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TABLE OF CONTENTS........................................................................................................... 1 I. INTRODUCTION.............................................................................................................. 2 Background.................................................................................................................... 2 Purpose......................................................................................................................... 2 Plan Organization........................................................................................................... 3 II. AUTHORITIES AND REFERENCES................................................................................. 4 III. EMERGENCY MANAGEMENT ORGANIZATION............................................................... 5 General Emergency
Responsibilities:.................................................................................... 5 Director.......................................................................................................................... 5 Executive Staff:............................................................................................................... 6 Chief, Division of Communicable Disease Control
(DCDC):.................................................. 6 DCDC Division Operations Center:.................................................................................... 6 Joint Medical/Health Emergency Operations
Center (JEOC):............................................... 6 IV. CONCEPT OF OPERATIONS.......................................................................................... 7 A. Planning for Influenza Pandemic:.................................................................................... 7 B. Normal (Day-to-Day) Operations:.................................................................................... 8 1. Surveillance........................................................................................................... 7 2. Vaccine
and Pharmaceutical Delivery....................................................................... 8 3. Emergency
Response and Communications............................................................. 9 C. Pandemic Operations:.................................................................................................... 9 Novel Virus Alert Stage...................................................................................................... 11 1. Surveillance.......................................................................................................... 11 2. Vaccine
and Pharmaceutical Delivery..................................................................... 10 3. Emergency
Response and Communications........................................................... 10 Pandemic Alert Stage........................................................................................................ 12 1. Surveillance.......................................................................................................... 12 2. Vaccine
and Pharmaceutical Delivery..................................................................... 13 3. Emergency
Response and Communications........................................................... 14 Pandemic Imminent Stage................................................................................................. 16 1. Surveillance.......................................................................................................... 16 2. Vaccine
and Pharmaceutical Delivery..................................................................... 16 3. Emergency
Response and Communications........................................................... 17 Pandemic Stage............................................................................................................... 18 1. Surveillance.......................................................................................................... 18 2. Vaccine
and Pharmaceutical Delivery..................................................................... 19 3. Emergency
Response and Communications........................................................... 19 Second Wave................................................................................................................... 19 V. APPENDICES.............................................................................................................. 21 i. Federal
Influenza Pandemic Responsibilities........................................................... 22 ii. Organizational
Abbreviations.................................................................................. 23 iii. State
of California Plans and Procedures that Apply to Epidemics............................. 24 iv. Emergency
Response Roster................................................................................ 25 v. Influenza Pandemic Planning Executive Committee List………………………………….26 |
INFLUENZA PANDEMIC RESPONSE PLAN
The worst natural
disaster in modern times was the infamous “Spanish flu” of 1918-1919, which
caused 20 million deaths worldwide and over 500,000 deaths in the U.S. Although the Asian influenza pandemic of
1957 and the Hong Kong influenza pandemic of 1968 were not as deadly as the
Spanish influenza pandemic, both were associated with high rates of illness and
social disruption.
Influenza is a highly
contagious viral disease. Pandemics
occur because of the ability of the influenza virus to change into new types,
or strains. People may be immune to
some strains of the disease either because they have had that strain of
influenza in the past or because they have recently received influenza vaccine. However, depending on how much the virus has
changed, people may have some, little, or no immunity to the new strain. Small changes can result in localized
epidemics. But, if a novel and highly
contagious strain of the influenza virus emerges, an influenza pandemic can
occur and affect populations around the world.
California, with its
West Coast location and several major ports of entry for flights and shipping
from Asia (a likely location for the development of a novel virus), would
likely be among the first U.S. locations for an influenza pandemic to establish
a foothold. The California Department
of Health Services (DHS) estimates that the impact of an influenza pandemic on
California’s 34 million population would include as many as 9.9 million persons
ill with influenza, 386,000 persons hospitalized, and 168,300 deaths. These estimates underscore the need for
advance planning to lessen the impact of a pandemic.
Most Californians are aware
of the need to plan for a disaster at an unknown time in the future because of
their familiarity with earthquakes.
Many of the planning principles for mitigating both types of natural
disasters are the same, yet there are also important differences. First, in a pandemic, there will be some
warning, which could range from weeks to 5-6 months while there is no warning
for earthquakes. Second, the duration
of a pandemic would range from months to a year or more, but earthquakes last
only minutes. Third, in a pandemic
there would be little or no outside assistance; In the early stages, those not
affected would be reluctant to be exposed to the disease, and later in the
development of the pandemic, the entire nation and world would be affected, and
there would be no “outside.” In
contrast, neighboring cities, counties, and states can be counted on to assist
with earthquake response.
A number of State
agencies have emergency response plans (c.f. Appendix 3). The Office of Emergency Services is responsible
for the State Emergency Plan, a
general plan that encompasses all State agencies and any disaster. The DHS Emergency Response Plan and Procedures
of 1994 is currently being revised, and the Division of Communicable Disease
Control (DCDC) is in the process of drafting a bioterrorism emergency response
plan. The influenza pandemic plan
presented here will be integrated as an annex to the DHS Emergency Response Plan and is based on the existing emergency
response structure, authorities, and responsibilities identified in that plan.
