Contra Costa County

PANDEMIC INFLUENZA PLAN

Version08/17/07

Contra Costa County Pandemic Influenza Plan

TABLE OF CONTENTS

Section I. Introduction and Overview 3Purpose

Concept of OperationsDescription of A PandemicPandemic Flu Phases TablePlanning Approach, Format, and AssumptionsVulnerable Populations ConsiderationsResponse Management and CoordinationPublic Health Role

Work Group RoleResponse Partners

Section 2. Disease Surveillance and Reporting 19SurveillanceReportingCommunity Updates and Emergency Systems Activations

Section 3. Laboratory Capacity 23Identification of Influenza A/H5

Laboratory Surge CapacitySpecific Actions

Interpandemic/Pandemic Alert PeriodPandemic PeriodPost Pandemic Period

Section 4. Clinical Case Management 28Interpandemic /Pandemic Alert Period

Provider Education and UpdatesVaccine and AntiviralsPatient PresentationPatient TreatmentPandemic Period

Section 5. Health Care Facility Planning 39IntroductionMedical Surge Capacity

Resources for Medical SurgeAlternative Care Sites

Alternate Care SEMS/NIMS RolesCCHS Alternate Care Site Process

Hospital Patient Surge Capacity- Table 1Hospital Patient Surge Capacity Pan Flu- Table 2Licensed In-patient Facilities- Table 3Outpatient Facilities- Table 4

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Section 6. Infection Prevention and Control Measures 55General Guidelines for Non Health Care Facilities (Schools,

Businesses, jails, board and care, etc.)Home CareGeneral Guidelines for Health Care Settings

Section 7 Non-Pharmaceutical Interventions 72Non-Pharmaceutical Interventions (NPIs)

CDC Severity IndexContra Costa Response Triggers Matrix

Vulnerable Populations Considerations

Section 8. Health Authority and Legal Issues 89DescriptionLegal ProceedingsWorkers Compensation Laws/LiabilitiesLicensing, Credentialing and Privileging

Section 9. Risk Communication and Public Information 99OverviewVulnerable Populations ConsiderationsCommunications InfrastructureCommunicating with the PublicWorking with the MediaRisk Communication StrategiesRisk Communication Guidance for HospitalsRisk Communication/Public Education Materials

Section 10.Behavioral Health and Psychosocial Services 117Interpandemic/Pandemic Alert PeriodPandemic PeriodPost Pandemic Period

Section 11.Ethics 120A Guide for Decision MakingKey Issues

Attachments 126

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INTRODUCTION AND OVERVIEW

Contra Costa Health Services (CCHS) has overall responsibility for protecting thepublic’s health during a health emergency. Currently, the potential exists for aninfluenza pandemic to cause serious illness and death to a large number of peoplethroughout the world. In response to this public health threat, CCHS has developed thisPlan to prepare for, respond to, mitigate, and recover from a potential influenzapandemic in the Contra Costa County Operational Area. CCHS, through its PublicHealth Division (CCPHD), will be the lead agency coordinating the local response withState and federal agencies and other local health care providers to a pandemicinfluenza (pandemic flu) outbreak in Contra Costa County.

The response will be carried out in accordance with this Pandemic InfluenzaPreparedness and Response Plan (Plan), and under the authority of the Local HealthOfficer. All emergency operations will be conducted in accordance with the CaliforniaStandardized Emergency Management System (SEMS) and the National IncidentManagement System (NIMS). The overriding goal of the public health response will beto minimize morbidity (illness) and mortality (death) due to all causes during theinfluenza emergency.

Concept of OperationsThis Plan serves as a reference and guide to facilitate the CCHS response to the healthcare needs of county residents if confronted by the impact of an influenza pandemic.The scope of this Plan includes actions defined in each of the plans mentioned belowspecific to the pandemic influenza context.

The Plan is an annex to the CCHS Emergency Response Plan, CCHS Public HealthDivision Emergency Response Plans, and the Contra Costa County EmergencyOperations Plan (Op Area) plan. It will be implemented in coordination with theRegional Disaster Medical Health Coordinator Interim Emergency Plan, the SanFrancisco Bay Area Regional Medical and Health Coordination Plan, the San FranciscoBay Area Regional Mass Care and Shelter Plan, and the State mutual aid mass fatalityplan.

Several CCHS Public Health Division Emergency Response Plans are particularlyrelevant to pandemic flu response and they are referenced in this Plan. These include:

Crisis and Emergency Risk Communication Plan Epidemiology and Disease Surveillance Plan Strategic National Stockpile Plan that includes the Mass Prophylaxis Plan CCHS Communication Go-Kit

This Plan has three primary purposes: to serve as a planning guide for public andprivate sector entities throughout the Op Area, including Contra Costa Health Services;to provide guidance and tools to the many partners in the community who will beaffected by the outbreak and involved in the response; and to guide activities to educateand prepare the general public regarding this public health threat. It is designed toengage other government entities, schools, businesses, families, individuals, and othercommunity partners to learn about, prepare for, and exercise components of the Plan.

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The development, refinement, and exercise of a pandemic influenza plan by allstakeholders are critical components of preparedness.

The primary objectives of this Plan are to: Limit the number of illnesses and deaths due to pandemic influenza by

promoting public and private sector partnerships to help ensure cross-agencycoordination in the planning for and responding to an outbreak of pandemicinfluenza;

Provide guidance for cities and Municipal Advisory Committees inunincorporated areas, and to coordinate their responses within the Contra CostaCounty Operational Area;

Preserve continuity of essential government functions and minimize socialdisruption and economic losses.

Pandemic Severity – The driver of local responseTo better predict the impact of a pandemic and to provide local decision-makers withrecommendations that are matched to the severity of an influenza pandemic, theCenters for Disease Control and Prevention (CDC), has developed a Pandemic SeverityIndex. This index uses the case fatality ratio (the proportion of deaths among critically illpersons) as the critical driver for determining the severity of a pandemic. Thecategories range from a 1 to a 5, with 1 being the least severe and 5 being the most. Asevere pandemic may indicate the need for more extreme measures to help prevent thespread of disease and loss of life. (See Sect. 7 for CDC Severity Index)

Description and History of a PandemicAn influenza pandemic is a worldwide outbreak that occurs when a new influenza virusappears or “emerges” in the human population that may cause serious illness or deathand spreads easily from person to person worldwide. Pandemics may be categorizedfrom mild to severe depending upon the number of people who become ill or die fromthe disease.

Pandemics are different from seasonal outbreaks of influenza that are caused bysubtypes of influenza viruses that already circulate among people. Pandemic outbreaksare caused by entirely new subtypes to which the population has no immunity becausethe subtype has either never circulated among people, or has not circulated for a longtime. Seasonal influenza occurs routinely worldwide each year, causing an average of36,000 deaths annually in the United States. Nearly 40 years have passed since the lastinfluenza pandemic.

Influenza viruses experience frequent, slight changes to their genetic structure.Occasionally they undergo a major change in genetic composition. It is this majorgenetic “shift” that creates a “novel” virus and the potential for a pandemic. The creationof a novel virus means that most, if not all, people in the world will have never beenexposed to the new strain and have no immunity. A new vaccine must be developed toprotect the population from the new virus strain, a process that takes 6-9 months.

Several characteristics of an influenza pandemic differentiate it from other public healthemergencies. Foremost, it has the potential to cause illness in a very large number ofpeople, overwhelming the health care system throughout the nation. A pandemicoutbreak could also jeopardize essential community services by causing high levels of

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absenteeism in critical positions in every workforce. Basic services, such as health care,law enforcement, fire, emergency response, communications, transportation, andutilities could be disrupted during a pandemic. Finally, a pandemic, unlike many otheremergency events, will last for months rather than days or weeks, disrupting supplychains for essential items such as food, water, and other essential provisions.

During the last century, there have been three influenza pandemics. The influenzapandemic of 1918 was especially severe, killing a large number of young, otherwisehealthy adults. That pandemic caused more than 500,000 deaths in the United Statesand an estimated 40 million deaths around the world. Subsequent pandemics in 1957-58 and 1968-69 caused far fewer fatalities in the U.S., 70,000 and 34,000 deathsrespectively, but caused significant illness and death around the world.

Planning Approach, Format and AssumptionsThe World Health Organization (WHO) identifies six distinct phases of a pandemic andthe Federal Government describes six response stages. This Plan incorporates allphases of the WHO model but organizes them by: Interpandemic / Pandemic AlertPeriod; Pandemic Period; and Post-Pandemic Period.

While the WHO Phases serve as a general planning guide and will trigger responseactions in Contra Costa County, the primary driver for local response will be the severityof the pandemic as defined by the CDC Severity Index. In response to a severepandemic influenza outbreak – a CDC Severity Index category 4 or 5 - this Planrecommends specific actions that may take place during any of the WHO orFederal Government Response Stages outlined in the Pandemic Flu Phases table(see next page). A severe pandemic may indicate the need for more extrememeasures to help prevent the spread of disease and loss of life while a less severepandemic may not require the same response. (See Sect. 7 Non-PharmaceuticalInterventions and Sect. 10 Ethics)

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This Plan is divided into sections. Each section describes a set of actions that arecritical for effective preparedness and response in the event of pandemic influenza.Each section provides a description of the critical capacity elements requiring specificactions and, where applicable, references tools to assist in implementing therecommended actions.

As appropriate, the actions are organized by Interpandemic/Pandemic Alert Period,Pandemic Period, and Post-Pandemic Period to more easily identify what actions needto occur in each period. The tools associated with the chapter are located in theappendices at the end of the document. However, in response to a severe pandemicinfluenza outbreak – a CDC Severity Index category 4 or 5 - this Plan recommendsspecific actions that may take place during any of the WHO or FederalGovernment Response Stages.

General Planning AssumptionsThe Centers for Disease Control and Prevention (CDC) estimates that a severeinfluenza pandemic could infect up to 200 million people in the U.S. and cause between100,000 and 200,000 deaths. Scientists and health officials throughout the world predictthat more influenza pandemics will occur in the 21st century.

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Planning Assumptions: Contra Costa CountyTotal*

Infected 337,630Outpatient 168,815Hospital 16,882ICU 3,022Ventilator 1,519Deaths 3,950

* Over 18 months based on CDC estimates

The following general assumptions apply to all parts of this Plan.• Influenza is highly communicable from person-to-person. People may be

asymptomatic while infectious and the incubation period may be as little as oneto four days, the same as with seasonal influenza.

• During the early stages, there will be little or no effective vaccine, and limitedsupplies of antiviral medications. Antivirals may prove inadequate for prophylaxisand treatment against the pandemic flu strain.

• Residents will be encouraged to reduce contact with others (social distancing)and will look to CCHS and Health Care Providers for information on diseasemanagement as well as guidance on how to access food, medications andmanage other basic needs.

• The epidemic is anticipated to occur in several waves over 18-24 months, andeach wave is expected to last 12 weeks.

• There will be a window period between waves during which there will be asubstantial decrease in the numbers of ill patients.

• Basic public and private infrastructure services will be disrupted and supply lineswill be impacted.

• Widespread illness throughout the state and county will increase the likelihood ofsignificant shortages of health care workers and first responders. Volunteers andretired professionals may be used to augment patient care in a variety of settingsas available and appropriate but the demand for health care services willchallenge the delivery system and limit medical mutual aid with California.

• The State Department of Public Health will issue guidance on the revision oftreatment standards to achieve optimal benefit for the most people.

• Permission to exceed licensed capacity may be granted by the State Departmentof Public Health during an emergency, and Alternate Care Sites will beestablished to reduce the demand for inpatient care and provide supportive care.

• Health care facility surge capacity of 1 case to 2000 population will need to berevised as the emergency situation changes over time.

• Health care providers must be prepared to manage the surge of pandemicinfluenza patients presenting for care based on predictions developed fromcurrently available data regarding influenza outbreaks:

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Vulnerable PopulationsPreparing for pandemic influenza requires specific attention to vulnerable populations toensure an effective response. CCHS is committed to providing health care services tothose in need and most vulnerable, and actively seeks to do so as part of its ReducingHealth Disparities commitment. Including vulnerable populations and the organizationsthat serve them in pandemic flu planning is consistent with CCHS’ mission to reducehealth and health care disparities and serve those most in need and vulnerable inContra Costa.

The definition of vulnerable populations extends beyond the notion of preparing to meetthe needs of culturally and linguistically diverse populations in Contra Costa County.CCHS and its partner agencies provide multilingual and culturally competent servicesthat will be integrated into the pandemic preparedness and response efforts. (Seeappendix for Vulnerable Population Service Provider Contact List).

Vulnerable populations may also include individuals in the community with physical,mental or medical care needs that may require assistance before, during and/or after adisaster or health emergency after exhausting their usual resources and supportnetwork. In the context of pandemic influenza, vulnerable populations can also refer to:

1. Members of our community with little or no ability to successfully prepare for,implement, or be fully responsible for their own emergency preparedness,response and recovery needs.

2. People whose life circumstances leave them unable or unwilling to followemergency instructions, as well as anyone unable or unwilling to fully accessor use traditional disaster preparedness and response services.

Several categories of vulnerable populations have been proposed and are definedbelow. Although these categories provide a basis for planning, it should not be assumedthat every person within the broad category would require an adapted response.

1. Physically disabled: Ranges from minor disabilities causing restriction ofsome motions of activities, to totally disabled requiring full-time attendant carefor feeding, toileting and personal care.

2. Mentally disabled: Ranges from minor disabilities where independence andability to function in most circumstances is retained, to no ability to safelysurvive independently, attend to personal care, etc. This also includes peoplewhose mental illness makes them a danger to themselves or others.

3. Blind: Includes the range of visual challenges and impairments—low vision,night blindness, color blindness, depth perception challenges, situational lossof sight, etc.

4. Deaf or hard-of-hearing: Includes late-deafened, hearing impaired, hard-of-hearing and the range of hearing challenges and impairments such assituational loss of hearing, limited range hearing, etc.

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5. Medically dependent/fragile: Includes people dependent on life sustainingmedications such as with HIV/AIDS and diabetes, or dependent onmedications to control conditions and maintain quality of life such as pain orseizure control medications, as well as the medically compromised whichincludes people with multiple chemical sensitivities or weakened immunesystems, and those who cannot be in (or use) public accommodations for avariety of reasons.

6. Seniors: Includes frail elderly, aged, elder citizens, older persons and therange of people whose needs are often determined by their age and age-related considerations.

7. Clients of the criminal justice system: Includes inmates, parolees, peopleunder house arrest, registered sex offenders, etc.

8. Limited English or non-English speaking: Includes monolingual individuals aswell as those with limited ability to speak, read, write or fully understandEnglish.

9. Homeless or shelter-dependent: Includes those marginally or temporarilyhoused or in shelters for abused women and children.

10.Culturally isolated: Includes people with little or no interaction or involvementoutside their immediate community. This is the broad meaning of the words‘culture’ and community’, including religious, ethnic, sexual orientation, etc.

11.Chemically dependent: Includes substance abusers and others who wouldexperience withdrawal, sickness or other symptoms due to lack of access,such as methadone users.

12.Children: Includes babies, infants, unattended minors, runaways and latchkeykids—any minor.

13.Single parents: Includes lone guardians, others with formal or informalchildcare responsibilities—especially those with no other support system.

14.Low income: Includes extremely low-income, without resources, withoutpolitical voice, limited access to services and limited ability to address theirown needs.

15.Geographically isolated: No access to services or information, limited accessto escape routes, or those for whom geography overwhelmingly determineslifestyles, habits, behaviors or options.

16.Persons distrusting of authority: Includes people without legal documentation,political dissidents, and others who will not avail themselves of government,American Red Cross or other traditional service providers for a variety ofreasons.

17.Animal owners: Includes owners of pets, companion animals or livestock —especially those who will make life and death decisions based on animals,

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such as refusing to evacuate or go to a shelter if it means separating from ananimal.

18.Emergent special needs: Includes those developing special needs because ofthe disaster, such as spontaneous anxiety/stress disorders, or recurrence of adormant health condition, etc.

19. Transient special needs: Includes people temporarily classified as specialneeds due to a temporary condition or status—such as tourists who will needcare until they can leave, those who can’t see until glasses are replaced, etc.

In responding to a pandemic influenza, some special needs will be obvious while othersmay be more difficult to detect. (See Appendix for Tips for First Responders)

Response Management and CoordinationThe County Health Officer has authority to enforce State statutes and regulations andCounty and City orders and ordinances. The California Government Code, Section101040, states " ... the County Health Officer may take any preventive measure that isnecessary to protect and preserve the public from any public health hazard during any'state of war emergency,' 'state of emergency, ' or 'local emergency' as defined bySection 8558 of the Government Code, within his or her jurisdiction." A localemergency can be declared due to health-related reasons. (See Sect. 8 HealthAuthority and Legal Issues).

A variety of local planning processes are occurring to ensure as comprehensive aprocess as possible to respond to pandemic influenza. This document identifiesprocesses managed under the auspices of the Health Officer, and provides guidance foragency and individual planning processes necessary to implement a response topandemic flu.

In an influenza epidemic, Contra Costa Health Services will institute a command andcontrol structure based on the Standardized Emergency Management System (SEMS),the National Incident Management System (NIMS) and the Incident Command System(ICS). SEMS, NIMS and ICS are described in detail in the Contra Costa HealthServices Emergency Plan.

The Health Services Director will activate the Department Operations Center (DOC)when the first human case of pandemic influenza, Severity Index, Category 4 or 5, isconfirmed in North America with global outbreaks worldwide. If the epidemic continuesto spread throughout the United States and/or the first case is documented in Californiaor the region, the Health Services Director will request the Emergency OperationsCenter (EOC) be activated and will report to that Center. The County Administrator isresponsible for the overall management of the EOC but the CCHS Director, who is alsothe County Health Officer, will lead the response in his role as Medical/Health BranchChief within the Operations Section. The Public Health Director or other designee of theCCHS Director will continue to direct the activities of the DOC.

Coordinated Responsibilities for Preparedness and ResponseThe Contra Costa Health Services Public Health Division (CCPHD) is the lead agencyinvolved in planning and preparing for pandemic influenza and responding to thepandemic when it occurs. To ensure a coordinated strategy aimed at protecting the

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public’s health and minimizing the impact of the pandemic influenza in Contra CostaCounty, CCPHD:

Conducts countywide surveillance to track the spread of the disease and itsimpact on the community and communicates with the Health Officer whensurveillance data indicate the potential need for a Health Emergency declaration;

Conducts laboratory testing for novel subtypes of influenza viruses andcoordinates and communicates with clinical and hospital laboratories regardingprocedures, specimen gathering and transportation, and novel strainidentification;

Prepares and activates the countywide Pandemic Influenza Response Plan,communicating with local, state, and federal partners, and overseeing publichealth response activities;

Activates and implements Strategic National Stockpile (SNS) and MassProphylaxis Plans (See SNS and Mass Prophylaxis Plans);

Coordinates the emergency public health response through the DepartmentOperations Center (DOC);

Educates the public, health care, businesses, response partners, communityagencies, and elected officials about influenza and preventive measures;

Implements disease containment strategies, such as social distancing; Participates in the health care system’s planning and response efforts for medical

surge capacity including mass casualty and mass fatality incidents; Directs mass vaccination efforts and plans for antiviral dispensing; Provides effective communications to the public, the media, elected officials,

health care providers, law enforcement, first responders, and business andcommunity leaders throughout public health emergencies;

Monitors and reports on the state of readiness of critical partners (e.g., cities,schools, businesses as well as local, state and federal governments).

The Pandemic Influenza Working Group of the Association of Bay Area Health Officials(ABAHO) is the regional planning body developing specific information and coreprocesses to guide the implementation of flu planning across the entire Bay Are. Keyactivities include:

Define triggers to activate emergency response plans at various stages of thepandemic;

Develop the ethical framework for decision-making and define triage guidelinesfor hospitalization, home care, long term care facilities, and referral to alternatecare facilities;

Develop policies, processes, or guidance for: enforcing isolation/quarantine,allocating vaccines, inventorying of essential health care items, assessing andexpanding capacity of long term care facilities, infectious disease reporting,specimen transport safety, and developing administration systems for alternativefacilities care;

The role of the Contra Costa Pandemic Flu working group, comprised of representativesfrom CCHS (including public health, EMS, environmental health, Contra Costa HealthPlan, mental health, the public health laboratory, and Contra Costa Regional MedicalCenter), private health care providers, the American Red Cross, Employment andHuman Services Department, local hospitals, schools, other licensed healthcarefacilities, businesses, law enforcement, Office of Emergency Services, and jails, amongothers, is to:

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Review and refine reporting processes for managing acute infections, including:surveillance forms, hospital admissions and discharges, laboratory confirmationprocesses, bed capacity, staffing, supply needs, and other critical items;

Develop a coordinated methodology to implement surge capacity response,including accelerating hospital discharge and deferring elective procedures;

Identify processes to address food and waste management needs; Develop Memoranda of Understanding (MOUs) with In Home Support Services

(IHSS), home health agencies, Skilled Nursing Facilities, hospitals, and otherhealth care facilities in Contra Costa;

Maintain ongoing coordination with law enforcement and other agencies withcritical roles in emergency response.

Continuity of GovernmentContra Costa Health Services is developing a Continuity of Government (COG) planthat will describe the essential functions that must continue in the event of a severepandemic influenza outbreak or other health emergency or disaster. The COG willdescribe how the following functions will be performed:

- control of communicable diseases- control/investigation of food borne illnesses- response to hazardous materials incidents- conducting critical laboratory tests- maintaining inpatient medical center functions- operating the 24/7 advice nurse unit- public information- vital records and databases

Response PartnersEffective preparedness and response requires the active participation of numerousparties whose responsibilities are summarized below. Specific responsibilities for keyresponse partners are included to highlight points of coordination between agenciesduring a pandemic. It is expected that health care providers, essential serviceproviders, schools, local government officials and business leaders will develop andincorporate procedures and protocols addressing influenza preparedness and responseactivities into their emergency response plans.

Governor’s OfficeThe Emergency Services Act authorizes the Governor during a state of emergency tosuspend any regulatory statute, or statute prescribing the procedure for conduct of statebusiness, or the orders, rules, or regulations of any state agency, where the Governordetermines and declares that strict compliance would in any way prevent, hinder, ordelay the mitigation of the effects of the emergency. The authority to suspend statutesis unique to the Governor.

California Department of Public Health (CDPH)The CDPH coordinates planning and preparedness efforts, surveillance activities, anddisease containment strategies at the state level and across mutual aid regions withinCalifornia. CDPH is also responsible for operating a biosafety level 3 laboratory,coordinating the receipt and distribution of pandemic information, distributing antiviralmedicines and vaccines from the state and federal Strategic National Stockpile to local

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health departments, overseeing facilities and staff licensure and health care regulations,and informing the public on the course of the pandemic and preventive measures.

Centers for Disease Control and Prevention (CDC)The CDC is responsible for national and international disease surveillance,communicating direction and information from the Federal government to the State andlocal public health agencies, investigating pandemic outbreaks, and overall monitoringthe impact of a pandemic. The CDC acts as the national liaison to the World HealthOrganization (WHO) and assumes a lead role in disease investigation.

U.S. Department of Health and Human Services (HHS)The responsibility of HHS is to provide overall guidance on pandemic influenza planningwithin the United States and coordinate the national response to an influenza pandemic.HHS works directly with State governments to ensure coordinated response efforts.

World Health Organization (WHO)WHO is responsible for monitoring global pandemic conditions and providinginformation updates. WHO facilitates enhanced global pandemic preparedness,surveillance, vaccine development and health response. WHO is the organizationresponsible for declaring a global pandemic phase and adjusting phases based oncurrent outbreak conditions.

California Department of Fish and GameThe California Department of Fish and Game plays a vital role in providing surveillancefor novel influenza viruses in birds. The mission of the CA Department of Fish andGame is to manage California's diverse fish, wildlife, and plant resources, and thehabitats upon which they depend, for their ecological values and for their use andenjoyment by the public. The Department of Fish and Game maintains native fish,wildlife, plant species and natural communities for their intrinsic and ecological valueand their benefits to people. This includes habitat protection and maintenance in asufficient amount and quality to ensure the survival of all species and naturalcommunities. The department is also responsible for the diversified use of fish andwildlife including recreational, commercial, scientific and educational uses.

CCHS and Other County Government Agencies and DepartmentsAll Contra Costa County government agencies and departments have various importantroles to play in preparing for and responding to an influenza pandemic. As an employerand provider of services, county government agencies and departments will need todevelop continuity of operations plans to protect the health and safety of employees,patients, and customers, such as taking steps to limit the spread of flu within workplacesto minimize disruption for its delivery of essential services. They may also need toprovide resources for the pandemic flu response (e.g., vacant space for Alternate CareSites, critical services provision, staffing, equipment, etc.) and develop plans thataddress roads, air travel, and provision of critical County services, such as socialservices, health services and jail services. Finally, all County employees may be calledupon to serve as Disaster Service Workers during the pandemic.

CCHS Public HealthThe Contra Costa Health Services Public Health Division (CCPHD) is the lead agencyinvolved in planning and preparing for pandemic influenza and responding to the

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pandemic when it occurs. (See Coordinated Responsibilities for Preparedness andResponse – above)

CCHS Emergency Medical Services (EMS)Facilitates and coordinates planning activities, including the identification of alternatecare sites, prioritizing and providing patient transport, planning for surge capacity needsdue to increased demand for service combined with increased employee absenteeism,and preparing responders for effective infection control. EMS will need to plan for andtrain personnel in personal protective equipment and other disease and infection controlmeasures.

CCHS Communications OfficeInforms the public and media about the status of emergency, mitigation steps, locations,and procedures for receiving vaccinations and/or anti-viral medications (See Section 8.Risk Communication and Public Information).

CCHS Environmental HealthSupports the delivery of messages regarding infection control, especially in medicalsettings, food establishments, and alternate care sites, and assists in the planning fordisposal of infectious waste.

CCHS Mental HealthDevelops and implements plans to address the psychosocial needs of health careworkers, Disaster Service Workers, Contra Costa County employees, and thecommunity at large, including maintaining essential workers and increasing staffingcapacity as necessary. (See Sect. 10 Behavioral Health and PsychosocialConsiderations)

Sheriff’s Office (SO)Coordinates law enforcement mutual aid resources, enforces emergency directives ofthe Health Officer, and coordinates force protection for Strategic National Stockpileassets. The Coroner plans for the disposition of a surge in deceased persons inaccordance with the Operational Area Mass Fatality Plan. Coordinates with localfuneral homes and mortuaries to ensure plans and mutual aid agreements are in place.

Contra Costa Office of Emergency Services (OES)Operates the County Emergency Operations Center (EOC) according to SEMS/NIMS,coordinates responding agencies, ensures availability of adequate resources, andrequests additional mutual aid resources in the event of a major disaster or healthemergency within the Operational Area.

Contra Costa Legal Counsel (and Judicial System where applicable)Facilitates the development of Public Health orders for a Declaration of Emergency,Health Officer Orders, and other related disease containment orders. The CourtSystem ensures that citizens are afforded due process as they are asked to comply withsuch orders. May assist in reviewing and resolving any legal issues that arise related towork place, occupational health, labor relations and overall medical response activities.

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Buchanan Field Airport / Contra Costa Public WorksThe Contra Costa Public Works staff housed at Buchanan Field Airport will collaboratewith CCPHD to prepare for evaluating and managing ill travelers taking off from andlanding at the airport. Activities include distributing health information for travelers;establishing enhanced surveillance at the airport during the early stages of thepandemic; and implementing the cancellation or limitation of nonessential travel to orfrom Buchanan Field.

Animal Services DepartmentThe Contra Costa Animal Services’ Department plays a vital role in providingsurveillance for novel influenza viruses in birds and other animals. They are alsoresponsible for establishing pet shelters in response to a major disaster or emergencywhen people are being sheltered due to the disaster. Their mission is to protect thecitizens of Contra Costa County from animal related disease and from animal injury,encourage responsible pet ownership and the humane treatment of animals, enforceState Laws and County Ordinances relating to the control of animals and animalwelfare, minimize animal suffering, reduce the number of animals that are euthanized inthe County, maximize the number of dogs licensed in the County, educate the publicregarding responsible pet ownership and provide a high level of humane care foranimals in our custody.

County Department of AgricultureThe Contra Costa County Department of Agriculture under the direction of the CaliforniaDepartment of Food and Agriculture, Department of Pesticide Regulations and Divisionof Measurement Standards, is responsible for conducting regulatory and serviceactivities pertaining to the agricultural industry and the consumers of our county. Theprimary purpose and objective of this office is the promotion and protection of thecounty agricultural industry, the environment, and the citizens and to ensure a safeplace to live and a fair marketplace for trade.

Employment and Human Services DepartmentThe Employment and Human Services Department (EHSD) is the lead Countydepartment responsible for coordinating emergency shelter and care. EHSDcoordinates these activities with the Office of Emergency Services and the AmericanRed Cross. EHSD will have a lead role in helping to establish and manage AlternateCare Sites in the event of a severe pandemic influenza outbreak.

Local Healthcare System Partners (Hospitals, Clinics, Providers)Healthcare partners will be instrumental in detecting influenza, limiting the spread ofdisease, and providing treatment to affected individuals. Healthcare partners should:

Develop a pandemic flu plan that details surge capacity addressing staffing, bedcapacity, and stockpiling of food, water, fuel, equipment and supplies;

Conduct enhanced surveillance among patients, staff and visitors and complywith public health orders for detecting, preventing and reporting cases ofpandemic flu;

Implement appropriate infection control measures and develop/provide educationand training to healthcare staff on recommended aspects of pandemic influenza;

Comply with admission, triage, and Occupational Health guidelines provided bythe CDC and/or CCPHD;

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Provide to CCPHD estimates of quantities of vaccine for healthcare staff andpatients and develop a vaccination plan for own facility;

Plan for additional site security for own facility; Develop a plan for Care of the Deceased and cooperate in fatality management

with guidance from the County Coroner; Participate in the Hospital Disaster Forum convened by CCHS to maximize the

health care system’s ability to:o identify and prioritize response issues affecting the county-wide health

system during a pandemic;o develop mechanisms to efficiently share information and resources

between health system partners;o Identify and communicate policy level recommendations regarding the

operations of the local health system to the local Health Officer for action.

