gowns, gloves, masks and eye protection (see PPE section below). Availability of hand washing/hand sanitization stations. Airborne Precautions These measures are designed to limit the spread of microorganisms that are small (5 μm or less). Because of their small size, these microorganisms may remain in the air for long periods of time. Microorganisms carried in this manner can be dispersed widely by air currents and may be inhaled by a susceptible host in the same room or over a longer distance, depending on environmental factors. All healthcare facilities and providers must ensure: Negative pressure, where available, is utilized in rooms where these patients are housed. Protective masks used by personnel are N95 respirators. Contact Precautions These measures are designed to limit the transmission of microorganisms that are spread by skin-to-skin contact or physical transfer of the microorganisms via unwashed hands or certain inanimate objects in the patient care environment. All healthcare facilities and providers will ensure PPE utilized include gloves, gowns for direct contact, and masks if splashing or aerosolization of secretions is anticipated (see PPE section below). Droplet Precautions These measures are designed to limit the transmission of organisms contained in the droplets generated from the infected person during coughing, sneezing and talking, and during the performance of certain procedures such as suctioning and bronchoscopy. These droplets are generally large and are propelled a short distance through the air and either land directly on the conjunctiva, nasal mucosa or mouth of another person, or on surfaces where they can contaminate the hands of another person. The unwashed contaminated hands will spread the pathogen when they touch the conjunctive, nasal mucosa or mouth of another. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission; that is, droplet transmission must not be confused with airborne transmission. All healthcare facility and providers will ensure: A N95 respirator and protective eyewear are utilized. Champaign-Urbana Pandemic Annex 8-9 Section 8 PPE includes gloves for direct contact and gowns, if soiling is anticipated. 8.2 Personal Protective Equipment 8.2.1 Overview During an influenza pandemic, masks and respirators, used in combination with other NPIs when close contact with someone who has pandemic influenza is expected, may help reduce the spread of influenza. A risk assessment to determine necessary PPE and work practices to avoid contact with blood or bodily fluids will help customize standard precautions to the healthcare setting of interest. Standard precautions include the use of gloves and facial (e.g., nose, mouth and eye) protection by healthcare workers when providing care to coughing or sneezing patients. In suggesting the use of these PPEs, CUPHD will follow the IDPH, HHS, OSHA and CDC interim recommendations based on the best judgment of public health experts who relied in part on information about the protective value of masks in healthcare facilities. Employees whose work involves close contact with humans or animals known or suspected to be infected with certain types of flu or pandemic influenza must be provided appropriate PPE. Employees providing direct care to patients known or suspected of being infected with pandemic influenza, or those employees working directly with animals known or suspected of being infected with influenza, should use full barrier PPE. Full barrier PPE includes: Respirator at least as protective as a NIOSH-certified N95 respirator* Gown Gloves Eye protection (e.g., face shield or goggles) Although most employees outside of healthcare or animal control settings will not need PPE, the need for PPE by employees whose regular duties involve possible contact with infected humans or animals will be evaluated on a case-by-case basis. *Respirators should be used in the context of a complete respiratory protection program as required by OSHA. This includes pre-use medical evaluation, training and fit testing, as well as seal-checking at time of use to ensure appropriate respirator selection and use. To be effective, respirators must seal properly to the wearer's face. Detailed information on respiratory protection programs is available at the following sites: http://www.osha.gov/SLTC/etools/respiratory/ http://www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/rpp/index.html 8-10 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES 8.2.2 Assorted Personal Protective Equipment Differences between Surgical Masks and Respirators Although some disposable respirators look similar to surgical masks, it is important that healthcare workers understand the significant functional difference between surgical masks and disposable respirators. Surgical Masks Surgical masks are not designed to prevent inhalation of airborne contaminants. Their ability to filter small particles varies greatly and cannot be assured to protect healthcare workers against airborne infectious agents. Instead, their underlying purpose is to prevent contamination of a sterile field or work environment by trapping bacteria and respiratory secretions that are expelled by the wearer (i.e., protecting the patient against infection from the healthcare worker). Surgical masks are also used as a physical barrier to protect the healthcare worker from hazards such as splashes of blood or bodily fluids. Surgical masks should be used once and then thrown away. When both fluid protection (e.g., blood splashes) and respiratory protection are needed, a surgical N95 respirator can be used. This respirator is approved by the FDA and certified by NIOSH. Respirators A respirator (e.g., an N95 or higher filtering face piece respirator approved by NIOSH) is designed to protect people from breathing in very small particles that might contain viruses. Healthcare workers use respirators when taking care of patients with diseases that can be spread through the air. N95 means the filter on the respirator screens out 95 percent of the particles (0.3 microns and larger) that could pass through. To be most effective, these types of respirators need to fit tightly to the face so that the air is breathed through the filter material. Fit testing is the usual method for assuring proper fit in workplaces where respirators are used. Respirators are not designed to form a tight fit on people with small faces (e.g., children) or people with facial hair. Men who have beards need to shave before using a respirator. N95 and higher respirators are less comfortable to wear than facemasks because they are more difficult to breathe through. Like surgical masks, most N95 respirators should be worn only once and then discarded. Particulate respirators can be divided into several types: Disposable or filtering face piece respirators, in which the entire respirator face piece is comprised of filter material. It is discarded when it becomes unsuitable for further use due to excessive breathing resistance (e.g., particulate clogging the filter), unacceptable contamination/soiling or physical damage. Reusable or elastomeric respirators, in which the face piece is cleaned, repaired and reused, but the filter cartridges are discarded and replaced when they become unsuitable for further use. Champaign-Urbana Pandemic Annex 8-11 Section 8 Powered air-purifying respirators, in which a battery-powered blower pulls contaminated air through filters, and then moves the filtered air to the wearer. All respirators used by employees are required to be tested and certified by NIOSH, which uses very high standards to test and approve respirators for occupational uses. NIOSH-certified particulate respirators are marked with the manufacturer’s name, part number, protection provided by the filter (e.g., N95) and “NIOSH.” This information is printed on the face piece, exhalation valve cover or head straps. If a respirator does not have these markings, and does not appear on one of the following lists, it has not been certified by NIOSH. A list of all NIOSH-certified disposable respirators is available at http://www.cdc.gov/niosh/npptl/respirators/disp_part/particlist.html. NIOSH also maintains a database of all NIOSH-certified respirators regardless of respirator type (the Certified Equipment List), which can be accessed at the