Pandemic Influenza Plan
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MEMORANDUM
August 31,2006
TO:
The Honorable Mayor and City Council Members
FROM:
Michael C. Van Milligen, City Manager
SUBJECT: Pandemic Influenza Plan
Public Health Specialist Mary Rose Corrigan has provided a copy of Annex F to the
Dubuque County Public Health Preparedness Plan. This is being submitted to the Iowa
Department of Public Health.
She has also detailed the next steps in the planning process.
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Michael C. Van Milligen
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Attachment
cc: Barry Lindahl, City Attorney
Cindy Steinhauser, Assistant City Manager
Mary Rose Corrigan, RN, Public Health Specialist
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MEMORANDUM
August 31,2006
FROM:
SUBJECT:
Michael C. Van Millige~ Manager
Mary Rose COrriga~Ublic Health Specialist
TO:
Pandemic Influenza Plan
INTRODUCTION
This memorandum submits the Dubuque County Pandemic Influenza Plan for City
Council review.
BACKGROUND
Under direction of the Iowa Department of Public Health (IDPH), the city formed a
Pandemic Planning Coordinating Committee (PPCC) in conjunction with the County
Health Department and the Dubuque Visiting Nurse Association (VNA.) Membership of
the PPCC includes the following:
Dubuque Community School District (Patrice Lambert)
Dubuque County Board of Health (Dr. John Viner)
Mercy Medical Center Infection Control practitioner (Ann Burds)
Mercy Medical Center ED Manager (Alice Prohascka)
Finley Hospital ED Educator (Cindy Temperly)
- Finley Hospital Infection Control practitioner (Jacquie Roth)
- Medical Associates Clinic (Kathy Kane and Dr Caceras)
Dan Brown (EMS)
Kim Wadding (Law Enforcement)
Dubuque Area Chamber of Commerce (Dan Cunningham)
Dubuque Area Labor Management Council (Kelly Cooper)
- Mary Rose Corrigan
- Tom Berger
- VNA (Nan Colin)
Dubuque County Health Department (Paul Buss)
This plan, which will become Annex F of the Dubuque County Public Health
Preparedness Plan after Board of Health approval in September, was formulated by
Nan Colin, Paul Buss and Mary Rose Corrigan utilizing an IDPH template.
The PPCC reviewed the plan and provided input. The plan has also been submitted to
IDPH as a performance measure for the Dubuque County Pandemic Influenza Planning
Contract.
Earlier this summer, a local pandemic influenza planning assessment was conducted
and subsequent work plan developed. This work plan will guide the further
development of the pandemic plan with more detail, policies and procedures along with
the necessary tools for implementation.
In addition, the PPCC has formed sub- committees to assist other community entities in
pandemic influenza plan development along with community education. The
committees include schools, health care, hospitals, business, community and education.
ANN EX F- DUBUQUE COUNTY PANDEMIC INFLUENZA PLAN
Oblectlves :
1. To establish a Dubuque County Pandemic Influenza (PI) Committee that will facilitate
preparation of plans by all sectors of the community that can be implemented when an
atypical influenza outbreak occurs.
2. To establish a method to communicate information on the status of atypical influenza
from throughout the US and Iowa to Dubuque County partners.
3. To establish a process for activation of the County PI Committee and, if indicated, the
County EOC, when atypical influenza occurs in Dubuque County.
Dubuque County Pandemic Influenza Committee Members (Organizations are listed, not
representatives):
. Dubuque County Board of Health
. Dubuque County BOH Physician Consultant
. Dubuque County Health Department
. Dubuque Visiting Nurse Association
. City of Dubuque Health Services
. Mercy Hospital Infection Control
. Finley Hospital Infection Control
. Mercy Hospital Emergency Department
. Finley Hosptial Emergency Department
. Dubuque EMS
. Dubuque EMA Coordinator
. City of Dubuque Police/Law Enforcement
. Dubuque County Sheriff's office
. Dubuque Community School District
. Western Dubuque Community School District
. Dubuque Area Chamber of Commerce
. Dubuque Area Labor Management Council
. Medical Associates Clinic Liaason
. Medical Associates Clinic Epidemiologist
BACKGROUND
According to the World Health Organization (WHO),
"An influenza pandemic occurs when a new influenza virus appears against
which the human population has no immunity, resulting in several
simultaneous epidemics worldwide with enormous numbers of deaths and
illness. With the increase in global transport and communications, as well
as urbanization and overcrowded conditions, epidemics due to the new
influenza virus are likely to quickly take hold around the world."
Influenza is a highly contagious respiratory virus that is responsible for annual
epidemics in the United States and other countries. Each year an average of
200,000 people are hospitalized and 36,000 die in the U.s. from influenza
infection or a secondary complication. During an influenza pandemic the level of
morbidity and mortality from influenza will likely increase dramatically worldwide.
During the last century, three influenza pandemics caused increased mortality,
morbidity and societal burden throughout the world above the levels seen with
usual yearly epidemics. The "Spanish" influenza pandemic of 1918 killed over
500,000 people in the United States and had a worldwide mortality of 20 to 40
million. The virus that year was notorious for its predilection for severely
affecting healthy young adults. Since 1918, two global outbreaks of influenza A
occurred. In 1957, Asian influenza caused approximately 80,000 deaths in the
United States. During the Hong Kong pandemic in 1968-69, mortality in the
United States was estimated at 30,000 deaths, with 51 million Americans
affected by influenza.
Influenza viruses are grouped into three types designated as A, Band C. Viruses
of the C type are common but usually cause no symptoms or only very mild
respiratory illness. They are not considered to be a public health concern. Type
B viruses cause sporadic outbreaks of more severe respiratory disease,
particularly among young children in school settings. Type A viruses typically
cause the majority of morbidity and mortality each year during the influenza
season. Both Band C viruses normally only infect humans. C viruses are stable,
but A and B viruses are prone to mutation.
