Alabama’s Pandemic Influenza Operational Plan April 16, 2007 Alabama’s Pandemic Influenza Operational Plan 04/16/07 1 Table of Contents Point of Contact for Submission 3 Acronyms and Abbreviations 3 Agencies Involved in Plan 5 Planning Assumptions 5 Thematic Area: Health Priority 1: Mass Vaccination 7 Priority 2: Public Health Continuity of Operation Plan (COOP) 14 Priority 3: Public Health Surveillance 23 Priority 3: Public Health Laboratory 30 Priority 4: Communications-Dissemination 34 Priority 4: Communications-Method 48 Priority 5: Community-Wide Healthcare Coalitions to Meet Patient Surge 50 Expected From Pandemic Influenza Priority 6: Facilitating Medical Surge 61 Priority 7: Fatality Management 74 Thematic Area: Education Priority 1: Policy Process for School Closure and the Communications Plan for 78 this Decision Priority 2: Education and Social Services in the Face of School Closures 78 Thematic Area: Continuity of Critical Functions Priority 1: Sustain/Support 17 Critical Infrastructure Sectors and Key Assets 86 Priority 2: Working with the Private Sector to Ensure Continuity of Operations for Critical Essential Services so that Critical Infrastructure Operations are 93 as “Near Normal” as Possible for Social and Economic Well-Being Priority 3: State Plans Must Conform to All NRP/NIMS Requirements 98 Thematic Area: Sustainment of Economy, Trade, and Business Priority 1: Mitigate the Impact of an Influenza Pandemic on Workers in the State 105 Priority 2: Assisting Employers in the State 105 Thematic Area: State Workforce Priority 1: Employment Policies during an Influenza Pandemic 117 Priority 2: Human Resource Policies for State Employees 117 Thematic Area: Safety and Public Security Priority 1: Coordination of Law Enforcement 130 Thematic Area: Agriculture and Food Priority 1: Critical Essential Functions for Food Safety 134 Priority 2: Operational Status of State-Inspected Slaughter and Food Processing 134 Establishments Including Talmadge Aiken Plants Priority 3: Communications Strategy for Interface with USDA Food Safety 134 Inspection Service and FDA’s Federal State Relations Priority 4: Ensure Adequate Reporting Systems Regarding Food Safety 134 Thematic Area: Foreign Diplomacy in United States Priority 1: State Advisories Regarding Diplomatic Missions 138 Appendices Appendix 1: Instructions for Preparing a Continuity of Operations Plan (COOP) 139 Appendix 2: Orders of Succession 141 Alabama’s Pandemic Influenza Operational Plan 04/16/07 2 Point of Contact for Submission Cindy Lesinger Pandemic Influenza Coordinator Alabama Department of Public Health 201 Monroe St. Montgomery, AL 36104 Phone: 334-206-3394 Cell: 334-202-0774 Email [email protected] Acronyms and Abbreviations AAA Alabama Ambulance Association ACIP Advisory Committee on Immunization Practices ADAI Alabama Department of Agriculture and Industries ADCNR Alabama Department of Conservation and Natural Resources ADMHMR Alabama Department of Mental Health and Mental Retardation AFDA Alabama Funeral Directors Association ADFS Alabama Department of Forensic Sciences ADHS Alabama Department of Homeland Security ADPH Alabama Department of Public Health AIMS Alabama Information Management System AlaHA Alabama Hospital Association ALNBS Alabama NEDSS-Based System ALERT Alabama Emergency Response Technology ANHA Alabama Nursing Home Association APHCA Alabama Primary Health Care Association BHPCD Bureau of Health Promotion and Chronic Disease BPharm,R.Ph. Bachelor of Science in Pharmacy Degree and Registered Pharmacist BPPS Bureau of Professional and Support Services BSL Biosecurity Level CDC Centers for Disease Control and Prevention CEU Continued Educational Units CEP Center for Emergency Preparedness CHD County Health Department CMHC Community Mental Health Center CO Carbon Dioxide 2 COM Colleges of Medicine COOP Continuity of Operation Plan DFA Direct Fluorescent Antibody DMORT Disaster Mortuary Operations Response Team EMA Emergency Management Agencies EOC Emergency Operation Center EP Emergency Preparedness EMS Emergency Medical Services EMT-P Emergency Medical Technician – Paramedic EPI Epidemiology Division ESF Emergency Support Function FAPhA Fellow in the American Pharmacists Association FBI Federal Bureau of Investigations FDA Food and Drug Administration Alabama’s Pandemic Influenza Operational Plan 04/16/07 3 GAR Governor’s Authorized Representative HAI Hemagglutination Inhibition HHS Department of Health and Human Services HSPD Homeland Security Presidential Directive ICS Incident Command System ICU Intensive Care Unit ILI Influenza-like Illness IM Instant Messenger ISD Information Services Division IT Information Technology JIC Joint Information Center JIS Joint Information System LEA Local Education Agencies LEPC Local Emergency Preparedness Committees MBA Masters in Business Administration MNS Medical Needs Shelter MOU Memorandums of Understanding NEDSS National Electronic Disease Surveillance System NVAC National Vaccine Advisory Committee NIMS National Incident Management System NRP National Response Plan PDA Personal Digital