Why Plan for a Pandemic?

Why Plan for a Pandemic? December 2007 Wisconsin Veterans Home at King Compiled by: Gail Boushon, Risk Management Officer 715-256-3230/ gail.boushon@dva.state.wi.us From: PowerPoint presentations from the WI Dept of Health and Family Services OSHA’s “Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and Healthcare Employers”

What Is Seasonal Influenza? • A respiratory disease caused by influenza virus. • Abrupt onset of fever, cough, sore throat, chills, body aches. • Not typically associated with vomiting or diarrhea. • Typical incubation period • 1–5 days (usually 1-3 days).

Avian Influenza - Highly Pathogenic H5N1 Outbreaks in Asia • Incubation period of up to 10 days • Primarily affected children & young adults (good immune systems) • Initially developed typical seasonal influenza symptoms – high fever/cough • But...lower respiratory tract symptoms (rather than upper) – shortness of breath and viral pneumonia • Diarrhea, abdominal pain, vomiting also frequently reported

Avian Influenza (H5N1) • Of the human cases, most had direct contact with infected domestic poultry • Several isolated cases are suspected to be spread from human to human • Lack of upper respiratory involvement appears to limit ability to cough up virus for easy human to human infection

Avian Flu has affected humans: • Azerbaijan – 8 cases/5 deaths • Cambodia – 7 cases/7 deaths • China – 25 cases/16 deaths • Djibouti – 1 case/0 deaths • Egypt – 38 cases/15 deaths • Indonesia – 113 cases/91 deaths • Iraq – 3 cases/2 deaths • Lao People’s– 2 cases/2 deaths • Nigeria – 1 case/1 death • Thailand – 25 cases/17 deaths • Turkey – 12 cases/4 deaths • Viet Nam – 100 cases/46 deaths Total – 335 cases/206 deaths – 61% death rate

Does Avian Influenza Always Result In Pandemic Influenza? NO!!!

For Avian Influenza To Become Pandemic, It Must: Be able to consistently spread from human-to-human

Possible Transmission Methods • 1957 – one study indicated person-to-person not consistent with airborne but another showed airborne based on reduction in illness rate from 19% to 2% in wards with UV ceiling lights • 2003 – conjunctivitis suggests transmission of H7N7 via the mucous members of the eye • Detection of infectious virus & ribonucleic acid in blood, cerebrospinal fluid & feces of one child raises potential for transmission by contact with these fluids, as well as respiratory secretions

Pandemic Influenza “An influenza pandemic is unlike any other public health emergency or disaster”

Seasonal Versus Pandemic Influenza In an affected community, a pandemic outbreak will last 6-8 weeks, with at least 2 pandemic disease waves.

1999 1997 2000 2001 1998

SPREAD OF A NOVEL VIRUS IN THE U.S.

Influenza: Seasonal Impact WISCONSIN Population ~5.4 million Outpatient Care 120,000-240,000 ~5%-20% Infected (270,000-1.1 million) Deaths ~600-1000 Hospitalized 3,500-7,000

Influenza: Pandemic Impact WISCONSIN Population ~5.4 million Outpatient Care 1.4 Million ~35% Infected 1.9 million Deaths ~8500 Hospitalized 27,400

What We Know And Don’t Know • An influenza pandemic is likely to occur at some time in our life • An influenza pandemic is not imminent • An influenza pandemic will affect everyone!!! • We do not know when it will occur • Need to prepare for increased absenteeism • Need to prepare now!!

Why Plan For A Pandemic? • The Pandemic will be so widespread, that we cannot count on the government to take care of us. • Resources – both people and supplies – will be in short supply at some point during the Pandemic. • There will be great need for health care. • We will not want to walk away from our residents, as was done in Hurricane Katrina.

Why plan? • On average, how many employees do you allow on pre-approved leave? • How many call in sick? • How many call in sick during “cold and flu season”?

Department of Homeland Security Pandemic COOP Planning Scenarios • Scenario 1 • 30 – 40% absenteeism • Commodity availability sustained – some reduction food

Department of Homeland Security Pandemic COOP Planning Scenarios • Scenario 2 • 40% absenteeism, including many key senior & line management & technical staff • Commodity availability sustained – considerable reduction food & fuel – localized disruptions of electrical supply & potable water

Department of Homeland Security Pandemic COOP Planning Scenarios • Scenario 3 • 50% absenteeism, including most key senior, management, & technical staff • Extensive & extended local & regional disruptions in availability of food, fuel, potable water, communications & power

Why plan? Think about . . . How are you going to operate if absenteeism is 30%, 40% or more for 3 weeks to 3 months?

Why plan? Oh, and by the way…. • Your suppliers & vendors may not be able to deliver • There may be increased demand for your services • Some key employees will never return • Some will quit, some retire, some die • Hiring replacements may be difficult • Quarantine/social distancing limits movement

Begin Planning • By reviewing your services and tasks: • By priority • By when it needs to be done/how long it can be postponed • Assume no regulations apply; do the best you can with what you have

State Enterprise Priority Levels Enterprise Priority Level I A business service whose activities cannot be interrupted for any period of time. Examples: • State level executive, health and military command and control and supporting communications infrastructure, • Essential law enforcement activities including law enforcement communications infrastructure, • State provided custodial care such as hospitals, nursing homes and prisons, and • Agency command, control and communications for agency with Enterprise Priority Level I services.

