nsw pandemic action plan - abc
TRANSCRIPT
NSW Health Interim InfluenzaPandemic Action Plan
November 2005
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PREFACE Pandemics are epidemics of disease that occur on a worldwide scale. Although it is now common to speak of pandemics of non-infectious conditions such as obesity or diabetes, pandemics are traditionally caused by infectious diseases such as influenza. Although unpredictable in their timing, history tells us that influenza pandemics can be expected to occur every 10 to 50 years and it is almost certain that they will continue to occur. It is this level of certainty, and the fact that almost all humans will be vulnerable, that makes it paramount that planning is carried out at all levels of government. Pandemics have also been highly variable in their impact but to properly prepare, it is prudent that planning efforts be aimed towards a pandemic on the more severe end of the spectrum.
Plans that deal with the threat of pandemic influenza exist at all levels of governance – international, national, state/territory, and locally – as well as within private sector and other non-governmental organisations and it is important that these plans are aligned. The World Health Organization (WHO) has taken the lead role internationally and has urged governments around the world to formulate pandemic plans. In response, the Australian Government released the Australian Management plan for Pandemic Influenza (AMPPI) in June, 2005. The NSW Health Interim Influenza Pandemic Action Plan is the pandemic plan for the state of NSW. Plans also exist at the Area Health Service (AHS) level in NSW but these may be plans for generic emergencies rather than being specific for pandemic influenza.
There will be some aspects of this plan that will challenge conventional paradigms, such as the current Australian Government proposal for reserving the majority of the antiviral medication stockpile for prevention rather than for treatment of cases, closure of schools and universities to prevent spread of infection, and the concept of quarantining people who have been exposed to the pandemic virus but are yet to exhibit symptoms. A balance needs to be struck between the rights of individuals and the protection of the public health. Widespread stakeholder consultation will be required following the release of this plan to ensure this balance has been achieved.
As it is not possible to predict the behaviour of a pandemic in advance, a feature of a good influenza pandemic plan is that it must allow for considerable flexibility. To this end, in each of the key pandemic planning areas in the state plan, various strategies will be devised in advance to cover all likely scenarios. From the outset of a pandemic, the behaviour of the pandemic influenza virus will be closely monitored and the best response strategy will be adopted.
Producing a plan is only one part of overall preparedness for pandemic influenza – it must then be communicated to stakeholders, tested, and revised as required. A strategy is already underway to communicate key elements of the plan to all stakeholders – all parts of the health sector, other government agencies, industry, and the public – and this will continue after release of the plan. Experience gained during this process will inform the next iteration of the plan.
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AUTHORISATION
The NSW Health Interim Influenza Pandemic Action Plan serves as a supporting document to the New South Wales Health Public Health Services Sub Plan. It details the specific public health emergency arrangements to deal with potential or actual outbreaks of infectious disease that pose a risk to the community of significant morbidity and/or mortality.
This Plan is authorised in accordance with the provision of the Public Health Act 1991 and Regulations.
RECOMMENDED _____________________________________ Dr Kerry Chant
Chairperson, Infectious Disease Emergency Advisory Group
Dated: 11th November 2005
ENDORSED _____________________________________ Dr Denise Robinson
NSW Chief Health Officer
Dated: 11th November 2005
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TABLE OF CONTENTS
PREFACE ...............................................................................................................................1
TABLE OF CONTENTS .......................................................................................................3
HOW TO USE THIS DOCUMENT .....................................................................................5
1 AIM AND OBJECTIVES .............................................................................................6
2 TABLE OF ACRONYMS.............................................................................................7
3 INTRODUCTION .........................................................................................................9
3.1 Authority .................................................................................................................9 3.2 Structure..................................................................................................................9 3.3 Background ...........................................................................................................15 3.4 Concept of pandemic phases.................................................................................18 3.5 Concept of operations in the NSW pandemic plan................................................21
4 KEY ELEMENTS OF PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE...........................................................................................................................23
4.1 Control, command and coordination ....................................................................23 4.2 Communications....................................................................................................24 4.3 Surveillance and monitoring.................................................................................25 4.4 Infection control....................................................................................................27 4.5 Laboratory ............................................................................................................28 4.6 Vaccination ...........................................................................................................29 4.7 National and state medical stockpiles (NMS and SMS)........................................30 4.8 Case definition and management ..........................................................................31 4.9 Community management.......................................................................................31 4.10 Health care infrastructure.....................................................................................32 4.11 Workforce issues ...................................................................................................34 4.12 Role of general practitioners (GPs)......................................................................36 4.13 Measures to increase social distance....................................................................37 4.14 Patient transportation ...........................................................................................37 4.15 Mental health ........................................................................................................38 4.16 Storage and disposal of bodies .............................................................................38 4.17 Border control and quarantine .............................................................................39
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4.18 Testing of the plan.................................................................................................40 4.19 Travel advisories...................................................................................................40
5 RESPONSE ACTIONS FOR NSW............................................................................41
6 ANNEXES ....................................................................................................................82
ANNEX A: Definitions.......................................................................................................82 ANNEX B: Diagram showing the position of the NSW Health Influenza Pandemic Action Plan within the hierarchy of NSW emergency management plans ....................................86 ANNEX C: Command and control arrangements during an influenza pandemic .............87 ANNEX D: Description of the Australian (Aus) and Overseas pandemic phases .............90 ANNEX E: Incident Control System: Background.............................................................94
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HOW TO USE THIS DOCUMENT This plan provides a framework to aid the NSW health sector in responding to an influenza pandemic. Non-health sector government agencies and the private sector should develop their own pandemic response plans, and should endeavour to ensure these are consistent with the NSW pandemic plan.
The plan deals with the state response to pandemic influenza and it should be read in conjunction with Australian Management Plan for Pandemic Influenza (AMPPI), which delineates the roles of national agencies and those of the states and territories. It is designed to be used not only during times of a pandemic, but also between pandemics, as preparation during this time is essential.
The two key chapters in this plan are Chapter 4 - Key Elements of Pandemic Influenza Preparedness and Response, and Chapter 5 – Response Actions for NSW. The former describes the important areas that need to be addressed in a pandemic plan, and the activities in NSW that are planned, or in train, to address these. Chapter 5 shows in tabular format the important aspects in responding to the threat of a pandemic according to the World Health Organization influenza pandemic phases, and assigns roles and responsibilities to specific groups.
In order to prevent duplication of effort and to ensure a standardised approach to a pandemic by the NSW health sector, a number of supporting documents to this plan will be produced that are designed to be used by all Area Health Services – either “off-the-shelf” or else able to be easily adapted to reflect local circumstances. Along with the state pandemic plan, these documents will be available on the NSW Health website.
The plan should be seen as an evolving document, which will undergo iterative refinement, with regular updates in light of new evidence or experience. It will be completely revised should advances in our understanding of the threat of pandemic influenza, and how to respond to it, require such changes.
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1 AIM AND OBJECTIVES
Aim
The aim of this plan is to minimise mortality and morbidity, social disruption, and economic consequences associated with an influenza pandemic in NSW by articulating the NSW Public Health management arrangements for a threatened or actual influenza pandemic.
Objectives • to minimise the rate of spread of the pandemic in order to ease the impact on
the health system and “buy” time until an effective vaccine becomes available
• to describe actions required to mitigate the effect of an influenza pandemic in NSW at various stages of a pandemic
• to provide policy direction for preparation of AHS influenza pandemic emergency plans
• to ensure that clinical care capacity, which will necessarily be stressed during a pandemic, is used in the most efficient manner possible
• to effectively monitor and report on the epidemiology of the pandemic
• to ensure timely, authoritative and accurate information is disseminated to the public and media prior to, and during, a pandemic
• to ensure continuation of other core health business
• to ensure effective intersectoral collaboration by clearly defining roles and responsibilities and lines of communications between various key agencies in the planning and implementation of this plan.
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2 TABLE OF ACRONYMS AHDMPC Australian Health Disaster Management Policy Committee AHMAC Australian Health Minister’s Advisory Committee AHS Area Health Service AIDB AIDS/Infectious Diseases Branch (NSW Health) AMPII Australian management plan for pandemic influenza (2005) AQIS Australian Quarantine Inspection Service ASNSW Ambulance Service of NSW CDB Communicable Disease Branch (NSW Health) CDNA Communicable Disease Network Australia CDU Counter Disaster Unit (NSW Health) CE Chief Executive (of NSW Area Health Services) CER Centre for Epidemiology and Research (NSW Health) CHO NSW Chief Health Officer CHP The Centre for Health Protection (NSW Health) CQO Chief Quarantine Officer CMO Australian Government Chief Medical Officer DFAT Department of Foreign Affairs and Trade DOCS Department of Community Services DoHA Australian Government Department of Health and Ageing DPI NSW Department of Primary Industries GP General practitioner HSDCC Health Services Disaster Control Centre HSFAC Health Service Functional Area Coordinator HT Health Technology ICP Infection Control Practitioner IDEA Group Infectious Disease Emergency Advisory Group IDETF (Australian Government) Interdepartmental Emergency Taskforce NEMRN National Emergency Media Response Network NIPAC National Influenza Pandemic Action Committee NIR National Incident Room NMS National medical stockpile OCRS (National) Outbreak Response Reporting System PHEOC Public Health Emergency Operations Centre PHLN Public Health Laboratory Network PHREDSS Public Health Real-time Emergency Department Surveillance System PHU Public health unit PPE Personal protective equipment SEALS South East Area Laboratory Service SEMC State Emergency Management Committee SEOC State Emergency Operating Centre
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SEOCON State Emergency Operating Centre Controller SIM Strategic Information Management Branch (NSW Health) SMS State medical stockpile WHO World Health Organization WHOCC WHO Collaborating Centre for Reference and Research on Influenza
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3 INTRODUCTION
3.1 Authority This plan is a Standing Operating Guideline of the NSW Health Public Health Services Supporting Plan to the NSW Health State Disaster Plan (NSW HEALTHPLAN) developed pursuant to the State Emergency and Rescue Management Act 1989 (as amended).
Although this plan has been devised in preparation for an influenza pandemic in NSW, much of it is applicable to the state response to other infectious diseases emergencies such as the deliberate release of biological agents, severe acute respiratory syndrome (SARS), and other remerging or newly emerging infectious disease threats.
3.2 Structure
NSW HEALTH ARRANGEMENTS
This plan needs to be read in conjunction with NSW HEALTHPLAN which sets out in general terms NSW Health’s roles and responsibilities for managing the health response in disasters. ANNEX B shows the relationships between the state influenza pandemic plan and other NSW emergency plans.
During infectious disease emergencies, the State Public Health Controller, reporting to the Chief Health Officer, is responsible for the implementation of population health measures as defined in the NSW Public Health Services Supporting Plan, which describes the roles and responsibilities of Public Health within the NSW HEALTHPLAN framework. In very large-scale emergencies (such as a severe influenza pandemic) that lead to the activation of NSW HEALTHPLAN, the State Health Services Functional Area Coordinator (State HSFAC) assumes control to ensure an integrated whole-of-health response. In these circumstances, the Public Health Controller continues to lead population health operations, and the four other controllers (medical services, ambulance, mental health and communications) lead their operations. The functions of the Public Health Controller upon activation of NSW HEALTHPLAN are defined in NSW HEALTHPLAN. NSW Health is the state’s “lead agency” in large-scale infectious disease emergencies.
ANNEX C shows the NSW (upon activation of NSW HEALTHPLAN) and national command and control arrangements that would operate during an influenza pandemic.
Disease notification and response The NSW Public Health Act 1991 and regulations pursuant to it specify those infectious diseases that are required to be notified by medical practitioners, hospitals, laboratories, childcare directors and school principals. Influenza is a laboratory-notifiable disease and plans are underway to make avian influenza in humans is also notifiable by doctors and hospitals.
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In accord with guidance provided in the NSW Health Notifiable Diseases Manual, public health units (PHU) are responsible for receiving and responding to notifications, including those for influenza.
Notifications are forwarded by public health units to the Communicable Diseases Branch (CDB) of NSW Health for collation and analysis.
Investigation of public health risks The responsibility for investigating public health risks is vested in PHU directors (by delegation) and in AHS Medical Officers of Health (by statute) to investigate and respond to potential or actual public health risks, including those caused by an infectious disease, and to report such actions to the Director-General, NSW Health.
Centre for Health Protection (CHP) The CHP within the NSW Health’s Population Health Division is responsible for policy direction, funding and support in relation to public health aspects of emergency management in NSW.
The Director is, ex officio, the State Public Health Controller and, in conjunction with the State HSFAC, will have lead responsibility for the public health aspects of the response to an infectious disease emergency such as an influenza pandemic. The Public Health Emergency Operations Centre (PHEOC) at North Sydney will be made operational during such an emergency and the public health response coordinated from here.
Within the Centre for Health Protection, the Communicable Diseases Branch (CDB) has a lead role in the development of this plan and providing public health advice during an emergency. The AIDS/Infectious Diseases Branch (AIDB), Environmental Health Branch and Pharmaceutical Services Branch have supporting roles in relation to this plan.
The Counter Disaster Unit (CDU) The CDU is managed jointly by NSW Health and the Ambulance Service of NSW (ASNSW) and addresses all health aspects of emergency management in NSW, including response to terrorism. The director is, ex officio, the State HSFAC, and will exercise overall control during the response phase of a pandemic upon activation of NSW HEALTHPLAN. The Health Services Disaster Control Centre (HSDCC) will be made operational and the overall health response coordinated from there. The State Public Health Controller provides public health liaison officers to the HSDCC to ensure integration with the PHEOC.
As well as having a key role in response to an influenza pandemic, the CDU will also have a major role in pandemic planning, preparedness, response, and recovery, especially in relation to clinical capacity, logistics functions, and delineation of the control and coordination arrangements.
NSW Department of Primary Industries (DPI) NSW DPI is the lead agency during responses to avian influenza outbreaks in domestic poultry flocks during Aus 1-2 phase of the Interpandemic period and the Aus 3 phase of the Pandemic Alert period. During these phases, and when required, NSW Health and the NSW Food Authority will provide close support to NSW DPI regarding issues related to human health, especially if the strain of avian influenza is known to cause human disease.
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NSW Infectious Diseases Emergency Advisory (IDEA) Group The IDEA Group is a state committee formed in 2004 to oversee biopreparedness activities in NSW. It is chaired by the Director, Centre for Health Protection, and reports to the Chief Health Officer. The committee comprises experts in the fields of public health, clinical medicine, infection control, microbiology, and counter disaster.
Centre for Epidemiology and Research (CER) With respect to this plan, the CER of NSW Health is responsible for the operation of surveillance systems important for pandemic preparedness, including the Public Health Real-time Emergency Department Surveillance System (PHREDSS) and the NSW Health Survey (and its associated computer-assisted telephone interview facility). CER will assist with the design, implementation and operation of additional surveillance, data management and analysis facilities required by this plan. CER also administers the NSW public health officer and biostatistics training programmes, which are expected to provide significant “surge” capacity for personnel trained in public health methods in both the preparatory and pandemic phases.
Strategic Information Management Branch (SIM) and Health Technology (HT) SIM plans and funds the development of information systems within NSW Health. SIM will assist and advise CHP and CER in the design and commissioning of new and upgraded information systems required by this plan. HT implements and operates shared information technology services for NSW Health. In conjunction with Area Health Services, HT bears responsibility for the maintenance of routine information systems before and during a pandemic, as well as assisting with the deployment of new systems required by this plan.
Area Health Services (AHS) AHSs bear responsibility for prevention, preparedness, response and recovery at a local level. These responsibilities includes those in both clinical and public health domains, and involves the participation of supporting services including, but not limited to, finance, supply, information technology and human resources.
Ongoing coordination of these activities is generally undertaken by the AHS HSFAC and the AHS Healthplan committee, with co-option of representatives of supporting services as required.
In addition, pathology laboratories within AHSs, which provide clinical diagnostic services for influenza and other respiratory pathogens, are required to support the public health and clinical activities specified in this plan.
Public health units undertake the public health aspects of emergency management at local level.
When NSW HEALTHPLAN is activated, control of all public health resources at the AHS level, including where necessary local government officers, is vested in the AHS Public Health Controller.
The AHS Public Health Controller works closely with the AHS HSFAC who controls deployment of medical, ambulance, mental health and other non-public health resources (i.e., various support services) as necessary during an infectious diseases emergency.