Every year influenza viruses change because they have the ability to mutate
genetically. Both influenza A and B viruses can undergo the minor genetic
variations known as antigenic drift. Antigenic drift is a gradual change caused by
minor point mutations in the viral genes that results in small changes to the
surface proteins of the influenza virus. Antigenic drift occurs continuously, and is
the reason that the make-up of the influenza vaccine is changed almost every
year.
Influenza A virus is unique in that it can infect a variety of animals, with wild
birds being the natural reservoir. It can undergo the major genetic reassortment
known as antigenic shift. This sudden change happens infrequently and often
occurs as a result of a recombination of human influenza A with an animal
influenza A virus.
This recombination results in a new subtype of influenza A to which the human
population has little or no immunity. An antigenic shift is often the impetus for
an influenza pandemic.
The impact of an influenza pandemic on the local healthcare system could be
devastating. It is likely that 15-35% of Iowa's population will be affected. There
is a potential for high levels of morbidity and mortality, as well as the significant
disruption to society, making planning for the next influenza pandemic
imperative.
I. PURPOSE
The purpose of this plan annex is to ensure an immediate and effective local
response in the event of an influenza pandemic to limit the morbidity and
mortality of Dubuque County residents and to keep economic loss and social
disruption to a minimum. All components of the bio-emergency plan remain
applicable and relevant to this pandemic influenza annex, including but not
limited to; maintenance, exercise, activation, authority and NIMS Compliance.
II. ASSUMPTIONS AND PLANNING FACTORS
For Basic Assumptions common to all public health emergencies, see Annex A Public
Health Preparedness Plan
· There may be very little warning. Most experts believe that we will have
between one and Six months between the time that a novel influenza strain
is identified outside of the U.S. and the time that outbreaks begin to occur
in the U.S.
· Outbreaks may occur simultaneously throughout much of the U.S.,
preventing shifts in human and material resources that normally occur with
other natural localized or regional disasters.
· The effect of influenza on individual communities will be relatively
prolonged -- weeks to months.
· The impact of a pandemic could have a devastating effect on the health and
well being of the American public.
· Effective preventive and therapeutic measures -- including vaccines and
antiviral agents -- will likely be in short supply, as well as antibiotics to
treat secondary infections.
· Health-care workers and other first responders will likely be at even higher
risk of exposure and illness than the general population, creating the
potential to further impede care of victims.
· Widespread illness in the community will increase the likelihood of sudden
and potentially significant shortages of personnel in other sectors that
provide critical community services, including military personnel, police,
firefighters, utility workers, and transportation workers.
. Local Emergency Planning Committees are currently in place or being
established. These committees are or will begin to address the Pandemic
Influenza planning process.
III. PLAN ORGANIZATION
Issues basic to any type of public health emergency or disaster are contained in the Public
Health Preparedness Plan and will be referred to by annex and page number. Issues specific to
Pandemic Influenza and Public Health Preparedness Planning are found in this Annex F.
This plan annex recognizes the World Heath Organization's Pandemic Periods and
six phases of Pandemic Influenza and relates planning factors related to
surveillance by each phase.
Inter-oandemic oeriod-
Phase 1: No new influenza virus subtypes in humans; subtype that has
caused human infection may be present in animals.
Phase 2: As above, but circulating animal subtype poses substantial risk of
human disease.
Pandemic alert oeriod-
Phase 3: Human infection with new subtype, no human to human spread,
or rare spread to close contact.
Phase 4: Small clusters with limited human-to-human transmission, highly
localized spread, suggesting virus is not well adapted to humans.
Phase 5: Larger clusters, but human-to-human spread still localized, virus
increasingly better adapted to humans, but not yet fully transmissible.
Pandemic oeriod-
Phase 6: Increased and sustained transmission in general population.
This plan annex recognizes the Iowa Pandemic Period Progressions. The
progressions are part of Phase 6 of the Pandemic period described above. The
plan is designed to outline the objectives regardless of the order in which
progressions might appear. For example, the pandemic strain may appear in
Iowa before any other state and the objectives in this plan would still apply.
The progressions are the following:
· Pandemic strain is circulating throughout the world but is not yet in the
u.s.
· Pandemic strain is circulating in the U.S. but is not yet in Iowa.
· Pandemic strain is circulating in Iowa.
Influenza Specific Surveillance by Phases:
In the event of an influenza pandemic, routine local surveillance systems will be
rapidly adapted or enhanced to respond to the challenges of a pandemic in order
to support the surveillance activities conducted at the state level. Enhanced
surveillance would be any additional component or improvement to the current
surveillance system as directed by the IDPH.
The IDPH's routine influenza surveillance is conducted from October to May each
year; yet some influenza components of the surveillance is system are conducted
year-round. In the event of influenza pandemic Dubuque County will assist the
IDPH in surveillance efforts for each phase as listed below.
Phases 1 and 2:
. Continue with current local routine influenza surveillance methods:
. Maintain communication with IDPH allowing for rapid communication should
a strain which affects humans and animals be detected.
Phase 3:
. Continue ongoing activities from previous phases as appropriate.
. Communicate with IDPH as they will monitor and revise recommendations
from the CDC for any additional surveillance activities that should be
undertaken.
. IDPH may consider expanding virologic and disease-based surveillance to
year-round surveillance. Dubuque County will support IDPH by
communicating with:
o Sentinel providers that monitor III year-round;
o Schools, child care and long-term care participants.
. Educating local physicians to screen for III in persons traveling from
geographic areas in which pandemic strains have been isolated and/or in
areas where there has been confirmed highly pathogenic avian influenza
(HPAI) activity.