State Enterprise Priority Levels Enterprise Priority Level II A business service whose activities could be interrupted temporarily, but for no more than one week. Examples: • Benefits payments to individuals, and • State and agency payroll

State Enterprise Priority Levels Enterprise Priority Level III A business service whose activities could be interrupted temporarily, but for no more than one month. Examples: • Payments to vendors and businesses, • Payments to governmental entities, and • Quarterly business processes

State Enterprise Priority Levels Enterprise Priority Level IV All other business services that could be interrupted for from six weeks to three months, the likely duration of a pandemic wave. Examples: • Program planning (other than for the present emergency), • IT application enhancement or development (other than that directly supporting the present emergency), • Training, Licensing, • Most regulatory activities (not directly supporting the present emergency), and • Budgeting, accounting and reporting.

Create Your Plan – Expand on Your Coop • Communications • Supplies • Utilities • Security • Staffing

What’s Not in Your COOP Plan • Protection of your workforce • Wide-spread supply chain disruptions • Possible increased need for your services • Security procedures for quarantine and potential black-market thefts

PBX Home Fax Office Cell Satellite PBX .. .. .. Mobile Switch .. .. Local Switch Problem: Communications During an Emergency, Mass Calling Causes Network Congestion Congestion at many points! Public Network

Problem: Supplies • Just-in-time purchasing doesn’t work in an emergency - need to be self-sufficient • Disruptions to the supply chain can be expected to become extreme as a world-wide Pandemic results in world-wide shortages • Cannot count on the government to provide • Need critical supplies for an 8-week peak Pandemic activity period

Problem: Utilities • Interruptions to utility services are anticipated and usually addressed in COOP by use of emergency generators • Once interruptions are encountered during a Pandemic, might not be remedied until the Pandemic ends • How do you run a generator without fuel? Obtain water when bottled water is not available? Heat?

Security • Need to keep infected people away from non-infected people • Checkpoints and screening • Locked buildings/units • Need to keep staff, visitors, patients from removing valuable supplies

Problem: Staffing • Pandemic staffing levels as low as 50% • Requires prioritization of tasks and re-allocation of available staff • Staff need to be cross-trained, with at least 3 people for key tasks • Detailed manuals/training videos needed to assist untrained staff • Staff need to be protected from infection

Protection of the Workforce

Occupational Surveillance • Track workers assigned to care for patients with pandemic influenza • Track workers who have recovered from pandemic influenza • Track reasons for absenteeism • Screen workers for symptoms before each shift – exclude from duty • Test symptomatic/exposed workers

Infection Control • Standard Precautions • Droplet Precautions • Airborne Precautions • Contact Precautions

Possible Transmission Methods • 1957 – one study indicated person-to-person not consistent with airborne but another showed airborne based on reduction in illness rate from 19% to 2% in wards with UV ceiling lights • 2003 – conjunctivitis suggests transmission of H7N7 via the mucous members of the eye • Detection of infectious virus & ribonucleic acid in blood, cerebrospinal fluid & feces of one child raises potential for transmission by contact with these fluids, as well as respiratory secretions

Infection Control • Standard Precautions • Gloves and nose, mouth & eye protection • Hand hygiene • SOP for handling/disinfecting

Infection Control • Droplet Precautions • 3 feet of separation • Surgical mask within 3 feet of coughing/sneezing person • Standard cough etiquette • Consider cohorting patients • Does not protect from aerosol transmission, including aerosol-generating activities as sputum induction or bronchoscopy

Infection Control • Airborne Precautions • NIOSH-certified N95 particulate respirator or better for caregivers • Negative pressure room/area • Alternatives: single room or cohorting • Keep door closed • Provide own hand washing sink, toilet, bathing • Separate from high risk patients • Limit access/# of persons entering

Infection Control • Contact Precautions During aerosol-generating procedures and when contact with infectious fluids is anticipated and if diarrhea is associated with the Pandemic • PPE - including gown • Dedicated patient care equipment • Limiting patient movement • Private room or consider cohorting • Frequent cleaning of all “touchable” surfaces

Infection Control • Other – • Social distancing • If sick, stay home • Limit transport/movement • If transport necessary, maximize vehicle ventilation (do not use recirculating mode) • Mask patient or wear N95 respirator • Use vehicle with separate driver compartment when possible

Social Distancing • Consider how to limit contact • 3-6 feet between people • Limited/no sharing of equipment • Workspace/Workstations • Meetings/Conference Rooms • Cafeterias/Dining Rooms • Work at home – business functions such as payroll/billing • Reduce meetings, travel

Treatment and Prevention • Vaccinations – including seasonal flu and pneumococcal polysaccharide • Use of antivirals – oseltamivir as prophylaxis of healthcare workers or within 48 hours for treatment • Limited availability of monovalent vaccine expected 4-6 months after identification of specific pandemic virus strain

Personal Protective Equipment • Gloves – latex, vinyl, nitrile, or other synthetic materials - with no need to double glove • Gowns – not recommended for routine use, but when soiling anticipated • Goggles/face shields – not recommended for routine use, but within 3 feet and as needed to protect against likely sprays/splatters

Personal Protective Equipment • Respiratory Protection • N95 air-purifying respirators filter particulate hazards • All elastomeric and same filtering facepiece respirators have exhalation valves that reduce excessive dampness & warmth from exhaled breath but cannot be worn by infected person • Surgical mask prevents contamination of the environment by trapping bacteria & secretions expelled by wearer and protects wearer from splashes of blood & bodily fluids but does not filter small particles unless it is a surgical N95 • Wearing multiple surgical masks will not provide same protection as N95 respirator

Respirators • Need to be fit-tested • Considered contaminated after worn in presence of infectious patient; avoid touching exterior • World-wide shortage probable; may need to reuse • Not obviously soiled or damaged (creased/torn) and functions correctly • Limit to single wearer (label prior to use) • Consider wearing faceshield that does not interfere with fit or seal (remove upon leaving room, clean/disinfect) • Hang respirator in designated area/place in bag • Use care when placing used respirator on face

Why Plan for a Pandemic?