Assistants PDF Portable Document Format PHA Public Health Area PhD Doctor of Philosophy PHIN Public Health Information Network PI Pandemic Influenza PIO Public Information Officer POD Points of Dispensing PPE Personal Protective Equipment RN Registered Nurse RSS Receiving, Storage, and Staging SBE State Board of Education SCO State Coordinating Officer SDE State Department of Education or ADOE SHO State Health Officer SMORT State Mortuary Operations Response Team SOG Standard Operating Guidelines SNS Strategic National Stockpile SPHL State Public Health Laboratories STI Software Technology, Inc. U.S. United States USDA United States Department of Agriculture WHO World Health Organization Alabama’s Pandemic Influenza Operational Plan 04/16/07 4 Agencies Involved in Plan Alabama Governor’s Office Alabama Department of Agriculture and Industries Alabama Department of Economic and Community Affairs Alabama Department of Education Alabama Department of Emergency Management Agency Alabama Department of Finance Information Services Division Alabama Department of Human Resources Alabama Department of Industrial Relations Alabama Department of Mental Health and Mental Retardation Alabama Department of Personnel Alabama Department of Public Health Pharmacy Division Center for Emergency Preparedness Alabama Department of Public Safety Alabama Department of Senior Services Planning Assumptions All Thematic Area priorities are based on HHS’s Pandemic Influenza (PI) Planning Assumptions. In addition, each Thematic Area may have specific assumptions that will be presented at the beginning of each priority. HHS PI Planning Assumptions • Susceptibility to the pandemic influenza virus will be universal. • Efficient and sustained person-to-person transmission signals an imminent pandemic. • The clinical disease attack rate will likely be 30% or higher in the overall population during the pandemic. Illness rates will be highest among school-aged children (about 40%) and decline with age. Among working adults, an average of 20% will become ill during a community outbreak. • Some persons will become infected but not develop clinically significant symptoms. Asymptomatic or minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection. • Of those who become ill with influenza, 50% will seek outpatient medical care. • With the availability of effective antiviral drugs for treatment, this proportion may be higher in the next pandemic. • The number of hospitalizations and deaths will depend on the virulence of the pandemic virus. Estimates differ about 10-fold between more and less severe scenarios. Two scenarios are presented based on extrapolation of past pandemic experience (Table 1). Planning should include the more severe scenario. • Risk groups for severe and fatal infection cannot be predicted with certainty but are likely to include infants, the elderly, pregnant women, and persons with chronic medical conditions. • Rates of absenteeism will depend on the severity of the pandemic. Alabama’s Pandemic Influenza Operational Plan 04/16/07 5 o In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members and fear of infection may reach 40% during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak. o Certain public health measures (dismissing students from schools, quarantining household contacts of infected individuals, “snow days”) are likely to increase rates of absenteeism. • The typical incubation period (interval between infection and onset of symptoms) for influenza is approximately 2 days. • Persons may shed virus and transmit infection for up to one day before, and typically for 3-5 days after, the onset of illness. Viral shedding and the risk of transmission will be greatest during the first 2 days of illness. Children usually shed the greatest amount of virus and, therefore, are likely to pose the greatest risk for transmission. • On average, each infected person will transmit infection to approximately two people. • In an affected community, a pandemic outbreak will last about 6 to 8 weeks. • Multiple waves (periods during which community outbreaks occur across the country) of illness could occur with each wave lasting 2-3 months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty. Table 1. Number of Episodes of Illness, Healthcare Utilization, and Death Associated with Moderate and Severe Pandemic Influenza Scenarios* Alabama’s Data Alabama’s Data Moderate Severe Characteristic Based on Based on (1958/68-like) (1918-like) Population Population Illness 90 million (30%) 1,350,000 90 million (30%) 1,350,000 Outpatient medical 675,000 675,000 45 million (50%) 45 million (50%) care Hospitalization 865,000 12,975 9,900,000 148,500 ICU care 128,750 1,931 1,485,000 22,275 Mechanical ventilation 64,875 973 745,500 11,183 Deaths 209,000 3,135 1,903,000 28,545 Alabama’s Pandemic Influenza Operational Plan 04/16/07 6 Thematic Area: Health Priority 1: Mass Vaccination Lead Agency Alabama Department of Public Health (ADPH) 201 Monroe Street Montgomery, AL 36104 Agency Contact Information Christopher S. Hutto, MBA, EMT-P SNS