· Communicate with local veterinarians regarding animal influenza
surveillance.
Phase 4:
· Continue ongoing activities from previous phases as appropriate.
Phase 5:
. Continue ongoing activities from previous phases as appropriate.
. Communicate with IDPH regarding monitoring and revising
recommendations from the CDC for any additional surveillance activities.
. Communicate with IDPH regarding case definition, based on description of
known cases from affected countries.
. Educate schools to report weekly absentee levels.
Phase 6:
. Continue ongoing activities from previous phases.
. Communicate with IDPH for direction as they may consider initiating travel
screening methods at incoming Iowa conveyance locations and in health
care settings for III and international exposure.
Strategies if current systems of ILl surveillance and lab testing are
exceeding capacity:
. CADE may choose to switch to active surveillance and call providers on a
weekly basis. Dubuque County will support this effort by communicating
with local providers and healthcare facilities for this information.
. Dubuque County will utilize Iowa's Capacity Reporting System (estimated
to be operational winter 2005) to monitor III within the county. Iowa's
Capacity Reporting System will provide real-time information on the
capacity of Iowa's hospitals and EMS transport services in the event of a
disaster. The system can be modified so IDPH can request that
hospitals relay information from their Infection Control Providers on the
number of inpatients within their facility meeting a defined case definition
of illness in the event of a pandemic. The system could also be used to
identify how many persons are presenting to Iowa's emergency
departments who meet the defined case definition for influenza-like illness.
(Iowa's Capacity Reporting System could be activated at any phase and
level).
. Dubuque County will closely monitor Iowa's Health Alert Network as it will
likely be used in conjunction with the Iowa Capacity Reporting System to
notify LPHA's, hospitals and EMS transport services.
. In collaboration with the IDPH develop a system to assess vaccine priority
groups, coverage and determine number of persons who remain
unprotected.
. Consider using antibody testing to determine who may be immune if the
public situation becomes extreme and immunologically-protected
volunteers are needed.
. IDPH will monitor and revise recommendations from the CDC and notify
LPHAs for any additional surveillance activities that should be undertaken.
Pre-vaccine preparedness: Your Pandemic Flu annex should include actions to
be taken in the event that a vaccine is not available or in very limited supply
once the novel virus has reached your population. LPHA will need to prepare
procedures for monitoring vaccine effectiveness and vaccination rates with
mechanisms of reporting to IDPH.
Utilizing guidance from the IDPH for use of Anti-virals: Your Pandemic flu
annex will include how your agency will receive and utilize all guidance from the
IDPH regarding the use of antl-virals.
Utilizing guidance from the IDPH for prioritization of vaccine once
available: Your Pandemic flu annex should include how your agency will receive
and utilize all guidance from the IDPH regarding the prioritization of vaccine once
available. Include how the LPHA and healthcare providers will report vaccine
adverse reactions to IDPH, who will then submit the information into the national
reporting program VAERS.
Developing and maintaining procedures for implementing this plan: The
local agency must develop triggers, policies and staff procedures for each
component of this plan for implementation, the plan must state how this will be
achieved. Identify the authorities to activate the plan.
IV. CONCEPT OF OPERATIONS
The protection of the health and welfare of the residents of Dubuque County, Iowa will be
managed at the local level. IDPH, other state and federal agencies (CDC, NIH, DHHS) when
appropriate, will provide technical assistance when requested or in cases where needs
exceed the capability of local response resources. In extreme circumstances, such as the
incapacitation of local authorities, the state may move beyond an advisory role and assume
direction and control responsibilities within the affected jurisdiction(s).
In a very large outbreak of Pandemic Influenza, many or all Iowa communities will be affected
and the state may not be able to meet all requests for assistance. Under these
circumstances the state will use available mechanisms, including the Strategic National
Stockpile, for obtaining resources and other assistance from the federal government.
With assistance from state and, in some instances, federal agencies, local jurisdictions will be
responsible for these planning areas:
1. Command and Control: Should this Pandemic Influenza plan be implemented and
community partners mobilize, Dubuque County EOC will be activated at the request
of the Health Department and/or Board of Health. With activation of the ECO, the
County will provide effective leadership and coordination using the NIMS and Incident
Command model. See County Preparedness Plan Annex A and the County Multi-
hazard Plan. See Appendix D of this Annex H for an organizational chart for
Dubuque County Incident Command.
2. Communication: With implementation of Annex H Pandemic Influenza Plan, the
Public Information Officer will use resources in Annex B of the County Preparedness
Plan to provide information to the general public through the media and other
information outlets, to maintain an uninterrupted flow of information among response
partners, and to facilitate communication among federal, state and local agencies.
This will include communication to update partners as the epidemic unfolds. Local
partners will include contacts in the medical community including hospitals, clinics,
and long-term care facilities as well as contacts in the school districts, colleges,
business partners, law enforcement, and emergency medical systems.
Communication will be in appropriate languages and include concepts of health
literacy so the average citizen can understand the content.
Prior to the need to activate the PI plan, the PIO and the Pandemic Influenza
Planning Committee will craft messages to educate healthcare providers,
businesses, schools, and individual citizens about pandemic influenza, public health
and infection control measures that will contain the illness, and the need for advance
planning to ensure continuity of services in all sectors.
3. Administration and finance: For administration of the implemented plan, see
Annex A of the County Preparedness Plan and the County Multi-Hazard Plan Part A.
For resource management, see County Preparedness Plan Annex E.
4. Information and technology management: Dubuque County provides for
Information Technology through the county systems. Laptop computers have been
purchased and are available for use during the outbreak. EOC will utilize these
computers to easily access the county plans, access databases, access the Internet
for CDC and IDPH links as well as communicating with local partners via email. The
County and the Finley Hospital (for VNA staff) network will both be used to
communicate throughout the County and State. The County IT provider will maintain
the County resources and Finley IT will be able to assist VNA staff to maintain the
Finley network.
