PLAN FOR SOUTH CAROLINA’S RESPONSE
TO AN INFLUENZA PANDEMIC
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THE NEXT
INFLUENZA PANDEMIC UNFOLDS…………………………. |
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I. |
COMMAND,
CONTROL, AND MANAGEMENT PROCEDURES………. |
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II. |
SURVEILLANCE…………………………………………………………….. |
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III. |
VACCINE AND
ANTIVIRAL DELIVERY…………………………………… |
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IV. |
EMERGENCY
RESPONSE………………………………………………… |
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V. |
COMMUNICATIONS…………………………………………………………. |
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APPENDICES |
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The next influenza pandemic unfolds ...
An outbreak of unusually severe respiratory illness is identified
in a small village in South China. At least 25 cases have occurred, affecting
all age groups; 20 patients required hospitalization at the local provincial
hospital, 5 of whom died from fulminant pneumonia and acute respiratory
failure. Surveillance in surrounding areas increases, and new cases begin to be
identified throughout the Province. Viral cultures collected from several of
the initial patients are positive for type A influenza virus, but cannot be
further subtyped by the Provincial or national laboratory with available
reagents. The isolates are sent to the World Health Organization (WHO)
Reference Center for Influenza at the Centers for Disease Control and
Prevention (CDC), Atlanta, for further characterization. CDC determines, using
special reagents, that the isolates are type A H7N1, a subtype never before
isolated from humans. This information is immediately transmitted back to the
Chinese Ministry of Health, and throughout the WHO network. CDC dispatches a
team of epidemiologists and laboratory personnel to further study the
epidemiologic and clinical features of the disease, and notifies quarantine
stations and large hospitals at major U.S. ports of entry to be on the alert
for arriving passengers with severe respiratory illness. Isolates of the new
H7N1 strain are sent to the FDA to begin work on producing a reference strain
for vaccine production, and influenza vaccine manufacturers are placed on
alert. The novel influenza virus begins to make headlines in every major
newspaper, and becomes the lead story on major news networks. Key U.S.
government officials are briefed on a daily basis as surveillance is
intensified throughout Southeast Asia and the Pacific Rim.
Over the next two months, outbreaks begin to appear in Hong Kong,
Singapore, South Korea and Japan. Although cases are reported in all age
groups, young adults appear to be the most severely affected, and case-fatality
rates approach 5%. Widespread panic begins because vaccine is not yet available
and supplies of antiviral drugs are severely limited. Several weeks later, the
CDC reports that H7N1 virus has been isolated from ill airline passengers
arriving from Hong Kong and Tokyo in Los Angeles, Honolulu, Chicago and New
York. States and local areas are asked to intensify influenza surveillance
activities and vaccine manufacturers are requested to go into full production.
A few more weeks pass and focal outbreaks begin to be reported
throughout the United States. Rates of absenteeism in schools and businesses
begin to rise. Phones at physician offices and health departments begin to ring
constantly. The media reports exaggerated accounts of illness. Citizens begin
to clamor for vaccine, but only 10% of the estimated needs are available.
Police departments, local utility companies and mass transit authorities begin
to have severe personnel shortages, resulting in severe disruption of routine
services. Hospitals and outpatient clinics become severely short-staffed when
physicians, nurses and other health-care workers become ill. Elderly patients
with chronic, unstable medical conditions are afraid to venture out for fear of
becoming seriously ill with influenza. Intensive care units at local hospitals
become overwhelmed, and soon there are widespread shortages of mechanical
ventilators for treatment of patients with pneumonia. Family members are
distraught and outraged when loved ones die within a matter of a few days.
Looting becomes a serious problem in major metropolitan areas due to shortages
of police officers. Several major airports close because of high absenteeism
among air traffic controllers. Further deterioration in health and other
essential community services occurs over the next 6-8 weeks as illness sweeps
across the country ....
Are you and others within your
jurisdiction prepared?
I. COMMAND,
CONTROL AND MANAGEMENT PROCEDURES
(“CONCEPT
OF OPERATIONS”)
A.
Command and
Management during a Pandemic
While the SC Emergency Operations Plan
should be the basis for our Pandemic Plan, influenza pandemics present certain
special challenges that must be addressed specifically, e.g. a special
surveillance system, rapid delivery of vaccines and antiviral drugs and a plan
for prioritization of recipients, legal authority to allocate these
appropriately, etc. These unique aspects of an influenza pandemic should be
addressed in an Annex to that SC EOP.
Environmental
Control in concert with the Director of Emergency Preparedness Division (EPD)
and the Deputy Commissioner for Health, will designate a Pandemic Influenza
Response Management Group (“Pandemic Response Group”, PRG) consisting of the
following persons or their designees:
State Epidemiologist (Chair), representative of Emergency Preparedness
Division (EPD), representative of the Governor’s Office, State Laboratory
Director, Director of DHEC Immunization and Prevention Branch, two DHEC
District Health Directors (DHDs), representative of SC Hospital Alliance (SCHA)
, representative of SC Medical Association (SCMA), and the DHEC and/or EPD
Public Information Officer.
Physicians by medical specialties, physicians volunteering for
disaster service, infection control practitioners, district epi-teams, acute-care
hospitals, chronic-care hospitals, federal and military hospitals, skilled
nursing facilities, clinical laboratories and laboratory directors, National
Guard medical units, DHEC health district offices, state emergency response
regional offices, county emergency preparedness directors, county coroners and
medical examiners, funeral homes and morticians, pharmacies by whether
certified to give immunizations, members of state Rapid Response Teams, DMAT, and DMORT Teams
Because the antigenic properties of influenza viruses are
constantly changing, both virologic surveillance -- in which influenza viruses
are isolated for antigenic and genetic analysis -- and disease surveillance --
in which the epidemiologic features and clinical impact of new variants are
assessed -- should be viewed as equally critical for pandemic preparedness.
In the United States, international influenza surveillance
activities are coordinated at the CDC by the WHO Collaborating Center for
Influenza Reference and Research. The
CDC participates in WHO's global influenza network with approximately 110
national laboratories in over 80 countries and four International Reference
Centers. The CDC maintains frequent
communications with WHO Headquarters in Geneva, with the other three WHO
International Reference Centers, and with national laboratories worldwide
concerning the numbers and types/subtypes of influenza viruses isolated and the
extent of influenza like disease which taking place at the time of virus isolation.
A.
National
Surveillance
National surveillance in the U.S. is also coordinated by CDC, with
State and county health departments assuming primary responsibility for
carrying out virologic, mortality, and morbidity components. These activities
currently c
uenza-like
illness (ILI) per total number of patient visits by age group each week; (4)
Vital Statistics Offices of 122 U.S. cities which report, each week, the
percentage of total deaths caused by influenza and pneumonia (ICD-9 codes
480-487); and (5) a variety of other sources which spontaneously report
influenza outbreaks or other influenza-associated events.
