PLAN FOR SOUTH CAROLINA’S RESPONSE

TO AN INFLUENZA PANDEMIC

 

April 3, 2000

 

TABLE OF CONTENTS

 

THE NEXT INFLUENZA PANDEMIC UNFOLDS………………………….

Page 3

I.

COMMAND, CONTROL, AND MANAGEMENT PROCEDURES……….

Page 4

II.

SURVEILLANCE……………………………………………………………..

Page 5

III.

VACCINE AND ANTIVIRAL DELIVERY……………………………………

Page 9

IV.

EMERGENCY RESPONSE…………………………………………………

Page 17

V.

COMMUNICATIONS………………………………………………………….

Page 19

APPENDICES

………………………………………………………………………………….

Page 21

 

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.

 

  1. When the “Pandemic Alert” stage has been declared, the Commissioner of Health and

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.  

 

  1. This Group will be responsible for administering the State’s response to the pandemic through the “Pandemic Over” stage, including responsibility each of the Major Priority Activities presented below, including the State’s legal authority to allocate distribution of influenza vaccine and antiviral drugs.   Most of the necessary management activities will have to be done through working partnerships with health, medical, pharmacy, coroner, and emergency response organizations in the State, which the Group will be responsible for reactivating, or initiating if they have not already been addressed through this Plan.  The PRG will meet as frequently as needed to assure effective control and coordination of pandemic response activities, more often as the pandemic moves closer to the State.

 

  1. This Group through the Chair will be responsible for convening a Pandemic Response Team (PRT) to assist in the management of activities during the pandemic response, which will include staff from appropriate DHEC divisions and EPD, as allocated by Commissioner of DHEC and  Director of EPD.   An Administrative Coordinator (Operations Manager) will be assigned to the Team to explicitly track and follow up on assigned responsibilities assigned and provide administrative support.

 

  1. The PRG Chair will be responsible for regular communication with all involved state government organizations within and outside DHEC and EPD (“horizontal communication”), and for assuring that regular communication, information and instructions are provided to the South Carolina public on the progress and preparations for the pandemic.

 

  1. If the PRG determines that more staff assistance is required, they will submit a request to the DHEC Deputy Commissioner for Health Services for help, specifying what skills and numbers are needed.   After consideration of what ongoing activities must be continued, the Deputy Commissioner will re-assign staff to the PRG for the duration of the Pandemic.   During this period the PRG through the PST leader will be responsible for directing the duties of all reassigned employees.

 

  1. During the Pre-Pandemic Period, specific electronic Resource Lists of potential partnering organizations and persons for the pandemic stage will be developed and disseminated.  These will include name or organization/person, specific function relevant to a pandemic response, address or location, telephone/fax numbers, and e-mail address.  The following general categories  of resource organizations are available or should be developed:

 

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

 

 

II. SURVEILLANCE

 

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

 

  1. Annual mail-outs are conducted preceding each influenza season.  They briefly describe the reporting requirements for influenza and the rationale for surveillance.   In the future the threat of pandemic flu, and the important role of providers in surveillance will be included in these annual mailings.  The annual mail-outs also include information encouraging providers to offer influenza and pneumococcal vaccine to appropriate populations.  We have decided against the promotion of year-round influenza surveillance because of impressions that this could become too burdensome for disease reporters, or desensitize them to participating during peak influenza season.  Annual notices should explain that young adults have been more severely effected in pandemic years than in inter-pandemic periods and will be encouraged to consider influenza vaccination every year.
  2. The current sentinel-physician network, providing about one sentinel site per 50,000 of the state’s population, should be more than adequate.   If significant gaps are identified in the geographic representativeness of the sites, efforts will be made to enroll additional sites to cover gaps.  Additional sites using private sector employee health programs should be added, particularly those industries in the state that have an international base and large numbers of employees that travel widely.  They may serve as potential sources of influenza importations.

 

  1. District level responsibilities

 

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.

 

4.       Identify additional sources of influenza surveillance data

 

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

6)   assess the medical, social and economic impact of the pandemic

 

III. VACCINE AND ANTIVIRAL DELIVERY

 

Background

 

 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.

 

Assumptions

 

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

 

Direction and Control of Vaccination Activities

 

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.

 

Vaccine Purchase for Public Sector Programs

 

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.

 

Setting Vaccination Priorities

 

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.

 

Role of Private Sector in Pandemic Influenza Immunization

 

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 and Assessment of Vaccine Utilization

 

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.

 

Risk Management: Adverse Events and Legal Issues

 

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.)

 

DELIVERY OF ANTIVIRAL AGENTS

 

Background

 

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]

 

 

V. COMMUNICATIONS: HARDWARE, SOFTWARE, PROCEDURES AND CONTENT

 

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)