5. Logistics: The County EOC will function consistent with NIMS guidelines. County
Logistics officer will work with planning to ensure that needed resources are available
when needed. See Annex A of the Preparedness Plan for detail. Logistics and
Planning Sections will communicate with each other and with the EOC Commander
to prioritize needs and ensure resources provided in a timely manner. Dubuque
County EMA will be part of Logistics so as to access mutual aide and compact
agreements with other counties and entities. These agreements are included in the
County Multi-Hazard plan so established paths of accessing materials can be quickly
expedited.
6. Pre-vaccine preparedness: Dubuque County EOC will communicate with IDPH for
accurate information on vaccine development and availability. Prior to vaccine
development, key elements for containing the epidemic include:
. Communicating with the public on the need to stay home when sick, using
acetomenaphine or ibuprophene for discomfort and fever control, ensuring
adequate fluid intake, using proper infection control practices including
handwashing and control of secretions.
. Establishing urgent care centers to divert people from use of hospital emergency
rooms. Communicating to the public appropriate criteria for use of the urgent
centers, specifically when to seek additional care for those at high risk for
complications (immuniosuppressed, very young or very old persons, etc)
. Special Care Centers for those who need nursing care but have no caregiver
available. May include those with no caregiver but also those who have
caregivers needed to staff hospitals, long-term care centers, schools. Or the
Special Care Centers.
. Decision on large gatherings of people including whether to suspend services at
child daycare centers and schools. EOC will consult with IDPH and with local
partners on risk of continuing school/day care and public gathers verses the
effect on the workforce in all industries including healthcare providers.
. The VNA will provide IDPH with information on influenza vaccination levels for
normal strains in Dubuque County. IRIS will be utilized to give idea of vaccination
levels in the general population.
. The VNA will work with other providers on logs to monitor surveillance for the
variant strain so case investigation and reporting of cases is done throughout the
epidemic. The VNA will set up a database to organize the symptomatic cases
reported and will report the information to CADE using routine mechanisms. By
continuing to conduct surveillance, the VNA and IDPH will be able to determine if
measures such as use of any limited vaccine or isolation/quarantine is effective in
decreasing spread of the disease.
Once the vaccine is available, the VNA will work with community partners to hold
vaccination clinics and dispense vaccine to schools, colleges, long-term care
centers, and other healthcare providers. As the vaccine is given, the effect on
numbers of new cases reported should become evident.
7. Utilizing guidance from the IDPH for use of Anti-virals: The EOC will review us of
anti-virals with the County physician consultant and IDPH. The decision on using
anti-virals will depend on the recommendation and availability of the drugs. If use of
anti-virals is effective in decreasing the severity of the disease for this strain, the
method of dispensing will be impacted by the adequacy of the supply. If supply is
limited, the medication may be distributed by physician providers, urgent care
centers, special needs centers, or hospitals. If the supply is plentiful, alternate routes
of dispensing to people sick at home may be used such as home care nursing staff
from agencies. Mass dispensing clinics are unlikely since gathering large groups of ill
people to get medication could be counterproductive.
8. Utilizing guidance from the IDPH for prioritization of vaccine once available:
When the vaccine effective against this strain of influenza has been developed and is
available for distribution, the Dubuque County Board of Health and the EOC will
consult with IDPH to determine appropriate receipt and use of the vaccine. The EOC
will implement planning for distribution whether in special clinics or through other
health provider networks. All health providers distributing vaccine will report any
vaccine adverse reactions and submit the information to VAERS, the national
reporting program.
9. Distribution of vaccine and antivirals:
For vaccine and antiviral distribution, Dubuque County will use the SNS/POD clinic
plans.
Special Needs Populations including long-term care (LTC) and home bound: Vaccine
and antiviral medication would be distributed through the LTC facility staff and with
the help of home care agencies. Memorandum of understandings with the home
care agencies and LTC facilities will be in effect. Education will be provided to all
facilities and agencies regarding cold chain, vaccine/medication specific education
including use of Vaccine Information Sheets, and reporting to V AERS of any
medication reactions or adverse reactions.
All vaccine and antiviral medication will be maintained at recommended temperatures
by storing in refrigeration until ready to dispense to clinics, LTC facilities, and home
care agencies. During clinics, the cold chain will be maintained by use of cold packs
and thermometers to monitor and document that proper temperatures were
maintained. Home care staff will be educated about the need to maintain cold chain
from refrigerator to patient being vaccinated.
10. Surveillance: With onset of Pandemic Influenza Phase 4, local public health
personnel will be aware of national and state public health reports on spread of the
new-strain of influenza.
The VNA will communicate with local hospitals and healthcare providers regarding
communication of numbers of patients seen with symptoms or confirmed influenza.
Log templates will be provided to healthcare partners to aid surveillance and will be
faxed to the VNA daily or every other day as determined by the volume of cases
seen.
As Phase 5 and 6 occur, the VNA will be in communication with IDPH CADE
regarding surveillance and control methods.
For specific information on Dubuque County surveillance, see Annex C of County
Plan.
11. Rapid and efficient laboratory diagnostics: Note: Dubuque United Clinical
Laboratory representative is providing detail of lab response so will be added.
12. Personal protective equipment (PPE) and Infection Control:
Key to limiting and controlling the influenza outbreak is the need for use of PPE to
reduce spread of the organism. Standard surgical/patient masks are recommended;
N-95 masks are not necessary. Patients will known upper respiratory infections,
should be considered possibly infectious with influenza and caregivers encouraged to
use standard masks and handwashing after patient contact or contact with
secretions. (See IDPH Pandemic Influenza plan for more information).
