TORONTO PUBLIC HEALTH PLAN FOR AN INFLUENZA PANDEMIC. Toronto Public Health Plan for an Influenza Pandemic

TORONTO PUBLIC HEALTH PLAN FOR AN INFLUENZA PANDEMIC Toronto Public Health Plan for an Influenza Pandemic June 2014

TABLE OF CONTENTS CHAPTER 1 INTRODUCTION/CONTEXT... 4 General Planning Assumptions... 5 Vaccine-specific Planning Assumptions... 6 Risk Scenarios... 7 Roles of Organizations... 9 Guiding principles... 12 CHAPTER 2 PREPAREDNESS... 14 Toronto Public Health Emergency Plan (TPHEP)... 14 Functional Components... 14 Networks and Partners... 14 On-going TPH pan flu preparedness... 15 Other preparedness... 16 CHAPTER 3 RESPONSE... 17 OHPIP Public Health Unit responsibilities... 17 Incident Management System (IMS) Functional Component... 20 CHAPTER 4 RECOVERY... 21 IMS and Recovery... 21 Recovery Phase Focus... 21 CHAPTER 5 MAINTENANCE PLAN... 22 External Monitoring... 22 Staff Education and Training... 22 Role Assignment... 22

ACRONYMS Business Continuity Plan (BCP) Canadian Pandemic Influenza Plan (CPIP) Emergency Services Portal (ESP) Flu Assessment Centre (FAC) Health Equity Impact Assessment (HEIA) Health Protection and Promotion Act (HPPA) Important Health Notices (IHNs) Incident Management System (IMS) Infection Prevention and Control Canada (IPAC) Local Health Integration Networks (LHINs) Medical Officer of Health (MOH) Ministry Emergency Operations Centre (MEOC) Ministry of Health and Long-Term Care (MOHLTC) Occupational health and safety (OHS) Occupational Health and Safety Act (OHSA) Ontario Health Plan for an Influenza Pandemic (OHPIP) Ontario Influenza Response Plan (OIRP) Ontario Public Health Standards (OPHS) Public Health Agency of Canada (PHAC) Public Health Incident Manager (PHIM) Public Health Ontario (PHO) Public Health Units (PHUs) Regional Infection Control Network (RICN) Toronto Public Health (TPH) Toronto Public Health Emergency Plan (TPHEP) Toronto Public Health Plan for an Influenza Pandemic (TPHPIP) Toronto's Office of Emergency Management (OEM) Vaccine Delivery Agent (VDA) Page 3 of 22

CHAPTER 1 Introduction/Context Introduction Influenza is a common and highly contagious viral respiratory illness which presents with acute onset of fever, cough and one or more of the following: sore throat, arthralgia, myalgia, or prostration (as well as gastrointestinal symptoms in children under five). Influenza is primarily droplet spread: it can be directly transmitted from person-to-person when people infected with influenza cough or sneeze, and droplets of respiratory secretions come into contact with mucous membranes of the mouth, nose, and possibly eyes of another person. Particles expelled by a coughing or sneezing person can travel some distance and may be inhaled by someone who is within two meters of a coughing or sneezing person. Because the virus in droplets can survive for extended periods of time on surfaces or hands, the virus can also be contact spread: people can acquire influenza indirectly by touching contaminated hands, surfaces and objects, and then touching their mouth, nose or eyes. Influenza epidemics or outbreaks occur in our community almost every year, usually in the winter. A pandemic is an epidemic that occurs worldwide or over a large area, crossing international boundaries and usually affects a large number of people. Historically influenza pandemics have occurred three or four times each century, with the last one occurring in 2009. While the exact timing and severity of a pandemic cannot be predicted, most health experts agree that pandemics will continue to occur as the influenza virus can shift and novel strains can occur. Planning and preparedness activities for pandemics are ongoing, with the goals of minimizing illness, death and societal disruption. Toronto Public Health (TPH) is the lead health agency for pandemic influenza planning, preparedness, response and recovery in the City of Toronto. Local planning is based on the Canadian Pandemic Influenza Plan (CPIP) and the Ontario Health Plan for an Influenza Pandemic (OHPIP). TPH responsibilities are outlined in the OHPIP and include components of a health sector response related to: Health System Communications Surveillance Public Health Measures Occupational Health & Safety and Infection Prevention & Control Outpatient Care & Treatment Immunization Primary Health Care Services INTRODUCTION/CONTEXT Chapter 1 Page 4 of 22