American Red CrossDuring a pandemic flu event, the American Red Cross (ARC) will provide for feedingand bulk distribution for isolated and quarantined individuals, either directly or byconvening and collaborating with others who are willing to provide these services. TheARC will not operate special, medical needs shelters, or alternate care sites, nor deliverdirect medical care, but will provide significant support to these types of facilities.

The Red Cross is not able to commit Red Cross workers to local public health overflowfacilities without appropriate worker protections, including liability coverage and workersafety measures. The Red Cross continues to explore the legal, risk and workerprotection considerations for a possible Red Cross support role in these facilities.These efforts include seeking federal assistance for a variety of protections for workers,as well as similar assistance at the state level.

BusinessesLocal businesses should plan for continuity of operations in the event that infrastructureand other services are disrupted by employee absenteeism, a drop in customer base,and/or absenteeism in outside partners, services or other organizations. Business plansshould prioritize activities and address how the critical activities will continue in the faceof shortages in supplies, deliveries and staff.

Two important aspects, where applicable, will be to address providing essentialproducts to the public (e.g., food, water, waste disposal, utilities, communications, andpharmacy merchandise) and planning for the potential suspension of public assemblybusiness services (e.g., entertainment venues, hotels, restaurants, etc.). Localbusinesses will play a key role in protecting the health and safety of their employeesand customers by instituting protocols to limit the spread of disease in the workplace,and may be asked to provide resources for the pandemic flu response (i.e., space forAlternate Care Sites, critical supply provision, etc.).

Local GovernmentsLocal governments should have continuity of government plans that consider thelikelihood of a flu pandemic; take steps to limit the spread of flu within their workplaces;and cooperate with CCHS to provide resources for the pandemic flu response (e.g.,vacant space for Alternate Care Sites, critical services provision, etc.). Localgovernment also has a direct role in coordinating emergency services, providing law

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enforcement and providing Disaster Service Workers in response to a pandemicinfluenza outbreak.

Local Law EnforcementThe main responsibilities of law enforcement will be to maintain social order, providesecurity, and assist in the enforcement of Health Officer Orders as necessary. Securityneeds will be likely at pharmacies, hospitals, Alternate Care Sites, during closures ofvenues, and at point of dispensing (POD) sites once vaccines or other medicationsbecomes available. Law enforcement personnel will need to plan for and trainpersonnel in personal protective equipment and other disease and infection controlmeasures. Law enforcement should have continuity of operations plans that considerthe likelihood of a flu pandemic; take steps to limit the spread of flu within theirworkplace; and provide resources for the pandemic flu response.

Fire ServicesAs critical first responders, City and County Fire Departments will need to plan forincreases in employee absenteeism due to pandemic flu and an increase in demand forservices. Fire Services will need to plan for and train personnel in personal protectiveequipment and other disease and infection control measures. Fire Services shouldhave continuity of operations plans that consider the likelihood of a flu pandemic; takesteps to limit the spread of flu within their jurisdictions (i.e., “no work while sick” andpersonal hygiene practices); and cooperate with CCHS to provide resources for thepandemic flu response.

Colleges and UniversitiesColleges and universities will need to incorporate some of the same responsibilitiesassigned to businesses, schools, and city government. Depending on their size,colleges may need to assign space for Alternate Care Sites and/or mass prophylaxissites, address how to provide basic survival services to students isolated in dormitories,and make academic plans should the university/college need to be closed for severalmonths. Colleges and universities should have continuity of business plans thatconsider the likelihood of a flu pandemic; take steps to limit the spread of flu within theirinstitution; and cooperate with the CCPHD to provide resources for the pandemic fluresponse (e.g., space for Alternate Care Sites, critical supply provision, etc.). Collegeswith health care and closely related educational departments will participate inworkgroups discussing means to address staff shortages.

Community and Faith-based OrganizationsCommunity and faith-based organizations will be responsible for their own continuity ofoperations planning in the event of an influenza pandemic. These organizations play akey role in providing support services to individuals, neighborhoods and theircustomer/client base during a pandemic and may be called upon for assistance withintheir communities as appropriate.

Schools (Including Preschools, Child Care Centers, Family Day Care Providers)All school districts and preschool and other child care providers should take steps tolimit the spread of flu within their settings (see Contra Costa Pandemic Flu Toolkit forSchools and Toolkit for Child Care Providers at www.cchealth.org). Schools may needto be closed for as long as several months, and should have contingency options ifordered closed as part of a social distancing strategy (e.g., home schooling lessonplans for parents; catch-up school calendars, etc.).

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News MediaThe news media have a primary role in providing public education during the alertperiod, as well as timely and accurate public information throughout the pandemicperiod. News media organizations will need to consider planning for their continuedoperations during a pandemic, addressing the issue of high absenteeism and, whereindicated, providing personal protective equipment to personnel expected to work in apublic setting. (See pandemic flu media checklist at www.cchealth.org)

Individual ResidentsIndividuals and families, in order to protect themselves and limit the spread of thedisease, will need to take responsibility for keeping informed about the risk for pandemicflu and take appropriate common-sense actions such as practicing good hygiene andpreparing their own pandemic flu emergency kits. Individuals and families should alsobecome familiar with isolation, quarantine and social distance measures they may berequired to take during a pandemic.

As part of the overall emergency preparation plan, each household will need to discussand plan for scenarios such as closure of daycare and school facilities, possible returnof college-aged youth to the home, and care for elderly family members living alone.Health care and emergency responders may not be available to return home for periodsof time. (See Appendix for a list of minimum emergency supplies, as well as Appendixfor Home Care instructions.)

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Section 2 Disease Surveillance and Reporting

Introduction

Accurate and timely surveillance is critical for early detection, identification andmonitoring of disease progression in a community. The data supplied by surveillancesystems supports implementation of control measures such as restricting travel, closingschools and canceling public gatherings, initiating antiviral and vaccine usage in definedtarget groups, activating surge plans, assessing the impact of a pandemic on thehealthcare system, and assessing the social and economic impact on society. Thegoals of influenza disease surveillance in Contra Costa County are to: (1) serve as anearly warning system to detect increases in influenza-like illnesses (ILI) (2) to tracktrends in influenza disease activity by monitoring the impact of the pandemic on health(e.g., by tracking hospitalizations and deaths), and (3) to identify populations that areseverely affected.

Contra Costa Health Services will initiate an enhanced surveillance system for ILI insentinel school-based clinics. (See also Pandemic Action Kit for Schools online atwww.cchealth.org) and work closely with California Department of Health Services(CDHS) and private sector healthcare organizations and providers to implement activesurveillance in hospital settings. (Refer to the CCHS Epidemiology and SurveillancePlan)

Additional Planning Assumptions: Additional disease investigation staff will be added to the current workforce to

ensure capacity to conduct surveillance. “Just in time training” will be needed for all available public health staff

Interpandemic/Pandemic Alert Period (WHO Phases 1-5)The primary Surveillance objectives for the Interpandemic/pandemic alert period are:

1. Early identification and treatment of infection with a novel or pandemic influenzastrain in Contra Costa County;

2. Timely and accurate reporting and monitoring of suspect cases; and3. Timely dissemination of updates and recommendations to the healthcare

community

CCHS receives surveillance information through a variety of systems routinely in placeand from special systems in place through CDHS. These systems, described below, willremain in place during the pandemic with modifications as indicated to support earlyidentification and referral to treatment of pandemic flu reported in Contra Costa.

Confidential Morbidity Report (CMR) and the Automated Vital Statistics System(AVSS)The Confidential Morbidity Report (CMR) is mandated by Title 17, California Code ofRegulations (CCR), sections 2500, 2593, 264-2643, and 2800-2812: ReportableDiseases and Conditions. Healthcare providers, laboratories, and schools withknowledge of a case of any reportable disease are required to report this information tothe health officer in the jurisdiction of the case’s residence. Cases are reported byphone and fax. In addition to reportable disease, outbreaks of any disease arereportable.

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The Automated Vital Statistics System (AVSS) is a statewide automated informationsystem for public health records. Counties routinely enter information on reportablediseases and vital statistics into AVSS. This data is readily accessible to the CaliforniaDepartment Health Services, and subsequently to the Centers for Disease Control andPrevention (CDC).

CMRs are routinely managed and routed by public health staff. Diseases of particularconcern or those that require further investigation are routed to public health nursesworking in CCHS’s Disease Investigation Unit. If needed, additional case reportingforms are completed. Weekly reports from AVSS are used to summarize diseaseactivity in the county. Outbreaks of influenza should be reported immediately to thehealth department and entered into AVSS. (Refer to the CCHS Epidemiology andSurveillance Plan)

During a pandemic alert it is likely that influenza would be added to the list of reportablediseases. CMRs would be used to monitor and collect data on all cases in the county.Epidemiological investigation and contact tracing for known cases would be used toidentify additional cases.

Public Health Nurses’ DatabasePublic health nurses working in the Disease Investigation unit maintain a databasecontaining all the communicable disease cases currently under investigation, includingcases associated with an outbreak. This database is used to investigate cases, monitorprogress, and analyze disease occurrence. CCHS staff enter information on cases thatneed to be investigated, including the source of the report, assigned investigator, datesand times associated with the investigation, and demographic information about thecase. Cases are reviewed by disease type to identify potential clusters among existingcases. Analysis includes travel history, food history, sensitive occupation andattendance at large events.

During the alert stage, clusters would be recognized as described above and theemergency systems would be activated.

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Influenza Illness SurveillanceUpon laboratory confirmation of the first case of novel influenza virus in Contra CostaCounty, CCHS will initiate enhanced surveillance, case detection, contact tracing, andinfection control. CCHS will actively monitor any changes in recommendations andguidelines for surveillance and diagnostic testing from CDC. Additionally, CCHS will:

Communicate with CDHS via weekly electronic communications, CD Brief, theVRDL, California Influenza Surveillance Project website, and conference calls toshare information on surveillance criteria, case management, specimencollection, and appropriate testing.

Maintain all other existing enhanced surveillance systems. Work with CDHS to utilize an outbreak management system for case

investigations, case management, case ascertainment, case reporting,surveillance, and data analysis.

Review contingency plans to further enhance influenza surveillance if efficientperson to person transmission of the novel virus is confirmed, including trainingadditional personnel on surveillance, case detection, contact tracing, andinfection control issues.

Coordinate with the CCHS Communications Officer to post updated informationon the CCHS website.

During a pandemic alert, the most important role of surveillance is to identify the timing,location, and the extent of the novel influenza strain infection in order to guideimplementation of outbreak control and other response activities. CCHS will continuesurveillance activities of the prior phases and will also:

Work closely with CDHS to manage new suspect cases, provide furtherconfirmatory testing, and implement containment strategies to prevent or limitlocal spread (e.g., isolation and quarantine, antiviral treatment, and/orprophylaxis).

Provide technical assistance to guide expanded testing on specific cases thatrepresent risk of spread of the novel virus infection in the community, includingthose who have an epidemiologic link to infected cases. CCHS will communicatewith CDHS concerning management, reference laboratory testing, andcontainment strategies in these cases.

Laboratory Surveillance- See Sect. 3 Laboratory Capacity.

ReportingInfluenza is not currently a reportable disease in California because of the large numberof cases that occur each year with a non-specific clinical presentation and no routinelaboratory confirmation. During a pandemic response, Contra Costa’s CommunicableDisease Chief or the Director of Public Health acting on behalf of the Health Officer maydeclare the circulating strain of influenza causing the pandemic a Disease of PublicHealth Significance, requiring health care providers and/ or laboratories to report cases.Information on how and to whom to report, along with forms, is available on the CCHSwebsite. (Refer to the CCHS Epidemiology and Surveillance Plan) (See also in thisplan, Sect. 4 Clinical Case Management for Provider Education Updates)

Community Updates and Emergency Systems Activation and PlanningWhen communicable disease outbreaks take on more than localized significance,CCHS has access to a variety of electronic emergency notification systems such asEPI-X, CAHAN, and Reddinet to initiate and /or respond to emergency provider alerts

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and messages. (For more information, see also the Appendix CommunicationsMethods table.)

In addition to the electronic surveillance activation systems, CCHS monitors Kaiserfacilities’ diagnosis and pharmacy surveillance systems and the daily CDC and Statereports. When any of these sources indicates a potential upswing in influenza casesCCHS will utilize all available venues for rapid dissemination of key providerinformation, including:

Meet with the local Journal Club (Bay Area Infection Control Nurses,Physicians and Practitioners) to update and gather more information in orderto identify groups at increased risk and inform local practitioners of the needto increase specimen collections for detection of a novel virus and to alertlaboratories to prepare for increased numbers of specimens.

Distribute specimen collection kits to hospitals and clinicians and obtaincooperation to facilitate sending isolates to the Public Health Laboratory.

Coordinate information dissemination with Communications Officer and staff,including notification of health officer and other internal systems. (See Sect. 9Risk Communication and Public Education)

Pandemic Period (WHO Phase 6)The surveillance objectives during the Pandemic Period include:

1. Monitoring the epidemiology and impact of the pandemic in Contra Costa andassisting in disease containment and planning.

2. Continue the enhanced surveillance activities of the previous phase

As the disease phase changes, surveillance and reporting will also change. Whencommunity transmission is established and monitoring numbers of suspected andconfirmed cases becomes overwhelming, CCHS and CDHS will collect only aggregatenumbers (batch reporting) of suspected and confirmed cases, as well as other importantmorbidity and mortality markers such as numbers of hospitalizations and deaths. Whenthe pandemic is well under way, surveillance for novel virus infection will primarily relyon clinical diagnoses made in outpatient clinics, emergency departments, inpatientwards, and intensive care units. Batch reporting will be required on at least a weeklybasis from the largest health care providers in the county and may be required from callhandling centers and ancillary care facilities. Data for case fatality rates will becollected and analyzed for resource implications.

Calls from the public can be answered by the Public Health Advice Nurse, orif the call volume warrants, the Health Emergency Call Center may beactivated (see Sect. 9 Risk Communications and Public Education)

Postpandemic PeriodThe surveillance objectives for the postpandemic period are to:

1. Clarify the disease situation and to assist the community in recovery through thedissemination of information.2. Evaluate the efficacy of containment and emergency management strategies.

Surveillance data case fatality data will be reviewed and analyzed to determineadditional resource needs and revise reporting systems as appropriate.

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Section 3. Laboratory CapacityThe Contra Costa Public Health Laboratory is a modern, state-of-the-art public healthlaboratory with capabilities to rapidly identify Influenza A/H5 in specimens from patientswith influenza-like illness. The laboratory has the ability to perform direct antigen testsfor Influenza A and B, isolation of Influenza viruses in cell culture, detection of InfluenzaA and B RNA directly from patient specimens by reverse transcriptase polymerasechain reaction (RT-PCR), and subtyping of Influenza A viruses (H1, H3, and H5) by RT-PCR.

The strategy for initial laboratory testing is to rapidly identify an influenza A virusinfection and to exclude other common viral respiratory infections. Results of rapidantigen and RT-PCR assays are available within 1-3 hours of receipt of the sample inthe Contra Costa Public Health Laboratory. Subtyping of influenza A viruses detectedby PCR will require an additional 2 hours.

Identification of Influenza A/H5An immunochromatographic assay is used to detect influenza A or B viruses directly inthe clinical sample. Clinical specimens, obtained as soon as possible after the onset ofsymptoms, are preferable as the number of virus infected cells decreases during thecourse of infection. This assay can distinguish between influenza A and B but notbetween subtypes of influenza A. This assay can also be used to identify influenza A orB virus isolated in cell culture. This assay is rapid, requiring only 15 minutes, but it isless sensitive than isolation of the virus in cell culture or detection of viral RNA by RT-PCR. This assay is performed in the Biosafety Level 2 Virology Laboratory.

Virus isolation is a sensitive technique with the advantage that the virus is available bothfor identification and further antigenic and genetic characterization including vaccinedevelopment and subtyping of influenza A isolates. The clinical specimen is treated withantibiotics and inoculated into a Rhesus monkey cell line for culturing respiratoryviruses. Influenza viruses are usually detected in 1 to 7 days. Identification of a viralisolate is then done using an immunofluorescent antibody assay (approximately 2hours). Subtyping of an influenza A isolate is performed using PCR (approximately 3hours). Initial culturing and identification (including PCR) are performed in the BiosafetyLevel 2 Virology Laboratory. Biosafety Level 3 Ag (BSL-3 (Ag)) practices, proceduresand facilities are required to work with the Highly Pathogenic Avian Influenza (H5N1).This requires registration as a Select Agent Laboratory and a BSL-3 (Ag) facility. TheContra Costa Public Health Laboratory is registered as a Select Agent Laboratory andhas a BSL-3 facility. However, once a virus isolate has been identified as influenza AH5N1, our laboratory will not perform any additional testing on the isolate because ourfacility does not have a specific permit from APHIS and is not approved as anagricultural (Ag) BSL-3 laboratory. We will transfer the isolate to the State VRDL foradditional characterization.

Polymerase chain reaction (PCR) is a powerful and sensitive technique for theidentification of influenza virus genomes. The influenza virus genome is single strandedRNA, and a DNA copy (cDNA) must be synthesized first using a reverse transcriptase(RT) polymerase. The procedure for amplifying the RNA genome (RT-PCR) requires apair of oligonucleotide primers. These primer pairs are designed on the basis of theknown HA sequences of influenza A and B and of A subtypes (H1, H3 and H5). The RT-PCR assay requires approximately 3 hours to perform from the time the specimen is

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received in the Contra Costa Public Health Laboratory. PCR is performed in theBiosafety Level 2 Virology Laboratory.

No serologic tests for influenza infection are available at the Contra Costa Public HealthLaboratory.

The above assays are routinely performed by the Contra Costa Public HealthLaboratory during the influenza season, but are available all year long for detection ofnon-contemporary strains or avian strains of influenza. Avian testing is not performed atthe Contra Costa Public Health Laboratory. Contact the University of California, Davis orthe California Department of Agriculture regarding animal testing.

Laboratory Surge CapacityCurrently there is one Senior Public Health Microbiologist and four Public HealthMicrobiologists assigned to the Virology/Immunology section of the Contra Costa PublicHealth Laboratory. All of these individuals have been trained and are experienced inperforming the influenza direct immunochromatographic assay and virus isolation in cellculture. Five individuals in the laboratory have been trained and are experienced inperforming the influenza RT-PCR assays. Four additional Public Health Microbiologistshave been trained in performing virus isolation in cell culture and in performing theinfluenza direct immunochromatographic assay. All Senior Public Health Microbiologistswill be trained in performing the RT-PCR influenza assay by December 31, 2007.

Collaboration with Respiratory Laboratory Network (CDC/VRDL/CAPHLD)The Contra Costa Public Health Laboratory is an active participant in the RespiratoryLaboratory Network (RLN). We participated in all teleconferences and training activitiesprovided to date by the RLN. We have received and validated the use of the CDCreagents for influenza A and B and for subtyping of H1, H3, and H5 influenza A viruses.We also have purchased and evaluated two commercial RT-PCR assays for influenza Aand H5 viruses. We have shared this evaluation data with the State VRDL and the otherlocal public health laboratories in California through the CAPHLD.On December 19, 2005 the Contra Costa Public Health Laboratory sent a communityupdate on Avian Influenza Testing to all clinical laboratories in Contra Costa County.This update was based on the State VRDL recommendations and included informationon criteria for testing, reporting and consultation, safety, testing at their facility,laboratory specimen collection and shipping.

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Specific Actions during Pandemic Influenza Stages

Interpandemic/Pandemic Alert (WHO Phases 1-5)

1) Contra Costa Public Health Laboratory will encourage clinical laboratories in ContraCosta County to submit specimens from suspected cases of human infection with novelinfluenza for viral testing at the Contra Costa Public Health Laboratory.

a) Contra Costa Public Health Laboratory will continue to distribute as theybecome available VRDL guidelines describing how to request testing for novel influenzavirus.

b) Contra Costa Public Health Laboratory will continue to distribute as theybecome available VRDL protocols to ensure clinical laboratories in Contra Costa Countynotify us that they are requesting testing for novel influenza virus.

c) Contra Costa Public Health Laboratory will continue to distribute as theybecome available VRDL guidelines for specimen collection, handling, and shipping, andpost them on the Contra Costa Public Health website.

d) Contra Costa Public Health Laboratory will abide by and distribute to clinicallaboratories in Contra Costa County VRDL laboratory biosafety guidelines for handlingand processing specimens or isolates of influenza A (H5N1) strains as they becomeavailable and to post them on the Contra Costa Public Health website.

2) Contra Costa Public Health Laboratory will continue to provide enhanced laboratorytesting protocols in support of and in coordination with enhanced human surveillanceprotocols. We will maintain the capacity for subtype testing for influenza A (H1, H3, andH5). We will maintain the capacity to test to identify other respiratory pathogens thatpresent with influenza-like illness. We will coordinate with the VRDL transporting to theCDC any influenza A virus that can not be subtyped.

3) Contra Costa Public Health Laboratory will provide detailed guidance to local clinicallaboratories on alternative diagnostic testing options, including rapid antigen detection,immunofluorescence assays, and PCR, including required biosafety levels.

4) Contra Costa Public Health Laboratory will work with the VRDL to developcontingency plans for possible nationwide supply and reagent shortages, includingperforming inventory of our own supplies and equipment and determining trigger pointsfor ordering surge supplies. We will accept and use reagents prepared by the CDC orVRDL for identifying the novel virus strain as a part of our participation in the RLN. Wewill also continue to evaluate and stock commercially available influenza A H5 reagentsand associated supplies for possible surge capacity use.

5) Contra Costa Public Health Laboratory will continue to develop appropriate personnelcapacity (including training) to support enhanced laboratory surveillance for influenza atthe County level. We will evaluate internally the need for additional personnel surgecapacity, including re-certification of non-traditional labor pool and redirection and hiringof additional laboratory employees.

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6) Contra Costa Public Health Laboratory will work to develop contingency plans toensure adequate laboratory capacity for diagnostic testing of bacterial agents and otherpathogens associated with infections secondary to influenza.

7) Contra Costa Public Health Laboratory will institute surveillance for influenza-likeillness among its own laboratory personnel working with novel influenza viruses, andadopt the VRDL’s protocols for clinical assessment and management of exposedlaboratory personnel (both symptomatic and asymptomatic) when the protocols becomeavailable.

8) Contra Costa Public Health Laboratory will consider upgrading its BSL-3 laboratory toBSL-3 (Ag) enhanced to provide additional pandemic influenza laboratory capacity inthe State’s public health system, if State funding is made available.

9) Contra Costa Public Health Laboratory will review, based on VRDLrecommendations, and revise enhanced laboratory diagnostic protocols for influenzaand other respiratory pathogens that may mimic influenza and distribute these to localclinical laboratories.

10) Contra Costa Public Health Laboratory will develop contingencies and protocols atthe local level to deal with redirecting resources to influenza testing and for rationinginfluenza testing.

11) Contra Costa Public Health Laboratory will review changes to technical guidance byVRDL and participate in training as needed.

12) Contra Costa Public Health Laboratory will delineate resources needed to maintainexpanded critical laboratory testing capacity during a pandemic, including laboratoryequipment and supplies, re-certification of non-traditional labor pool, and redirection andhiring of additional laboratory employees.

13) Contra Costa Public Health Laboratory will consider expanded diagnostic testingincluding antiviral resistance testing, neutralizing antibody assays to test for immunity tothe novel virus, and egg-based or other alternate culture methods to isolate novelviruses that are difficult to grow by standard culture methods to provide additionalpandemic influenza laboratory capacity in the State’s public health system, if Statefunding is made available.

14) Contra Costa Public Health Laboratory will ensure capacity to perform/support localspecial clinical and epidemiological studies.

Pandemic (WHO Phase 6)

1) Contra Costa Public Health Laboratory will review recommendations from the VRDLand enhance, as needed, diagnostic capacity for novel strain virus, with particularattention to rationing laboratory testing.

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2) Contra Costa Public Health Laboratory will continue other pre-phase 6 activities asappropriate.

Postpandemic (WHO Postpandemic Period)

1) Contra Costa Public Health Laboratory will continue to provide laboratory services formore typical wintertime ‘epidemic’ influenza cycle

2) Contra Costa Public Health Laboratory will be prepared for a possible second waveof the pandemic influenza

Appendix1. Community Update: Avian Influenza Testing 12/19/2005

a. Criteria for testingb. Reporting/Consultationc. Safetyd. Testing at your facilitye. Laboratory specimen collectionf. Resources/More information

2. Algorithm for submittal of specimens for suspect avian influenza cases – ContraCosta County – 2006

3. Influenza Testing Algorithm at Contra Costa Public Health Laboratory

4. Laboratory Biosafety Guidelines for Handling and Processing Specimens orIsolates of Novel Influenza Strains

5. Laboratory Personnel Available for Response to Pandemic Influenza

6. List of Supplies Needed for 100% Increase in Laboratory Processing

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Section 4 Clinical Case Management

IntroductionThis section is intended to provide community-wide standardized procedures by whichhealthcare providers may (1) efficiently diagnose cases of novel and pandemicinfluenza infection, (2) evaluate and manage patients with novel and pandemicinfluenza infection, (3) triage cases to appropriate levels of care, (4) determine whenantiviral treatment can and should be initiated, and (5) determine when and how toadminister prophylaxis in the form of antiviral agents and vaccinations. In addition, thesection describes actions that may be performed by Contra Costa Health Services tosupport healthcare providers in these activities.

Actions recommended to contain the spread of infection, once a case has beenidentified, are described in the Infection Control and Prevention Section.

The management of influenza is based primarily on sound clinical assessment andmanagement of individual patients as well as an assessment of locally availableresources such as rapid diagnostics, antiviral drugs and vaccines, and medical care.Early identification of cases through heightened clinical awareness and diseasesurveillance and swift action for isolation and initiation of treatment can benefit theindividual patient and may slow the spread of influenza within the community.

This section draws in part on studies conducted and/or reviewed by the World HealthOrganization (WHO). WHO convened a panel of experts who rated mortality, durationof hospitalization, incidence of lower respiratory tract complications, resistance andserious adverse effects as critical outcomes for the assessment of the treatmentinterventions for the currently circulating H5N1 infected patients. It is unknowable if thecurrent H5N1 virus will ever mutate to become easily transmittable from person-to-person-to-person. Thus, this section describes the general case managementguidelines for a novel strain of pandemic influenza, irrespective of its type.

This section includes clinical guidelines and recommendations for the management ofinfluenza and related issues. These guidelines may change as new informationbecomes available. The clinical guidelines presented in this section are based onexisting guidance from the Centers for Disease Control and Prevention (CDC) and theUS Department of Health and Human Services (HHS). Directives or Orders issued bythe Health Officer require compliance with a specified action to protect the health andwelfare of the community. See Health Officer Authority Section for legal authorities.

Additional Planning Assumptions Neither the clinical characteristics of a novel or pandemic influenza virus strain

nor the groups at highest risk can be defined beforehand. Thus, risk groupsfor severe and fatal infections can differ significantly from those of inter-pandemic influenza strains.

The incubation period for seasonal human influenza averages one to fourdays. CCHS assumes this would approximate the incubation period for anovel virus strain that is transmitted between people by respiratory secretions.

People may be asymptomatic while infectious. Viral shedding will occur one-half to one day prior to the onset of illness.

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Shedding will be the heaviest in the first two days after symptoms develop.Children are typically heavy shedders in the first few days of illness (one dayprior to onset of illness and two days after).

Interpandemic/Pandemic Alert Period (WHO Phases 1- 5)The objectives for clinical management during the Interpandemic/Pandemic Alert periodare:

1. Regular education and updates to healthcare providers on recommendedpractices and protocols pertaining to novel and pandemic influenza;

2. A standardized process for vaccine and antiviral procurement and distribution aspossible;

3. Early identification and proper management of cases to help control the spreadof disease in the pandemic alert phases; and

4. Appropriate triage of cases once the pandemic is underway.

Provider Education and UpdatesThroughout the pandemic phases it is imperative for health care providers to keep fullyinformed on the progression of the disease as well as clinical treatment and reportingguidelines and directives. All providers are advised to be alert for physician notices andother information distributed by CCHS. Useful websites include the CCHS website -www.cchealth.org, the CDPH site - www.pandemicflu.gov, the World HealthOrganization site - www.who.int and the CDC site - www.cdc.gov/flu/avian . (For moreinformation on the communication methods CCHS uses, see Sect. 9 RiskCommunication and Public Education)

CCHS will ensure that clinicians and laboratory scientists know how to access the mostcurrent recommendations for novel influenza case identification, management, andlaboratory testing by distributing protocols in settings where cases (and their contacts)might be diagnosed. In conjunction with the CDPH and CDC, CCHS will develop anddistribute guidance on managing patients who test negative for novel influenza virus,addressing the potential for false negative findings and the clinical and epidemiologiccriteria that would warrant continued suspicion.Additionally, CCHS will:

Revise and distribute virus transmission prevention and control guidelines toreflect the changing recommendations for clinical standards;

Distribute reminders to clinicians and laboratory scientists on how to accessthe most up-to-date recommendations for novel influenza case identification,management, and laboratory testing;

Distribute revised guidance on vaccination, prophylaxis, and treatmentrecommendations based on most current national and staterecommendations, including a prioritized list of treatment and prophylaxispriority recipients and will work to ensure the revised guidance is madeavailable to healthcare practitioners;

Revise and distribute protocols and guidelines of the pandemic alert phase toreflect any substantial increased risk, as needed;

Distribute Health Officer directives where indicated; Provide interim and emergency updates on disease surveillance as the

pandemic progresses; Develop and distribute standardized patient education materials, in

collaboration with the CDPH and CDC (see Sect. 9 Risk Communication andPublic Education)

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Develop processes to coordinate access to vaccines, antiviral drugs, andother medications needed to mitigate and manage secondary infections.