following site: http://www.cdc.gov/niosh/celintro.html Goggles/Face Shields The HHS Pandemic Influenza Plan does not recommend the use of goggles or face shields for routine contact with patients with pandemic influenza; however, if sprays or splatters of infectious material are likely, it states that goggles or a face shield should be worn as recommended for standard precautions. If a pandemic influenza patient is coughing, any healthcare worker who needs to be within three feet of the infected patient is likely to encounter sprays of infectious material. Eye and face protection should be used in this situation, as well as during the performance of aerosol-generating procedures. Facemasks are loose fitting, disposable masks that cover the nose and mouth. These include products labeled as surgical, dental, medical procedure, isolation and laser masks. Facemasks help stop droplets from being spread by the person wearing them. They also keep splashes or sprays from reaching the mouth and nose of the person wearing the facemask. They are not designed to protect the person wearing it against breathing in very small particles. Facemasks should be used once and then discarded. Gloves HHS recommends the use of gloves made of latex, vinyl, nitrile or other synthetic materials as appropriate, when there is contact with blood and other bodily fluids, including respiratory secretions. HHS further suggests: There is no need to double-glove. Gloves should be removed and discarded after patient care. Gloves should not be washed or reused. Hand hygiene should be performed after glove removal. Because glove supplies may be limited in the event of pandemic influenza, other barriers such as disposable paper towels should be used when there is limited contact 8-12 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES with respiratory secretions, such as handling used facial tissues. Hand hygiene should be practiced consistently in this situation. Indications for, and limitations of, glove use include the following: Hand contamination may occur as a result of small, undetected holes in examination gloves. Contamination may occur during glove removal. Wearing gloves does not replace the need for hand hygiene. Failure to remove gloves after caring for a patient may lead to transmission of microorganisms from one patient to another. Gowns Healthcare workers should wear an isolation gown when it is anticipated that soiling of clothes or uniform with blood or other bodily fluids—including respiratory secretions—may occur. HHS states that most routine pandemic influenza patient encounters do not necessitate the use of gowns. Examples of when a gown may be needed include procedures such as intubation or when closely holding a pediatric patient. Isolation gowns can be disposable and made of synthetic material, or reusable and made of washable cloth. Gowns should be the appropriate size to fully cover the areas requiring protection. After patient care is performed, the gown should be removed and placed in a laundry receptacle or waste container, as appropriate. Hand hygiene should follow. Additional Personal Protective Equipment Instructions Materials Management/Equipment Availability Agencies must ensure that appropriate PPE is available for employee and patient use. As the pandemic widens, shortages can be anticipated. Agencies must maintain constant inventory oversight of basic infection control equipment, including gloves, N95 masks, gowns, waste disposal bags, alcohol-based hand gel and antiseptic hand wash, tissues and the like. Shortages in other materials are also anticipated. Consider whether work procedures can be modified to avoid the need for PPE during a pandemic. Agencies should assess their expected service delivery needs during a pandemic and consider the current recommended personal protection guidelines. If personal protection is expected to be necessary during a pandemic, agencies should follow any applicable OSHA regulations and make arrangements in advance to evaluate, train and equip employees with the appropriate PPE. Employees that are issued PPE are required to wear the equipment. Agencies that have a clear need for PPE during a pandemic (e.g., direct care of individuals ill with influenza or other critical services where PPE is required) should consider the gradual stockpiling of nonperishable PPE. Champaign-Urbana Pandemic Annex 8-13 Section 8 Employees Instruction Employee education will need to focus on appropriate PPE as well as proper donning and doffing sequence. Information on immunization and medications used for prophylaxis as well as review of all isolation precautions will also be needed. Educational offerings will likely need to be repeated and perhaps revised every three to six months. To maintain employee interest, it will be necessary to develop different types of presentations that can be rotated and sent out to remote sites (e.g. ambulatory care centers). Patient Education Handouts will need to be developed on many topics, including infection prevention and control in a home setting. Instruction on patient home care and self-care will be critical because of the expected surge in patients and overcrowding of healthcare facilities. Non-critical patients should be encouraged not to come to hospitals or healthcare centers. Information and fact sheets on immunization and prophylactic medications will also be needed. Other recommended actions include: Plan education for all levels of employees on newly developed policies as well as influenza Promote influenza vaccination for all employees Institute “Cover your Cough” signage Develop strategies to provide masks, tissues and appropriate disposal containers in emergency departments and ambulatory care sites Strongly encourage immunization and provide healthcare workers with immunization free of charge Reinforce existing policies for respiratory hygiene, isolation precautions and hand hygiene Educate healthcare workers to facilitate rapid identification of potential cases of influenza due to a novel strain with pandemic potential Increase surveillance for flu-like illness Assess current levels of N95 mask availability and begin to consider some stockpiling Develop teaching handouts to address issues related to home care of patients with influenza, antiviral medication, influenza vaccine declination forms and symptom diaries Maintain close contact with CUPHD and other healthcare infection control and prevention practitioners in Champaign County Conduct frequent review of current literature to ensure that the most recent recommendations have been considered in the development of any policies, procedures, or patient and employee management recommendations 8-14 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES Signage and Policy Implementation Daily rounds will be needed to ensure that signs are posted in necessary locations and in a variety of languages. Waiting areas will need to have a supply of tissues and/or masks as well as appropriate disposal containers. Patient Management As more patients present for care, the number of negative pressure isolation rooms will not be adequate. Thought must be given to housing patients in designated areas. The optimal characteristics for a designated area would include: Ability to create negative pressure rooms within this area Ability to limit access to the area Room for storage/stockpiling of supplies Ability to house more than one person within the room Criteria for placing patients on this floor, as well as assigning staff to this floor, will need to ensure that patients have documented illness with the pandemic influenza, and staff will need to have received full immunization. Administration will need to consider whether assignment to these areas will be voluntary or mandatory. Nutrition, Laundry and Environmental Services At this time, there is no recommendation regarding the use of disposable dishes and eating utensils. Standard precautions should be observed when handling dishes and utensils used by patients with influenza. Laundry should also be handled using standard precautions. No additional precautions are recommended at this time. Cleaning and disinfection of environmental surfaces are important infection control measures in healthcare facilities. In addition to routine daily environmental decontamination, healthcare personnel should perform more frequent disinfection of commonly touched surfaces in patient rooms and common areas. All rooms should be terminally cleaned after discharge. Postmortem Care Standard precautions should be followed when caring for deceased persons. If autopsy or other procedures are performed on a person suspected or known to have died from pandemic influenza, a Personal Air Purifying Respirator (PAPR) should be utilized. 