The purpose of this Influenza Pandemic Response Plan is to
provide a guide for the California Department of Health Services (DHS) on how
to detect and respond to an influenza pandemic. The plan describes the emergency management concepts and
structure under which DHS will operate and the roles and responsibilities of
federal, state, and local agencies. The
plan lists the responsibilities and activities that apply to the Director, the
executive staff, the Deputy Director for Prevention Services, and the
divisions, branches, and the laboratories that have a role in an influenza
pandemic emergency response.
The Influenza Pandemic Response Plan should
be read and understood prior an influenza pandemic. It is a dynamic document that will be updated to reflect new
developments in the understanding of the influenza virus, its spread,
treatment, and prevention. The plan
will also incorporate changes in response roles and improvements in response
capability developed through ongoing planning efforts.
The plan is divided
into the following major sections:
I. Introduction
Provides
an overview of the background and purpose of the plan
II. Authorities and References
Identifies
the legal authorities and references that allow pandemic response activities
III. Emergency Management Organization
Describes
the emergency management structure that will be implemented for the DHS
response to an influenza pandemic.
IV. Concept of Operations
Describes
the emergency response procedures that will be implemented and the responsible
DHS organizational units. This section
also identifies the relationship of the DHS response activities to those of
federal, state, and local government, health care providers, and others.
The
section is divided into the five influenza pandemic stages listed in Pandemic Influenza: a Planning Guide for
State and Local Officials, Version 2.1, January 1999. This document is available at www.cdc.gov/od/nvpo/pandemicflu.htm. (Hereafter, this guide will be referred to
as the Federal Planning Guide.)
Stages
of Pandemic Influenza
·
Novel
virus alert. Novel
virus detected in one or more humans. Little
or no immunity in the general population.
Potential, but not inevitable precursor to a pandemic.
·
Pandemic
alert. Novel
virus demonstrates sustained person-to-person transmission and causes multiple
cases in the same geographic area.
·
Pandemic
imminent. Novel
virus causing unusually high rates of morbidity and mortality in multiple,
widespread geographic areas
·
Pandemic. Further spread with
involvement of multiple continents; formal declaration made
·
Second
wave. Recurrence
of epidemic activity within several months following the initial wave of
infection.
Within
each pandemic stage, this plan presents the concepts of statewide operation for
the following essential functions, which are adapted from those described in
the Federal Planning Guide:
·
Surveillance
·
Vaccine
and Pharmaceutical Delivery
·
Emergency
Response and Communications
V. Appendix
Includes
supporting documents: Federal responsibilities, a list of organizational abbreviations,
lists of other State plans that apply to epidemics, and a telephone roster
|
Department of Health
Services Groups |
|
|
DCDC |
Division of Communicable Disease Control |
|
IB |
Immunization Branch |
|
VFC |
Vaccines for Children Program |
|
VRDL |
Viral and Rickettsial Disease Laboratory |
|
DISB |
Disease Investigations and Surveillance
Branch |
|
EPO |
Emergency Preparedness Office |
|
OPA |
Office of Public Affairs |
|
|
|
Others
|
|
|
CDC |
Centers for Disease Control and Prevention, US Department
of Health and Human Services |
|
OES |
Office of Emergency Services, Office of
the Governor |
|
EMSA |
Emergency Management and Services
Agency, Health and Welfare Agency |
|
JEOC |
Joint Emergency Operations Center, DHS
and EMSA |
|
RDMHC |
Regional Disaster Medical/Health
Coordinator, DHS and EMSA |
|
LHDs |
Local health departments |
|
CPA |
California Pharmacists Association |
|
CMA |
California Medical Association |
|
HAN |
Health Alert Network |
·
California Emergency Services Act (Government
Code, Title 2, Division 1, Chapter 7, Section 8550 et seq.).
·
California Health and Safety Code, Sections 100170-100180,
120125-120140 and 120145-120150.
·
Department of Health Services, Emergency Response Plan and Procedures,
January 1994, which is a reference for:
-
Executive Order No. W-9-91
-
Administrative Order No. 79-22
-
Memorandum of Understanding, Department of Health
Services and Emergency Medical Services Authority, July 1988
·
Emergency Medical Services Authority, Disaster Medical Response Plan, July
1992
·
Office of Emergency Services, State Emergency Plan, May 1998
·
Federal Emergency Management Agency, Federal Response Plan, April 1999
·
Regional Medical/Health Coordinator Emergency
Plans
As
noted previously, this plan is intended to serve as a disaster-specific annex
to the DHS Emergency Response Plan and
Procedures. The relationship of DHS
to the State emergency response structure and the roles and responsibilities of
DHS Executive Staff, and the various divisions, branches, and sections of the
department are described in the DHS plan.
This section describes the emergency management structure that will be
implemented in response to a pandemic influenza outbreak and the relationship
with local, regional, state and federal response agencies.
Following a proclamation of
a local emergency or state of emergency as a result of the impact of influenza
in California, the DHS emergency response organization will be activated. The DHS response will be conducted in
accordance with the Standardized Emergency Management System (SEMS), as
described in the DHS emergency plan.
·
In coordination with the Emergency Preparedness
Office, activate the DHS emergency organization as appropriate.
·
Ensure close coordination and communication of
DHS activities with the Health and Human Services Agency, Governor’s Emergency
Council, and the Governor.