Public Service Announcements and press releases will be sent out encouraging
people to use diligent handwashing and use of masks (even use of kerchiefs as
masks) when in contact with ill individuals.
Most important is the message that people ill with influenza symptoms should stay
home for the duration of their symptoms. People who are not able to care for
themselves and are ill should contact the Public Health local toll-free number to leam
of the nearest special needs center for nursing care.
Each business, agency, and facility is being encouraged to have their own
organization pandemic influenza plan. Part of the education in the business
community is the need have a change in mindset so that employees are encouraged
to stay home from work if they are ill with influenza symptoms. Plans must encourage
staff to avoid working and spreading the illness throughout their workforce or to their
customers.
13. Isolation and Quarantine: See Annex C of the Public Health Preparedness Plan as
well as the Dubuque County ordinance for detailed information on Isolation and
Quarantine. Annex C includes drafts/templates that can be used. The VNA will
monitor compliance with Isolation/Quarantine and the Dubuque County Sheriff's office
will enforce the ordinance.
14. Management of psychological consequences: See Annex D of the Public Health
Preparedness Plan.
Additional resources are:
Resoondina to the Needs of Peoole with Serious and Persistent Mental Illness in
Times of Maior Disaster. (US HHS Publication# SMA 96-3077)
Psvchosociallssues for Older Adults in Disasters (US HHS Publication # SMA 99-
3323)
15. Surge Capacity: See Annex D for County plans for dealing with surge capacity. In
addition to working with home care agencies, LTC facilities, and establishing special
care centers for those who do not have caregivers, a plan to offer 3-4 hour classes in
collaboration with the Red Cross to teach individuals how to be caregivers will be
helpful in training our population to care for their own families and neighbors.
Citizens who are less ill with uncomplicated influenza symptoms are encouraged to
stay home, push fluids, take antipyretics (to reduce the fever and acheness), and rest.
To decrease and handle surge in the hospital emergency departments, the plan is to
implement urgent care centers to serve those who are more acutely ill and need to
see a healthcare provider.
Hospital emergency departments should be reserved for those who are very ill with
complications of influenza such as pneumonia, adult respiratory distress syndrome,
or dehydration.
The County lac will determine when urgent care centers or special care centers are
to be implemented. Personnel to staff, location of centers, and equipment and
supplies will be mobilized by planning and logistics officers. Volunteers will be key to
helping to staff centers. Schools of nursing will be contacted to help staff centers.
16. Mass Fatalities management: The Dubuque County Multi Hazard Plan, Annex S,
details handling of bodies with mass deaths. The County Preparedness Plan, Annex
D, has limited information regarding management of bodies from mass fatalities.
Funeral homes will be key to ensuring that families are given choices for proper
funeral arrangements. Above all, family wishes are to be respected and
accommodated. Standard precautions are appropriate for handling bodies of those
who have died from influenza. An additional resource is WHO Guidelines for
Handling of Dead Bodies.
17. Developing and maintaining procedures for implementing this plan:
The Dubuque County Health Department in conjunction with the VNA and the City
Health Department had developed policies and protocols for implementation of this
pandemic influenza plan. Policies and protocols will be reviewed annually to ensure
the plan is current and up-to-date.
18. Plan exercise and management:
The Pandemic Influenza plan will be exercised annually by the Health Department
and its partners. The exercise may be tabletop, functional, or full exercise. A written
report will be completed, submitted to the Board of Health and Board of Supervisors
including the lessons leamed/after action report, and any needed modifications to this
plan as a result of the drill.
19. All plans are NIMS Compliant:
This Dubuque County Pandemic Influenza plan will utilize the NIMS and lac
protocols to ensure a uniform approach to handling the pandemic emergency.
Reference the Dubuque County Annex A for specific information on NIMS
compliance and lac operations.
V. PLAN IMPLEMENTATION
Dependant on the pandemic period and phase there may be a variety of response partners
required to implement this plan. Below is a list of possible representatives required.
Local elected official{s) Dubuque County Board of Supervlsors-589-4441
(Courthouse) or dispatcher call 911
Local Public Health Agency Administrator (or other designated LPHA emergency
contact) Dubuque Co. Health Dept, Dr. Paul Buss: 557-7396
Visitina Nurse Association, Nan Colin RN: 556-6200 or 563-590-0647
Public health nurse{s) CathY Tieskoetter: 556-6200 or 580-0620
Environmental health officer{s) Dr. Buss: 557-7396
Tim Link, City Health Dept at 589-4181
Communicable disease specialist{s) Dr. John Viner: 557-9111;
Dr. Caceres: 589-3430
Local hospital{s) (includes emergency department contact and infection control
practitioner, at a minimum)
Mercy Medical Center ED: 589-9666, DyersYllle: 1-563-543-2250
Finley Hospital ED: 589-2461
Mercy Medical Center ICP: 589-8072
Finley HospitallCP: 589-2514
Local health-care providers See Annex B contact list
Emergency Medical Services Administrator{s) See Annex A Contact List
Public Information Officer Mary Rose Corrigan: 589-4181
Law enforcement (sheriff and/or local oolice chiefs) See Annex A Contact List
Fire chief{s) See Annex A Contact List
School Nurse{s) Patrice Lambert: 552-3084 cell 563-599-2360
Sheila Knaoo: 563-744-3371
School Administrator{s) John Burghart 552-5103 cell 563-599-5306
West Dubuque 563744-3885
Emergency Management Coordinator Tom Berger 589-4170 or County dispatcher
Volunteer Organizations RSVP 589-2622
Local Red Cross Dubuque Chapter 583-6451
LIST OF APPENDIX
APPENDIX A: CURRENT PRIORITY GROUPS FOR VACCINATION
APPENDIX B: SURVEILLANCE BY INFLUENZA ACTIVITY LEVEL
APPENDIX C: RESPIRATORY HYGIENE COUGH ETTIQUETTE GUIDELINES
APPENDIX D: INCIDENT COMMAND STRUCTURE
APPENDIX I: PANDEMIC INFLUENZA FACT SHEET I
APPENDIX II: PANDEMIC INFLUENZA FACT SHEET II
Appendix A: CURRENT PRIORITY GROUPS FOR VACCINATION
Tier Priority groupt
1 A Persons aged ~65 Ylil8lS wif1 rx.morbid conditions
Resldants of long.ler~fadlJk:.s
Total
8 ~rsons ag9d 2.J34 )'Gars wtth OJmolbid coo:litions
Persons aged ~65 years wi1hout comorbid conditions
Children aged 6-23 months
Prlillgnant women
Total
C H~1h.car9 PQIrsonrllilll
Household contacts .....d out-of-home C3rer.;Jivers .x children agGld <6 morths
Total
2 Housllihold contacts of chldr",n and ad..tIls a.t InctMSed risk for
in1Iuenzo-<<llat9d ~Icatlons 70..g 1S.2tt 1:2.8
HealthYP'l'f'Sonsaged50-64yri)arS 17.7 ~.8' 5.3
Total 88.0 20.6 1L 1
.3 Persons 8ged2--40 years without hi~Hisk conditions 1OS.5 14.8' 15.6
. Estimates are-for 2003--04 season for most adult groups aoo the 2004-05 season for I1'103t pediatric groups becau$Q nationallntluenza vacdnation data
on childreon werEl- not availajje. for 2003.