8.2.3 Pandemic Response Period General During the peak of the pandemic it may be necessary to establish a triage center outside of the entrance to the emergency department or health center. This area would need to be staffed and equipped to screen patients and direct them to an appropriate Champaign-Urbana Pandemic Annex 8-15 Section 8 treatment area. Separate areas will be needed for persons with influenza-like symptoms and persons needing to be seen for other healthcare issues. Patients should be managed according to all previously outlined precautions. Additionally, a secure method to transition patients out of the hospital and into alternate care sites and/or home care will be needed. The goal of infection prevention and control in the alternate care sites will be to limit the transmission of virus within and out of the site. Sites are expected to have staffing mixes (healthcare professionals and volunteers) and no special air handling capacities, so strict attention must be paid to respiratory etiquette, hand hygiene, droplet and contact precautions. Whenever possible, symptomatic persons awaiting examination and diagnosis should be masked and separated from those persons being seen for other reasons. During this period, infection prevention and control activities will be focused on: Participation in any daily meetings regarding bed utilization and patient management Enforcing all infection prevention and control recommendations Meeting all requirements regarding reporting to local, state and federal agencies as required by law Facilitating patient transfer when needed Daily rounds to ensure that all cases are reported and appropriate infection prevention measures are in place Provision of immunization and/or prophylactic medication to all hospital and health center employees Monitoring employee sick calls and employees who have received either vaccination and/or prophylaxis Serving as a clearinghouse for current information and treatment guidelines, and distributing educational materials as needed Frequent assessment of supplies—work in close collaboration with materials management and pharmacy Attending all countywide meetings as required Assisting and facilitating discussions regarding patient care and resource allocation Nutrition, Laundry and Environmental Services Although no recommendation exists for the use of disposable utensils and dishes, it may be necessary to utilize them as the pandemic spreads and the potential for shortages increases within the nutrition services departments. Laundry should continue to be handled using standard precautions until such time as additional precautions are recommended. As the pandemic spreads there may be shortages or delay in laundry delivery and creative alternatives may be needed. Cleaning and 8-16 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES disinfection of environmental surfaces are important infection control measures in healthcare facilities. In addition to routine daily environmental decontamination, healthcare personnel should perform more frequent disinfection of commonly touched surfaces in patient rooms and common areas. All rooms should be terminally cleaned after discharge. Postmortem Care Standard precautions should be followed when caring for deceased persons. Autopsies will likely not be done and there may be large numbers of bodies requiring storage. It may be necessary to have an alternative morgue set up. Human Resources As the pandemic progresses, manpower will be stretched and it will likely become necessary to utilize volunteer physicians and nurses and to cross-train employees to do alternate jobs. All individuals will need specific infection control training to ensure policies and procedures are followed. Employee Health During a pandemic, employee health strategies will be in effect. As the pandemic peaks, methods will need to be developed to screen healthcare workers for influenzalike illness at the start of their shift. Additionally, it will be necessary to establish return-to-work criteria for employees. 8.2.4 Post-Pandemic (Recovery) Period Continue infection control activities per normal operations. 8.3 Non-Pharmaceutical Intervention 8.3.1 Overview According to the CDC, it is highly unlikely that the most effective tool for mitigating a pandemic (i.e., a well-matched pandemic strain vaccine) will be available when a pandemic begins. This means that we must be prepared to face the first wave of the pandemic without a vaccine and potentially without sufficient quantities of influenza antiviral medications. In addition, it is not known if current influenza antiviral medications will be effective against a future pandemic strain. With that caution as a planning assumption, it is clear that a combination of pharmaceutical and NPIs, during the duration of the pandemic, must be used to reduce the number of persons infected. NPIs may help reduce the number of infected persons by reducing contact between infected and uninfected persons. Reducing the number of persons infected will, in turn, lessen the need for healthcare services and minimize the impact of a pandemic on the economy and society. Champaign-Urbana Pandemic Annex 8-17 Section 8 NPIs refer to measures that attempt to slow introduction of disease and subsequent transmission until more definitive public health measures (e.g., antivirals and vaccine) are available. The major goals of promoting the use of NPIs are to: Delay the increase of cases in order to “buy time” for production and distribution of a well-matched pandemic strain vaccine Decrease the pandemic peak (the highest number of cases at a given time) Reduce the total number of cases, thus reducing illness and death Decrease demand for medical services at the peak of the epidemic and throughout the epidemic wave Protect health workers and first responders to ensure the well-being of the Champaign County community CUPHD will make decisions about which NPIs should be used carefully, recognizing that there will be consequences of the interventions, such as increased workplace absenteeism related to child-minding responsibilities if schools dismiss students and childcare programs close. 8.3.2 Non-Pharmaceutical Intervention Community Control Measures No intervention short of mass vaccination of the public will dramatically reduce transmission when used alone. Mathematical modeling of pandemic influenza scenarios in the U.S., however, suggests that pandemic mitigation strategies utilizing multiple NPIs may decrease transmission substantially and that even greater reductions may be achieved when such measures are combined with the targeted use of antiviral medications for treatment and prophylaxis. Recent preliminary analyses of cities affected by the 1918 pandemic show a highly significant association between the early use of multiple NPIs and reductions in peak cases. These measures are to be initiated early, before explosive growth of the epidemic, and, in the case of severe pandemics, should be maintained consistently during an epidemic wave in a community. CUPHD will consider the following NPIs, depending on the phase and severity of the pandemic: Isolation and treatment (as appropriate) with influenza antiviral medications of all persons with confirmed or probable pandemic influenza. Isolation may occur in the home, healthcare setting or alternate care site, depending on the severity of an individual’s illness and/or the current capacity of the healthcare infrastructure. Voluntary home quarantine of members of households with confirmed or probable influenza case(s). Consider combining this intervention with the prophylactic use of antiviral medications, providing that sufficient quantities of effective medications exist and that a feasible means of distributing them is in place. Social distancing for children/students, such as dismissal of students from school—including