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Legislation The following acts and their respective regulations are most relevant to this plan:
• State Emergency Rescue and Management Act 1989 (as amended) • Public Health Act 1991 • Health Administration Act 1982 • Health Records Privacy and Information Act 2002 • Health Services Act 1997 • Local Government Act 1993 • Poisons and Therapeutic Goods Act 1966
NSW Health policy documents This plan is to be implemented in conjunction with the following NSW policy directives:
• PD_2005-247, NSW Infection Control Policy • PD_2005-338, Occupation Screening and Vaccination against Infectious
Diseases • PD_2005-359, Notification of Infectious Disease under the Public Health Act
1991 • PD_2005-374, Standing Orders for Administration of Medication in a Public
Health Emergency
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NATIONAL ARRANGEMENTS
ANNEX C shows the national and NSW command and control arrangements that would operate during an emergency caused by an influenza pandemic.
Pandemic Influenza Interdepartmental Emergency Taskforce (IDETF) During a pandemic, the Australian Government response and assessment will be coordinated by a Pandemic Influenza IDETF. It will be composed of a number of Australian Government agencies, one of which will be delegated as the lead agency.
Australian Health Disaster Management Policy Committee (AHDMPC) The AHDMPC is a national committee chaired by the Deputy Secretary of the Department of Health and Ageing which has representation of the states and territories (via their Chief Health Officers (CHOs)), the defence forces, and Emergency Management Australia. For pandemic-related matters, it is advised by the Australian Chief Medical Officer (CMO).
The AHDMPC has a key role during the pandemic preparedness phase in developing nationally-consistent health policy. During the response phases, the AHDMPC will advise the IDETF and also form the conduit for communicating national policy advice to the jurisdictions.
The Australian Chief Medical Officer (CMO) The CMO will be advised by an expert clinical group drawn from the National Influenza Pandemic Action Committee (NIPAC) and the Communicable Diseases Network of Australia (CDNA). With this advice, the CMO will be responsible for determining each phase of the pandemic, unless already determined by the WHO. For decisions relating to application of quarantine powers under the Quarantine Act 1908, the CMO, as director of human quarantine and delegate of the Minister of Health and Ageing, may make the final decision following consultation with relevant agencies.
Australian Government Department of Health and Ageing (DoHA) At the beginning of a pandemic the DoHA national incident room (NIR) and DoHA surge team will be activated. Prior to activation of the IDETF, the DoHA, along with the CMO’s expert clinical advisory group and the AHDMPC, will coordinate the Australian Government response and assessment through the pandemic influenza Inter-departmental Committee (IDC). Although another government agency may play the lead role in the IDETF, the DoHA will assist in overseeing the national response, collect and analyse national surveillance data, and will coordinate the supply and distribution of agents such an antivirals from the national medical stockpile and a pandemic vaccine, when available. It will be responsible for the communication of national aspects of the pandemic to the public and to the World Health Organization (WHO). DoHA has representation on NIPAC, CDNA, and AHDMPC.
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National Influenza Pandemic Action Committee (NIPAC) NIPAC is the key national body charged with providing scientific and clinical advice on pandemic influenza preparedness and response. It reports to the CMO.
Communicable Diseases Network of Australia (CDNA) CDNA is the peak national body for the co-ordination of communicable disease surveillance, prevention and control. It reports to Australian Health Ministers' Advisory Committee (AHMAC) through the National Public Health Partnership.
During an influenza pandemic, CDNA will oversee surveillance and monitoring and will provide advice on the operational response to the CMO and to the DoHA.
Public Health Laboratory Network (PHLN) The PHLN is a collaborative group of laboratory representatives which aims to enhance the national capacity for the laboratory-based detection and surveillance of agents and vectors of communicable diseases. It reports to Australian Health Ministers' Advisory Committee (AHMC) through National Public Health Partnership via CDNA.
During an influenza pandemic, the key roles of the PHLN will be to ensure laboratory diagnostic capability is met and to provide laboratory-related advice concerning surveillance and response activities.
Australia Quarantine Inspection Service (AQIS) AQIS, a unit of the Australian Governement Department of Agriculture, Forestry and Fisheries (DAFF), is responsible for administration of the Quarantine Act 1908 in collaboration with authorised human quarantine officers within each state/territory health department.
Jurisdictional health authorities The state and territory health authorities are responsible for disease control activities in their jurisdictions. Each jurisdiction has representation on AHMAC via their Chief Executive Officers of Health, Australian Health Minister’s Committee (AHMAC) via their health ministers, AHDMPC via their CHOs, and on CDNA via their communicable disease control unit managers.
The jurisdictions act as the “effector arm” of Australian Government human quarantine laws. Under the Quarantine Act 1908, the CMO provides directions to Chief Quarantine Officers (CQOs) in each jurisdiction relating to quarantine matters.
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3.3 Background Influenza is a highly contagious viral disease of the respiratory tract. It continues to be a major threat to public health worldwide because of its ability to spread rapidly through populations and its marked tendency for mutation, leading to emergence of new strains.
The disease is characterised by rapid onset of symptoms including fever, chills, sore throat, stuffy or runny nose, headache, dry cough, fatigue and aching. Influenza is easily spread through airborne droplets from an infected person, direct contact (e.g., shaking hands), or indirect contact with objects contaminated with secretions.
Influenza viruses are classified into types, subtypes and strains. There are two important types of influenza virus – A and B. A variety of subtypes have been identified, characterised by distinct differences in the surface proteins (antigens) of the virus. All of these subtypes are present in bird populations, while only a few are found in humans and some are found in other mammals such as pigs.
Small mutations regularly occur and create variation in these surface proteins, giving rise to new strains through “antigenic drift”. Greater variation is generally associated with greater epidemic potential. Epidemics of influenza A and/or B occur annually in NSW during winter and early spring, and are associated with significant morbidity and mortality from complications such as viral or bacterial pneumonia, particularly in people over 65 years of age and those with certain pre-existing medical conditions.
At unpredictable intervals, totally new influenza A virus subtypes appear in the human population (“antigenic shift”) resulting in severe influenza epidemics occurring throughout the world. Such a phenomenon is termed an influenza pandemic. The high attack rate and severity of illness that is seen in this situation is due to lack of existing immunity in the human population. Possible mechanisms for the emergence of new subtypes in humans are direct transmission from birds or animals, or genetic mixing between bird and human viruses in humans or in an intermediate species such as pigs.
For a pandemic to occur, three criteria need to be fulfilled: (i) a novel influenza virus appears to which the world’s population has little or no immunity, (ii) the new virus must be virulent enough to cause disease, and, (iii) the new virus must have the capacity to spread efficiently from person to person. In December 2003, the H5N1 highly pathogenic avian influenza virus strain re-emerged in poultry in South Korea and has since spread to flocks of domestic and wild birds in countries of south and southeast Asia, central Asia, and Europe. It has caused severe disease in a relatively small number of number of humans. This strain therefore fulfils the first two criteria for a pandemic and most scientists agree that the risk of the H5N1virus changing into a form that is readily transmitted between humans, and thus fulfilling the third criterion, is at its highest level for several decades.
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INFLUENZA PANDEMICS OF THE 20TH CENTURY
Three pandemics occurred during the 20th century: in 1918-1919, 1957-1958 and 1968. Of these, the 1918-1919 pandemic (‘Spanish influenza’) was the most devastating. At its peak it incapacitated cities and paralysed health care systems in many countries, and caused between 20 and 40 million deaths worldwide.
In NSW, 37% of the population was estimated to have been infected, with a case fatality rate of 1.3%1. Mortality in the 1918-1919 pandemic was consistently greatest among 20 to 40 year-olds, for reasons poorly understood. The 1957 ‘Asian influenza’ pandemic, in which infection rates varied between 20% and 70%, and the 1968 ‘Hong Kong influenza’ pandemic, with infection rates between 25% and 30%, were associated with much lower case fatality rates of 0.01% to 0.05%, predominantly in those over 65 years of age.
The occurrence of the next pandemic of influenza is unpredictable and it could appear at any time of the year. A pandemic is likely to have a major impact upon the community due to the large proportion who become ill simultaneously, and the large absolute number of the infected who develop complications resulting in hospitalisation and/or death. Since the mid-1990s, outbreaks of avian influenza in birds and associated human cases, has also led to increased concern around the world about the likelihood of pandemic influenza. As a result, the WHO has urged all countries to develop detailed pandemic plans2.
MODELLING THE IMPACT OF PANDEMIC INFLUENZA IN NSW
All pandemics behave differently and predicting the impact of the next influenza pandemic with any degree of precision is impossible. However, it is possible to derive a range of estimates of the potential impact of an influenza pandemic by using epidemiological data collected during previous pandemics to provide estimates for important parameters. These estimates can only ever be considered as approximations but they do provide a valuable tool in guiding the formulation of response plans.
Estimates of excess deaths, hospitalisations and outpatient visits likely to occur in NSW in a pandemic have been calculated using the Meltzer Model Mapper3. This model, originally developed using lower and upper estimates of age-specific attack rates from previous pandemics in the United States4, is applied to NSW population data from the Australian Bureau of Statistics (ABS) 1996 census. For overall symptomatic attack rates between 10 and 50%, the excess number of persons dying, requiring hospitalisation or outpatient visits secondary to influenza or its complications, is estimated to fall between the figures shown below in Table 1.
These estimated numbers could arise over a six to eight week period and the likely
1Report on the influenza epidemic in NSW in 1919. RT Paton, NSW Director General of Public Health 2 WHO Global Influenza preparedness plan http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_5/en/ 3National Key Centre for Social Applications of Geographical Information Systems. Influenza Pandemic Model (Meltzer Model). http:/www.gisca.Adelaide.edu.au/gisca/SIShealth_influenza.html but no longer available – similar modelling software, termed FluAID 2.0, can be found at http://www2.cdc.gov/od/fluaid/download_started.htm) 4Meltzer MI, Cox NJ, Fukuda K. 1999b. Modeling the economic impact of pandemic influenza in the United States: Implications for setting priorities for intervention. Background paper: available at: http://www.cdc.gov/ncidod/eid/vol5no5/melt_back.htm (accessed October 2005)
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attack rate (those who become infected with influenza and display symptoms) is between 20 and 30%.
These calculations reveal that an attack rate of 25% could result in more than 10 000 deaths in a two-month period, in addition to the background number of deaths. As there are around 45 000 deaths per year from all causes in NSW, a 25% attack rate could therefore result in more than double the usual number of deaths over a two-month period.
Attack rate
Outpatient visits Hospitalisations Deaths
Lower estimate
Upper estimate
Lower estimate
Upper estimate
Lower estimate
Upper estimate
10% 251 300 297 900 2 500 10 000 900 4 200
20% 502 700 595 800 5 100 20 000 1 800 8 300
30% 754 000 893 600 7 600 30 000 2 800 12 500
40% 1 005 300 1 191 500 10 200 40 000 3 700 16 600
50% 1 256 600 1 489 400 12 700 50 000 4 600 20 800
Table 1. Estimates of deaths, hospitalisations, and outpatient visits in NSW due to a hypothetical influenza pandemic with different attack rates, based on ABS 1996 population data for NSW.
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3.4 Concept of pandemic phases In 2005, the WHO released the WHO global influenza preparedness plan5, the first revision of its 1999 influenza pandemic plan. In the 1999 plan, the response to a pandemic was based around the concept of three “periods” of a pandemic – the interpandemic, pandemic and postpandemic periods. Each period was subdivided into one or more “phases”. The 2005 plan continues with the concept of pandemic periods and phases although these have been modified; the original “Pandemic period” has been divided into two separate periods – “Pandemic Alert period” and “Pandemic period” – and the global pandemic phases have been redefined in order to:
• address the public health risks of influenza infection in animals, such as the H5N1 influenza virus subtype in poultry flocks in Asia which has persisted from 2003 onwards
• link phase changes more directly with changes in public health response • focus on early events during a “Pandemic Alert” period when rapid,
coordinated global and national actions might help to possibly contain or delay the spread of a new human influenza strain.
• allow for national authorities to subdivide certain phases at the national level to reflect the national situation.
This model has been adopted at the national level, with “Overseas” and “Australian” (Aus) phases now defined in the revised national plan - The Australian Management Plan for Pandemic Influenza6 (AMPII) (see Table 2). A more thorough description of the WHO pandemic phases is shown in ANNEX D.
The various pandemic phases have a bearing on allocation of lead agency responsibilities with respect to NSW emergency management arrangements (Table 3). For outbreaks of avian influenza in birds, including when there are cases of transmission of infection from birds to humans, the Department of Primary Industries (DPI) will be the lead agency with NSW Health playing a supporting role (i.e., prior to Pandemic Alert period, Aus 4 phase). Once Pandemic Alert period, Aus 4 phase is reached in NSW (i.e., where there is limited human-to-human transmission), consideration will be made for activation of NSW HEALTHPLAN, in which case NSW Health will become the lead agency. In an overwhelming emergency where a whole-of-government response is required, the NSW Government can activate NSW Displan, in which case the State Emergency Services becomes the lead agency.
5WHO global influenza preparedness plan, 2005. http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_5/en/ (accessed October 2005) 6 The Australian Management Plan for Pandemic Influenza, June 2005 http://www.health.gov.au/internet/wcms/publishing.nsf/Content/FC517607D6EE443ECA2570190019CDF7/$File/pandemic_plan.pdf (accessed October 2005)
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Table 2. World Health Organization phases of an influenza pandemic (from the Australian Management Plan for Pandemic Influenza6).
Period Global Phase
Australian Phase
Description of Phase Main strategy
Aus 0 No circulating animal influenza subtypes in Australia that have caused human disease.
Overseas 1 Animal infection overseas: the risk of human infection or disease is considered low. 1
Aus 1 Animal infection in Australia: the risk of human infection or disease is considered low.
Overseas 2 Animal infection overseas: substantial risk of human disease.
Inter-pandemic
2 Aus 2 Animal infection in Australia: substantial risk of
human disease.
Overseas 3 Human infection overseas with new subtype(s) but no human-to-human spread or at most rare instances of spread to a close contact. 3
Aus 3 Human infection in Australia with new subtype(s) but no human-to-human spread or at most rare instances of spread to a close contact
Overseas 4
Human infection overseas: small cluster(s), limited human-to-human transmission, spread highly localised, suggesting the virus is not well adapted to humans. 4
Aus 4
Human infection in Australia: small cluster(s), limited human-to-human transmission, spread highly localised, suggesting the virus is not well adapted to humans.
Overseas 5
Human infection overseas: larger cluster(s) but human-to-human transmission still localised, suggesting the virus is becoming increasingly better adapted to humans, but may not yet be fully adapted (substantial pandemic risk).
Pandemic Alert
5
Aus 5
Human infection in Australia: larger cluster(s) but human-to-human transmission still localised, suggesting the virus is becoming increasingly better adapted to humans, but may not yet be fully adapted (substantial pandemic risk).
Overseas 6 Pandemic overseas- not in Australia: increased and sustained transmission in general population.
Aus 6a Pandemic in Australia: localised (one area of country)
Aus 6b Pandemic in Australia: widespread Aus 6c Pandemic in Australia: subsided
Pandemic 6
Aus 6d Pandemic in Australia: next wave
Containment
Maintenance of essential services
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Table 3. Schema showing NSW lead agency responsibility within the framework of the World Health Organization (WHO) pandemic phases.
WHO Pandemic Period WHO Pandemic Phase
Lead agency under NSW emergency
management arrangements*
Interpandemic Aus 1 - 2
NSW Department of Primary Industries
Aus 3 NSW Department of Primary Industries
Pandemic Alert
Aus 4 -6 NSW Health
Pandemic Aus 6 NSW Health
* Consideration for activation of NSW HEALTHPLAN would be at Aus 4 phase. In a very large incident where a whole-of-government response is required, the NSW Government can activate NSW Displan, in which case the State Emergency Services becomes the lead agency.
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3.5 Concept of operations in the NSW pandemic plan
The accepted paradigm for emergency management in NSW is one of prevention, preparedness, response and recovery (PPRR) and this plan will adopt the same framework. Although the terminology is different, the concept of operations in the pandemic phased approach of the WHO is the same.
PREVENTION
Definition
• The identification and assessment of hazards and the taking of actions to avoid the hazard.
Equivalent WHO pandemic period
• Interpandemic period.