Coordinator Pharmacy Division Phone: 334-206-3378 Email: [email protected] Charles C. Thomas, BPharm, R.Ph, FAPhA State Pharmacy Director Phone: 334-206-5666 Email: [email protected] F. Winkler Sims Immunization Division Director Phone: 334-206-5023 Email: [email protected] Dena Donovan Management Support Director Phone: 334-206-5672 Email: [email protected] Summary of Current Activities Alabama is well prepared to vaccinate the general population. In 2006, the Centers for Disease Control and Prevention (CDC) conducted an assessment, and the Alabama Department of Public Health Strategic National Stockpile (SNS) Plan received a “Green” rating. For the past several years, ADPH SNS Program has conducted Points of Dispensing (POD) training. POD training allows staff and volunteers to practice various scenarios involving the possibility of a contagious public health crisis. Pandemic Influenza (PI) is the focus of the 2007 POD trainings. Two trainings have been conducted for volunteers from the civilian population. Two additional trainings will also be conducted for the Poarch Band of Creek Indians on their reservation and another for Maxwell Air Force Base personnel. In March 2007, an SNS exercise was conducted involving the transportation and security of antiviral medication from a Receiving, Storage, and Staging (RSS) site to other named receiving centers throughout the state. This exercise consisted of dividing boxes by population size, placing them on the trucks, and having armed security escort Alabama’s Pandemic Influenza Operational Plan 04/16/07 7 the product to county destinations. When the boxes were delivered to the five different catchment areas, the local Emergency Management Agencies (EMAs) then escorted distribution of the boxes to county health departments (CHD). Specific Planning Assumptions: • Pre-pandemic vaccine will be shipped for immediate administration once sustained person-to-person transmission has been documented anywhere in the world. • Although uncertain as to amount available, only U.S. manufactured vaccines will be available for U.S. purchase during a pandemic. • U.S. will boost its manufacturing capability in the upcoming years. • States will follow the HHS priority groupings for pre-pandemic and pandemic vaccine. • The rank order of priority groups is subject to change. • Priority groups will be vaccinated sequentially. • Distribution of pandemic vaccine will be similar to pre-pandemic vaccine, except that it will take place over time as vaccine stocks become available. • A secure internet site will be available to track shipping status of vaccine shipments into the state. • Ancillary vaccination supplies will not be provided by SNS. • The number of doses administered will need to be reported to CDC on a weekly basis, along with other minimum data sets. • Community pharmacists will be available to administer vaccines and other treatments to patients going to the pharmacy for treatment. • ADPH will control the receipt, distribution, and administration of the vaccine stockpiles, both pre-pandemic and pandemic. Supply and demand will determine the amount of control over receipt, distribution, and administration. Operation Plan In the event of a pandemic, ADPH will distribute the vaccines available. These medications are securely stored in a warehouse following proper vaccine storage and handling protocols to maintain the cold chain, under the direction and supervision of the State Pharmacy Director. The method of distribution will follow the state’s SNS plan. In this plan, five predetermined (RSS) sites have been identified. Prior to sending the product to the RSS sites around the state, the amount of vaccinations available at that time will be divided and packaged to reflect population density in each catchment area. A pick list will accompany the medication, which will require a signature for release. This pick list will act as a receipt. At this time, ADPH is working with the Alabama Department of Conservation and Natural Resources (ADCNR), who has statewide police jurisdiction, to form a written agreement to escort the medication to the RSS sites in such an event. EMA in each RSS site is responsible for distributing any materials to their “catchment area.” EMA in each RSS site will contract a trucking company to transport the vaccinations to the counties in their catchment area. The security at this point will be determined by regional and local EMA. Communication will be vital throughout transportation process. Alabama’s Pandemic Influenza Operational Plan 04/16/07 8 Transporters will be required to call in upon arrival at their checkpoints and at the final destination. CHDs will provide the medical professionals for the actual administration and dispensing of the vaccine. Some of this staff will be ADPH employees, but many of them will be volunteers. During an event and prior to opening individual PODs, all safety and health issues will be discussed with staff and their families. Delegation of Authority • Dr. Donald Williamson, State Health Officer (SHO), will order the distribution of the