public and private schools, as well as colleges and 8-18 Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES universities—and school-based activities, in addition to closure of childcare programs. This should be coupled with protecting children and teenagers through social distancing in the community to achieve reductions of out-of-school social contacts and community mixing. Use of social distancing measures to reduce contact between adults in the community and workplace (e.g., cancellation of large public gatherings, and alteration of workplace environments and schedules to decrease social density and preserve a healthy workplace to the greatest extent possible without disrupting essential services). Travel restrictions to reduce contact between Champaign County residents and travelers arriving at Willard Airport and bus and train stations from outside the area, state or country. Promotion of individual infection control measures, such as hand hygiene and cough etiquette, and use of PPE such as masks or respirators by first responders and health workers to limit the spread of the disease. Public education, which will reduce the demand for medical services throughout the epidemic. Measures to assist essential services to continue operating. Enforcement of Isolation, Quarantine, Social Distancing and Travel Restrictions The CUPHD Public Health Administrator has broad authority to act to protect the health and welfare of the community. Based on the SARS experience in 2003, it is anticipated that individuals will comply with social distancing orders such as isolation or quarantine. In rare instances, it may be necessary to enforce isolation or quarantine orders. To prepare law enforcement to respond to a pandemic, CUPHD will: Inform law enforcement about Health Officer authority to order isolation, quarantine and social distancing measures Establish mechanisms of communication between CUPHD and law enforcement Instruct law enforcement on PPE should they be called upon to enforce isolation, quarantine or social distancing measures Request law enforcement assistance with any of the following: Enforce isolation and quarantine orders Assist to provide security at private and public hospitals Provide perimeter security at isolation/quarantine alternate care sites Provide security (escort) for physicians, EMS personnel, ambulance personnel, other care providers or support personnel, as required Conduct area evacuations and secure evacuated areas Champaign-Urbana Pandemic Annex 8-19 Section 8 Evacuate and secure public assembly venues when social distancing is required by Public Health Order or other declaration 8.3.3 Criteria for Determining Community Control Measures Actual decisions about how to protect the public before an effective vaccine is available and/or when limited pharmaceuticals are available will be based on a complex number of factors present at the time of the pandemic. In addition to the severity and phase of a pandemic, the following factors will help guide health officials on which NPIs should be used. Ethical considerations Impact of the NPIs on society as a whole, on specific subpopulations, the healthcare delivery system and critical infrastructure Benefits of the interventions Available resources Feasibility of success based on such things as the community’s ability and likelihood to comply Direct and indirect costs Common sense The public’s perspective of the protective measures Guidance and coordination with IDPH and neighboring counties As was presented in the Introduction, the CDC has developed the PSI to introduce categories of pandemic intensity, similar to the system used to measure hurricane strength. The following table presents recommended NPIs within the context of the PSI. Table 8-1 Non-Pharmaceutical Intervention Recommendations Based on Pandemic Severity Index PSI Interventions by Setting Home Voluntary isolation of ill at home (adults and children); combine with use of antiviral treatment as available and indicated Voluntary quarantine of household members in homes with ill persons (adults and children); consider combining with antiviral prophylaxis if effective, feasible and sufficient quantities School Child Social Distancing 8-20 1 2 and 3 4 and 5 Recommend Recommend Recommend Generally Not Recommended Consider Recommend Champaign-Urbana Pandemic Annex MITIGATION STRATEGIES PSI - Dismissal of students from schools and school-based activities and closure of child care programs - Reduce out-of-school social contacts and community mixing Workplace/Community Adult Social Distancing - Decrease number of social contacts (e.g., encourage teleconferences and alternatives to face-to-face meetings) - Increase distance between persons (e.g., reduce density in public transit, workplace) - Modify, postpone or cancel selected public gatherings to promote social distance (e.g., postpone indoor arena events, theater performances) - Modify workplace schedules and practices (e.g., telework, stagger shifts) Champaign-Urbana Pandemic Annex Generally Not Recommended Consider < 4 weeks Recommend < 12 weeks Generally Not Recommended Consider < 4 weeks Recommend < 12 weeks Generally Not Recommended Consider Recommend Generally Not Recommended Consider Recommend Generally Not Recommended Consider Recommend Generally Not Recommended Consider Recommend 8-21 Section 9 RISK COMMUNICATION 9.1 Overview Risk communication and public education play a vital role in pandemic flu preparedness and response. Strong risk communication and public outreach activities help build trust, confidence and cooperation, and support effective preparedness and response efforts. Dissemination and sharing of timely and accurate information will be one of the most important facets of the pandemic response. Instructing the public and partners in actions they can take to minimize their risk of exposure, or actions to take if they have been exposed, will reduce the spread of the pandemic and may also serve to reduce anxiety and unnecessary demands on vital services. This section will help guide and prepare the CUPHD in communicating key messages to the general public, the news media, healthcare providers and other partners and stakeholders (e.g., first responders, law enforcement, local government, schools and businesses) before, during and after a pandemic influenza. 9.1.1 Coordination The CUPHD PIO will—in consultation with the CUPHD Public Health Administrator, the Infectious Disease and Management Division staff, the IDPH and the CDC, as appropriate—identify public health issues and concerns that will need to be addressed or may need to be addressed through public information messages regarding pandemic influenza, as well as identify affected target audiences for messages. CUPHD will also coordinate, as appropriate, dissemination of information with the County PIO and Champaign County EMA (see the Champaign County EOP for more information). 9.1.2 Risk Communication Principles In all emergency communication efforts, CUPHD will make every effort to adhere to risk communication and ethics principles: Be first, be right and be credible. Balance the public’s “need to know” in a timely manner with the need to ensure that information is accurate. Engage the public in a manner that allows non-expert citizens to combine technical facts with their values. Provide enough information to create “transparency” so that the public understands how decisions are made, who is making the decisions, and where the resources are going. Champaign-Urbana Pandemic Annex 9-1 Section 9 9.1.3 Risk Communication Planning Assumptions and Considerations An influenza pandemic will generate intense and sustained demand for information from the public, healthcare providers, policy makers and the news media. Informing healthcare providers and the public about influenza disease and the course of the pandemic, the ability to treat mild illness at home, and the availability of antivirals and vaccine will be important to ensuring appropriate use of medical resources. It will also help to avoid possible panic or overwhelming of vaccine delivery sites. Effective communication with community leaders and the media is important to maintain public awareness, avoid social disruption and provide information on evolving pandemic response activities. Spokespersons need to acknowledge the anxiety, distress and grief people will experience during a major public health crisis such as a pandemic. Communication efforts will be directed to rapid sharing of appropriate, up-to-date information on the progression of the outbreak, the possible disruptions to routines and events, and contingency measures. The public must be provided as much information as possible to help them understand that uncertainty is part of the process and that answers may change as new information and science becomes available. Emergency communication is approved by the CUPHD Public Health Administrator or the Administrator’s designee. All government and non-government resources will use a single source of information on Champaign County’s position regarding the emergency. Federal partners at the CDC and HHS will provide regular updates regarding the pandemic. Local information will be provided to IDPH through existing reporting systems from local sources, such as local health departments, hospitals, physician’s offices and schools. Coordination of release of information among federal, state and local health officials is critical to avoid confusion that can undermine public trust, raise fear and anxiety, and impede response measures. 