·
Activate the DHS Disaster Policy Council*
to make high-level policy decisions and ensure that all DHS organizational
units implement these decisions.
·
Provide policy direction to the emergency
response organization.
·
Ensure that all necessary DHS resources are
directed to respond to the emergency.
·
Ensure that continuity of DHS management and
operations is maintained through a clear command authority and identification
of staff to assume higher level responsibilities in the event of the absence or
incapacity of key DHS leadership.
·
Staff the Disaster Policy Council at the request of
the Director to ensure consensus on policy decisions and carry out these
decisions within assigned programs.
·
Ensure that staff is provided for the Joint
Emergency Operations Center or to respond to DHS, state, or local agency mutual
aid needs upon request.
·
Implement a Division Operations Center to
accomplish all program responsibilities defined in the concept of
operations.
·
Ensure that all primary SEMS functions
(Management, Operations, Planning, Logistics, and Finance) are addressed within
the Division Operations Center.
·
Manage the Division Operations Center to ensure
the development of an Incident Action Plan and implementation of the action
plan by the various DCDC programs.
·
Provide a DCDC liaison to ensure coordination of
division activities with the Joint Medical/Health Emergency Operations Center
(JEOC) in Sacramento.
·
Serve as the primary “field” operations location
to coordinate State-level disease surveillance, prevention, and control
activities to support local government and to fulfill DHS statutory
responsibilities.
·
Ensure close coordination and communication with
the Joint Emergency Operations Center (JEOC) for resource assistance and to maintain
information flow to the DHS Director and Executive Staff, Emergency Management
and Services Agency (EMSA), Office of Emergency Services (OES), and other
agencies as appropriate.
Coordinate
State-level medical and health information and resources by:
·
Acquiring public health and medical personnel
upon request of an affected region.
·
Acquiring medical supplies, pharmaceuticals and
equipment upon request of an affected region.
·
Coordinating resource acquisition and support for
DHS field emergency response activities.
·
Ensuring coordination with the OES State
Operations Center or Regional Emergency Operations Centers as appropriate.
·
Ensuring information flow to DHS and EMSA management
and executive staff, OES, and other agencies.
Prior to the occurrence of an influenza pandemic it is
essential that plans for detection and response are in place at the national,
state, and local levels of government. The following is a description of key
planning activities:
·
Meet with medical, public health, and emergency
response partners to develop prioritization plan for
distribution/administration of vaccines. (Supplies are likely to be
insufficient to meet demand during a pandemic situation.) (DCDC)
·
Ensure that each local health department has a
plan in place for surveillance in an influenza pandemic. (In rural areas,
regional plans may be appropriate.) The local plans must include the same
components as the state plan: surveillance of influenza cases, vaccine and
pharmaceutical distribution and administration, and emergency response and
communication. (DCDC, EPO)
·
Establish a dissemination plan for influenza
surveillance information, applicable to both normal influenza seasons and
pandemic situations. (OPA, DCDC)
·
Establish DHS plan for committing needed
resources in case of an influenza pandemic (DHS Office of the Director)
·
Establish plan to secure and utilize refrigerated
depots for storage of vaccines and other influenza-related pharmaceuticals, as
well as vehicles for their distribution to selected sites for administration.
(IB, EPO, EMSA)
·
Establish a plan for maintenance of operations in
case of increased workload and/or staff losses during a pandemic, including
cross training of staff and plans for redirection of staff from related
positions. (DCDC, EPO)
The
following is a description of influenza-related responsibilities and activities
that are conducted each year. These
activities form the base upon which influenza pandemic activities will be
added.
Surveillance
is key to recognizing a new strain of influenza at its source, determining its potential
for transmission, and tracking its spread.
The World Health Organization (WHO) maintains four collaborating centers
for influenza located in London, Atlanta, Tokyo and Melbourne. In addition, there are 110 national
collaborating laboratories in 79 countries.
One of these collaborating laboratories is the Department of Health
Services’ (DHS) Viral and Rickettsial Disease Laboratory (VRDL), located in
Berkeley. The Federal government and
WHO will coordinate national and international surveillance. Alerts on the various pandemic phases will
come from WHO and CDC to DHS. CDC will
issue travel alerts.
Influenza
is not a reportable disease in California.
However, DCDC collaborates with public and private institutions to
obtain information about the occurrence of disease. During the influenza season (late October through late April),
DCDC collects data from the following surveillance systems:
·
Antigenic and genetic characterization of
influenza isolates to identify novel viruses: Kaiser and local health
department (LHD) laboratories collect specimens and forward isolates to VRDL
for detailed characterization. (VRDL, LHDs, private providers)
·
Weekly reports of influenza and other respiratory
virus isolations and detections from 21 laboratories throughout the State.
(VRDL)
·
Inpatient hospitalization from 3 Kaiser
facilities in Southern California and 18 in Northern California. This inpatient system consists of weekly
reports of admitting diagnoses in which the key words “flu,” “influenza,” or
“pneumonia” appear. (VRDL)
·
Weekly reports of influenza antiviral
prescriptions in Northern and Southern California Kaiser pharmacies. (VRDL)
·
A network of 12 sentinel physicians throughout
the state that report to CDC the percentage of patients, by age group, with
influenza like illness (ILI) on a weekly basis. (CDC, VRDL)
·
Passive reporting of influenza outbreaks. (DISB)
·
Receive reports of Vaccine Adverse Reporting
Events, enter information into database, and forward copy to Vaccine Adverse
Reporting Event System. Periodically analyze data to identify increased
frequency of complaints and types of complaints. (IB)
While
the sentinel physicians report directly to CDC, they are activated at the
beginning of each influenza surveillance season by DCDC.