t C€II1ain pQrsons might be ildLKkld in mol'Q tlan cne group.
e. Based on 2003 population es1imalE's from the U. S. CE>osus Bureau.
11 Based on h 2003 National HQ8Ith hKJrvlgw SurVQlj (NHISI br nonlrstlulooaJlZ9d adults (CDC, lI'lpubllsMd data. 20(6).
.. Based Of] tl1o9 1QQQ National NUf5lng Home Survey (COC, unpu~ished data. 20CX3).
tt Vaccination coverage for p'Kiatrlc groups is based on estimatQ6 from the- BMavioral Risk Factor SurvEoiRanCQ Sys1em (MMWR 2005:54:304-71.
Vaccination coverag.e for adults is ba8~d on"*" 200:3 NHIS
TABLE. Priority group$ for vaccination with Inactivated Inftuenza vaccine and estimated vaccination COVEH'8ge for 2003"
Popul.Uon E.stlm.tMi EetlmlllMi no. of
In 20034' v.ccln.lion persons vaccinated
(millions) coy.rag. (%) (rnIl11onlJ)
18.2 70.01 12.0
1.7 80.0'. 1.3
19.9 71.4 14.2
42.4 .34..3tt 14.5
17.7 00.81 10.8
6.0 48.4tt 2.9
4.0 12.81 0.5
70.1 40.8 28.7
7.0 40.11 2.8
5.0 17.3tt 0.9
12.0 30.6 3.7
These groups will be evaluated during a pandemic, and recommendations from IDPH will
depend upon characteristics of the causative virus (e.g. transmissibility, virulence, initial
geographic distribution, age specific attack rates, complication rates and vaccine
effectiveness)
Appendix B: SURVEILLANCE BY INFLUENZA ACTIVITY LEVEL
Activity III Laboratory data
Level activitv* /Outbreaks
No activity Low And No lab confirmed cases'
Not increased And Isolated lab-confirmed cases
Sporadic OR
Not increased And Lab confirmed outbreak in one institution'
Increased III in 1 Recent (within the past 3 weeks) lab evidence of
region**; III activity And influenza in region with increased III
in other regions is not
increased
OR
Local 2 or more institutional Recent (within the past 3 weeks) lab evidence of
outbreaks (Ill or lab influenza in region with the outbreaks; virus
confirmed) in 1 And activity is no greater than sporadic in other
region; III activity in regions
other regions is not
increased
Increased III in ;:: 2 Recent (within the past 3 weeks) lab confirmed
but less than half of And influenza in the affected regions
Regional the rea ions
( doesn't OR
apply to Institutional Recent (within the past 3 weeks) lab confirmed
states with outbreaks (Ill or lab influenza in the affected regions
::; 4 regions) confirmed) in ;:: 2 and And
less than half of the
reaions
Increased III and/or Recent (within the past 3 weeks) lab confirmed
institutional outbreaks influenza in the state
Widespread (Ill or lab confirmed) And
in at least half of the
regions
. .
III activity can be assessed uSing a vanety of data sources including sentinel provIders, school/workplace absenteeism,
and other syndromic surveillance systems that monitor influenza-like illness.
. Lab confirmed case = case confirmed by rapid diagnostic test, antigen detection, culture, or peR. Care should be given
when relying on results of point of care rapid diagnostic test kits during times when influenza is not circulating widely.
The sensitivity and specificity of these tests vary and the predicative value positive may be low outside the time of peak
influenza activity. Therefore, a state may wish to obtain laboratory confirmation of influenza by testing methods other
than point of care rapid tests for reporting the first laboratory confirmed case of influenza of the season.
~ Institution Includes nursing home, hospitall prison, school, etc.
4 Region: population under surveillance in a defined geographical subdivision of a state. A region could be comprised of
one or more counties and would be based on each state's specific circumstances. Depending on the size of the statel the
number of regions could range from two to approximately 12. The definition of regions would be left to the state but
existing state health districts could be used in many states. Allowing states to define regions would avoid somewhat
arbitrary county lines and allow states to make divisions that make sense based on geographic population clusters.
Focusing on regions larger than counties would also improve the likelihood that data needed for estimating activity would
be available.
