Pandemic Roohullah Shabon 09

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Slide 1: 

Ontario’s geography and population covered by 36 local public health agencies • Can be variously referred to a “health units,” “public health units,” “public health departments,” “community health departments Populations from 35,000 to 2.6 million Budgets from 2.8 million to 130+ million Geographic size varies enormously ”

Public Health Core Functions : 

Public Health Core Functions • Population health assessment, e.g. morbidity, mortality, risk factors • Surveillance, e.g. infectious diseases, syndromic patterns • Health promotion, e.g. healthy eating/active living, tobacco use prevention Health protection, e.g. environmental hazards, food/water safety • Disease prevention, e.g. immunization programs, sexual health services • Emergency preparedness and planning, e.g. pandemic planning

Public Health Staffing : 

Public Health Staffing • Local public health agencies headed by Medical Officer of Health Core staff involved in emergency planning and Response Public Health Legislation Relevant to Pandemic Planning: Section 25-27: duty of physicians/RN(EC)/hospital administrators to report cases/carriers of designated reportable diseases to MOH Section 29.1-29.2: MOH authority to issue orders to hospitals / LTCFs to prevent and/or control infectious disease outbreaks • Section 30: duty to report to MOH deaths due to reportable diseases • Section 34: duty to report non-compliance with treatment of a communicable disease • Section 35: MOH application to Ontario Court of Justice if non-compliance with Section 22 order, e.g failure to comply with isolation or quarantine Section 38: duty to report to MOH adverse reactions t immunizations Section 77.1: authority of the CMOH to investigate, prevent and/or eliminate risks to health anywhere in Ontario • Section 77.4: authority of the Minister to requisition facilities for isolation purposes • Section 77.5: authority of the Minister for the emergency procurement of medication and supplies (e.g. anti-virals stockpiled by public or private sector) authority of the CMOH to order the collection, retention and/or use of previously collected specimens necessary to address a risk to health • Section 100: definitions of offences for violation of MOH orders

Public Health Standards Relevanto Pandemic Planning : 

Public Health Standards Relevanto Pandemic Planning The New Ontario Public Health Standards have two key Program Standards relevant to pandemic planning by local public health agencies: • Infectious Diseases Prevention and Control • Public Health Emergency Preparedness Each of the above Program Standards have established Protocols that again specify expectations that will be relevant to pandemic planning and response: • Institutional Outbreak Prevention and Control Protocol • Public Health Emergency Preparedness Protocol

Both the Public Health Emergency PreparednessStandard and Protocol outline what is required bylocal public health agencies, especially as thisrelates to:• Assessment, especially hazard identification/riskassessment• Emergency planning• Risk communication and public awareness• Education, training and exercis : 

Both the Public Health Emergency PreparednessStandard and Protocol outline what is required bylocal public health agencies, especially as thisrelates to:• Assessment, especially hazard identification/riskassessment• Emergency planning• Risk communication and public awareness• Education, training and exercis

Provincial Public Health PandemicEmergency Response : 

Provincial Public Health PandemicEmergency Response In the event of an influenza pandemic, the Ministr of Health and Long Term Care will be the lead provincial Ministry. The following figure from the Ontario Health Plan for an Influenza Pandemic (OHPIP) 2007 articulates the provincial and local/regional roles and responsibilities.

Local Public Health AgencyPandemic Roles and Responsibilities : 

Local Public Health AgencyPandemic Roles and Responsibilities Local public health agency pandemic planning responsibilities largely defined by OHPIP Numerous components of the OHPIP have seen substantial changes and/or developments over the various iterations of the OHPIPs to date, especially in areas such as: – Anti-viral treatment vs. prophylaxis policies – Anti-viral treatment guidelines, distribution and access – Primary care pandemic influenza response, especially numbers of purpose of Flu Assessment Centres – Public health measures – Surveillance measures

The following descriptions of key PH pandemic planning/response rolesand responsibilities are congruent with current iterations of theCanadian and Ontario Pandemic Plans, but are subject to change asfederal and provincial plans evolve : 