DCDC
has a “flu team” consisting of representatives of the Disease Investigations
and Surveillance Branch (DISB), VRDL and the Immunization Branch (IB). The team meets weekly throughout the
influenza season to review surveillance data, to discuss the level of influenza
disease activity, to coordinate efforts of the separate groups, to coordinate
with the Office of Public Affairs (OPA) about communication with the press, and
to assign tasks when action is needed.
2. Vaccine
and Pharmaceutical Delivery
Vaccine Delivery
Since 1973, the
Immunization Branch (IB) has received State funding annually to purchase
influenza and pneumococcal vaccine for local health departments (LHDs). The
local departments in turn administer the vaccines to the identified high-risk
groups, defined by the enabling legislation as persons age 60 years and older
and persons with chronic medical conditions as defined by the US Public Health
Service. In the 1999-2000 influenza
season, the Immunization Branch (IB) distributed 730,000 doses of influenza
vaccine and 31,900 doses of pneumococcal vaccine to LHDs.
The vaccine manufacturers
send the vaccine to IB for distribution to LHDs except Los Angeles County,
which receives its shipment directly.
IB packages and ships the vaccine to LHDs using commercial shipping
companies. IB estimates that
State-purchased vaccine constitutes about 25% of all influenza vaccine
delivered in California with the remaining 75% purchased and administered in
the private sector.
In
addition to the IB delivery system, the Vaccines for Children Program (VFC)
provides vaccine to children who are covered by the Child Health and
Disabilities Prevention Program (CHDP) or Medi-Cal, or who do not have any
medical insurance. Approximately 4,500
physicians at 3,000 sites order vaccine from VFC. About 100,000 doses of influenza vaccine were delivered to VFC
providers in 1999. VFC contracts with a
vaccine distributor that delivers the vaccines directly to the physicians.
Pharmaceutical
Delivery
The antiviral drugs, amantadine
and rimantadine, are currently used for prophylaxis and treatment of
influenza. The new antiviral agents,
oseltamivir and zanamivir, are currently licensed for treatment and may
eventually be approved for prophylaxis.
Under non-pandemic circumstances,
DHS has no role in pharmaceutical delivery.
For
normal operations of the Emergency Response System, see Section III, EMERGENCY
MANAGEMENT ORGANIZATION (above).
The
DHS Office of Public Affairs (OPA) has primary responsibility for dissemination
of public health information. All press
releases are channeled though OPA. DCDC
informs LHDs of important communicable disease information using the CD Briefs. CD Briefs is sent by
fax and by e-mail to health officers, communicable disease controllers,
laboratory directors, and to a limited number of private physicians in a timely
manner.
Forty-seven
of the State’s 62 LHDs are connected to the Internet, about 500 addresses are
reached by e-mail, and an additional 100 are reached by fax.
In
the early stages of a pandemic, there may be no vaccine at all. The Federal Planning Guide indicates that a minimum of 6-8 months would elapse
before the tens of millions of doses needed could be produced for
distribution. When vaccine first
becomes available the demand will likely exceed the supply. This will occur
because there will be only limited quantities produced initially and it is
likely that two doses will be needed rather than the usual single dose, with a
booster following approximately 30 days after the first injection.
Pharmaceutical
delivery will become an important issue during a pandemic. While antiviral agents will play a role in
both prophylaxis and treatment of influenza, the existing supplies would
certainly fall short of the need. As
the pandemic progresses, there may not be sufficient supplies of antibiotics
for treating persons with complications of influenza.
In addition to supply
problems, other difficulties are associated with use of antiviral agents. Priorities for target groups and the use of
limited supplies for prophylaxis versus therapy have not yet been established. Widespread use of antivirals and antibiotics
could lead to emergence of drug-resistant viral strains. Adverse anti-viral reactions and liability
issues will also be of concern. DHS has
no role in pharmaceutical delivery in non-pandemic years. However, in a
pandemic, DHS would provide its normal consultation on the handling and
administration of pharmaceuticals.
Novel
virus detected in one or more humans.
Little or no immunity in the
general
population. Potential, but not
inevitable precursor to a pandemic.
At this stage personnel
in all of the essential functions—surveillance, vaccine and pharmaceutical
delivery and emergency response and communications—are responsible for
monitoring reports from the World Health Organization (WHO), the Centers for
Disease Control and Prevention (CDC) and national teams in the country in which
the novel virus is detected and disseminating the information to LHDs. (DCDC,
EPO)
·
If the alert is given outside of the normal late
October-late April influenza surveillance season:
-
Request that Kaiser surveillance system sites,
collaborating laboratories and LHDs consider what steps would need to be taken
to activate the system. (DCDC)
-
Request that the sentinel physicians be prepared
to begin reporting to CDC. (DCDC)
(During the normal influenza season, these systems will already be active.)