Objectives
• To mitigate the risk of a pandemic strain developing.
Strategies
It is unlikely that a pandemic strain will develop in Australia due to the low population density and relatively low level of interaction between humans and animals. However, we can help reduce the risk of a pandemic strain developing by encouraging and supporting national and international efforts to:
• improve surveillance of novel animal and human influenza strains • effectively control known outbreaks of avian influenza in animals and humans • gain high vaccination coverage for the known circulating human strains of
influenza to lessen the chance of reassortment occurring due to dual infection with human and animal strains
• undertake research aimed at gaining insight into how novel influenza strains develop.
PREPAREDNESS
Definition
• The arrangements or plans to deal with an emergency or the effects of an emergency.
Equivalent WHO pandemic period
• Interpandemic and Pandemic Alert periods. Objectives
• To develop, implement and test pandemic influenza plans and associated infrastructure at the state and AHS levels.
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• To closely monitor international developments with respect to: o changing risk of novel strains developing o new evidence that could lead to enhancement of current plans.
• To ensure an open and transparent dialogue regarding pandemic preparedness with the public, healthcare professionals, and industry.
RESPONSE
Definition
• The process of combating an emergency and of providing immediate relief for persons affected by an emergency.
Equivalent WHO pandemic period
• Pandemic period.
Objectives
• In the early phases of the pandemic, to contain the spread of infection by timely identification of cases and contacts, isolation of cases, and quarantining of contacts.
• In later phases of a pandemic: o to reduce morbidity and mortality o to enable the fabric of society to be maintained by ensuring continuity
of essential services. Response strategy
During the pandemic response stage, the Incident Command System (ICS) will be utilised. The ICS is a component of the Australian Inter-service Incident Management System (AIIMS) and has been adopted by the majority of emergency services throughout Australia since the late 1980s.
Background information on ICS, including a table showing how the key components of a pandemic response might be grouped into each of the ‘functional areas’ of the system, is shown in ANNEX E.
RECOVERY
Definition • Returning a community to its normal level of functioning after an emergency.
Equivalent WHO pandemic period • Pandemic period.
Objectives • To resume normal functioning of the state health system. • To restock NSW health supplies of to pre-pandemic levels. • To analyse the risk of a subsequent waves of the pandemic and plan
accordingly. • To analyse epidemiological and other data and report on NSW’s response to
the pandemic. • To adequately debrief personnel involved in the pandemic response.
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4 KEY ELEMENTS OF PANDEMIC INFLUENZA PREPAREDNESS AND
RESPONSE This chapter outlines the important preparedness activities that need to be addressed in a state pandemic influenza plan. Initiatives already in place in NSW to complete these activities are described, gaps identified, and roles and responsibilities assigned.
4.1 Control, command and coordination
Background
An effective control structure with clear lines of command and coordination is vital to the success of any emergency response. This structure should be tested frequently through desktop and other exercises.
Strategies
• The national arrangements for control, command and coordination are described in AMPPI.
• The NSW arrangements for control, command and coordination are described in NSW HEALTHPLAN and NSW Health Public Health Services Supporting Plan.
• Exercise Eleusis, a national exercise to test Australia’s response to an incursion of avian influenza, is planned for late 2005. This will be an important test of the communication channels between the agricultural and health sectors at both the national and state/territory levels.
• A state-wide pandemic influenza exercise called Exercise Warning Shot was carried out in NSW in 2003.
• A national pandemic influenza exercise is planned for late 2006.
• Responses to real emergencies, and other emergency exercises such as those concerning counter terrorism, also provide valuable learning experiences for improving command and control structures.
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4.2 Communications
Background
Effective communication will be essential in assuring a coordinated and controlled response during an influenza pandemic. A key lesson from the SARS response was the importance of timely and accurate communication from a small number credible of spokespeople. The main audiences can be considered as the public, and, health care workers, key government agencies, and industry.
Some disease control mechanisms that may be employed during a pandemic will be novel for the public and may cause alarm. Examples include prioritisation of groups for antiviral agents and vaccination, closure of schools and universities, and mandatory quarantine. These issues must be clearly communicated to the public.
Strategies for communication with the public
• In the Interpandemic and Pandemic Alert periods, the health sector should articulate key elements of the plan to the public and enter into a dialogue with it. The chief responsibility for this lies with the Australian Chief Medical Officer and the DoHA, with advice from the National Emergency Media Response Network (NERMN). Nominated spokespeople from NSW Health will be identified in the Interpandemic and Pandemic Alert periods to articulate to the public how these measures would impact upon the state.
• The Media Unit of NSW Health has developed a communications strategy for use during infectious diseases emergencies that will be used during a pandemic.
Strategies for communication with key government agencies and industry
Following the release of this plan, much effort will need to be made in engaging the many stakeholders regarding their roles in pandemic preparedness and response.
• A communication strategy will be devised by NSW Health to raise awareness of the plan, and advise them of their roles within it, to:
o government agencies other than health to ensure whole-of-government involvement in preparedness
o industry groups.
• NSW Health will enter into a dialogue with AHSs to raise awareness of this plan and to ensure Area plans are standardised and align with the state plan.
• In June 2005, a two-year project coordinated by the Centre for Epidemiology and Research to improve communication channels and methods of communication with health care workers was commenced.
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4.3 Surveillance and monitoring
Background
Surveillance can be defined as the systematic collection and analysis of health data and the timely dissemination of information to those who need to know so that action can be taken. The objectives of routine influenza surveillance in the Interpandemic and Pandemic Alert periods are to:
• identify the current level and trends in influenza activity • obtain a crude indicator of weekly caseload • determine the nature of circulating strains, including novel subtypes.
Influenza surveillance in NSW is coordinated by CDB and is multi-faceted. Some components offer year-round data (laboratory surveillance, Public Health Real-time Emergency Department Surveillance System (PHREDSS), while others are restricted to the traditional influenza ‘season’ of June to October (GPSS). Influenza notification data is sent daily to the DoHA as a component of the National Notifiable Diseases Surveillance System (NNDSS).
The components of influenza surveillance in NSW are:
• GPSS. Clinical reports of influenza-like illness are provided by NSW general practitioners to a variable number of participating public health units. Seventeen GPs were involved in 2005, ten from metropolitan areas and seven from rural areas. Public health units provide figures on a weekly basis during winter to CDB.
• Laboratory data. All laboratory-confirmed diagnoses of influenza are notified to CDB on a weekly basis during winter by major public laboratories including ICPMR (Institute of Clinical Pathology & Medical Research), SEALS (South East Area Laboratory Service), SWAPS (South West Area Pathology Service), NCH (New Children's Hospital), and Hunter Area Pathology Service (HAPS). Laboratory-confirmed influenza is a notifiable disease in Australia and all laboratories in NSW are required to notify their local public health units, which record details in the Notifiable Diseases Database.
• PHREDSS. The Centre for Epidemiology and Research (CER) operate PHREDDS which records in real time separation data for a number of conditions, including influenza-like illness, from metropolitan emergency departments in NSW.
• Passive reporting by clinicians of unusual clusters of influenza-like illness. • WHO Collaborating Centre for Reference and Research on Influenza
(WHOCC). Major public laboratories in Australia send a proportion of influenza isolates to the WHOCC in Melbourne. The WHOCC provides regular updates to CDB on international and national influenza activity.
The objectives of influenza surveillance and methods of data collection will vary according to the phase of the pandemic (see Chapter 8: Response Actions for NSW). Additional monitoring and surveillance systems that may be employed during varying phases of Pandemic Alert (Overseas and Aus 3-5) and Pandemic (Overseas and Aus 6) periods include:
• data collection on possible and confirmed cases of pandemic influenza • surveillance of influenza-like illness in health care workers exposed to
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suspect, probable or confirmed pandemic influenza cases or their specimens • monitoring the effectiveness of, and adverse events associated with, antivirals
and vaccines • border exit screening for influenza-like illness in travellers from affected
regions • border entry screening for influenza-like illness in people travelling to
unaffected countries • hospital-based surveillance:
o influenza and pneumonia cases (i.e., presentations to emergency departments, ICU bed occupancy, deaths)
o staff absenteeism. • monitoring absenteeism amongst emergency services personnel.
Strategies
• CDB to continue to coordinate traditional methods of influenza surveillance in NSW.
• The Surveillance and Monitoring Subcommittee of the IDEA Group to devise methods for undertaking new influenza monitoring and surveillance systems required in Pandemic Alert (Overseas and Aus 3-5) and pandemic (Overseas and Aus 6) periods (listed above).
• CER to recruit additional emergency departments for participation in PHREDDS, especially in rural areas.
• CDB to develop strategies to enable the implementation of the seasonal components of influenza surveillance if Overseas or Aus phase 5 or 6 is declared out of season.
• CDB and CER, with assistance from Strategic Information Management Branch (SIM) and Health Technology (HT), to enable electronic notification of cases of infectious disease, including influenza, from laboratories as soon as possible.
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4.4 Infection control
Background
Preventing the spread of avian or pandemic influenza within healthcare facilities will rely on high-quality and effective infection control practices. Both Standard Precautions and Additional Precautions - airborne, droplet and contact - are recommended to minimise the risk of transmission of influenza. Although transmission of avian influenza (i.e., before it transforms into a pandemic strain) to humans is far less likely than for pandemic influenza, the same infection control precautions are recommended.
Front-line healthcare workers – particularly those working in emergency departments, intensive care units and respiratory units are likely to be at greater risk of exposure to influenza in a pandemic situation. However, all healthcare workers need to be provided with infection control information, access to appropriate personal protective equipment (PPE) and education regarding use of PPE, if there is potential for exposure to avian or pandemic influenza viruses.
A healthcare workforce with a thorough knowledge of, and capacity to adopt, recommended infection control practices is more likely to be assured of personal protection and hence more motivated to work in an environment where there is risk of transmission.
Members of the general community also require information regarding strategies to minimise their risk of exposure to influenza and the risk that they will transmit the virus to others if they are infectious.
Strategies
• The AIDB of NSW Health will coordinate the development of standardised infection control education packages and information resources for use across NSW.
• The AIDB will prepare a strategy for rapid and effective dissemination of information relating to infection control precautions for healthcare workers, primary providers, non-health sector workplaces, essential services personnel, airlines, schools, and prisons.
• NSW Health will develop and implement strategies to improve adherence to infection control policies and procedures by healthcare workers.
• The NSW Health Infection Control Policy will be available for all healthcare facilities by December 2005. The policy will include precautions for influenza that are easy to understand and apply.
• Through ongoing hospital workforce training schemes, AHSs are responsible for ensuring their hospital workforce is equipped with adequate infection control skills.
• The Infection Control Subcommittee of the IDEA Group will develop infection control protocols specific for avian and pandemic influenza to be used by AHSs.
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4.5 Laboratory Background
During an influenza pandemic, all laboratories will face a significant surge in demand for diagnostic tests as well as experiencing increases in staff absenteeism. In NSW there are six laboratories which routinely detect influenza viruses - the Institute of Clinical Pathology & Medical Research (ICPMR) at Westmead Hospital, South East Area Laboratory Service (SEALS) at the Prince of Wales Hospital, Hunter Area Pathology Service (HAPS) at John Hunter Hospital, South Western Area Pathology Service (SWAPS) at Liverpool Hospital, Central Sydney Pathology at Royal Prince Alfred Hospital, Pacific Laboratory Medical Service (PaLMS) at Royal North Shore Hospital, and the Department of Virology and Microbiology at the Children’s Hospital at Westmead. Two of these laboratories, ICPMR and SEALS, are members of the Public Health Laboratory Network. ICPMR is one of three WHO National Influenza Centres in Australia.
The objectives of testing for pandemic influenza will vary according to the phase of a pandemic. In the containment phase, the emphasis will be on early, accurate diagnosis so that appropriate disease control activities can be carried out. When the pandemic becomes more widespread, the pre-test probability of influenza being the cause of an influenza-like illness will be high, and laboratory confirmation will be less important. However, during this later stage of a pandemic, there may be a requirement for serological monitoring of groups who are at higher risk of infection, which will place an additional burden on laboratories.
Strategies
• In order to have an adequate state-wide capacity to detect novel influenza strains in humans, certain public health laboratories have developed diagnostic tests for H5N1 avian influenza, and are developing tests for other novel influenza strains that have the potential to become pandemic strains. Robust serological tests will also need to be available for use during a pandemic.
• During the Interpandemic and Pandemic Alert periods, laboratories will develop plans to respond to the surge in demand for diagnostic tests and for laboratory personnel.
• The Laboratory Subcommittee of the IDEA Group will develop protocols for specimen collection and diagnostic workup of patients suspected of having avian or pandemic influenza.
• The NSW Microbiology Laboratory Network comprises representatives from public and private laboratories, AHS PHUs, and the Centre for Health Protection of NSW Health. It provides an interface for public and private laboratory sectors to discuss laboratory issues relating to avian and pandemic influenza.
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4.6 Vaccination Background
In late 2004, the Australian Government contracted two vaccine manufacturers (CSL Limited and Sanofi-Pasteur) to supply inter-pandemic influenza vaccines for a period of 3 years and to provide vaccine for the Australian population during a pandemic. In 2005, both companies began trialing a candidate human H5N1 vaccine. Depending on the outcomes of these trials in early 2006, further consideration will be given to preferred strategies to vaccinate the population.
Due to the lead-time required to manufacture a new vaccine, it is likely to take several weeks or months after the onset of a pandemic before a vaccine first becomes available. From that point, it will take several weeks to produce enough vaccine for the whole population. Until a vaccine becomes available, other measures to protect the population, such as personal hygiene, personal protective equipment (PPE), antiviral medications and isolation of affected persons will be utilised.
The pandemic vaccine will be released by the Australian Government to the designated vaccine repositories in each state and territory in multidose containers. The states and territories will be responsible for providing the vaccine to their populations according to nationally-agreed priority groups. For vaccines aimed towards novel influenza strains, at least two doses several weeks apart will be required to provide immunity.
Strategies
• NSW Health will liaise with DoHA to devise plans for deployment of vaccine from the NMS to a NSW repository.
• The Centre for Health Protection will liaise with CDU to formulate plans for the pandemic vaccine to be distributed to designated secure vaccine storage sites in each AHS.
• Prioritisation of vaccine recipients will need to be decided within a whole-of-government framework.
• In the Interpandemic and Pandemic Alert periods, each AHS will be required to identify appropriate secure vaccine storage and vaccination clinic sites. A framework for mass vaccination will be developed to aid this process.
• It will be the responsibility of each AHS to organise the vaccination of firstly, the priority groups, and then the remainder of the population.
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4.7 National and state medical stockpiles (NMS and SMS)
Background During a pandemic, there will be a sudden and significant surge in world-wide demand for personal protective equipment (PPE) and anti-influenza medications. The only way to ensure supply is to stockpile these resources in the Interpandemic and Pandemic Alert periods.
Since 2003, the Australian Government has developed an NMS made up of medications, vaccines, PPE, and other equipment to aid Australian’s response to major infectious disease threats. The NMS includes a supply of antiviral drugs active against influenza (predominantly oseltamivir, with some zanamivir), although the limited size of this stockpile necessitates that the use of the materials it contains be prioritised carefully.
NSW Health also maintains a smaller SMS of items than can be utilised in a health emergency. In 2005, the stockpile was enhanced with enough antiviral medications (for prophylaxis) and complete PPE ensembles to protect approximately 3 300 health care workers for 1 month (if the stockpiled antiviral medications were to be used for treatment rather than prophylaxis, there is enough to treat 10 000 cases). This will enable rapid protection of key elements of the workforce whilst other resources are being mobilised.
Strategies
• The Australian Government is in the process of developing plans for dispersing items from the NMS to states and territories (National Medical Stockpile Deployment Plan and National Medical Stockpile Dispersing Plan). CDU is the responsible state agency within NSW.
• The CDU is responsible for maintaining the SMS.
• In the Interpandemic and Pandemic Alert periods, protocols will be developed by the CDU for receiving resources from the NMS, and deploying resources from the SMS to AHS repositories.
• AHSs will incorporate details regarding the local distribution of resources received from the SMS.
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4.8 Case definition and management Background
Because clinical features of influenza due to a novel strain may differ from what is usually experienced with interpandemic human influenza, an accurate case definition for influenza caused by a pandemic strain cannot be made until the pandemic commences.