Vaccine Procurement and DistributionThe plan for distribution of vaccines assumes that strain-specific vaccine will becomeavailable at some point after the first wave of the pandemic, limiting the amount ofeffective vaccine available in Contra Costa. The CDPH will determine the guidelines forthe allocation and distribution of vaccines and the County Health Officer will issuedirectives on the prioritization and use of vaccines based on state and federalguidelines.

(For more information about the CDPH Vaccine Prioritization Plan and supplementaldocuments available online, see appendix.)

For more detailed information about the process by which Contra Costa requestsvaccine from CDHS and the distribution of vaccine, see the Contra CostaCounty/Operational Area SNS Management Plan, Draft v.2.0 (2/26/07) - Section V:Management of SNS Operations (pgs. 14 - 18).

During the pandemic alert phase, CCHS will Review current supply usage and estimate the amount of vaccine needed for

priority populations; Develop and disseminate a plan for vaccine coverage for priority populations; Develop and disseminate a plan for distribution of vaccines based on the amount

of available vaccine, priority populations, availability of site and staffingresources, and other variables.

Work to enhance vaccine coverage for seasonal flu and pneumonia in high riskpopulations and health care staff;

Refine and disseminate data collection and reporting tools; Activate vaccine coverage plans at the direction of the Health Officer.

Antiviral Procurement and DistributionPandemic AlertDuring the alert period, the CDPH will stockpile for Contra Costa County, antiviralmedications necessary for medical management of approximately 25% of the County’spopulation.

However, the CDPH is responsible for the storage of antivirals and no product willbe distributed from the state storage site(s) until a pandemic is declared or theState Public Health Officer orders its release to local health departments. Thiswould likely be prior to cases within California, assuming a WHO phase 6pandemic has been declared anywhere in the world. (according to Contra CostaCounty/Operational Area SNS Management Plan, Draft v.2.0 (2/26/07)

After estimating the general amounts needed to treat and provide prophylaxis to prioritypopulations, CCHS will encourage local health care facilities to also stockpile antivirals.

Pandemic PeriodDuring the pandemic period, antiviral medications will be requested from the StrategicNational Stockpile (See CCHS Emergency Response Plan and the Contra CostaCounty/Operational Area SNS Management Plan, Draft v.2.0 (2/26/07). Limited

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availability of medications from national sources is likely to impact the size of the cacheand the supply is expected to be quickly exhausted.

The primary antiviral procurement objectives during this phase of the epidemic are to1. Ensure prophylaxis of health care infrastructure and critical emergency response

providers, and2. Treat those at greatest risk for severe illness and death

During this phase of the epidemic, the Health Officer will issue directives for the use oflimited antivirals, for instance limiting the use of medications for prophylaxis of closecontacts in an effort to contain the pandemic.

Guidelines for Healthcare Providers

Early IdentificationSee Appendix 3 Laboratory Capacity

Diagnosis of patients with novel or pandemic influenza virus infections

Alert PeriodDuring the alert period, astute clinicians will provide the key to early detection of novelinfluenza virus infections in Contra Costa County. The current novel influenza A virus ofconcern is avian influenza A, subtype H5N1, which has been transmitted from birds tohumans in parts of Asia and the Pacific, Europe and Eurasia, and the Near East.Exposure risk for avian influenza (H5N1) is highest for persons who have had directcontact with infected poultry, or surfaces and objects contaminated by their droppings(e.g. persons exposed during slaughter, de-feathering, butchering, and preparation ofpoultry for cooking). Therefore, individuals who have traveled to a country with avianinfluenza A (H5N1) who report direct exposure to sick or dying poultry and who exhibitrespiratory symptoms should be considered at highest risk. During the alert period, thelikelihood that a patient presenting with respiratory illness in Contra Costa County willbe diagnosed with novel influenza A (H5N1) is low and depends upon anepidemiological link to this type of exposure. Therefore, only patients meeting bothclinical and epidemiologic criteria for suspected influenza A (H5N1) should be evaluatedfor possible novel influenza infection.

Although the epidemiologic criteria here described for novel influenza are based onrecent human cases of avian influenza A (H5N1), the process for identifying andmanaging cases of novel influenza A infection will be similar, regardless of the specificnovel influenza strain. In the future, other novel influenza A viruses might becomesignificantly associated with human disease and develop pandemic potential. If thisoccurs, this guidance will be updated.

During this time (August 2007), exposure for avian influenza is highest for persons withdirect contact with infected poultry or surfaces / equipment contaminated withdroppings. Individuals who have traveled to a country reporting H5N1 and who exhibitrespiratory symptoms are at highest risk for avian influenza.

Key features of the currently circulating potential pandemic influenza strain(H5N1) are an initial symptom of high fever and influenza like illness with lowerrespiratory tract symptoms. Diarrhea, vomiting, abdominal pain and pleuritic pain and

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bleeding from the nose and gums have been reported early in the course of illness insome patients. Watery diarrhea without blood or inflammatory changes is morecommon and may precede respiratory manifestations by up to one (1) week.

Lower respiratory tract symptoms develop early in the course of illness. Respiratorydistress, tachypnea and inspiratory crackles are common. Sputum production isvariable and sometimes bloody. Almost 100% of patients have clinically apparentpneumonia.

Usually Chest X-ray findings were present 7 days after the onset of fever. Thesefindings include:

Diffuse, multifocal or patchy infiltrates Interstitial Infiltrates Segmental or lobar consolidation with air Bronchograms Pleural effusions are uncommon. Diffuse bilateral ground-glass infiltrates are seen when the illness has progressed

to respiratory failure (along with manifestations of acute respiratory distresssyndrome (ARDS))

Multi-organ failure with signs of renal dysfunction and sometimes cardiac dilatation andsupraventricular tachyarrythmias has been common.

During the pandemic alert period any patient seen in Contra Costa Countymeeting both the clinical and epidemiological criteria below should be evaluatedfor possible novel infection.

1. A patient who has an illness that requires hospitalization or is fatal; AND has or had adocumented temperature of ≥ 38oC (>100.4oF); AND has radiographically confirmedpneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratoryillness for which an alternative diagnosis has not yet been established; AND has at leastone of the potential exposure criteria

• a history of recent travel to a country with a pandemic influenza straindocumented in poultry, wild birds, humans, and/or history and potential contactwith ill or dead wild or domestic birds within 10 days of symptom onset, ANDat least one of the following potential exposures: Direct contact with (e.g., touching) sick or dead domestic poultry; Direct contact with surfaces contaminated with poultry feces; Consumption of raw or incompletely cooked poultry or poultry products; Direct contact with sick or dead wild birds suspected or confirmed to have a

pandemic influenza infection. Close contact (within 3 feet) of a person who has been hospitalized or died

due to a severe unexplained respiratory illness Was in close contact (within 3 feet) of an ill person who has confirmed or

suspected pandemic influenza infection Worked with a live pandemic influenza virus in a laboratory.

Any patient who meets the criteria listed above should be considered a suspect caseand laboratory testing is recommended.

Patient Treatment and Management issues

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Specific guidance for management of illness include:

Fever management – Fever management can significantly improve the comfortof patients with influenza and may be particularly important for children with ahistory of febrile convulsions and for those attempting to maintain their hydrationstatus at home. Antipyretics including acetaminophen and ibuprofen areappropriate for use in the management of fever caused by influenza. In order toavoid an overdose, patients taking an antipyretic should be advised to avoidconcurrently using over-the-counter preparations containing the samemedication. Aspirin and other salicylates should be avoided in children under theage of 18 years, because of the association between aspirin treatment and thedevelopment of Reye syndrome - a potentially fatal acute disease of the liveraccompanied by hyperammonemic encephalopathy - in children with influenza.

Maintenance of hydration – Insensible fluid losses caused by fever andtachypnea, coupled with malaise and poor appetite, place patients with influenzaat significant risk for dehydration. In addition, some patients suffer fluid loss fromvomiting. Patients should be advised to rest in bed and drink plenty of fluids.Patients unable to maintain their hydration through oral intake will require IVfluids.

Bronchospasm – Patients with influenza may experience significantbronchospasm, particularly those with underlying inflammatory diseases of theairways including asthma. Treatment with bronchodilators and anti-inflammatoryagents (e.g., inhaled or systemic corticosteroids) should be considered andshould be tailored to the severity of the clinical signs and symptoms. Becausethe use of nebulized medications is thought to increase the risk of transmission ofinfluenza, medications administered orally or by MDI are preferred.

Antivirals – Early antiviral therapy shortens the duration of illness due toseasonal influenza and may have similar effects on illness due to novel orpandemic influenza viruses. Therefore, the use of antiviral agents for treatmentshould be considered, particularly for those at highest risk of severecomplications of influenza infection. Prophylaxis should be considered for closecontacts of patients with influenza, particularly if they are unvaccinated and athigh risk for complications if infected.

Monitoring for complications – Diffuse primary influenza virus pneumonia mayappear after 3-5 days of illness and is often life-threatening. Influenza viralpneumonia is characterized by severe dyspnea, cyanosis, and the production ofsmall amounts of bloody sputum. Signs of secondary bacterial pneumonia mayinclude a reappearance of fever after an afebrile period, tachypnea, increasingcough and shortness of breath, signs of respiratory distress (e.g., grunting, nasalflaring, and retractions of the chest wall), pleuritic chest pain, and hypoxia.

Bacterial tracheitis, which presents with signs of airway obstruction suggestiveof croup, may also complicate influenza and may be life-threatening.

Otitis media is a common complication of influenza, especially in young children.Oral antibiotic therapy and medication to relieve pain may be useful in thissituation.

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Myocarditis may be seen with influenza infection but fortunately is relativelyuncommon.

Encephalitis and meningitis, though rare, may complicate influenza infection.

Additional complications that may be seen in children include apnea (especially younginfants), febrile seizures, and vomiting with dehydration. Asthma exacerbations,although common in children with influenza, may be seen in influenza patients of anyage and should be appropriately managed and monitored. Viral myositis, typicallyinvolving the calves, may also be seen in children with influenza A, although thiscomplication is more commonly seen with influenza B.

Antiviral TreatmentThe WHO recommends that patients with suspected clinical pandemic Influenza Ashould be started immediately on a neuraminidase inhibitor. Early treatment will providethe greatest benefit. At this time, (August 2007) there is no data that supports regimesother than the standard dosing of Oseltamivir (Tamiflu) or Zanamivir (Relenza). Moststudies of these drugs were based on treatment/prophylaxis of seasonal flu.

Oseltamivir (Tamiflu)Oseltamivir treatment may be of net clinical benefit to these H5N1 patients. The clinicalrecommendation is that in patients with confirmed or strongly suspected H5N1 infection,clinicians should administer Oseltamivir treatment as soon as possible. This isclassified as a strong recommendation, very low quality evidence. At this time novariation from the dosing described below or length of treatment from that described forseasonal influenza. Oseltamivir is administered by mouth and is available as a capsule(75mg) or as a powder for oral suspension. These recommendations apply to adults,pregnant women and children.

The recommended dosing is as followed:AntiviralAgent

Age 1- 6years

Age 7-9years

Age 10-12years

Age 13-64 Age > 65years

Oseltamivir Varies byweight

Varies byweight

Varies byweight

75 mg twicea day

75 mg twicea day

*dose reduction is recommended for patients with renal impairment (creatinineclearance between 10-30ml/min)

Weight adjustment criteria for children older than 1 year:</= 15 kg 30 mg twice daily>15 to 23kg 45 mg twice daily>23 to 40kg 60 mg twice daily>40kg 75 mg twice daily

The most commonly reported adverse effect is nausea and vomiting. Rare cases ofanaphylaxis and serious skin reactions have been reported.

Zanamivir (Relenza)No clinical trials have evaluated Zanamivir in the treatment of H5N1 patients. There arevery few studies describing animal and in vitro data about the effects of zanamivir onthe H5N1 virus. This drug is not approved for children < 7 years of age. The

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recommendation in patients with confirmed or strongly suspected infection with avianinfluenza A (H5N1) is that clinicians might administer zanamivir. This recommendationis classified as a weak recommendation with very low quality evidence. At this time thestandard dosing and length of treatment regimes are recommended.

Zanamivir is available for oral inhalation only using a diskhaler device.AntiviralAgent

Age 1- 6years

Age 7-9years

Age 10-12years

Age 13-64 Age > 65years

Zanamivir N/A 10 mg twicea day

10mg twicea day

10mg twicea day

10 mg twicea day

No dosing adjust is needed for patients with hepatic or renal impairment.

Other treatment measures will likely be supportive in nature.

Antivirals as prophylaxisAntivirals are not recommended as a form of prophylaxis at this time.

Infection Control Measures(See Sect. 6 Infection Prevention and Control for infection control and preventionmeasures to reduce the risk of exposure and transmission, and Sect. 7 Non-Pharamceutical Interventions.) Effective infection control processes are consistent androutine, specific to the mode of transmission and rely on prompt identification andisolation of suspect and confirmed cases to reduce transmission.

ReportingAs soon as a patient is identified as suspected of possible avian influenza or novelpandemic flu virus, providers are to notify the Contra Costa Health ServicesCommunicable Diseases Program (925-313-6740). After hours, notify the HealthOfficer by calling the Sheriff’s Office dispatch (925-646-2441) and asking for the HealthOfficer. If the patient is hospitalized, providers must also immediately notify the hospitalinfection control practitioner. The Confidential Morbity Report form is available fordownload on the CCHS website www.cchealth.org

Triage to Alternate Care SitesDuring the Alert phase of the pandemic existing standards of care will be followed. Asthe pandemic progresses, existing services and resources will be stretched. (See Sect.5 Health Care Facility Planning for a description of Surge Capacity and Alternate CareSites.)

During the pandemic phase and if the pandemic is a category four or five, the HealthOfficer may activate alternate care sites. An alternate care site as defined in ContraCosta County is a specialized County-operated emergency shelter where, under certaindefined emergency conditions, sick or injured persons may be provided temporaryshelter and limited medical care for one to several days until discharged from care oruntil more appropriate care becomes available.

CCHS will develop standardized criteria for triaging patients and resources during thisalert period of the pandemic and disseminate information via physician notices andother venues. (See Sect. 9 Risk Communication and Public Education)

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CCHS will develop and communicate standardized clinical criteria for triage of patientsto care in the inpatient acute-care hospital setting vs. the alternate care site vs. homecare. This Plan describes some information for the management of patients with novelor pandemic influenza infection at home. (See appendix for Pandemic Flu Home CareGuidelines).

Nursing advice and triage by telephoneDuring the pandemic, healthcare providers are likely to be overwhelmed with patientcare duties and may be unable to handle the volume of calls they receive for influenza-like illness (ILI). CCHS will activate the Health Emergency Information Line (HEIL)(888) 959-9911 and/or the Health Emergency Call Center to provide telephone triageand nursing advice to the general public.

Home Care Guidelines and Supportive CareIn the event the pandemic overwhelms resources of hospitals and alternate care sites,patients may need to be cared for at home. The following are some guidelines forhomecare: (See also Sect. 6 Infection Prevention and Control guidelines at home andAppendix Red Cross Home Care brochure)

Fever controlFever is defined as a temperature of 38oC (100.4oF) measured orally or rectally.

It is not strictly necessary to treat fever because fever is not inherently harmful.However, most patients are more comfortable if their fever is controlled during wakinghours, and control of fever may help to prevent dehydration as fever increasesinsensible water losses. Fever control may be particularly important for children with ahistory of febrile convulsions. Fever can usually be safely controlled withacetaminophen and/or ibuprofen, in both children and adults. Aspirin should not beused in children <18 years of age because of a known association with Reye’ssyndrome.

Influenza patients managed at home should be instructed in the proper use ofantipyretics. In order to avoid an overdose, patients taking an antipyretic should beadvised to avoid concurrently using over-the-counter preparations containing the samemedication.

Fever should prompt a medical evaluation for infants under 2 months of age and forpatients who are severely immunocompromised. In addition, fever reappearing after aprolonged afebrile period may herald the appearance of a secondary bacterial infectionand should prompt a medical evaluation.

Maintaining HydrationInsensible fluid loss caused by fever and tachypnea, coupled with malaise and poorappetite, place patients with influenza at significant risk for dehydration. In addition,some patients – especially young children - suffer fluid loss from vomiting. Patientsmanaged at home should be advised to rest in bed and drink plenty of fluids.Caregivers concerned that an influenza patient is at risk for dehydration because ofdecreased oral intake should actively encourage fluids by mouth provided the patient isable to drink.

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Infants and young children (<5 years of age) with signs of dehydration should be initiallymanaged with commercial rehydration solutions, in addition to breast milk or infantformula as appropriate. A recipe for cereal-based oral rehydration solution (CBORS) isprovided as an alternative to commercial rehydration solutions for this age group, but itshould ONLY be used if the commercial products are not available because of thepotential for hazardous mixing errors.

A simple recipe for rehydration solution suitable for use in older children and adultsconsists of 4 cups of clean water, 2 tablespoons of sugar, and ½ teaspoon of salt. Thesolution should not be boiled as this will concentrate the solutes. In situations wherewater must be boiled before use (e.g., if a “Boil Water” order has been issued), thewater should first be boiled and the sugar and salt added after the water has cooled.Patients should not consume alcoholic beverages while ill with influenza, as this willincrease the risk of dehydration, in addition to compromising hepatic and CNS function.

Caregivers should monitor influenza patients for signs of dehydration, which mayinclude dry mouth, dry or sunken eyes, and decreased urine output. Severelydehydrated patients may have loose or doughy skin, a rapid heart rate, and changes inmental status. If a patient ill with influenza is unable to take fluids by mouth, or isshowing signs of dehydration, a clinical assessment is warranted. This is particularlycritical for the very young (infants), the elderly, and patients with underlying chronicdisease, especially cardiac, renal or metabolic diseases such as diabetes.

Airway supportThe comfort of patients with influenza may sometimes be improved with nasaldecongestants (e.g., pseudoephedrine), expectorants (e.g., guaifenesin), and coughsuppressants (e.g., dextromethorphan). These agents do not hasten the resolution ofdisease, however.

Influenza patients experiencing bronchospasm, including those with asthma, will needto maximize the use of their controller (anti-inflammatory) medications and usebronchodilators as prescribed by their healthcare providers. Because the use ofnebulized medications is thought to increase the risk of transmission of influenza,medications administered orally or by MDI are preferred. Healthcare providers shouldconsider providing extra prescriptions or supplies of quick relief and controllermedications, including systemic steroids as indicated, for use by patients with asthma inadvance of the pandemic. Healthcare providers should also provide explicit instructionsfor monitoring these patients at home, tailored to the needs of each patient, includinginstructions regarding when to seek medical care urgently.

Getting HelpDuring the pandemic, influenza patients and their caregivers at home will need accessto medical advice by telephone. It is anticipated that this resource may reduce the riskof serious morbidity and mortality at home while relieving the burden on clinics andhospitals of triaging and managing patients that can be safely treated at home.

Patients with chronic diseases (asthma, cardiovascular disease, severe neuromusculardisease, diabetes, renal failure, immunocompromising conditions, etc.) should beencouraged to maintain close contact with the healthcare providers who manage thesediseases during the course of their illness with influenza. Patients who are pregnantshould be encouraged to contact their prenatal care provider as well.

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In addition, individuals with influenza and their caregivers should be encouraged to seekmedical advice in the following situations:

fever in patients under 2 months of age, or in the immunocompromisedfever uncontrolled by antipyreticsfever persisting for more than 3 days, or reappearing after a prolonged period

without fever (suggests secondary bacterial infection)signs of dehydration (dry mouth, dry eyes, decreased urine output, doughy or

loose skin, rapid heart rate)wheezing or difficulty breathingshortness of breathsigns of respiratory distress (e.g., grunting, nasal flaring, retractions of the

chest wall)bloody sputumchest paincroupy cough (may suggest bacterial tracheitis)severe ear pain or severe muscle painchanges in mental status, irritabilityprotracted vomiting

Healthcare providers unable to handle the volume of influenza-related calls during thepandemic may refer patients calling with influenza-like illness to CCHS’ HealthEmergency Information Line (888) 959-9911.

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Section 5. Health Care Facility Planning

IntroductionThe capacity to maintain essential health care services during a pandemic will begreatly reduced and rely extensively on triage, self care at home, use of alternate staffand assignment to alternate care facilities. Those individuals admitted to hospitalfacilities will be acutely ill and the health care delivery system will be overwhelmed. Toensure that the existing health care delivery system can respond to a rapid surge intransmission, collaborative planning partnerships both internally and externally arerequirements for each health care provider.

The purpose of this section is to provide overall planning guidance as well as theframework for the management of medical surge needs resulting from an incident thatoverwhelms the capacity of hospitals in Contra Costa and nearby counties in order tomeet the overall goal of minimizing mortality and morbidity. This module is to be usedwhen needed in conjunction with the Contra Costa Health Services Emergency Planand the Contra Costa County Emergency Operations Plan. (See also Sect. 6 InfectionPrevention and Control for more information on home care)

Contra Costa Health Services (CCHS) has a dual role in this plan:1) As the County Health Authority, CCHS Divisions and programs are responsible fordeveloping policies and guidance for health care providers in Contra Costa to ensurethat the local planning process for pandemic flu is comprehensive and in accordancewith State, local, and Federal requirements. CCHS has convened and oversees theprimary pandemic flu workgroups for Contra Costa.2) As a direct health care provider, Contra Costa Regional Medical Center and Clinics(CCRMC) is responsible for following all directives issued by the Health Authority toContra Costa health care providers.

Interpandemic /Pandemic Alert Period (WHO Phases 1-5)The primary Health Facility Planning objectives during the Interpandemic/PandemicAlert period are to:

1. Ensure information exchange in a timely fashion;2. Develop and streamline processes to improve facility response capacity;3. Train staff to respond to a rapidly changing disease process;4. Identify and act on areas needing further discussion and planning;5. Develop local Medical Surge Capacity.

Consistency in planning will extend local capacity to address rapidly changing healthcare needs in the community. Each Hospital should be prepared to identify and providecare to individuals with the influenza virus as part of routine operations and respond to asignificant escalation in demand for services in the event of a pandemic outbreak.

To prepare for pandemic influenza, all health care facilities in Contra Costa shoulddevelop an internal planning team with representation from infection control, materialsmanagement, vaccines and pharmaceuticals, morgue, triage, communications, nutrition,security, personnel, surveillance, and other essential health care components. Thepurpose of this internal team is to develop a functional plan to:

Prepare the facility to respond to pandemic flu; Identify and report pandemic flu progression in Contra Costa County;

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Respond to county-wide health care surge needs; Maintain the fullest level of health care services possible during a changing

epidemic; Participate in Countywide workgroup efforts to increase coordination of response

and information exchange.

1. Medical Surge CapacityMedical surge capacity refers to the ability to evaluate and care for a markedlyincreased volume of patients – challenging or exceeding the normal capacity of ahospital or healthcare system. Individual hospitals plan for and routinely handle surgerequirements resulting from seasonal fluctuations in respiratory ailments,environmentally based conditions, and community incidents. In Contra Costa County,as throughout most of California, hospitals routinely operate at or near capacity.Moderately sized incidents with several to, perhaps, hundreds of patients are handled inaccordance with the County’s Multicasualty Incident Plan. Patients are transported tohospitals throughout the county and throughout the region to avoid overloading anysingle hospital. However, very large-scale incidents or widespread disease outbreaksmay overwhelm the capacity of many or all hospitals and other health care providers ina region. Responding to such incidents requires the close coordination and cooperationof hospitals, health centers and community clinics, governmental agencies, and otherhealthcare providers.

The purpose of this section is to provide a framework for the management of medicalsurge needs resulting from an incident that overwhelms the capacity of hospitals inContra Costa and nearby counties in order to meet the overall goal of minimizingmortality and morbidity. This section includes the County’s Emergency Medical ServicesAgency’s Medical Surge Capacity Plan and the response to an infectious diseaseoutbreak.

Emergency Operations and ManagementThe Medical Surge Capacity Plan is a tool to be used when needed in conjunction withthe Contra Costa Health Services Emergency Plan and the Contra Costa CountyEmergency Operations Plan. Contra Costa Health Services will be the lead agencycoordinating medical surge activities. Emergency operations shall be conducted inaccordance with the California Standardized Emergency Management System (SEMS)and the National Incident Management System (NIMS).

Surge Levels

Surge Level 0 – No External Trigger

Surge Level 0 is the normal operating level of the county’s hospitals andincludes expanded operations that hospitals can carry out on their own authorityto meet variations in demand. Under Surge Level 0, hospitals may be on CensusAlert 1 or 2 and may have been granted Staffing Program Flexibility and/orIncreased Patient Accommodation from the State Department of Health Services.Hospitals comply with all DHS requirements.

Surge Level 1 – Local Emergency and Health Officer Directive / NoAlternate Care Sites

Surge Level 1 shall be in effect when, during a duly proclaimed localemergency, a directive is issued by the County Health Officer for hospitals to

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expand capacity beyond normally permitted levels. Under Surge Level 1,inpatient services are provided at facilities under hospital control. Clinics may beenlisted to provide triage, dispensing of antibiotics or other pharmaceuticals, andoutpatient treatment of patients not requiring hospitalization.

(a) The trigger for consideration of a Surge Level 1 directive shall be adetermination by the County EMS Agency that most or all hospitals inContra Costa and adjacent counties are at or near peak capacity and thatthere is a high probability that the number of patients requiring hospitaltreatment will increase.

(b) Prior to issuing a Surge Level 1 directive, the Health Officer shall confer withthe County Emergency Services Director, hospital representatives, and theState Health Officer or his representative.

(c) While a Surge Level 1 directive is in place, the County Health ServicesDepartmental Operating Center (DOC) shall be activated.

(d) While a Surge Level 1 directive is in place, hospitals shall only depart fromexisting patient capacity, staffing ratio, and other patient care standards asspecifically authorized by the Health Officer as necessary to protect thepublic health and safety. All departures from existing standards shall berecorded by the hospital and reported as soon as practical to the DOC.

(e) Hospitals shall seek to maintain or return to normal standards as conditionspermit.

Pandemic Period (WHO Phase 6)The Planning objective during this phase is:

1. Ensure supportive care for those who cannot access hospital care.

Surge Level 2 – Local Emergency and Health Officer Directive / AlternateCare Site(s)

Surge Level 2 shall be in effect when, during a duly proclaimed localemergency, a directive is issued by the County Health Officer for theestablishment of one or more Alternate Care Sites to provide supportive andother care for persons for whom hospitalization is not available due to lack ofhospital capacity under Surge Level 1 conditions. Under Surge Level 2, alldirectives and requirements set forth above under Surge Level 1 remain in effect.In addition, County Health Services shall establish one or more Alternate CareSites at facilities designated by the Health Officer. (See Alternate Care Sitessection below)

(a) The trigger for consideration of a Surge Level 2 directive shall be a findingby the Health Services DOC Director that the number of persons requiringinpatient care exceeds the capabilities of hospitals in the county operatingunder Surge Level 1.

(b) Prior to issuing a Surge Level 2 directive, the Health Officer shall confer withthe County Emergency Services Director, hospital representatives, and theState Health Officer or his representative.

(c) Upon issuance of a Surge Level 2 directive, the Health Services DOCDirector shall establish under the Operations Section, an Alternate Care SiteBranch. The Alternate Care Site Branch Director shall be responsible for

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securing and opening Alternate Care Site facilities, securing medical andancillary staff, securing logistical support including security, establishingoperating guidelines and patient care standards, and appointing a MedicalDirector and Site Administrator for each Alternate Care Site.

(d) Each Alternate Care Site shall implement a system for patient triage, patientadmission, patient care, medical record keeping, patient discharge ortransfer, and personnel record keeping.

(e) The Health Officer shall appoint one or more persons as an Ethics Advisoror Ethics Advisory Committee to advise the Health Officer on criteria fordirection of patients to Alternate Care Sites. The Ethics Advisor or chair ofthe Ethics Advisory Committee shall be a physician with training in medicalethics.

(f) The Health Officer shall appoint an Alternate Care Site Inspector withappropriate staff to regularly inspect and report to the Health Officer on thestatus of each Alternate Care Site with respect to sanitation, medical, andother conditions.

(g) The Health Services DOC Director shall endeavor to close Alternate CareSites as soon as practical upon determination that inpatient care can behandled at hospital facilities.

Planning Scenarios

The need for surge capacity may arise from a number of different scenarios rangingfrom a great earthquake to a highly toxic and widespread chemical release to pandemicinfluenza or other acutely infectious disease outbreak. The circumstances of such anincident may be natural or manmade, accidental or deliberate, time limited or continuingover an extensive period, localized in one county or region or spread over the state ornation. Each scenario presents its own set of considerations and constraints that willimpinge on how surge capacity is handled. Key variables affecting surge capacityinclude:

(1) Number of patients

(2) Acuity of patients

Decontamination required?

Treat and release or hospital admission?

Specialized or complex surgical or medical treatment needed?

Ventilator needed?

Isolation required?

(3) Duration of incident

(4) Geographic scope

Are other areas impacted so that outside assistance is not available?

(5) Impact of incident on medical personnel and facilities

Earthquake damage to hospitals?

Hospital staff impacted by illness?

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While each event will present its own unique set of challenges, for planningpurposes four general scenarios have been considered.

Scenario #1 – Acute Infectious Disease

This scenario includes pandemic influenza, novel diseases such as severeacute respiratory syndrome (SARS), and infectious diseases thought to bepotentially associated with bioterrorism such as smallpox. The scenario presentsspecial challenges related to potential long duration, widespread impact, impact onhealth care workers, and impact on supply lines and community infrastructure.Additionally, there may be need for isolation and other protective measures. Largenumbers of patients may be ventilator dependent.