9.1.4 Vulnerable Population Considerations CUPHD is committed to providing healthcare services to those in need and most vulnerable, and actively seeks to do so. Including vulnerable populations and the organizations that serve them in pandemic flu risk communication planning is consistent with CUPHD’s mission to improve the health, safety and well-being of the community through prevention, education, collaboration and regulation. 9-2 Champaign-Urbana Pandemic Annex RISK COMMUNICATION The following issues will be taken into consideration as preparedness and response actions are implemented: Key messages delivered in multiple languages (e.g., English and Spanish, and others as resources allow) Key messages delivered using multiple communication modes Key messages delivered through grassroots mechanisms (e.g., community- and faith-based) to people who are homeless, geographically or culturally isolated Key messages delivered to people who are homebound, including those with services (e.g., Senior Transportation, First Call for Help) and without services 9.1.5 Desired Outcomes Provide timely and accurate pre-event information to the public about pandemic influenza, pandemic influenza preparedness and actions, and CUPHD plans. During a pandemic event, provide the most current and accurate information, including what is happening, what is being done and what people can do to protect themselves. 9.2 Communications Infrastructure CUPHD will use a range of communication methods, as appropriate, to notify CUPHD staff, health providers, first responders, partners, stakeholders, the public and the media of changes in pandemic flu stages, and recommend actions, such as the use of PPE and social distancing. 9.2.1 Interpandemic/Pandemic Alert Period During this period, CUPHD will: Test local communication systems through training, drills and exercises to ensure that local and statewide communications are functional Establish and maintain health provider contact information Maintain fax and email contact list for media Maintain fax and email contact list for CBOs Maintain contact list for business and industry partners, schools and colleges, day care providers, organizations that serve vulnerable populations, etc. 9.2.2 Pandemic Response Period During a pandemic, CUPHD will follow WHO, HHS, CDC and IDPH guidance to issue recommendations locally, and will: Champaign-Urbana Pandemic Annex 9-3 Section 9 Use CUPHD communication methods to notify hospitals, public and private healthcare providers, first responders, other appropriate PIOs, and other public and private sector partners and stakeholders of the change in pandemic stage Implement contingency plans, if any, for obtaining critical hardware, software or personnel to expand communication systems if needed for a pandemic Maintain ongoing communication with healthcare providers, first responders, and all partners and stakeholders, including posting information on the CUPHD website 9.2.3 Post-Pandemic (Recovery) Period During this period, CUPHD will: Take appropriate corrective action steps identified in after action reports (AARs) Return to Interpandemic/Pandemic Alert Period activities 9.3 Communicating with the General Public 9.3.1 Message Development Messages are developed with key CUPHD staff and are approved by the CUPHD Public Health Administrator or the Administrator’s designee, and, as appropriate, with the IDPH. CUPHD also will coordinate, as appropriate, with the Champaign County EMA. During the course of pre-event activities and especially during a pandemic influenza event, messages and other information will be updated and customized. Interpandemic/Pandemic Alert Period During this period, CUPHD will: Develop key messages for printed materials, public presentations and the media Provide a solid foundation of information upon which future actions can be based Develop key messages to address CUPHD activities, including planning efforts, as well as avian or swine influenza education, pandemic influenza and general preparations Pandemic Response Period During this period, CUPHD will: Update and further develop key messages as the situation warrants Develop messages to be used primarily for communicating key actions to the general public through the media Post materials to the CUPHD website as they are developed 9-4 Champaign-Urbana Pandemic Annex RISK COMMUNICATION Post-Pandemic (Recovery) Period During this period, CUPHD will: Take appropriate corrective action steps identified in AARs Return to Interpandemic/Pandemic Alert Period activities 9.3.2 Public Education and Awareness Campaign The public is more likely to respond and cooperate more readily if they are involved in the discussions and planning for pandemic influenza; have general knowledge of the situation; are aware of the issues and concerns that are to be addressed; and understand their individual roles and responsibilities. Planning checklists for individuals and families, workplace, schools, healthcare providers, and community and faith-based organizations have been created and are posted on the CDC pandemic flu web page (http://www.pandemicflu.gov/plan/checklists.html). Interpandemic/Pandemic Alert Period During this period, CUPHD will conduct a public education and awareness campaign as resources allow. Key messages are used in the various components of the campaign, which is directed at the general public and conducted in both English and Spanish. Pandemic Response Period During this period, CUPHD will: Continue and increase public education and awareness campaign as resources allow. Key messages are used in the various components of the campaign, which is directed at the general public and conducted in both English and Spanish Use pandemic flu information materials available in Amharic, Arabic, Chinese, Farsi, Russian and Vietnamese on the CDC’s pandemic flu website (www.pandemicflu.gov) Update current materials and develop new materials as the situation warrants. Updated materials will be posted as they are developed to the CUPHD website, the Health Emergency Information Line (HEIL), etc. Post-Pandemic (Recovery) Period During this period, CUPHD will: Take appropriate corrective action steps identified in AARs Return to Interpandemic/Pandemic Alert Period activities 9.3.3 Message Dissemination Depending on resources, the following tools may be used to disseminate the message: Champaign-Urbana Pandemic Annex 9-5 Section 9 Educational materials on pandemic flu Media campaigns Bill inserts Web postings Phone scripts Radio ads and Public Service Announcements (PSAs) Print ads Theater and mall signs Bus shelters, bus interior signs and bus boards Billboards Television ads Emergency alerts such as ChampCoPrepares.com Speakers bureau Collateral materials/handouts Special events/venues such as health fairs, public meetings, etc. Direct mail HEIL, if created 9.4 Working with the Media 9.4.1 Communicating with the Media Interpandemic/Pandemic Alert Period During this period, CUPHD will: Develop a packet of materials for the media, including CUPHD materials as well as approved outside materials. These materials include samples of public education materials, and guidelines for planning and personal protection. Hold informational meetings with the media to educate them on Champaign County preparedness activities, pandemic influenza and their role in helping CUPHD educate the public on the pandemic threat. Pandemic Response Period During this period, CUPHD will communicate regularly with media to disseminate updated public information and risk communication materials about pandemic flu as part of ongoing media outreach through press releases, web postings, media interviews and press conferences. 