Appendix c:
GUIDELINES
RESPIRATORY
HYGIENE
COUGH
ETTIQUETTE
Respiratory Hygiene/Cough Etiquette Program Guidelines
. Post visual alerts instructing patients and persons who accompany them to inform
personnel if they have symptoms of respiratory infection.
. Provide tissues to patients and visitors to cover their mouth and nose when coughing and
sneezing.
. Provide easily accessible disposal containers for tissues.
. Provide dispensers of alcohol-based hand rubs.
. Ensure supplies for hand washing are available at sinks.
. Offer masks to persons who are coughing.
· Encourage coughing persons to sit at least three feet away from others or having a
separate waiting area for them.
· Ensure health personnel observe droplet precautions in addition to standard precautions.
Appendix D: INCIDENT COMMAND STRUCTURE
EOC
UNIFIED COMMAND
FOR
PUBLIC HEALTH EMERGENCY
ELECTED OFFICIALS
EOC MANAGER
Dubuque County Health
Director (or alternate)
PIO
Communications Annex B
Planning
1
1
1
Annex C
(Surveillance, EPI
Investigation &
Control)
1
Annex D
Medical Response
Annex A
(Direction, Control
Coordination)
Admin
Annex E
Resource
Management
Attachment 1
Fact Sheet
Pandemic Influenza
Medical and Public Health Professionals
What is pandemic influenza?
Annual outbreaks of influenza are due to minor changes in the surface proteins of
the viruses that enable the viruses to evade the immunity humans have
developed after previous infections with the viruses or in response to
vaccinations. When a major change in either one or both of their surface proteins
occurs spontaneously, no one will have partial or full immunity against infection
because it is a completely new virus. If this new virus also has the capacity to
spread from person-to-person, then a pandemic will occur. The surface proteins
monitored for change are hemagglutinnin (H) and neuraminidase (N). The H
surface protein is responsible for cell attachment and entry and is the major
antigen of the virus against which antibodies are produced. There are 14
subtypes of Hand 9 subtypes of N. Each time a new strain is discovered, the
strain subtype of Hand N are given determined resulting in the strain type.
Previous influenza pandemics have been associated with changes in H structure.
In order for a strain of influenza to be distinguished as pandemic, it must meet
the following criteria:
· The virus must have the ability to infect humans and cause high mortality
(death);
· Existence of a global human population that is immunologically naive;
and
· Efficient and sustained human-to-human spread.
What is the role of livestock and other animals in spreading
pandemic influenza?
Animals are often the source of novel strains of influenza for several
reasons. First, viruses must change so they have the ability to infect
an animal. Second, animals may become infected with several strains
of influenza which allows strains to share genes and further mutate.
These mutations may either be drifts, which are slight mutations or
shifts which are significant enough to allow a virus to infect large
numbers of humans or another animal species.
Why do the H5 strains of influenza have the potential to cause
pandemic influenza?
All known subtypes of influenza have the ability to infect birds. H5 and
H7 subtypes can be further distinguished as either "low pathogenicity"
or "high pathogenicity". H5 viruses have nine potential subtypes and
have been documented in humans, sometimes causing severe illness
or death. Human infection with H7 is rare, but can occur in people
who have close contact with infected birds. H5Nl and H7N7 strains
are of particular interest at this time, and the H5Nl strain has caused
the most recent cases resulting in severe illness or death.
Will stockpiling of antivirals affect my ability to prescribe
antivirals for my patients?
The federal government is purchasing a large amount of antiviral
medication from the manufacturer. There have been no indications
at this time that this will affect routine medical care.
Will there be a vaccine for pandemic influenza?
There is not a vaccine for avian influenza although there are now
researchers working with national governments to develop a vaccine.
Will antiviral medication (such as Tamiflu) be effective against
pandemic influenza?
No one knows definitively whether anitivirals such as Tamiflu will be
effective against pandemic influenza. It is likely that a pandemic
strain will be unlike previous strains and therefore may be resistant
to antivirals and existing vaccines.
Do I need to vaccinate patients for pandemic influenza?
There is no vaccine for pandemic influenza and we are not
experiencing pandemic influenza anywhere in the world.
What is the Iowa Dept. of Public Health doing to prepare for
pandemic influenza?
The Iowa Dept. of Public Health (IDPH) is developing a pandemic
influenza response plan in the event that pandemic influenza occurs in
Iowa. The state health department also watches for the different
types of influenza in people who visit their doctor, attend school, child
care or live in a long-term care facility. For more information on
influenza, pandemic influenza and avian influenza refer to our website
at www.idph.state.ia.us/adper/flu.asp.
Iowa Dept. of Public Health Updated 10/25/05 Center for
Acute Disease Epidemiology
What can I do to prepare my practice and my patients for
pandemic influenza?
The best way to protect your patients is to educate them on the basics
of disease prevention: 1) when and how to wash hands or use alcohol
gels, 2) to cover mouth and nose when coughing or sneezing, using
disposable tissues, throwing them away after use and than washing
hands or using an alcohol based hand gel. Encourage your patients to
get the influenza vaccine every year to lower their chances of getting
both causes of influenza at once and ensure that your patients in the
recommended groups have received the pneumococcal vaccine to
lower their chances of getting a bacterial pneumonia along with
influenza.
Should I screen patients for exposure to avian influenza? If
yes, who should I screen?
Ask about risk factors for acquiring disease. Have they traveled to an
area of the world that is currently experiencing avian influenza, were
they exposed to poultry or to persons who were ill with influenza like
illness (Ill) after exposure to poultry? If yes are they currently ill? If
III is present you should notify the health department and test for
influenza. There is no recommendation or reason to test persons who
do not have symptoms.