Scenario #2 – Acute Botulinum or other Acute Chemical Poisoning

This scenario includes major industrial accidents (refineries, chemicalplants, tank cars), industrial sabotage, or terrorist attack. While relativelylocalized and time limited when compared to pandemic influenza, this scenariohas the potential of affecting a population over many square miles and may resultin patients seeking medical treatment over days or weeks. In 1993, an Oleum(sulfuric acid) railroad tank car release in Contra Costa County sent 22,000persons to local hospitals and clinics seeking treatment over a 10-day period.While very few persons required emergency treatment or hospitalization, thesheer volume of patients severely impacted hospital resources and required theestablishment of an alternate (non-hospital) to provide patient screening andtriage over a period of several days. Under Scenario #2, there may be need forlarge amounts of nerve agent antidotes or anti-toxin not normally available inquantity at local hospitals. There may also be a demand for ventilators.

Scenario #3 – Trauma and Burn Care

Scenario #3 includes major earthquake and large-scale attack byexplosive or incendiary device. This scenario is much more time limited and isapt to be more geographically focused. A great earthquake on the Haywardfault, however, is likely to cause widespread death and destruction throughoutthe East Bay and is likely to cripple hospitals located along the fault.

Scenario #4 – Radiation Induced Injury

This scenario includes spread of radioactive material over a largepopulation by “dirty bomb” or other means, as well as attack by nuclearexplosion. Depending on the device or material used, medical issues range fromminor to catastrophic. Psychological effects may be profound. Staff availabilitymay be impacted due to illness or safety concerns.

Resources for Medical Surge

1. Facilities

(a) Acute care hospitals

Table 1 shows the surge capacities reported by each of the county’seight acute care hospitals under each of the four planning scenarios. Surgecapacity is reported as the number of additional patients (all patients andmonitored patients) that could be handled by the hospital over and above theaverage daily census under "altered standards of care.”

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“Altered standards of care” is defined by the federal Health & Human ServicesAgency for Healthcare Research and Quality:

Under normal standards of care, a provider must use the degree of skill anddiligence in the diagnosis, treatment and overall management of each patientthat a reasonable prudent provider in the same field of practice in Californiawould have used under the circumstances of the case. Altered standards ofcare represent a shift, during a mass casualty event that compromises theability of local or regional health systems to deliver services consistent withestablished standards of care, to providing care and allocation scarceequipment, supplies, and personnel in a way that saves the largest number oflives.

The numbers are reflective of physical capacity without regard to staffing.The table also shows for each hospital the sources of the reported surgecapacity; e.g., available staffed beds, early discharges, surge tents, etc.While surge capacity is reported without regard to staffing capability, a largeproportion of the surge capacity reported by each facility (varies by scenario)is from staffed vacant beds, early discharges, and cancelled electiveprocedures. Thus, a certain amount of surge can be accomplished withoutcompromising staffing levels.

Surge capacity to handle a major influenza epidemic is shown in Table2. These figures utilize the reported surge capacities for an acute infectiousdisease scenario and the estimated increased hospital bed demandcalculated using the Centers for Disease Control and Prevention FluSurge 2.0software. Demand assumptions are for the peak week of a 12-week duration,35 percent infection rate event. Overall, Contra Costa would have sufficienthospital beds to provide medical surge for the projected 530 additionalpatients, but would be short almost one hundred monitored beds.

(b) Other in-patient facilities

Skilled nursing and other non-acute-care in-patient facilities represent asecondary source of surge capacity. Table 3 provides a listing of all licensedin-patient facilities in the county (including the Veterans AdministrationMartinez Rehabilitation and Long Term Care facility, which is not licensed bythe State). Not including acute care hospitals, these inpatient facilitiesaccount for a total of 3,525 beds. Assuming these facilities collectively couldhandle a surge of ten percent of licensed capacity, they could absorb some350 additional patients. Primary use for this additional capacity wouldprobably be for lower acuity patients discharged from acute care hospitals.

(c) Outpatient facilities

Table 4 lists Contra Costa Health Services health centers and otherlicensed outpatient facilities including community clinics, dialysis clinics,private psychiatric clinics, and surgi-centers. CCHS and community clinicscan provide important resources for dispensing, triage, and outpatient care todivert patients away from hospital emergency departments when hospitalcare is not required. All community clinics are represented by the CommunityClinic Consortium of Contra Costa County. Through the Consortium,community clinics have developed disaster plans, have acquired disaster andpersonal protective equipment and supplies, and have participated withContra Costa Health Services in disaster exercises.

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(d) Closed hospitals

The three closed hospitals – Los Medanos, VA Martinez, and DoctorsPinole – are accounted for under outpatient facilities.

(e) Alternate Care Sites

Schools, hotels, or other facilities may be designated as Alternate CareSites during a disaster or other large-scale emergency. The level of care will beprimarily supportive care. Alternate Care Sites will be operated under the auspicesof Contra Costa Health Services with logistical support provided by the AmericanRed Cross. (See Alternate Care Sites below)

2. Personnel

Hospitals in Contra Costa and throughout most of the state operate at or near theminimum nurse staffing level required for the number of patients in the facility. Whilethe number of personnel may be increased significantly on a short-term basis tohandle certain surge situations, it is clear that, under any long-term scenarioinvolving infectious disease or other conditions that may incapacitate hospital staff orpresent significant hazards to hospital staff, care may have to be provided under“altered standards of care” conditions that depart significantly from existing staffingratios.

(a) Hospital and skilled nursing facility personnel can be effectively increased by50 percent through implementation of extended shifts. Accommodation willneed to be made for staff childcare.

(b) Contra Costa Health Services nursing personnel not normally assigned tohospital or health center operations may be reassigned to provide patientcare at hospitals, health centers, clinics, or Alternate Care Sites.

(c) Field paramedics and EMT’s may be enlisted to assist in patient care atAlternate Care Sites.

(d) Volunteer nurses and physicians may be recruited from the community asneeded.

3. Equipment and supplies

Contra Costa’s hospitals and clinics have obtained a wide variety of disasterequipment and supplies under the federal Health Resources and ServicesAdministration (HRSA) grants. Major categories of disaster equipment andsupplies that impact surge capacity are as follows: (Some items may have beenordered, but not yet delivered.)

(a) Decontamination units – all hospitals are equipped with decontamination unitsand related equipment and supplies.

(b) Surge shelters – all hospitals are equipped with two surge shelter tents andrelated equipment and supplies (cots, lighting, generators, heaters, etc.) tohandle up to 18 non-ambulatory patients per tent.

(c) Trauma and burn cache – John Muir Trauma Center has been equipped withan augmented trauma and burn cache designed to handle 50 traumapatients.

(d) Pharmaceuticals – All hospitals have stockpiled (or are in the process ofobtaining a stockpile) of two pharmaceutical caches and additionalDoxycycline capsules for prophylaxis of healthcare workers and family

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members. Additionally, CCRMC has stockpiled Doxycycline for prophylaxisof all first responders and family members. The County has a plan in placefor implementation of the Strategic National Stockpile.

(e) Ventilators – Hospitals report a total inventory of 123 full-scale ventilators andan average daily usage of 65, leaving an average availability of 58 full-scaleventilators to meet surge needs. Hospitals report that an additional 72 full-scale ventilators can be obtained from affiliated facilities or leased fromvendors, bring the total number of full-scale ventilators available for surge toabout 130. HRSA Year 4 funding is being used to purchase 320 disposableventilators to be stockpiled (40-each) at the county’s eight acute carehospitals.

(f) ChemPacks – Four CDC hospital ChemPacks are planned (2-each at the VAMartinez facility and at the San Ramon Regional Medical Center) containingchemical and nerve-agent antidotes to treat 1,000 persons each, or a total of4,000 persons.

(g) Protective supplies and equipment – All hospitals have obtained protectiveequipment and supplies including powered air purifying respirators (PAPR’s),protective clothing, HEPA filters, and supplies of N95 masks. Except for thePAPR’s, community clinics have obtained similar protective equipment andsupplies for disaster response.

(h) Communications and infrastructure – All hospitals and community clinics haveobtained portable satellite telephones for backup communications in the eventof a disaster. Community clinics have upgraded computer networks, installedemergency power, and obtained outside lighting to enhance operationalcapabilities.

4. Resource Tracking

Contra Costa has established a web-based Asset Logistics andResources Management System (ALARMS) developed by Ecology andEnvironment, Inc. to inventory disaster medical supplies and equipment at eachfacility and to track usage during an actual disaster. Each facility has access toreview all inventoried equipment and supplies and, when completed, will haveaccess to update its own inventory.

Alternate Care Site PlanningAn Alternate Care Site as defined in Contra Costa County is a specialized County-operated emergency shelter where, under certain defined emergency conditions, sick orinjured persons may be provided temporary shelter and limited medical care for one toseveral days until discharged from care or until more appropriate care becomesavailable.

An Alternate Care Site is operated jointly by the Contra Costa County Employment andHuman Services Department, which is responsible for administration of the AlternateCare Site, and Contra Costa Health Services, which is responsible for medical care.Both County departments work in partnership with the county Office of EmergencyServices (OES) and the American Red Cross*, which will provide non-medical logisticalsupport including cots, bedding, food, and other supplies normally used in establishingand operating a shelter facility. *(Planning agreements are still being discussed with theAmerican Red Cross regarding ACSs) but tentative response roles are as follows.

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America Red Cross role and response during a pandemicDuring a flu pandemic event, the Red Cross will:

Provide for feeding and bulk distribution for isolated and quarantined individuals,either directly or by convening and collaborating with others who are willing toprovide these services;

Continue to respond to disasters of all sizes; Participate in community education; and Ensure a safe and adequate blood supply.

Special Needs Shelters and Alternate Care SitesWhile the Red Cross does not operate special or medical needs shelters nor do theydeliver direct medical care, the Red Cross does anticipate receiving requests to providesignificant support to these types of facilities. This support could be in the form ofmaterial support (i.e. food, supplies) and/or human resources support (supplementalstaff or shelter management).

The Red Cross is not able to commit Red Cross workers to local public health overflowfacilities without appropriate worker protections, including liability coverage and workersafety measures. The Red Cross continues to explore the legal, risk and workerprotection considerations for a possible Red Cross support role in these facilities. Theseefforts include seeking federal assistance for a variety of protections for workers, as wellas similar assistance at the state level.

Vulnerable Populations ConsiderationsThe following issues will be taken into consideration in activating alternate care sites toserve people with special needs.

1. Consider prioritizing hospitalization versus assignment to Alternate Care Sites forsome individuals who may have extensive existing medical needs. Consideradmissions criteria to Alternate Care Site, skilled nursing facilities, licensed carefacilities or staying at home with attendants depending upon levels of careneeded.

2. Consider the assistive care needs of vulnerable populations at Alternate CareSites.

a. The assistive care needs of vulnerable populations including, but notlimited to, persons with impaired mobility, medically dependent/fragile,severe chronic disease, or developmental disabilities must be taken intoaccount at the time of the triage decision. Based upon need, someAlternate Care Sites may be designated for particular target populations.

b. Alternate Care Sites designated for vulnerable populations groups requirestaffing (for example, medical health professionals for a site catering topersons with severe chronic disease), equipment (for example, hydrauliclifts for persons unable to assist with transfers) and other considerations(for example, wide aisles to enable wheelchair access).

c. The Alternate Care Site will provide medications or Personal ProtectiveEquipment (PPE) to caregivers or family members that accompany theperson with special needs.

3. Ensure multilingual staff capacity at Alternate Care Sites.4. Consider optimal location of care for patients who are incarcerated, registered

sex offenders, etc.

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Activating Alternate Care SitesThe decision to initiate Alternate Care Site operations shall be made by the CountyHealth Officer primarily when, in accordance with the County Medical Surge Plan,hospitals and other health care facilities have implemented their own surge plans andremain overwhelmed. Under such circumstances, certain categories of patients may beadvised to receive care at home as appropriate hospital resources are simply notavailable. Persons whose condition falls within the criteria for home care, but who donot have necessary support available for home care, may be cared for at an AlternateCare Site. The Alternate Care Site is a transitional holding facility caring for patientsover a period of days to weeks until able to care for themselves, released to anappropriate caregiver, transferred to a skilled nursing facility or acute care hospital, ordiseased. An Alternate Care Site would not normally accept transfers from licensedhealth care facilities.

While primarily envisioned as a facility to be activated if needed during severe pandemicinfluenza, the Alternate Care Site could be used under any scenario in which there wasa need for the County to provide shelter and low acuity or palliative patient care. Undermost circumstances, however, it should be assumed that care can be better providedusing existing facilities even when those facilities must be operated beyond normalcapacity.

The Alternate Care Site Operations Manual has been adapted from the U.S. ArmyConcept or Operations for the Acute Care Center manual developed under theBiological Weapons Improved Response Program. The Concept of Operations for theAcute Care Center was written to assist planners, administrators, responders, medicalprofessionals, public health, and emergency management personnel in better preparingfor and providing mass casualty care. The concept of operations describes the specificcommand organization, operational execution, and the logistical and staffingrequirements associated with the Acute Care Center as envisioned in the U.S. Armydocument.

While the U.S. Army document uses the term “Acute Care Center,” the mission orpurpose of the Alternate Care Site as planned for Contra Costa County more closelyreflects that of the Alternate Care Site as described in the federal Health and HumanServices community planning guide on Mass Medical Care with Scare Resources1 thanan acute care hospital.

Major issues to be considered include:

• Physical plant: location, size, characteristics, and security needs

• Staffing: personnel needs, volunteers, credentialing

• Level and scope of care: disaster care vs. non-disaster care, agent-specific carevs. generic care, changing standard of care in mass casualty environmentsCommand, control, and communication: Incident Command System, fail-safecommunications

• Integration with federal and state response: framework of local response

1 Phillips SJ, Knebel A, eds. Mass Medical Care with Scarce Resources: A Community Planning Guide. Preparedby Health Systems Research, Inc., an Altarum company, under contract No. 290-04-0010. AHRQ Publication No.07-001. Rockville, MD: United States Health and Human Services Agency for Healthcare Research and Quality2007.

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compatible with outside resources.

(Please see Appendix for Healthcare Surge reference documents)

Alternate Care SEMS/NIMS Roles

Operations Section Chief- Receives information from the Care and Shelter, Medical/Health and Red

Cross Branches- Requests assistance from Logistics Section- Provides situation information to EOC Coordinator/PIO

Care and Shelter Branch Directoro Directs establishment of alternate care site in coordination with the Red Crosso Receives information from the Alternate Care Site Division Unified Commando Provides information to and receives directives from the Operations Section

Chiefo Makes request to Operations Chief for Logistics assistance (more cots, food

etc)

Alternate Care Site Unit Leader: OperationsReceives list of approved alternate care sites from OES and

Health OfficerCoordinates staffing, supplies, transportation etc for alternate

care sitesWorks with CCHS ACS Unit Medical Leader to establish Unified

commandProvides Information to and receives directives from the Care

and Shelter Branch DirectorReceives information from and provides directives to the AC

Operations Leaders at each AC Site.

Alternate Care Site Unit Leader: MedicalOversees medical staffing and operations for Alternate Care

SitesWorks with CCHS ACS Unit Operations Leader to establish

Unified commandProvides Information to and receives directives from the

Medical/Health Branch DirectorReceives information from and provides directives to the ACS

Medical Leaders at each AC site.

ACS Operations Leader – Unified Site Command Oversees the staffing, supplies etc for a specific AC site Establishes intake operations Works with the ACS Medical Leader to establish Unified

site command Provides information to and receives directives from the

Alternative Care Site Unit Leader: Operations

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ACS Medical Leader – Unified Site Command Oversees the medical operations for a specific AC site Establishes medical triage Works with the ACS Operations Leader to establish

unified site command Provides information to and receives directives from the

Alternative Care Site Unit Leader: Medical

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Section 6. Infection Prevention and Control Guidelines For Non-HealthCare and Health Care Settings

IntroductionThis section provides general infection control guidance, including the use ofPersonal Protective Equipment (PPE), for both non-health care settings(workplaces, jails, schools, etc.) and health care settings. (See also Sect. 7 Non-Pharmaceutical Interventions for community disease control and preventionmeasures, and see Sect. 4 Clinical Case Management Section for information onvaccines and antivirals.)

The CDC, WHO, the California Department of Public Health, and the federalOccupational Safety and Health Administration (OSHA) have all issuedguidelines and recommendations that are consistent with current scientificknowledge and accepted infection prevention and control practices. Theseguidelines will undergo modification as more is known about the characteristicsof the pandemic influenza strain and as new medications and vaccines becomeavailable. Strategies that may be appropriate at the early onset of the pandemic,such as isolation and quarantine of individuals suspected or infected withpandemic flu, may not be sustainable over the course of the pandemic. Suppliesmay become scarce, human resources may fluctuate and care delivery mayrequire modification. After pandemic flu begins circulating in Contra Costa, fullcommunity cooperation will be necessary to control the spread of the disease.

I. The essential goal of infection prevention and control is to minimizethe transmission of illness from infected individuals to non-infectedindividuals. This is accomplished through practices designed toprevent the spread of disease throughout all levels of thecommunity.

This section is divided into two broad categories:A. general infection control guidelines for non-health care facilities such as

businesses, schools, board and care facilities, jails etc. and for home care;B. more detailed infection control guidelines for licensed and acute care

facilities

Interpandemic/Pandemic Alert Period (WHO phases 1-5)The primary Infection Control objectives during the Interpandemic/PandemicAlert period are to:

1. implement effective control measures to slow the spread of pandemic flu;2. ensure common understanding of appropriate infection control measures

across all levels of care in Contra Costa

Modes of influenza transmissionThe mode of transmission defines how an infectious viral particle is transmittedfrom an infected person (“source person”) to a well person (“susceptible person”)and causes infection. The major mode of transmission for influenza is not

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Section 6. Infection Prevention and Control Guidelines For Non-HealthCare and Health Care Settings

IntroductionThis section provides general infection control guidance, including the use ofPersonal Protective Equipment (PPE), for both non-health care settings(workplaces, jails, schools, etc.) and health care settings. (See also Sect. 7 Non-Pharmaceutical Interventions for community disease control and preventionmeasures, and see Sect. 4 Clinical Case Management Section for information onvaccines and antivirals.)

The CDC, WHO, the California Department of Public Health, and the federalOccupational Safety and Health Administration (OSHA) have all issuedguidelines and recommendations that are consistent with current scientificknowledge and accepted infection prevention and control practices. Theseguidelines will undergo modification as more is known about the characteristicsof the pandemic influenza strain and as new medications and vaccines becomeavailable. Strategies that may be appropriate at the early onset of the pandemic,such as isolation and quarantine of individuals suspected or infected withpandemic flu, may not be sustainable over the course of the pandemic. Suppliesmay become scarce, human resources may fluctuate and care delivery mayrequire modification. After pandemic flu begins circulating in Contra Costa, fullcommunity cooperation will be necessary to control the spread of the disease.

The essential goal of infection prevention and control is to minimize thetransmission of illness from infected individuals to non-infected individuals. Thisis accomplished through practices designed to prevent the spread of diseasethroughout all levels of the community.

This section is divided into two broad categories:C. general infection control guidelines for non-health care facilities such as

businesses, schools, board and care facilities, jails etc. and for home care;D. more detailed infection control guidelines for licensed and acute care

facilities

Interpandemic/Pandemic Alert Period (WHO phases 1-5)The primary Infection Control objectives during the Interpandemic/PandemicAlert period are to:

3. implement effective control measures to slow the spread of pandemic flu;4. ensure common understanding of appropriate infection control measures

across all levels of care in Contra Costa

Modes of influenza transmissionThe mode of transmission defines how an infectious viral particle is transmittedfrom an infected person (“source person”) to a well person (“susceptible person”)and causes infection. The major mode of transmission for influenza is notentirely clear. However, the pattern of person-to-person spread is generally

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consistent with spread through close contact (i.e. exposure to large respiratorydroplets, direct contact, or near-range exposure to aerosols). Some studiessupport airborne transmission through small particle aerosols; however, there islittle evidence of airborne transmission over long distances or prolonged periodsof time. Unfortunately, the relative contributions and clinical importance of thedifferent modes of influenza transmission are currently unknown.

1. Droplet Transmission – Droplet transmission occurs when a person whohas symptomatic illness or who is a carrier of the virus (“source person”)generates droplets containing virus when they cough, sneeze or talk.These droplets then contact the conjunctivae (covering of the eyeball) orthe mucous membranes of the nose or mouth of a susceptible person, andcause infection. Transmission via large-particle droplets (> 10 m indiameter) requires close contact between source and recipient persons,because droplets do not remain suspended in the air and generally travelonly short distances (about 3 feet) through the air. Because droplets donot remain suspended in the air, special air handling and ventilation arenot required to prevent droplet transmission.

2. Contact transmission – Direct contact transmission involves skin-to-skincontact and physical transfer of virus from an infected person to asusceptible person (e.g., by hand contact). Indirect-contact transmissioninvolves contact of a susceptible host with a contaminated intermediateobject, usually inanimate, in the person’s environment.

3. Transmission via contaminated hands and fomites (objects) has beensuggested as a contributing factor in some studies. However, there isinsufficient data to determine the proportion of influenza transmission thatis attributable to direct or indirect contact. In an experimental study,influenza viruses could be transferred from hard, non-porous surfacessuch as stainless steel and plastic to hands for 24 hours and from tissuesto hands for up to 15 minutes. Virus can survive on hands for up to 5minutes after transfer from an environmental surface. Higher humidityshortens virus survival.

4. Airborne transmission – Airborne transmission occurs by dissemination ofeither airborne droplet nuclei (< 5 m in diameter) or small particles in therespirable size range containing the infectious agent into the air.Microorganisms carried in this manner may be dispersed over longdistances by air currents and may be inhaled by susceptible individualswho have not had face-to-face contact with (or been in the same roomwith) the infectious individual. Organisms transmitted in this manner mustbe capable of sustaining infectivity, despite desiccation and environmentalvariation that generally limit survival in the airborne state. Preventing thespread of agents that are transmitted by the airborne route requires theuse of special air handling and ventilation systems (e.g. negative pressurerooms).

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Small particle aerosols. There is no evidence that influenza transmissioncan occur across long distances (e.g. through ventilation systems) orthrough prolonged residence in air, as seen with airborne diseases suchas tuberculosis. However, transmission may occur at shorter distancesthrough inhalation of small particle aerosols (droplet nuclei), particularly inshared spaces with poor air circulation.

In summary, the precise mode of transmission, and the relative contribution ofdroplet transmission versus airborne transmission versus contact transmissionare not known. However, several observations suggest that the influenza isspread primarily through close contact (i.e. exposure to large respiratory droplets,direct contact, or near-range exposure to aerosols), and does not travel longdistances (i.e. through ventilation systems). Our recommendations are thusbased on close contact spread.

A. GENERAL GUIDELINES FOR NON-HEALTHCARE SETTINGS

Schools, Businesses, Jails, Board and Care Facilities, etc.The most important element in preventing the spread of influenza is to preventintroduction of the virus into the respiratory tract. During the alert period andthroughout the pandemic each facility in Contra Costa County should establishand implement basic infection control practices to limit transmission of andexposure to pandemic influenza, including policies to decrease the spread ofpandemic flu in the workplace, such as “no work while sick” and appropriatepersonal hygiene policies. (See also CCHS’ Pandemic Action Planning Kit forschools and day care providers at www.cchealth.org for public educationmaterials such as “Cover Your Cough” posters and fact sheets, as well as Sect. 9Risk Communication and Public Information of this plan.)

Infection control practices to prevent spread of diseaseThe following recommendations are based on what is known about the modes ofinfluenza transmission. The most important concept in preventing the spread ofinfluenza is to prevent the direct and indirect inoculation of the respiratory tract.(For information on the use of vaccines and antiviral drugs, see Sect. 4 ClinicalCase Management.) There are four major ways to accomplish this:

1. Protect the well with personal protective equipment (PPE) and handhygiene

a. Hand hygieneIf hands are visibly soiled, wash them with warm water and

soapIf hands are not visibly soiled, perform hand hygiene.Perform hand hygiene after contact with a person who may

be ill, after removing mask or gloves, or after touching itemsor surfaces that may be soiled.

b. Persons in contact with individuals suspected to be infected withinfluenza (during transport of an ill person, or in the home, in the

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jails, or in a daycare, school or work setting) can protectthemselves by doing the following:Wear a surgical or procedure mask when in close contact (<

3 feet) with an infectious person. A mask should bechanged and discarded when it becomes moist. Performhand hygiene after touching or discarding a mask.

Wear gloves if there is likely to be contact with respiratorysecretions. Discard gloves immediately after use and performhand hygiene.

2. Limit contact between infected and not infected persons.a. Whenever possible, isolate infected persons. In the workplace or

school, persons with symptoms of influenza (fever, headache,myalgia [muscle pain], prostration, cough, rhinitis [runny nose], orsore throat) should be sent home. If they cannot be sent homeimmediately, confine to a separate room. If contact betweeninfected and not infected cannot be avoided (e.g. during transport ina car), place a surgical or procedure mask over the nose andmouth of the ill person, and open the windows to increase aircirculation.

For workers uncertain of potential exposure (such as in a day carecenter), wear a surgical or procedure mask when in close contact(less than 3 feet) with a potentially infectious person. Change themask when it becomes moist, and perform hand hygiene afterdiscarding the mask. Wear gloves if there is contact with respiratorysecretions and discard gloves immediately after use and performhand hygiene.

3. Contain infectious respiratory secretions of the ill.a. All persons with signs and symptoms of a respiratory infection,

regardless of presumed cause, should:Cover their nose and mouth when coughing or sneezing,

preferably with a tissue or clothUse tissues to contain respiratory secretionsDispose of tissues in the nearest waste receptacle after usePerform hand hygiene after contact with respiratory

secretions and contaminated objects/materialsb. Schools, workplaces, businesses and other places where people

congregate should ensure availability of supplies to facilitate use oftissues, proper disposal and hand hygiene. Wherever possible,Provide tissues and garbage receptaclesProvide facilities for hand hygiene; either sink, water and

soap, or alcohol-based hand rub dispensers

4. Promote air circulation and keep environment cleana. Good air circulation has been shown to decrease the chance of

spreading respiratory viruses.

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When caring for a patient in the home, or a residentialfacility, place a patient in a separate room with an operablewindow. Keep window open as the climate permits, and ifnecessary use a fan to circulate the fresh air.

UV light can kill the influenza virus. Open the shades andallow sunlight into the room.

b. Waste disposalTissues used by the ill person and other waste should be

placed in a bag and disposed of with other household waste.c. Linen and laundry

Laundry may be washed in a standard washing machinewith warm or cold water and detergent. It is not necessary toseparate soiled linen and laundry used by a patient withinfluenza from other household laundry. Care should beused when handling soiled laundry (i.e. avoid “hugging” thelaundry) to avoid self-contamination. Hand hygiene shouldbe performed after handling soiled laundry.

d. Dishes and utensilsSoiled dishes and eating utensils should be washed either in adishwasher or by hand with warm water and soap. Separation ofeating utensils for use by a patient with influenza is notnecessary.

e. Environmental cleaning and disinfectionEnvironmental surfaces in the home, workplace, school, etc.,can be cleaned using normal procedures. An EPA-registeredhospital disinfectant can be used according to manufacture’sinstructions, but is not necessary. There is no evidence tosupport the widespread disinfection of the environment or air.

Infection control considerations for specific settingsFor each of the settings described below, the infection control guidancedescribed under “Infection control practices to prevent spread of disease” appliesas well as the setting-specific guidance below.

1. Home CareThe use of respiratory hygiene, hand hygiene, cough etiquette, and droplet,and contact precautions are recommended, as possible. (See outline belowand Appendix for Home Care Brochure and Sect. 4 Clinical CaseManagement.)

Symptomatic patients who do not require hospitalization should not go towork, school, childcare centers or other public areas until fourteen days afterthe onset of symptoms. During this time, the additional infection preventionrecommendations below should be used to minimize the potential fortransmission:

a. Physically separate the patient with influenza from non-ill persons

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living in the home as much as possible. If more than one person inthe home has influenza, all ill persons can share the same room.Ideally the patient(s) with influenza should have their own room withwindows that open to increase air circulation.

b. The patient should cover mouth and nose with a facial tissue whencoughing or sneezing; wear a surgical mask when uninfectedpersons enter the room or, if unable, uninfected persons shouldwear an N-95 respirator when entering the room;

c. When travel outside the home is necessary for a patient (e.g. formedical care), the patient should cover the mouth and nose whencoughing and sneezing and should wear a mask.

d. As much as is possible, one person in the home should be thedesignated caregiver and all others should limit contact to theextent possible.

e. Follow general infection control measures described above.

Caregivers should: Wear disposable gloves when in contact with the ill person’s blood and body

fluids (including respiratory secretions or items such as disposable tissuescontaminated with respiratory secretions) and the immediate environment.Immediately after activities involving contact with blood and body fluidsincluding respiratory secretions, gloves should be removed and discardedand hand hygiene should be performed. Gloves are not intended to replaceproper hand hygiene;

Wash hands with soap and water after gloved and ungloved contact with theill person’s blood and body fluids (including respiratory secretions or itemssuch as disposable tissues contaminated with respiratory secretions) and theill person’s immediate environment. Alcohol-based hand hygiene productscan be used after removing gloves when hands are not visibly soiled withrespiratory secretions, blood and other body fluids and soap and water is notimmediately accessible. Gloves should never be washed or reused;

Unwashed dishes and utensils should not be shared. Wash dishes andutensils with warm to hot water and any commercial detergent after each use.Disposable plates or eating utensils are not necessary;

Clean and disinfect environmental surfaces in the kitchen, bathroom andbedroom at least daily with a household cleaner diluted and used according tomanufacturer’s instructions. Bleach, if used, should be diluted 1 part bleachto 10 parts water. A fresh solution should be mixed daily;

Linens should not be shared between household members until they havebeen washed. Wash clothes, bed linens and towels in water at anytemperature using any commercial laundry product and dry at an appropriatefabric temperature. Gloves should be worn when handling soiled linens;

Dispose of waste soiled with respiratory secretions, blood or other body fluids,and surgical masks as normal household waste;

Any rented, non-disposable medical or respiratory equipment should beplaced in a plastic bag and labeled contaminated prior to their return.