vaccines statewide and for SNS, when necessary. SHO has been delegated to order SNS under the authority of the Governor. • Charles Thomas, State Pharmacy Director, will receive the call from Dr. Williamson and begin the process of distributing the vaccinations. • Chris Hutto, State SNS Coordinator, will receive the call from Charles Thomas to assist in distribution of vaccinations. • State EMA will receive the call from Dr. Williamson to have regional and local EMAs prepare to receive the vaccines and set up PODs. • EMA Directors in each RSS city will receive the call from the State EMA and begin setting up their RSS sites. • County EMA Directors will receive the call from the State EMA and begin setting up PODs in their county. • ADPH Emergency Preparedness (EP) Coordinators will receive the order from Dr. Williamson or his designee to staff the county PODs with pre-assigned personnel and volunteers. All personnel will follow ADPH’s written policies for confidentiality, discrimination, conduct, harassment, employee-labor relations, pay and leave, hiring, and a drug/tobacco free workplace. Any public health staff is required to read and sign these policies when hired. Any volunteer will sign the ADPH Volunteer Policy which not only addresses these issues, but also gives them immunity from law suits. For any employee that can perform their job via telecommunication and/or the internet, this will be allowed. However, most will either be working in a dispensing site, or stationed at a central Emergency Operation Center (EOC). At this time, our designated priority groups follow the Advisory Committee on Immunization Practices (ACIP) and National Vaccine Advisory Committee (NVAC) Vaccine and Antiviral Priority Group Recommendations. Reconstitution will follow a similar procedure as standing up PODs. As soon as an event has officially ended, volunteers will be dismissed. Volunteers will be encouraged to help with any clean-up efforts associated with their site jobs. The health department employees will repackage any unused supplies and properly dispose of any medical wastes. EMA will ensure that any equipment they supplied at POD sites has been properly stored or returned. Any unused vaccinations will be stored at local health departments unless otherwise directed by the SHO. Alabama’s Pandemic Influenza Operational Plan 04/16/07 9 Benchmark1 Individual vaccination clinics have been chosen by local EP coordinators, in conjunction with local EMAs. Selection of clinic sites, both size and quantity will be determined by the amount of vaccine available and the size of the population. Clinic sites are listed in the SNS plan for each county. Primary sites listed are local health departments, civic centers, and school gymnasiums. Alternative sites have been identified such as churches, climate-controlled warehouses, local pharmacies and health clinics. In a worst case scenario, large tents will be used. Benchmark 2 Each local EMA has an SNS plan in place that corresponds to the state SNS plan which includes all aspects of operations, from medical to security to transportation of the product. In our plans, essential functions of EMAs are security during transportation to the dispensing sites, providing a suitable dispensing site, and basic equipment (tables, chairs, etc.), any emergency medical transportation, and lay people to help with nonprofessional tasks. The essential functions of ADPH are providing the specific supplies such as proper medications, supplies associated with proper administration of the vaccinations, an informational video for those in line to be treated, informational handouts, necessary medically-oriented forms, communication equipment for the use of site staff, and health professional personnel to run the PODs. All vital records will be collected by qualified site staff and maintained by ADPH. Benchmark 3 During POD training, we ask participants to sign up to volunteer during an actual event. This list is kept in a database for each public health area (PHA) in the state. The database consists of nurses, pharmacists, pharmacy technicians, social workers, emergency medical technicians, and physicians. When the need arises, the area health departments will utilize their volunteer lists in order to fully staff the PODs. Yearly Estimate Allocation of Vaccine Based on Vaccine Availability Assumptions and Project Area Population Size* 2006 2008 County Population 90 ug/0.5% 30 ug/1.5% 10 ug/4.5% 90 ug/2.0% 30 ug/6.0% 10 ug/18% Colbert 54,824 274 822 2,467 1,096 3,289 9,868 Franklin 30,823 154 462 1,387 616 1,849 5,548 Lauderdale 87,515 438 1,313 3,938 1,750 5,251 15,753 Marion 30,267 151 454 1,362 605 1,816 5,448 Walker 70,005 350 1,050 3,150 1,400 4,200 12,601 Winston 24,475 122 367 1,101 490 1,469 4,406 PHA 1 Total 297,909 1,490 4,469 13,406 5,958 17,875 53,624 Cullman 79,189 396 1,188 3,564 1,584 4,751 14,254 Jackson 53,821 269 807 2,422 1,076 3,229 9,688 Lawrence 34,418 172 516 1,549 688 2,065 6,195 Limestone 69,387 347 1,041 3,122 1,388 4,163 12,490 Alabama’s Pandemic Influenza Operational Plan 04/16/07 10