TPH organizes its response activities according to the Toronto Public Health Emergency Plan (TPHEP) and its Functional Components. This plan outlines both TPH s internal approach and how TPH works with the City of Toronto's Office of Emergency Management (OEM). General Planning Assumptions The Toronto Public Health Plan for an Influenza Pandemic (TPHPIP) is based on planning assumptions outlined in national and provincial preparedness plans. Below is a summary of the main planning assumptions adopted by TPH from the OHPIP 2013. Origin and Timing The next pandemic could emerge anywhere in the world including in Ontario. The next pandemic could emerge at any time of the year. Ontario has little lead time between when a pandemic virus is first identified and when it arrives in the province. Transmission The pandemic virus behaves like seasonal influenza viruses in significant ways, including the incubation period, period of communicability and methods of transmission. The pandemic strain is primarily community spread; that is, it is transmitted from person-toperson in the community as well as in institutional settings. Pandemic Epidemiology An influenza pandemic consists of two or more waves or intense periods of viral transmission. The novel influenza virus displaces other circulating seasonal influenza strains during the pandemic. Clinical Features As with seasonal influenza, the severity of the pandemic cannot be predicted, may be partially determined by the effectiveness of interventions, such as treatment with antivirals and is not easily determinable at the start of an outbreak. As with seasonal influenza, the clinical severity of the illness experienced by Ontarians who are infected by the pandemic virus varies considerably: some individuals who are infected do not display any clinical symptoms, while others become quite ill, may require hospitalization and may even die. INTRODUCTION/CONTEXT Chapter 1 Page 5 of 22

The groups at increased risk for severe disease and complications during an influenza pandemic are similar to those for seasonal influenza; however, there may be additional high-risk groups because of specific features of the pandemic virus. Vulnerable populations that typically experience a disproportionate burden of negative health outcomes, or are more vulnerable to these outcomes because of the effects of the social determinants of health, are more severely affected by the pandemic than other members of the community. This includes Ontarians with low incomes, who face language barriers, and who are homeless. Interventions Vaccine is available in time to have an impact on the overall pandemic; however, it is not available for the first wave. The Ministry of Health and Long-Term Care (MOHLTC) maintains an antiviral stockpile to provide treatment for individuals that meet its clinical recommendations. The efficacy and dose requirements of antivirals are not known until the pandemic begins and may differ from that of seasonal influenza; therefore, recommendations may change. Vaccine-specific Planning Assumptions In addition to the general planning assumptions above, the provincial strategy is also based on the following vaccine-specific assumptions: As the pandemic vaccine is not available for several months into an influenza pandemic, Public Health Units (PHUs) and other health system partners have time to adapt their seasonal influenza immunization programs to meet the requirements of the provincial pandemic immunization strategy. Given the limited supply and high demand for vaccine in the initial rollout of the strategy, the MOHLTC may need to identify key population groups that receive the vaccine first (e.g., high risk groups, health workers). As key population groups complete their immunizations, additional groups are added and therefore the target population changes over the course of the strategy. Vaccine supply is not consistent throughout the rollout of the strategy; therefore, the strategy must be adaptable. There is significant media interest, especially in the initial stages of the rollout when the demand for vaccine is likely greater than the supply. Large numbers of health care providers are mobilized to support rollout of the immunization strategy, especially when public demand and vaccine supply are both high. Over time, these resources can be deployed to support other pandemic response activities. INTRODUCTION/CONTEXT Chapter 1 Page 6 of 22