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2. Schools and Daycare Providers (See also CCHS’ Schools PandemicAction Planning Kit for schools and day care providers atwww.cchealth.org)

a. Keep sick students, teachers and other workers away from schoolor daycare while ill.

b. If there will be a lag time between when a potentially infectiousperson is identified and when they can leave school, move them toa separate and well ventilated room during the waiting period.

c. Promote respiratory hygiene, cough etiquette and hand hygiene asfor any respiratory infection.

d. Routine environmental cleaning is adequate.

3. Workplace (See also Sect. 7 Non-pharmaceutical Interventions)a. Keep sick workers away from the workplace while ill and potentially

infectious (up to 14 days from onset of illness; this may be revisedto a shorter period when more is known about the virus).

b. If there will be a lag time between when a potentially infectiousperson is identified and when they can leave the workplace, movethem to a separate and well ventilated room during the waitingperiod.

c. Promote respiratory hygiene, cough etiquette and hand hygiene asfor any respiratory infection.

d. Routine environmental cleaning is adequate.

4. Jails, Correctional Facilities, Locked WardsJails, correctional facilities, or other locked wards represent uniquesettings in which crowding, barrack-style living, and freedom of mobilitymay increase transmission of influenza and special care should be takento identify infectious inmates as early as possible.

a. To the extent possible, house inmates into three groups:i. Illii. Exposediii. Not ill and not exposed

b. Keep ill inmates in a well-ventilated room or rooms physicallyseparate from the remainder of the population.

c. Avoid allowing jail staff assigned to the ill inmates to float or haveany contact with the second or third groups.

d. Promote respiratory hygiene, cough etiquette and hand hygiene asfor any respiratory infection.

e. Once a pandemic is established, considering using masks for allinmates and staff.

f. Routine environmental cleaning is adequate.

5. Law EnforcementFor law enforcement personnel, who may have contact with or transport illpeople or those who have been potentially exposed to pandemic flu, followlaw enforcement’s standard procedures for infection control andimplement PPE protocol per departmental policy and use patrol cars with

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plastic dividers that separate officers from suspect/passenger. Followinfection control guidelines above, including for the workplace, and:

a. If contact between infected and not infected cannot be avoided(e.g. during transport in a car), place a surgical or procedure maskover the nose and mouth of the ill person, and open the windows toincrease air circulation.

b. For workers uncertain of potential exposure, wear a surgical orprocedure mask when in close contact, or in an enclosed area (lessthan 3 feet) with a potentially infectious person. Change the maskwhen it becomes moist, washing hands with soap and water or analcohol based hand rub after discarding the mask. Wear gloves ifthere is contact with respiratory secretions and discard glovesimmediately after use, washing hands or using an alcohol basedhand rub.

c. Symptoms of flu include muscle ache, headache, fever, cough,runny nose, and/or sore throat. Provide a mask to the individual tocover the face and mouth, and increase the amount of fresh aircirculating in the room.

d. Law enforcement vehicles should be equipped with masks andalcohol hand sanitizer.

6. Pre-hospital care situations (emergency medical services/ambulancedrivers, etc.)

For ambulance drivers or others who may transport ill patients or suspectedcases of pandemic flu, implement usual standard protocol and:

a. Screen patients requiring emergency transport for symptoms ofinfluenza

b. Follow standard and droplet precautions when transportingsymptomatic patients

c. Once pandemic influenza has been identified in the community, useN-95 respirators for all patient transport.

d. If possible, place a surgical or procedure mask on the patient tocontain droplets expelled during coughing. If this is not possible,(i.e. would further compromise respiratory status, difficult for thepatient to wear), have the patient cover the mouth/nose with tissuewhen coughing, or use the most practical alternative to containrespiratory secretions.

e. Oxygen delivery with a non-rebreather face mask can be used toprovide oxygen support during transport. If needed, positive-pressure ventilation should be performed using resuscitation bag-valve mask.

f. Unless medically necessary to support life, aerosol-generatingprocedures (i.e. mechanical ventilation) should be avoided duringpre-hospital care.

g. Optimize the vehicle’s ventilation to increase the volume of airexchange during transport. When possible, use vehicles that haveseparate driver and patient compartments that can provide

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separate ventilation to each area.h. Notify the receiving facility that a patient with possible pandemic

influenza is being transported.i. Follow standard operating procedures for routine cleaning of

emergency vehicles and reusable patient care equipment.

B. GENERAL GUIDELINES FOR HEALTH CARE SETTINGS (Hospitals,health centers, etc.)In addition to the above guidelines, health care facilities are encouraged toimplement additional precautions:

Standard PrecautionsThese precautions are designed to reduce the risk of transmission ofmicroorganisms from both recognized and unrecognized sources of infectionwithin healthcare facilities. The precautions apply to blood and all body fluidsexcept sweat regardless of whether or not they contain visible blood, non-intact skin and mucous membranes. All healthcare facilities and providersmust ensure: Barriers are used to protect the skin and mucous membranes of the

healthcare worker from contact with the blood and/or body fluids of thepatient. Standard Precautions are to be observed in all patient careinteractions.

The availability of personal protective equipment (PPE), including gowns,gloves, masks and eye protection (See PPE section below).

Ensure the availability of hand washing/hand sanitization stations.

Airborne PrecautionsThese measures are designed to limit the spread of microorganisms that aresmall (5 µm or less). Because of their small size, these microorganisms mayremain in the air for long periods of time. Microorganisms carried in this mannercan be dispersed widely by air currents and may be inhaled by a susceptible hostin the same room or over a longer distance depending on environmental factors.All Healthcare facilities and providers must ensure:

Negative pressure – where available is utilized in rooms where thesepatients are housed.

Protective masks used by personnel should be an N95 respirator.

Contact PrecautionsThese measures are designed to limit the transmission of microorganisms thatare spread by skin-to-skin contact or physical transfer of the microorganisms viaunwashed hands or certain inanimate objects in the patient care environment.All Healthcare facilities and providers will ensure:

Personal protective equipment utilized will include gloves, gowns for directcontact and masks if splashing or aerosolization of secretions isanticipated. (See PPE section below)

Droplet Precautions

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These measures are designed to limit the transmission of organisms contained inthe droplets that are generated from the infected person during coughing,sneezing and talking and during the performance of certain procedures such assuctioning and bronchoscopy. These droplets are generally large and arepropelled a short distance through the air and either land directly on theconjunctiva, nasal mucosa or mouth of another person or on surfaces where theycan contaminate the hands of another person. The unwashed contaminatedhands will spread the pathogen when they touch the conjunctive, nasal mucosaor mouth of another. Because droplets do not remain suspended in the air,special air handling and ventilation are not required to prevent droplettransmission; that is, droplet transmission must not be confused with airbornetransmission. All Healthcare facility and providers will ensure:

A N95 respirator and protective eyewear is utilized. Personal protective equipment needed includes gloves for direct contact,

gowns if soiling is anticipated.

Personal Protective Equipment (PPE)During an influenza pandemic, masks and respirators - called PersonalProtective Equipment (PPE) - used in combination with other Non-Pharmaceutical Interventions (NPIs) when close contact is expected withsomeone who has pandemic influenza - may help reduce the spread of influenza.( See Sect. 7 Non-Pharmaceutical Interventions)

A risk assessment to determine necessary PPE and work practices to avoidcontact with blood, body fluids, excretions, and secretions will help to customizestandard precautions to the healthcare setting of interest. Standard precautionsinclude the use of gloves and facial (nose, mouth, and eye) protection byhealthcare workers when providing care to coughing/sneezing patients.

In suggesting the use of these PPEs, CCHS will follow the CDHS, DHHS, OSHA,and CDC interim recommendations based on the best judgment of public healthexperts who relied in part on information about the protective value of masks inhealthcare facilities.

Employees whose work involves close contact with humans or animals known orsuspected to be infected with certain types of flu or pandemic influenza must beprovided appropriate PPE. Employees providing direct care to patients known orsuspected of being infected with pandemic influenza or those employees workingdirectly with animals known or suspected of being infected with influenza shoulduse “full barrier” PPE.Full barrier PPE includes:• respirator at least as protective as a NIOSH-certified N95 respirator;*• gown;• gloves; and• eye protection (faceshield/goggles).

Although most employees outside of healthcare or animal control settings will notneed PPE, the need for PPE by employees whose regular duties do not involve

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possible contact with infected humans or animals will be evaluated on a case-by-case basis.

*Respirators should be used in the context of a complete respiratory protectionprogram as required by OSHA. This includes pre-use medical evaluation,training, and fit testing, as well as seal checking at time of use to ensureappropriate respirator selection and use. To be effective, respirators must sealproperly to the wearer's face. Detailed information on respiratory protectionprograms is available at: http://www.osha.gov/SLTC/etools/respiratory/ andhttp://www.health.state.mn.us/divs/idepc/dtopics/infectioncontrol/rpp/index.html

Assorted PPE

Differences between Surgical Masks and RespiratorsAlthough some disposable respirators look similar to surgical masks, it isimportant that healthcare workers understand the significant functional differencebetween surgical masks and disposable respirators.

Surgical MasksSurgical masks are not designed to prevent inhalation of airborne contaminants.Their ability to filter small particles varies greatly and cannot be assured toprotect healthcare workers against airborne infectious agents. Instead, theirunderlying purpose is to prevent contamination of a sterile field or workenvironment by trapping bacteria and respiratory secretions that are expelled bythe wearer (i.e., protecting the patient against infection from the healthcareworker). Surgical mask are also used as a physical barrier to protect thehealthcare worker from hazards such as splashes of blood or bodily fluids.Surgical masks should be used once and then thrown away.

When both fluid protection (e.g., blood splashes) and respiratory protection areneeded, a “surgical N95” respirator can be used. This respirator is approved byFDA and certified by NIOSH.

RespiratorsA respirator (e.g., an N95 or higher filtering face piece respirator approved by theNational Institute for Occupational Safety and Health) is designed to protectpeople from breathing in very small particles, which might contain viruses.Healthcare workers, such as nurses and doctors, use respirators when takingcare of patients with diseases that can be spread through the air.

“N95” means the filter on the respirator screens out 95 percent of the particles(0.3 microns and larger) that could pass through. To be most effective, thesetypes of respirators need to fit tightly to the face so that the air is breathedthrough the filter material. “Fit testing” is the usual method for assuring proper fitin workplaces where respirators are used. Respirators are not designed to form atight fit on people with small faces (e.g., children) or facial hair. Men who havebeards need to shave before using.

N95 and higher respirators are less comfortable to wear than facemasks

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because they are more difficult to breathe through.

Like surgical masks, most N95 respirators should be worn only once and thenthrown away in the trash.

Particulate respirators can be divided into several types:• Disposable or filtering face piece respirators, where the entire respirator facepiece is comprised of filter material. It is discarded when it becomes unsuitablefor further use due toexcessive breathing resistance (e.g., particulate clogging the filter), unacceptablecontamination/soiling, or physical damage.• Reusable or elastomeric respirators, where the face piece is cleaned, repaired,and reused, but the filter cartridges are discarded and replaced when theybecome unsuitable for further use.• Powered air-purifying respirators, where a battery-powered blower pullscontaminated airthrough filters, then moves the filtered air to the wearer.

All respirators used by employees are required to be tested and certified byNIOSH. NIOSH uses very high standards to test and approve respirators foroccupational uses. NIOSH-certified particulate respirators are marked with themanufacturer’s name, the part number, the protection provided by the filter (e.g.,N95), and “NIOSH.” This information is printed on the face piece, exhalationvalve cover, or head straps. If a respirator does not have thesemarkings and does not appear on one of the following lists, it has not beencertified by NIOSH.

A list of all NIOSH-certified disposable respirators is available at:http://www.cdc.gov/niosh/npptl/respirators/disp_part/particlist.htmlNIOSH also maintains a database of all NIOSH-certified respirators regardless ofrespirator type (the Certified Equipment List), which can be accessed at:http://www.cdc.gov/niosh/celintro.html

Goggles/Face ShieldsThe HHS Pandemic Influenza Plan does not recommend the use of goggles orface shields for routine contact with patients with pandemic influenza; however, ifsprays or splatters of infectious material are likely, it states that goggles or a faceshield should be worn as recommended for standard precautions.

If a pandemic influenza patient is coughing, any healthcare worker who needs tobe within 3 feet of the infected patient is likely to encounter sprays of infectiousmaterial. Eye and face protection should be used in this situation, as well asduring the performance of aerosol-generating procedures.

Facemasks are loose fitting, disposable masks that cover the nose and mouth.These include products labeled as surgical, dental, medical procedure, isolation,and laser masks. Facemasks help stop droplets from being spread by the personwearing them. They also keep splashes or sprays from reaching the mouth andnose of the person wearing the facemask. They are not designed to protect the

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person wearing it against breathing in very small particles. Facemasks should beused once and then thrown away in the trash.

GlovesHHS recommends the use of gloves made of latex, vinyl, nitrile, or othersynthetic materials as appropriate, when there is contact with blood and otherbodily fluids, including respiratory secretions.• There is no need to double-glove.• Gloves should be removed and discarded after patient care.• Gloves should not be washed or reused.• Hand hygiene should be done after glove removal.Because glove supplies may be limited in the event of pandemic influenza, otherbarriers such as disposable paper towels should be used when there is limitedcontact with respiratory secretions, such as handling used facial tissues. Handhygiene should be practiced consistently in this situation.

Indications for, and limitations of, glove use• Hand contamination may occur as a result of small, undetected holes inexamination gloves• Contamination may occur during glove removal• Wearing gloves does not replace the need for hand hygiene• Failure to remove gloves after caring for a patient may lead to transmission ofmicroorganisms from one patient to another

Gowns• Healthcare workers should wear an isolation gown when it is anticipated thatsoiling ofclothes or uniform with blood or other bodily fluids, including respiratorysecretions, mayoccur. HHS states that most routine pandemic influenza patient encounters donot necessitate the use of gowns. Examples of when a gown may be neededinclude procedures such as intubation or when closely holding a pediatric patient.• Isolation gowns can be disposable and made of synthetic material or reusableand made ofwashable cloth.• Gowns should be the appropriate size to fully cover the areas requiringprotection.• After patient care is performed, the gown should be removed and placed in alaundryreceptacle or waste container, as appropriate. Hand hygiene should follow.

Materials Management/Equipment AvailabilityDaily contact is needed with Materials Management to ensure that appropriatePPE is available for employee and patient use. Stockpile equipment as needed.As the pandemic widens, shortages can be anticipated. Materials managementmust maintain constant inventory oversight of basic infection control equipmentincluding: gloves, N95 masks, gowns, waste disposal bags, alcohol based handgel and antiseptic hand wash, tissues, and the like. Shortages in other materials

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are also anticipated. Consider whether work procedures can be modified to avoidthe need for PPE during a pandemic. Agencies should assess their expectedservice delivery needs during a pandemic and consider the currentrecommended personal protection guidelines. If personal protection is expectedto be necessary during a pandemic, agencies should make arrangements inadvance to evaluate, train, and equip employees with the appropriate PPE.

1. Agencies will be responsible for providing employees with properly selectedand fitted PPE when needed during a pandemic. Agencies must provide trainingon the proper use of PPE. Agencies must follow any applicable OSHAregulations. Employees that are issued PPE are required to wear the equipment.

2. Agencies that have a clear need for PPE during a pandemic (direct care ofindividuals ill with influenza or other critical services where PPE is required)should consider the gradual stockpiling of nonperishable PPE.

Employee Instruction. Employee education will need to focus on appropriatepersonal protective equipment (PPE) as well as proper donning and doffingsequence. Information on immunization and medications used for prophylaxis aswell as review of all isolation precautions will also be needed. (See Sect.4Clinical Case Management for information on vaccines and antivirals; and Sect. 9Risk Communications and Public Education for lists of disease preventionmaterials, such as posters, etc.)

Educational offerings will likely need to be repeated and perhaps revised everythree to six months. To maintain employee interest, it will be necessary todevelop different types of presentations that can be rotated and sent out toremote sites (e.g. Ambulatory Care Centers).

Patient EducationHandouts will need to be developed on many topics including infectionprevention and control in the home setting. Instruction on patient home care andself-care will be critical because of the expected surge in patients andovercrowding of health care facilities. Non-critical patients should be encouragednot to come to hospitals or health care centers. Information and fact sheets onimmunization and prophylactic medications will also be needed. (See Sect. 9Risk Communications and Public Education for lists of disease preventionmaterials, such as posters, etc, and Risk Communication Guidance forHospitals.)

Also: Plan education for all levels of employees on newly developed policies as

well as influenza; Promote influenza vaccination for all employees; Institute “Cover your Cough” signage; Develop strategies to provide masks, tissues and appropriate disposal

containers in Emergency Department and Ambulatory Care sites; Immunization should be strongly encouraged and healthcare workers

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should be provided with immunization free of charge. Reinforcement of existing policies for Respiratory Hygiene, Isolation

Precautions, Hand Hygiene; Education of healthcare workers to facilitate rapid identification of potential

cases of Influenza due to a novel strain with pandemic potential; Increased surveillance for flu-like illness; Assessment of current levels of N95 mask availability, begin to consider

some stockpiling; Develop teaching handouts address issues related to home care of

patients with influenza, antiviral medication, influenza vaccine declinationforms, and symptom diaries;

Maintaining close contact with CCHS and other health care infectioncontrol and prevention practitioners in Contra Costa County.

Conducting frequent review of current literature to ensure that the mostrecent recommendations have been considered in the development of anypolicies, procedures or patient and employee managementrecommendations.

Signage and Policy Implementation. Daily rounds will be needed to insure thatsigns are posted in necessary locations and in a variety of languages. Waitingareas will need to have a supply of tissues and/or masks and appropriatedisposal containers.

Patient Management. (See also Sect. 4 Clinical Case Management and Sect. 5Health Care Facility Planning)As more patients present for care, the number of negative pressure isolationrooms will not be adequate. Thought must be given to housing patients indesignated areas. The optimal characteristics for a designated area wouldinclude:

Ability to create negative pressure rooms within this area. Ability to limit access to the area Room for storage/stockpiling supplies. Ability to house more than one person within the room.

Criteria for placing patients on this floor as well as assigning staff to this floor willneed to ensure that the patients have documented illness with the pandemicinfluenza and the staff will need to have received full immunization.Administration will need to consider whether assignment to these areas will bevoluntary or mandatory.

Nutrition, Laundry and Environmental ServicesAt this time there is no recommendation regarding the use of disposable dishesand eating utensils. Standard Precautions should be observed when handlingdishes and utensils used by patients with influenza. Laundry should also behandled using Standard Precautions and no additional precautions arerecommended at this time.

Cleaning and disinfection of environmental surfaces are important infection

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control measures in healthcare facilities. In addition to routine dailyenvironmental decontamination, healthcare personnel should perform morefrequent disinfection of commonly touched surfaces in patient rooms andcommon areas. All rooms should be terminally cleaned after discharge.

Post Mortem CareStandard Precautions should be followed when caring for deceased persons. Ifautopsy or other procedures are performed on a person suspected or known tohave died from pandemic influenza, a Personal Air Purifying Respirator (PAPR)should be utilized.

Pandemic PeriodDuring the peak of the pandemic it may be necessary to establish a triage centeroutside of the entrance to the Emergency Department or health center. Thisarea would need to be staffed and equipped to screen patients and direct them toan appropriate treatment area. Separate areas will be needed for persons withinfluenza like symptoms and persons needing to be seen for other health careissues.

Patients should be managed according to all previously outlined precautions.Additionally a secure method to transition patients out of the hospital and intoalternate care sites and/or home care will be needed.

The goal of infection prevention and control in the alternate care sites will be tolimit the transmission of virus within and out of the site. Sites are expected tohave staffing mixes (healthcare professionals and volunteers) and no special airhandling capacities, so strict attention must be paid to Respiratory Etiquette,Hand Hygiene, Droplet and Contact precautions. Whenever possible,symptomatic persons awaiting examination and diagnosis should be masked andseparated from those persons being seen for other reasons.

During this phase infection prevention and control activities will be focused on: Participation in any daily meetings regarding bed utilization and patient

management; Enforcement of all infection prevention and control recommendations; Meeting all requirements regarding reporting to local, state and federal

agencies as required by law; Facilitation of patient transfer when needed; Daily rounds to ensure that all cases reported and appropriate infection

prevention measures in place; Provision of immunization and/or prophylactic medication to all hospital

and health center employees; Monitoring employee sick calls and employees who have received either

vaccination and/or prophylaxis; Serving as a clearinghouse for current information and treatment

guidelines and distributing educational materials as needed; Frequent assessment of supplies – work in close collaboration with

materials management and pharmacy;

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Attend all county wide meetings as required; Assist and facilitate discussions regarding patient care, resource

allocation.

Nutrition, Laundry and Environmental ServicesAlthough no recommendation exists for the use of disposable utensils anddishes, it may be necessary to utilize them as the pandemic spreads and theremay be shortages within the Nutrition Services Department. Laundry shouldcontinue to be handled using Standard Precautions until such time as additionalprecautions are recommended. As the pandemic spreads there may beshortages or delay in laundry delivery and creative alternatives may be needed.Cleaning and disinfection of environmental surfaces are important infectioncontrol measures in healthcare facilities. In addition to routine dailyenvironmental decontamination, healthcare personnel should perform morefrequent disinfection of commonly touched surfaces in patient rooms andcommon areas. All rooms should be terminally cleaned after discharge.

Post Mortem CareStandard Precautions should be followed when caring for deceased persons.Autopsies will likely not be done and there may be large numbers of bodiesrequiring storage. It may be necessary to have an alternative morgue set up.

Human ResourcesAs the pandemic progresses, manpower will be stretched and it will likely benecessary to utilize volunteer physicians and nurses and to cross trainemployees to do alternate jobs. All individuals will need specific infection controltraining to ensure policies and procedures are followed.

Employee HealthEmployee health strategies will be in effect. As the epidemic peaks, methods willneed to be developed to screen healthcare workers for influenza like illness atthe start of their shift. Additionally it will be necessary to establish return to workcriteria for employees.

Post-Pandemic PeriodContinue infection control activities per normal operations.

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Section 7. Non-Pharmaceutical Interventions

IntroductionAccording to the CDC, it is highly unlikely that the most effective tool formitigating a pandemic (i.e., a well-matched pandemic strain vaccine) will beavailable when a pandemic begins. This means that we must be prepared toface the first wave of the pandemic without vaccine and potentially withoutsufficient quantities of influenza antiviral medications. In addition, it is not knownif current influenza antiviral medications will be effective against a futurepandemic strain.”1

With that caution as a planning assumption, it is clear that a combination ofpharmaceutical and non-pharmaceutical interventions (NPIs) during the durationof the pandemic must be used to reduce the number of persons infected.

NPIs may help reduce the number of infected persons by reducing contactbetween infected and uninfected persons. Reducing the number of personsinfected will, in turn, lessen the need for healthcare services and minimize theimpact of a pandemic on the economy and society.

The major goals of promoting the use of non-pharmaceutical interventions are to:

1) Delay the increase of cases in order to “buy time” for production anddistribution of a well-matched pandemic strain vaccine, and

2) Decrease the epidemic peak (the highest number of cases at a giventime), and

3) Reduce the total number of cases, thus reducing illness and death, and

4) Decrease demand for medical services at the peak of the epidemic andthroughout the epidemic wave

5) Protect health workers and first responders to ensure the well-being of theContra Costa community.

Pandemic Severity – The driver of local responseTo better predict the impact of a pandemic and to provide local decision-makerswith recommendations that are matched to the severity of an influenza pandemic,the Centers for Disease Control and Prevention (CDC), has developed aPandemic Severity Index. This index uses the case fatality ratio (the proportionof deaths among critically ill persons) as the critical driver for determining theseverity of a pandemic. The categories range from a 1 to a 5, with 1 being the

1 Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in theUnited States

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least severe and 5 being the most. A severe pandemic may indicate the need formore extreme measures to help prevent the spread of disease and loss of life.Therefore, the primary driver for response in Contra Costa County will be theseverity of the pandemic as defined by the CDC Pandemic Severity Indexbelow.

CDC Pandemic Severity Index

CCHS will make decisions about which of non-pharmaceutical interventionsshould be used carefully, recognizing that there will be consequences of theinterventions, such as increased workplace absenteeism related to child-mindingresponsibilities if schools dismiss students and childcare programs close.

In addition, because Contra Costa is an integral part of the San Francisco BayArea and residents of Contra Costa commute to work and school in othercounties, decisions regarding the use of NPIs and other pandemic flu responsesmust be coordinated with other Bay Area Counties.

Non Pharmaceutical Interventions DefinitionNon-pharmaceutical interventions (NPIs) refer to measures that attempt to slowintroduction of disease and subsequent transmission until more definitive publichealth measures (anti-virals and vaccine) are available.

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No intervention short of mass vaccination of the public will dramatically reducetransmission when used alone. Mathematical modeling of pandemic influenzascenarios in the United States, however, suggests that pandemic mitigationstrategies utilizing multiple NPIs may decrease transmission substantiallyand that even greater reductions may be achieved when such measures arecombined with the targeted use of antiviral medications for treatment andprophylaxis. Recent preliminary analyses of cities affected by the 1918 pandemicshow a highly significant association between the early use of multiple NPIs andreductions in peak cases.

These measures are to be initiated early before explosive growth of the epidemicand, in the case of severe pandemics, that they be maintained consistentlyduring an epidemic wave in a community.

Contra Costa Health Services will consider the following NPIs, depending on thephase and severity of the pandemic.

1. Isolation and treatment (as appropriate) with influenza antiviralmedications of all persons with confirmed or probable pandemic influenza.Isolation may occur in the home, healthcare setting, or alternate care site,depending on the severity of an individual’s illness and /or the currentcapacity of the healthcare infrastructure.

2. Voluntary home quarantine of members of households with confirmed orprobable influenza case(s). Consider combining this intervention with theprophylactic use of antiviral medications, providing sufficient quantities ofeffective medications exist and that a feasible means of distributing themis in place.

3. Social distancing for children/students such as dismissal of studentsfrom school (including public and private schools as well as colleges anduniversities) and school-based activities and closure of childcareprograms, coupled with protecting children and teenagers through socialdistancing in the community to achieve reductions of out-of-school socialcontacts and community mixing.

4. Use of social distancing measures to reduce contact between adultsin the community and workplace, including, for example, cancellation oflarge public gatherings and alteration of workplace environments andschedules to decrease social density and preserve a healthy workplace tothe greatest extent possible without disrupting essential services.

5. Travel Restrictions to reduce contact between Contra Costa residentsand travelers arriving at Buchanan airport and at local marinas fromoutside the area, state or country.

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6. Promotion of individual infection control measures, such as handhygiene and cough etiquette and use of personal protective equipment(PPE) such as masks or respirators by first responders and health workersto limit the spread of the disease.

7. Public education that will reduce the demand for medical servicesthroughout the epidemic.

8. Measures to assist essential services to continue operating.

Enforcement of Isolation, Quarantine, Social Distancing and TravelRestrictionsThe County Health Officer has broad authority to act to protect the health andwelfare of the community. (See Sect. 8 Health Officer Authority)

Based on the SARS experience, which showed that most people would comply, itis anticipated that individuals will comply with social distancing orders such asisolation or quarantine. In rare instances it may be necessary to enforce isolationor quarantine orders.

To prepare law enforcement to respond to a pandemic, Contra Costa HealthServices will:

1. Inform law enforcement about health officer authority to order isolation,quarantine and social distancing measures.

2. Establish mechanisms of communication between Health Officer and lawenforcement.

3. Instruct law enforcement on PPE should they be called upon to enforceisolation, quarantine, or social distancing measures.

4. Request law enforcement assistance with any of the following:

a. Enforce isolation and quarantine orders.b. Assist to provide security at private and public hospitals.c. Provide perimeter security at isolation/quarantine alternate

care sites.d. Detain individuals not in compliance with a Health Officer

Order (misdemeanor).e. Provide security (escort) for physicians, EMS personnel,

ambulance personnel, other care providers or supportpersonnel, as required.

f. Conduct area evacuations and secure evacuated areas.

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g. Evacuate and secure public assembly venues when socialdistancing is required by Health Officer Order or otherdeclaration.

Criteria for Determining Community Control MeasuresActual decisions about how to protect the public before an effective vaccine isavailable and/or when limited pharmaceuticals are available will be based on acomplex number of factors present at the time of the pandemic. In addition to theseverity and phase of a pandemic, the following factors will help guide healthofficials on which NPIs should be used. These include:

- Ethical considerations

- Impact of the NPIs on society as a whole, on specific subpopulations,the health care delivery system and the critical infrastructure

- Benefits of the interventions

- Available resources

- Feasibility of success based on such things as the community’s abilityand likelihood to comply

- Direct and indirect costs

- Common sense

- The public’s perspective of the protective measures

A Regional ApproachBecause Contra Costa is one of 10 Counties comprising the Bay Area, CCHS iscommitted to a regional approach to implementing NPIs for the followingreasons:

- According to the U.S. Census, 40% of Contra Costa’s workforce -more than 500,000 workers - commutes to jobs in other parts of theBay Area. (51% to Alameda; 26.5% to San Francisco; 10.4% to theSilicon Valley)

- The Bay area shares a common media market, so residents getinformation, messages and instructions from all surrounding counties.

- Compliance with NPIs requires the public trust and confidence and acoordinated message from local health agencies is critical foraccomplishing that objective.

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Bay Area Health Officers have agreed that the following NPIs will be utilized in a coordinated manner*. (*Where there isnot consensus Health Officers will confer by conference call prior to releasing any NPI guidance).