·
Increase communication with quarantine stations
concerning procedures for detecting novel virus importation by new arrivals
from the countries where the novel virus originated and/or is spreading. (DCDC)
·
Obtain appropriate reagents from CDC to detect
and identify the novel strain. (VRDL)
Remain
ready for the possibility that novel
virus alert could progress to the pandemic
alert stage.
·
Ensure communication between the DCDC
epidemiology and laboratory surveillance programs and the Emergency Management
and Services Agency (EMSA) and the Governor’s Office of Emergency Services
(OES). (DCDC, EPO, EMSA, OES)
·
Ensure communication with local Emergency
Response Systems. (DCDC, OPA, EMSA,
OES)
·
Develop press release templates. (DCDC, OPA)
·
Notify OPA, EMSA and OES of the novel virus
alert. Assist OPA to develop materials for responding to questions that may
come from the media. (DCDC, EPO)
Novel
virus demonstrates sustained person-to-person transmission and causes multiple
cases in the same geographic area.
Novel
virus alert activities will be continued at a more advanced level,
and other activities will be added.
·
Outside of normal surveillance season, alert the
surveillance systems listed below to activate.
(DCDC) (During normal influenza
season, above surveillance systems will already be active.)
-
Kaiser facilities’ inpatient diagnosis and
pharmacy surveillance systems
-
Collaborating laboratories and LHDs
-
California sentinel physicians that report
directly to CDC
·
Screen travelers from influenza areas for signs
of infection. (Quarantine stations)
·
Meet with surveillance partners to increase
amount of patient demographic information collected, in order to identify
groups with increased risk. (DCDC, IB)
·
Inform surveillance partners of the need to increase
specimen collection for detection of novel virus and alert laboratories to
prepare for increased numbers of specimens.
(VRDL)
·
Implement surveillance of passengers arriving
from countries of high influenza morbidity to monitor those passengers with
influenza-like illness and attempt to obtain specimens for virologic
characterization. (DCDC, Quarantine
Stations)
·
Recruit additional physicians to obtain influenza
isolates and send them to VRDL. If
necessary distribute specimen collection kits to LHDs and obtain cooperation to
facilitate sending isolates to VRDL.
(VRDL)
·
Recruit additional pharmacies, such as a large
pharmacy chain, to participate in reporting antiviral prescriptions
filled. (DCDC)
·
Maintain communication with CDC concerning laboratory
surveillance findings. (VRDL)
·
Assess inventory of equipment and supplies,
noting what is needed. (VDRL)
·
Develop contingency plans for procurement of
laboratory equipment and supplies, and also for possible redirection and hiring
of additional laboratory employees.
(VRDL)
·
Obtain authorization for special funding for
additional laboratory testing personnel from DCDC, Prevention Services and the
Director of DHS. (VRDL)
·
Explore re-certification of non-traditional labor
pool and redirection of staff with appropriate skills to alleviate need for
additional laboratory personnel, both at DHS and LHDs. (DCDC)
During
the pandemic alert stage, vaccine would not yet be available, and may
not be for several months.
·
Maintain close contact with CDC and FDA to obtain
information on plans for vaccine manufacture.
(IB)
·
Prepare to implement plan for storing and delivering
vaccine as it becomes available to DHS (vs. private distribution), with variations
by number of doses. (IB, EMSA)
·
Review elements of plan for vaccine delivery with
partners and stakeholders. (IB, LHDs)
·
Ensure that human resources, equipment and plans
for mass immunization clinics are in place.
(IB, LHDs)
·
Ensure adequate staffing and communications for
VAERS system. (IB)
·
Plan for using VFC distribution system for VFC
children. If appropriate, increase
award to vaccine distribution company.
(IB, VFC)
·
Obtain latest California DHS recommendations for
priority groups for vaccine allocation and modify as necessary based on current
surveillance data. (DCDC Division
Operations Center)
·
Meet with California Pharmacists’ Association and
California Medical Association to discuss potential need to: (IB)
-
increase antiviral and anti-microbial supplies
-
increase role of pharmacists in vaccine delivery
·
Develop a satellite broadcast script for
training/refresher on vaccine administration techniques for persons who do not
normally administer vaccines, but will be enlisted to do so in a pandemic. (IB)
-
Broadcast to local LHD and other downlink sites
-
Provide video copies of the broadcast for local
training
·
Ensure communication among the epidemiology and
laboratory surveillance programs and emergency management. (JEOC)
·
Alert surveillance groups to increase
surveillance activities (see Surveillance section above). (DCDC)
·
Identify contact person for communication with
WHO, CDC and national teams in countries of origin. (DCDC)
·
Identify spokesperson (with backup person) for
communication with press, public, etc.