9-6 Champaign-Urbana Pandemic Annex RISK COMMUNICATION Post-Pandemic (Recovery) Period During this period, CUPHD will: Take appropriate corrective action steps identified in AARs Update materials as needed Return to Interpandemic/Pandemic Alert Period activities 9.4.2 Spokesperson Training Interpandemic/Pandemic Alert Period During this period, CUPHD will: Identify, train and drill CUPHD and other county spokespersons on specific pandemic influenza risk communications Conduct an informational training with healthcare provider PIOs and appropriate members of the county’s PIOs Pandemic Response Period During this period, CUPHD will distribute to spokespersons updated public information and risk communication materials about pandemic flu as part of ongoing public outreach. Post-Pandemic (Recovery) Period During this period, CUPHD will: Take appropriate corrective steps identified in AARs Update training and materials as needed Return to Interpandemic/Pandemic Alert Period activities as appropriate 9.5 Coordinating with Healthcare Public Information Officers Interpandemic/Pandemic Alert Period During this period, CUPHD will: Maintain a hospital PIO contact list Provide the hospital PIOs with pandemic influenza materials and updates Pandemic Response Period During this period, CUPHD will: Champaign-Urbana Pandemic Annex 9-7 Section 9 Communicate regularly with hospital PIOs about CUPHD activities as well as any new developments regarding avian, swine and/or pandemic flu. Healthcare PIO information will be communicated primarily through email and fax, as appropriate Provide updated public information and risk communication materials about pandemic flu regularly as part of ongoing public outreach Post-Pandemic (Recovery) Period During this period, CUPHD will: Take appropriate corrective steps identified in AARs Update training and materials as needed Return to Interpandemic/Pandemic Alert Period activities as appropriate 9.6 Communicating with Key Partners The CUPHD PIO provides support to CUPHD staff and programs that are primarily responsible for outreach, coordination and content development with key partners and stakeholders. These key partners include the Champaign County Board, businesses, local governments, Parkland College and the University of Illinois at UrbanaChampaign, community-based and faith-based organizations, Champaign County Corner, county government, emergency medical services and pre-hospital responders, fire services, Champaign County legal/court system, law enforcement agencies, local healthcare system, mental health facilities, news media, University of Illinois-Willard Airport, local transit and area schools. Interpandemic/Pandemic Alert Period During this period, CUPHD will: Maintain contact lists for business and industry partners, schools and colleges, day care centers, organizations that serve vulnerable populations, etc. Make existing materials available for distribution. Key partners may use these materials for distribution to employees, customers, clients, vendors, students, etc. Post all information to the CUPHD website. Pandemic Response Period During this period, CUPHD will distribute regularly, as part of ongoing public outreach, updated information and risk communication materials about pandemic flu. Post-Pandemic (Recovery) Period During this period, CUPHD will: Take appropriate corrective steps identified in AARs Update training and materials as needed 9-8 Champaign-Urbana Pandemic Annex RISK COMMUNICATION Return to Interpandemic/Pandemic Alert Period activities as appropriate 9.7 Risk Communication/Public Education Strategies and Key Messages CUPHD will use the following communication strategies as appropriate to notify providers, first responders, partners, stakeholders, the public and the media of changes in pandemic flu stages, and inform them of recommended actions to prepare for, prevent, respond to and recover from pandemic flu. Based on federal and state guidance, and in consultation with the CUPHD Public Administrator and CUPHD Infectious Disease Division, the CUPHD PIO will perform public education activities and disseminate information on recommended actions to the public, such as the use of PPE, school dismissal or closures, and other risk reduction measures. 9.7.1 Interpandemic/Pandemic Alert Period Strategy The CUPHD PIO and staff will prepare to respond to a pandemic through the following activities and strategies: Conduct community education and media campaigns on pandemic flu, disease prevention and CUPHD preparedness activities. Work with schools, child care providers, law enforcement and volunteer organizations (e.g., American Red Cross) to coordinate pandemic flu preparedness and response plans. Maintain and update the pandemic flu plan components as needed, including fact sheets, media contact lists and website. Create and maintain a pandemic preparedness page on the CUPHD website. Create and update pandemic flu messages to be activated when needed on the HEIL. Designate and train appropriate pandemic spokespersons. Develop pandemic flu materials for advice nurses and staff should a Health Emergency Call Center be created. Educate CUPHD staff about pandemic flu planning, preparedness and response. Key Messages General public education about pandemic flu. What to consider when preparing for a pandemic (home, business, etc.). Champaign County and CUPHD is planning for the event of pandemic influenza. Champaign-Urbana Pandemic Annex 9-9 Section 9 Planning is not just a government issue. Every resident and business must take responsibility to prepare themselves, their families and their business for pandemic influenza. Practice good hygiene habits such as hand washing and covering coughs and sneezes with a tissue or sleeve to prevent the spread of germs. Promote seasonal flu and pneumonia vaccination. Encourage residents to ChampCoPrepares.com. sign up for local emergency alerts on 9.7.2 Pandemic Response Period Strategy During this period, communicating information to the public in a timely and accurate manner will be essential to ensure compliance with health directives. CUPHD will use a variety of strategies to communicate with partners and the public to provide appropriate messages. To get information out quickly, CUPHD will use a number of redundant communications methods, including the following: If created, update the HEIL on a regular basis as appropriate. Activate Health Emergency Call Center, as needed. Modify and update written materials (e.g., fact sheets, materials for schools) as needed. Post documents intended for electronic distribution on CIPHD website. Provide press releases, web postings, media interviews and press conferences for media on a timely basis. Implement public information campaigns by creating PSAs to air on local cable and satellite television, as well as broadcast media. Provide advice nurses, call center staff and any phone answerers with latest pandemic flu information on prevention, treatment, etc. Alert schools, child care providers, law enforcement and other local public and private agencies of the need to activate their own pandemic flu response plans. Provide risk communication guidance to hospitals in Champaign County. Disseminate guidelines on influenza precautions for workplaces, healthcare facilities, schools, jails and prisons, public safety agencies and individuals. Provide internal information to employees through the Intranet, All Staff email messages, the media and other mechanisms. Communicate with partners and stakeholders (including Champaign County Board) and keep them updated, including if and when school and child care closures or dismissals are needed. 