WHO PHASE 4 PHASE 5 W H O P H A S E 6Fed Gov Resp Stages STAGE 2 STAGE 3 STAGE 4 STAGE 5a STAGE 5b STAGE 6

Response Triggers

Small clustersoverseas. Limitedhuman-humantransmsn, spread ishighly localized

Large clustersoverseas, w/localizedtransmission

Widespreadoutbreaks inmultiplelocationsoverseas

First humancase in NorthAmerica, withglobaloutbreaks

Spread throughoutU.S. and/or firstcase in state/region

Spreadthroughoutstate/region

Recovery andpreparation fornext phase

Contra CostaResponse Actions

ISO / QUARNTN- Suspected

I: HO orderedHome IsolationQ: HO ordered HomeQuarantine

I: HO orderedHome IsolationQ: HO orderedHomeQuarantine

I: HO orderedHome IsolationQ: HO orderedHome Quarantine

I: HO orderedHome IsolationQ: HO orderedHome Quarantine

I: HO ordered HomeIsolationQ: HO ordered HomeQuarantine

I: HOorderedHomeIsolationQ: HOorderedHomeQuarantine

I: HO orderedHome IsolationQ: HO orderedHome Quarantine

- Probable

I: HO orderedHome IsolationQ: HO ordered HomeQuarantine

I: HO orderedHome IsolationQ: HO orderedHomeQuarantine

I: HO orderedHome IsolationQ: HO orderedHome Quarantine

I: HO orderedHome IsolationQ: HO orderedHome Quarantine

I: HO ordered HomeIsolationQ: HO ordered HomeQuarantine

EnforcedSocialDistancing

Enforced SocialDistancing

Confirmed by lab*Unlikely to have labconfirmation afterapproximately first 10confirmed cases.

I: HO ordered HomeIsolationQ: HO ordered HomeQuarantine

EnforcedSocialDistancing

Enforced SocialDistancing

SOCIAL DISTN*Children:Childcare programs Preparedness

Preparednessand riskcommunication

Preparednessand riskcommunication

Preparednessand riskcommunication

HO will considerclosing childcare > 5children

Closechildcare > 5children orall daycares Consider re-open

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K-12 schools Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

HO will considerdismissing students

Dismiss students Consider re-open

Colleges Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Strict social distance –consider closureand/or quarantineprivate residentialschools

Strict social distance– consider closureand/or quarantineprivate residentialschools

Consider re-open

Social cntcts - child Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Minimize Minimize Limit

*Adult:Workplace Modify

Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Implement NPI plans.Minimize contact

Minimize contact Reduce contact

Public gatherings AllowCancel selectedinternatlconventions

Cancel selectedinternatlconventions

Cancel largenational events

Cancel large, non-essential publicgathering

Cancel non-essentialpublic gatherings

Allow some events

Social cntcts -adult Preparedness Preparedness Preparedness Preparedness Minimize Minimize. Limit

ESSENTIAL SVCSPublic Transport

Preparedness Preparedness Preparedness Preparedness Reduce contact Minimize contact Reduce contact

Food markets Preparedness Preparedness Preparedness Preparedness Reduce contact Minimize contact Reduce contactEssential Services

Public InfoPromote NPIsas appropriate

Promote NPIsand emphasizesocial distancingas appropriate

Continue to promotesocial distancing.Consider studentdismissal and otherstrategic socialdistancing measures

K-12 schools Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

HO will considerdismissing students

Dismiss students Consider re-open

Colleges Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Strict social distance –consider closureand/or quarantineprivate residentialschools

Strict social distance– consider closureand/or quarantineprivate residentialschools

Consider re-open

Social cntcts - child Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Minimize Minimize Limit

*Adult:Workplace Modify

Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Implement NPI plans.Minimize contact

Minimize contact Reduce contact

Public gatherings AllowCancel selectedinternatlconventions

Cancel selectedinternatlconventions

Cancel largenational events

Cancel large, non-essential publicgathering

Cancel non-essentialpublic gatherings

Allow some events

Social cntcts -adult Preparedness Preparedness Preparedness Preparedness Minimize Minimize. Limit

ESSENTIAL SVCSPublic Transport

Preparedness Preparedness Preparedness Preparedness Reduce contact Minimize contact Reduce contact

Food markets Preparedness Preparedness Preparedness Preparedness Reduce contact Minimize contact Reduce contactEssential Services

Public InfoPromote NPIsas appropriate

Promote NPIsand emphasizesocial distancingas appropriate

Continue to promotesocial distancing.Consider studentdismissal and otherstrategic socialdistancing measures

K-12 schools Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

HO will considerdismissing students

Dismiss students Consider re-open

Colleges Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Strict social distance –consider closureand/or quarantineprivate residentialschools

Strict social distance– consider closureand/or quarantineprivate residentialschools

Consider re-open

Social cntcts - child Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Minimize Minimize Limit

*Adult:Workplace Modify

Preparedness PreparednessPreparednessand NPImessages

Preparednessand NPImessages

Implement NPI plans.Minimize contact

Minimize contact Reduce contact

Public gatherings AllowCancel selectedinternatlconventions

Cancel selectedinternatlconventions

Cancel largenational events

Cancel large, non-essential publicgathering

Cancel non-essentialpublic gatherings

Allow some events

Social cntcts -adult Preparedness Preparedness Preparedness Preparedness Minimize Minimize. Limit

ESSENTIAL SVCSPublic Transport

Preparedness Preparedness Preparedness Preparedness Reduce contact Minimize contact Reduce contact

Food markets Preparedness Preparedness Preparedness Preparedness Reduce contact Minimize contact Reduce contactEssential Services

Public InfoPromote NPIsas appropriate

Promote NPIsand emphasizesocial distancingas appropriate

Continue to promotesocial distancing.Consider studentdismissal and otherstrategic socialdistancing measures

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Non-Pharmaceutical Intervention Strategies

This section describes a number of NPIs that may be used by Contra Costa HealthServices to limit community transmission during a pandemic. These planning strategiesare likely to evolve as more information about their effectiveness and feasibilitybecomes available.

To minimize economic and social costs to the Contra Costa community, it will beimportant to carefully select interventions appropriate to the pandemic severity level –not to early and not too late. Unfortunately, during an emerging pandemic, there may belittle information about the number of cases and deaths resulting from infection with thevirus.

A. Isolation and Quarantine

Isolation is defined as separation of infected persons from other persons for the periodof communicability in such places and under such conditions as will prevent thetransmission of the infectious agent. Isolation will slow, but not stop the spread ofinfluenza, as transmission can occur prior to the onset of symptoms, and in personswho have mild or asymptomatic infection. Isolation may occur in the home orhealthcare setting, depending on the severity of an individual’s illness and /or thecurrent capacity of the healthcare infrastructure.

Quarantine is defined as the limitation of freedom of movement of persons or animalsthat have been exposed to a communicable disease for a period of time equal to thelongest usual incubation period of the disease, in such manner as to present effectivecontact with those not so exposed. Quarantine measures will be limited in use and mayonly be used early on or very late in the pandemic when cases are limited, or in uniquesituations such as potential exposure during flight travel.

Home quarantine of members of households with confirmed or probable influenzacase(s) and consideration of combining this intervention with the prophylactic use ofantiviral medications, providing sufficient quantities of effective medications exist andthat a feasible means of distributing them is in place.

During a pandemic, isolation and quarantine measures may be implemented todecrease the spread of disease. Isolation and quarantine as NPIs are expected to bemost effective during the very early on in the pandemic and then in later phases. As thepandemic widens, it may no longer be feasible to monitor all individuals who areisolated in their homes, requiring a greater reliance on individual responsibility andneighborhood-based support systems. In addition, once the pandemic is underway,these two strategies are anticipated to have limited effectiveness in preventing thetransmission of pandemic influenza because of the following:

- Short incubation period of the illness- The early peak infectivity of the illness (peak shedding of virus occurs in the

first 24 – 72 hours of illness)- Ability of persons with asymptomatic infection to transmit the virus- Possibility that early symptoms among persons infected with a novel virus

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strain may be non-specific, delaying recognition and implementation ofcontainment

The County Health Officer(s) is responsible for ordering home isolation. Public HealthDivision staff is responsible for monitoring. Division staff may:

- Monitor home isolation orders and check for signs and symptoms of influenzain household contacts

- Identify alternative care sites for isolation of individuals who have nosubstantial healthcare requirements and/or persons for whom home isolationis indicated but who do not have access to an appropriate home setting, suchas travelers and homeless populations.

- Promote the use of Community Emergency Response Teams (CERT) and/orother neighborhood-based methods for providing support to individuals whoare in home isolation.

- Implement procedures for identification and quarantine of close contacts.- Issue quarantine orders to identify contacts for home or community-based

quarantine.- Institute quarantine for exposed healthcare and other essential workers in

their work locations.- Lift the quarantine orders

Social DistancingSocial distancing measures are designed to reduce interactions among groups mostlikely to spread the virus and thus slow or limit transmission of the virus. These NPIsmay occur at two levels:

- Measures that affect groups of exposed at-risk individuals. The intervention isapplied to specific groups or persons identified in specific sites or buildings,most but not necessarily all of whom are risk of exposure to influenza.Examples include quarantine of groups of exposed persons in a definedsetting (e.g., school, workplace, airplane, etc.); cancellation of public events;closure of office buildings, schools, and/or shopping malls; and closure ofpublic transportation such as bus lines.

- Measures that affect communities. When community-wide measures areused, the measures affect the entire community, including both exposed andnon-exposed persons. Examples include snow days, self-shielding, andwidespread community quarantine (cordon sanitaire).

The County Health Officer will confer with partners in the State Department of PublicHealth, the Association of Bay Area Health Officers, the Contra Costa College Districtand the County Office of Education to determine which NPIs are appropriate beforeissuing an order affecting schools or communities.

1. Child Social Distancing

The goal of NPIs in this category is to protect children and to decrease transmissionamong children in dense classroom and non-school settings and, thus to decrease

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introduction into households and the community at large. However, maintaining thestrict confinement of children during a pandemic would raise significant problems formany families and may cause psychosocial stress to children and adolescents. Theseconsiderations must be weighed against the severity of a given pandemic virus to thecommunity at large and to children in particular.

Social distancing interventions for children include:

- Children and staff stay home if they have symptoms- Respiratory and hand hygiene measures increased- Disinfection of physical premises heightened- Dismissal of students from classrooms and closure of childcare programs,- Protecting children and teenagers through social distancing in the community

to achieve reductions of out-of-school social contacts and community mixing.- Although the available evidence currently does not permit the specification of

a “safe” group size, activities that recreate the typical density and numbers ofchildren in school classrooms are clearly to be avoided. Gatherings ofchildren that are comparable to family-size units may be acceptable and couldbe important in facilitating social interaction and play behaviors for childrenand promoting emotional and psychosocial stability.

- Mixing between such groups be minimized (e.g., children should not movefrom group to group or have extended social contacts outside the designatedgroup).

Currently a three-tiered strategy for triggering these interventions will be recommended:- No dismissal of students from schools or closure of childcare facilities in a

Category 1 pandemic- Short-term (up to 4 weeks) cancellation of classes and closure of childcare

facilities during a Category 2 or Category 3 pandemic- Prolonged (up to 12 weeks) dismissal of students and closure of childcare

facilities during a severe influenza pandemic during a Category 4 or Category5

Requirements for success of these interventions include:- Consistent implementation among all schools in a region being affected by an

outbreak of pandemic influenza,- Community and parental commitment to keeping children from congregating

out of school,- Alternative options for the education and social interaction of the children- Clear legal authorities for decisions to dismiss students from classes and

identification of the decision-makers, and support for parents and adolescentswho need to stay home from work.

2. Social Distancing at Colleges and Universities

Addressing this population is complex. Contra Costa has three community colleges anda number of other private colleges including J.F.K University and St. Mary’s. Theseinstitutions are primarily commuter colleges but they present unique challenges in termsof pre-pandemic planning because many aspects of student life and activity encompassfactors that are common to both the child school environment (e.g., classroom/dormitory

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density) and the adult sphere (e.g., commuting longer distances for universityattendance and participating in activities and behaviors associated with an older studentpopulation).

At the onset of a pandemic, many parents may want their children who are attendingcollege or university to return home from school. Immediately following theannouncement of an outbreak, colleges and universities should prepare to manage orassist large numbers of students departing school and returning home within a shorttime span.

Pre-pandemic planning to identify those students likely to return home and those whomay require assistance for imminent travel may allow more effective management of thesituation. In addition, planning should be considered for those students who may beunable to return home during a pandemic and who will need to be housed and fed.

The following actions should be considered:

- Students, faculty and staff stay home if they have symptoms- Respiratory and hand hygiene measures increased- Disinfection of physical premises increased- Group social activities such as dances, parties and sporting events are

canceled.- In-person instruction is suspended.

3. Adult Social Distancing

Workplaces - Social distancing measures for adults include provisions for bothworkplaces and the community and may play an important role in slowing or limitingcommunity transmission. The goals of workplace measures are to reduce transmissionwithin the workplace and thus into the community at large; to ensure a safe workingenvironment and promote confidence in the workplace; and to maintain businesscontinuity, especially for critical infrastructure. The commitment of employers toproviding options and making changes in work environments to reduce contacts whilemaintaining operations is critical to reducing transmission.

The following are measures to reduce transmission:

- Implementation of infection control measures such as sneeze guards, handhygiene stations, no touch trash cans, automatic door openers

- Reduce density of the workplace through telework/telecommuting andmodified work schedules such as staggered shifts

- Alternatives to in-person meetings- Decrease sharing work equipment and supplies- Increased cleaning of high touch areas- Modify sick leave policies to cover both persons who are isolated or

quarantined in their homes even if they are not diagnosed as a case and alsocaretakers of ill cases and children who are dismissed from school.

Social Gatherings- Public gatherings can provide a target-rich environment for

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transmission. Large gatherings (such as sporting events, concerts at locales such asthe Concord Pavilion, holiday celebrations, and festivals such as the Pittsburg SeafoodFestival), as well as smaller social activities (such as weddings, funerals, and religiousservices), may need to be curtailed, postponed, or cancelled altogether.

By placing such limitations, social interactions and transmission of disease can bereduced. Closing public facilities or facilities where large groups congregate also canreduce opportunities for disease transmission through social interactions.

Public facilities—schools, government offices, transportation hubs, museums, libraries,and convention centers—would be the first considered for closing.

Within communities, the support of political and business leaders as well as publicsupport is critical to limiting transmission through social gatherings.

C. Travel Restrictions

Travel restrictions have been shown to reduce geographic spread, as well as total andlocal incidence during a disease outbreak. Restrictions may be placed on some or allmodes oftransportation—air, rail, boats and bus—and may include a range of increasinglystringent limitations, from issuing travel warnings to closing high-risk stops, limitingschedules, or canceling travel routes altogether.1

1. Screening TravelersIf an influenza pandemic begins outside the United States, public health authoritiesmight screen inbound travelers from affected areas to decrease disease importation intothe United States. If a pandemic begins in or spreads to the United States, healthauthorities might screen outbound passengers to decrease exportation of disease. Earlyin a pandemic, state and local health departments, including Contra Costa, may alsoimplement domestic travel-related measures to slow disease spread within the UnitedStates. Because some persons infected with influenza will still be in the incubationperiod and might have no or only mild symptoms but could spread the virus, it will notbe possible to identify and isolate all arriving infected or ill passengers and quarantinefellow passengers.

Once a pandemic is underway, exit screening of travelers from affected areas (“sourcecontrol”) is likely to be more efficient than entry screening to identify ill travelers. Early ina pandemic, this intervention may decrease disease introductions into the U.S. Later,however, as pandemic disease spreads in communities, ongoing transmission amonglocal residents will likely exceed new introductions and, therefore, federal authoritiesmight modify or discontinue exit screening.

2. Mass transitModifications to mass transit policies/ridership to decrease passenger density may alsoreduce transmission risk, but such changes may require running additional trains andbuses, which may be challenging due to transit employee absenteeism, equipmentavailability, and the transit authority’s financial ability to operate nearly empty train cars

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or buses. CCHS would support regional mass transit carriers polices and would directlocal carriers such as County Connections and Tri-Delta to follow decisions beingimplemented regionally.

3. Voluntary actionsVoluntary limitations on travel during a pandemic alert and pandemic will also decreasethe amount of disease spread. Limiting or canceling travel of U.S. residents and othersfrom affected countries will depend on the properties of the pandemic virus thatemerges, and will be informed by the facts on the ground at the time of the emergence.2

4. Traffic at Local Airports

Airports are another location where transmission may occur as travelers from otherparts of California, the U.S. and elsewhere arrive in private planes. To preventtransmission from cases identified at this County-owned facility, CCHS may do any ofthe following activities at Buchanan and Byron Airports:

- Meet the airplane to assess ill passengers symptoms- Notify the Quarantine station, DHS and CCHS- Provide crew with guidance- Coordinate with AMR to provide safe ambulance transport to an appropriate

hospital- Follow-up to manage travel contacts/quarantine passengers- Develop and/or issue travel health alert notices, travel contact notices, and

close contact notices- Recommend the cancellation of nonessential travel- Implement pre-departure screening (e.g., temperature screening or visual

screening) of outbound travelers.

5. Working with local Marinas

Access to Contra Costa is also available through 57 boating marinas in the County.There are 174,000 registered boats in the County. In addition, there are dockingfacilities are local businesses including C & H Sugar in Crockett, Chevron in Richmondand others.

During a pandemic, CCHS will:

- Alert local marina managers about the pandemic- Distribute travel alerts to marina managers- Encourage them to assist in educating marina customers about NPIs- Provide information that will enable marina managers to notify CCHS of

possible cases during the early stages of a pandemic

D. Promotion of individual infection control measures

1. Handwashing and Cough Etiquette

2HHS Pandemic Influenza Plan. U.S. Department of Health and Human Services, November 2005.p. S9-

3

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During a period of pandemic influenza, the public health community will stress theimportance of universal hygiene and wellness behavior including hand washing, coughetiquette, receiving adequate sleep, exercising, and eating a balanced diet. Handwashing, in particular, is one of the most important things one can do to protect oneselffrom illness and prevent the spread of infection. Officials also will be concerned thatthose who present with influenza symptoms seek proper care at the appropriate timeand those without symptoms, particularly those individuals comprising the criticalworkforce infrastructure (i.e., medical personnel, teachers, etc.), continue their dailyroutine as directed.3

CCHS public education efforts will focusing on encouraging the public that, as basic asthey appear, these measures represent concrete actions that can reduce transmissionof the virus and, if used appropriately, will save lives. Communications may include:

- public signage (e.g., on billboards; along major thoroughfares; in grocerystores, offices, buildings, and restrooms; and throughout public transportationsystems

- Written handouts or flyers distributed by postal mail or at public gatherings(such as transit stations); and

- Public service announcements in print media as well as on radio, television,and the Internet.

2. Personal Protective Equipment

During an influenza pandemic, masks and respirators — called Personal ProtectiveEquipment (PPE) — used in combination with other NPIs when close contact isexpected with someone who has pandemic influenza — may help prevent some spreadof influenza.

In suggesting the use of these PPEs, CCHS will follow the Department of Health andHuman Services’ (HHS) Centers for Disease Control and Prevention (CDC) interimadvice to the public, released in Spring 2007, about the use of Personal ProtectiveEquipment (PPE) in certain public (non-occupational) settings during an influenzapandemic. There is very little research about the value of masks to protect people inpublic settings. These interim recommendations are based on the best judgment ofpublic health experts who relied in part on information about the protective value ofmasks in healthcare facilities.

Facemasks and respirators have different qualities and offer different types and levelsof protection. Neither a facemask nor a respirator will provide complete protection froma virus and if used, must be used in combination with other NPIs.

Facemask Use

Facemasks are loose fitting, disposable masks that cover the nose and mouth. Theseinclude products labeled as surgical, dental, medical procedure, isolation, and laser

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masks. Facemasks help stop droplets from being spread by the person wearing them.They also keep splashes or sprays from reaching the mouth and nose of the personwearing the facemask. They are not designed to protect the person wearing it againstbreathing in very small particles. Facemasks should be used once and then thrownaway in the trash.

People should consider wearing a facemask during an influenza pandemic if they:

- Are sick with the flu and think they might have unavoidable close contact withother people (within about 3 feet). People who are sick with the flu shouldstay home and avoid contact with others.

- Live with someone who has the flu symptoms (and therefore might be in theearly stages of infection) or will be spending time in a crowded public placeand thus may be in close contact with infected people. During a pandemic,people should limit the amount of time they spend in crowded places andconsider wearing a facemask while they are there.

- Are well and do not expect to be in close contact with a sick person but needto be in a crowded place. Again, people should limit the amount of time theyspend in crowded places and wear a facemask while they are there.

Respirator Use

A respirator (e.g., an N95 or higher filtering facepiece respirator approved by theNational Institute for Occupational Safety and Health) is designed to protect people frombreathing in very small particles, which might contain viruses. N95 respirators aregenerally used in construction and other jobs that involve dust and small particles.Healthcare workers, such as nurses and doctors, also use respirators when taking careof patients with diseases that can be spread through the air.

“N95” means the filter on the respirator screens out 95 percent of the particles (0.3microns and larger) that could pass through. To be most effective, these types ofrespirators need to fit tightly to the face so that the air is breathed through the filtermaterial. “Fit testing” is the usual method for assuring proper fit in workplaces whererespirators are used. Respirators are not designed to form a tight fit on people withsmall faces (e.g., children) or facial hair. Men who have beards need to shave beforeusing. N95 and higher respirators are less comfortable to wear than facemasksbecause they are more difficult to breathe through. If people have a heart or lungdisease or other health condition, they may have trouble breathing through respiratorsand should talk with their doctor before using a respirator.

Like surgical masks, most N95 respirators should be worn only once and then thrownaway in the trash.

People should consider using a respirator if they:

- Are taking care of a sick person at home (and if a respirator is unavailable,use of a mask should be considered).

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E. Reducing the Demand for Medical Services

Use of NPIs can reduce the demand for medical services by reducing the number ofpandemic flu cases. Public education can also reduce the demand for medicalservices, especially hospital care, or spread it out over a longer time, reducing thestress on the health care system.

Contra Costa Health Services will provide guidance to the public during a pandemic onself-care, proper use of medical services, availability of vaccination and will encouragethe use of NPIs. OF P

F. Measures to Insure Continued Operations of Essential Services

To prevent severe disruption of society, a number of essential services must continue.(See Sect. 1 Continuity of Operations for a complete description of those services).

NPIs can play a major role in ensuring that those services continue to operate, even ifthey are reduced in scope.

1. Public transport

Modifying mass transit policies and ridership to decrease passenger density mayreduce risk transmission. The following measures should be considered:

- Increase the frequency and number of buses to decrease rider density- Decrease the number of buses to reflect rider and passenger absenteeism- Increase frequency of disinfecting vehicles- Implement infection control equipment such as hand hygiene stations and

sneeze guards- Encourage passengers to wear masks- Redirect employees to essential services

2. Food Markets

Grocery stores and supermarkets are important food resources during apandemic and communities should implement strategies to ensure that theyremain open. The following measures should be considered:

- CCHS should educate “mom and pop” providers through the CaliforniaGrocers Association, the Yemini Grocers Association and similarorganizations.

- Markets should encourage low shopper density by limited the number ofcustomers in the market at one time.

- Use of masks should be encouraged- Shoppers should be encouraged to maintain a distance of at least six feet.

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Vulnerable Population considerationsThe following issues will be taken into consideration as preparedness and responseactions are implemented:

Infection control for individuals who are medically compromised and are at homeor in the Alternate Care Site.

Infection control for very young children (<2 years of age) and frail elderly whoare at home or in the Alternate Care Site.

Isolation for people who have pandemic influenza and are homeless; considerplacement in an Alternate Care Site.

Multilingual information on home isolation procedures. Alternative communication modes about infection control, home isolation, and

social distancing measures to people who are illiterate or blind. Support for people who are homebound or geographically isolated individuals.

Support for people with limited economic means who require isolation.

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Section 8. Health Officer Legal Authority During Pandemic Influenza

IntroductionA critical function of Contra Costa Health Services (CCHS) is its ability to invoke its legalauthority to implement actions to limit the spread of disease. During pandemicinfluenza, CCHS may need to invoke such authority. While numerous federal, state andlocal statutes authorize public health actions to address pandemic influenza,cooperation with local law enforcement and the legal system will be critical to ensurethat the spread of disease is effectively constrained.

At the federal level, the Public Health Service Act grants authority to the Secretary ofHealth and Human Services to make and enforce regulations. These regulations existto prevent the introduction, transmission, or spread of communicable diseases fromforeign countries into the United States or from one State or locality to another1. Theauthority granted to the California Department of Public Health (CDPH) in emergenciesand disasters allows the department to take any necessary action to protect andpreserve the public health including controlling local health authorities.2

This section provides references and documentation regarding the legal authority ofPublic Health and the Health Officer in emergencies such as pandemic influenza. It alsoincludes the legal actions and procedures required for local preparation and response topandemic influenza. The section is consistent with current California guidance onHealth Officer authorities as defined in the Health Officer Practice Guide forCommunicable Disease Control.3

Desired Outcomes1. Adherence to legal processes for issuance of Declaration of Emergency, Health

Officer Orders and Directives, and other public health actions.2. Adherence to legal requirements for workers compensation, licensing, and

credentialing for Disaster Service Workers and Medical Disaster Volunteers.3. Effective and efficient identification and resolution of legal issues related to

pandemic influenza response.4. Identification and adherence to legal authority for Contra Costa County Health

Officer, personnel, and volunteers during emergency declaration for a pandemicflu emergency response.

1 42.U.S.C.2642 CA HSC § 100180; Abbot, D. and McGurk. (1998), Authority and Responsibility of Local Officers inEmergencies and Disasters, California Department of Health Services.3 Health Officer Practice Guide for Communicable Disease Control (2005). California Department of HealthServices. www.sccphd.org.

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Health Officer Legal Authority

Description of Health Officer Authority

Alert Period

1. The public at large, affected individuals, special populations, health careproviders (including CCHS), hospitals and health care systems, first responders,law enforcement agencies, schools, the business community and media willreceive relevant information on the authority of the Health Officer.

2. Contra Costa County Counsel’s Office and the Health Officer will draft or updatelegal orders, forms and templates relevant to Health Officer authorities. SampleHealth Officer Orders are available on the CDPH website. They include:

a. Health Officer Order for Isolationb. Health Officer Order for Quarantinec. Health Officer Order for Medical Evaluation

3. The Health Officer and the Health Emergency Response Unit will review andrevise documents describing Public Health’s legal authority relevant to pandemicflu.

4. The CCHS Public Information Officer will post the information on Legal Authorityon the Contra Costa Public Health website.

5. The Contra Costa County Emergency Operations Center (EOC), DesignatedLegal Officer (the Legal Officer position is located in the EOC/NIMSorganizational structure under the Management Section) will establish a LegalTeam. The Legal Team will advise the Health Officer and EOC Director onimplications of contemplated emergency actions and policies, and assist inpreparing legal documents. The Legal Officer and Health Officer will conductoutreach to the court and other members of the legal community for input andcoordination regarding legal issues that may arise during the pandemic period.

Pandemic Period

1. Legal actions related to issuing an order for isolation or quarantine may include:a. Health Officer detains patient(s) for isolation or quarantine under an oral

order. 4

b. Within 12 hours of detaining, Health Officer issues a written order forisolation or quarantine

c. Patient may either consent or object to Health Officer orderd. County holds informal hearing for any patient who objects to detentione. Health Officer may petition Superior Court for detention ordersf. Alternatively, patients may seek a court order requiring their release from

detention

4 “In General, isolation and quarantine orders should be in writing. However, facts and circumstances may dictatethe initial use of an oral order which will be confirmed in writing at the earliest possible opportunity.” HealthOfficer Practice Guide for Communicable Disease Control in California.

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g. The court may hold a hearing and issue a court order either allowingfurther detention or requiring the patient’s release

h. The Health Officer’s order may expire in accordance with the date on theorder

i. The Health Officer may rescind a prior order in writing

2. Upon Activation of the EOC, the EOC Designated Legal Officer will activate theLegal Team as needed. The Legal Team will:

a. Provide legal advice to the Health Officer during preparation of HealthOfficer Orders and Health Alerts.

b. Assist the Health Officer in preparing notifications and instructions to lawenforcement.

c. Notify the Courts and other members of the legal community when HealthOfficer Orders have been issued.

d. Assist in petitioning the courts for court orders should that be required

3. Health Officer, EOC Legal Officer, and the EOC Operations Section, LawEnforcement Branch will prepare daily law enforcement updates for lawenforcement morning briefings. Instructions for law enforcement personnel willinclude information regarding use of personal protective equipment (PPE),enforcement of Health Officer orders, and location of detention facilities if theseitems are relevant. These instructions will be transmitted in the form of a HealthAlert for Law Enforcement for Isolation and Quarantine. Law enforcement will beprepared to enforce Health Officer Orders and other related declarations, whichmay include:

a. Assist in providing security at private and public hospitals

b. Provide perimeter security at field treatment sites and alternate carefacilities

c. Detain individuals who refuse to comply with a Health Officer Order5

d. Assist at jails and correctional facilities

e. Provide security (escort) for physicians, EMS personnel, ambulancepersonnel, other care providers or support personnel, as required

f. Conduct area evacuations and secure evacuated areas

g. Evacuate and secure public assembly venues when social distancing isrequired by Health Officer Order

h. Close and secure roads and highways, restricting or limiting access to ageographic area as appropriate

i. Assist with enforcement of school exclusion orders and school closures asappropriate

j. Enforce curfews when they are required

5 It is a misdemeanor to violate a health officer’s isolation/quarantine order under Health and Safety Code § 120275

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Social Distancing MeasuresBoth the Health Officer and local law enforcement agencies have specific legal authorityfor controlling the movement of individuals (social distancing) to protect the health andsafety of the public by limiting the spread of disease.