(OPA, DCDC)
·
Prepare fact sheets detailing responses to
questions coming from the media and the public. (CDC, DCDC, OPA)
-
Include documents intended for electronic
distribution on the DHS web site
-
Include telecommuting advice to employers, labor
organizations
·
Respond to media inquiries regarding
outbreak. (CDC, OPA/DCDC spokesperson,
LHDs)
·
Alert ports of entry to situation. (CDC, DCDC)
·
Notify hospitals, care providers, emergency
responders, coroners and mortuary organizations. (EMSA, DCDC to LHDs, local emergency management agencies, via the
Health Alert Network [HAN])
·
Alert LHDs to increase laboratory surveillance,
disease surveillance; alert emergency responders to work with EMSs to inventory
critical supplies and solve problems (EMSA, EPO, JEOC, RDMHC)
·
Alert neighborhood-watch or other community-based
response organizations. (local
emergency management agencies, OES)
·
Conduct inventory of critical equipment, supplies
and personnel, including statewide availability of: hospital beds, antiviral
pharmaceuticals, refrigerated depots for vaccines, and transport for delivery
of vaccines. (EMSA, VRDL, IB,
hospitals, pre-hospital care providers, private providers)
·
Identify methods to address personnel and supply
shortfalls. (EPO, local emergency
management agencies, hospitals, care providers, mortuaries)
·
Send bulletins to private providers. (CDC to DCDC to LHDs, HMOs, Medi-Cal, local
medical societies, Vaccines for Children [VFC] providers, et al.)
·
Issue guidelines on influenza precautions for
workplaces, emergency departments, airlines, schools, jails and prisons, public
safety agencies, and individuals. (CDC to
DHS to LHDs, local emergency management agencies)
·
Issue Travel Alert. (CDC to DCDC to LHDs)
Novel
virus causing unusually high rates of morbidity and mortality in widespread
geographic areas
In
the pandemic imminent stage the pandemic alert activities will
continue at an intensified level.
·
Outside of normal surveillance season, verify
that surveillance facilities have activated and are reporting to DCDC and
VRDL. (DCDC, VRDL)
·
Report the data collected to all participating
facilities as well as CDC, LHDs and EPO.
(DCDC, VRDL)
·
Analyze the inpatient data to determine which
population groups are at greatest risk and provide the information to CDC and
to those determining priority groups for vaccine allocation when the supply is
limited. (IB)
·
Consider special studies. (DCDC)
-
to describe unusual clinical syndromes
-
to describe unusual pathologic features
associated with fatal cases
-
conduct efficacy studies of vaccination or chemoprophylaxis
-
assess the effectiveness of control measures such
as school and business closings
·
Maintain increased laboratory surveillance and
other activities outlined previously in the pandemic alert section. (VRDL)
2. Vaccine
and Pharmaceutical Delivery
·
Continue activities as listed in pandemic
alert stage, including meetings with the California Pharmacists Association
(CPA) and the California Medical Association (CMA). (IB,VRDL)
·
If vaccine delivery date predicted by CDC, work
with LHDs to: (IB)
-
Provide date
-
Review distribution plan and update when new
information is available
-
Obtain signed agreements with LHDs and private
providers on priority order of groups to receive vaccine when supply is
limited.
-
Alert to need for security at immunization sites
(LHDs, local law enforcement)
-
Alert to need for reporting adverse events to
VAERS system
·
If vaccine is available, fully activate the
immunization program. (IB with LHDs)
·
Obtain data on antiviral and anti-microbial
supplies. (DCDC, IB)
·
Prepare or update recommendations and plans for
allocation of antiviral and anti-microbial supplies. (DCDC, IB)
3. Emergency Response and Communications
·
Notify EMSA, OES of Pandemic Imminent Stage (EPO)
·
Step up information flow to LHDs, medical providers
and all other stakeholders. (DCDC/EPO,
OPA, EMSA)
·
Update documents and fact sheets based on current
surveillance information. (DCDC, OPA)
·
Post information on web site (DCDC, OPA) and via
Health Alert Network (HAN) to LHDs.
(DCDC, OPA)
·
·
Provide translations of all public information
messages into Spanish and the 14 other major languages in California. (DCDC, EPO, OPA)
·
·
Send notice to hospitals, care providers,
emergency responders. (EMSA, DCDC to
LHDs, EMS Agencies, via HAN)
·
·
Monitor the ability of hospitals and outpatient
clinics to cope with increased patient loads.
(EPO, EMSA)
·
·
Implement health education campaign with emphasis
on the following: (CDC, DHS, LHD, HMOs, EMS Agencies, and medical societies, et
al.)
·
- Hand washing
·
- Stay home rather than be exposed to/spread the
influenza virus
·
- Check on family, friends living alone
·
- Vaccination clinic locations
·
- Signs, symptoms
·
- Vaccine safety and storage
·
·
Implement a telecommuting system so more people
can stay home. (employers, labor
organizations)
·
·
Activate emergency response system. (local Emergency Management Agency [EMA],
OES, DHS/EMSA, EMS Agencies, hospitals)
·
·
Plan for implementation of emergency medical
treatment sites and temporary infirmary locations. (LHD, local EMA, healthcare system in coordination with local
mass-care organizations such as Red Cross, Salvation Army)
·
·
Implement mutual aid or other procedures to
address supply and personnel shortfalls.
(EMA, LHO, RDMHC, DHS, EMSA, OES)
·
·
Conduct inventory of critical supplies/personnel
and solve problems: shortage of supplies (gloves, safety needles, ventilators),
personnel shortage (how to get non-traditional labor pool re-certified or
alternative staff redirected).
(DHS/EMSA)
·
·
Develop plan for counseling/psychiatric
services. (Department of Mental Health,
public and private mental health agencies)
·
·
Develop plans for children orphaned by death of
parents. (Department of Social
Services, public and private welfare agencies)
Pandemic Stage
Further spread of
influenza disease with involvement of multiple continents.
2.