The decision to use mechanical ventilation as a treatment modality is a clinical one and would remain so during a pandemic. However, the availability of mechanical ventilators will be limited during a pandemic, and treatment will, for the most part, consist of antibiotics and antiviral medication (if indicated and available), and supportive treatment.
Strategies
• In the Interpandemic and Pandemic Alert periods, the Clinical Subcommittee of the IDEA Group will formulate algorithms and protocols for patient triage and management.
• Soon after a pandemic strain is reported, CDNA will develop a national case definition using all available evidence to ensure national consistency in case reporting.
• Prior to, and during, the containment stage, an expert panel of health care professionals will be available at short notice to advise on difficult cases. This will be coordinated by NSW Health.
• In 2005, with funds provided by the Australian Government, NSW Health enhanced the state’s capacity to be able to manage critically ill patients in a pandemic by purchasing additional mechanical ventilators. These will be stored in the SMS and a training and maintenance program will be conducted by CDU.
• NSW Health will keep an up-to-date state-wide inventory of mechanical ventilators and other related resource requirements. .
4.9 Community management Background A vital activity during a pandemic is to ensure that the needs of those being cared for in the community, and/or in isolation or quarantine, be adequately addressed. This will include health care (physical and psychological), and provision of goods and services.
Strategies
• In the Interpandemic and Pandemic Alert periods, the Community Management Subcommittee of the IDEA Group will formulate strategies to address issues relating to community management.
• The NSW Department of Community Services (DOCS) have well established plans for dealing with community support during emergencies. The applicability of these plans for use during an influenza pandemic needs to be reviewed.
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4.10 Health care infrastructure FEVER CLINICS
Background Fever clinics are facilities discrete from existing hospital emergency departments for assessing and triaging symptomatic individuals during an infectious disease emergency. Their purpose is to ensure:
• emergency departments and general practice surgeries are not overwhelmed with pandemic influenza cases and can continue, as far as possible, their routine functions
• within-hospital transmission of infection is minimised by ensuring potentially infectious patients visiting the clinic are kept separate from other patients seeking care in the health care facility
• a standardised method for assessing and managing patients is adopted.
Patients assessed in fever clinics would be assessed as being appropriate for care at home, as requiring further assessment and possible admission to designated influenza hospitals (see below), or as requiring care in a ‘staging facility’ (see below), according to their risk of disease, severity of illness, and ability to cope at home.
Strategies
• Prior to the onset of a pandemic, each AHS is required to identify sites for fever clinic(s) in, or close to, all hospitals with an emergency department using a framework developed by NSW Health.
• At Pandemic Alert period, Overseas 4 phase, the AHSs should anticipate the fever clinics and staging facilities becoming operational and begin readying the nominated facilities for use. The State HSFAC, with advice from the HSDCC, will advise the stage at which fever clinics (and staging facilities and influenza hospitals) are to be made operational in the AHSs.
STAGING FACILITIES
Background ‘Staging facility’ is a general term for a facility to accommodate patients where it is impractical to manage them at home or in a hospital. The role of will vary according to the size the pandemic but would, in general, have a supportive role for patients rather than an interventional one.
Staging facilities may be required to accommodate patients when:
• patients are not unwell enough to require acute hospital care but are unable to be managed at home because of lack of adequate social supports e.g., travellers, the frail elderly
• when hospitals are full, in which case the facility can be regarded as an ‘overflow’ facility
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• when convalescing patients need a higher level of support than they can receive at home, in which case the facility can be regarded ‘step-down’ facility.
Facilities and staffing required would be at a less intensive level than that of a medical ward in an acute care hospital.
Strategies
• In the Interpandemic and Pandemic Alert periods, each AHS is required to identify sites for staging facility(s) using a framework developed by NSW Health. The number of staging facilities in a particular AHS will depend upon the number and concentration of the residents and clinicians of the AHS, and the ease with which the population can access the facility (i.e., geographical spread of the AHS).
• In liaison with AHSs, CDU will manage a state-wide inventory of sites for staging facilities.
• During a pandemic, the State HSFAC, with advice from the HSDCC, will advise the stage at which staging facilities (and fever clinics and influenza hospitals) are to be made operational in the AHSs. Geographical variability in attack rates may dictate that staging facilities may not be required to be established in all AHSs simultaneously.
• At Pandemic Alert period, Overseas 4 phase, the AHSs should anticipate the fever clinics and staging facilities becoming operational and begin readying the nominated facilities for use. On instruction from the State HSFAC to AHSs, the fever clinics and staging facilities are to be made operational.
DEDICATED INFLUENZA HOSPITALS
Background
The aims of designating certain hospitals as influenza hospitals during a pandemic is to reduce the overall risk of hospital-transmitted infection as well as allowing others to carry out ‘core’ hospital functions of the state. Suitability will depend upon the size, layout, and areas of expertise of the hospital workforce. However, to ensure that NSW has the flexibility to cope with any grade of pandemic, from mild to a severe, all state hospitals should be considered as potential influenza hospitals.
In the early stage of a pandemic, the order in which influenza hospitals will be brought on-line will be largely dictated by the geographical location of disease activity.
Part of the process of identifying influenza hospitals would be to also identify certain other hospitals that have important state-wide functions to be kept as free as possible of patients infected with the influenza virus.
Strategies
• NSW Health will collaborate with AHSs to grade the suitability of all hospitals for influenza hospitals and manage a state-wide inventory of them.
• During a pandemic, the State HSFAC, with advice from the HSDCC, will advise the stage at which influenza hospitals are to be made operational in the AHSs. Geographical variability in attack rates may dictate that these may not be required to be established in all AHSs simultaneously.
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ISOLATION FACILITIES WITHIN HOSPITALS
Background
The ability to isolate patients with communicable respiratory infections is a key method of containment. Isolation rooms within hospitals, including negative pressure rooms, are an important component of this. It is essential, therefore, in planning for a response to pandemic influenza that the number, design and location of these facilities are known, both within a hospital and across the state.
There are a limited number of isolation rooms within NSW health care facilities and it is likely that they would be of most benefit during the containment stage of a pandemic (and prior). Once the pandemic virus reaches the stage of sustained transmission, other containment strategies will need to be employed for hospitalised patients (e.g., strict infection control practices, designated influenza hospitals, cohorting of patients).
Strategies
• The Australian Government initiative in 2005 to purchase portable machines designed to transform a positively pressured room into a negative pressured one may improve isolation room capacity in NSW. NSW Health will manage these and develop guidelines for their use.
• The NSW Health Facility Guidelines were released in December 2004, which included information relating to the design of isolation facilities. This will enable a standardised approach to the layout of isolation rooms in hospitals constructed in the future.
• NSW Health is responsible for keeping information relating to isolation facilities in NSW up to date.
4.11 Workforce issues
WORKFORCE EDUCATION AND TRAINING
Background
In the event of public health emergency such as an influenza pandemic, public health personnel and other health workers must be prepared to respond. Training our workforce is an important step for preparation, and should encompass infection control and use of personal protective equipment.
Strategies
• Training should be developed and conducted to give effect to this plan in relation to the following groups:
o front-line clinical health care staff such as those working in emergency departments, ICU, and respiratory wards
o the public health workforce more broadly o primary health care and other acute clinical staff o emergency services personnel as appropriate.
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• The development and implementation of state-wide training program for health care workers staff will be undertaken by NSW Health in collaboration with AHSs.
WORKFORCE SURGE CAPACITY
Background
Staff absenteeism during an influenza pandemic may place significant strain placed on both public and private elements of the workforce. In the health sector this strain will be especially acute with the added burden of a diversion of a proportion of the workforce to care for the potentially large number of influenza cases.
The absenteeism rate will vary according to the severity and longevity of the pandemic, its timing (higher if it occurs during the winter), whether schools and child-care centres are closed, and what percentage of the working population will elect to stay at home for other reasons. A pandemic may last between eight and twelve weeks and a peak absenteeism rate of around 30% might be expected if it were a severe pandemic (not including those who will elect to stay at home for other reasons).
Depending on the scale of a pandemic, valuable temporary additions to the health workforce could include medical and nursing students, dentists, retired general practitioners, emergency service workers, and volunteer organisations.
Strategies
• The Workforce Subcommittee of the IDEA Group will develop plans to cope with the health workforce surge capacity.
• Private companies and government agencies should develop business continuity plans to cope with high levels of absenteeism during an influenza pandemic.
• In the Pandemic Alert period, AHSs will identify staff for potential fever clinics who would receive appropriate training in infection control and case management prior to a pandemic. This would allow rapid mobilisation of fever clinic teams comprising motivated and well-trained health professionals in the event of a pandemic.
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4.12 Role of general practitioners (GPs) Background
During a pandemic, a key challenge for GPs will be the minimisation of disruption to their routine work in the face of potentially large number of influenza cases. One of the aims of establishing fever clinics is to ease the burden on GPs (and emergency departments) by providing alternative assessment facilities for people with symptoms of influenza. However, it is inevitable that GPs will required to assess influenza cases and it is imperative that they are aware of methods to reduce the risk of transmission from their patients to themselves.
Strategies
• GPs should ensure that tools and strategies to assist them in managing patients during a pandemic exist and that they know how to access them. Examples include fact sheets on pandemic influenza, guidelines for patient management, and protocols and training in infection control.
• In 2005, the Australian Government developed and released:
o a pandemic preparedness ‘kit’ for medical practitioners entitled Preparing for a pandemic: a practical guide for medical practitioners8.
o Prepared and protected, an instructional video demonstrating preferred infection control practices and personal protective equipment for respiratory diseases.
• The NSW Health project to improve communications to health care workers during a public health emergency, described in 4.2 Communications above, will consider issues related to communication with GPs.
• In the Interpandemic and Pandemic Alert periods NSW Health will engage the GP workforce to more clearly delineate their roles during an influenza pandemic.
8 available at http://www.health.gov.au/internet/wcms/publishing.nsf/content/pubhlth-pandemic-gp.htm
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4.13 Measures to increase social distance Background
The aim of implementing measures to increase social distance during a pandemic is to minimise transmission of the virus by keeping infectious cases away from susceptible people. These measures include limiting mass gatherings (such as major sporting events and music concerts) and closure of child-care centres, schools and universities. The effect of these measures on workforce absenteeism and the disruption to the amenity of day-to-day life will be considerable and the decision to instigate such a strategy would need to be carefully considered in light of all available evidence.
Strategies
• Policy relating to measures to increase social distance will need to be made within a whole-of-government framework, with advice from NSW Health.
• During the Pandemic period, the State HSFAC will be responsible for implementing the state mass gathering strategy.
4.14 Patient transportation Background
Due to the high transmissibility of influenza, patient transportation should be kept to a minimum. During transportation of patients with any communicable disease, it is essential that the risk of transmission of infection to ambulance staff is minimised by instituting effective infection control methods.
The Ambulance Service of NSW (ASNSW) must ensure that it is able to continue its day-to-day business in the face of an influenza pandemic.
Strategies
• In the Interpandemic and Pandemic Alert periods, ASNSW will:
o develop plans for road and air transportation of pandemic influenza patients, including whilst ensuring continuation of core ambulance business
o develop state-wide transportation plans for materials and pharmaceuticals
o liaise with AHSs to ensure ambulance planning is appropriate for their needs
o ensure existing protocols are adapted where necessary to accommodate the impact of a pandemic on ambulance operations
o develop and implement training programs for ASNSW personnel to ensure the risk of transmission of infection to personnel is minimised.
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4.15 Mental health Background
In an influenza pandemic, there will be effects on the mental health of individuals due to direct experience with sick and dying loved ones, and on the population as a whole, and these effects may be long lasting. The sections of the workforce that are at increased risk of infection, such as healthcare workers, is an especially vulnerable group due to a real or perceived increased risk of becoming infected themselves, and/or transmitting infection to their friends and families. The particular mental health needs of marginalised populations such as homeless people also need to be considered.Along with additional pandemic-related mental health needs of the community, providing care for those with pre-existing mental illness will need to continue.
Strategies
• In the Interpandemic and Pandemic Alert periods, the Centre for Mental Health within NSW Health will:
o review the Mental Health sub-plan of NSW HEALTHPLAN in light of a possible influenza pandemic
o identify key groups at risk for mental health problems in a pandemic and devise methods to manage the risk.
4.16 Storage and disposal of bodies Background During an influenza pandemic, there will be an increase in mortality causing strain on existing capacity for the storage and disposal of dead bodies. The magnitude of the impact will be largely dependent on the virulence of the pandemic influenza virus strain. Cultural and religious sensitivities will have a very large influence on any plans dealing with this issue.
The NSW Disaster Victim Identification (DVI) Committee is a state committee chaired by State Coroner that guides policy development relating to storage of bodies and identifying victims of disasters.
Strategies • The Centre for Health Protection to consult with the NSW State Coroner to
determine if existing policy regarding mass storage and disposal of bodies will be applicable in a pandemic setting.
• The State Coroner and the Institute of Forensic Medicine to determine capacity and strategies to cope with theoretical increase in numbers of deceased.
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4.17 Border control and quarantine Background
The Australian Government is responsible for devising policy relating to border control activities. Australia, being an island nation, has a greater opportunity than other countries to prevent or delay the entry of pandemic influenza into Australia, as it did in 1918. Accordingly, the Government is prepared to implement border measures with this objective in mind. These measures may include placing health care professionals at the airport, introducing a requirement for positive pratique for incoming aircraft or vessels, screening incoming and/or outgoing passengers for influenza signs or symptoms, providing health declaration cards at ports of entry, quarantining of aircraft and passengers, and closing external borders.
The objectives of quarantine activities in Australia are to ensure that, as far as possible, diseases of human quarantine concern do not enter the country, and to control and eradicate these diseases if they are identified in Australia. The Australian Government has broad powers under the Quarantine Act 1908 to enable this. In extreme circumstances, this may include quarantining whole towns or regions.
The day-to-day delivery of human quarantine activities is the responsibility of Australian Quarantine Inspection Service (AQIS) and state/territory health authorities but the overall responsibility for human quarantine policy lies with the Director of Human Quarantine (DHQ) (the CMO).
Strategies • In the Interpandemic and Pandemic Alert periods:
o the Australian Government, in consultation with the states and territories, will more closely define border and quarantine policy for use during a pandemic
o NSW Health to devise strategies for ensuring capacity to respond to requests from the Australian Government to provide assistance with border control activities.
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4.18 Testing of the plan Background
Testing of any emergency plan is essential in order to identify weaknesses. Choosing the frequency of testing is arbitrary but at the least should be conducted following any major revision of the pandemic plan.
The only formal large-scale exercise to test NSW’s response to a pandemic was carried out in 2003 - Exercise Warning Shot. A number of recommendations were made that have been, or are being, implemented.
The SARS crisis in 2003 acted as a “real life exercise” that tested many aspects of state’s response mechanisms to an external infectious disease threat, mirroring what might be expected in the early stages of an influenza pandemic.
Strategies
• NSW Health has responsibility for conducting exercises to test NSW infectious disease emergency. When in the state or national interest, NSW Health will assign representatives to participate in national and interstate biopreparedness exercises.
• In late 2005, NSW Health will participate in Exercise Eleusis, a national exercise designed to test Australia’s ability to manage an incursion of avian influenza. It will test the links between the agriculture and health sectors at the national and state levels.
• A national pandemic influenza exercise is planned for 2006.
4.19 Travel advisories Background
The Australian Government Department of Foreign Affairs and Trade are responsible for issuing travel warnings for Australians during all pandemic phases.
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5 RESPONSE ACTIONS FOR NSW The following tables define actions required by various agencies within the NSW health sector at each phase of an influenza pandemic. The format of the tables closely follows the equivalent chapter in AMPPI (2005), and the action items within the tables include all of those items identified in AMPPI to be the responsibility of states and territories, together with additional items not described in the national plan. The tables do not include roles and responsibilities of national agencies - refer to AMPPI for a description of these.
INTER-PANDEMIC PERIOD - AUS PHASE 0
Goal To adequately prepare Australia to enable the smooth and timely implementation of the specific activities required in the various phases of pandemic planning.
Definition No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is not present in animals in Australia.
Action Roles And Responsibilities
Planning and coordination
• Develop and maintain state and Area Health Service (AHS) pandemic action plans.
• The Communicable Diseases Branch (CDB) to develop and maintain the NSW Health Influenza Pandemic Action Plan.