Alert Period

1. Inform local law enforcement agencies and fire services about legal authoritiesrelated to social distancing measures. The following measures are permitted tocontrol the spread of disease and/or address a public health disaster:

a. Highway ClosuresCalifornia Department of Transportation has the authority to restrict

traffic or close state highway for the protection of the public.6

California Highway Patrol, police departments, and the Office of theSheriff may close highway(s) if there is a threat to public health orsafety caused by dangerous substances.7

b. Area Closures and/or EvacuationsThe Health Officer has the authority to “close the area where the

menace exists” if the calamity, caused by “flood, storm, fire,earthquake, explosion, accident or other disaster” has created “animmediate menace to the public health.”8

The Sheriff and Chief of Police have responsibility for closing areas tothe public and consequently to order an evacuation whenever amenace to the public health or safety is created by a calamity.9

c. Law enforcement officers have the authority to close or restrict access toan area whenever a menace to the public health or safety is created by acalamity.10

d. Public Assembly/Venue ClosureThe Health Officer has the authority to “forbid the holding of any

meeting or gathering, either public or private, and to close any placewhere meetings are held to prevent the spread of disease” wheneveran epidemic or any contagious or infectious disease is prevalent in thecounty.11

e. CurfewsDuring a declared local emergency the local government may impose

a curfew to preserve the public order and safety. Curfews can beproclaimed by the Board of Supervisors (BOS), an official designatedby the BOS (through a county ordinance), or the Governor.12

f. Exclusion from School

6 CA Street and Highways Code §1247 CA Vehicle Code § 28128 CA Penal Code § 409.59 CA Penal Code § 409.510 CA Penal Code § 409.511 Santa Clara County Ordinance Code § A18-1412 CA Government Code § 8634

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The Health Officer has the authority to exclude from schools certainpersons, including students, teachers, and other staff who are understrict isolation/quarantine orders. 13

Pandemic Period

1. The Health Officer and EOC will coordinate activities to support social distancingmeasures directed from the Health Officer or EOC including:

a. Manage proclamations, declarations required for social distancingmeasures.

b. Coordinate law enforcement support for the implementation of socialdistancing measures.

c. Issue Emergency Alert System broadcasts regarding status of socialdistancing measures.

Due Process

Substantive and procedural due process rights are implicated when the governmentseeks to deprive an individual of “life, liberty or property” interests within the meaning ofthe Due Process Clause of the Fifth and Fourteenth Amendment to the U.S.Constitution. Freedom from restraint of movement is a personal liberty interest that isprotected by both the federal and the California constitution. 14 Due process calls forprotections as the particular situation demands. In most instances, the basic elementsof procedural due process include:

1. Right to have adequate notice of the reason for the government’s action2. Right to be heard and to object to the government’s action3. Access to legal counsel4. A final administrative decision that is subject to review in a court of law

The written orders issued by the Health Officer include notice of the individual’s dueprocess rights per Contra Costa County Counsel. Furthermore, an order of isolationshall be issued only in cases deemed necessary and in a manner that is least restrictiveto prevent human exposure.15

Legal Proceedings

Alert Period

1. The EOC Legal Team will meet to plan for and address legal issues associatedwith processing court petitions regarding isolation/quarantine matters.

2. The Legal Officer will conduct outreach to the court and other members of thelegal community for input and coordination regarding legal issues that may ariseduring the pandemic period.

13 CA HSC §12023014 In re Roger S (1977) 19 C. 3d 921,92715 CA HSC § 101080

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Pandemic Period

1. Upon activation of the EOC, the EOC Designated Legal Officer will activate theLegal Team as needed. The Legal Team in conjunction with the EOC OperationsSection will:

a. Coordinate requests from isolated or quarantined individuals, groups orothers affected by Health Officer Orders for legal assistance.

b. Notify the courts of Health Officer orders that have been issued and assistin coordination of individual or group due process proceedings.

c. Provide legal advice to the Health Officer during preparation of HealthOfficer Orders and Health Alerts.

d. Develop appropriate legal documentation for individuals or groups indetention or released from detention for the purpose of isolation orquarantine.

e. Assist the Health Officer in preparing notifications and instructions to lawenforcement for detention during isolation or quarantine operations.

f. Assist in petitioning the courts for a court order for isolation and/orquarantine as appropriate.

g. The Legal Officer and the Health Officer will meet with the judiciary andother members of the legal community to coordinate and implement thePublic Health Department’s response to legal issues that arise during thepandemic period.

Workers Compensation Laws/Liability

Worker Compensation LawsCalifornia's Workers' Compensation laws are administered by the state Division ofWorkers' Compensation and the Workers' Compensation Appeals Board.16 CaliforniaWorkers' Compensation provides a no fault system which is designed to provide aninjured worker with benefits and to protect employers from civil liability for most injuriessustained within the course and scope of employment. It is based on the existence of anemployer/employee relationship, and as a general rule it does not extend worker'scompensation benefits to volunteers.

Workers’ Compensation Benefits for Disaster Service Worker Volunteers areadministered by the Governor’s Office of Emergency Services.17 Insurance coverage forDisaster Service Worker volunteers is provided by the State Compensation InsuranceFund. A Disaster Service Worker Volunteer is any person registered with an accreditedDisaster Council for the purpose of engaging in disaster service without pay or otherconsideration.18 Disaster Service Worker volunteers includes public employeesperforming disaster work that is outside the course and scope of their employmentwithout pay and also includes any person impressed into service during a state of waremergency, a state of emergency or a local emergency by a person having authority tocommand the aid of citizens in the execution of his or her duties.19 All registered

16 California's Workers' Compensation laws can be found in Labor Code sections 3200 - 6208.17 Labor Code § 435018 Cal. Labor Code §3211.92(a)19 Cal. Labor Code §3211.92(b)

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Disaster Service Worker volunteers must take and subscribe to an oath before enteringupon their duties. All governmental employees are already considered Disaster ServiceWorkers and have taken the oath as a condition of their employment.20 A DisasterService Worker does not include any member registered as an active firefightingmember of any regularly organized volunteer fire department.21

Volunteers who spontaneously come forward to assist can become registered asDisaster Service Worker volunteers. To be covered for workers’ compensationbenefits, these Disaster Service Worker volunteers must meet all of the requirements asindicated in the Disaster Service Worker Volunteer Program Regulations.Requirements include taking and subscribing to the oath before entering their duties.22

Disaster Service Worker volunteers may be eligible for workers' compensation benefitsfor "Occupational Illness" which is defined in the California Code of Regulations as "anyabnormal condition or disorder caused by exposure to environmental factors associatedwith employment including chronic illnesses or disease which may be caused byinhalation, absorption, ingestion or direct contact."23 This would include infectiousdiseases that are of particular concern in a pandemic flu outbreak.

To demonstrate eligibility for worker's compensation benefits, a DSW volunteer mustdemonstrate that the occupational disease/illness or injury arose out of and in thecourse of the volunteer's activities as a Disaster Service Worker and must demonstratethat the activities involved peculiar or unusual risks of contracting the disease. As apractical matter, during a pandemic flu outbreak, it may be difficult to prove that thedisease was contracted in the course of employment if many individuals in the generalpopulation are also susceptible.

Alert Period

1. The Public Health Emergency Response Unit coordinates with HumanResources to obtain a State of California informational pamphlet on workers’compensation eligibility and benefits for Disaster Service Workers under theCalifornia Emergency Services Act entitled, “Information for the Disaster ServiceWorker; Helpful Information about Workers’ Compensation Benefits”

2. Human Resources will train selected Public Health staff on how to complete andprocess SCIF (State Compensation Insurance Fund) Form 3301, SCIF Form3267, and other relevant documents required to process State compensationclaims for Disaster Service Workers.

3. The Public Health Emergency Response Unit will train volunteers on how tocomplete and process SCIF (State Compensation Insurance Fund) Form 3301,SCIF Form 3267, and other relevant documents required to process Statecompensation claims for Disaster Service Workers.

4. The Public Health Emergency Response Unit distributes an informational packet(described in #1 above) on workers’ compensation eligibility and benefits to allvolunteers.

20 Cal. Govt. Code §310021 Cal. Labor Code §3211.92(d)22 DSWVP regulations are contained in California Code of Regulations Title 19, § 2570-§2573.323 California Code of Regulations, Title 8 section 1400

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Pandemic Period

1. Public Health Emergency Response Unit staff distributes information and FAQ onworkers’ compensation eligibility and benefits (described in # 1 above) tovolunteers when they report for official activation at a disaster or emergencyevent.

2. Upon activation of the CCHS DOC, the Finance Section will have available forDisaster Service Workers the Workers’ Compensation Claim and Report ofOccupational Injury or Illness forms necessary to be completed in the event of aninjury or illness.

Liability and Immunity for Contra Costa County Employees and VolunteersCivil liability refers to the potential legal responsibility of a person or entity for actionsthat result in injuries or losses to others. State law protects County employees frompersonal civil liability for negligent acts they commit, provided that they were actingwithin the course and scope of their employment. 24 In lawsuits alleging negligence onthe part of a county public health department official, the county employee would berepresented by County Counsel because the county has the responsibility to defendand indemnify the county employee so long as the employee reasonably and in goodfaith cooperates with the county staff and appointed counsel.25

County emergency preparedness and response volunteers may benefit from liabilityprotection under three different sets of laws: the California Emergency Services Act 26,California Good Samaritan laws and the Federal Volunteer Protection Act of 1997 27.While the degree of protection afforded varies from statute to statute, it can generally besaid that more protections apply once a state of local emergency is officially declared.28

The California Emergency Services Act provides statutory protection to certain medicalvolunteers who render services during a state of local emergency. Specifically, theEmergency Services Act mandates that physicians, nurses and other specified healthcare professionals, who render services during a time of war, state or local emergency,shall not be liable for any injury sustained as a result of that service except where theinjury is caused by a willful act or omission.29

The Emergency Services Act also affords immunity to non-licensed medical volunteersin emergency situations. It provides that Disaster Service Workers volunteers andunregistered volunteers that are “duly impressed into service during a state of waremergency, a state of emergency or a local emergency” have the same degree ofresponsibility for their actions and enjoy the same immunities as officers and employeesof the state and counties performing similar work for their respective entities.30

24 California Government Code § 82525 California Government Code § 99526 California Government Code § 8550 et seq.27 42 U.S.C. § 14501-1450528 Either the County Board of Supervisors or its designees may declare a state of local emergency if there exists“conditions of disaster or of extreme peril to safety of persons or property…” Government Code § § 8558(c), 8630.29 California Government Code § 865930 California Government Code § 8657

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California provides additional statutory protections to specified volunteers under itsGood Samaritan laws. For example, the Business and Professions Code has twoprovisions that specifically protect doctors who render emergency aid from liability forcivil damages under specified circumstances.31 Good Samaritan immunity also extendsto licensed registered nurses and vocational nurses who render emergency care“outside both the place and the course of that person’s employment.”32 Immunity is lostif the nurse is grossly negligent.

In addition, the California Health and Safety Code grants protection against liability forindividuals who render emergency care at the “scene of an emergency.” The codereads as follows:

No person who in good faith, and not for compensation, rendersemergency care at the scene of an emergency shall be liable for any civildamages resulting from any act or omission. The scene of an emergencyshall not include emergency departments and other places where medicalcare is usually offered.33

The federal Volunteer Protection Act of 1997 limits the personal tort liability ofvolunteers at nonprofit organizations and government entities. 34 In order for immunityto apply, volunteers much act within the scope of their responsibilities at the time of theact or omission, and must be properly licensed or certified.35

The Volunteer Protection Act excludes tort protection to volunteers in the following sixinstances: 1) for willful or criminal misconduct, 2) gross negligence, 3) harm due to theuse of a motor vehicle, vessel or aircraft or any vehicle for which a license or insuranceis required; 4) flagrant indifference to the rights or safety of the individual harmed; 5)sexual misconduct, hate crimes, crimes of violence and 6) conduct while under the useof alcohol or drugs.36

Alert Period

1. The Public Health Emergency Response Unit coordinates with HumanResources and Contra Costa County Counsel’s Office to review and distributewritten information on issues of liability and immunity for volunteers in a disasterevent.

2. The Public Health Emergency Response Unit distributes information on volunteerliability and immunity (described in #1) to Public Health’s pre-registered medicaland non-medical volunteers.

31 California Business and Professions Code §§ 2395-239632 California Business and Professions Code § 2727.5, 2861.533 California Health and Safety Code § 1799.10234 42 U.S.C. § 14501-1450535 42 U.S.C. § 1450336 42 U.S.C. §14503(a)

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Pandemic Period

1. The Public Health Emergency Response Unit distributes information and FAQ onvolunteer liability and immunity to all volunteers when they report for officialactivation at a disaster or emergency event.

Licensing, Credentialing and PrivilegingLicensing, credentialing and privileging comprise a regulatory framework designed toimpose and maintain quality control in the provision of health care. This legalframework is applicable both prior to and during an emergency or disaster. Hospitalsand other health care entities are required to adhere to credentialing requirements ofthe Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).Existing scope of practice, legal and professional requirements, and guidelines may beflexed by the Governor during a state of emergency.37

The Public Health Emergency Response Unit will issue identification cards to DisasterService Workers involved in health emergency response.

Alert Period

1. The Public Health Emergency Response Unit develops protocols for rapidlyverifying medical volunteer credentials of volunteer participants who wish toassist in disaster response.

2. The Public Health Emergency Response Unit develops procedures foradministering the Loyalty Oath, required of Disaster Service Workers throughGovernment Code § 3102, to volunteers who wish to assist in health emergencyresponse.

3. The County Office of Emergency Services (OES) develops a list of localauthorities that can administer the Loyalty Oath to Disaster Service Workers.

4. The Public Health Emergency Response Unit maintains a database of pre-registered health emergency response volunteers that have taken the oath of aDisaster Service Worker.

Pandemic Period

1. The Public Health Emergency Response Unit under direction of the HealthOfficer or designated authority activates pre-registered health emergencyvolunteers if required, and monitors their deployment.

2. The Public Health Emergency Response Unit will validate any unverifiedcredentials of volunteers and ensure the oath of a Disaster Service Worker istaken before enlisting the services of any volunteer.

37 California Government Code § 178.5 Article 5, California Government Code § 179.5 Article 6

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Section 9. Risk Communication and Public Education

1. INTRODUCTION

Risk communication and public education play a vital role in pandemic flu preparednessand response. Strong risk communications and public outreach activities help buildtrust, confidence and cooperation, and support effective preparedness and responseefforts.

Dissemination and sharing of timely and accurate information will be one of the mostimportant facets of the pandemic response. Instructing the public and partners inactions they can take to minimize their risk of exposure or actions to take if they havebeen exposed will reduce the spread of the pandemic and may also serve to reduceanxiety and unnecessary demands on vital services.

In conjunction with CCHS’ overall Crisis and Emergency Risk Communications (CERC)plan and Go-Kit, this module will help guide and prepare CCHS in communicating keymessages to the general public, the news media, health care providers and otherpartners and stakeholders (first responders, law enforcement, local government,schools and businesses, etc.) before, during, and after a pandemic influenza.

A. Coordination

The CCHS Communications Officer and communications staff will (in consultation withthe county Health Officer, CCHS Communicable Disease staff, the CaliforniaDepartment of Health Services (CDHS), and the Centers for Disease Control andPrevention (CDC), as appropriate) identify public health issues and concerns that will ormay need to be addressed through public information messages regarding pandemicinfluenza and identify affected target audiences for messages.

CCHS also will coordinate, as appropriate, dissemination of information with the CountyChief Public Communications Officer and the Office of Emergency Services. (See theCCHS CERC Plan for more info).

Because many Contra Costa residents commute to other Bay Area counties andresidents of other counties commute to Contra Costa, in conducting its riskcommunication efforts, CCHS will coordinate with the Association of Bay Area HealthOfficers (ABAHO) and the Pacific Coast Risk Communication leads.

B. Risk Communications Principles

In all emergency communication efforts, CCHS will make every effort to adhere to riskcommunication and ethics principles:

- Be first, be right and be credible (Balance the public’s “need to know”information in a timely manner with the need to ensure that the information is

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accurate)- Engage the public in a manner that allows non-expert citizens to combine

technical facts with their values- Provide enough information to create “transparency” so the public

understands how decisions are made, who is making the decisions andwhere the resources are going

VI. VULNERABLE POPULATIONS CONSIDERATIONS

CCHS is committed to providing health care services to those in need and mostvulnerable, and actively seeks to do so as part of its Reducing Health Disparitiescommitment. Including vulnerable populations and the organizations that serve them inpandemic flu risk communication planning is consistent with CCHS’ mission to reducehealth and health care disparities and serve those most in need and vulnerable inContra Costa.

The following issues will be taken into consideration as preparedness and responseactions are implemented:

1. Key messages delivered in multiple languages (English and Spanish, and othersas resources allow).

2. Key messages delivered in multiple communication modes.3. Key messages delivered through grass roots mechanisms (community- and faith-

based) to people who are homeless, geographically or culturally isolated.4. Key messages delivered to people who are homebound, including those with

services (Meals On Wheels, In-Home Support Services, etc.) and withoutservices.

B. Desired Outcomes

1. Provide timely and accurate pre-event information to the public about pandemicinfluenza, pandemic influenza preparedness and actions, as well as CCHS plans.

2. During a pandemic event, provide the most current and accurate informationincluding what is happening, what is being done, and what people can do toprotect themselves.

C. Phases

The World Health Organization (WHO) identifies six distinct phases of a pandemic.For the purposes of planning, CCHS has incorporated these six phases into threeperiods: Interpandemic/Pandemic Alert Period; Pandemic Period; and Post-Pandemic Period. In CCHS’ CERC plan, these periods correspond to PreparednessActivities; Response Activities; and Recovery Activities. In particular, CCHS will usethe CDC’s Severity Index and the Contra Costa to recommend appropriate actionsfor CCHS staff, health providers, first responders, partners, schools, stakeholders,the public and the media, along with the WHO phases, the Federal GovernmentResponse Stages. (See Sect. 1 Introduction for the Pandemic Flu Phases Table andSect. 7 Non-Pharmaceutical Interventions for the CDC Severity Index and theContra Costa Response Triggers Matrix)

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II. COMMUNICATIONS INFRASTRUCTURE

CCHS will use a range of communication methods (see Appendex CCHS Methodsof Communications tablefor a complete listing of priority communication channelsand redundant communications) as appropriate to notify CCHS staff, healthproviders, first responders, partners, stakeholders, the public and media of changesin pandemic flu stages and to inform them of recommended actions, such as the useof Personal Protective Equipment (PPE) and social distancing.

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:

Test local communication systems, including ReddiNet, CAHAN, satellitephones, Blast Fax, the CCHS website and website remote access (HEWIE),Health Emergency Information Line (HEIL), the Health Emergency Call Center,the Incident Response Information System (IRIS), etc., through trainings, drillsand exercises to ensure that local and statewide communications are functional.

Establish and maintain health care provider contact info in Blast Fax. Maintain Media Blast Fax and email contact list. Maintain Blast Fax for CBOS, etc. Maintain contact lists for business and industry partners, schools and colleges,

day care providers, organizations that serve vulnerable populations, etc. (Seecomplete list of contacts in Appendix and also in the CCHS CERC plan Go-Kit.)

Utilize 211: as this system rolls out in Contra Costa County, CCHS will make useof the service, which includes the County Online Resource Database (CORD),which is maintained by the Contra Costa Crisis Center and provides a one-stopservice for information and referrals for the public (available also on the CCHSwebsite site: www.cchealth.org).

B. Pandemic Period

During a pandemic, CCHS will follow WHO, CDHS and CDC guidance to issuerecommendations locally, and will:

Use CCHS communications methods to notify hospitals, public and private healthcare providers, first responders, other appropriate Public Information Officers,and other public and private sector partners and stakeholders of the change inpandemic stage.

Implement contingency plans, if any, for obtaining critical hardware, software, orpersonnel to expand communications systems if needed for a pandemic.

Maintain ongoing communication with health care providers, first responders, allpartners and stakeholders, including posting information on the CCHS website,CAHAN, and ReddiNet.

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C. Post Pandemic Period (Recovery) Take appropriate corrective action steps identified in After Action reports. Return to Interpandemic/Pandemic Alert Period Activities.

III. COMMUNICATING WITH THE GENERAL PUBLIC

Message DevelopmentMessages are developed with key CCHS staff and are approved by the Health Officer,and as appropriate with the CDHS and CDC. CCHS also will coordinate, as appropriate,with the Association of Bay Area Health Officers (ABAHO) and the Pacific Coast RiskCommunication leads.

During the course of pre-event activities and especially during a pandemic influenzaevent, messages and other information will be updated and customized.

A description of key messages is included in the final section of this module and alsoincluded in the Pandemic Flu Section of the CCHS CERC Plan Go-Kit.

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Develop key messages for printed materials, public presentations, and for the newsmedia. Provide a solid foundation of information upon which future actions can bebased. Key messages address CCHS activities, including planning efforts, as well asavian influenza education, pandemic influenza and general preparations.

B. Pandemic PeriodUpdate and further develop key messages as the situation warrants. Messages areused primarily for communicating key actions to the general public through the newsmedia. Materials will be posted to the CCHS website as they are developed.

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports.Return to Interpandemic/Pandemic Alert Period Activities.

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Public Education & Awareness CampaignThe public is more likely to respond and cooperate more readily if they are involved inthe discussions and planning for pandemic influenza, have general knowledge of thesituation, are aware of the issues and concerns that are to be addressed, andunderstand their individual role and responsibilities. Planning checklists for individualsand families, businesses, faith-based organizations and community organizations havebeen created and are posted on the CCHS pandemic flu web page (www.cchealth.org).

See the appendix for CCHS’ pandemic planning tool kits for schools and day careproviders and checklists for law enforcement, media and others.

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Conduct a public education and awareness campaign as resources allow. Key messageare used in the various components of the campaign, which is directed to the generalpublic and conducted in two languages, English and Spanish. (See RiskCommunication/Public education Strategies section of this module for a full list ofcommunication strategies.)

Depending on resources, the following tools may be utilized in a public education andawareness campaign:

Education materials on pandemic fluMedia campaignsBill InsertsWeb PostingsScriptsRadio Ads and PSAsPrint adsTheater and Mall SignsBus Shelters, Bus Interior Signs, Bus BoardBillboardsTelevision adsContra Costa Television showsHealth Emergency Information Line (HEIL)

B. Pandemic PeriodDuring this period, CCHS will:

Continue and increase public education and awareness campaign as resources allow.Key messages are used in the various components of the campaign, which is directedto the general public and conducted in two languages, English and Spanish.

Use pandemic flu information materials available in Chinese and Vietnamese on thefederal government’s pandemic flu website (www.pandemicflu.gov)

Update current materials and develop new materials as the situation warrants. Updatedmaterials will be posted as they are developed to the CCHS website, the HEIL line, etc.

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C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports.Return to Interpandemic/Pandemic Alert Period Activities.

Materials Development

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Develop materials providing information to the general public, media and healthcare andother partners. Pandemic Flu Preparedness Tool Kits have been developed for schools,day care providers and the media and are available for download on the CCHS website.

The following tools are available on the CCHS website (www.cchealth.org) and in theCCHS CERC plan Go-Kit: (Most are available in both English and Spanish)

Planning ToolsPandemic Flu School Action KitPandemic Flu Kit for Child Care ProvidersPandemic Flu Planning Checklist for Individuals and FamiliesPandemic Flu Planning Checklists for: businesses, travel industry, schools,

child care providers and preschools and colleges, law enforcement andmedia.

Fact Sheets/Brochures (many available in multiple languages)Ways to Protect Yourself brochureFacts about Pandemic FluParents TipsWhat You Can Do to Prepare for Pandemic FluHome Care for Pandemic Flu (American Red Cross)Resources for Emergency Information

Posters (many available in multiple languages)Cover Your Cough PosterGerm Free ZoneBe A Germ StopperStopping the Flu is Up to You!Keep Our School HealthyHow Does Seasonal Flu Differ from Pandemic Flu?Stop DiseaseWash Your Hands PosterDuring a Flu Outbreak: When do I keep my child home?

Power Points/VideosPandemic Flu Power Point presentationLocally produced videos on health emergency issues in both Spanish and

English, including one on the difference between Avian Flu and Seasonal Flu.(See Appendix )

B. Pandemic Period

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Update current materials and develop new materials as the situation warrants. Updatedmaterials will be posted to the CCHS website as they are developed.

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports.Return to Interpandemic/Pandemic Alert Period Activities, as appropriate.

Health Emergency Information Line

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Update the Health Emergency Information Line (HEIL), which already includes pre-recorded scripts in English and Spanish. The HEIL recordings will reflect updatedpandemic influenza information.

B. Pandemic PeriodHEIL will be fully activated and messages deployed to respond to calls from the generalpublic. Scripts will be updated and staff will be briefed at regular intervals. The HealthEmergency Call Center may be activated as part of the EOC activation to handle callsfrom the public.

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports.Return to Interpandemic/Pandemic Alert Period Activities, appropriate. Messages will beremoved as appropriate and returned to normal mode.

CCHS website

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:A Pandemic Influenza page has been created on CCHS’s website- which also isavailable in Spanish- and is updated as new information is available. The webpageincludes pandemic planning and preparedness materials for the general public as wellas schools, CBOs, law enforcement, media, health care providers, etc. The webpagealso includes links to the state health department and CDC.

B. Pandemic PeriodThe website will be updated regularly. The website also can be remotely accessedthrough CCHS’ HEWIE program, though which CCHS communications staff implementan emergency activation status and post information remotely as needed.

C. Post Pandemic Period (Recovery)HEWIE will be deactivated as appropriate and CCHS will take appropriate correctiveaction steps identified in After Action reports. Return to Interpandemic/Pandemic AlertPeriod Activities, as appropriate.

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IV. WORKING WITH THE NEWS MEDIA

Media Information/Education

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Develop a packet of materials for the news media. The packet includes CCHS materialsas well as approved outside materials. These materials include samples of publiceducation materials, guidelines for business planning, and guidelines for personalprotection. CCHS has already distributed a “Media Pandemic Flu Planning Kit” to localmedia.

The following tools are included in the Media Pan Flu Kit (which is in the CCHS CERCGo-Kit)

Media Pandemic Influenza Preparedness ChecklistSelf Care for the MediaNewsroom Planning for Crisis Coverage

Hold informational meetings, which are done as part of periodic Media Roundtablespresented by CCHS and the Contra Costa Emergency Public Information Officer team(EPIO), which staff the county’s Public Information Center (PIC) during an EOCactivation or would work in a JIC, if activated. (See the CCHS CERC Plan for moreinfo).

B. Pandemic PeriodCommunicate regularly with the media to disseminate pandemic flu information.Refer to the CCHS CERC plan for more details.

More pan flu education materials will be distributed to the media as appropriate,including:

Cover Your Cough PosterWash Your Hands PosterHome Care for Pandemic Flu (American Red Cross)Resources for Emergency InformationWays to Protect Yourself brochure

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports. Updatematerials as needed. Return to Interpandemic/Pandemic Alert Period Activities,appropriate.

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Communicating with the Media

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Inform the media of ongoing pandemic flu preparedness activities and conductinformation meetings.

B. Pandemic Period

During this period, CCHS will:Updated public information and risk communication materials about pandemic flu will bedistributed regularly to the media as part of ongoing media outreach through pressreleases, web postings, media interviews and press conferences. (See section belowfor a full list of communication strategies, and refer to the CCHS CERC plan Go-Kit for acomplete description of risk communication implementation.)

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports. Updatematerials as needed. Return to Interpandemic/Pandemic Alert Period Activities, asappropriate.

Spokesperson Training

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Identify, train and drill CCHS and other county spokespersons on specific pandemicinfluenza risk communications. Conduct an informational training with healthcareprovider PIOs and appropriate members of the county’s Emergency Public InformationOfficer team (EPIO) and/or the Contra Costa PIN group.

The following tools have or will be developed:

Crisis and Emergency Risk Communication (CERC) trainingsTalking Points

B. Pandemic PeriodUpdated public information and risk communication materials about pandemic flu will bedistributed regularly as part of ongoing public outreach. Refer to the CCHS CERC planfor a complete description of risk communication implementation.

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports. Updatetraining and materials as needed. Return to Interpandemic/Pandemic Alert PeriodActivities, as appropriate.

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V. COORDINATING WITH HEALTHCARE PUBLIC INFORMATION OFFICERS

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:CCHS is currently working with local hospital PIOs through the Hospital Disaster Forumto maintain a hospital PIO contact list. (See section below on Risk CommunicationGuidance for Hospitals and Sect. 6. Infection Control and Prevention for infectioncontrol guidance for hospitals and health care providers.)

The following tools have been or are being developed for hospitals:Pandemic Flu Fact SheetsFrequently Asked Questions, Cover Your Cough posters, etc.Pandemic Influenza UpdatesOther Materials as determined and approved

B. Pandemic Period

During this period, CCHS will:Communicate regularly with hospital PIOs about CCHS activities as well as any newdevelopments regarding avian and/or pandemic flu. Healthcare PIO information will becommunicated primarily through email, Reddinet, CAHAN and fax, as appropriate.

Provide updated public information and risk communication materials about pandemicflu will be distributed regularly as part of ongoing public outreach. (See section below fora full list of communication strategies, and refer to the CCHS CERC plan Go-Kit for acomplete description of risk communication implementation.)

The following tools will be utilized for providing current information:Health alertsPandemic Influenza

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports. Updatetraining and materials as needed. Return to Interpandemic/Pandemic Alert PeriodActivities, as appropriate.

VI. COMMUNICATING WITH KEY PARTNERS

The CCHS Communications Officer and CEI unit provides support to Public Health staffand programs that are primarily responsible for outreach, coordination and contentdevelopment with key partners and stakeholders. These key partners include: theCounty Board of Supervisors, businesses, city governments, colleges and universities,community-based and faith-based organizations, coroner, county government,emergency medical services and pre-hospital responders, environmental health, fireservices, County legal/court system, law enforcement agencies, local healthcaresystem, mental health, news media, airport, local transit and schools.

Maintain contact lists for business and industry partners, schools and colleges, day

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cares, organizations that serve vulnerable populations, etc. (See complete list ofcontacts in Appendix and also in the CCHS CERC plan Go-Kit)

Provide Existing Materials

A. Interpandemic/Pandemic Alert Period

During this period, CCHS will:Make existing materials available for distribution. Key partners may use these materialsfor distribution to employees, customers, clients, vendors, etc. Post all information to theCCHS website.The following tools will be provided to key partner organizations:

Fact Sheets – Pandemic Flu, Avian Flu, Isolation & QuarantineFrequently Asked QuestionsPandemic Influenza UpdatesScriptsPan Flu preparedness checklistsOther materials as developed

B. Pandemic PeriodUpdated public information and risk communication materials about pandemic flu will bedistributed regularly as part of ongoing public outreach. Refer to the CCHS CERC Planfor a complete description of risk communication implementation.