Influenza
morbidity and mortality surveillance systems will likely become
overwhelmed.
·
Continue to monitor selected vital statistics for
mortality and morbidity data received from the inpatient diagnosis surveillance
system to establish age- and geographic area-specific rates. (DCDC influenza team members)
·
Use above data to establish priority groups for
immunization as vaccine availability changes, providing data to CDC, LHDs and
private providers. (DCDC)
·
·
Continue to monitor reports from WHO and CDC on
national and worldwide morbidity and mortality data. (DCDC)
·
·
Discontinue monitoring arrivals at California quarantine
stations and deploy personnel to higher priority pandemic activities. (DCDC)
·
·
Laboratory surveillance will focus on detection
of antigenic drift variants and reassortant viruses that could limit the
efficacy of vaccines produced against the original pandemic strain. Personnel who are not incapacitated by
influenza will be diverted to higher priority pandemic
mitigation efforts. (VRDL)
2. Vaccine and Pharmaceutical Delivery
Continue
all pandemic imminent activities.
Presumably vaccine would be available for a sizable proportion of the
State’s population.
·
Monitor VAERS data for evidence of adverse
reactions to the influenza vaccine. Report findings routinely to DCDC Workgroup
and to CDC. (IB)
·
Modify recommendations and agreements on priority
groups for receiving the vaccine to reflect greater availability of
vaccine. (IB)
·
·
Review surveillance data for changes in risk
factors that could require modification of recommendations for priority groups
for receiving vaccine. (VRDL, IB)
·
·
Monitor availability of antivirals and, when
appropriate, recommend changes in priority groups for receiving vaccine or
antivirals. (CPA, CMA, IB)
·
3.
Emergency
Response and Communications
All
of the activities of the Pandemic Imminent stage and the following:
·
Notify EMSA, OES of Pandemic Stage (EPO)
·
Increase public information effort designed to
keep ill persons at home, providing translations into Spanish and 14 other
languages. (LHO, DHS-DCDC, OPA, health
care providers)
·
·
Distribute masks to public if appropriate. (LHDs
and/or local pharmacies)
·
[E1]If
law enforcement mutual aid system is overwhelmed, request Governor to issue
waiver to allow National Guard and military to act as law enforcement. (OES)
·
·
If medical/health mutual aid system is
overwhelmed, request health care workers from other states, federal
government. (DHS/EMSA via OES)
·
·
Implement emergency medical treatment sites and
temporary infirmary locations as necessary to respond to overwhelming
caseload. (local EMA, LHD, health care
system, mass-care organizations)
Second Wave
1.
Surveillance
Typically
in a pandemic, the number of new cases of influenza peaks and then declines,
giving the impression that the pandemic is over. Then within a few months, influenza incidence once again
increases. State and local officials
and health care providers need to remain vigilant for a return of the epidemic
activity. This is especially difficult
given that all personnel and supplies involved in responding to the epidemic
will be exhausted by efforts to respond to the pandemic. The perceived “end of the pandemic” may be
viewed as an opportunity to relax and recover.
However, all essential functions should
be restored to return to pandemic imminent status.
Vital
statistics personnel who provide the data to DCDC will probably still be
backlogged with reports, but should be encouraged to maintain extra staffing
levels.
All
sources of surveillance data will need to be convinced that their contributions
are still essential because of the likelihood of a second wave. If the decline in the number of cases occurs
outside the normal influenza season, it will be necessary to explain the
importance of maintaining vigilance because the second wave could occur at any
time.
Continue
immunization efforts in lower risk groups as vaccine becomes available.
Laboratory Surveillance. This
essential function should also return to pandemic imminent status while
maintaining surveillance for possible antigenic drift.
V. APPENDICES
i.
Federal Influenza Pandemic Responsibilities
The Federal government
has assumed primary responsibility for the following influenza vaccine-related
activities:
·
Vaccine research and development
·
Coordinating national and international
surveillance
·
Providing guidance on which target groups should
receive vaccine, in priority order
·
Devising a suitable liability program for vaccine
manufacturers and persons administering the vaccine. Liability protection will likely be made available through new
congressional legislation.
·
Developing a national clearinghouse for vaccine
availability information, vaccine distribution and redistribution
·
Developing “generic” guidelines and/or information
templates that can be modified and adapted as needed at the State and local
levels, including: fact sheets and Q & As on influenza, influenza vaccine
·
Strategies and guidelines for interacting with
the media and communicating effectively with public health and medical
communities and the general public
·
Guidelines for triage and treatment of influenza
patients in outpatient, inpatient and non-traditional settings
·
Developing at the national level a central
surveillance system for vaccine-associated adverse events
·
·
In an influenza pandemic, responsibility for
purchase of vaccine will likely be shared between Federal, state, and local
authorities.
·
ii.
Organizational Abbreviations
CDC Centers for Disease Control and
Prevention
CMA California Medical Association
CPA California Pharmacists
Association
DCDC Division of Communicable Disease
Control, DHS
DHS California Department of Health
Services
DISB Disease Investigations and
Surveillance Branch, DHS
EMS Emergency Medical Services
EPO Emergency Preparedness Office,
DHS
IB Immunization Branch, DHS
JEOC Joint Medical/Health Emergency
Operations Center
LHDs Local health departments
OES Office of Emergency Services
OPA Office of Public Affairs, DHS
RDMHC Regional Disaster Medical/Health Coordinator
VFC Vaccines for Children Program
VRDL Viral and Rickettsial Disease
Laboratory, DHS
iii.