B.
Routine
Influenza Surveillance Activities in South Carolina
1.
Physician
Reporting - Influenza-like illness (ILI) is one of the mandated reportable
conditions in South Carolina; reporting is required by number only. ILI reports, along with the Source County of
the report, are entered into the disease surveillance data set and transmitted
weekly to the CDC via the National Electronic Telecommunications System for
Surveillance (NETSS). Physician
participation in this passive reporting system is generally poor.
2.
Viral
isolates - The DHEC Division of Laboratories (DOL) is capable of performing
influenza viral isolation and typing and subtyping for influenza A
isolates. They also perform influenza
serodiagnosis by complement fixation testing of acute and convalescent
sera. DOL is currently the only
in-state diagnostic lab that offers viral isolation. Some out-of-state commercial labs may perform viral isolations
for South Carolina physicians.
Laboratories are also required to report influenza isolates and
serologies to DHEC, and these like ILI reports are transmitted to CDC via
NETSS.
3.
Sentinel
Surveillance Sites
a)
DOL
coordinates the Influenza Surveillance Program for the 70 participating
sentinel physicians, colleges, hospitals and local health departments. Sites submit clinical samples for viral
isolation and typing. There is
currently about 1 sentinel site per 50,000 population, which exceeds the
national recommendation to establish one sentinel site per 250,000
population.
b)
The DHEC
Acute Disease Epidemiology Division has established a sentinel surveillance
system for influenza in 65 elementary schools throughout the state (five
schools in each of the 13 Health Districts).
Each week the participating schools fax reports that are compiled by the
surveillance coordinator who monitors absenteeism looking for rates of 10% or
greater lasting for several days.
Influenza is almost unique as a cause for high workplace and school
absenteeism and this surveillance system therefore provides our most timely and
geographically representative information about influenza circulation in the
state.
C.
National activities to enhance surveillance
1.
Improve
“early warning” and “readiness” capability - Although the basic influenza
surveillance infrastructure in the U.S. has generally been adequate to monitor,
on a "macro" level, the spread and impact of "drifted"
strains, the sensitivity of detecting an isolated importation event is
generally poor. There is a need to
enhance our surveillance activities to improve our ability to detect
importation and initial spread of novel variants emerging from other countries.
2.
Ability to
rapidly expand surveillance activities - Contingency plans for rapid expansion
of the basic surveillance systems are necessary to provide the level of detail
necessary to track the spread and impact of a pandemic variant in State and
local communities and to modify control measures as needed.
3.
Improved
ability to detect the emergence of novel variants in the U.S. - Although most novel strains of influenza
(pandemic variants) have emerged from China and the Pacific Rim, such variants
could arise in the U.S. Efforts are now
underway at the national level and in selected States to examine the potential
for highly pathogenic avian strains that are detected on poultry farms
nationwide and among live bird markets to be transmitted to humans. CDC is also
collaborating with USDA to determine if influenza viruses are being transmitted
to humans from infected swine and horses during outbreaks of influenza-like
disease in domestic farm animals.
DURING THE PRE-PANDEMIC PERIOD:
A.
Improve
virologic surveillance capability - The DHEC DOL can identify and type
influenza viruses and perform influenza A subtyping. It is estimated that DOL’s viral isolation capacity is about 100
isolates per week. The primary
limitation is the availability of tissue culture media, which would have to be
ordered two weeks in advance of the need.
Tissue culture could become limited in the event of a pandemic. As the use of antiviral agents for the
treatment and prophylaxis of influenza increase laboratories should address
their capability to conduct testing and surveillance for resistant viral
strains.
B.
Enhance
Disease-based surveillance capability
a.
District Epi
Teams will appoint an influenza surveillance coordinator in each district. Each surveillance coordinator will be given
a copy of the plan and information about influenza surveillance enhancements. In the event of a novel virus alert this
person will assume responsibility for supporting the enhanced surveillance
activity in their district. They will
maintain communications with local disease reporters, serve as contacts for
receiving surveillance data from additional reporting sites, and locally
disseminate surveillance data. This
responsibility will be delegated in advance and back-up personnel will be
identified in the event of staff absences.
b.
During any
stage of influenza transmission clusters of upper respiratory ILI will be rapidly
investigated and swabs for viral isolation will be collected to confirm or rule
out influenza. For influenza confirmed
outbreaks the population at risk, attack rate, and vaccine efficacy, if
applicable, will be defined. For those
outbreaks involving institutions education about future prevention will be
provided.
a.
Travelling
military personnel may be a potential source of importation of novel influenza
strains. Contacts will be established and
maintained with the preventive medicine and hospital epidemiology programs at
the state’s three military hospitals: Moncreif Army Community Hospital, Ft.
Jackson, Shaw Air Force Base Hospital, and the Naval Hospital in Charleston. Military medical facilities maintain their
own disease surveillance systems.
Standard, routine reporting systems should be established between these
facilities and DHEC. This data should
be included in the statewide surveillance data.
b.
Emergency
Departments and Managed Care Organizations should be included in the enhanced
surveillance activities. Department
heads affiliated with these should receive the annual communications described
above that will be sent to private practice physicians.
c.
The Catawba
Health District has initiated sentinel surveillance for influenza based in
nursing homes in the district. In this
system DHEC provides influenza isolation kits to participating facilities and a
point of contact for reporting clusters of ILI to DHEC has been
established. Other districts have been
encouraged to develop similar systems.
d.
Death
Certificate Data – DHEC will request that the Office of Vital Records and
Public Health Statistics generate a data set containing deaths coded as
attributable to P and I. (ICD-9 codes 480-487). The Board of Funeral Directors will be involved to emphasize the
importance of timely and accurate completion of death certificates to enhance
influenza mortality surveillance.
e.
Contacts
will be established with state airports and shipping ports to develop plans for
how to monitor for the possible importation of ILI in the event of the
identification of a novel strain.
C.
Develop
enhanced electronic and telecommunications capability for compiling,
transmitting and disseminating data.
This enhancement should address the handling of data at several
levels:
1)
Data
transmittal within DHEC can be improved.
The DHEC Division of Acute Disease Epidemiology is pilot testing an
electronic data transmittal of influenza viral isolation data from the DOL to the
Acute Disease Epi Division. This data
is now used as a reference but if the pilot is successful, information about
circulating strains could be transmitted electronically to each health
district. Health districts could them
more easily distribute data to their local reporting partners. Improved dissemination of influenza data
would better serve health care providers at the local level and would probably
stimulate additional reporting. The
electronic data could also be compiled in weekly summary reports.