C. Post Pandemic Period (Recovery)Take appropriate corrective action steps identified in After Action reports. Updatetraining and materials as needed. Return to Interpandemic/Pandemic Alert PeriodActivities, appropriate.

VII. RISK COMMUNICATION/PUBLIC EDUCATION STRATEGIES

CCHS will use the following communication strategies as appropriate to notify providers,first responders, partners, stakeholders, the public and media of changes in pandemicflu stages and inform them of recommended actions to prepare for, prevent, respond to,and recover from pandemic flu. Based on federal and state guidance and in consultationwith the County Health Officer and CCHS Communicable Disease staff, CCHScommunications staff will perform public education activities and disseminateinformation on recommended actions to the public, such as the use of PersonalProtective Equipment (PPE), school dismissal or closures and other risk reductionmeasures.

A. Interpandemic/Pandemic Alert PeriodThe CCHS Communications Officer/PIO and staff will prepare on an ongoing basis torespond to a pandemic through the following preparedness activities and strategies:

- Conduct community education and media campaigns on pandemic flu, diseaseprevention and CCHS preparedness activities.

- Work with schools, child care providers, law enforcement and volunteerorganizations (such as the American Red Cross) to coordinate pandemic flu

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preparedness and response plans (i.e. CCHS’ Pandemic Action Kit for Schoolsand the Law Enforcement Pan Flu Preparedness Checklist- see CCHS website).

- Maintain and update the CCHS CERC plan and pandemic flu plan componentsas needed, including fact sheets, media contact lists, Blast Fax list, website.

- Create and maintain a Pandemic Preparedness page on the CCHS website.- Create and update pandemic flu messages to be activated when needed on the

Health Emergency Information Line (HEIL).- Designate and train appropriate pandemic spokespersons.- Develop pandemic flu materials for advice nurses and staff that would be in the

Health Emergency Call Center.- Educate CCHS staff about pandemic flu planning, preparedness and response.

B. Pandemic PeriodDuring this period, communicating information to the public in a timely and accuratemanner will be essential to ensure compliance with health directives. CCHS will use avariety of strategies to communicate with partners and the public to provide appropriatemessages.

Pandemic Period StrategiesTo get out information quickly, CCHS will use a number of redundant communicationsmethods:

- Update the Health Emergency Information Line (HEIL) on a regular basis asappropriate.

- Activate Health Emergency Call Center, as needed.- Modify and update written materials (such as fact sheets, materials in the

Schools Pandemic Action Kit, etc.) as needed.- Activate emergency mode for CCHS website if appropriate.- Post documents intended for electronic distribution on CCHS website.- Provide press releases, web postings, media interviews and press conferences

for media on a timely basis- Modify, if necessary, templates and prepared key messages in the CCHS CERC

Go-Kit.- Implement public information campaigns by creating PSAs to air on local cable

television, as well as broadcast media.- Provide advice nurses, call center staff and any phone answerers with latest

pandemic flu information on prevention, treatment, etc.- Alert schools, child care providers, law enforcement and other local public and

private agencies of the need to activate their own pandemic flu response plans.- Provide risk communication guidance to hospitals in Contra Costa.- Disseminate guidelines on influenza precautions for workplaces, health care

facilities, schools, jails and prisons, public safety agencies, and individuals.- Provide internal information to employees through the CCHS Employee

Emergency Hotline, Intranet, Incident Response Information System (IRIS), AllStaff email messages, the media and other mechanisms.

- Communicate with partners and stakeholders (including county Board ofSupervisors) and keep them updated, including if and when school and child careclosures or dismissals are needed.

- Coordinate messages with appropriate agencies, such as the county Office of

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Emergency Services, the state health department, the CDC and lawenforcement.

- Identify contact person (and backup person) for communication with stateDepartment of Health Services risk communication/PIO staff.

- Use PIO mutual aid as needed.- Staff Public Information Center at county Emergency Operation Center and/or

Joint Information Center (JIC) as needed.

Pandemic Period MessagesDuring a Pandemic Period, messages that need to be communicated will includeinformation on at least the following (See CCHS CERC Go-Kit Pandemic Flu Section formessages.)

- Projected severity of the new virus.- Current surveillance information.- Travel alert information received from the State and/or CDC.- Risk reduction tips and other instructions to the general public, health care

providers, first responders, partners and stakeholders, including the importanceof hand washing, social distancing and other nonpharmaceutical interventions, asappropriate.

- Availability and location of vaccine supply and antiviral use, as applicable.- Locations of mass vaccination clinics (PODs) and instructions for getting and

taking medications.- Vaccination priorities, as applicable.- Availability of CCHS essential services.

C. Post-Pandemic Period (Recovery)Because pandemic flu is predicted to come in waves, the recovery period may bedelayed for several cycles. CCHS’ goal is to return CCHS services to normal asquickly as possible. Recovery period activities will include:

- Restore website, HEIL and Employee Emergency Information Hotline to normalfunction.

- Correct deficiencies identified in After Action Reports.- Update Fact Sheets and appropriate materials in the CCHS CERC Go-Kit.- Evaluate media coverage.- Return to Interpandemic/Pandemic Alert Period activities.

VIII Hospital Risk CommunicationPandemic influenza risk communication strategies are a critical and necessarycomponent of pandemic influenza preparedness and response. Hospitals will play animportant role in providing vital information to the public, health care providers andhospital staff before, during and after a pandemic to help ensure people respondappropriately to outbreak situations and follow public health measures. To ensure thatthis information be consistent, accurate and timely, it is critical that hospitals coordinatepandemic flu messages with local public health officials.

The CCHS Communications Officer/Public Information Officer (CCHS PIO) willcollaborate with the Contra Costa County Chief Public Communications Officer and/or

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the County’s Emergency Public Information Office (EPIO), taking the lead indevelopment of public health and medical risk communication materials for release tothe public, business community, schools, and critical infrastructure including healthcarefacilities. Hospital Public Information Officers (PIOs) should initiate and maintain a closeworking relationship with the CCHS PIO, if they have not already done so.

Information regarding a pandemic and the planning for it is coming from a variety ofsources. The federal government provides background information and frequentupdates for healthcare professionals through the website, www.pandemicflu.gov.Additionally the Centers for Disease Control (CDC) provide information through CDC’sEmergency Communication System. At the state level, the California Department ofHealth Services (CDHS) provides clinician alerts using the California Health AlertNetwork (CAHAN), and convenes regular conference calls with local Health Officersand other partners. Information is also provided by Local Health Officer through CCHSto hospitals and health care centers via alerts, the Hospital Disaster Forum and otherpartners, such as the Community Clinics Consortium. To reduce the likelihood ofconflicting or confusing messages across the healthcare system, every effort should bemade to coordinate media content between CCHS and hospitals. This is true duringboth the Interpandemic/Alert Period and Pandemic Period

Interpandemic/Alert Period

During the Interpandemic/Alert Period it is important for hospitals to establishmethodologies for assuring that the most current information is being received from andprovided to the CCHS PIO. Communication channels may include: REDDINET,CAHAN, Blast Fax, email, etc. (See Appendix CCHS Communication Methods for a fulldescription of the possible communications methods.)

Information received should be shared with those appropriate individuals within theorganization, such as health care providers, other staff, patients and partners. Hospitalsare encouraged to include risk communications strategies in their hospital pandemicplan, and preparation for implementing the following strategies are recommended:

1. External Communication

a. The CCHS PIO will maintain a single source of contact with each hospital.Current contact information should be provided by each hospital and aplan developed to ensure the information is updated, as needed.

b. Hospital PIOs should consider participating in a PIO network, such as theContra Costa Public Information Network, and/or attending the HospitalDisaster Forum meetings.

c. Hospitals should prepare, or utilize messages provided by CCHS PIO orEPIO, for use in call centers, websites, hotlines, recorded messages, etc.These messages should be differentiated for patients, community, andemployees.

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d. Hospitals should identify and train individuals who may be expected tosupport the hospital PIO or serve as the hospital spokesperson duringperiods where there is increased communication flow related to pandemicflu.

2. Internal Communication

a. Hospitals will develop mechanisms for sharing pandemic flu planning withemployees.

b. Hospitals will develop frequently asked questions, or utilize those providedby CCHS, which target hospital personnel, differentiating them forpatients, and the community.

Pandemic Period

During the pandemic period, hospital PIOs are encouraged to:

1. Maintain a single source of contact with the CCHS PIO, ensuring this informationis updated, as needed.

2. Use established mechanisms for external communication with the media and aPIO network.

3. Determine how to keep administrators, personnel, patients, and visitors informedof the ongoing impact of pandemic influenza on the facility and the community;

4. Ensure capacity for increases in communication flow related to pandemic flu; and5. Establish communication with any area Joint Information Center (JIC) as

appropriate, if activated. The county Emergency Operations Center may open aJIC.

Education and TrainingEach hospital is encouraged to develop an education and training plan that addressesthe needs of staff, patients, family members, and visitors. Hospitals will need to assignresponsibility for coordination of the pandemic influenza education and training programand identify training materials—in different languages and at different reading levels, asneeded—from HHS agencies, state and local health departments, and professionalassociations.

The following guidelines, taken from the HHS Pandemic Influenza Plan, provide a basisfor inclusion of education and training in the hospital’s Pandemic Influenza Plan. CCHSand/or the state health department will provide current information that should be usedin developing education and training content.

Interpandemic/Alert Period

Each hospital is encouraged to develop a plan to provide staff education. Topics forstaff education should include infection control strategies for the control of influenza,including respiratory hygiene/cough etiquette, hand hygiene, standard precautions,droplet precautions, and, airborne precautions. (See also Sect. 6 Infection Control andPrevention guidelines for health care settings.)

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1. Hospital-specific topics for staff education should include:

a. Policies and procedures for the care of pandemic influenza patients,including how and where pandemic influenza patients will be located;

b. Pandemic staffing contingency plans, including how the facility will dealwith illness in personnel;

c. Policies for visitation;d. System for reporting suspected cases of infection caused by novel

influenza strains during the Interpandemic and Alert periods to CCHS;and,

e. Measures to protect family and other close contacts from secondaryoccupational exposure;

2. Hospitals should also:

a. Establish a schedule for training/education of clinical staff and amechanism for documenting participation. Use annual infection controlupdates/meetings, medical Grand Rounds, and other educational venuesas opportunities for training on pandemic influenza;

b. Cross-train clinical personnel, including outpatient healthcare providers,who can provide support for essential patient-care areas (e.g., emergencydepartment, ICU, medical units);

c. Train intake and triage staff to detect patients with influenza symptomsand to implement immediate containment measures to preventtransmission;

d. Create a mechanism for supplying social workers, psychologists,psychiatrists, and nurses with guidance for providing psychologicalsupport to patients and hospital personnel during influenza pandemic.Hospitals should also provide psychological-support training to appropriateindividuals who are not mental health professionals (e.g., primary-careclinicians, leaders of community and faith-based organizations); and,

e. Develop a strategy for “just-in-time” training of non-clinical staff who mightbe asked to assist clinical personnel (e.g., help with triage, distribute foodtrays, transport patients), students, retired health professionals, andvolunteers who might be asked to provide basic care (e.g., bathing,monitoring of vital signs); and other potential in-hospital caregivers (e.g.,family members of patients).

3. Education of patient, family members, and visitorsa. Patients and others should know what they can do to prevent disease

transmission in the hospital, as well as at home and in communitysettings.

b. Identify and utilize language-specific and reading-level appropriatematerials, provided by CCHS, CDHS and CDC for educating patients,family members, and hospital visitors during an influenza pandemic.Develop a plan for distributing information to all persons who enter thehospital.

c. Identify staff to answer questions about procedures for preventinginfluenza transmission.

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Pandemic Period

Hospitals will implement the mechanisms created to distribute updated informationaland educational materials to hospital visitors, patients, and patient community, on anon-going basis. It will be essential that the hospital PIO maintain regular contact with theCCHS PIO to ensure the hospital receives the most updated pandemic flu guidance andto the assigned Education and Training staff receive the most current information to usein their training.

Training and education should be ongoing and include information on:

a. Disease prevention precautions.b. Home self-care information.c. The need to either postpone non-critical appointments or procedures or provide

alternative ways for patients to be seen for non-urgent needs.d. The need to advise public to only use the Emergency Department for true

medical emergencies.

Section 9 Risk Communication and Public Education Tools

Some of these materials are included in the Appendix.See also the CCHS CERC Go-Kit for these materials and more or visit CCHS website(www.cchealth.org)Most of these materials are available in both English and Spanish

Planning ToolsPandemic Flu School Action KitPandemic Flu Kit for Child Care ProvidersPandemic Flu Planning Checklist for Individuals and FamiliesPandemic Flu Planning Checklists for: businesses, travel industry, schools,

child care and preschools and colleges.

Fact Sheets/BrochuresWays to Protect Yourself brochureFacts about Pandemic FluParents TipsWhat You Can Do to Prepare for Pandemic FluHome Care for Pandemic Flu (American Red Cross)Resources for Emergency Information

PostersCover Your Cough PosterGerm Free ZoneBe A Germ StopperStopping the Flu is Up to You! (English and Spanish)Keep Our School HealthyHow Does Seasonal Flu Differ from Pandemic Flu?

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Stop DiseaseWash Your Hands PosterDuring a Flu Outbreak: When do I keep my child home?

Power Points/VideosPandemic Flu Power Point presentationLocally produced videos on health emergency issues in both Spanish and

English, including one the difference between Avian Flu and Seasonal Flu.

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Section 10. Behavioral Health and Psychosocial Considerations

IntroductionIn responding to community behavioral health and psychosocial needs during aninfluenza pandemic, considerations will be based upon tested principles used duringpreviously defined traumatic events or disasters. While a pandemic in itself does not fallunder the definition outlined in the Disaster Relief and Emergency Assistance Act,planning assumptions used will follow those of emergency disaster planning principles.An influenza pandemic is a major public health threat, and it is anticipated that there willbe widespread affect on the general population.

During the Interpandemic/Pandemic Alert: It will be necessary to determine, thescope of impact, speed of onset, duration of impact, and the social preparednessfor the event. There is a “dose-response” relationship between communityimpact and psychological impact. Researchers have found higher levels ofanxiety, depression, etc., and generalized distress associated with widespreadcommunity impact. (During an influenza pandemic, the basic fabric of communitylife remains intact), therefore there is a foundation from which recovery canoccur. Even alerted to an impending pandemic, the community can continue withmany of its familiar routines.

The following behavioral health and psychosocial considerations are:o Respond to public’s warning of the potential for a pandemic;o Conduct needs assessment by gathering information about the physical

and/or emotional impact of the pandemic alert and about the possiblemental health needs of the population. The assessment of thecommunity’s response to the pandemic alert will be conductedcollaboratively with the Public Health Division.

o Provide consultation to the decision makers in the provision of mentalhealth services, etc., to the decision makers, managers, supervisors, andline workers. Support decision makers in solving problems involvingpolicy, organization functioning, and service provision.

o Use community outreach strategies to reach the public to ascertain needand to reach as many people as necessary. Outreach should be providedto the public, disaster service workers, and members of the community intheir natural environment. Researchers have consistently shown that themore personal exposure someone has to the “disaster” impact, the greaterhis or her post-disaster reaction.

o Conduct psycho-educational groups to debrief and defuse public healthworkers, community members and others in their natural environment.These psycho-educational groups can address the reactions of thoseinvolved, and will obtain needed information on normal stress reactionsand to obtain information on coping strategies and recovery resources.

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Pandemic Response: A prolonged “impact” period with no clear end impedes therecovery process. The community response may be one of an extended periodof anticipation, which may cause the suffering of effects of chronic stress andanxiety due to the extended period of anticipation or threat. Because the“endpoint” of a pandemic can be ambiguous, the extended period of anticipationwill have an impact on individuals. It will also have an impact on those servingthe public health needs during the influenza pandemic.

During the influenza pandemic, it will be necessary to continue with the steps asoutlined, above, in the early stages of a pandemic, as follows:

Continually assess the community’s mental health needs during thepandemic.

Periodically re-institute the other core components of assessment andrecovery planning, including: consultation, outreach, debriefing anddefusing, education, and as needed, crisis counseling (for disasterworkers and community members). Those steps are outlined earlier, in“Interpandemic Response”.

*Continual active outreach to the community, going to sites wherecommunity members are involved in the activities of their daily lives. Suchplaces should include neighborhoods, schools, shelters, service centers,family assistance centers, respite sites for public health workers, hospitals,churches, community centers, etc. (*This may not be possible if strictsocial distancing measures are in place).

Manage stress and prevent compassion fatigue for both public health andmental health workers. This is an important issue in “disaster” mentalhealth. Additionally, studies have shown that “disaster” mental healthworkers, and others, can have stress reactions to the incidents, and thismay result in patterns of mental and physical distress for theseprofessionals.

Utilize stress management strategies to support workers, includingbriefings, supervision, consultation, continuing education, and if needed,psychotherapy. Further strategies include making provisions fororganizational support and workplace strategies, defusing, and debriefing.When working as teams, professional development strategies andpersonal strategies are equally important.

Assure the preservation of the physical, mental, social, and spiritual healthof workers during pandemic response and recovery.

It may be necessary to provide Critical Incident Stress Management(CISM) to mitigate the impact of pandemic stress and accelerate therecovery of persons impacted by the pandemic. Principles of CriticalIncident Stress Debriefing may also be applied if group “crisis intervention”is needed.

*Support groups for pandemic influenza workers are a “mainstay” in anydisaster mental health program. Support groups can be effective becausethey provide normalization, universalization, education, and sharing ofresources, and they help members to feel understood and to optimize andreinforce accomplishments, coping, and recovery. (*This may not bepossible if strict social distancing measures are in place).

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Provide education services such as workshops, presentations,conferences, use of media, etc., to offer information and training on topicsspecific to “disaster” psychology and mental health in order to supportindividual, family, disaster service worker, and community recovery. Itmay be necessary to conduct brief interviews with those already affectedor impacted by the pandemic during this phase.

Post-Pandemic Response: Outreach approaches that offer practical assistancewith problem solving and accessing resources are a key to successful recoveryprogram. Mental Health workers can assist the community members withproblem solving and decision-making. They can also help community membersidentify specific concerns, set priorities, explore alternatives, seek out resources,and choose a personal plan of action. Mental Health workers can help directlywith things such as filling out forms, locating healthcare or childcare, and findingtransportation. They can also make referrals to specific resources, such asassistance with financial matters, etc.

Support systems are crucial to recovery following a pandemic. The mostimportant support group for individuals is the family, and Mental Health workerscan continue to provide resources to this support group.

For those with limited (family) support systems, a support group can be helpful.

Additionally, mental health workers may involve themselves in communityorganization activities. Community organization brings community memberstogether to deal with concrete issues of concern to them.

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Section 11. Ethics

I. IntroductionWhen influenza pandemic strikes the world many people, ranging fromgovernment and medical leaders to health care workers, will face a host ofdifficult decisions that will affect people’s freedoms and their chances of survival.

The World Health Organization, in describing international human rightsprinciples, stresses that while individual rights and freedoms must be protected,these freedoms can be restricted when the public’s health is threatened.1

CCHS is committed to conducting its pandemic flu planning and response effortsusing widely held ethical values to make these decisions.

Fairness is a fundamental concern of decision making in times of crisis andresource limitations. Three principles2 related to fairness that CCHS will consideras it makes these difficult decisions include: that CCHS will consider as it makesthese difficult decisions include:

- Public engagement that allows non-expert citizens to place technicalfacts within the context of public values

- Publicity that actively communicates with stakeholders.- Review that allows stakeholders to provide information and acts as an

appeal process.

Decisions should aim to promote the common good and avoid social and familialfragmentation. They should adhere to the “precautionary principle” of publichealth:3

- Transparency so that the public understands how decisions are made- Inclusion so that stakeholders can make their voices heard- Accountability so that the public knows who is making the decisions

and where the resources are going

CCHS will use the guidelines described in this section, documents such as theSurge Related Ethical Principles issued by the California Department of HealthServices, and the direction of the Contra Costa Regional Medical Center EthicsCommittee to guide decision-making.

2. A Guide for Decision making

Many issues will be raised during the pandemic that cannot be resolved inadvanced. To assist decision making during the pandemic, CCHS will use a

1 Addressing Ethical Issues in Pandemic Influenza Planning. WHO. 20062 Accountability for Reasonableness. Daniels 2000.3 Ethics and Emergency Preparedness. Harvey Kayman, MD, MPH, PHMO III

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guide developed by the University of Toronto. This guide emphasizes attention to15 ethical values, of which 10 are substantive values and five are proceduralvalues. They should be seen as a package of interdependent values that areimportant in any democratic society. They apply to the key areas described in IIIbelow.

Ten substantive values to guide ethical decision-making

Substantive value Description

Individual liberty In a public health crisis, restrictions to individual liberty may benecessary to protect the public from serious harm. Restrictionsto individual liberty should:

• Be proportional, necessary, and relevant;

• Employ the least restrictive means; and

• Be applied equitably.

Proportionality Proportionality requires that restrictions to individual liberty andmeasures taken to protect the public from harm should notexceed what is necessary to address the actual level of risk toor critical needs of the community.

Protection of the publicfrom harm

To protect the public from harm, health care organizations andpublic health authorities may be required to take actions thatimpinge on individual liberty. Decision makers should:

• Weigh the imperative for compliance;

• Provide reasons for public health measures toencourage compliance; and

• Establish mechanisms to review decisions.Privacy Individuals have a right to privacy in health care. In a public

health crisis, it may be necessary to override this right to protectthe public from serious harm.

Duty to provide care Inherent to all codes of ethics for health care professionals isthe duty to provide care and to respond to suffering. Health care

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Duty to provide care –continued

Providers will have to weigh demands of theirprofessional roles against other competing obligationsto their own health, and to family and friends.Moreover, health care workers will face significantchallenges related to resource allocation, scope ofpractice, professional liability, and workplaceconditions.

Reciprocity Reciprocity requires that society support those whoface a disproportionate burden in protecting the publicgood, and take steps to minimize burdens as much aspossible. Measures to protect the public good are likelyto impose a disproportionate burden on health careworkers, patients, and their families.

Equity All patients have an equal claim to receive the healthcare they need under normal conditions. During apandemic, difficult decisions will need to be madeabout which health services to maintain and which todefer. Depending on the severity of the health crisis,this could curtail not only elective surgeries, but couldalso limit the provision of emergency or necessaryservices.

Trust Trust is an essential component of the relationshipsamong clinicians and patients, staff and theirorganizations, the public and health care providers ororganizations, and among organizations within a healthsystem. Decision makers will be confronted with thechallenge of maintaining stakeholder trust whilesimultaneously implementing various control measuresduring an evolving health crisis. Trust is enhanced byupholding such process values as transparency.

Solidarity As the world learned from SARS, a pandemic influenzaoutbreak will require a new vision of global solidarityand a vision of solidarity among nations. A pandemiccan challenge conventional ideas of nationalsovereignty, security or territoriality. It also requiressolidarity within and among health care institutions. Itcalls for collaborative approaches that set asidetraditional values of self-interest or territoriality amonghealth care professionals, services, or institutions.

Stewardship Those entrusted with governance roles should beguided by the notion of stewardship. Inherent instewardship are the notions of trust, ethical behavior,and good decision-making. This implies that decisionsregarding resources are intended to achieve the bestpatient health and public health outcomes given theunique circumstances of the influenza crisis.

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Five procedural values to guide decision making

Procedural value Description

Reasonable Decisions should be based on reasons (i.e., evidence, principles, andvalues) that stakeholders can agree are relevant to meeting healthneeds in a pandemic influenza crisis. The decisions should be madeby people who are credible and accountable.

Open and transparent The process by which decisions are made must be open to scrutiny,and the basis upon which decisions are made should be publiclyaccessible.

Inclusive Decisions should be made explicitly with stakeholder views in mind,and there should be opportunities to engage stakeholders in thedecision-making process.

Responsive There should be opportunities to revisit and revise decisions as newinformation emerges throughout the crisis. There should bemechanisms to address disputes and complaints.

Accountable There should be mechanisms in place to ensure that decision makersare answerable for their actions and inactions. Defense of actions andinactions should be grounded in the 14 other ethical values proposedabove.

III. Key Issues to be addressed

Four key ethical issues must be addressed in pandemic flu planning1

A. Health Workers

Health workers have a duty to provide care during a communicable diseaseoutbreak. CCHS is committed to promoting worker safety at all times, and tosupporting workers in the discharge of their duties throughout a period ofextraordinary demands;

CCHS will endeavor to make public the criteria used to deploy employees toassignments during the outbreak, and to ensure that duty assignments arereasonably equitable with respect to the distribution of risk among individuals andoccupational categories.

B. Restricting the Liberty of the Public

Until a new flu vaccine is developed or other medications are found to controlpandemic flu, restrictive measures may be one of the important public health tools toreduce spread of this communicable disease. Governments may need to limit threebasic personal freedoms that we take from granted: mobility, freedom of assembly

1 Developed by the Pandemic Influenza Working Group at the University of Toronto

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and privacy. There may be a need to close schools, cancel public gatherings andsporting events, and impose quarantine, isolation and even detention.

In making decisions that restrict the liberty of the public, CCHS will:

1. Balance personal autonomy and individual liberties with protection of the publicand promotion of the common good

2. Make every effort to ensure that no part of the community is more impacted thananother sector unless there is a reasonable health-related reason for targeting aparticular sector.

3. Use the least restrictive means necessary4. Allow for safeguards such as the right of appeal.5. Explain the reasons for restrictive measures;6. Describe the benefits of compliance7. Outline the consequences of non-compliance.8. Minimize stigmatization9. To the extent consistent with public safety, protect the privacy of individuals

and/or communities affected by quarantine or other restrictive measures.10.Work with its partners such as Employment and Human Services and the Office

of Emergency Services to arrange for support services to individualsand/communities impacted by quarantine and other restrictions.

C. Allocating Scarce Resources

During a pandemic, the human and material resources of health care will be rapidlyoverwhelmed. There will be scarcities of medicines, equipment and health careworkers in all countries, with less-developed nations facing some of the greatestscarcities. There will be cases of people who will possibly have to forego medicalcare for other serious medical conditions. Hospitals will be strained beyond theircapacity to accommodate seriously ill patients and alternate methods of care willhave to be provided.

Priority setting to allocate scare resources such as vaccines and antiviralsmedicines, providers’ time, ventilators and hospital beds, will be necessary.

It is important to recognize that in a pandemic flu situation, resource limitation maymean that some people who need and deserve resources will not get them and thatthere will be no distribution plans that can avoid harm to all. The task is to decidewho amongst those with a legitimate need shall receive the resources.

If resources are scarce and priorities have to be established, CCHS will:

1. Make every effort to insure that the allocation process is fair and promoteshuman dignity.

2. Publicize a clear rationale for giving priority access to health care services,including antivirals and vaccines, to particular groups, such as front line healthworkers and those in emergency services. CCHS will use the strategiesdescribed in the Crisis and Emergency Risk Communications plan to initiate andfacilitate constructive public discussion about these choices.

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3. As time and health considerations permit, engage its stakeholders (including theBoard of Supervisors, Office of Emergency Services, Hospital Disaster Council,unions, Medical Staff, Bioethics Committee, Senior Staff, the public and otherpartners) in determining what criteria should be used to make resource allocationdecisions (e.g., access to ventilators during the crisis, and access to healthservices for other illnesses).

4. Provide formal mechanisms for stakeholders to bring forward new information, toappeal or raise concerns about particular allocation decisions, and to resolvedisputes. To accomplish this, it will use its website, Health EmergencyInformation Line, County Call Center and other feedback mechanisms.

D. Complying with Global Advisories

One way that governments and the World Health Organization seek to control thespread of communicable diseases is through restrictions on travel. Especially duringthe early stages of what looks like a pandemic, travel advisories can help to slow thespread of the virus. These restrictions can impose severe penalties not only onindividuals, but also on entire regions.

CCHS will comply with travel advisories and other global directives and will use thestrategies described in its Crisis and Risk Communications Plan to disseminatetravel advisories to the public in a timely manner.

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List of Attachments

Laboratory SectionCriteria for testingAlgorithm for submittal of specimens for Suspect avian influenza cases ContraCosta CountyInfluenza Testing Algorithm At Contra Costa Public Health LaboratoryLaboratory Biosafety Guidelines for Handling and Processing Specimens orIsolates of Novel Influenza StrainsLaboratory Personnel Available for Response to Pandemic InfluenzaList of Supplies Needed for 100% Increase in Laboratory Processing

Public InformationAvian Flu Fact Sheet (English)Avian Flu Fact Sheet (Spanish)Contra Costa Health Services Communications MethodsCover Your Cough FlyerHandwashing Flyer (English)Handwashing Flyer (Spanish)Seasonal vs Pandemic Flu Fact SheetStop Disease FlyerPandemic Influenza Fact SheetPandemic Flu Preparedness Supplies for Families and IndividualsTips for First Responders

ChecklistsBusiness ChecklistChild Care and Preschool ChecklistColleges and Universities ChecklistDisaster Supplies ChecklistEMS ChecklistFaith-based and CBO ChecklistFamily Pandemic Plan (Spanish)Home Health Care ChecklistIndividuals and Families ChecklistLong-term Care ChecklistMedia ChecklistMedical Offices and Clinics ChecklistPreparedness ChecklistSchool ChecklistTravel Checklist

Home CareARC Home Care for Pandemic Flu (English)ARC Home Care for Pandemic Flu (Spanish)

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AdministrativeCCC EOC SEMS Organization StructureLegal Authority LawsVulnerable Populations Agency Contact ListGo Kit Table of ContentsPandemic Influenza Business Contacts

Healthcare SurgeCCHS Alternate Care Site ProcessFoundational Knowledge for Healthcare SurgePandemic Influenza Estimates

Pan Flu Response Phases and Triggers for ActionWHO/CDC and Contra Costa Pandemic Response Phases and Triggers forAction