State of California Plans and Procedures that Apply to Epidemics
California Disaster and
Civil Defense Master Mutual Aid Agreement
Disaster Assistance
Procedure Manual
Disaster Medical
Response Plan*
Emergency Action Plan
(Cal OSHA)
Hazard Mitigation Plans
Medical/Health Mutual
Aid*
Mental Health Mutual
Aid*
Mutual Aid Regional
Plans and Procedures
Natural Disaster
Assistance Act...Eligibility Guidelines and Claiming Instructions
OASIS** Guidelines
Governor’s Office of
Emergency Services (OES) Operational Recovery Plan
SEMS*** Guidance (i.e.,
ACI, Guidelines, Regulations, Local Emergency Planning Guidance*)
State Agency Disaster
Response Planning Guidelines
State Agency Emergency
Plans (relating to Executive Order/Adm. Orders)
Telecommunications
Plans
* Under development
** Operational Area Satellite Information
System, which may be used to transfer information from counties to the state
*** State Emergency
Management System
Source: California State Emergency Plan, May 1998,
pp. 30-33
iv. Emergency Response Roster
FOR AFTER HOURS EMERGENCIES CONTACT DHS DUTY OFFICER
SACRAMENTO: (916)
262-1621 (OES WARNING CENTER)
BERKELEY: (510)
540-2308
PRIMARY CONTACTS OFFICE
PHONE OFFICE ADDRESS
DIRECTOR, DHS
Bontá, Diana (916)
657-1425 714 P St.,
Sacramento
DEPUTY DIR, PREVENTION
SERVICES.
Reilly, Kevin (Acting) (916)
657-1493 714 P St., Sacramento
CHIEF, DIV. OF
COMMUNICABLE DISEASE
CONTROL
Felten, Jim (Acting) (916)
323-1157 714 P Street,
Sacramento
CHIEF, EMERGENCY
PREPAREDNESS
OFFICE
Abbott, David (916) 323-3675 601 N 7th St., Sacramento
INFLUENZA PANDEMIC
PROJECT LEAD,
IMMUNIZATION BRANCH.
Tran, Mary (510) 540-2065 2151 Berkeley Way, Berkeley
CHIEF, RESPIRATORY,
AIDS, AND SUPPORT
SECTION, VIRAL AND
RICKETTSIAL
DISEASES LABORATORY
Hendry, R. Michael (510)
540-2573 2151 Berkeley Way,
Berkeley
v. Influenza Pandemic Planning Executive
Committee Members
Dave Abbott
Health Program
Specialist II
Emergency Preparedness
Office
DHS
Dean Blumberg, M.D.
U.C. Davis Medical
Center
Christine K. Cahill
Licensing and
Certification
DHS
Wendi Cate
Immunization Branch,
DHS
Barbara Center, R.N.
Region II RDMCH Project
Specialist
Contra Costa Emergency
Medical Services
Nathan Chatman
Immunization Program
Field
Representative
Immunization Branch,
DHS
Karen Furst, M.D.
Health Officer
San Joaquin County Health
Department
Dorel Harms
California Healthcare
Association
Lee Borenstein
Sydney Harvey, Director
Los Angeles County
Public Health Laboratories
R. Michael Hendry,
D.Sc., Chief
Respiratory, AIDS, and
Support Section
Viral and Rickettsial
Disease Laboratory
Sharon Hietala, Ph.D.
Immunologist
California Veterinary
Diagnostic Laboratory
Scott Lewis
Health Program
Specialist II
Emergency Preparedness
Office
Environmental
Management Branch
Stephen Mader, M.D.
U.S. Indian Health
Service
S. Michael Marcy, M.D.
Kaiser Foundation
Hospital
Donna Martin
American Red Cross
Carlo Michelotti
California Pharmacists
Association
Wendy Dodgin
Linda Pryor
Emergency Services
Coordinator
Office of Emergency
Services
Planning and
Technological Assistance Branch
Richard Rios
Fresno County Health
Department
Jon Rosenberg, M.D.
Disease Investigations
and Surveillance Branch, DHS
Jeffrey L. Rubin
Division Chief
Emergency Medical
Services Authority
Disaster Medical
Services Division
Mark Sawyer, M.D.
University of San Diego
Verdie Thompson
Director of Nursing
Berkeley Public Health
Department
Karen Tracy, R.N.
Indian Health Program,
DHS
Mary Nelson Tran,
Ph.D., M.P.H.
Immunization Branch
Laura J. Venegas
Disaster Medical
Specialist
Emergency Medical Services
Authority
Disaster Medical
Services Division
Stephen H. Waterman,
M.D., M.P.H.
Medical Epidemiology
Liaison to DHS Office of Binational Border Health, CDC
* The Disaster Policy Council is comprised
of the executive staff of the department. The Council acts as an advisory body
to inform the Director of the status of the Department’s disaster response. The
Council is also responsible to formulate the high-level policy decisions that
govern the department’s response and recovery activities. Department of Health Services Emergency Plan.
[E1]Should the normal supply system such as pharmacies be used here instead of the LHD?