Risk Scenarios In the MOHLTC model outlined below (Figure 1), severity is measured along two dimensions transmissibility of the virus and clinical severity of illness. There are four severity scenarios ranging from a mild scenario that is similar to seasonal influenza (low transmissibility and low clinical severity) to the most severe scenario with high transmission and high clinical severity rates. As well, the OHPIP severity model includes an initial stage before severity is known when the limited availability of surveillance data does not allow for confident identification of severity. The severity may not be clearly known until after an influenza pandemic is over. The MOHLTC uses surveillance data to estimate severity. This model has been used to provide information on the types of responses that may be used during an influenza pandemic. As more information about the severity of an influenza pandemic is available, the MOHLTC will establish and communicate the provincial response strategies such as the outpatient care & treatment, immunization, public health measures, antiviral distribution and surveillance. Figure 1 outlines the four severity scenarios used in the OHPIP. (Source: OHPIP. Image by MOHLTC) INTRODUCTION/CONTEXT Chapter 1 Page 7 of 22

TABLE 2. EXAMPLES AND IMPACT OF SEVERITY SCENARIOS Overall severity Characteristics Examples Impact on health system Before severity is Known Limited surveillance data available Either in the prepandemic phase or early in the pandemic, before there is enough information available to determine the seventy of the pandemic Un Known Low transmissibility & low dinical seventy Cumulative attack rate 14 : < 21% Ro {basic reproduction number) 15 : <1.6 Typical seasonal influenza epidemics 2009 influenza pandemic 1968 influenza pandemic Comparable to seasonal influenza case Fatal~ Rate (CFR) : <0.25% High transmissibility & low dinical seventy Cumulative attack rate: ~ 1 % Ro~ 1. 6 CFR: <0.25% 1927-28 seasonal influenza epidemic Significant workplace absenteeism High burden on outpatient and acute services Low transmissibility & high clinical seventy Cumulative attack rate: < 21% Ro: <1.6 1957 influenza pandemic High burden on critical health care services C FR:~0. 25% 14 The cumulative attack rate is the percentage of people Who (are expected to) become symptomatic at some point dunng the influenza pandemic. 15 The basic reproductive number is the number of secondary cases one case should produce in a completely susceptible population. 16 The case fatality rate is the ratio of deaths Within a designated population of cases over the course of a pandemic. Table 2 outlines how various influenza pandemics and seasonal epidemics are categorized in this model and the major health system impacts. (Source: OHPIP. Image by MOHLTC) INTRODUCTION/CONTEXT Chapter 1 Page 8 of 22

Roles of Organizations World Health Organization Coordinate international response activities under the International Health Regulations Perform international surveillance and provide an early assessment of pandemic severity in order to help countries determine the level of intervention needed in the response Declare an influenza pandemic Select the pandemic vaccine strain and determine the time to begin production of the pandemic vaccine Federal (Public Health Agency of Canada) Coordinate national pandemic influenza response activities, including nation-wide surveillance, international liaison and coordination of the vaccine response, as outlined in the CPIP Province of Ontario (Ministry of Health and Long-Term Care) (through the Ministry Emergency Operations Centre (MEOC)) Liaise with Public Health Agency of Canada (PHAC) and other provinces and territories Collaborate with Public Health Ontario (PHO) to use surveillance information to determine severity Develop recommendations and provincial response strategies for the provincial health system, as well as others affected by public health measures Communicate with provincial health system partners through situation reports, Important Health Notices (IHNs), the Health Care Provider Hotline, the Health Stakeholder Teleconference, the MOHLTC website and other methods Develop and issue directives, orders and requests as per the Health Protection and Promotion Act (HPPA), Long-Term Care Homes Act and other relevant provincial legislation Communicate with the public through media briefings, the MOHLTC website and other methods Solicit and respond to feedback and input from provincial health system partners Deploy supplies & equipment from the MOHLTC stockpile to health workers and health sector employers Deploy antivirals from the MOHLTC stockpile to community-based pharmacies and other dispensing sites INTRODUCTION/CONTEXT Chapter 1 Page 9 of 22