Links
. Information about influenza pandemics (Centers for Disease
Control)
. National Pandemic Influenza Preoaredness and Resoonse Plan
(Health and Human Services)
. WHO
Iowa Dept. of Public Health Updated 10/25/05 Center for
Acute Disease Epidemiology
Attachment 2
Fact Sheet
Pandemic Influenza
General Public
What is "pandemic influenza"?
Pandemic influenza refers to a very severe strain of influenza that has
the ability to spread across the world. The word, "pandemic", means
that a disease has caused illness in a person on nearly every
continent. Many other diseases throughout the history of the world
have been pandemic. An example is HIVjAIDS. HIVjAIDS is currently
pandemic since it has become widespread roughout the world.
Influenza occurs at different times throughout the world. Influenza
season strikes in the U.S. in the fall and winter months likely because
people stay inside often and are in close contact with others who may
be ill.
What is the difference between influenza (flu) and pandemic
influenza?
Influenza (flu) happens every year in nearly every country in the
world. It spreads through a population for a few months and then will
disappear or will move onto another country. Influenza usually occurs
in the fall and winter months. Also, people who usually become ill with
influenza are the elderly, the very young and people with chronic
medical conditions.
Pandemic influenza could strike at any time in the year. The strain will
be one never seen before and there will not likely be a vaccine
immediately available. It will spread quicker and easier from person to
person compared to non-pandemic influenza. Pandemic influenza may
cause illness in any person, and in the past has caused illness in more
healthy, middle-aged people than those who usually become ill with
influenza. It will probably circulate several times around the world, or
in "waves". Overall, pandemic influenza will cause more disease and
death than seasonal influenza.
How often do influenza pandemics occur?
Pandemics of influenza have occurred three times about every 100
years. From 1900-2000, there were three influenza pandemics, all
about 30 years apart.
What is Avian or Bird Flu?
Avian influenza is currently making many different types of birds in
Asia sick. There are several different types of avian influenza and
most types are found in birds. Avian influenza is often found in birds
and is not easily spread from birds to people. The type found in birds
in Asia right now has spread to a few people, but has not spread from
person to person. There is concern about this type of avian influenza
because it is a type of influenza that has caused serious illness in
people in the past. The influenza virus changes all the time so there is
also worry if this type of avian influenza ever changed so that it could
spread person to person, many people would become ill.
Can pandemic influenza infect animals?
Influenza infects different types of animals, usually pigs, birds and
sometimes horses, cats, dogs and other animals. Pandemic influenza
will likely be able to infect animals and may even infect people
because of their contact with infected animals.
Most household pets in the U.S. do not carry or are able to catch
strains of influenza that make people ill therefore you do not need to
worry about your household pet infecting you or your family with
influenza during normal influenza season. If pandemic influenza
occurs, you may need to take action to protect your pet and your
family.
What is the Iowa Department of Public Health doing to prevent
and/or prepare for pandemic influenza?
Throughout every "flu season", usually in the fall and winter months,
Iowa Dept. of Public Health (IDPH) tracks the different types of
influenza that occur in people who visit their doctor, attend school,
child care or live in a long term care facility. IDPH is also developing a
pandemic influenza response plan. For more information on influenza,
pandemic influenza and avian influenza refer to our website at
www.idph.state.ia.us!adper!f1u .aSD.
Is there a vaccine for pandemic influenza?
Currently, there is not a vaccine for pandemic influenza because we do
not know what strain will cause pandemic influenza. Many national
governments are working with researchers and scientists on a vaccine
. '
against the H5Nl strain of avian influenza, which has infected people
and birds in Asia.
Is Iowa stockpiling vaccine for the public?
IDPH is not stockpiling vaccine or antiviral medication for pandemic
influenza for three reasons.
o The federal government has started to stockpile antiviral
medication.
o For a vaccine to provide protection, it must be specific against
the new strain of influenza (the vaccine must "match" the strain
causing human illness).
o Even though the federal government has started to stockpile
antiviral medication, there is no guarantee this medication will
be effective or prevent illness due to a new strain of influenza.
The best preparation and defense for a possible pandemic is the ability
to detect and identify a new strain of influenza virus quickly, and then
determine the best response measures to limit exposure and spread,
and identify medication(s) to effectively treat the disease.
Is there medicine for pandemic influenza?
Depending on the type of influenza, there may be no medicine a
limited amount of medicine to treat those who are ill. Once a
pandemic strain is identified, then public health officials will have to
determine if any current medications may be used or if new ones need
to be developed.
The federal government is stockpiling antiviral medication in the event
that a pandemic of influenza happens. However, there is no guarantee
that the medication they are stockpiling will work against the
pandemic strain of influenza.
Is Iowa or the U.S. government stockpiling medication for
pandemic influenza?
Iowa is not stockpiling medication and does not the Iowa Dept. of
Public Health recommend health care professional stockpile antiviral
medication. The U.S. government is currently increasing the stockpile
of an antiviral drug in the event that it may be effective against the
kind of influenza virus causing the pandemic.
How can I protect my family from pandemic influenza?
The best way to protect yourself and others is to do the following:
o Wash your hands frequently with warm water and soap and
, ' .
scrubbing for at least 15 seconds.
o Cover your mouth and nose when coughing or sneezing and to
use disposable tissues.
o Use an alcohol-based hand sanitizer when hands are not visibly
soiled.
o Get the influenza vaccine every year to significantly lower your
chances of getting pneumonia due to influenza.
o People over the age of 65 and others with underlying illness
should also receive the pneumococcal vaccine to lower their
chances of getting a bacterial pneumonia and / or along with
influenza.
o If you are ill, stay home and call your doctor.
Links
. Information about influenza oandemics (Centers for Disease Control)
. National Pandemic Influenza Preparedness and Resoonse Plan
(Health and Human Services)
. WHO