• The Centre for Mental Health to develop and maintain a plan for managing mental health during a pandemic.
• AHSs to develop and maintain Area influenza pandemic plans (or generic infectious disease emergency plans) and ensure these plans are compatible with the state plan.
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• Maintain routine influenza surveillance through sentinel general practitioners (GPs) and National Notifiable Diseases Surveillance System (NNDSS).
• CDB to: o convene the Influenza Surveillance Advisory Committee (ISAC) annually. o collate, analyse, and report weekly on the results of influenza surveillance.
• Public Health Units (PHUs) to recruit GPs into the General Practitioner Sentinel Surveillance (GPSS) system, collate data from individual GPs and forward to CDB.
Monitoring and Surveillance
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains.
• The Public Health Laboratory Network (PHLN) laboratories to forward influenza virus isolates to the WHO Collaborating Centre for Reference and Research on Influenza (WHOCC) in Melbourne as part of the national contribution to global influenza surveillance.
• Prepare materials and equipment required for urgent deployment at the declaration of particular phases of a pandemic.
• CDB, via the Infection Control Subcommittee of the NSW Infectious Disease Emergency Advisory (IDEA) Group, to develop infection control resources for use during a pandemic, including guidelines on the use of personal protective equipment (PPE) and infection control posters
• The Counter Disaster Unit (CDU) to procure and manage a stockpile of equipment for use during an infectious disease emergency, including items of PPE
• Australian Government agencies to prepare resources for use at borders, such as passenger arrival information cards.
Non-pharmacological public health measures
• Agree on key essential services to target for additional infection protection measures during an influenza pandemic (i.e., PPE and antivirals).
• Identify personnel for designated essential services teams in these services.
• CDB to: o collaborate with other Australian jurisdictions to develop a consistent list of priority
groups for additional infection protection methods in a pandemic o liaise with essential services agencies to identify key personnel to be targeted for
additional infection protection methods in a pandemic.
Vaccines and antivirals
• Develop antiviral/vaccine deployment plans.
• CDU to: o collaborate with AIDS/Infectious Diseases Branch (AIDB) to develop a system for
distributing pandemic vaccine to designated vaccine sites in each AHS o develop a system for distributing antiviral agents to areas of need during a pandemic.
• AHS to: o develop a plan to vaccinate designated pandemic priority groups first, followed by the
remainder of the population o identify secure pandemic vaccine storage and vaccination clinic sites using the
framework developed by NSW Health.
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• Promote use of interpandemic (or seasonal) influenza and pneumococcal vaccine in high-risk groups.
• The Centre for Health Protection (CHP) to: o promote annual influenza vaccination through state GP organisations, the state media,
AHSs, and aged care facilities o fund immunisation coordinators in each AHS o maintain a vaccine distribution system to providers across the state o promote use of pneumococcal vaccine in high-risk groups.
• AHS to: o promote pneumococcal and annual influenza vaccination at the local level through GP
organisations and via the local media. Health care and emergency response
• Test and review health sector and emergency services capacity to respond to a pandemic threat.
• CHP to: o coordinate the development and testing of the state pandemic influenza plan o enter into a dialogue with AHSs to raise awareness of the state plan and to ensure Area
plans are standardised and align with the state plan. • CDU, in collaboration with the CHP, to engage with NSW emergency services and other
agencies within NSW Health to review and test pandemic preparedness. • NSW Health to participate in national exercises designed to test preparedness for infectious
disease emergencies. • CDB to closely monitor international developments with respect to changing pandemic risk
and new evidence that could lead to enhancement of the current state plan. • AHSs to: o review and test Area pandemic influenza plans and ensure these plans are compatible
with the state plan o participate in exercises designed to test the state plan.
Communications • Review communications strategies in readiness for a pandemic.
• Media Unit of NSW Health to review strategies for communicating with the public during an influenza pandemic.
• The Centre for Epidemiology and Research (CER) to coordinate the component of the Public Health Preparedness Project concerned with communications between health care workers.
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INTER-PANDEMIC PERIOD - GLOBAL PHASE 1
Goal To work in close collaboration with animal health authorities to limit risks of human infection.
(a) Animal cases outside Australia (Overseas 1)
Definition No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is present in animals overseas. The risk of human infection or disease is considered to be low.
Action Roles And Responsibilities
Planning and coordination
• Review state plans, assess preparedness status and identify immediate actions to fill gaps.
• CHP to review state plans, assess preparedness status and identify immediate actions to fill gaps.
• AHS to review Area plans, assess preparedness status and identify immediate actions to fill gaps.
• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per Aus 0).
• As per Aus 0. Monitoring and Surveillance
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas.
• PHLN laboratories to: o forward influenza virus isolates to the WHOCC as part of
the national contribution to global influenza surveillance (as per Aus 0)
o develop/maintain the capacity to identify novel influenza strains in travellers returning from high-risk areas overseas.
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Non-pharmacological public health measures
(next 3 dot- points as per Aus 0) • Prepare materials and equipment required for urgent
deployment at the declaration of particular phases of a pandemic.
• Agree on key essential services to target for additional infection protection measures during an influenza pandemic (i.e., PPE and antivirals).
• Identify personnel for designated essential services teams in these services.
• As per Aus 0.
Vaccines and antivirals
• Promote use of interpandemic (or seasonal) and influenza pneumococcal vaccine in high-risk groups.
• As per Aus 0.
• Test and review health sector and emergency services capacity to respond to a pandemic threat (as per Aus 0).
• As per Aus 0. Health care and emergency response
• Update infection control guidelines for individuals with exposure to an affected animal or its environment overseas, including those involved in monitoring/education.
• Update existing detection and clinical care guidelines for human cases.
• CDB, via the: o Infection Control Subcommittee of the IDEA Group, to
update infection control guidelines for those with exposure overseas to an affected animal or its environment.
o Clinical Management Subcommittee of the IDEA Group, develop/update detection and clinical care guidelines for human cases.
Communications • Implement Influenza Pandemic and Communicable Diseases Communications Plan in collaboration with Department of Primary Industries (DPI) and NSW Food Authority.
• NSW Health Media Unit in conjunction with media units from the DPI and the NSW Food Authority.
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(b) Animal cases within Australia (Aus 1)
Definition No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is present in animals in Australia. The risk of human infection or disease is considered to be low.
Action Roles And Responsibilities
Planning and coordination
• Develop and maintain state and Area pandemic influenza plans (as per Aus 0).
• As per Aus 0.
• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0).
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas or within Australia.
• PHLN laboratories to: o forward influenza virus isolates to the WHOCC (as per previous phases) o have the capacity to identify novel influenza strains in travellers returning from
high-risk areas overseas or within Australia.
Monitoring and Surveillance
• Serosurveys, data collection and epidemiological analysis to identify human respiratory infections associated with exposure to infected animals (e.g., in poultry workers, veterinarians, and poultry cullers) through Outbreak Case Reporting System (OCRS).
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease.
• Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO.
• CDB to collaborate with PHUs and industry to ensure human respiratory infections associated with exposure to infected animals are appropriately investigated. Reporting to be done through OCRS.
• CDB to collaborate with PHUs to: o ensure passively reported unusual clusters of influenza-like illness or acute
respiratory disease are appropriately investigated. Reporting to be done through OCRS
o ensure reports of possible human cases with an epidemiological link to affected areas are appropriately investigated.
• PHUs to investigate immediately and report to CDB on the same day: o human respiratory infections associated with exposure to infected animals o unusual clusters of influenza-like illness or acute respiratory disease o possible human cases with an epidemiological link to affected areas.
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Non-pharmacological public health measures
• Prepare materials and equipment required for urgent deployment at the declaration of particular phases of a pandemic.
• Agree on key essential services to target for additional infection protection measures during an influenza pandemic (e.g., health care workers, public utility workers, police).
• Identify personnel for designated essential services teams in these services (All above points as per Aus 0.)
• As per previous phases (see Aus 0).
• Promote use of interpandemic (or seasonal) and influenza pneumococcal vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 0).
• Promote interpandemic influenza vaccination for poultry cullers.
• The CHP to collaborate with the DPI to encourage the poultry industry to arrange for poultry cullers to be vaccinated annually with interpandemic influenza vaccination.
• PHUs to promote interpandemic influenza vaccination for poultry cullers locally.
Vaccines and antivirals
• Provide antivirals for exposed individuals. • Maintain a register of all individuals
receiving antivirals.
• CDB to: o collaborate with PHUs to ensure antiviral agents are supplied to exposed
individuals, as per state and national guidelines o maintain a central register of all individuals receiving antivirals.
• PHUs to: o coordinate distribution of antiviral agents to exposed individuals. o maintain a register of all individuals receiving antivirals in their Area and
forward this data to CDB.
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Health care and emergency response
• Disseminate and implement infection control guidelines for individuals with exposure to an affected animal or its environment, including those involved in monitoring/education.
• Update and disseminate detection and clinical care guidelines for human cases.
• CDB to: o disseminate to PHUs infection control guidelines for those with exposure
overseas to an affected animal or its environment o update detection and clinical care guidelines for human cases and disseminate
to PHUs. • PHUs to: o implement where applicable, and disseminate to health care facilities, updated
infection control guidelines for those with exposure to an affected animal or its environment
o disseminate detection and clinical care guidelines for human cases to health care facilities and clinicians in their Areas.
Communications • Implement Influenza Pandemic and Communicable Diseases Communications Plan in collaboration with DPI and NSW Food Authority (as per OS 1).
• As per OS 1.
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INTERPANDEMIC PERIOD - GLOBAL PHASE 2
Goal Containment of animal outbreaks and prevention of human cases.
(a) Animal cases outside Australia (Overseas 2)
Definition
No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is present in animals overseas. The risk of human infection or disease is considered to be substantial.
Action Roles And Responsibilities
Planning and coordination
• Assess preparedness status and identify immediate actions to fill gaps. Prepare to move from preparedness to response.
• CHP to review state plans, assess preparedness status, identify immediate actions to fill gaps, and prepare to move from preparedness to response.
• AHS to review Area plans, assess preparedness status, identify immediate actions to fill gaps, and prepare to move from preparedness to response.
• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0). Monitoring and Surveillance
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas (as per OS 1).
• As per OS 1.
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Non-pharmacological public health measures
(next 3 dot- points as per previous phases) • Prepare materials and equipment required for urgent deployment at
the declaration of particular phases of a pandemic. • Agree on key essential services to target for additional infection
protection measures during an influenza pandemic (i.e., PPE and antivirals)
• Identify personnel for designated essential services teams in these services.
• As per previous phases (see Aus 0)
Vaccines and antivirals
• Promote use of interpandemic (or seasonal) and influenza pneumococcal vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 0).
• Test and review health sector and emergency services capacity to respond to a pandemic threat (as per Aus 0 and OS 1).
• As per previous phases (see Aus 0). Health care and emergency response
• Update, disseminate and implement infection control guidelines for individuals with exposure overseas to an affected animal or its environment, including those involved in monitoring/education (as per OS 1).
• Update and disseminate detection and clinical care guidelines for human cases (as per Aus 1).
• As per OS 1.
Communications • NSW Health spokespeople to be nominated for media interviews. • NSW Health Media Unit to nominate spokespeople.
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(b) Animal cases within Australia (Aus 2)
Definition No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is present in animals in Australia. The risk of human infection or disease is considered to be substantial.
Action Roles And Responsibilities
Planning and coordination
• Assess preparedness status and identify immediate actions to fill gaps. • CHP to review state plans, assess preparedness status, identify immediate actions to fill gaps.
• AHS to review Area plans, assess preparedness status, identify immediate actions to fill gaps.
Monitoring and Surveillance
(next 5 dot-points as per previous phases) • Maintain routine influenza surveillance through sentinel GPs and
NNDSS • Laboratory surveillance to monitor influenza virus isolates and detect
local novel influenza strains in travellers returning from high-risk areas overseas or within Australia.
• Serosurveys, data collection and epidemiological analysis to identify human respiratory infections associated with exposure to infected animals (e.g., in poultry workers, veterinarians, and poultry cullers) through Outbreak Case Reporting System (OCRS).
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease.
• Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO.
• As per previous phases (see Aus 0).
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Non-pharmacological public health measures
(next 3 dot-points as per previous phases) • Prepare materials and equipment required for urgent deployment at the
declaration of particular phases of a pandemic. • Agree on key essential services to target for additional infection
protection measures during an influenza pandemic (i.e., PPE and antivirals).
• Identify personnel for designated essential services teams in these services.
• As per previous phases (see Aus 0).
• Promote use of interpandemic (or seasonal) and influenza pneumococcal vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 0). Vaccines and antivirals
• Promote interpandemic influenza vaccination for poultry cullers (as per Aus 1).
• Provide antivirals for exposed individuals (as per Aus 1). • Maintain a register of all individuals receiving antivirals (as per Aus 1).
• As per Aus 1.
• Test and review health sector and emergency services capacity to respond to a pandemic threat (as per previous phases).
• As per previous phases (see Aus 0).
• Disseminate and implement infection control guidelines for those with exposure to an affected animal or its environment, including monitoring/education.
• The CHP to disseminate to PHUs updated infection control guidelines for those with exposure to an affected animal or its environment overseas or in Australia.
• PHUs to implement where applicable, and disseminate to health care facilities, updated infection control guidelines for those with exposure to an affected animal or its environment overseas or in Australia.
Health care and emergency response
• Update and disseminate detection and clinical care guidelines for human cases
• As per previous phases (see OS 1).
Communications • Keep public informed. • Keep poultry industry informed.
• NSW Health Media Unit to collaborate with the DPI and NSW Food Authority to devise appropriate messages for poultry workers and the public.
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PANDEMIC ALERT - GLOBAL PHASE 3
Goal Ensure rapid characterisation of the new virus subtype and early detection, notification and response to additional cases.
(a) Human cases outside Australia (Overseas 3)
Definition
Human infection(s) with a new subtype overseas, but no human-to-human spread, or at most rare instances of spread to a close contact.
Action Roles And Responsibilities
Planning and coordination
• Assess preparedness status and identify immediate actions to fill gaps. Prepare to move from preparedness to response (as per previous phases).
• As per previous phases (see OS 2).
• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0).
• Data collection and epidemiological analysis on suspect, possible and confirmed cases in those with travel history in affected area through OCRS.
• CDB to collaborate with PHUs to ensure: o suspect, possible and confirmed cases in those with
travel history in affected areas are appropriately investigated (within 24 hours) and reported through OCRS.
Monitoring and Surveillance
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per Aus 1 and 2).
• Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO (as per previous phases).
• As per previous phases (see Aus 1).
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• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas (as per previous phases).
• As per previous phases (see Aus 1).
• Ensure laboratories can safely test samples for pandemic strain and forward to WHOCC.
• Identification of laboratories for diagnosis of new strain – distribution of reagents.
• PHLN laboratories to procure the appropriate reagents and safely test samples for potential pandemic strains and forward isolates to the WHOCC.
Non-pharmacological public health measures
(next 3 dot-points as per previous phases) • Prepare materials and equipment required for urgent deployment
at the declaration of particular phases of a pandemic. • Agree on key essential services to target for additional infection
protection measures during an influenza pandemic (i.e., PPE and antivirals).
• Identify personnel for designated essential services teams in these services.
As per previous phases (see Aus 0).
• Promote use of interpandemic (or seasonal) and influenza pneumococcal vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 0).
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see Aus 1).
Vaccines and antivirals
• Provide antivirals for exposed individuals and cases. • CDB to collaborate with PHUs to ensure antiviral agents are supplied to exposed individuals and cases.
• PHUs to: o coordinate distribution of antiviral agents to exposed
individuals o collaborate with clinicians to ensure antiviral agents
are available to cases.
Pandemic alert period, Overseas 3 phase
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• Review plans for health care delivery • Consider sites/equipment for designated influenza hospitals/
fever clinics. • Consider sites/equipment for designated mass quarantine areas. • Review availability of personnel, supplies and materials for
infection control and clinical care.
• CDU to: o review plans for state-wide health care delivery o in collaboration with AHSs, consider sites/equipment
for designated influenza hospitals/ fever clinics o consider sites/equipment for designated mass
quarantine areas. o review plans for maintaining workforce surge capacity o review contents of the SMS and upgrade if necessary.
• CDB to collaborate with CDU to consider sites/equipment for designated influenza hospitals/ fever clinics (as per previous phases).