Public Health Ontario (through the MEOC) Support the MOHLTC to use surveillance information to determine severity Lead and coordinate the provincial surveillance strategy Coordinate and provide provincial influenza laboratory testing Provide scientific and technical advice to the MOHLTC (e.g., advice on infection prevention and control measures) Generate knowledge translation tools and offer training opportunities to supplement the MOHLTC s recommendations, directives and response strategies Ministry of Labour (MOL) Provide occupational health and safety (OHS) advice to the MOHLTC (through the MEOC) Enforce the Occupational Health and Safety Act (OHSA) and its regulations Office of the Fire Marshal and Emergency Management Coordinate the provincial response to an influenza pandemic, with an emphasis on coordinating responses to non-health system impacts and consequences as outlined in the Provincial Coordination Plan for an Influenza Pandemic Local Health Integration Networks (LHINs) Liaise between transfer payment (TP) organizations and the MOHLTC Participate in the coordination of local care & treatment Toronto Public Health Follow MOHLTC recommendations, directives, orders and requests Develop and issue orders (as per the HPPA) Lead local implementation of the surveillance strategy Lead local implementation of immunization strategy Lead local implementation of public health measures Participate in the coordination of local care and treatment Continue to provide other public health services INTRODUCTION/CONTEXT Chapter 1 Page 10 of 22

Health liaison organizations (provincial associations, unions and regulatory bodies) Liaise between members and the MOHLTC Share best practices among sector/membership Health workers and health sector employers Follow MOHLTC recommendations, directives, orders and requests Follow PHU orders Continue to provide safe and effective care Participate in the coordination of local care & treatment Participate in research and surveillance activities Practice and role model appropriate behaviour to protect clients/patients/residents (C/P/Rs) and prevent further spread of influenza (e.g. get immunized; practise respiratory etiquette and hand hygiene; stay home when sick) Other employers Implement public health measures Follow MOHLTC orders and requests Follow PHU orders Encourage immunization among employees Be immunized as soon as possible Public Follow public health measures such as staying home when symptomatic, performing hand hygiene and keeping commonly touched surfaces clean Follow MOHLTC and PHU orders Be immunized as soon as possible INTRODUCTION/CONTEXT Chapter 1 Page 11 of 22

Guiding principles The actions of the MOHLTC during a pandemic response are based on the following guiding principles. Many of these principles are useful in guiding the decision making of other parties, including health sector employers, health workers, emergency planners and other public health leaders. Evidence The MOHLTC uses scientific and technical evidence to inform decision-making, including evidence on the risk posed by the pandemic. The MOHLTC partners closely with PHO to obtain, understand and communicate the evidence. Legislation The MOHLTC responds based on provincial legislative requirements and responsibilities. Precautionary principle The MOHLTC does not await scientific certainty before taking action to protect health. For example, the MOHLTC considers the precautionary principle when developing recommendations and directives related to OHS & Infection Prevention and Control Canada (IPAC) measures, especially during the early stages of an influenza pandemic when scientific evidence on the severity of the novel virus is limited. Ontario Public Service values The MOHLTC uses the Ontario Public Service values to inform decision making during an influenza pandemic. Work is underway federally to develop an ethical framework for the CPIP. Future versions of the Ontario Influenza Response Plan (OIRP) will include an ethical framework that aligns with that in the CPIP. Health equity The MOHLTC considers the needs of vulnerable populations when developing response and recovery measures. To accomplish this, use the MOHLTC Health Equity Impact Assessment (HEIA), a decision support tool developed by the ministry to identify how a health program, service or policy impacts population groups in different ways. Work is underway at the MOHLTC to adapt the HEIA for a health emergency management context to ensure that provincial and local interventions do not exacerbate health disparities during an emergency. INTRODUCTION/CONTEXT Chapter 1 Page 12 of 22

Communication principles The MOHLTC bases its communications with the provincial health system and the public on the following principles: Timeliness Transparency Accessibility Credibility INTRODUCTION/CONTEXT Chapter 1 Page 13 of 22