2)
As much as
possible all providers should be included in the surveillance communications
loop. Weekly summary reports of flu
activity could also be distributed by local health departments to physician
offices, hospitals ICPs, sentinel schools, nursing homes, health care centers
in universities and in industry, and to health departments of neighboring
states. Reports could be posted on the DHEC Web site.
3)
DHEC DOL has
the capability to maintain a statewide lab users group linked by e-mail to
enhance communications among laboratories.
D. Animal surveillance – Those
in the state with expertise to monitor for avian, swine, and equine influenza
should develop plans to monitor for clinically consistent clusters of illnesses
in these animal groups and be vigilant for the potential for interspecies
transmission. The State Veterinarian
should coordinate this with the Clemson Livestock and Poultry Lab and the State
Public Health Veterinarian at DHEC.
DURING THE NOVEL VIRUS ALERT:
A.
DHEC Acute
Disease Epi Division will monitor bulletins from CDC regarding virologic,
epidemiologic and clinical findings associated with new variants isolated
within or outside the U.S.
B.
DHEC DOL
will obtain appropriate reagents from CDC to detect and identify the novel
strain if it is found to have the potential for sustained transmission in
humans. If other medical centers have
developed the expertise for viral isolation, the influenza kits will also be
distributed to all these sites. If
viral isolation capability is not widely available, state and local hospital
labs will be encouraged to stock and use rapid antigen tests. DOL will perform viral isolations to monitor
the circulating strains in South Carolina and to detect any antigenic drift or
shift in circulating strains. The H and
N types identified will be submitted to CDC.
C.
The
appropriate partners and stakeholders in the pandemic influenza planning will
meet within 2 weeks of the novel virus alert and review major elements of
enhanced surveillance activities and modify and update plan as needed.
D.
To detect
possible importation and local spread, the enhanced surveillance activities
described above that have not already been implemented will be activated. Those participants in enhanced surveillance
will be notified to begin weekly reports to the identified points of contact on
the District Epi Teams. Data about severe respiratory illness and unexplained
deaths should be captured from local hospitals and nursing homes. Surveillance for severe respiratory
illnesses among travelers from geographic areas in which the novel strains have
been isolated should be conducted.
Plans that have been put in place with South Carolina airports,
airlines, and commercial and passengers shipping lines will be implemented by
contacting the responsible parties with those entities. All surveillance data will be transmitted to
CDC via NETSS.
E. To keep communities informed and to prevent
the dissemination of misinformation, media representatives should be involved
in designing a plan for the collaborative dissemination of regular, relevant,
and timely surveillance data to the general public from an official source.
DURING THE PANDEMIC ALERT:
DHEC has broad authority to implement the
enhanced surveillance activities described above and to change reporting
requirements to conduct adequate surveillance in the event of a pandemic flu
alert. Regulation 44-1-80 states: “The Board of Health and Environmental Control…shall
investigate the reported causes of communicable or epidemic disease and shall
enforce or prescribe such preventive measures as may be needed to suppress or
prevent the spread of such diseases by proper quarantine or other measures of
prevention, as may be necessary to protect the citizens of the State.”
A.
In the event
of a pandemic flu alert, DHEC would change to designation of influenza to an
urgently reportable condition.
Providers will receive notification of this change by DHEC
communications with the Medical Association, Hospital Association, local
medical societies, and special mailings.
DHEC would request daily reporting of the total number of P and I
patients and total number of patients seen at emergency departments and large
primary care practices. The designated
influenza surveillance coordinators of the District Epi Teams would assume the
responsibility to be reassigned to specifically conduct and maintain enhanced
surveillance activities.
B.
Fully
activate enhanced surveillance activities; assess functionality, timeliness and
completeness of reporting (including "zero case" reporting), data
entry and dissemination, and links and feedback at higher and local levels of
the system. Include age group at each surveillance site; and characterize the
denominator to have a better idea where to utilize vaccine.
C.
Include
airlines and airports in surveillance of persons travelling from geographic
areas in which the novel strains have been isolated.
DURING THE PANDEMIC IMMINENT STAGE:
A.
Implement
and pilot-test final modifications, if any, in enhanced surveillance system.
Monitor the ability of hospitals and outpatient clinics to cope with increased
patient loads,
B.
In
collaboration with CDC and other groups at the national level, consideration
would be given to any special studies that could be conducted without further
compromising the anticipated limited resources. Special studies might include some of the following:
1)
collecting
data to document outbreaks of influenza in different population groups
2)
determining
age-specific attack rates, morbidity and mortality
3)
working with
health care providers and pathologists to collect data about any unusual
clinical syndromes associated with influenza infection (as well as risk factors
for those syndromes and appropriate treatment), or unusual pathologic features
associated with fatal cases
4)
conduct
efficacy studies of vaccination or chemoprophylaxis
5)
assess the
effectiveness of traditional control measures such as school and business
closings
Since its development more than 50 years ago, influenza vaccine
has been the cornerstone of influenza prevention and control. Vaccination will
also serve as the central preventive strategy during the next pandemic.
The World Health Organization (WHO)
collaborating influenza centers detect and monitor new variants of influenza
virus throughout the year for potential inclusion in the next year's vaccine.
Vaccine strains are chosen by spring. The four licensed U.S. manufacturers make
~70-80 million doses over the winter through summer months and the vaccine is
administered, primarily to "high risk" patients (as currently defined
by the Advisory Committee on Immunization Practices), from September through
January. Approximately 90% of all doses are administered through the private
sector, with most States and counties offering relatively small amounts of
vaccine through publicly funded programs. This system has served the American
public well -- with record levels of vaccination coverage during the 1990's--
and continues to improve over time.
Despite our ongoing improvements in the
manufacturing and delivery of annual flu vaccine the next pandemic will pose a
number of challenges, particularly to State and local health departments which
clearly must serve as the "linchpin" of vaccination delivery efforts:
·
The target
population for vaccination will be expanded far beyond the typical
"high-risk" groups to encompass, ideally, the entire U.S. population.
·
The
"warning period" preceding spread of the pandemic strain in the U.S.
is likely to be relatively short, so that vaccine will have to be distributed
and administered as rapidly as possible.
·
It is likely
that a severe and/or moderate vaccine shortage will exist, especially early on
during the course of the pandemic. Moreover, it is possible that no vaccine
will be available.
·
The
emergence of a pandemic strain will likely require a second dose of vaccine ~30
days later.
It is likely that the public sector will
take responsibility for vaccinating health care workers, other "first
responders", certain essential community servants, and the poor and the
uninsured.
Success of the pandemic vaccination program
will be determined in large part by the strength of State and local vaccination
programs during the inter-pandemic period.