• Review plans for community support. • CHP to review plans for community support in the event of a pandemic.
• For those with exposure to cases, initiate monitoring/education through public health units.
• PHUs to coordinate the monitoring/education of those with exposure to cases.
Health care and emergency response
• Update and disseminate infection control guidelines for human cases and those with exposure to cases overseas (as per previous phases).
• Update and disseminate detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases (see OS 1).
• Keep public informed.
• NSW Health Media to collaborate with DoHA and media units of other states and territories to prepare messages for the public.
• NSW Health to provide spokespeople for media interviews.
• CDB to update NSW Health Website with information on avian influenza.
• Regular communication to public health network. • CDB to provide regular updates the public health network.
Communications
• Keep poultry industry informed. • NSW Health Media Unit to collaborate with the DPI and NSW Food Authority to devise appropriate messages for poultry industry.
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(b) Human cases within Australia (Aus 3)
Definition Human infection(s) with a new subtype in Australia, but no human-to-human spread, or at most rare instances of spread to a close contact.
Action Roles And Responsibilities
Planning and coordination
• Assess preparedness status and identify immediate actions to fill gaps (as per Aus 2).
• As Aus 2.
• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0).
• Data collection and epidemiological analysis on suspect, possible and confirmed cases in those with travel history in affected area through OCRS (as per OS 3).
• As per OS 3.
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per previous phases).
• Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO (as per previous phases).
• As per previous phases (see Aus 1).
Monitoring and Surveillance
• Ensure laboratories can safely test samples for pandemic strain and forward to WHOCC (as per OS 3).
• As per OS 3
Pandemic alert period, Aus 3 phase
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• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas or within Australia (as per previous phases).
o As per previous phases (see Aus 1)
• Isolation of pandemic virus strain for vaccine production.
• PHLN laboratories to endeavour to isolate pandemic virus strain for vaccine production, in collaboration with WHOCC
Non-pharmacological public health measures
• Assess state antiviral stocks. • Assess state and territory antiviral
deployment plans.
• CDU to: o assess stock of antiviral agents in NSW o review deployment plans for antiviral agents from NMS and SMS.
• AHSs to review Area deployment plans for antiviral agents. • Promote use of interpandemic (or
seasonal) and influenza pneumococcal vaccine in high-risk groups (as per previous phases).
• The CHP to promote use of interpandemic (or seasonal) and influenza pneumococcal vaccine in high-risk groups (as per previous phases).
• AHSs to promote pneumococcal and annual influenza vaccination at the local level (as per previous phases).
• Provide antivirals for exposed individuals and cases.
• As per OS 3.
Vaccines and antivirals
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see Aus 1).
(next 6 dot-points as per OS 3) • Review plans for health care delivery. • Consider sites/equipment for designated
influenza hospitals/ fever clinics • Consider sites/equipment for designated
mass quarantine areas. • Review availability of personnel, supplies
and materials for infection control and clinical care.
• As per OS 3. Health care and emergency response
• Review plans for community support. • As per OS 3.
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• For those with exposure to cases, initiate monitoring/education through public health units.
• As per OS 3.
• Disseminate and implement infection control guidelines for human cases and those with exposure to cases (as per previous phases).
• Disseminate and implement detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases (see OS 1).
Communications Next 3 dot-points as per OS 3 • Keep public informed. • Regular communication to public health
network. • Keep poultry industry informed.
• As per OS 3
Pandemic alert period, Overseas 4 phase
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PANDEMIC ALERT - GLOBAL PHASE 4
Goal Contain the new virus within limited foci or delay spread to gain time to implement additional measures, including pandemic strain vaccine development.
(a) Human cases outside Australia (Overseas 4)
Definition Small cluster(s) consistent with limited human-to-human transmission overseas but spread is highly localised, suggesting the virus is not well adapted to humans.
Action Roles And Responsibilities
Planning and coordination
• Assess preparedness status and identify immediate actions to fill gaps (as per previous phases).
• As per previous phases (Aus 2).
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• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0).
• Data collection and epidemiological analysis on suspect, possible and confirmed cases in those with travel history in affected area through OCRS (as per OS 3).
• As per OS 3
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per previous phases).
• Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO (as per previous phases).
• As per previous phases (see Aus 1).
• Ensure laboratories can safely test samples for pandemic strain and forward to WHOCC (as per previous phases).
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas (as per previous phases).
• As per previous phases (see OS 3).
• Identification of laboratories for diagnosis of new strain – distribution of reagents (as per OS 3).
• As per OS 3
Monitoring and Surveillance
• Border entry screening for influenza-like illness in travellers from affected regions (positive pratique, health declaration cards, thermal scanning, nurse assessments).
• The management of border issues is the responsibility of Australian Government agencies.
• NSW Health to respond to requests from the Australian Government regarding border entry screening.
• AHSs to respond to requests for resources from NSW Health regarding border exit screening, e.g., supplying health care workers for screening incoming passengers.
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Non-pharmacological public health measures
(next 3 dot-points as per previous phases) • Prepare materials and equipment required for urgent deployment at the
declaration of particular phases of a pandemic. • Agree on key essential services to target for additional infection protection
measures during an influenza pandemic (i.e., PPE and antivirals). • Identify personnel for designated essential services teams in these
services.
• As per previous phases (see Aus 0).
• Promote use of pneumococcal vaccine and interpandemic (or seasonal) and influenza (if still in production) vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 3).
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see Aus 1).
Vaccines and antivirals
• Provide antivirals for border workers, health care workers, exposed individuals, and cases.
• CDB to collaborate with PHUs and managers of health care facilities to ensure antiviral agents are supplied to: o border workers, health care workers at risk
for exposure, and exposed individuals (for prophylaxis)
o cases (for treatment). • PHUs to: o coordinate distribution of antiviral agents to
exposed individuals o collaborate with health care facilities
administrators to ensure prophylactic antiviral agents are available to health care workers
o collaborate with managers at borders to ensure prophylactic antiviral agents are available to border workers at risk for exposure
o collaborate with clinicians to ensure antiviral agents are available to cases.
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• Review readiness of deployment strategies for antivirals and vaccines. • Organise storage of vaccine and antivirals.
• CDU to: o review readiness of state deployment
strategies for vaccines (in collaboration with AIDB), and antivirals
o ensure plans are in place for storage of vaccines and antivirals from the national medical stockpile (NMS).
• AHS to review readiness of Area storage and deployment strategies for vaccines and antivirals
(next 6 dot-points as per previous phases) • Review plans for health care delivery • Consider sites/equipment for designated influenza hospitals/ fever clinics. • Consider sites/equipment for designated mass quarantine areas. • Review availability of personnel, supplies and materials for infection control
and clinical care.
• CDU to: o review plans for state-wide health care
delivery o in collaboration with AHSs, consider
sites/equipment for designated influenza hospitals/ fever clinics
o consider sites/equipment for designated mass quarantine areas
o review plans for maintaining workforce surge capacity
o review contents of the SMS and upgrade if necessary.
• CDB to collaborate with CDU to consider sites/equipment for designated influenza hospitals/ fever clinics (as per previous phases).
• Review plans for community support. • As per previous phases (see OS 3). • For those with exposure to cases, initiate monitoring/education through
public health units. • As per previous phases (see OS 3).
Health care and emergency response
• Update and disseminate infection control guidelines for human cases and those with exposure to cases overseas (as per OS 2).
• Update and disseminate detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases (see OS 2).
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• Activate contingency plans for system case management capacity. • Update and reinforce alert messages to health care facilities and work
force. • Initiate contact quarantine.
• NSW Health to activate contingency plans for system case management capacity.
• CDB to coordinate the communication of alert messages to health care facilities and work force.
• PHU to coordinate the monitoring/education of those with exposure to cases, who will now be required to be quarantined (preferably at home).
Next 2 dot-points as per previous phases. • Keep public informed. • Regular communication to health workforce.
As per previous phases (see OS 3) Communications
• Inform medical practitioners. • CHO to write to write to all doctors updating and informing them.
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(b) Human cases within Australia (Aus 4)
Definition Small cluster(s) consistent with limited human-to-human transmission in Australia but spread is highly localised, suggesting the virus is not well adapted to humans.
Action Roles And Responsibilities
• Assess preparedness status and identify immediate actions to fill gaps (as per previous phases).
• As per previous phases (Aus 2). Planning and coordination
• Consider activating NSW HEALTHPLAN. • State HSFAC to consider activating NSW HEALTHPLAN. • If NSW HEALTHPLAN activated, the Health Services Disaster Control
Centre at (HSDCC) and the Public Health Emergency Operations Centre (PHEOC) to be made operational.
• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0).
• Data collection and epidemiological analysis on suspect, possible and confirmed cases in those with travel history in affected area through OCRS (as per previous phases).
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per previous phases).
• Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO (as per previous phases).
• As per previous phases (see OS 3). As per previous phases (see Aus 1).
Monitoring and Surveillance
• Surveillance of influenza-like illness in health care workers exposed to suspect, probable or confirmed pandemic influenza cases or their specimens.
• CDB to review and update strategy for surveillance of influenza-like illness in exposed health care workers and disseminate it to PHUs.
• PHUs to collaborate with health care facility managers to introduce a surveillance system for influenza-like illness in exposed health care workers.
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• Ensure laboratories can safely test samples for pandemic strain and forward to WHOCC (as per previous phases).
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas and in Australia (as per previous phases).
• As per previous phases (see OS 3).
• Isolation of pandemic virus strain for vaccine production (as per Aus 3).
• As per Aus 3.
• Border screening for influenza-like illness in travellers from affected regions (positive pratique, health declaration cards, thermal scanning, nurse assessments) (as per OS 4).
• As per OS 4.
• Consider internal regional quarantine measures (e.g., isolation of a town or region).
The decision to implement internal quarantine measures would be made by the Australian Government on advice from the Director of Human Quarantine (DHQ) and carried out under powers of the Quarantine Act 1908. The decision would be communicated to the states and territories via the AHDMPC. The State Emergency Operations Centre Controller (SEOCON) would be responsible for implementing these measures within a whole-of-government framework.
Non-pharmacological public health measures
• Assess state antiviral stocks (as per Aus 3). • Assess state and territory antiviral deployment plans
(as per Aus 3).
• As per Aus 3.
• Promote use of pneumococcal vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 0).
• Provide antivirals for border workers, health care workers, exposed individuals, and cases (as per OS4).
• As per OS 4.
Vaccines and antivirals
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see Aus 1).
Health care and emergency response
• Activate designated influenza hospitals, fever clinics. • The State HSFAC will decide on the timing of activation of designated influenza hospitals and fever clinics.
• AHS to bring on-line designated influenza hospitals and fever clinics.
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(next 3 dot points as per OS 4) • Activate contingency plans for system case
management capacity. • Update and reinforce alert messages to health care
facilities and work force. • Implement contact quarantine.
• As per OS 4.
• Disseminate and implement infection control guidelines for human cases and those with exposure to cases (as per previous phases).
• Disseminate and implement detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases (see OS 1).
• Keep public informed (as per previous phases).
• As per previous phases (see OS 3) Communications
• Keep health care workforce informed • CHP to provide regular communication to health workforce.
Pandemic alert period, Overseas 5 phase
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PANDEMIC ALERT - GLOBAL PHASE 5
Goal Maximise efforts to contain or delay spread, to possibly avert a pandemic and to gain time to implement pandemic response.
(a) Human cases outside Australia (Overseas 5)
Definition Larger cluster(s) but human-to-human spread still localised overseas, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk).
Action Roles And Responsibilities
Planning and coordination
• Assess preparedness status and identify immediate actions to fill gaps (as per previous phases).
• As per previous phases (Aus 2).
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• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0).
• Initiate sentinel surveillance if out of influenza season. • If out of the influenza surveillance season: o CDB to coordinate the initiation of those
components of the system that are currently inactive
o PHUs to respond at a local level to a request by CDB to initiate those components of the influenza surveillance system that are currently inactive.
• Data collection and epidemiological analysis on suspect, possible and confirmed cases in those with travel history in affected area through OCRS (as per previous phases).
• As per previous phases (see OS 3).
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per previous phases).Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO (as per previous phases).
• As per previous phases (see Aus 1).
• Ensure laboratories can safely test samples for pandemic strain and forward to WHOCC (as per previous phases).
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas (as per previous phases).
• As per previous phases (see OS 3).
Monitoring and surveillance
• Border screening for influenza-like illness in travellers from affected regions (positive pratique, health declaration cards, thermal scanning, nurse assessments) (as per previous phases).
• As per previous phases (see OS 4).
• Consider internal regional quarantine measures (e.g., isolation of a town or region) (as per Aus 4).
• As per Aus 4. Non-pharmacological public health measures
• Assess state antiviral stocks (as per previous phases) • Assess state and territory antiviral deployment plans (as per previous phases)
• As per previous phases (see Aus 3).
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Vaccines and antivirals
• Promote use of pneumococcal vaccine in high-risk groups (as per previous phases).
• Provide antivirals for border workers, health care workers, exposed individuals, and cases (as per previous phases).
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see Aus 0). • As per previous phases (see OS 4).
• As per previous phases (see Aus 1).
• Consider sites/equipment for designated influenza hospitals/ fever clinics (as per previous phases).
• As per previous phases (see OS 3).
• Update and disseminate and implement infection control guidelines for human cases and those with exposure to cases overseas (as per previous phases).
• Update and disseminate and implement detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases (see OS 2).
Health care and emergency response
(next 3 dot-points as per OS 4 and Aus 4) • Activate contingency plans for system case management capacity. • Update and reinforce alert messages to health care facilities and work force. • Initiate contact quarantine
• As per previous phases (see OS 4).
• Keep public informed (as per previous phases). • As per previous phases (see OS 3). Communications • Keep health care workforce informed • As per Aus 4.
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(b) Human cases within Australia (Aus 5)
Definition Larger cluster(s), but human-to-human spread still localised in Australia, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk).
Action Roles And Responsibilities
Planning and coordination
• Consider activation of NSW HEALTHPLAN (if not already activated) (as per Aus 4).
• As per Aus 4.
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• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0)
• Data collection and epidemiological analysis on suspect, possible and confirmed cases in those with travel history in affected area through OCRS (as per previous phases).
• As per previous phases (see OS 3)
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per previous phases).
• Investigate within 24 hours all reports of possible human cases with an epidemiological link to affected areas using national guidelines, in consultation with WHO (as per previous phases).
• As per previous phases (see Aus 1)
• Surveillance of influenza-like illness in health care workers exposed to suspect, probable or confirmed pandemic influenza cases or their specimens (as per Aus 4).
• As per Aus 4
• Ensure laboratories can safely test samples for pandemic strain and forward to WHOCC (as per previous phases).
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in travellers returning from high-risk areas overseas and in Australia (as per).
• As per previous phases (see OS 3)
• Isolation of pandemic virus strain for vaccine production (as per previous phases).
• As per previous phases (see Aus 3)
Monitoring and surveillance
• Border exit and entry screening screening
• NSW Health to respond to requests for assistance from the Australian Government regarding border exit and entry screening.
• AHS to respond to requests for resources from NSW Health regarding border exit and entry screening, e.g., supplying health care workers for screening of incoming passengers.
Non-pharmacological public health
• Consider internal regional quarantine measures (e.g., isolation of a town or region) (as per Aus 4).
• As per Aus 4.
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measures • Consider measures to increase social distance (e.g., school and work closures, limiting mass gatherings).
• The decision to implement measures to increase social distance would be made by the SEOCON on advice from the State HSFAC. The SEOCON would be responsible for implementing such measures within a whole-of-government framework.
• Promote use of pneumococcal vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 0).
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see Aus 1).
Vaccines and antivirals
• Provide antivirals for agreed priority groups. • CDB to: o collaborate with CDU, PHUs, and governing bodies of relevant
agreed antiviral priority groups regarding distribution of antiviral agents
o ensure antiviral agents are supplied to agreed priority groups. • PHUs to coordinate distribution of antiviral agents to agreed priority
groups • Activate designated influenza hospitals and fever clinics
(as per Aus 4). • As per Aus 4.
(next 3 dot-points as per previous phases) • Activate contingency plans for system case
management capacity. • Update and reinforce alert messages to health care
facilities and work force. • Implement contact quarantine.
• As per previous phases (see OS 4).