CHAPTER 2 Preparedness Toronto Public Health Emergency Plan (TPHEP) TPH Emergency Plan (TPHEP) outlines the emergency management concepts including response structures, staff roles and responsibilities, resource mobilization and communication processes that Toronto Public Health uses to respond to emergencies. This Plan is based on the principle that, to be effective, emergency management arrangements need to be simple and allow for flexibility. When working in environments that are known to be dynamic and confusing, it is clearly advantageous to have simple and flexible arrangements in addition to staff that are trained and have a clear understanding of their roles and responsibilities. TPHEP is for Toronto Public Health staff use. TPHEP is reviewed annually and updated, if needed, to reflect new knowledge and best practices as well as comply with Ontario Public Health Standards (OPHS). Functional Components Functional components are frameworks of essential response elements that may be used in any type of emergency event. TPH currently has four functional components: Incident Management System (IMS) Emergency Communication Strategy Divisional Operations Centre Psychosocial Support Protocol Networks and Partners Emergency events are complex and dynamic situations that can also be dangerous. A prompt and coordinated response from many agencies reduces risk to life, health and social order. The nature and magnitude of the emergency or incident triggers the appropriate level of response by the Province, City and TPH. TPH is engaged in ongoing emergency planning and preparedness activities with OEM, Shelter, Support and Housing Administration and other City agencies. TPH also works together on common emergency management goals with other government agencies and organizations including the LHINs, local health sector, vulnerable populations, and other community groups. PREPAREDNESS Chapter 2 Page 14 of 22

On-going TPH pan flu preparedness TPH is engaged in various on-going initiatives that support pan flu preparedness, these include: Employee Services Portal (ESP) ESP is an integrated secure intranet portal which includes staff emergency contact information and replaces the previous paper-based system of collecting, tracking and maintaining personal contact and skills information for the 'TPH Emergency Call-out List'. All TPH staff fill in their personal contact info on-line through the Employee Contact Info app in ESP rather than provide it on paper to their supervisor or manager. The information is secured and protected on City servers and used during emergencies to contact staff. The user receives an email twice a year to ensure that their contact information and skills are up-to-date. TPH can also produce reports through ESP of languages spoken, training received, etc which can assist during the redeployment of TPH staff. TPH Continuity Planning TPH Continuity Planning is a planning process that analyses the time-criticality of business processes, determines the most appropriate resilience and recovery objectives, and documents the strategies approved to achieve those objectives on the Business Continuity Plan (BCP). The BCP is written at the business process level. BCPs are event neutral and can be used in a pandemic to restore a business process if disrupted. All BCPs are reviewed and updated at least annually. There is also an annual exercise component to ensure readiness and preparedness. Respirator Fit Testing (RFT) TPH is committed to maintaining a healthy and safe work environment. All employees must be fit tested to an N95 respirator to ensure employee health and safety as part of their work. Fit testing is mandatory for all TPH staff as all staff could be assigned to work during a pandemic that requires them to wear an N95 respirator. All staff will be fit-tested within two years of start date and every two years thereafter. Staff who cannot be fit tested due to an accommodation or other reviewed and approved reason will not be assigned to work that requires N95 respirators. TPH will provide employees timely access to N95 respirators as required. TPH maintains a four-week stockpile of N95 respirators based on types and sizes from the most recent fit-testing process. Employees who may be required to use N95 respirators in their usual work will receive training on procedures for donning, doffing, using, caring, storing and maintaining N95 by their program. Programs will maintain training records as required. Employees who do not usually require N95 respirators will be provided instruction on donning, doffing and using N95 respirators when they do their RFT and when required to use the respirators. Mass Immunization Clinic (MIC) Plan Mass Immunization Clinics are a major responsibility for local health units. They are complex and resource intense during the time of a pandemic. TPH (through CDC) maintains a specific operational plan to meet this need. PREPAREDNESS Chapter 2 Page 15 of 22

Other preparedness Deploying Staff Resources Emergency Response This policy provides direction for the deployment of TPH staff and external staff under contract to TPH during an emergency response. PREPAREDNESS Chapter 2 Page 16 of 22