Public confidence in the benefits of influenza vaccine must continue to
improve, and there must be increased emphasis on the use of pneumococcal
vaccine. Current coverage levels among high-risk persons are only 15-45% for
pneumococcal vaccine and 27-65% for influenza vaccine. To ensure more routine
acceptance of influenza vaccine, consideration should be given to expansion of
immunization promotion activities, to include media involvement. If additional
public funds are available to purchase and administer pneumonia vaccine, these
should be targeted to reach persons in “high-risk” groups, including those
under age 65 with chronic medical conditions.
1.
All persons
will be susceptible
2.
Due to vaccine
shortage, a priority list of vaccinees will need to be developed and adhered
to.
3.
One month’s
supply of vaccine will cover at most 20% of the state’s population.
4.
At least the
first month’s supply of vaccine will be purchased federally and distributed to
the states.
5.
All vaccine
available to the state may arrive via a single allotment.
6.
Two doses of
vaccine will be required per person vaccinated
7.
There may be
up to 40% attrition of essential personnel in the health care delivery sector.
8.
Vaccine
delivery will take priority over antiviral delivery.
9.
Federal
government’s stated responsibilities during a pandemic will be fulfilled, to
include point #4
Goals (in order of priority)
1.
Efficient
and rapid allocation, distribution, and administration of vaccine to officially
designated high priority groups
2.
High rates
of second dose completion (target 80% of high priority groups)
3.
Prompt
reallocation and redistribution of unused vaccine (though there may be little
or none)
Vaccine Delivery
Responsible Authority: DHEC Division of
Immunization. Will be responsible for:
1.
Command and
Control Functions, including:
·
Assurance of
redundancy
·
Communication
within the overall pandemic command
structure
·
Assurance of
legal authority for pandemic immunization activities
(Statute 44-29-210: Physicians, registered
nurses and certain authorized public health employees participating in mass
immunization projects exempt from liability)
·
Coordination
of vaccination activities with neighboring states and with groups such the VA
hospitals, IHS, military installations, etc.
2.
Acting as a
center for vaccine inventories and distribution
3.
Maintaining
supplies of federally distributed vaccine in central and ancillary storage
facilities.
Ultimate responsibility for above would
rest with a “vaccine controller” who, along with a designated back up in case
of illness, would oversee distribution of available vaccine and verify that
vaccine is being provided to priority groups.
The Immunization
Division has already stated its willingness to purchase vaccine during a
pandemic for use by both the public and private sector. The amount obtained will need to be
increased far above the current levels of influenza vaccine purchase; however,
the ability to purchase vaccine may be limited by shortages of supply (though
all states likely to receive some doses of vaccine), available storage, and the
amount of supplementary Federal funding available. The purchase of vaccine
using state funds may not be necessary until the second month of a pandemic and
may NOT be an option due to lack of vaccine availability.
Health Department vaccine purchase will
need to take priority over private sector purchase in a vaccine shortage
scenario. The possibility of vaccine reallocation to the private sector AFTER
priority public health activities have been accomplished should be anticipated.
This would best be accomplished by using the existing VAFAC vaccine
distribution network.
There should be a standing group of
advisors to the governor’s office to determine lists of priority groups for
vaccination. The proposed structure will be similar to that of a hospital
ethics board. The “Vaccine Priority Group” (VPG) will need to acknowledge that
their decisions center around potentially conflicting values and that a key
question to address will be “What are we hoping to prevent?” (Death, serious
illness, overall burden of illness, economic and productivity loss) The
advisory group should be broadly representative and should include
epidemiologists, other public health officials, ethicists, the faith community,
representatives of the medical community, business, law enforcement,
transportation, and citizens. The body’s makeup will be determined in advance
of the pandemic. The planning process should be presented to legislators.
The advisory group should generate more
than one plan for vaccine prioritization based on at least three scenarios:
severe or moderate vaccine shortage or no vaccine shortage. Several lists of
priority groups should be developed, rather than a single one, since the
epidemiologic characteristics of a pandemic strain cannot now be predicted. If
spread proceeds West to East, information about what population groups are at
highest risk will likely be available. It should be acknowledged that the order
of priority may change when the characteristics of the pandemic strain are
better defined. Decisions must involve overall pandemic command/control
structure.
“Essential service
workers” will be defined and prioritized as part of the above process; examples
identified from both planning workgroups include health care workers, EMS,
essential public service personnel such as public utility workers, police and
fire personnel, utility workers and public and private transportation workers.
Very specific lists of personnel will need to be developed and prioritized with
input from all parties so that no essential community workers are overlooked
and “fall between the cracks”. For example, severe illness among funeral
service personnel could have severe consequences for public morale and
potentially for the public’s health as well. Within priority groups, highest
priority subgroups should be identified, since vaccine shortages may preclude
immunizing all of the state’s 100,000 emergency responders and health care
personnel. Consideration should also be given to administration of vaccine to
elementary, secondary, and post-secondary school students, who number almost a
million in South Carolina and who may serve as points of entry for disease into
the community.
Resources for determining priority list for vaccination:
·
Federal
guidelines and published research
·
Surveillance
data on novel strain (CDC, WHO, DHEC
Division of Epidemiology)
Suggested
priorities for vaccine administration given limited supplies are the following:
(Also see Appendices A & B)
1)
First dose
for all high priority groups
2)
Second dose
for all high priority groups
3)
Private
sector, with first administration to high priority groups (possibility may
exist that sufficient supplies will be only enough to provide one dose for high
priority individuals, and that there will be no “supplementary” vaccine
available for private sector use.)
Sample criteria
for release of vaccine to the private sector have been developed; the
feasibility of adhering to and enforcing such criteria during a pandemic is
uncertain.
A single dose
vaccine strategy may need to be considered by the VPG if vaccine is in extremely
short supply, in the interest of protecting more persons in priority and/or
high risk groups.
An executive order on vaccine priority
from the Governor’s office would follow recommendations of the standing
advisory group. The priority list should be publicized once generated. Though
some advance notice to public of who priority groups are and how decision was
made will be necessary, shipment of vaccine to sites and administration of flu
vaccine should be “unannounced” to the extent possible.
Vaccine Allocation, Distribution, and Selection of Sites for
Vaccine Administration
Control of
vaccine distribution by DHEC Immunization Division will help to insure
equitable distribution to priority groups regardless of income or access to
care and will also facilitate distribution of vaccine to essential community
servants. All public sector vaccination would occur under DHEC auspices, but
not necessarily exclusively through DHEC staff and facilities
DHEC currently
distributes approximately 65,000 doses of flu vaccine annually to public health
departments. Coverage of 20% of the population with two doses of vaccine would
involve provision of between 1.5 and 2 million doses of vaccine within a 2
month period. (See Appendix D) It is anticipated based on CDC estimates that
only about half of this number of doses will initially be available; up to 80%
of vaccine, and possibly ALL vaccine during the first month, will need to be
provided by the public sector. The Division of Immunization estimates that at
least two weeks would be necessary for vaccine distribution to all providers.