9-10 Champaign-Urbana Pandemic Annex RISK COMMUNICATION Coordinate messages with appropriate agencies, such as the Champaign County EMA, IDPH, CDC and law enforcement agencies. Identify contact person (and backup person) for communication with IDPH communication staff. Use PIO mutual aid as necessary; however, be aware that in a pandemic every county across the U.S. will be hit at approximately the same time. Relying on mutual aid will likely be a risky strategy. Staff the PIO position at the Champaign County EOC and/or Joint Information Center (JIC) as needed. Key Messages Projected severity of the novel virus. Current surveillance information. Travel alert information received from the state and/or CDC. Provide updates about Champaign County, Illinois State and federal response activities. Announce the availability of a telephone hotline and website updates. Update public about critical services that are still available. Disseminate information about how to stop the spread of the disease. These should be risk reduction tips and other instructions to the general public, healthcare providers, first responders, and partners and stakeholders, and should include the importance of hand washing, social distancing and other NPIs, as appropriate. Offer suggestions on how to care for sick family members. Provide information about isolation and quarantine. Declare school and business closures as necessary. Provide updates on the availability/status of antiviral medications and/or vaccines. Provide information on how and where to get antiviral medications and/or vaccines, if available. Communicate with and update healthcare providers on: Pandemic flu status Screening Infection control Reporting Treatment Lab protocols Champaign-Urbana Pandemic Annex 9-11 Section 9 Vaccine/antiviral status and priority groups Provide updated guidance on infection control, health monitoring and precautions to businesses, schools and the general public. 9.7.3 Post-Pandemic (Recovery) Period Strategy A pandemic flu is predicted to come in waves; the recovery period may be delayed by several waves. CUPHD’s goal is to return CUPHD services to normal as quickly as possible. Recovery period activities will include: Return website to normal function Deactivate communication tools specifically activated for the pandemic. These may include HEIL and the Health Emergency Call Center Have the public, media and key partners prepare AARs on how well CUPHD performed during the pandemic event; correct deficiencies identified in the AARs Update fact sheets and appropriate materials Evaluate media coverage Return to Interpandemic/Pandemic Alert Period activities Key Messages Officially declare the pandemic over and summarize the impact on the county and the county’s preparedness and response efforts. Announce the deactivation of any communication tools specifically activated for the pandemic. Continue messages on importance of hygiene to prevent flu and other illnesses. Continue messages to promote seasonal flu and pneumonia vaccinations. Provide information regarding community resources and strategies for psychosocial effects. 9.8 Risk Communication Guidance for Hospitals 9.8.1 Risk Communication Strategies Pandemic influenza risk communication strategies are a critical and necessary component of pandemic influenza preparedness and response. Hospitals will play an important role in providing vital information to the public, healthcare providers and hospital staff before, during and after a pandemic to help ensure people respond 9-12 Champaign-Urbana Pandemic Annex RISK COMMUNICATION appropriately to outbreak situations and follow public health measures. To ensure that this information is consistent, accurate and timely, it is critical that hospitals coordinate pandemic flu messages with CUPHD. The CUPHD PIO will collaborate with Champaign County’s PIO, taking the lead in development of public health and medical risk communication materials for release to the public, business community, schools and critical infrastructure, including healthcare facilities. Hospital PIOs should initiate and maintain a close working relationship with the CUPHD PIO, if they have not already done so. Information regarding a pandemic and the planning for it is coming from a variety of sources. The federal government provides background information and frequent updates for healthcare professionals through the CDC’s website at www.pandemicflu.gov/. Additionally, the CDC provides information through their Emergency Communication System. The IDPH is tasked by the Governor to coordinate public health, medical emergency and risk communication messages for the state. In that role, IDPH will provide background information and frequent updates for healthcare professionals. To reduce the likelihood of conflicting or confusing messages across the healthcare system, every effort should be made to coordinate media content between CUPHD and hospitals. This is true during both the Interpandemic/Pandemic Alert Period and the Pandemic Response Period. Interpandemic/Pandemic Alert Period During the Interpandemic/Pandemic Alert Period, it is important for hospitals to establish methodologies for assuring that the most current information is being received from and provided to the CUPHD PIO. Information received should be shared with appropriate individuals within the organization, such as healthcare providers, other staff, patients and partners. Hospitals are encouraged to include risk communication strategies in their hospital pandemic plan. Preparations for implementing the following strategies are recommended. External Communication The CUPHD PIO will maintain a single source of contact with each hospital. Current contact information should be provided by each hospital, and a plan developed to ensure the information is updated, as needed. Hospital PIOs should consider participating in a PIO network. Hospitals should prepare or use messages provided by the CUPHD PIO for use in call centers, websites, hotlines, recorded messages, etc. These messages should be differentiated for patients, community and employees. Hospitals should identify and train individuals who may be expected to support the hospital PIO or serve as the hospital spokesperson during periods where there is increased communication flow related to pandemic flu. Champaign-Urbana Pandemic Annex 9-13 Section 9 Internal Communication Hospitals will develop mechanisms for sharing pandemic flu planning with employees. Hospitals will develop frequently asked questions or use those provided by CUPHD, which target hospital personal, differentiating them for patients and the community. Pandemic Response Period During the Pandemic Response Period, hospital PIOs are encouraged to: Maintain a single source of contact with the CUPHD PIO, ensuring this information is updated, as needed Use established mechanisms for external communication with the media and a PIO network Determine how to keep administrators, personnel, patients and visitors informed of the ongoing impact of pandemic influenza on the facility and the community Ensure capacity for increases in communication flow related to the pandemic flu Establish communication with any area JIC as appropriate, if activated. The Champaign County EOC may open a JIC 9.8.2 Education and Training Each hospital is encouraged to develop an education and training plan that addresses the needs of staff, patients, family members and visitors. Hospitals will need to assign responsibility for coordination of the pandemic influenza education and training program and identify training materials—in different languages and at different reading levels, as needed—from HHS agencies, IDPH and CUPHD, and professional associations. The following guidelines, taken from the HHS Pandemic Influenza Plan, provide a basis for inclusion of education and training in the hospital’s pandemic influenza plan. CUPHD and/or IDPH will provide current information that should be used in developing education and training content. Interpandemic/Pandemic Alert Period Each hospital is encouraged to develop a plan to provide staff education. Staff education should include infection control strategies for influenza, including respiratory hygiene/cough etiquette, hand hygiene, standard precautions, droplet precautions and airborne precautions (see also the section on Infection Control and Prevention