The following descriptions of key PH pandemic planning/response rolesand responsibilities are congruent with current iterations of theCanadian and Ontario Pandemic Plans, but are subject to change asfederal and provincial plans evolve Business continuity planning • Planning specific to key responsibilities, especially: – Surveillance – Risk communication/public education – Public health measures – social distancing – Mass immunization clinics – Mass casualty plans Support for primary care pandemic planning, especially the need for temporary Flu Assessment Centres • Support for local planning re. anti-viral distribution and use • Coordination of cross-sectoral pandemic planning within the health unit jurisdiction (assists and coordinates, DOES NOT do the planning for other sectors, e.g. hospitals, LTCFs, primary care, etc.) Establishment of health/health-related sector Emergency Control Group structure and functions • Promotion of personal/family emergency preparedness

Pandemic Influenza BusinessContinuity Planning (BCP) : 

Pandemic Influenza BusinessContinuity Planning (BCP) 2 Incumbent upon all public sector organizations, strongly urged/advised for private sector BCP has the following planning components: • Infection prevention and control practices, resources, materials and supplies (to safeguard and reduce the impacts on pandemic influenza on staff) • Internal communication strategies, audiences and channels – pre-pandemic, intra-pandemic and post-pandemic

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Definition of essential (must be provided), required (can be reduced in intensity or frequency but should still be provided) and non-essential (can be deferred/cancelled during the peak periods of pandemic activity) programs and services • Staff deployment/re-deployment policies in light of the above, including development of job action sheets, training, etc. for staff re-deployed from less-essential to essential programs and services

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HR policies and practices to address re-deployment and alternative work demands, e.g. tele-work options • As an example, for the Niagara Region Public Health Infectious Diseases Program, the following routine, non-pandemic activities are considered essential in the event of a pandemic: – Case and contact management of selected reportable infectious diseases, e.g. E. coli, hepatitis A, meningococcal infections, invasive Group A strep – Case and contact management of pulmonary TB (not extra-pulmonary cases) – Yellow Fever travel vaccinations – Institutional outbreaks (non-pandemic, e.g. enteric) – Community outbreaks (non-pandemic, e.g. foodborne

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Non-essential program activities that could be curtailed/significantly scaled back: • Travel clinic counseling and immunization clinics • Case/contact management of other reportable IDs, e.g. enteric infections • Social marketing/public education activities (unless related to pandemic) • Hepatitis C case management • Routine committee/liaison work, e.g. non-outbreak-related IP&C Committee meetings Estimating numbers of management and staff to address essential programs and services results in additional staff numbers that can be allocated to pandemic response activities

Surveillance for PandemicInfluenza Activity : 

Surveillance for PandemicInfluenza Activity Surveillance is the ongoing collection, analysis and interpretation of health data, with timely dissemination of these results to guide prevention and response activities Essential to determine the arrival, spread and impacts of/consequent response to pandemic influenza at a local level Pandemic influenza surveillance activities will be a key activity of local public health agencies, with regular reporting to the Ministry allowing an accurate, timely and complete provincial picture of pandemic activity and impacts

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32 The following types of surveillance will form a comprehensive surveillance approach to pandemic influenza: • Lab/virology surveillance: to detect pandemic strains, monitor antigen drift, assess anti-viral resistance patterns, detect non- pandemic respiratory viruses that could also be causing ILI illnesses/outbreaks • Disease/epidemiologic surveillance: to monitor disease activity levels, subpopulations at risk, hospitalization and case fatality rates, etc. • Vaccine/anti-viral uptake surveillance: to monitor, evaluate and adapt guidelines for the use/re-allocation of vaccines and anti-viral supplies • Adverse events surveillance: as they relate to vaccine and/or anti-viral use

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Surveillance during Phase 6.2, i.e. confirmed, widespread pandemic influenza activity in Ontario, will depend on the following local data sources: • Lab reports of confirmed influenza cases • Flu assessment centre daily visit reports • Sentinel primary care reporting of daily ILI rates • Hospital reports of daily ER visits, admissions and deaths • Institutional reports of ILI outbreaks • School/workplace ILI absenteeism data • Physician/institutional reports of adverse events to anti-virals/vaccines

Pandemic PlanningAssessment CentrePlanning and Implementation : 

Pandemic PlanningAssessment CentrePlanning and Implementation Objectives: To meet the population’s need for influenza assessment, treatment and referral services. To provide a timely way to assess people with symptoms of influenza-like illness and to identify those who need hospital care.