Distribution to all DHEC Health Districts may be feasible within a shorter
period of time.
Shipping of vaccine-related supplies,
obtained either from inventory or via purchase, should be an integral part of
vaccine distribution plans. County Health Department supply inventories are
unlikely to be adequate for mass vaccination campaigns.
Prior to a
pandemic, contact should be made via established distribution channels such as
VAFAC to 1) address vaccine distribution policy during a pandemic and 2)
provide an information packet regarding vaccine storage, administration, and
security under pandemic conditions. This information packet should also be
distributed during the pre-pandemic period to all county health departments,
and it should be ensured that this information resides with more than one
person per county and that redundancy of knowledge and responsibility for
pandemic activities is present locally.
In-person or distance learning can be used to supplement pandemic
preparedness at the county health department level. (VIS distribution, if
required, will need to wait for approval/distribution of this statement at the
federal level)
Potential threats to vaccine supplies
include theft and improper diversion; either could result in “black markets”. Security and oversight will be needed
at all points in the supply and distribution chain if DHEC is to be the sole
recipient of pandemic strain vaccine. DHEC Bureau of Disease Control staff will
aid county health departments in generating estimates for doses of vaccine
needed for high priority groups. Division of shipments will likely be needed
due to vaccine shortage and will guard against an entire county’s shipment
being lost to malfeasance. “Dummy shipments” are one potential security
strategy to guard against vaccine theft, however there may not be personnel to
spare for such decoys. Groups likely to be key participants in securing vaccine
include National Guard units and highway patrol. The “chain of evidence”
concept used in forensic investigations may be a useful strategy, especially
since documentation of maintenance of the “cold chain” is already required for
all vaccines. It will also be necessary to ensure that the distribution system does
not break down because of failure to immunize key groups of workers.
Manpower
limitations may make preferable shipment of vaccine to the 13 Health Districts
rather than individual counties, with the District Health Director (DHD)
responsible for developing distribution plans for individual counties. The DHD will need to make arrangements for
an alternate person or persons to implement this activity in case of illness.
Security will be needed by county health departments, since they may serve as
centers for reallocation of unused vaccine to local providers, possibly through
distribution networks such as VAFAC (500 practices which serve as primary
immunization sites for children 0-18 years of age).
County health
departments should consider distribution points such as police or fire stations
or mobile vans to target specific groups of high priority workers. Since most
hospitals are part of VAFAC bringing vaccine to hospitals for their health care
workers is a logical plan. If clinic sites other than the health department are
deemed necessary or preferable, local law enforcement should be sought as
partners to help determine sites that can be secured. Buildings that already
have security infrastructure, such as courthouses, jails, prisons and some schools
should be identified as potential sites for vaccine administration.
“Convenience sites” where high priority persons are likely to be present, such
as public or private clinics with days designated for care of pregnant women,
Federally Qualified health centers, and nursing homes, should be sought out.
Use of these sites for vaccination may be preferable to asking persons to
congregate in armories, schools, and churches where transmission of illness may
be promoted. Local government may need to ensure “eminent domain” and other
legal authorities, though a community-wide cooperative effort is obviously
preferable to coercion.
Many health care and
other work sites already use place of employment as site for immunization.
During the interpandemic period, outreach strategies for high priority groups
including essential service workers should be part of ongoing efforts to
improve adult immunization levels:
·
Targeting of offsite employees at health care and other facilities
·
Going to the employees actual work location and immunizing “on the
fly” may be preferable since this avoids congregating potentially infectious
persons together.
·
Recognize that healthy working adults can be a difficult to
immunize group; aggressive outreach campaigns may result in only 30-50% annual
coverage of employees.
·
Occupational Health outreach to industries for flu immunization; if
already established, will facilitate immunization of workers in identified high
priority industries
·
Most fire, police, etc. have contracts with medical care providers
for provision of preventive and other services. Such established mechanisms can
facilitate immunization of essential community workers
Pharmacies can also be used as vaccine
administration centers, particularly in rural communities that lack other
medical infrastructure (Pending legislation would permit pharmacists to provide
immunizations; this would be of potential benefit for the pandemic planning
effort). Other potential immunization sites include churches and schools of
nursing.
Review and modification of the vaccine
distribution plan with state and local immunization partners will be undertaken
periodically as needed and during the “novel virus alert” stage.
Vaccine
Storage, Administration, and Mass Vaccination Strategies
Local health departments
need to plan for increased personnel needs related to vaccine administration,
taking into account that their ranks will likely be thinned by illness.
Depending on availability, “alternate”
vaccine providers such as health profession students and trained lay persons
may be utilized. Volunteer recruitment and training plans may need
modifications for the special circumstances of a pandemic. (For example
“orientation periods” will likely need to be eliminated or shortened)
Non-essential health department activities as defined locally may need to be
suspended and personnel diverted into vaccine administration and record
keeping. Available personnel (esp. admin) could be used for sign-in and data
entry, even if unable to give shots. Non-essential personnel of health dept
(and possibly private health sector as well not part of the vaccine effort and
not in high priority groups could be furloughed, reducing their risk of
catching or spreading influenza. Expansion
of current standing orders for influenza vaccine administration prior to a
pandemic event may lessen the burden of paperwork.
County health
departments will also need to insure adequate and safe storage for vaccine and
associated supplies. Use of refrigerated tractor-trailer vans stationed at
hospitals is one storage scenario, though they will require 24 hour security
and may not be available if excess storage is required for large numbers of
deceased persons. Though state Immunization Division of DHEC will be
responsible for provision of tracking software (PATS), local jurisdictions will
need to coordinate with local and state resources to insure adequate manpower
for their use. Decisions on which key vaccinee data to capture will be made
centrally; local jurisdictions will be responsible for providing manpower for
data entry.
Vaccine teams would
consist of one person to sign in, one to draw up vaccine, one to administer
vaccine, and a 4th person, for minimal data entry. Using this
“station” approach it is anticipated that the time for vaccine administration
could be reduced from the current estimate of 6 minutes per vaccinee. All
personnel involved in above “teams” should be immunized.
Use of multi-dose
injectors (if technically and legally feasible) is one strategy for increasing
efficiency of mass vaccination efforts. If available every attempt should be
made to share this technology equitably with all public vaccine administration
centers. If the Division of Immunization anticipates use of this technology, a
rank order priority list of sites will need to be developed if there is a
shortage of jet injector guns.