Guidelines for Healthcare Settings). Hospital-specific topics for staff education should include: Policies and procedures for the care of pandemic influenza patients, including how and where pandemic influenza patients will be located 9-14 Champaign-Urbana Pandemic Annex RISK COMMUNICATION Pandemic staffing contingency plans, including how the facility will deal with illness in personnel Policies for visitation System for reporting suspected cases of infection caused by novel influenza strains during the Interpandemic/Pandemic Alert Period to CUPHD Measures to protect family and other close contacts from secondary occupational exposure Hospitals should also: Establish a schedule for training/education of clinical staff and a mechanism for documenting participation. Use annual infection control updates/meetings, Medical Grand Rounds and other educational venues as opportunities for training on pandemic influenza Cross-train clinical personnel—including outpatient healthcare providers—who can provide support for essential patient-care areas (e.g., emergency department, ICU, medical units) Train intake and triage staff to detect patients with influenza symptoms and to implement immediate containment measures to prevent transmission Create a mechanism for supplying social workers, psychologists, psychiatrists and nurses with guidance for providing psychological support to patients and hospital personnel during an influenza pandemic. Hospitals should also provide psychological-support training to appropriate individuals who are not mental health professionals (e.g., primary-care clinicians, leaders of community and faith-based organizations) Develop a strategy for “just-in-time” training of non-clinical staff who might be asked to assist clinical personnel (e.g., help with triage, distribute food trays, transport patients), students, retired health professionals and volunteers who might be asked to provide basic care (e.g., bathing, monitoring of vital signs) and other potential in-hospital caregivers (e.g., family members of patients) Education of patients, family members and visitors should: Ensure that patients and others know what they can do to prevent disease transmission in the hospital, as well as at home and in community settings. Identify and use language-specific and reading-level appropriate materials, provided by CUPHD, IDPH and CDC for educating patients, family members and hospital visitors during an influenza pandemic. Develop a plan for distributing information to all persons who enter the hospital. Identify staff to answer questions about procedures for preventing influenza transmission. Champaign-Urbana Pandemic Annex 9-15 Section 9 Pandemic Response Period Hospitals will implement the mechanisms created to distribute updated informational and educational materials to hospital visitors and the patient community on an ongoing basis. It will be essential that the hospital PIO maintain regular contact with the CUPHD PIO to ensure that the hospital receives the most updated pandemic flu guidance and that the assigned Education and Training staff receive the most current information to use in their training. Training and education should be ongoing and incorporate information on the following: Disease prevention precautions Home self-care information The need to either postpone non-critical appointments or procedures or provide alternative ways for patients to be seen for non-urgent needs The need to advise the public to only use the emergency department for true medical emergencies 9-16 Champaign-Urbana Pandemic Annex Section 10 MAINTENANCE OF ESSENTIAL SERVICES One of the critical needs during a flu pandemic will be to maintain essential community services. With the possibility that 25 to 35 percent of the workforce could be absent due to illness, it may be difficult to maintain adequate staffing for certain critical functions. There is the possibility that services could be disrupted if significant numbers of public health, law enforcement, fire and emergency response, medical care, transportation, communications and public utility personnel are unable to carry out critical functions due to illness. Government agencies and private businesses, particularly those that provide essential services to the public, must develop and maintain continuity of operations plans and protocols that address the unique consequences of a pandemic. Local EMAs in Champaign County will lead continuity of government planning and preparedness within their jurisdictions, with technical support provided by CUPHD. Local EMAs in Champaign County will also participate in and support logistical and non-medical infrastructure planning with hospital facilities within their jurisdictions. CUPHD will develop continuity of operations plans that address the following, at a minimum: Line of succession for the agency Approval of continuity of operations plans by the Champaign Urbana Board of Health Identification of mission essential services and priorities Procedures for the reassignment of employees to support public health functions essential during a public health emergency Redundancy of mission critical communication and information systems Physical relocation of critical CUPHD functions Maintenance of Essential Services by Period During Interpandemic/Pandemic Alert Period All divisions and sections in CUPHD will develop plans for maintaining essential services during a pandemic. The PIO will continue to educate government agencies, non-profit organizations and businesses that provide essential community services about the need for continuity planning in advance of a pandemic. Champaign-Urbana Pandemic Annex 10-1 Section 10 During Pandemic Response Period CUPHD will update its essential services plans and request that its community partners update their plans. The Public Health Administrator will determine the appropriate time to implement CUPHD continuity of operations plans and protocols, and will advise community partners to implement their plans as needed. 10-2 Champaign-Urbana Pandemic Annex Section 11 PLAN DEVELOPMENT AND MAINTENANCE 11.1 Plan Development The CUPHD Public Health Administrator will direct the development of and approve the Pandemic Plan. The CUPHD Public Health Administrator may be assisted by such individuals as the Administrator directs. 11.2 Distribution Once approved, the Pandemic Plan will be distributed to the following: IPHD All divisions within CUPHD Champaign County EMA Stakeholders, partner agencies and organizations, and other pertinent individuals and programs within Champaign County Health departments/districts of neighboring counties The website 11.3 Review and Update This Plan will be updated based on the deficiencies identified in AARs from actual pandemic situations or exercises, when there are changes in pandemic threats, resources and capabilities, or when there is a change in agency structure. This Plan must be revised or updated by a formal change at least every five years. The responsibility for coordinating the revision of the Plan rests with the CUPHD Public Health Administrator. Champaign-Urbana Pandemic Annex 11-1 Section 12 ACRONYMS AND ABBREVIATIONS AAR After Action Report ACIP Advisory Committee on Immunization Practices CBO Community-Based Organization CDC Centers for Disease Control and Prevention CFR Case Fatality Ratio CUPHD Champaign-Urbana Public Health District EMA Emergency Management Agency EMS Emergency Medical Services EOC Emergency Operations Center EOP Emergency Operations Plan Flu Influenza H Hemagglutinin HEIL Health Emergency Information Line HHS United States Department of Health and Human Services IDPH Illinois Department of Public Health JIC Joint Information Center N Neuraminadase NIOSH National Institute for Occupational Safety and Health NPI Non-Pharmaceutical Intervention NVAC National Vaccine Advisory Committee OSHA Occupational Safety and Health Administration PAPR Personal Air Purifying Respirator PEP Post-Exposure Prophylaxis PIO Public Information Officer Plan The Champaign-Urbana Public Health District Pandemic Influenza Plan PPE Personal Protective Equipment PSA Public Service Announcement PSI Pandemic Severity Index Champaign-Urbana Pandemic Annex 12-1 Section 12 SNS Strategic National Stockpile WHO World Health Organization 12-2 Champaign-Urbana Pandemic Annex