Planning Assumptions : 

Planning Assumptions The CHC is responsible for leading the establishment of Flu Centres. No single group or organization will be able to absorb the projected number of people who will develop signs or symptoms of influenza-like illness. The public will need information to understand how to access the health care system. Due to the pandemic, many routine public health activities will be curtailed, allowing Sudbury and District Health Unit staff to be re-deployed to assist with the establishment and maintenance of support assessment centres. Health care workers will need to focus on those aspects of assessment and treatment of ill individuals that require their expertise. • Volunteers will play an important part in supporting people with influenza in the community

Components Developed : 


Criteria For Opening FluCentres : 

Criteria For Opening FluCentres 20 Confirmation of a moderate or severe pandemic in a neighboring area Projection of surge demand on the Sudbury Regional Hospital exceeds capacity Proportion of influenza cases requiring hospitalization Reports from physicians or walk-in clinics that they cannot accommodate all patients requesting appointments for influenza-like illness Estimating the length of time required to set-up a Flu Centre

Primary Care PandemicPlanning/Flu Assessment Centres : 

Primary Care PandemicPlanning/Flu Assessment Centres Primary care needs during a pandemic expected to come from a variety of sources: • Self-care, assisted by web-based and other education modalities • Tele-health • Primary care practices • Flu assessment centres • Hospital ERs

Slide 22: 

OHPIP 2007 and earlier versions made certain assumptions re. the capacity of the primary care system to remain functional and absorb the additional clinical ILI load imposed by the pandemic, leading to a systematic plan to address primary pandemic care needs via influenza assessment centres (IAC).

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These IACs would be geographically dispersed, fully staffed to provide maximal access, provide initial assessment, treatment and referral services for local populations with ILI, thus safeguarding hospital resources and capacity, especially ERs

Slide 24: 

The OHPIP 2007 saw most of primary ILI care being provided by IACs, although the responsibility for planning this infrastructure remained unclear, was assigned in some instances to local public health agencies, and had areas of residual planning uncertainty: • Siting and staffing/HR/training issues • Compensation, disability and life insurance issues for professional staff • Liability protection for staff providing clinical assessments beyond their normal scope of supervision/practice

Slide 25: 

Recent re-visiting of pandemic planning assumptions has reassessed the capacity of the primary care system to undertake business continuity planning and accommodate much of the need for primary ILI assessment and treatment. • The 2008 version of the OHPIP has proposed a more limited role for IACs, while bolstering the capacity of the primary care to respond to pandemic assessment, treatment and referral needs.

Slide 26: 

IACs will have a more limited role to address the healthcare needs of populations without access to primary care practitioners, and to provide primary care surge capacity for the peak weeks of the first pandemic wave when primary care may not be able to cope with clinical demands. • Responsibilities for planning of this revised set of expectations for IAC infrastructure remains to be determined, could be vested with local public health agencies, but may be the expectation of other local health system actors such as hospitals or LHINs.

Infection Control : 

Infection Control Providing education Ensuring hand hygiene supplies (i.e. alcohol- based hand rub) are readily available Posting signs about routine infection prevention and control measures (i.e. hand hygiene, cough etiquette) Providing guidance on personal protective practices and equipment

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Establishing and maintaining cleaning procedures and a regular cleaning schedule for workspace and equipment that will support the operation of the Flu Centre • Working with other health care workers in the community to implement and reinforce an awareness campaign about routine infection prevention and control practices that can prevent the spread of respiratory illness

Transportation : 

Transportation The transportation protocol for the transfer of patien to and from a Flu Centre to an acute care facility i as follows: • The facilitating nurse or designate will coordinate the transport. • Precautions will be taken in preparation for transport • All medications/equipment not directly attached to the patient and required for patient care must be transported in a biohazard bag • Patients will follow a specific transfer route

Risk Communication andPublic Education : 

Risk Communication andPublic Education Local MOH will have a key role in terms of risk communication and public education Messaging will require close coordination with and complement provincial risk communication/public education efforts Local messaging will need to be cognizant of the daily Ministry information cycle

Topics likely to be addressed could includethe following: : 