Health care and emergency response
• Disseminate and implement infection control guidelines for human cases and those with exposure to cases (as per previous phases).
• Disseminate and implement detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases (see OS 1).
• Keep public informed (as per previous phases). • As per previous phases (see OS 3). Communications • Keep health care workforce informed • As per Aus 4.
Pandemic period, Overseas 6 phase
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PANDEMIC - GLOBAL PHASE 6
Goal Delay of entry of pandemic virus into Australia; containment of human outbreaks once Australia is affected; while chains of transmission are still identifiable, to delay rate of spread; and, once pandemic is established in Australia, maintain essential services.
(a) Human cases outside Australia (Overseas 6)
Definition Increased and sustained transmission in the general population overseas.
Action Roles And Responsibilities
• Assess preparedness status and identify immediate actions to fill gaps (as per previous phases).
• As per previous phases (Aus 2). Planning and coordination
• Consider activation of NSW HEALTHPLAN (if not already activated) (as per previous phases).
• As per previous phases (see Aus 4)
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• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• As per previous phases (see Aus 0).
• Initiate sentinel surveillance if out of ‘ influenza season’ (as per OS 5). • As per OS 5. • Data collection and epidemiological analysis on suspect, possible and
confirmed cases through OCRS (as per previous phases). • As per previous phases (see OS 3).
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per previous phases).
• As per previous phases (see OS 1).
• Investigate within 24 hours all reports of possible human cases. • CDB to collaborate with PHUs to ensure all reports of possible cases are appropriately investigated (within 24 hours), and suspect, possible and confirmed cases reported through OCRS.
• PHUs to: o investigate immediately, and report to CDB
on the same day, all reports of possible human cases
o report to CDB all data relating to suspect, possible and confirmed cases.
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in those from high-risk areas overseas or within Australia (as per previous phases).
• As per previous phases (see. OS 3).
Monitoring and Surveillance
• Border screening for influenza-like illness in travellers from affected regions (positive pratique, health declaration cards, thermal scanning, nurse assessments) (as per previous phases).
• As per previous phases (see OS 4).
Non-pharmacological public health measures
• Implement mass quarantine measures at international borders, if requested by the Australian Government.
• State HSFAC to liaise with SEOCON to implement mass quarantine measures at international borders, if requested.
• Promote use of pneumococcal vaccine in high-risk groups (as per previous phases).
• As per previous phases (see Aus 1). Vaccines and antivirals
• Maintain register of individuals administered antivirals (as per previous phases). • As per previous phases (see Aus 1).
Pandemic period, Overseas 6 phase
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• Provide antivirals for agreed priority groups (as per Aus 5). • As per Aus 5.
• Review NMS deployment strategies. • Review vaccine deployment strategies. • Pandemic vaccination, when available.
• CDU to review the state deployment strategy for NMS (including pandemic vaccine if available).
• If pandemic vaccine if available, CHP to activate state pandemic vaccination plan.
• AHSs: o to review local vaccine deployment strategies o if pandemic vaccine is available, AHSs to
activate local pandemic vaccination plan. • Consider sites/equipment for designated influenza hospitals and fever clinics
(as per previous phases). • As per previous phases.
• Update and disseminate and implement infection control guidelines for human cases and those with exposure to cases overseas (as per previous phases).
• Update and disseminate and implement detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases.
Health care and emergency response
• Activate contingency plans for system case management capacity. • Update and reinforce alert messages to health care facilities and work force.
• As per previous phases.
• Keep public informed (as per previous phases). • As per previous phases (see OS 3). Communications • Keep health care workforce informed. • As per previous phases (see Aus 4).
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(b) Early pandemic phase in Australia (Aus 6a)
Definition Increased and sustained transmission in the general population in Australia, but cases are still localised to one area of the country.
Action Roles And Responsibilities
Planning and coordination
• Activate NSW HEALTHPLAN (if not already activated) (as per previous phases). • As per previous phases (see Aus 4).
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• Maintain routine influenza surveillance through sentinel GPs and NNDSS (as per previous phases).
• Initiate/maintain sentinel surveillance if out of ‘influenza season’ (as per previous phases).
• As per previous phases (see Aus 0).
• Facilitate studies to measure effectiveness of antivirals and/or vaccines and adverse events associated with antiviral and/or vaccine use.
• CDB to collaborate with PHUs to facilitate the conduct of studies to measure effectiveness of antivirals and/or vaccines and adverse events associated with antiviral and/or vaccine use.
• Data collection and epidemiological analysis on suspect, possible and confirmed cases through OCRS (as per previous phases).
• Passive reporting of unusual clusters of influenza-like illness or acute respiratory disease (as per previous phases).
• As per previous phases.
• Surveillance of influenza-like illness in health care workers exposed to suspect, probable or confirmed pandemic influenza cases or their specimens (as per Aus 4).
• As per Aus 4.
• Hospital-based surveillance. • Monitor absenteeism among essential services personnel.
• CDB to collaborate with: o PHUs to devise strategies for
hospital-based surveillance. o essential services to establish a
system for monitoring absenteeism.
• PHUs to collaborate with hospitals regarding the introduction and collection of data relating to hospital-based surveillance.
Monitoring and Surveillance
• Laboratory surveillance to monitor influenza virus isolates and detect local novel influenza strains in those from high risk areas overseas or within Australia (as per previous phases).
• As per previous phases.
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• Additional laboratory resources operational and resourced. • NSW Microbiology Laboratory Network to devise strategies to ensure laboratories are adequately resourced and operational.
• AHSs to activate additional laboratory resources, as required.
• Border screening for influenza-like illness in travellers from affected regions (positive pratique, health declaration cards, thermal scanning, nurse assessments) (as per previous phases).
• As per previous phases (see OS 4).
• Border exit screening (of travellers to unaffected countries). • As per Aus 5. Non-pharmacological public health measures
• Consider measures to increase social distance (e.g., school and work closures and limiting mass gatherings) (as per Aus 5).
• AS per Aus 5.
• Promote use of pneumococcal vaccine in high-risk groups at the local level (as per previous phases).
As per previous phases (see Aus 1).
• Pandemic vaccination (as per OS 6). • As per OS 6
Vaccines and antivirals
• Antivirals for agreed priority groups (as per previous phases). • Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see Aus 5).
• Activate designated influenza hospitals and fever clinics (as per Aus 4 and 5). • As per previous phases (see Aus 4) • Activate contingency plans for system case management capacity (as per previous
phases). • Update and reinforce alert messages to health care facilities and work force (as per
previous phases).
• As per previous phases. Health care and emergency response
• Disseminate and implement infection control guidelines for human cases and those with exposure to cases (as per previous phases).
• Disseminate and implement detection and clinical care guidelines for human cases (as per previous phases).
• As per previous phases.
• Keep public informed (as per previous phases). • As per previous phases (see OS 3). Communications • Keep health care workforce informed. • As per previous phases (see Aus 4).
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(c) Early pandemic phase in Australia (Aus 6b)
Definition Increased and sustained transmission in the general population in Australia; cases occurring in multiple regions of the country.
Action Roles And Responsibilities
Planning and coordination
• Change strategy from containment to maintenance of essential services.
• All of health sector to change to maintenance of essential services strategy.
• Surveillance through routine and hospital-based systems.
• CDB to: o maintain routine influenza surveillance (as per previous phases). o record and analyse hospital-based surveillance data received from
PHUs. • PHUs to: o collate data from GPs involved in the GPSS and forward to CDB (as per
previous phases). o collate data from hospitals involved in hospital-based surveillance and
forward to CDB. • Monitor absenteeism among essential services
personnel (as per Aus 6a). • As per Aus 6a.
Monitoring and Surveillance
• Selected laboratory surveillance to isolate local pandemic influenza virus to compare with vaccine strains and assess susceptibility to antiviral drugs.
• PHLN laboratories to collaborate with WHOCC to isolate local pandemic influenza virus to compare with vaccine strains and assess susceptibility to antiviral drugs
Non-pharmacological public health measures
• Consider measures to increase social distance (e.g., school and work closures and limiting mass gatherings) (as per Aus 5).
• As per Aus 5.
Vaccines and antivirals
• Pandemic vaccination (as per previous phases).
• As per previous phases (see OS 6).
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• Provision of antivirals for agreed priority groups. • HSDCC to take heed of change to the overarching strategy from containment to maintenance of essential services, and change state antiviral strategy accordingly
• CDB to collaborate with CDU and governing bodies of relevant agreed antiviral priority groups to coordinate state-wide distribution of antiviral agents (as per Aus 5 and OS 6).
• PHUs to collaborate with CDB and local governing bodies of relevant agreed antiviral priority groups to coordinate local distribution of antiviral agents (as per Aus 5 and OS 6).
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases.
( next 5 dot-points as per previous phases) • Activate designated influenza hospitals, fever clinics. • Activate contingency plans for system case
management capacity. • Update and reinforce alert messages to health care
facilities and work force. • Disseminate and implement infection control
guidelines for human cases and those with exposure to cases.
• Disseminate and implement detection and clinical care guidelines for human cases.
• As per previous phases. Health care and emergency response
• Review feasibility of contact tracing. • Review contact quarantine.
• CDB to liaise with PHUs to determine the feasibility of continuing with contact tracing and quarantine.
• Keep public informed (as per previous phases). • As per previous phases (see OS 3). Communications • Keep health care workforce informed. • As per previous phases (see Aus 4).
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(d) Early pandemic phase in Australia (Aus 6c)
Definition Increased and sustained transmission in the general population in Australia but the number of cases subsiding.
Action Roles And Responsibilities
Planning and coordination
• No new actions.
• Surveillance through routine and hospital systems (as per Aus 6b).
• Monitor absenteeism among essential services personnel (as per Aus 6a and 6b).
• Selected laboratory surveillance to isolate local pandemic influenza virus to compare with vaccine strains and assess susceptibility to antiviral drugs (as per Aus 6b).
• As per Aus 6b
Monitoring and Surveillance
PLUS
• Review need for border screening. • Analyse and report on epidemiological and
clinical data to prepare for possible second wave.
PLUS
• In collaboration with Australian Government authorities, CHP to review need for border screening.
• CDB to analyse epidemiological and clinical data to prepare for second wave.
Non-pharmacological public health measures
• Consider measures to increase social distance (e.g., school and work closures and limiting mass gatherings) (as per previous phases).
• As per previous phases (see Aus 5).
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Vaccines and antivirals
• Pandemic vaccination (as per previous phases).
• As per previous phases (see OS 6).
Health care and emergency response
• Provision of antivirals for agreed priority groups (as per Aus 6b).
• As per Aus 6b.
• Keep public informed (as per previous phases).
• As per previous phases (see OS 3). Communications
• Keep health care workforce informed. • As per previous phases (see Aus 4).
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(e) Next wave of pandemic in Australia (Aus 6d)
Definition The next wave of the pandemic has reached Australia indicated by an increase again in the number of cases.
Action Roles And Responsibilities
Planning and coordination
• Assess preparedness status and identify immediate actions to fill gaps (as per previous phases).
• As per previous phases (Aus 2).
Monitoring and Surveillance
• As per Aus 6c. • As per Aus 6c.
Non-pharmacological public health measures
• As per previous phases. • As per previous phases (see Aus 6b).
Vaccines and antivirals
• Pandemic vaccination (as per previous phases).
• Maintain register of individuals administered antivirals (as per previous phases).
• As per previous phases (see .
Health care and emergency response
• As per previous phases. • As per previous phases (see Aus 6b).
• Keep public informed (as per previous phases).
• As per previous phases (see OS 3). Communications
• Keep health care workforce informed. • As per previous phases (see Aus 4).
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6 ANNEXES
ANNEX A: Definitions These definitions should be read in conjunction with those contained in the NSW Public Health Services Supporting Plan
NOTE: The definitions used in this plan are sourced from the NSW State Emergency and Rescue Management Act (1989), as amended, the NSW State Disaster Plan (Displan), and various Functional Area Supporting Plans. Where possible, the reference source is identified as part of the definition e.g., the State Emergency and Rescue Management Act (1989), as amended, is identified as SERM Act.
Area Health Service Area Health Services are the administrative units of the NSW Department of Health, defined by geographical boundaries, which are responsible for the administration of the NSW Department of Health’s policies and responsibilities in that Area.
Area Health Services Functional Area Coordinator (Area HSFAC) An appointed position at Area Health Service level, that has the authority to coordinate and commit all health resources within an Area or region, during activation of the Area Healthplan. The Area HSFAC will be the State HSFAC’s point of contact within an Area Health Service.
Command The authority to command is established by legislation or by agreement with the agency / organisation. Command relates to agencies / organisations only, and operates vertically within the agency / organisation.
Control The overall direction of the activities, agencies or individuals concerned. (Source: SERM Act). Control operates horizontally across all agencies / organisations, functions and individuals. Situations are controlled.
Coordination The bringing together of agencies and individuals to ensure effective emergency or rescue management, but does not include the control of agencies, organisations and individuals by direction. (Source: SERM Act).
Emergency An emergency due to actual or imminent occurrence (such as fire, flood, storm, earthquake, explosion, terrorist act, accident, epidemic or warlike action) which:
endangers, or threatens to endanger, the safety or health of persons or animals in the State, or destroys or damages, or threatens to destroy or damage, any property in the State, being an emergency which requires a significant and coordinated response. (Source: SERM Act)
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For the purposes of the definition of emergency, property in the State includes any part of the environment of the State. Accordingly, a reference in the Act to:
a. threats or danger to property includes a reference to threats or danger to the environment, and
b. the protection of property includes a reference to the protection of the environment.
Emergency Services Organisation The Police Service, Fire Brigades, Rural Fire Service, Ambulance Service, State Emergency Service, Volunteer Rescue Association or any other agency which manages or controls an accredited rescue unit. (source: SERM Act).
Functional Area A category of services involved in the preparations for an emergency, including the following:
• Agriculture and Animal Services • Communication Services • Energy and Utility Supply Services • Engineering Services • Environmental Services • Health Services • Public Information Services • Transport Services • Disaster Recovery Human Services • Functional Area Coordinator
The nominated coordinator of a Functional Area, tasked to coordinate the provision of Functional Area support and resources for emergency response and initial recovery operations, who, by agreement of Participating and Supporting Organisations within the Functional Area, has the authority to commit the resources of those organisations.
Health Commander The Commander appointed by the State or Area HSFAC to coordinate and control all health operations at the site.
Health Emergency An emergency due to actual or imminent occurrence which endangers or threatens to endanger the safety and health of persons in the state of NSW and requires a significant and coordinated whole of health response. This particularly applies to human infectious disease emergencies from whatever cause.
Health Incident A localised event, either accidental or deliberate, which may result in death or injury, which requires a normal response from an agency, or agencies from one or more of the components of NSW Health.
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Health Services Any medical, hospital, ambulance, paramedical, community health or environmental health service or any other service relating to the maintenance or improvement of the health, or restoration to health, of persons or the prevention of disease in or injury to persons. (Health Administration Act, 1982 No 135).
Health Services Disaster Control Centre (HSDCC) Is the state level Health services operations centre and is manned when NSW HEALTHPLAN is activated. The HSDCC incorporates all elements of the strategic level management of an emergency and includes the State Ambulance EOC.
Incident Control System (ICS) An internationally recognised system for managing any type of incident that has been adopted by NSW Health the majority of emergency services throughout Australia (see ANNEX E for more information).
Lead (or combat) Agency The agency identified in Displan as the agency primarily responsible for controlling the response to a particular emergency. Synonymous with “lead” agency.
NSW Department of Health NSW Health is the lead agency for health emergencies within NSW. Five major contributing health service components constitutes the whole of health response incorporating an all-hazards approach. They are:
• Medical Services • Ambulance Services • Mental Health Services • Public Health Services • Health Communications. • Participating Organisations
Statutory authorities, volunteer organisations and other agencies who have given formal notice that that they are willing to participate in the event of an emergency in NSW.
Standing Operating Guidelines The internal response guidelines which document operational and administrative procedures to be followed during activation of this plan.
State of Emergency A state of emergency declared by the Premier under Section 33 (1) of the State Emergency and Rescue Management Act (1989), as amended.
NOTE: Other New South Wales legislation also provides for a declaration of an "emergency" which has different meanings and different authorities within that specific legislation – that is: Essential Services Act, 1988: Dam Safety Act, 1978: and Rural Fires Act, 1997 (as amended).