Small-scale surveys indicate that most
health plans would provide assistance in vaccinating members and non-members,
provide manpower and funding for immunization, convene vaccination clinics, and
coordinate activities with local public health. Liaison with health insurance
companies and managed care plans is most likely to be practically accomplished
at the state rather than local level; there are already public/private
partnerships for other public health activities such as CAUSE (Careful
Antibiotic Use Campaign). One approach would be the designation of a single
individual (with at least one designated backup) who would serve as the point
of contact for pandemic activity coordination with DHEC. Another small survey
of family practitioners indicated that a majority were willing to see
additional patients and/or volunteer for public mass programs, and that the
vast majority did not expect to use usual commercial sources for their vaccine
supply. This suggests that county health departments should plan joint
activities in advance with local hospitals, medical societies, and practices
and maintain a written Pandemic Activities Cooperation Plan that is
periodically updated.
Tracking of # vaccine doses given and #
separate persons vaccinated are key variables. Tracking will require
data-sharing and close cooperation between DHEC Divisions of Immunization and
Epidemiology.
Use of current “VACMAN” program to track
vaccine doses is one way to monitor equitability of distribution. Existing
software (PATS) should be used whenever feasible to track second dose delivery
in public health clinics. Access of mass vaccination teams to laptop computers
for data entry should be assured. A roster type system can be used as a back
up.
Ideally, the vaccine administration
database could track adverse reactions and provide a reminder/recall system for
second dose administration; the priority activity, given limited administrative
resources, should be reminder/recall. The national VAERS system is already in
place for reporting of adverse vaccine-associated events, though underreporting
occurs and would almost certainly worsen during a pandemic.
Electronic recording and transfer of data
from local to state level should be used whenever possible. When this is not technically feasible, a
written protocol regarding vaccine information transfer should be in place
which specifies responsible sending and receiving parties, information to be
shared ROUTINELY, and mode of transmission of information .The use of couriers
is NOT recommended as this does not represent a good use of state resources and
poses security concerns. Data entry is conceived of as a local function and
data analysis as a centralized one. In conjunction with overall pandemic
planning communication activities, an electronic network will be established to
link immunization sites, disseminate information, and track inventory.
The feasibility of tracking all doses
given in the private sector is uncertain, but this would help to provide a more
complete picture of vaccination coverage and could provide some degree of
assurance that vaccine was being used for persons in high priority groups.
Tracking and utilization databases will be
a key component of post-pandemic evaluation of the state’s disease prevention
efforts. A summary report with recommendations for future mass vaccination
efforts will be compiled and distributed to all public and private vaccine
partners. Responsibility for this will reside at the state government level.
Management of vaccine-associated adverse reactions
1.
Immediate
care
These include the
possibility of serious reactions such as anaphylaxis in egg/poultry allergic
persons, needlesticks to HCW’s, and possible allergy to latex
“Sign in” function during
mass vaccination should include screening questions about allergies and
obtaining consent
2.
Long-term
issues (medicolegal liability etc.)
State law (Statute 44-29-210) exempts
physicians, registered nurses and certain authorized public health employees
participating in mass immunization projects from liability except that arising
from gross negligence.
Involvement of State Attorney General will be important for
determinations such as:
1. The applicability of the
National Vaccine Compensation Act to mass vaccination campaigns.
2. The medicolegal
implications of rationing the vaccine, including potential liability claims
against the “vaccine priority
decision group” arising from persons or groups not designated for vaccination.
ü In the event of a pandemic, refusal of
people in recommended/required groups to be vaccinated is likely to be much
less of a problem than requests/demands from persons in low priority groups for
limited supplies of vaccine.
3. Legal authority for institution of specific disease control
requirements for health care institutions. (Example: since influenza has great
potential for spread within health care settings, mandatory influenza
immunization could be justified.)
The antiviral agents amantadine and
rimantadine interfere with the replication of type A influenza viruses. Many
studies have shown both drugs to be 70%-90% effective in preventing illnesses
caused by a wide variety of naturally occurring strains in both children and
adults; most experts believe that similar levels of efficacy can be achieved
with pandemic strains. Amantadine and rimantadine can also reduce the severity
and duration of signs and symptoms of influenza A illness when administered
within 48 hours of illness onset.
Because of their "generic"
usefulness against all known influenza A viruses, amantadine and rimantadine
might be expected to play an important role in prevention and treatment of
pandemic influenza, especially during times when sufficient supplies of vaccine
may not be available. However, there are a series of formidable problems and
limitations associated with widespread use of these antiviral agents:
1. Under present circumstances, the supply of these drugs would be
well below the anticipated demand during an influenza pandemic.
2. Relative priorities
regarding target groups and the use of limited supplies for chemoprophylaxis
versus therapy have not yet been established.
3. Widespread use of rimantadine and amantadine could lead to the
widespread emergence of drug-resistant viral strains.
4. Adverse reactions and liability issues will be of great concern.
The potential for adverse drug reactions associated with amantadine, and to a
lesser extent rimantadine, and potential adverse interactions with other drugs
have raised concerns about safety and legal liability in a scenario of
large-scale distribution and use of these antiviral agents.
If newer antiviral
medications are adopted as part of pandemic strategy, issues will need to be
reassessed, since these drugs have more favorable side effect profiles, but are
more expensive and of uncertain benefit to high risk patients.
Until these and other
issues can be resolved at the national level, priority planning activities at
the State and local levels for allocation and distribution of antiviral agents
should be relatively limited.
At this time, South Carolina does not
foresee a major role for distribution and allocation of antiviral agents as
part of the response to an influenza pandemic. State estimates also indicate
that available supplies would provide preventive therapy to less than 1% of
persons at risk and if used for treatment would cover only 12% of cases.
In the event that
antiviral use is determined to be a feasible part of a pandemic strategy,
priority groups should be identified for their use, and prevention vs.
treatment options should be weighed. The “Vaccine Priority Group” can develop
potential strategies for antiviral delivery and can make determination as to
how use of such medications can best be integrated into State’s pandemic response
strategy.
IV. EMERGENCY RESPONSE: HEALTH AND MEDICAL & MAINTENANCE OF
CRITICAL SERVICES
- HEALTH EFFECTS -
All States and local areas have emergency response plans that are
geared towards natural disasters. The next influenza pandemic is likely to pose
a series of unique challenges that may not be accounted for in available
"All Hazard" plans:
•Unlike the typical focal disaster, the influenza pandemic will be
widespread, with many geographic areas affected simultaneously. Thus, every
community will have to be prepared, rather than (e.g.) pooling resources from
several contiguous counties, or relying on State personnel for help.