CHAPTER 3 Response OHPIP Public Health Unit responsibilities * PHU includes boards of health, medical officers of health (MOHs) and other PHU health workers (e.g., public health inspectors, epidemiologists, public health nurses). Chapter PHU responsibility IMS Function/ Sub-Function 1 - Introduction 1. Follow MOHLTC recommendations, directives, orders and requests 2. Develop and issue orders** (MOH / Operations Function) 3. Lead local implementation of the surveillance strategy 4. Lead local implementation of immunization 5. Participate in the coordination of local care & treatment 1. All (If appropriate) 2. MOH / Operations 3. Operations (Epidemiological Investigations) 4. Operations 5. Liaison / Operations 6. Command & Operations 7. Continuity of Operations Team & Command 6. Lead local implementation of public health measures 7. Continue to provide other public health services 2 - Health System Communications 1. Communicate with local health system partners to coordinate the local response 2. Analyze, report and communicate local surveillance information to local health system partners 3. Follow MOHLTC recommendations, directives, orders and requests 4. Communicate and reinforce the MOHLTC s recommendations and response strategies with local health system partners; may provide additional interpretation, targeted information and knowledge translation tools 5. Communicate with the public on risk and appropriate public health measures 6. Contribute to the MOHLTC s risk communication based on local surveillance information 7. Develop and issue orders 1. PHIM & Liaison 2. Planning & Liaison 3. All 4. Command 5. Command 6. Command & Planning 7. MOH & Operations RESPONSE Chapter 3 Page 17 of 22

Chapter PHU responsibility IMS Function/ Sub-Function 3 - Surveillance 1. Collect local data as per the provincial surveillance strategy 2. Lead and implement local surveillance initiatives 3. Report local data to PHO and contribute any analytic or interpretive insights to the MOHLTC and PHO 4. Analyze, report and communicate local surveillance information to local health system partners 5. Interpret provincial, national and international data for relevance to the local context and communicate this information to local health system partners 6. Facilitate the collection of samples during institutional outbreaks 1. Operations 2. Operations 3. Operations (Surveillance), Planning 4. Communications, Operations 5. Operations (Surveillance), Command 6. Operations 4 - Public Health Measures 5 - OH&S and Infection Prevention Control 6 - Outpatient Care and Treatment*** 1. Provide advice to the MOHLTC to support the development, evaluation and refinement of the provincial public health measures strategy 2. Develop, implement and evaluate public health measures based on the provincial strategy 3. Develop and issue orders as per the HPPA 1. Undertake various roles as described in the Ontario Public Health Standard on Infectious Disease Prevention and Control 2. Promote and reinforce MOHLTC recommendations locally 1. Communicate surveillance information and information on local health system demand and capacity with local health system partners, PHO and the MOHLTC to inform opening and closing of FACs 2. Implement telephone information service 1. Planning / Liaison 2. PHIM & Planning 3. MOH & Operations 1. Operations 2. Communication Note: This is the expected role of TPH in the local public health response. The City of Toronto, as a health sector employer, is responsible for the health of city employees, including TPH employees. This will be done by HR, OH&S and the IMS Safety Function. 1. Communication 2. Operations (Hotline Operation) 3. Operations, Liaison RESPONSE Chapter 3 Page 18 of 22

Chapter PHU responsibility IMS Function/ Sub-Function based on capacity and local need 3. In coordination with the RICN(s), support FACs to implement effective IPAC measures 7 - Immunization 1. Develop and implement a regional pandemic immunization program**** that includes: Identification and engagement of local VDAs Inventory management that addresses the receipt of vaccine from the MOHLTC and the allocation and distribution to local VDAs Public and health sector communications, including communication with local VDAs Support local VDAs during the planning and implementation of their organizational pandemic immunization programs Administer vaccine, as per the PHU role in the regional pandemic immunization program Participate in the evaluation process developed by PHO and the MOHLTC 1. Plan developed prior to response and implemented by Operations, MIC 8 - Laboratory Services No PHU responsibility 9 - Primary Health Care Services 1. In coordination with the RICN(s), support local FACs to implement effective IPAC measures 1. Operations, Liaison ** Refers to orders made by MOHs and public health inspectors as per the HPPA *** Lead FAC Agency The MOHLTC has not named the lead FAC Agency. If PHUs become the Lead FAC Agency additional responsibilities will include: Work with local health care providers/ organizations to identify primary health care organizations and emergency departments that could act as FACs (prior to response) RESPONSE Chapter 3 Page 19 of 22