Topics likely to be addressed could includethe following: • Updates on the local spread, extent and impacts of the pandemic • Infection prevention and control measures to be used i the home/community • Options for assessment and treatment of ILI • Care/treatment options for ill family members • Implementation of/alterations to public health measures, e.g. school closures, cancellation of community gatherings/functions, etc. • Location/hours of operation of mass immunization clinics

Public Health Measures : 

Public Health Measures Non-medical interventions used to reduce the spread of pandemic influenza, slow the rate of progression of the pandemic and reduce overall morbidity and mortality • Involve such measures as: • Public education • Travel advisories/restrictions, screening of travelers • Case and contact management • Social distancing measures

Slide 33: 

PH measures seek to implement interventions that are effective, feasible and acceptable, clear in their timing and duration, while seeking to minimize adverse social, economic and political consequences • Because of the likely widespread nature of pandemic activity and impacts, decisions to implement PH measures will be made by CMOH in consultation with local MOHs and others, although timing of implementation and duration of measures will depend on variations in local pandemic epidemiology across health unit jurisdictions

Slide 34: 

Full set of definitions and descriptions of PH measures found in Table 6.1 of OHPIP 2008 Types and intensity of PH measures to be determined by severity of pandemic influenza as assessed by case fatality rates (CFR): • CFR <0.1% - mild pandemic • CFR 0.1 to <1% - moderate pandemic • CFR 1% or higher - severe pandemic

Slide 35: 

PH measures should be based on evidence of effectiveness, as derived from: • Evaluations of previous pandemic interventions • Knowledge of pandemic epidemiology (e.g. infectiousness during incubation period, principle modes of transmission) • Modeling of impacts of interventions • U.S. Centres for Disease Control have judged the following PH measures to have evidence of effectiveness: • Hand hygiene • Social distancing strategies in child care facilities • School closures + other measures to disrupt youth networks • Low cost social distancing measures to disrupt adult networks • Closure of major airport hubs (vs. smaller airports)

Mass Immunization Clinics : 

Mass Immunization Clinics 10 Pandemic influenza vaccination may not be available for significant prevention/control of the first pandemic wave, but could be essential for preventing/reducing subsequent pandemic waves Availability of pandemic vaccine will depend on a number of factors: • Particular strain of pandemic influenza and ability to use this strain to produce vaccine using established technical methods • Production capacity and international decisions re. vaccine distribution • Decisions made at federal and provincial levels re. priority groups for initial vaccination vs. community-wide access to vaccination • Effectiveness of one vs. two-dose vaccine strategies

Slide 37: 

Canadian and provincial pandemic plans have still not finalized decisions re. initial access of priority groups (e.g. healthcare workers, public safety workers, critical infrastructure staff) to pandemic vaccine vs. broader community access Local public health agency pandemic plans have all included mass immunization clinic components, to assure that they are capable of vaccinating the general populations within their jurisdictions when sufficient quantities of pandemic vaccine become available These mass vaccination plans assess sites/location, vaccination clinic structure and staffing, data/information systems, logistics and supplies, communications plans, security measures, etc. • Assume that priority groups will have initial access to pandemic vaccine, using “push” mechanisms, i.e. distribution of vaccine to their institutions/organizations where there is the capacity to assess, provide vaccinations and screen for adverse events, thus reduce demands on local public health systems

Public Health PandemicPlanning – Challenges : 

Public Health PandemicPlanning – Challenges Plethora of unresolved pandemic planning issues at the national and provincial level, that impede local-region-wide planning, e.g. anti-viral treatment vs. prophylaxis policies and priorities, professional regulatory and liability issues Substantive changes between versions of the OHPIP that have significant effects on local/region-wide planning, e.g. changing emphasis/expectations on IACs Getting plans beyond the initial conceptual structures and down to the detailed, integrated and operational levels that will be needed Assuring that region-wide plans are fully reviewed re their complementarities, comprehensiveness and compatibility of assumptions, e.g. not assuming logistic support in certain plans from other sectors when those sectors haven’t built such support projections into their own plans Different levels of understanding and commitment across diverse public and private sector entities that need to be involved in pandemic planning Huge challenges in realistically exercising local and region-wide pandemic plans

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