•If influenza-associated
illness is especially severe (as in 1918, for example), local health services
could easily become overwhelmed very quickly, with:
•potential shortfalls of ICU beds, ventilators and other
critical-care needs •potential shortages of antiviral agents (see above) and
antibiotics for treatment of secondary (bacterial) pneumonia; •potential needs
for ancillary or "non-traditional" treatment centers; •potential high
demand for mortuary/funeral services; and •potential high demand for social and
counseling services
Moreover, unlike natural disasters, demands on medical care in each
community will last 6-8 weeks until the "first wave" of infection is
complete.
•Unlike the typical disaster, essential community servants
themselves (e.g., medical-care personnel, police, firefighters, ambulance
drivers, and other first responders) will be just as likely -- or even more
likely (because of increased exposure) -- to be affected by influenza than the
general public.
•Because of the threat of exposure to influenza, the elderly and
other high-risk populations may be fearful of leaving their homes and seeking
proper medical attention for chronic medical conditions, and may require home
visits for health care.
The following guidelines are presently being developed at the
national level, and will be made available to State and local officials as soon
as possible:
•Generic "fact sheets"/Q & A's on
influenza, influenza vaccine, and antiviral agents
•Strategies and guidelines for interacting with
the media and for communicating effectively with stakeholders and the general
public
•Guidelines for triage and treatment of influenza
patients in outpatient, inpatient and non-traditional medical care settings
•Guidelines for setting up and operating mass
vaccination programs
•Guidelines for distribution and use of antiviral
agents
•Guidelines for the use and potential effectiveness
(or non-effectiveness) of "traditional" ("generic") disease
control measures such as the use of masks and other hygienic barriers, as well
as strategies to curtail community transmission such as cancellation of large
community events and temporary closure of schools and large,
"non-essential" businesses. It should be noted that the value of
these and other measures is largely uncertain at the present time.
- EFFECTS ON OTHER ESSENTIAL SERVICES (HUMAN INFRASTRUCTURE) -
In contrast to typical natural disasters -- in which critical
components of the physical infrastructure may be threatened or destroyed -- an
influenza pandemic may also pose significant threats to the human
infrastructure responsible for critical community services due to widespread
absenteeism. Examples of such services (and personnel) in the non-health sector
might include highly specialized workers in the public safety, utility,
transportation and food service industries, and will likely vary from
jurisdiction to jurisdiction. State and local officials should carefully
consider which services (and key personnel within relevant firms or
organizations) are "essential" -- i.e., which services, if
interrupted, and which workers, if absent, would pose a serious threat to
public safety or would significantly interfere with the ongoing response to the
pandemic.
Based on the dual concerns of maintaining essential services in
both the health and non-health sectors, a summary of priority activities
follows.
Current SC Emergency Operations
All-Hazards Plan, and the county-level plans, do not take into account the
unique challenges to be posed by an influenza pandemic (or by any pandemic of
an emerging infectious agent), and such special challenges musts be addressed
in an Annex to the EOP, as soon as possible in county EOPs, and in the plans of
private-sector health care organizations such as hospitals. In general it should be assumed that at the
peak of the first pandemic wave (and to a lesser extent during the second wave
as it occurs) that 30-50% of essential community services and medical personnel
may not be reporting to work, requiring replacement personnel and overtime work
for healthy personnel. Key for this
planning will be doing ongoing revised projections of the number of cases by
degree of morbidity/disability, and the numbers of cases in key community
service personnel (who may have different proportions affected than the general
population because of age and exposure differences.)
A.
Medical and
Health Care Response
1.
Command and
Management
a.
State – When
a Pandemic Alert has been declared, the PRG will meet to initiate response
planning. Among their first official
activities will be to hold a statewide meeting of representatives of hospital
administrators, hospital emergency department chiefs, and pharmacists to
present technical information on the pandemic and initiative local planning for
bed, equipment and staff capacities.
The PRG through its PRT will provide technical assistance for this
meeting, as well as ongoing assistance during the pandemic. Recurrences of this meeting might occur if
needed for unusual manifestations of the pandemic.
b.
Local –
Where feasible, county emergency preparedness directors and DHEC DHDs will
promote formation of a county pandemic response group.
2.
Inventory of
essential medical hospital beds, equipment and personnel.
The PRG has the
responsibility to assure that an initial inventory of essential beds, equipment
and personnel is conducted at the state level, and should promotion this inventory
at the county level. The following
items at least should be included:
acute-care beds, ICU capacity, ventilators, relevant antibiotics,
antivirals, specimen collection materials, mortuary capacity, social services
and counseling.
3.
The PRG has the
responsibility for assuring that all administrators of essential medical
services are regularly notified of the status of the pandemic, of projected
dates for appearance of the pandemic strain in their locality, and of
projections for morbidity by category in their locality. This notification and education should
include all acute-care physicians, infection control practitioners, emergency
room staff, urgent care centers, DHEC DHDs, university health care facilities,
and school nurses.
B.
Other
Essential Community Services
The main function of the PRG and PRT will
be to provide regular updated projections of the appearance of the initial
pandemic cases in the State, and of the expected level of morbidity and number
temporarily disabled by age group, for planning by local emergency management
and law enforcement organizations.
1. It is assumed that at the point of a
Pandemic Alert, a statewide level 4-readiness level will be declared, and the
State and the DHEC EOCs will be opened.
This group will coordinate availability and support of police, fire,
emergency medical technical/ambulance, transportation, essential communication,
potable water and sewage services, etc.
At least daily county-level assessments of the status of these essential
community services will be reported to the
SEOC. Daily communication of
status of such services will be made to the public.
{This Plan will have to be integrated into the SC Emergency
Operations “All-Hazards” Plan, perhaps
as an appendix]
Dissemination and sharing of timely, accurate and culturally
appropriate information among public health officials, medical care providers,
the media and the general public will clearly be one of most important facets
of the pandemic response. Because large communications networks must already be
"up and running" for multiple purposes (see below), and with very
little advance warning, it is essential that the function and content of such
networks be firmly established during the pre-pandemic period. These activities
will require:
•Inventories of existing communications systems (hardware and
software)
•Identification of gaps in existing systems that will require
additional human and financial resources •Efforts to acquire these additional
resources and for enhancements of existing systems.
In order to develop a comprehensive, national communications
strategy to better ensure dissemination of -- and access to -- consistent,
accurate and timely information, a series of activities is presently underway
at the national level, including:
•Continuous improvements in pre-pandemic period communications
systems (primarily based at CDC), including enhancements of existing Internet
sites, toll-free information lines, surveillance bulletins, routine Q & A's
on influenza, influenza vaccine, antiviral agents, etc.