Develop local outpatient care & treatment arrangements, ensuring that the needs of vulnerable populations and those that do not have access to primary health care services are addressed (prior to response) Coordinate with local acute care settings, LHIN, PHU and the MOHLTC regarding the opening and closing FACs based on the risk of acute care settings being overwhelmed (Operations) Coordinate the implementation of FACs, including liaising between FACs and the MOHLTC (Operations) Advertise FAC locations and hours of operation (Operations & Emergency Information) Gather reporting data from FACs and share with the MOHLTC (Planning & Liaison) Coordinate the submission of FAC expenses to the MOHLTC for reimbursement (F&A & Operations) **** Regional pandemic immunization programs build upon the provincial pandemic immunization strategy Incident Management System (IMS) Functional Component The IMS Functional Component outlines the principles, structures and processes of IMS that are scalable to manage all emergency incidents at TPH. Additional IMS response related tools and resources for each of the functions and sub-functions are available on the TPH Emergency Planning & Preparedness intranet website. RESPONSE Chapter 3 Page 20 of 22

CHAPTER 4 Recovery Recovery begins when the emergency incident/event is deemed under control by the Public Health Incident Manager (PHIM). This chapter provides guidance in returning to normal public health operations after a pandemic. Recovery activities often begin before the response phase ends. There will likely be transitional measures as the emergency response winds down and are determined by the nature and magnitude of the emergency. IMS and Recovery Within IMS, the Planning function is responsible for collecting, organizing, analyzing, interpreting and reporting incident information through the situation assessment sub-function. As this information is shared at the business cycle meetings, a decision will be made that the event is under control. Based on the information gathered from functions/sub-functions and under the direction of PHIM, the Planning function will propose a course(s) of action(s) for the recovery phase of the event and eventual return to normal operations. The eventual decision will be made by Command, a response evaluation may follow. Recovery Phase Focus During the recovery phase, TPH considers the timelines and sequencing for: Deactivating specific IMS functions and sub-functions. Resuming TPH programs and services that may have been reduced or stopped during the emergency response. Returning staff to their usual work, including communication. Communicating recovery strategies to key stakeholders. (e.g. community and City stakeholders, public) During the Recovery Phase, TPH focuses on 4 main areas: Operations, equipment and supplies, staff and communicating with external partners. RECOVERY Chapter 4 Page 21 of 22

CHAPTER 5 Maintenance Plan External Monitoring TPH will continue to monitor a variety of websites and publications for ongoing surveillance information related to pandemic influenza. This includes: World Health Organization, FluWatch (Public Health Agency of Canada), Ministry of Health and Long Term Care, ProMED, etc. Staff Education and Training Training is an essential component of emergency preparedness. It's also a requirement under both the provincial Emergency Management and Civil Protection Act and the Ontario Public Health Standards. Staff training is carried out to ensure TPH is prepared to respond effectively and efficiently to emergencies. Training includes e-learning, traditional courses, staff workshops and emergency exercises, which can include table top, functional exercises and drills. Incident Management System Training The IMS Basic on-line training course is required for all TPH staff. This course provides information on emergency management at TPH, basic IMS structure, terminology and tools. It is intended for all staff, whether assisting at an incident/event or working in supportive roles. TPH non-union staff who have been assigned to an IMS function or sub-function shall take IMS function specific training. This training enhances TPH's ability to respond to large-scale or prolonged emergencies, including pandemic influenza. It ensures non-union staff are familiar with their roles and responsibilities within the context of IMS. The Emergency Planning & Preparedness team in Planning & Performance schedules this training regularly. Non-union staff assigned to IMS roles will be invited to the training as appropriate. IMS training is also available through OEM. This training is geared to TPH management. It is supported with EPP resources and the number of spots available to TPH is limited to six per year. Role Assignment All non-union staff have been pre-assigned to specific IMS roles. Directors review these assignments and the MOH approves them. MAINTENANCE Chapter 5 Page 22 of 22