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State Emergency Management Committee The committee constituted under the State Emergency and Rescue Management Act, 1989 (as amended), as the principal committee established under this Act for the purposes of emergency management throughout the State, and, in particular, is responsible for emergency planning at State level.
State Emergency Operations Controller (SEOCON) The person appointed by the Governor, on the recommendation of the Minister, responsible, in the event of an emergency, which affects more than one District, for controlling the allocation of resources in response to the emergency. The appointee establishes and controls the State Emergency Operations Centre (SEOC). (Source: SERM Act).
State Health Services Functional Area Coordinator (State HSFAC) Is a senior medical officer appointed by the Minister for Health or delegate, who has the responsibility for the control and coordination of the arrangements detailed in NSW HEALTHPLAN. The State HSFAC is contactable 24 hours through the Ambulance Service of NSW.
Supporting Organisations Organisations that have indicated a willingness to participate and provide specialist support resources to an emergency.
Supporting Plans A plan prepared by an agency / organisation or functional area, which describes the support which is to be provided to the controlling or coordinating authority during emergency operations. It is an action plan which describes how the agency / organisation or functional area is to be coordinated in order to fulfil the roles and responsibilities allocated.
Whole-of-Health NSW HEALTHPLAN provides for five major contributing health service components (see NSW Department of Health), which constitutes the whole-of-health response incorporating an all-hazards approach and outlines their agreed roles and functions.
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ANNEX B: Diagram showing the position of the NSW Health Influenza Pandemic Action Plan within the hierarchy of NSW emergency management plans
NSW Displan
CommunicationsPlan
NSW Health Pandemic Influenza Action Plan
Other Special Operating Guidelines
NSW HEALTHPLAN Other supporting plans
Ambulance Plan
Mental Health Plan
Public Health Plan
Medical Plan
Health services supporting plans
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ANNEX C: Command and control arrangements during an influenza pandemic
(a) National.
• The CMO, with advice from an expert advisory group drawn from NIPAC, CDNA and DoHA, is responsible for declaring different phases of the pandemic in Australia. From of the Pandemic Alert period, consideration will be given to forming an lnter-departmental Taskforce (IDETF) and a lead agency chosen. The IDETF would make the key pandemic decisions nationally, with the AHDMPC having the dual role of advising the IDETF and being responsible for advising the states and territories of decisions made by the IDETF.
(b) State.
• During Aus 1-3 phases, the Department of Primary Industries (DPI) would be the lead agency in responding to outbreaks as the emergency would be primarily a concern of the Agricultural Sector. NSW Health would play a supporting with respect to human health issues.
• Consideration for activating NSW HEALTHPLAN will commence at Overseas phase 4. The responsibility for this is vested in the State HSFAC but would only be done in consultation with the CHO who would be advised by the IDEA Group. Once NSW HEALTHPLAN is activated, NSW Health becomes the lead agency.
• The State HSFAC will assume the role of the ‘Incident Controller’, the person who has overall management of the response, and will formulate an Incident Management Team (see ANNEX E: Incident Control System: Background). A major change to the command structure under the arrangements of NSW HEALTHPLAN is that the all personnel of NSW Health and other health services are then responsible to the State HSFAC, rather than to AHS Chief Executives. In addition, all material resources of NSW Health and other Health Services will be available to the State HSFAC to allow an effective response.
• The coordination of the state response will be carried out by the Health Services Disaster Control Committee (HSDCC), which will be chaired by the Incident Controller. The control centre is located at Everleigh, Sydney.
• On activation of NSW HEALTHPLAN, the Public Health Emergency Operating Centre (PHEOC) in North Sydney will be opened and the public health response will be coordinated through this centre. A whole-of-government response would be required in the event of a severe pandemic, and this will be lead by the State Emergency Operations Controller (SEOCON) who will operate from the State Emergency Operations Centre (SEOC). HSDCC would report to it.
• The Health Services Disaster Control Centre at Everleigh will also be made operational to take a monitoring role and provide a link to the State Emergency Operating Centre. This permits a whole-of-health approach within a whole-of-government framework.
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• The five contributing health service components of NSW HEALTHPLAN - Medical Services, Ambulance Services, Mental Health Services, Public Health Services, and Health Communications – all have supporting plans to NSW HEALTHPLAN and these would also be activated. Control of each of these services would be vested in ‘Controllers’. The Public Health Controller would activate the NSW Public Health Disaster Control Centre in North Sydney where coordination of public health services would occur.
(c) Area Health Service.
• AHSs will activate their emergency management plans according to local arrangements.
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Figure: Command and control arrangements during an influenza pandemic.
NSW Arrangements(Upon activation of HEALTHPLAN)
National Arrangements
Premier’s DepartmentMinister for Health
Director General
Chief Health Officer
State Health Services FunctionalArea Coordinator
Public Health Mental Health Medical Communications Ambulance
Infectious Disease EmergencyAdvisory Group
StateEmergencyOperationsController
Dept. Prime Minister andCabinet
Australian Government Inter-Departmental Emergency TaskForce
(consider establishing Overseas 4 phase)>_
Australian Health DisasterManagement Policy Committee Chief Medical Officer
Expert Advisory Group(From CDNA and NIPAC)
Emergency ManagementAustralia
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ANNEX D: Description of the Australian (Aus) and Overseas pandemic phases9 The phases are intended to guide actions rather than be a strict categorisation of the events.
Interpandemic period10
Aus 0 phase: No new11 influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is not present in animals in Australia. Rationale: Influenza subtypes that have caused human infection and/or disease may not always be present in wild birds or other animal species in Australia. The WHO Global Phases do not include a Phase 0 because globally, it is likely that influenza sub-types that have caused human infection/ and or disease will always be present in wild birds or other animal species, but this is not the case in Australia. Lack of recognised animal or human infections does not mean that no action is needed. Preparedness requires planning and action in advance.
Overseas 1 phase: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is present in animals overseas. The risk of human infection or disease is considered to be low. Aus 1 phase: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection or disease is present in animals in Australia. The risk of human infection or disease is considered to be low. Rationale: Although the risk of human infection or disease is considered low, there are actions that differentiate this phase from phase Aus 0. (For example, enhanced surveillance in animals).
Overseas 2 phase: No new influenza virus subtypes have been detected in humans. However, the presence of a circulating animal influenza virus subtype overseas poses a substantial risk of human disease. Aus 2 phase: No new influenza virus subtypes have been detected in humans. However, the presence of a circulating animal influenza virus subtype in Australia poses a substantial risk of human disease. Rationale: Presence of animal infection caused by a virus of known human pathogenicity may pose a substantial risk to human health and justify public health measures to protect persons at risk.
9 From the Australian Management Plan for Pandemic Influenza, June 2005 http://www.health.gov.au/internet/wcms/publishing.nsf/Content/FC517607D6EE443ECA2570190019CDF7/$File/pandemic_plan.pdf (accessed October 2005) . 10 The new WHO phases states that the distinction between phase 1 and phase 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The distinction is based on various factors and their relative importance according to current scientific knowledge. Factors may include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife, whether the virus is enzootic or epizootic, geographically localised and/ or other scientific parameters. 11 WHO defines a new subtype as one which has not been circulated in humans for at least several decades and to which the great majority of the human population therefore lacks immunity.
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Pandemic Alert Period12
Overseas 3 phase: Human infections(s) with a new subtype overseas, but no human- to- human spread, or at most rare instances of spread to a close contact. Aus 3 phase: Human infections(s) with a new subtype in Australia, but no human- to- human spread, or at most rare instances of spread to a close contact. Rationale: The occurrence of cases of human disease increases the chance that the virus may adapt or reassort to become transmissible from human to human, especially if coinciding with a seasonal outbreak of influenza. Measures are needed to detect and prevent spread of disease. Rare instances of transmission to a close contact- for example, in a household or health care setting may occur, but do not alter the main attribute of this phase, i.e. that the virus is essentially not transmissible from human to human. Examples:
1. One or more unlinked human cases with a clear history of exposure to an animal source/ non- human source (with laboratory confirmation in a WHO Collaborating Center);
2. Rare instances of spread from a case to close household or unprotected healthcare contacts without evidence of sustained human to human transmission;
3. One or more small independent clusters of human cases (such as family members) who may have acquired infection from a common source or the environment but for whom human to human transmission cannot be excluded; and
4. Persons whose source of exposure cannot be determined, but are not associated with clusters or outbreaks of human cases.
Overseas 4 phase: Small cluster(s) consistent with limited human – to human transmission overseas but spread is highly localised, suggesting the virus is not well adapted to humans.13 Aus 4 phase: Small cluster(s) consistent with limited human – to human transmission in Australia but spread is highly localised, suggesting the virus is not well adapted to humans.14 Rationale: Virus has increased human- to human transmissibility but is not well adapted to humans and remains highly localised, so that its spread may possibly be delayed or contained.
12 In the WHO new pandemic phases it states that the distinction between phase 3, phase4, and phase 5 is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include rate of transmission, geographical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain), and /or other scientific parameters 13 An unusual cluster of cases or deaths from influenza- like illnesses can be defined as a group of cases (suspected, probably and/or confirmed) of individuals with disease onset within a period of two weeks in a same defined geographical area, presenting with similar clinical features including respiratory symptoms, and for which the epidemiological pattern or clinical features do not correspond to usual observation in cases of infection with seasonal influenza. The unusual observations may include: (i) unusual distribution by age group; (ii) severity of illness in adults in the absence of chronic disease; (iii) disease affecting special risk groups such as individuals exposed to potentially infective live or dead animals, or health care workers. 14 It will not be possible to calculate R0 in the early stages of a cluster; however modelling suggests that for a cluster with these characteristics, 0.4<Ro<1.0
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Examples:
1. One or more clusters involving a small number of human cases, e.g., a cluster of < 25 cases lasting <2 weeks; and
2. Appearance of a small number of human cases in one or several geographically- linked areas without a clear history of a non-human source of exposure, for which the most likely explanation is considered to be human-to-human transmission.
Overseas 5 phase: Larger cluster(s) but human-to-human spread still localised overseas, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk). Aus 5 phase: Larger cluster(s) but human-to-human spread still localised in Australia, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk).
Rationale: The virus is more adapted to humans, and therefore more easily transmissible among humans. It spreads in larger clusters, but spread is localised. This is likely to be the last chance for massive coordinated global intervention, targeted to one or more foci, to delay or contain spread. In view of possible delays in documenting spread of infection during phase 4, it is anticipated that there would be a low threshold for progress to phase 5.
Examples
1. Ongoing cluster-related transmission but total number of cases is not rapidly increasing, e.g., a cluster of 25-50 cases and lasting from 2-4 weeks;
2. Ongoing transmission but cases appear to be localized (remote village, university, military base, island);
3. In a community known to have a cluster, appearance of a small number of cases whose source of exposure is not readily apparent (e.g., beginning of more extensive spread); and
4. Appearance of clusters caused by same or closely related virus strains in one or more geographic areas without rapidly increasing numbers of cases.
Pandemic period
Overseas 6 phase: Increased and sustained transmission in the general population overseas.
Rationale: Major change in global surveillance and response strategy, since pandemic risk is imminent for all countries. The national response is determined primarily by the disease impact within the country. Aus 6a phase: Increased and sustained transmission in the general population in Australia, but cases are still localised to one area of the country. Aus 6b phase: Increased and sustained transmission in the general population in Australia and cases are occurring in multiple regions of the country. Aus 6c phase: Increased and sustained transmission in the general population in Australia and but the number of cases is subsiding. Aus 6d phase: The next wave of the pandemic has reached Australia indicated
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by an increase again in the number of cases. Rationale: Although a pandemic has been declared, because Australia is not as densely populated as other countries, there still exists the opportunity to try to contain the spread of the pandemic. This means that the actions at the different pandemic phases may still vary.
Post-pandemic period
A return to the inter-pandemic period (the expected levels of disease with a seasonal strain) follows, with regularly updated planning. An intensive phase of recovery and evaluation may be required.
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ANNEX E: Incident Control System: Background The incident control system (ICS) is an internationally recognised system for managing any type of incident and has been adopted by the majority of emergency services throughout Australia. The response to a pandemic will be managed according to the principles of ICS and these are outlined here.
Incident Control System (ICS) is a tool used to effectively accomplish the stated objectives relating to an incident.
ICS is a structure of delegation that ensures all vital management and information functions are undertaken to successfully manage an incident.
Two underlying principles of ICS are:
• Management by Objectives. This is a process of consultative management where the management team determines the desired outcomes of the incident.
• Span of Control. This is a concept which relates to the number of groups or individuals which one person can successfully supervise. At emergency incidents a maximum of five (5) reporting groups or individuals is considered to be the optimum, as this maintains a supervisor’s ability to effectively task, monitor and evaluate performance.
The ICS is divided into five (5) functional areas:
• Incident Control. The Incident Controller when NSW HEALTHPLAN is activated is the State HSFAC who controls all state level Health emergency operations. The State Medical Controller will manage the medical services component of a whole of Health response. Under the ICS structure it is the Incident Controller’s responsibility to approve the Incident Action Plan (IAP) that is arrived at through consultation with the five State Controllers.
• Operations. The operations section is established to combat the incident and is responsible for control of operations in accordance with the Incident Action Plan. Operations for each of the five major components of Health will be the responsibility of each of the State Controllers.
• Planning. The planning section is established to support the incident with responsibility for the collection and analysis of incident information, prediction of incident behaviour, maintaining a register to record the location and tasking of resources and the preparation of alternative strategies to control the incident. The State Controllers will appoint personnel to the planning section as appropriate to the operational needs of the emergency.
• Logistics. The logistics section is established to support the incident with responsibility for providing facilities, services and materials. The State Controllers will appoint personnel to the logistics section as appropriate to the operational needs of the emergency.
• Finance. The finance section will normally be established separate to the logistic section during emergencies of a protracted nature to ensure that accurate records of expenditure are kept for the purpose of cost recovery as appropriate.
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The Incident Management Team (IMT) If established, Logistics, Planning and Operations for a health response will work within a “Whole of Health” framework.
The type and scale of the incident does not affect the principles of the ICS. In a very large event such as an influenza pandemic, there will be multiple layers to the response structure e.g., national, state, and regional, but the functions of control, operations, planning, and logistics will operate for all of these layers. The accompanying table shows how the various components of a pandemic response might be grouped into ICS functions, and the key agency responsible for them.
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Table. Grouping of key components of a pandemic response into the Incident Control System’s (ICS) functional areas (from a state perspective). ICS Functional Area
Task Responsible agencies
Control Control, command, and coordination of response
IDEFT (national) HSDCC (state) Area Emergency Management Committees (local)
Communication to public NEMRN (national) Media Unit, NSW Health (state) AHS media units (local)
Communication to HCW and other key stakeholders
The Centre for Health Protection (state) Centre for Epidemiology and Research (state)
Fever clinics/Staging areas CDU (state) HSFAC (local)
Influenza hospitals CDU (state) HSFAC (local)
Laboratory issues PHLN laboratories (state and local) Other public and private laboratories (local)
Case management IDEA Group (state) Clinicians (local)
Community support DOCS (state and local) Area Emergency Management Committees (local)
Border control IDEFT and AQIS (national) CQO (state) AHS mental health services (local)
Operations
Mental health Centre for Mental Health (state) AHS mental health services (local)
Preparing influenza pandemic plans
CDB (state) Area Emergency Management Committees (local)
Surveillance
CDB and Centre for Epidemiology and Research (state) PHUs (local)
Infection control AIDB (state) NSW Infection Control network (local)
Travel advisories DFAT (national) School closure and mass gathering strategy
IDETF (national) HSDCC and Department of Education (state)
Vaccination strategy AIDB and CDU (state) AHS vaccination Coordinators (local) Area Emergency Management Committees (local)
National and state medical stockpiles
DoHA (national) CDU (state)
Workforce surge capacity SEMC and CDU (state) Industry groups (local) Area Emergency Management Committees (local)
Planning
Training CDB and CDU (state) Area Emergency Management Committees (local)
Resource procurement HSDCC Area HSFACs
Patient transportation NSW Ambulance Service, RFDS, CDU (state) Materials and pharmaceuticals transportation
ASNSW, CDU, SEMC (state) Area Emergency Management Committees (local) Logistics
Storage and disposal of dead bodies
CDU (state) Area Emergency Management Committees (local) Funeral services (local)