•Design and development of
a national, multi-component pandemic communications system -- consisting of
electronic (including a dedicated Web site, e-mail distribution, bulletin
board, information clearinghouse, etc.), telephonic, administrative and paper
components. Major focus will be creation of a Web site, with multi-level
password protected access, links to other Web sites, etc., for selected/varied
audiences
•Development of prototype communication materials for use during
the next pandemic in English, Spanish, and other languages used by State
residents:
•Pandemic-focused Q & A's/fact sheets/on-line/video and audio
clips, etc., on influenza, influenza vaccine, antiviral agents, etc., in
various languages
•Prototype press kits, bulletins, newsletters, etc.
•General preventive measures/do's and don'ts for the general public
•Information/guidelines for health-care providers
•Telephonic "hot line" systems (including hierarchical,
restricted components)
•Videoconferencing capability
•Training modules (Web-based, printed, video, etc.)
•"Canned"
presentations, slide sets, videos, documentaries
•Symposia on surveillance, treatment, prophylaxis, etc.
•Posters
One of the main intents of these activities is to facilitate and
streamline activities within State and local jurisdictions, and to reduce
duplication of efforts. "Generic" materials have been -- and will
continue to be -- developed in close collaboration with State and local
officials.
Based on the critical need to provide (and exchange) consistent,
accurate and timely information both horizontally and vertically, a summary of
priority activities follows:
Coordination and Communication
1. The PRG will assure that all DHEC and EPD
staff pandemic activities are coordinated with each other and with outside
partner organizations through regular internal and external meetings and
communication. It will exert substantial care to assure that: a) all significantly affected partners are
represented during critical decision-making meetings, and b) there is early notification to all with
significant need to know of all such decisions and key pandemic events. The major working document will be a pandemic-specific
Operational Plan (OP) written by
members of the PRG with assistance of the PRT, within two weeks after the
formation of the PRG. This OP will
take into consideration the recommendations of the 1999 R.P.I. Report on SC
preparedness for a weapons of mass destruction terrorist event, and must be
updated on a regular basis. Government
organizations with which the PRG must coordinate include (but are not limited
to) the Governor’s Office, DHEC, state EPD, county Emergency Preparedness
Directors, Department of Social Services, SLED, major county and city fire and
police departments, and others.
2.
The
following state and local government facilities are available to support the
pandemic response:
The 13 DHEC District Offices:
provide local liaison with hospitals and nursing facilities and
pharmacists, local coordination with county emergency preparedness directors,
as well as local “horizontal” and “vertical” communication , storage and
tracking of vaccine and drug delivery, provision of staff for immunization and
to staff emergency medical care facilities, responding to public questions
about the pandemic, etc.
The SC State Laboratory will be available for rapid tracking,
isolation and typing of influenza virus strains and storage and distribution of
vaccines and drugs.
The 5 state Emergency Response Regional Offices.
The state Emergency Operations Center (SEOC) as designated by the
Director of Emergency Preparedness,
and DHEC EOC, as designated by the DHEC Commissioner.
Plans for telephone banks
for providing public information will be made by the PRG.
Appendix A: Priority Groups for Vaccination
In view of the likely vaccine shortage, the U.S. Public Health
Service, in conjunction with various advisory committees, is in the process of
formulating recommendations for a rank-order list of high priority groups for
vaccination. The order of these groups will be based on a number of factors,
including the need to maintain those elements of community infrastructure that
are essential to carrying out the pandemic response plan; to limit mortality
among high-risk groups; to reduce morbidity in the general population; and to
minimize social disruption and economic losses. Once developed, the rank-order
list will also be subject to change -- and potentially on short notice --
depending on the epidemiologic and clinical features exhibited by the actual
pandemic strain. Thus, advance preparations must have a high degree of
flexibility built into the distribution system. Until the "default"
priority listing is finalized, State and local officials should begin to
formulate plans for vaccinating the following target groups:
Health-care workers and public health personnel involved in the
distribution of vaccine and antiviral agents
Persons responsible for community safety and security, e.g.,
police, firefighters, military personnel, National Guard, "first
responders" not included in first priority group (e.g., ambulance drivers)
Other highly skilled persons who provide essential community services
whose absence would either pose a significant hazard to public safety (e.g.,
nuclear power plant workers) or severely disrupt the pandemic response effort
(e.g., persons who operate regional telecommunications or electric utility
grids). [NOTE: Members of this target group are likely to vary widely from
jurisdiction to jurisdiction, depending on local circumstances.]
Persons traditionally considered to be at increased risk of severe
influenza illness and mortality, as currently defined by the ACIP:
Persons of any age with high-risk medical conditions
Pregnant women
Persons in nursing homes and other long-term care facilities
Persons >65 years of age without high-risk medical conditions
Infants age 6-12 months (if supported by epidemiologic and clinical
data)
Household contacts of persons with high-risk medical conditions
Persons not included in Group #3 above who, in the judgement of
State and local health officials, provide critical community services (e.g.,
utility workers, funeral services personnel, personnel involved in the
transport of essential goods such as food, etc.)
Healthy persons age 18-64 years
Pre-school-age (especially day-care-center attendees) and
school-age children [the population least likely to have severe illness]
Source: Pandemic Influenza: A Planning Guide for State and Local
Officials, Version 2.1, 1999
Appendix B: Setting vaccination priorities: Which age group or
group at risk should be vaccinated first?
Criteria for Prioritization: Risk for Death
High risk persons age 65 and above
Other persons age 65 and above
High risk persons age 0-19
High risk persons age 20-64
Other persons age 20-64
Other persons age 0-19
Criteria for Prioritization: Total Deaths
High risk persons age 20-64
High risk persons age 65 and above
High risk persons age 0-19
Other persons age 65 and above
Other persons age 20-64
Other persons age 0-19
Criteria for Prioritization: Returns due to vaccination
High risk persons age 20-64
High risk persons age 0-19
Other persons age 20-64
Other persons 0-19
High risk persons age 65 and above
Other persons age 65 and above
(From Centers for Disease Control Published Data, 1999)
Appendix C: A partial list of essential service workers to be
considered for priority vaccination
Health Care Workers: All personnel involved in patient care, both
direct and ancillary. All personnel in local and state health departments, EMS,
hospital and long term care facility workers including support personnel
(clerical, laundry, janitorial, etc.)
Essential Public Service Personnel: Law enforcement officers,
including auxiliary and volunteer police officers, firefighters, including
volunteers, public and private sanitation workers, and National Guard members.
Funeral directors and funeral home/morgue/mortuary personnel.
Public Utility workers: All personnel who provide water, power, and
waste treatment facilities operation.
Government workers: Government employees at all levels, including
legislators, who are not included in any of the above categories.
Public and private transportation workers: Air, rail, bus, and
truck operators and ancillary personnel.
(Modified from Appendix to West Virginia state Pandemic Influenza
Plan)